KALTENBORN’S JOINT
MOBILIZATION
Freddy M. Kaltenbom
practiced as a physical
therapist and physical
educator in his native
Norway. The Orthopedic
Manual Therapy (OMT)
Kaltenbom-Evjenth System
is a physical therapy
treatment approach.
JOINT MOBILIZATION
Manual therapy technique
Usedto modulate pain
Usedto increase ROM
Usedto treat joint dysfunctions that limit ROM
by specifically addressing altered joint
mechanics
Factors that may alter joint mechanics:
Pain & Muscle guarding
Joint hypomobility
Joint effusion
Contractures or adhesions in the joint capsules
or supporting ligaments
Malalignment or subluxation of bony surfaces
TERMINOLOGY
Mobilization – passive joint movement
for increasing ROM or decreasing pain
Applied to joints & related soft tissues at
varying speeds & amplitudes using
physiologic or accessory motions
Force is light enough that patient’s can
stop the movement
Manipulation – passive joint movement
for increasing joint mobility
Incorporates a sudden, forceful thrust that
is beyond the patient’s control
Self-Mobilization (Auto-mobilization) – self-
stretching techniques that specifically
use joint traction or glides that direct
the stretch force to the joint capsule
Mobilization with Movement (MWM) –
concurrent application of a sustained
accessory mobilization applied by a
therapist & an active physiologic
movement to end range applied by the
patient
Applied in a pain-free direction
Physiologic Movements
Osteokinematics
• motions of the bones
• movements done voluntarily
• “traditional” movements such as flexion,
extension, abduction, rotation.
• Accessory Movements – movements within the joint &
surrounding tissues that are necessary for normal ROM,
but can not be actively performed by the patient
• Component motions – motions that accompany
active motion, but are not under voluntary
control
• Ex: Upward rotation of scapula & rotation of clavicle
that occur with shoulder flexion
• Joint play – motions that occur within the joint
• Determined by joint capsule’s laxity
• Can be demonstrated passively, but not performed
actively
Arthrokinematics – motions of bone surfaces
within the joint
5 motions - Roll, Slide, Spin, Compression, Distraction
Muscle energy – use an active contraction of
deep muscles that attach near the joint & whose
line of pull can cause the desired accessory
motion
Therapist stabilizes segment on which the distal aspect
of the muscle attaches; command for an isometric
contraction of the muscle is given, which causes the
accessory movement of the joint
Thrust – high-velocity, short-amplitude motion
that the patient can not prevent
Performed at end of pathologic limit of the joint (snap
adhesions, stimulate joint receptors)
Biomechanics of joint motion
Physiological motion
Result of concentric or eccentric active muscle
contractions
Bones moving about an axis or through flexion,
extension, abduction, adduction or rotation
Accessory Motion
Motion of articular surfaces relative to one another
Generally associated with physiological movement
Necessary for full range of physiological motion to
occur
Ligament & joint capsule involvement in motion
BASIC CONCEPTS OF JOINT MOTION :
ARTHROKINEMATICS
1. Joint Shapes
Type of motion is influenced by
the shapes of the joint surfaces
Ovoid – one surface is convex,
other surface is concave
Sellar (saddle) – one surface is
concave in one direction &
convex in the other, with the
opposing surface convex &
concave respectively
2. Types of joint motion
5 types of joint arthrokinematics
Roll
Slide
Spin
Compression
Distraction
3 components of joint mobilization
Roll, Spin, Slide
Joint motion usually often involves a combination of
rolling, sliding & spinning
ROLL
A series of points on one
articulating surface come into
contact with a series of points
on another surface
Ball rolling on ground
Example: Femoral condyles rolling
on tibial plateau
Roll occurs in direction of movement
Occurs on incongruent (unequal)
surfaces
Usually occurs in combination with
sliding or spinning
SPIN
Occurswhen one bone rotates
around a stationary longitudinal
mechanical axis
Same point on the moving
surface creates an arc of a
circle as the bone spins
Example: Radial head at the
humeroradial joint during
pronation/supination; shoulder
flexion/extension; hip
flexion/extension
Spin does not occur by itself during normal
joint motion
SLIDE
Specific point on one surface comes into
contact with a series of points on another
surface
Surfaces are congruent
When a passive mobilization technique is
applied to produce a slide in the joint –
referred to as a GLIDE
Combined rolling-sliding in a joint
The more congruent the surfaces are, the
more sliding there is
The more incongruent the joint surfaces are,
the more rolling there is
Compression -
Decrease in space between two joint surfaces
Adds stability to a joint
Normal reaction of a joint to muscle contraction
Distraction -
Two surfaces are pulled apart
Often used in combination with joint mobilizations to
increase stretch of capsule.
