The Maitland Concept and Mobilisations PDF

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The Maitland Concept Physiological Vs Accessory Physiological Movements: Passive assessment of those movements that have been performed actively.   

Performed in a relaxed position Note where in the range symptoms are felt end of range

Accessory Movements: Cannot be performed actively but are essential for normal joint function  

Slide, glide, roll Loose packed positions

If accessory movements are limited and/or painful then the active movement will not be normal Application in Manual Therapy   

Cannot have full Physiological ROM without full Accessory ROM Physiological limited by restriction to muscles Accessory limited by restriction to joints and capsule

JOINT MOBILISATIONS Slow, PASSIVE, movements between articulating surfaces i.e joint surfaces which patient can control or prevent if they wish. In the knee this would be the distal femoral condyles and the proximal tibial condyles Trying to return joint back to normal (or as near normal) ACTIVE ROM and restore normal PASSIVE ROM REDUCE PAIN ASSOCIATED WITH INJURY Regain normal distribution of forces/stresses around joint Effects of Joint Mobilisation Neurophysiological effects –   

Stimulates mechanoreceptors to  pain Affect muscle spasm & muscle guarding – nociceptive stimulation Increase in awareness of position & motion because of afferent nerve impulses

Nutritional effects – 

Distraction or small gliding movements – cause synovial fluid movement



Movement can improve nutrient exchange due to joint swelling & immobilization

Mechanical effects –  

Improve mobility of hypomobile joints (adhesions & thickened CT from immobilization – loosens) Maintains extensibility & tensile strength of articular tissues

Receptors Activated  

Stiffness (joint or capsule) Joint Receptors (Pascinian Corpuscles) Ligament and Capsule Receptors (Ruffini nerve endings) Muscle pain or stiffness Muscle/Tendon Receptors (GTO/stretch reflex)

TECHNIQUE OF MOBILISATION Slow, PASSIVE, movements between articulating surfaces i.e joint surfaces which patient can control or prevent if they wish. Trying to return joint back to normal (or as near normal) ACTIVE ROM and restore normal PASSIVE ROM Regain normal distribution of forces/stresses around joint – think of compensatory movements Performing the movement in an oscillatory manner within a ROM where there is no stiffness, muscle spasm or pain whilst performing the technique Small or large amplitude from 30 seconds to several minutes Using compression as a treatment technique

MAITLAND CONCEPT •

PAIN FREE TECHNIQUES

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PASSIVE , OSCILLATORY MOVEMENTS

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WITHIN OR AT END OF RANGE

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PATIENT CENTRED, BASED ON SIGND AND SYMPTOMS

Patient centred approach to dealing with movement disorders It is inclusive and tries to place the patient and their main problems at the centre of everything the therapist does. It is a practical approach to treatment and is related to the patient’s signs and symptoms rather than to diagnosis. Passive movements form the basis of this technique The use of gentle, passive, rhythmic and oscillatory movements being performed within or at the end of range.

The following are important in the Maitland concept: Pain response to accessory movements performed in loose pack positions and within or at the end of range of physiological movements Pain response to combined movements Pain response to movement performed whilst the joint surfaces are held together compressed Pain response to ROM When pain is the problem, the patient can often demonstrate movement reproducing symptoms and this can often be the treatment choice based on clinician assessment.

Principles of Maitland Concept DURATION AND FREQUENCY Assessment of a segment – oscillation approx 3 x Duration of first Rx should be less than subsequent Rx – CAUTION TO PREVENT REACTION 3x 30 seconds Rest period between sets? SIN FACTOR AMPLITUDE Depth of force applied to movement End of range (EOR) based on severity of injury More severe closer to beginning point

Grading System The oscillatory movements are graded into four specific overlapping techniques. Grades I and II specifically provide oscillatory movements in a joint range which promotes a reduction in pain. Grades III and IV provide the patient with a decrease in stiffness and an increase in motion. The decision on which grade to apply is determined by the patients symptoms and from the evaluation through a subjective and objective assessment and from diagnostic mobilisations. It is hoped that performing mobilisations will improve normal passive range of motion or/and reduce painful joint movements

Maitland Grading System Grade I Small amplitude movement at the beginning of ROM. Early in ROM. Pain and spasm limit. Grade II Large amplitude movement within mid-range of movement. Pain and spasm limit as with Grade I. Progress from grade I. Grade III Large amplitude movement up to the limiting point in ROM. Used when joint stiffness, tissue tension limit. Grade IV Small amplitude right at the end of range into the point of limitation. Used as above for stiffness further into range. Progress from grade III. There is a grade V but this is a post-graduate mobilisation

TYPES OF MOBILISATION Physiological Flexion Extension Abduction Adduction Rotation Accessory Antero-Posterior (A-P) Postero-anterior (P-A) Distraction Longitudinal Sometimes – caudad/cephalad

Assessment of a Joint The Subjective History Behaviour of the symptoms The Objective History

Which passive movement closely relate to the patients symptoms/reproduce their symptoms OP acts as a diagnostic mobilisation Treatment Can be used as treatment techniques Assessment Used throughout treatment and following treatment

Contraindications and Precautions Contraindications Integrity of structures    

stage of healing - fracture, torn ligament etc osteoporosis inflammatory condition affecting joint - eg RA intra-articular structures/ fragments

Severe inflammation / infection Neurological impingement Steroidal drugs Red flags from E+A??

Precautions Passive motion done badly may cause: Additional damage Increase nociceptor response Vascular involvement Nerve damage Stretching wrong tissue

Recording Treatment Mobilisations Need to record: Position of the patient Position of joint – including support of towels/pillows

Type of mobilisation = physiological or accessory Selected treatment technique i.e phys flexion or A-P. Grade of technique Duration of technique i.e 3 x 30 Patient response during Rx – after 1st set etc Re-assessment of technique

Rationale for Use Effect > mechanical or neurophysiological Mechanoreceptors (stiffness) Nociceptors (pain) Grades I and II > reducing the stimulus to the mechanoreceptors and also reducing nociception and hyperalgesia. Grades III and IV are mainly to increase range of motion by returning a tissue such as the joint capsule to a “normal” condition and increasing mechanoreceptor input Aims to reduce pain, muscle guarding, stretching/lengthening tissue around joint, muscle tone, stretch reflex, proprioception Assess improvement = goniometer...