- Email: [email protected]
Joint Mobilization (Articulation, Nonthrust Technique; Nonimpulse Technique)
REFERENCES 1. Manheim CJ, Lavett DK: The myofascial release manual. Thorofare (NJ): Slack; 1989. 2. Ramsey SM: Holistic manual therapy techniques. Primary Care Clin Off Pract 24(4):759-786, 1997. 3. Barnes JF: Myofascial release: the search for excellence. A comprehensive evaluatory and treatment approach. John F. Barns PT and Rehabilitation Services; 1990. 4. Goodman CC: The cardiovascular system. In: Goodman CC, Boissonnault WG, Fuller KS, eds: Pathology: implications for the physical therapist, ed 2. Philadelphia: Saunders; 2003. 5. Manheim CJ: The myofascial release manual, ed 2. Thorofare (NJ): Slack; 1994. 6. Brashear HR Jr, Raney RB Sr: Shand’s handbook of orthopaedic surgery, ed 9. St. Louis: C.V. Mosby; 1978.
25
JOINT MOBILIZATION (ARTICULATION, NONTHRUST TECHNIQUE; NONIMPULSE TECHNIQUE) OVERVIEW. Joint mobilization (also called articulation, non-thrust) is a manual technique directed to the patient’s joint whereby the clinician imparts passive movements such as glides and distractions. The technique is characterized by lowvelocity movements (i.e., rather than high-velocity thrusts) and is generally slow enough for the patient to stop. The goal is to relieve pain or improve range of motion by improving joint play and restoring the roll and glide arthrokinematics of the joint.1 SUMMARY: CONTRAINDICATIONS AND PRECAUTIONS. Seven sources cited a total of 51 concerns for joint mobilization. Concerns ranged from four to 18 per source. All seven sources were physical therapists. The largest proportion of concerns were musculoskeletal (>40%). The most frequently cited concern was neoplasm followed by recent fracture and hypermobility. Part III • Interventions
285
286
Part III • Interventions
Several absolute CIs were also listed. Notes: Grieve,2 Kisner and Colby,1 and Sprague3 address spinal mobilization, peripheral joint mobilization, and the cervical spine concerns, respectively. Harris and Lundgren4 address pediatric concerns with nervous system disorders. ADVERSE EVENT. Michaeli,5 in a 1993 descriptive study, reported on a 75-year-old man who suffered a minor CVA with aphasia a day or two following an occipito-atlantal and atlantoaxial joint mobilization with a forceful rotatory component. No premanipulative screening was conducted.
Number of Concerns
20
Number of Concerns for Joint Mobilization per Source
Proportion of Concerns Based on ICD
Symptoms 15
Congenital Pregnancy
Procedural Injury Medical devices Infection Neoplasm 8% Mental
10
10% 42%
5 Musculoskeletal
Nervous
Top 7 Cited Concerns for Joint Mobilization (n = 7) Neoplasm Recent fracture Hypermobility Cauda equina lesion Bone disease
Circulatory Respiratory
Osteoporosis Rheumatoid arthritis 0
0
7 Physical Therapy Sources
1
2
3
4
5
6
Number of Citing Concerns
7
CONTRAINDICATIONS AND PRECAUTIONS A00B99 CERTAIN INFECTIONS AND PARASITIC DISEASES Issue
LOC
Source
Affil
Infection
ACI ACI ACI CI
Hertling and Kessler, 19966,a Grieve, 19892,b Paris, 19797 Cookson, 19798
PT PT PT PT
Tuberculosis
Rationale/Comment
Bacterial infection can affect bone and soft tissue.
a, Bacterial concerns; b, Infective arthritic concerns.
C00C97 NEOPLASMS Issue
LOC
Source
Affil
Rationale/Comment
Malignant tissue (previous)— non-spinal Neoplasm
Care
Grieve, 19892
PT
ACI ACI ACI CI CI Extreme care
Hertling and Kessler, 19966 Grieve, 19892,b Paris, 19797 Cookson, 19798 Sprague, 19833,a Kisner and Colby, 19961,c
PT PT PT PT PT PT
For spinal mobilization, if there is a previous history of a malignant tumor (non-spinal), one must “reasonably” exclude metastases to the spine. There may be undiscovered metastasis to bone.
a, Primary or secondary malignancy; b, Malignancy involving vertebral column; c, Extreme care if patient’s response and signs are favorable. Part III • Interventions
287
Part III • Interventions
288
F00F00 MENTAL AND BEHAVIORAL DISORDERS Issue
Developmental delay—generalized of unknown etiology (with hypotonia and ligamentous laxity) Neurosis—severe Psychologic pain
LOC
Source 4
Affil
Rationale/Comment
The patient may exhibit hypotonia and ligamentous laxity.