CONCAVE-CONVEX RULE
Concave – hollowed or rounded inward
Convex – curved or rounded outward
Concave-convex rule: concave
joint surfaces slide in the
SAME direction as the bone
movement (convex is STABLE)
Ifconcave joint is moving on
stationary convex surface – glide
occurs in same direction as roll
Convex-concave rule: convex
joint surfaces slide in the
OPPOSITE direction of the
bone movement (concave is
STABLE)
Ifconvex surface in moving on
stationary concave surface –
gliding occurs in opposite
direction to roll
EFFECTS OF JOINT MOBILIZATION
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
• Used to cause synovial fluid motion, bringing
nutrients to the avascular portions of
articualar cartilages
• Prevent the painful and degenerating effects
of stasis
INDICATIONS
Pain, muscle guarding and spasm
Reversible joint hypomobility- elongate
hypomobile capsular and ligamentous
connective tissue (stretch forces)
Positional faults/ subluxations- malposition
may result in limited ROM or pain
Progressive limitation- ex. Frozen shoulder
Functional immobility
CONTRAINDICATIONS AND
PRECAUTIONS
Contraindications: Precautions:
Hypermobility Malignancy
Joint effusion Bone disease
Inflammation Unhealed fracture
Total joint
replacements
Systemic connective
tissue diseases ex.
RA
Excessive pain
10 STEPS
1. Evaluation and Assessment
2. Determine grades and dosage
3. Patient position
4. Joint position
5. Stabilization
6. Treatment force
7. Direction of movement
8. Speed and rhythm
9. Initiation of treatment
[Link]
GRADES OR DOSAGES OF MOVEMENT
Kaltenborn’s Sustained Translatory Joint-Play
Techniques
Grade I (loosen): Small- amplitude distraction is
applied where no stress is placed on the capsule. It
equalizes cohesive forces, muscle tension, and
atmospheric pressure acting on the joint.
Grade II (tighten): Enough distraction is applied to
tighten the tissues around the joint. “taking up the
slack”
Grade III (stretch): A distraction is applied with an
amplitude large enough to place stretch on the joint
capsule and surrounding periarticular structures.
USES
Grade I distraction is used with all gliding motions and
may be used for relief of pain.
Grade II distraction is used for the initial treatment to
determine how sensitive the joint is. Once the joint
reaction is known, the treatment dosage is increased
or decreased accordingly.
Gentle grade II distraction applied intermittently may
be used to inhibit pain. grade II glides may be used to
maintain joint play when ROM is not allowed.
Grade III distractions are used to stretch the joint
structures and thus increase joint play.
JOINT POSITIONS
Resting position
Maximum joint play - position in which joint capsule
and ligaments are most relaxed
Evaluation and treatment position utilized with
hypomobile joints
Loose-packed position
Articulating surfaces are maximally separated
Joint will exhibit greatest amount of joint play
Position used for both traction and joint mobilization
Close-packed position
Joint surfaces are in maximal contact to each other
General rule: Extremes of joint motion are close-
packed, & midrange positions are loose-packed.
JOINT MOBILIZATION APPLICATION
All joint mobilizations follow the convex-concave
rule
Patient should be relaxed
Explain purpose of treatment & sensations to
expect to patient
Evaluate BEFORE & AFTER treatment
Stop the treatment if it is too painful for the
patient
Use proper body mechanics
Use gravity to assist the mobilization technique
if possible
Begin & end treatments with Grade I or II
oscillations
POSITIONING AND STABILIZATION
Patient & extremity should be positioned
so that the patient can RELAX
Initial mobilization is performed in a loose-
packed position
Insome cases, the position to use is the one in
which the joint is least painful
Firmly & comfortably stabilize one joint
segment, usually the proximal bone
Hand, belt, assistant
Prevents unwanted stress & makes the stretch
force more specific & effective
TREATMENT FORCE AND DIRECTION
OF MOVEMENT
Treatment force is applied as close to the
opposing joint surface as possible
The larger the contact surface is, the more comfortable
the procedure will be (use flat surface of hand vs.
thumb)
Direction of movement during treatment is
either PARALLEL or PERENDICULAR to the
treatment plane
TREATMENT PLANE
Treatment plane lies on the
concave articulating
surface, perpendicular to a
line from the center of the
convex articulating surface.
Joint traction techniques are
applied perpendicular to the
treatment plane
Entire bone is moved so that
the joint surfaces are separated
The Kaltenbom Treatment Plane passes
through the joint and lies at a right angle to a
line running from the axis of rotation in the
convex bony partner, to the deepest aspect
of the articulating concave surface. For
practical purposes, you can quickly estimate
where the treatment plane lies by imagining
that it lies on the concave articular surface.
The Kaltenbom Treatment Plane remains with
the concave joint surface whether the
moving joint partner is concave or convex.
SPEED, RHYTHM AND DURATION OF
MOVEMENT
For painful joints, apply intermittent
distraction for 7-10 seconds with a few
seconds of rest in between for several
cycles.
For restricted joints, apply a minimum of a
6-second stretch force, followed by partial
release then repeat with slow, intermittent
stretches at 3-4 second intervals.
