Maitland Grades of Mobilization in Physical Therapy

Physical therapy is a key treatment if you’ve had any injury. Moreover, it helps to rehabilitate after surgeries and different musculoskeletal pathologies. 

Physical therapy includes a variety of programs, but we’ll talk about hands-on treatment and one of its types. It’s called joint mobilization and it’s part of Maitland’s concept of manual mobilization theory. 

General concept of Maitland Physical therapy

Maitland Physical therapy offers a range of techniques, including manual therapy, therapeutic exercise, balance training, gait analysis, joint mobilization and soft tissue manipulation. Other treatments include dry needling, kinesio taping, aqua therapy and electrotherapy. It also provides pre- and post-operative care for orthopedic and sports injuries.

• Manual therapy is a hands-on approach which includes joint and soft tissue manipulation, mobilization and stretching. 
• Therapeutic exercise is used to improve strength, flexibility and coordination.
•  Balance training helps increase stability and proprioception while gait analysis allows the team to assess and modify any abnormalities in walking or running patterns. 
• Joint mobilization is a gentle technique used to restore the normal range of motion in a joint, while soft tissue manipulation is used to reduce tension, spasm and pain in muscles. 
• Dry needling treats trigger points, kinesio taping is used for support and injury recovery, aqua therapy is used for rehabilitation and electrotherapy helps reduce pain and inflammation.

What Is Joint Mobilization?

First of all, a joint mobilization is manual therapy. It eases pain and improves range of motion. It also allows your muscles to function better. 

Overall joint function usually improves when a therapist changes pressure in different sections. So, while they stabilize one part of a joint, another is constantly under manual pressure or traction. The motions are hypomobile and tight. 

However, different people tolerate treatment differently, so it’s extremely important to select the right type of mobilization. Why we treat and what for – are the core questions to a right cure. 

Types of Mobilizations

There are several subdivisions of categories of joint mobilizations. 

Manipulation: 

When the joint lacks mobility, this type of therapy will help to make it function well. The movements of the therapist should be at high speed, pushing and at a low amplitude. 

Oscillatory joint mobilizations: 

First, the therapist uses this technique to see if the joint can move as it’s supposed to. Second, they press in a soft manner and the speed of the movements is slow.  Lastly, the range of amplitude depends on the specific state of the joint. It is one of the most tolerable procedures  for patients. 

Sustained joint mobilizations: 

When the joint is compressed, the physical therapy practiotioner should reduce the tension. They use stretching techniques to relax soft mecidiyeköy escort tissues around the joint. The traction combines with relaxation helping to restore joint mobility. 

The principle of diagnosis according to Maitland physical therapy

Generally, to get the right diagnosis, a therapist should carry out neurodynamic and orthopaedic tests. Palpation is also required. The doctor should carefully collect the anamnesis: study the past treatment and assign instrumental studies if necessary. The last step of selecting a suitable treatment and making a diagnosis is filling out a body map. 

The body map includes: Subjective assessment, patient complaints, pain history. Based on the data obtained, we should form a “portrait of the disease” – this is the mechanism and nature of pain, its features and strength. As well as the necessary clinical information: 

• What hurts? 
• Where does it hurt? 
• When does it hurt? 
• What makes the pain easier? 
• What improves it?

 Next, the necessary plan of therapeutic measures is drawn up. A body map is a kind of “case history”, where the dynamics of the treatment performed and the method of therapy are recorded.

Therapeutic effects and the essence of the technique are the following:

1.  Painkiller (gate control theory, downward inhibition);
2. Restoration of the normal distribution of forces / stresses around the joint;
3. Stimulation of mechanoreceptors;
4. Nociceptive stimulation – influence on muscle spasm;
5. Increased awareness of position and movement due to afferent nerve impulses;
6. Mobilization – causes the movement of synovial fluid;
7. Improves tissue trophism and nutrient metabolism;
8. Improving the mobility of hypomobile joints.

Indications, Contraindications, Precautions 

Joint mobilization is a combination of complex techniques, which require several indications. 