CI
Harris and Lundgren, 1991
PT
Caution CI
Cookson, 19798 Sprague 19833
PT PT
G00G99 DISEASES OF THE NERVOUS SYSTEM Issue
LOC
Source
Affil
Rationale/Comment
Cauda equina lesions with bowel and bladder disturbance
ACI CI CI
Grieve, 19892 Cookson, 19798 Sprague, 19833,a
PT PT PT
Note: Cauda equina syndrome presents as flaccid paralysis of the lower limbs bilaterally, paralysis of the rectal and bladder sphincter, and anesthesis of the buttocks, perineum, and posterior legs and feet.9 Evaluate evidence of neural compression such as a positive Babinski, nonsegmental paresthesia, or spastic weakness resulting in spastic gait.8 Evaluate compression of 4th sacral root with signs of sexual impotence, impaired bowel and bladder, saddle area pain, and paraesthesia.8
Cerebral palsy—athetoid or ataxic
Strongly CI
Neurological signs Spasticity and older children with joint restrictions
Care Caution and conservative use
Spinal cord involvement of more than one spinal nerve root on one side or two adjacent roots in one limb only
ACI
Harris and Lundgren, 19914 Grieve, 19892 Harris and Lundgren, 19914
PT
Grieve, 19892
PT
PT PT
Neck movements (rapid, repetitive) in athetoid cerebral palsy can accelerate progression of cervical instability. See Manipulation. Reasons: First, immature growth plates are vulnerable to linear and torsional shears during growth spurts, which may be a particular issue with younger children. Second, children with CNS involvement may not adequately provide a history. Third, clinicians need the competence to differentiate capsular tightness from spasticity. Perform gentle oscillations and avoid techniques that cause pain or reactive muscle spasms. Avoid quick stretches to muscle surrounding joints in children with spasticity because of the concern for temporarily increasing spasticity.
a, Spinal cord compression.
Part III • Interventions
289
Part III • Interventions
290
I00I99 DISEASES OF THE CIRCULATORY SYSTEM Issue
LOC
Source 8
Affil
Rationale/Comment
If signs of circulatory disturbances are noted, consider the use of gentler techniques.8 Inquire about drop attack history, calcification of large blood vessels on x-ray; dizziness, visual disturbance related to neck posture, or vertebral artery disease of the cervical spine (i.e., vertebral artery occlusion; advanced arteriosclerosis).8 Also see Michaeli.5 Note: This maneuver is a component of the vertebral artery test, and dizziness may suggest circulatory embarrassment of the vertebral artery and a potential hazard for cervical techniques.
Circulatory disturbance
Caution
Cookson, 1979
PT
Dizziness aggravated by neck rotation or extension
Care
Grieve, 19892
PT
J00J99 DISEASES OF THE RESPIRATORY SYSTEM Issue
Upper respiratory tract infection
LOC
Avoid
Source
Paris, 1979
Affil 7
PT
Rationale/Comment
M00M99 DISEASES OF THE MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE Issue
Arthroses Autoimmune disease— advanced Bone disease
Connective tissue— weakened Deformity—operative Disc—herniation
LOC
Source
Affil 6
RCI CI
Hertling and Kessler, 1996 Cookson, 19798
PT PT
ACI Caution Extreme caution Extreme caution
Grieve, 19892,a,b Cookson, 19798,b Kisner and Colby, 19961,c Kisner and Colby, 19961
PT PT PT PT
Caution RCI
Cookson, 19798 Paris, 19797
PT PT
Disc—prolapse
RCI
Disc—prolapse, with neurological changes Hypermobility
ACI
Paris, 19797
PT
RCI Caution Caution CI
Paris, 19797 Cookson, 19798,d Grieve, 19892 Kisner and Colby, 19961
PT PT PT PT
Rationale/ Comment
In advanced autoimmune disease (i.e., ankylosing spondylitis), ligaments may become lax and spinal joints hypermobile. Vigorous manual techniques are CI.