PATIENT’S RESPONSE
May cause soreness
Perform joint mobilizations on alternate days
to allow soreness to decrease & tissue
healing to occur
Patient should perform ROM techniques
Patient’s joint & ROM should be reassessed
after treatment, & again before the next
treatment
Pain is always the guide
UPPER QUADRANT
Shoulder: GH joint, AC joint, SC joint
Elbow and forearm: humeroulnar,
humeroradial, proximal and distal radioulnar
joint
Wrist: radiocarpal joint
Hand and finger: CMC, intermetacarpal joints
LOWER QUADRANT
Hip
Knee and leg: tibiofemoral, patellofemoral,
tibiofibular
Ankle and foot: talocrural, subtalar, TMT and
intertarsal joints
OMT KALTENBORN- EVJENTH SYSTEM
PRACTICE
I. Physical diagnosis
(biomechanical and functional
assessment)
II. Treatment
III. Research
PHYSICAL DIAGNOSIS
A. Screening exam
B. Detailed exam
History
Inspection
Tests of function
Palpation
Neurological and vascular examination
C. Medical diagnostic studies
D. Diagnosis and trial treatment
TREATMENT
A. To relieve pain:
1. Immobilization
2. Thermo Hydro Electro (THE) therapy
3. Pain relief joint mobilization
4. Special procedures
B. To increase mobility:
1. STM
2. Joint mobilization- relax, stretch and manipulation
3. Neural tissue mobilization
4. Specialised exs
C. To limit movement:
1. Supportive devices
2. Specialized exs
3. Associated joint movts
RESEARCH
Clinical trials to determine the efficacy of
various single and combined treatment
methods.
SPINAL MOBILIZATION
Spinal movement
1. General movement
2. Specific movement- isolated movt of one
intervertebral segment (mobile segment)
Mobile segment
• Three joint complex
• Intervertebral disc joint and two facet joints
• In association with mus, ligaments,
neurovascular structures, connecting
adjacent vertebra etc.
SPINAL MOVEMENTS
Spinal ROM:
Cx Lx Tx (flexion and extension)
Coupled movements:
Side bending, rotation and flexion of spine
Lx Cx Tx
Based on flexion/extension of spine
Most ease of movement
*Kaltenborn(1960)
BONE AND JOINT MOVEMENT
Rotatoric
-Standard Roll- gliding
-Combined
Translatoric
-Longitudinal bone separation Traction
-Longitudinal bone approximation Compression
-Transverse Gliding
CONCAVE-CONVEX RULE
Occiput in relation to Atlas (C1) and Sacrum
in relation to innominates- convex rule
(Opposite direction)
Vertebrae from C2 to L5- concave rule
(Same direction )
END FEEL
Start First stop Final stop
End feel
Firm: spinal flexion, spinal coupled
movements
Hard: most spinal non coupled movements
Mus shortening: firmer, less elastic end feel
Mus spasm: more elastic and less soft end
feel, increased mus reactivity
* Hold-relax stretch manuver
SPECIFIC CONTRAINDICATIONS
Pathological changes due to neoplasm,
inflammation, infection(spondylitis, discitis),
osteopenia
Massive degenerative changes (spondylosis,
osteoarthrosis)
Loss of ligamentous stability
Certain congenital anomelies of spine-
dysplasia, aplasia, neoplasia
Positive screening tests- pain induced by
compression tests.
GOALS OF SPINAL JOINT
MOBILIZATION
1. Pain relief mobilization
Grade I-II SZ in the joint resting position
To ease severe pain, spasm and parasthesia,
and to help normalize joint fluid viscocities
that interferes with movement.
2. Relaxation mobilization
Grade I-II in the joint resting position
To relax muscle, decease pain and facilitate
movement ease
3. Stretch mobilization
Grade III in the joint resting position
Grade III at the point of restriction
To stretch shortened joint tissues, increase
ROM
4. Manipulation (Quick mobilization)
Grade III, high velocity, short amplitude, low
force traction-manipulation in the resting
position
Correct postural faults
LUMBAR MOBILIZATION
Lx traction/compression
Lumbar segment- cranial ventral, caudal
ventral
Rotation
Translatoric joint play
Lumbar traction- manual, with belt or Morgan
traction harness
L1-L5 traction
L5-S1 traction
CERVICAL MOBILIZATION
Cx traction/compression
Cx intervertebral foramen
Cx segment lateral glide
REFERENCES
1. Kisner and Colby, chapter 5: Peripheral Joint Mobilization,
Therapeutic Exrecise Foundations and Techniques, 5 th
edn, Jaypee publication, 2007, 109-145.
2. Freddy M. Kaltenborn, Manual Mobilization of the Joints:
Volume I, The Extremities, The Kaltenborn Method of Joint
Examination and Treatment, 6th edn, 2002.
3. Freddy M. Kaltenborn, Manual Mobilization of the Joints:
Volume II, The Spine, The Kaltenborn Method of Joint
Examination and Treatment, 6th edn, 2002.
4. [Link] (images)
- Thank you...
Shweta Nahar (Mpt II)