So, if you need to restore your articulations and improve motions, joint mobilizations will help you in it. Also, the therapy helps to control pain and relieves symptoms, reduces muscle guarding and enhances motor function. Although, there are several absolute contraindications which it is forbidden to cure using this type of physical therapy. 

Absolute contraindications

1. Fracture in treatment area
2. Spinal cord injury
3. Joint laxity
4. Joint arthritis
5. Surgery in the treatment area
6. Circulation problems
7. Cancer in treatment area
8. Acute inflammation
9. Stroke or heart problems
10. Joint swelling
11. Nerve injury
12. Blood clotting disorder 

You should also keep in mind that the following precautions are relative. Your doctor should examine you carefully before using this kind of physical therapy. 

2. Relative precautions

1. Skin rash or wound in treatment area
2. Joint replacements 
3. Bone disease 
4. Blood clotting therapy
5. Pregnancy
6. Long-term use of corticosteroids
7. Connective tissue disorder
8. Suspected cancer in treatment area

Mobilization Algorithm

When a patient comes to a doctor, their work starts with a proper analysis of a joint. The doctor asks several questions to understand what treatment suits best: 

1. Is the sign reproducible? 
2. In other words, what are the causes of the symptoms? 
3. What is the region of origin? 
4. Where are the symptoms? 
5. And how reactive or symptomatic is the individual?

When the doctor analyzes the answers and general state of a joint, he decides which treatment suits best. If it’s an instability syndrome, the patient needs to take stabilization exercises. If it’s a hypermobility syndrome, it needs joint mobilization. 

The concept of joint mobilization offers 4 grades of impact to the joint. So If you need to fire cutaneous and muscular receptors or change nociception, then your therapy will include Grades 1 and 2. Also these Grades will be used in firing proprioceptors and mechanoreceptors. Grades 1 and 2 are about neurophysiological aspects in joint mobilization. 

Grades 3 and 4 are about mechanical impacts. So these methods are used to break adhesions, alter positional relationships and diminish or eliminate barriers to normal motion. 

All these techniques (Grades 1-4) are not linear. In fact it means that if a patient needs grades 3 and 4, you shouldn’t start with 1 and 2. You can mix the Grades according to the situation, relating to neurophysiologic or mechanical effect. Everything will depend on the situation.

Starting with Grade 1 and moving to Grade 4, then returning to Grades 2 or 1 is also possible. You combine neurophysiological and mechanical effects, choosing the most helpful solution for a patient. So, the basic principle of this concept in individual approach, allowing to choose the most efficient treatment. 

Joint Mobilization Grades:

To make joint mobilizations more comfortable, as the process of separating joint surfaces isn’t comfortable, you should use a distraction technique. This technique includes perpendicular movements around the treating place. This type of distraction will help to prepare the joint to glide. 

Maitland based his concept on tissue resistance of the joint glides. All the 4 Grades perform different amplitude and resistance. So, they go like this: 

1. Grade 1 – the beginning of the range starts with a small amplitude. 
2. Grade 2 – it doesn’t reach the tissue resistance, although it has a larger amplitude. 
3. Grade 3 – here the limit of the range is reached. The largest amplitude provokes tissue resistance.
4. Grade 4 – at the limit of the range there is a smaller amplitude. 

Psychomotor Performance of Joint Mobilizations:

Being able to master your skills in joint mobilization techniques is a very important factor to provide the best treatment. Knowing the Grades is a core factor, but also you need to improve psychomotor skills. It’s quite a different set of abilities as it has a more clinical approach.

There should be a system of mobilization techniques according to medical recommendations. The recovery of the patient depends on how consistent the treatment will be. The process of learning joint mobilization techniques is quite long and challenging. Experienced doctors and novice clinicians should exchange their experience. Constant real-time feedback is a key factor to mastering skills. 

Physical therapy specialists use a variety of methods to treat the patient. Everything depends on the condition of the joint and joint mobilization is one of the tools. However, the correct treatment should be given taking into account the type of patients’ dominance.