Forceful mobilization, in the presence of weak connective tissue, such as from disuse, injury, surgery, or medications (corticosteroids), may destroy tissue. Note: Disc herniation involves the partial expulsion of nuclear material from the annulus into the canal, with the majority of material remaining in the annulus.1 This concern is dependent on skill level. Note: A disc prolapse results when the nuclear material frankly ruptures into the vertebral canal.1 This is a disc prolapse with serious neurological changes, including cord compression. Patients with hypermobility may have capsular or ligamentous necrosis. Anterior and posterior glides are contraindicated for anterior and posterior shoulder dislocations, respectively, during the rehabilitation phase (i.e., following reduction).1 Continued Part III • Interventions
291
Part III • Interventions
Issue
Hypermobility in associated joints Internal derangement Joint effusion
LOC
Source 1
Affil
Rationale/Comment
These joints need to be stabilized so mobilization forces do not stress them.
Extreme caution
Kisner and Colby, 1996
PT
RCI RCI CI RCI CI Avoid
Hertling and Kessler, 19966 Hertling and Kessler, 19966 Kisner and Colby, 19961 Hertling and Kessler, 19966 Kisner and Colby, 19961 Paris, 19797
PT PT PT PT PT PT
ACI
Paris, 19797
PT
Osteoporosis
Care ACI Caution
Grieve, 19892 Paris, 19797,d Cookson, 19798
PT PT PT
Rheumatica, polymyalgia Rheumatoid arthritis
Care CI Care Extreme caution
Grieve, 19892 Cookson, 19798 Grieve, 19892 Kisner and Colby, 19961
PT PT PT PT
Joint inflammation Ligaments—laxity (generally) Osteomyelitis
292
Do not stretch with joint mobilization because the joint capsule is already distended from the swelling and is limited by pain rather than fiber shortening.1 Do not stretch with joint mobilization as it will only increase pain, guarding, and tissue damage.1 Note: Because a goal of joint mobilization is soft tissue stretching, using this technique on a lax joint is counterintuitive and may create further, unwanted instability. Osteomyelitis is characterized by inflammation of bone, usually due to bacterial infection, bone destruction, abscess formation, and reactive formation of new bone. Avoid any technique (e.g., such as massage) that may mechanically spread infection.9 Note: Osteoporosis (porous bone) is characterized by reduced bone mass, with susceptibility to fractures, particularly vertebral compression fractures that are not usually associated with severe trauma.9 Mobilize with care, especially over osteoporotic ribs.2 This condition is regarded as an inflammatory arthritis of axial and limb girdle joints. This is an advanced autoimmune disease. Connective tissue is weakened and forceful peripheral mobilization may rupture tissue and lead to instability.1 One source suggests gentle mobilization in RA, but patient must not be acutely inflamed, the cervical spine must be avoided, and depleted bone structure (especially rib) must be respected.2
Rheumatoid collagen necrosis—of the vertebral ligament Scoliosis Spondylolisthesis
Spondylolysis
ACI
Grieve, 19892
PT
RCI RCI Care
Paris, 19797 Paris, 19797 Grieve, 19892
PT PT PT
RCI
Paris, 19797
PT
The cervical spine is particularly vulnerable.
Note: Spondylolisthesis (listhesis means “slipping”) is a defect in the isthmus that results in vertebral instability with a forward slipping of the spinal column from its base, common at the LS level. The ligament stability is relied upon.9 Techniques involving a “degree of energy” are contraindicated for spondylolisthesis.2 Note: Spondylolysis may cause neurological signs if an osteophyte encroaches on the spinal canal or intravertebral foramina.1
a, More involved than “simple osteoporosis”; b, Of the spine; c, Concerns for the periphery; d, Active.
O00O99 PREGNANCY, CHILDBIRTH, AND PUERPERIUM Issue
First trimester of pregnancy Last stage of pregnancy
LOC
Avoid CI Avoid CI
Source 7
Paris, 1979 Cookson, 19798 Paris, 19797 Cookson, 19798
Affil
Rationale/Comment
PT
There is the danger of precipitating a miscarriage in the first trimester. Vigorous maneuvers are CI.7
PT PT
Ligament are lax during the last stage of pregnancy.7 Vigorous maneuvers are CI.
Part III • Interventions
293
Part III • Interventions
294
Q00Q99 CONGENITAL MALFORMATIONS, DEFORMITIES AND CHROMOSOMAL ABNORMALITIES Issue
LOC
Deformity, congenital Down syndrome
Caution Strongly CI
Prader-Willi syndrome
Strongly CI
Source
Affil 8
Cookson, 1979 Harris and Lundgren, 19914
PT PT
Rationale/Comment
Twenty-three percent of individuals with Down syndrome have patella instability, 10% have hip subluxations or dislocations, and 15% have atlantoaxial instability. This syndrome presents with generalized hypotonia.
R00R99 SYMPTOMS, SIGNS, AND ABNORMAL CLINICAL AND LABORATORY FINDINGS NOT ELSEWHERE CLASSIFIED Issue
Elderly persons with weakened connective tissue and reduced circulation Debilitation—general Inflammation Pain, excessive a, Active inflammatory.
LOC
Source
Affil 1
Extreme caution
Kisner and Colby, 1996
PT
RCI Avoid ACI CI Extreme caution
Hertling and Kessler, 19966 Paris, 19797 Grieve, 19892,a Cookson, 19798 Kisner and Colby, 19961
PT PT PT PT PT
Rationale/Comment
E.g., poor general health.
Determine cause of pain.
S00T98 INJURY, POISONING, AND CERTAIN OTHER CONSEQUENCES OF EXTERNAL CAUSES Issue
LOC
Source
Affil
Ligament, rupture Fracture—recent
ACI ACI ACI Caution CI Extreme caution
Paris, 19797 Hertling and Kessler, 19966 Paris, 19797,a Cookson, 19798 Sprague, 19833 Kisner and Colby, 19961,b
PT PT PT PT PT PT
Rationale/Comment
a, Fracture; b, Use of joint mobilization (peripheral) depends on site of fracture and stabilization.
Y70Y82 MEDICAL DEVICES Issue
LOC
Source
Affil
Rationale/Comment
Total joint replacements
Extreme caution
Kisner and Colby, 19961
PT
The replacement mechanism is “self-limiting.”
Part III • Interventions
295
Part III • Interventions
296
PROCEDURAL CONCERN Issue
LOC
Source
Affil
Rationale/Comment
Spasms that protect a joint Temporary soreness after treatments
Advice Advice
Grieve, 19892
PT
Never push through spasms that are protecting a joint. Patient instructions may relieve unnecessary anxiety between sessions. Warn patients of temporary aftereffects of treatments (i.e., soreness; other “after-effects”).
ADVERSE EVENT Source
Background
Therapy
Outcome
Follow-up/ Interpretation
Michaeli, 19935 Mobility and complications Descriptive (questionnaire) Aust Physiother
A survey was sent to 250 physiotherapists who completed a postgraduate course in South Africa between 1971 and 1989.
153 surveys were returned (61% response rate) with 228,050 manipulative procedures reported between 1971 and 1989. A total of 29 patients receiving spinal (cervical, thoracic, lumbar) manipulations experienced 52 mostly minor complications (most were from cervical manipulations). Another 58 patients receiving cervical mobilization had 129 complications, including the following case: A 75-year-old man suffered a minor CVA with aphasia (residual deficit 2 years later) a day
Dizziness, severe headaches, and nausea were the most common side effects for both cervical manipulation and mobilization. Complications after cervical manipulation included dizziness, nausea, severe headaches, nystagmus, blurred vision, brachialgia (also with neurological deficits), loss of consciousness, and acute wry neck. All patients recovered without sequelae with an average recovery of 6.3 days. Complications after cervical mobilization included dizziness, severe headaches,
The authors conclude that spinal manipulation is relatively safe (by physiotherapists in South Africa). Therapists should be aware of the potential risks with cervical mobilization.
or two following successive treatments for neck pain. (The mobilization was a grade 4 unilateral PA pressure to the occipitoatlantal and atlantoaxial joints and a rotatory mobilization described by patient as a “strong twisting movement.” Note: Premanipulative procedures were not conducted and VBI symptoms were not reported by patient.)
nausea, brachialgia (also with neurological deficits), blurring vision, vomiting, nystagmus, increased pain >2 weeks, CVA, and skin clamminess. The majority had no sequelae. There was partial recovery noted in one person with a CVA and two patients with brachialgia with neurological deficits. No recovery was reported in another two patients with brachialgia with neurological deficits (loss of strength and reflexes).
REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. 9.