There are two categories of dominance: pain and stiffness. Maitland supposed that this categorization would help to choose the best Grade for a specific patient. An affected area can be treated more efficiently if the type of the dominance is clear. So a doctor can determine which type a patient has due to subjective and physical examination. 

Subjective examination: 

Variables	Pain dominant	Stiffness dominant
Area	Often diffuse	Often localized
Night pain	Often worse	Usually mild/moderate
Analgesics	Medium to high doses	Low doses, if any
Nature	Impairment/disability	Nuisance/annoyance
Kind	Pain: often burning, aching	Stiff: limited/restricted
Frequency	Constant/variable	Intermittent
Effects of activity	Aggravated by mild	Aggravated by vigorous
Intensity	≥5/10	≤4/10
Duration	Slow to stop or reduce	Short duration
History	Recent onset	Chronic

Physical examination

Variables	Pain dominant	Stiffness dominant
Range	Often afraid to move	Limited
Pain	Resting, early & mid range	Often end-range only
Spasm	Usually present	Seldom present
Repeated movements	Aggravates, unless preferred direction is used	Often increases range

As soon as the dominance type is determined, the physician can start to develop the treatment. So, they the right examination of subjective and physical states is the milestone of the correct plan. 

Treatment of pain and stiffness

Variables	Pain dominant	Stiffness dominant
Grades of movements	I & II	III & IV
Intent of exam & treatment	Reduce & eliminate pain	Introduce pain of disorder to increase range
Barriers	Short of barriers	Into P1 & R1, not S1
Focus of assessment	Pain behaviour	Range, respecting pain
Preferred movement	Most free	Most restricted
Suggested mechanism	Likely dominant inflammatory	Likely more mechanical
Adjectives used by patient	Pain, burning, throbbing, ache	Stiff, tight, boring, stabbing, shooting, restricted, limited

Therapeutic Effect: how and why it works

The process of pain-relieving is complex. It always involves interaction of a variety of systems which interact to produce it. That’s why there are a lot of theories which explain the therapeutic effect of mobilizations. The Pain Gate theory is one of the possible explanations which is based on pain transmission. 

Pain Gate Theory in physical therapy

Therapists use The Pain Gate theory to explain to the patients how the pain can be transmitted and why. It was proposed by Melzack and Wall in 1965. This theory is based on the function of sensory nerves. The stimuli is transmitted by three types of nerves: 

1. α-Beta fibres. They are myelinated and of large diameter. They are responsible for touch and pressure. The speed of impulse transmission is fast (50 m/s) 
2. α-Delta fibres. They are also myelinated and of large diameter. They are responsible for temperature and pain (well localized, sharp/prickly). The speed of impulse transmission is medium (15 m/s) 
3. C fibres. They aren’t myelinated and of small diameter. They are responsible for pain (dull, poorly localised, persistent). Their speed is slow (1 m/s) 

The conduction depends on the size of the fibre. So, the bigger the nerve is, the quicker the conduction is. The myelin sheath also influences the speed. The process of conduction is much more efficient in large myelinated nerves.

Conclusion

To conclude this information we can say that -Beta fibres are the fastest of the 3 types. They are followed by α-Delta fibres and finally C fibres. 

All these nerves form a point of contact (synapses) with the receiving cells. They travel up to the brain through the spinal cord. Through the thalamus they pass to the somatosensory zone of the cerebral cortex, the limbic system and other systems. Also there are interneurons in the spinal cord, which have an ability to influence the transmission of information. The interneurons act as the “gatekeeper”.

In addition, when there is no important information from the nerves, the gate is “closed”. On the contrary, when the smaller fibres are stimulated, the gate “opens” and we start to feel the pain. The speed of larger α-Delta fibres  is higher, so their signal comes to the brain faster, they “close” the gate and we don’t feel the pain.

Now remember, what happens when you stub your toe. You feel pain (smaller fibres are stimulated), then you start rubbing that piece of toe. In fact, you stimulate the α-Delta fibres and they “close” the gate. The pain stops. 

Generally, that’s a very rough explanation of how Maitland’s physical therapy works from a medical point of view.