Kisner C, Colby LA: Therapeutic exercise: foundations and techniques, ed 3. Philadelphia: F.A. Davis; 1996. Grieve GP: Contra-indications to spinal manipulation and allied treatments. Physiotherapy 75(8):445-453, 1989. Sprague RB: The acute cervical joint lock. Phys Ther 63(9):1439-1444, 1983. Harris SR, Lundgren BD: Joint mobilization for children with central nervous system disorders: indications and precautions. Phys Ther 71(12):890-896, 1991. Michaeli A: Reported occurrence and nature of complications following manipulative physiotherapy in South Africa. Aust Physiother 39(4):309-315, 1993. Hertling D, Kessler RM: Introduction to manual therapy. In Hertling D, Kessler RM, eds: Management of common musculoskeletal disorders: Physical therapy principles and methods, ed 3. Philadelphia: Lippincott-Raven; 1996. Paris SV: Mobilization of the spine. Phys Ther 59(8):988-985, 1979. Cookson JC: Orthopedic manual therapy: An overview. Phys Ther 59(3):259-267, 1979. Brashear HR Jr, Raney RB Sr: Shand’s handbook of orthopaedic surgery, ed 9. St. Louis: CV Mosby; 1978. Part III • Interventions
297
25
JOINT MOBILIZATION (ARTICULATION, NONTHRUST TECHNIQUE; NONIMPULSE TECHNIQUE) OVERVIEW. Joint mobilization (also called articulation, non-thrust) is a manual technique directed to the patient’s joint whereby the clinician imparts passive movements such as glides and distractions. The technique is characterized by lowvelocity movements (i.e., rather than high-velocity thrusts) and is generally slow enough for the patient to stop. The goal is to relieve pain or improve range of motion by improving joint play and restoring the roll and glide arthrokinematics of the joint.1 SUMMARY: CONTRAINDICATIONS AND PRECAUTIONS. Seven sources cited a total of 51 concerns for joint mobilization. Concerns ranged from four to 18 per source. All seven sources were physical therapists. The largest proportion of concerns were musculoskeletal (>40%). The most frequently cited concern was neoplasm followed by recent fracture and hypermobility. Part III • Interventions
285
286
Part III • Interventions
Several absolute CIs were also listed. Notes: Grieve,2 Kisner and Colby,1 and Sprague3 address spinal mobilization, peripheral joint mobilization, and the cervical spine concerns, respectively. Harris and Lundgren4 address pediatric concerns with nervous system disorders. ADVERSE EVENT. Michaeli,5 in a 1993 descriptive study, reported on a 75-year-old man who suffered a minor CVA with aphasia a day or two following an occipito-atlantal and atlantoaxial joint mobilization with a forceful rotatory component. No premanipulative screening was conducted.
Number of Concerns
20
Number of Concerns for Joint Mobilization per Source
Proportion of Concerns Based on ICD
Symptoms 15
Congenital Pregnancy
Procedural Injury Medical devices Infection Neoplasm 8% Mental
10
10% 42%
5 Musculoskeletal
Nervous
Top 7 Cited Concerns for Joint Mobilization (n = 7) Neoplasm Recent fracture Hypermobility Cauda equina lesion Bone disease
Circulatory Respiratory
Osteoporosis Rheumatoid arthritis 0
0
7 Physical Therapy Sources
1
2
3
4
5
6
Number of Citing Concerns
7
CONTRAINDICATIONS AND PRECAUTIONS A00B99 CERTAIN INFECTIONS AND PARASITIC DISEASES Issue
LOC
Source
Affil
Infection
ACI ACI ACI CI
Hertling and Kessler, 19966,a Grieve, 19892,b Paris, 19797 Cookson, 19798
PT PT PT PT
Tuberculosis
Rationale/Comment
Bacterial infection can affect bone and soft tissue.
a, Bacterial concerns; b, Infective arthritic concerns.
C00C97 NEOPLASMS Issue
LOC
Source
Affil
Rationale/Comment
Malignant tissue (previous)— non-spinal Neoplasm
Care
Grieve, 19892
PT
ACI ACI ACI CI CI Extreme care
Hertling and Kessler, 19966 Grieve, 19892,b Paris, 19797 Cookson, 19798 Sprague, 19833,a Kisner and Colby, 19961,c
PT PT PT PT PT PT
For spinal mobilization, if there is a previous history of a malignant tumor (non-spinal), one must “reasonably” exclude metastases to the spine. There may be undiscovered metastasis to bone.
a, Primary or secondary malignancy; b, Malignancy involving vertebral column; c, Extreme care if patient’s response and signs are favorable. Part III • Interventions
287
Part III • Interventions
288
F00F00 MENTAL AND BEHAVIORAL DISORDERS Issue
Developmental delay—generalized of unknown etiology (with hypotonia and ligamentous laxity) Neurosis—severe Psychologic pain
LOC
Source 4
Affil
Rationale/Comment
The patient may exhibit hypotonia and ligamentous laxity.
CI
Harris and Lundgren, 1991
PT
Caution CI
Cookson, 19798 Sprague 19833
PT PT
G00G99 DISEASES OF THE NERVOUS SYSTEM Issue
LOC
Source
Affil
Rationale/Comment
Cauda equina lesions with bowel and bladder disturbance
ACI CI CI
Grieve, 19892 Cookson, 19798 Sprague, 19833,a
PT PT PT
Note: Cauda equina syndrome presents as flaccid paralysis of the lower limbs bilaterally, paralysis of the rectal and bladder sphincter, and anesthesis of the buttocks, perineum, and posterior legs and feet.9 Evaluate evidence of neural compression such as a positive Babinski, nonsegmental paresthesia, or spastic weakness resulting in spastic gait.8 Evaluate compression of 4th sacral root with signs of sexual impotence, impaired bowel and bladder, saddle area pain, and paraesthesia.8
Cerebral palsy—athetoid or ataxic
Strongly CI
Neurological signs Spasticity and older children with joint restrictions
Care Caution and conservative use
Spinal cord involvement of more than one spinal nerve root on one side or two adjacent roots in one limb only
ACI
Harris and Lundgren, 19914 Grieve, 19892 Harris and Lundgren, 19914
PT
Grieve, 19892
PT
PT PT
Neck movements (rapid, repetitive) in athetoid cerebral palsy can accelerate progression of cervical instability. See Manipulation. Reasons: First, immature growth plates are vulnerable to linear and torsional shears during growth spurts, which may be a particular issue with younger children. Second, children with CNS involvement may not adequately provide a history. Third, clinicians need the competence to differentiate capsular tightness from spasticity. Perform gentle oscillations and avoid techniques that cause pain or reactive muscle spasms. Avoid quick stretches to muscle surrounding joints in children with spasticity because of the concern for temporarily increasing spasticity.
a, Spinal cord compression.
Part III • Interventions
289
Part III • Interventions
290
I00I99 DISEASES OF THE CIRCULATORY SYSTEM Issue
LOC
Source 8
Affil
Rationale/Comment
If signs of circulatory disturbances are noted, consider the use of gentler techniques.8 Inquire about drop attack history, calcification of large blood vessels on x-ray; dizziness, visual disturbance related to neck posture, or vertebral artery disease of the cervical spine (i.e., vertebral artery occlusion; advanced arteriosclerosis).8 Also see Michaeli.5 Note: This maneuver is a component of the vertebral artery test, and dizziness may suggest circulatory embarrassment of the vertebral artery and a potential hazard for cervical techniques.
Circulatory disturbance
Caution
Cookson, 1979
PT
Dizziness aggravated by neck rotation or extension
Care
Grieve, 19892
PT
J00J99 DISEASES OF THE RESPIRATORY SYSTEM Issue
Upper respiratory tract infection
LOC
Avoid
Source
Paris, 1979
Affil 7
PT
Rationale/Comment
M00M99 DISEASES OF THE MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE Issue
Arthroses Autoimmune disease— advanced Bone disease
Connective tissue— weakened Deformity—operative Disc—herniation
LOC
Source
Affil 6
RCI CI
Hertling and Kessler, 1996 Cookson, 19798
PT PT
ACI Caution Extreme caution Extreme caution
Grieve, 19892,a,b Cookson, 19798,b Kisner and Colby, 19961,c Kisner and Colby, 19961
PT PT PT PT
Caution RCI
Cookson, 19798 Paris, 19797
PT PT
Disc—prolapse
RCI
Disc—prolapse, with neurological changes Hypermobility
ACI
Paris, 19797
PT
RCI Caution Caution CI
Paris, 19797 Cookson, 19798,d Grieve, 19892 Kisner and Colby, 19961
PT PT PT PT
Rationale/ Comment
In advanced autoimmune disease (i.e., ankylosing spondylitis), ligaments may become lax and spinal joints hypermobile. Vigorous manual techniques are CI.
Forceful mobilization, in the presence of weak connective tissue, such as from disuse, injury, surgery, or medications (corticosteroids), may destroy tissue. Note: Disc herniation involves the partial expulsion of nuclear material from the annulus into the canal, with the majority of material remaining in the annulus.1 This concern is dependent on skill level. Note: A disc prolapse results when the nuclear material frankly ruptures into the vertebral canal.1 This is a disc prolapse with serious neurological changes, including cord compression. Patients with hypermobility may have capsular or ligamentous necrosis. Anterior and posterior glides are contraindicated for anterior and posterior shoulder dislocations, respectively, during the rehabilitation phase (i.e., following reduction).1 Continued Part III • Interventions
291
Part III • Interventions
Issue
Hypermobility in associated joints Internal derangement Joint effusion
LOC
Source 1
Affil
Rationale/Comment
These joints need to be stabilized so mobilization forces do not stress them.
Extreme caution
Kisner and Colby, 1996
PT
RCI RCI CI RCI CI Avoid
Hertling and Kessler, 19966 Hertling and Kessler, 19966 Kisner and Colby, 19961 Hertling and Kessler, 19966 Kisner and Colby, 19961 Paris, 19797
PT PT PT PT PT PT
ACI
Paris, 19797
PT
Osteoporosis
Care ACI Caution
Grieve, 19892 Paris, 19797,d Cookson, 19798
PT PT PT
Rheumatica, polymyalgia Rheumatoid arthritis
Care CI Care Extreme caution
Grieve, 19892 Cookson, 19798 Grieve, 19892 Kisner and Colby, 19961
PT PT PT PT
Joint inflammation Ligaments—laxity (generally) Osteomyelitis
292
Do not stretch with joint mobilization because the joint capsule is already distended from the swelling and is limited by pain rather than fiber shortening.1 Do not stretch with joint mobilization as it will only increase pain, guarding, and tissue damage.1 Note: Because a goal of joint mobilization is soft tissue stretching, using this technique on a lax joint is counterintuitive and may create further, unwanted instability. Osteomyelitis is characterized by inflammation of bone, usually due to bacterial infection, bone destruction, abscess formation, and reactive formation of new bone. Avoid any technique (e.g., such as massage) that may mechanically spread infection.9 Note: Osteoporosis (porous bone) is characterized by reduced bone mass, with susceptibility to fractures, particularly vertebral compression fractures that are not usually associated with severe trauma.9 Mobilize with care, especially over osteoporotic ribs.2 This condition is regarded as an inflammatory arthritis of axial and limb girdle joints. This is an advanced autoimmune disease. Connective tissue is weakened and forceful peripheral mobilization may rupture tissue and lead to instability.1 One source suggests gentle mobilization in RA, but patient must not be acutely inflamed, the cervical spine must be avoided, and depleted bone structure (especially rib) must be respected.2
Rheumatoid collagen necrosis—of the vertebral ligament Scoliosis Spondylolisthesis
Spondylolysis
ACI
Grieve, 19892
PT
RCI RCI Care
Paris, 19797 Paris, 19797 Grieve, 19892
PT PT PT
RCI
Paris, 19797
PT
The cervical spine is particularly vulnerable.
Note: Spondylolisthesis (listhesis means “slipping”) is a defect in the isthmus that results in vertebral instability with a forward slipping of the spinal column from its base, common at the LS level. The ligament stability is relied upon.9 Techniques involving a “degree of energy” are contraindicated for spondylolisthesis.2 Note: Spondylolysis may cause neurological signs if an osteophyte encroaches on the spinal canal or intravertebral foramina.1
a, More involved than “simple osteoporosis”; b, Of the spine; c, Concerns for the periphery; d, Active.
O00O99 PREGNANCY, CHILDBIRTH, AND PUERPERIUM Issue
First trimester of pregnancy Last stage of pregnancy
LOC
Avoid CI Avoid CI
Source 7
Paris, 1979 Cookson, 19798 Paris, 19797 Cookson, 19798
Affil
Rationale/Comment
PT
There is the danger of precipitating a miscarriage in the first trimester. Vigorous maneuvers are CI.7
PT PT
Ligament are lax during the last stage of pregnancy.7 Vigorous maneuvers are CI.
Part III • Interventions
293
Part III • Interventions
294
Q00Q99 CONGENITAL MALFORMATIONS, DEFORMITIES AND CHROMOSOMAL ABNORMALITIES Issue
LOC
Deformity, congenital Down syndrome
Caution Strongly CI
Prader-Willi syndrome
Strongly CI
Source
Affil 8
Cookson, 1979 Harris and Lundgren, 19914
PT PT
Rationale/Comment
Twenty-three percent of individuals with Down syndrome have patella instability, 10% have hip subluxations or dislocations, and 15% have atlantoaxial instability. This syndrome presents with generalized hypotonia.
R00R99 SYMPTOMS, SIGNS, AND ABNORMAL CLINICAL AND LABORATORY FINDINGS NOT ELSEWHERE CLASSIFIED Issue
Elderly persons with weakened connective tissue and reduced circulation Debilitation—general Inflammation Pain, excessive a, Active inflammatory.
LOC
Source
Affil 1
Extreme caution
Kisner and Colby, 1996
PT
RCI Avoid ACI CI Extreme caution
Hertling and Kessler, 19966 Paris, 19797 Grieve, 19892,a Cookson, 19798 Kisner and Colby, 19961
PT PT PT PT PT
Rationale/Comment
E.g., poor general health.
Determine cause of pain.
S00T98 INJURY, POISONING, AND CERTAIN OTHER CONSEQUENCES OF EXTERNAL CAUSES Issue
LOC
Source
Affil
Ligament, rupture Fracture—recent
ACI ACI ACI Caution CI Extreme caution
Paris, 19797 Hertling and Kessler, 19966 Paris, 19797,a Cookson, 19798 Sprague, 19833 Kisner and Colby, 19961,b
PT PT PT PT PT PT
Rationale/Comment
a, Fracture; b, Use of joint mobilization (peripheral) depends on site of fracture and stabilization.
Y70Y82 MEDICAL DEVICES Issue
LOC
Source
Affil
Rationale/Comment
Total joint replacements
Extreme caution
Kisner and Colby, 19961
PT
The replacement mechanism is “self-limiting.”
Part III • Interventions
295
Part III • Interventions
296
PROCEDURAL CONCERN Issue
LOC
Source
Affil
Rationale/Comment
Spasms that protect a joint Temporary soreness after treatments
Advice Advice
Grieve, 19892
PT
Never push through spasms that are protecting a joint. Patient instructions may relieve unnecessary anxiety between sessions. Warn patients of temporary aftereffects of treatments (i.e., soreness; other “after-effects”).
ADVERSE EVENT Source
Background
Therapy
Outcome
Follow-up/ Interpretation
Michaeli, 19935 Mobility and complications Descriptive (questionnaire) Aust Physiother
A survey was sent to 250 physiotherapists who completed a postgraduate course in South Africa between 1971 and 1989.
153 surveys were returned (61% response rate) with 228,050 manipulative procedures reported between 1971 and 1989. A total of 29 patients receiving spinal (cervical, thoracic, lumbar) manipulations experienced 52 mostly minor complications (most were from cervical manipulations). Another 58 patients receiving cervical mobilization had 129 complications, including the following case: A 75-year-old man suffered a minor CVA with aphasia (residual deficit 2 years later) a day
Dizziness, severe headaches, and nausea were the most common side effects for both cervical manipulation and mobilization. Complications after cervical manipulation included dizziness, nausea, severe headaches, nystagmus, blurred vision, brachialgia (also with neurological deficits), loss of consciousness, and acute wry neck. All patients recovered without sequelae with an average recovery of 6.3 days. Complications after cervical mobilization included dizziness, severe headaches,
The authors conclude that spinal manipulation is relatively safe (by physiotherapists in South Africa). Therapists should be aware of the potential risks with cervical mobilization.
or two following successive treatments for neck pain. (The mobilization was a grade 4 unilateral PA pressure to the occipitoatlantal and atlantoaxial joints and a rotatory mobilization described by patient as a “strong twisting movement.” Note: Premanipulative procedures were not conducted and VBI symptoms were not reported by patient.)
nausea, brachialgia (also with neurological deficits), blurring vision, vomiting, nystagmus, increased pain >2 weeks, CVA, and skin clamminess. The majority had no sequelae. There was partial recovery noted in one person with a CVA and two patients with brachialgia with neurological deficits. No recovery was reported in another two patients with brachialgia with neurological deficits (loss of strength and reflexes).
REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. 9.
Kisner C, Colby LA: Therapeutic exercise: foundations and techniques, ed 3. Philadelphia: F.A. Davis; 1996. Grieve GP: Contra-indications to spinal manipulation and allied treatments. Physiotherapy 75(8):445-453, 1989. Sprague RB: The acute cervical joint lock. Phys Ther 63(9):1439-1444, 1983. Harris SR, Lundgren BD: Joint mobilization for children with central nervous system disorders: indications and precautions. Phys Ther 71(12):890-896, 1991. Michaeli A: Reported occurrence and nature of complications following manipulative physiotherapy in South Africa. Aust Physiother 39(4):309-315, 1993. Hertling D, Kessler RM: Introduction to manual therapy. In Hertling D, Kessler RM, eds: Management of common musculoskeletal disorders: Physical therapy principles and methods, ed 3. Philadelphia: Lippincott-Raven; 1996. Paris SV: Mobilization of the spine. Phys Ther 59(8):988-985, 1979. Cookson JC: Orthopedic manual therapy: An overview. Phys Ther 59(3):259-267, 1979. Brashear HR Jr, Raney RB Sr: Shand’s handbook of orthopaedic surgery, ed 9. St. Louis: CV Mosby; 1978. Part III • Interventions
297