PT Classroom - Joint Balancing: Reduces Hypomobility, Restores Biomechanics by Kerry D’Ambrogio, DOM, AP, PT, DO-MTP

Kerry D’Ambrogio is a physical therapist, osteopath and board-certified acupuncture physician. He is the president and director of the D’Ambrogio Institute and Therapeutic Systems, Inc., in Sarasota, Fla. He is the co-author of Positional Release Therapy (Mosby). D’Ambrogio is a graduate of the physical therapy program at the University of Toronto (Canada), the osteopathic program at the Canadian Academy of Osteopathy (Hamilton, Ont.), the John Wernham College of Classical Osteopathy (Maidstone, England), and the acupuncture program at the Academy of Chinese Healing Arts (Sarasota, Fla.).

Joint Balancing: Reduces Hypomobility, Restores Biomechanics

Successful therapeutic intervention begins and ends with evaluation. Evaluation provides a sense of knowing and working with the source of dysfunction. When specific evaluation indicates a joint-related problem, Joint Balancing delivers an effective, targeted solution.

Joint Balancing is a direct technique that expands on the work and teachings of Fred Mitchell Sr., DO (Muscle Energy Techniques). It works to reduce joint hypomobility, muscle tension, fascial tension, pain, and swelling. Outcomes include the restoration of proper joint biomechanics, ROM, and postural alignment.

This gentle, hands-on approach is efficacious in the treatment of back pain, sciatica, neck pain, headaches, rib pain, upper and lower extremity orthopedic dysfunctions, swelling, and postural asymmetry.

Whole-Body Evaluation Is Essential

Years of practice have taught me many things, among them being the power and necessity of total-body evaluation. The total-body approach that has proven to be most effective with my patients is based on the principles known as ARTS, which stands for asymmetry, range of motion, tension tests, and special tests. The process enables therapists to effectively evaluate and monitor change prior to and after the treatment process.

Let’s look at an example based on a common complaint of back pain. Phil* came to the clinic looking for relief of acute lower back pain following a lifting injury at work. Initial assessment indicated pain of 6/10 at his right sacroiliac joint. He had limited range of motion and was very guarded in his movements.

I performed a total-body evaluation and a Total Body Balancing on him. Afterward, he indicated that the pain had diminished to about 3/10. He was moving better but still had some pain in his right sacroiliac joint. On reevaluation I found that he still had a dysfunction in the right side of his pelvis. At that point I did a specific evaluation to differentiate between joint, muscle, and/or fascial dysfunctions. To evaluate his pelvis I used a specific STAR sequence.

1. Special Test: A kinetic test was positive on the right side indicating an iliosacral dysfunction. Fascial glide tests were negative, ruling out fascial dysfunctions.

2. Tension Test: An iliosacral tension test was positive on the right, confirming joint hypomobility with the right iliosacral joint. Tender point tests were negative, ruling out muscle dysfunctions.

3. Asymmetry of posture: The right iliac crest, ischial tuberosity, ASIS, and PSIS were all superior on the right side. He also had a right short leg.

4. Range of motion: Assessment indicated decreased inferior traction of the right leg. PROM was assessed in the supine position on the positive tension test side (i.e. right).

From this specific evaluation, I was able to pinpoint Phil’s dysfunction as being joint related. The specific diagnosis was an upslip of the right innominate affecting the right iliosacral joint.

Application of Joint Balancing

Joint Balancing is a direct manual therapy in which we work in the direction of tension rather than from a position of ease. Using this approach the practitioner positions the patient’s affected joint at its restrictive barrier in one, two, or three planes of motion. A gentle isometric contraction is used to relax and lengthen the muscle and/or fascial tension and normalize the joint dysfunction.

For those who study Joint Balancing, coursework is divided into upper-quadrant techniques (cervical and thoracic spine, ribcage, shoulder, elbow, wrist and hand) and lower-quadrant techniques (lumbar spine, pelvis, sacrum [lumbosacral and sacroiliac joints], hips, knee, ankle, and foot).

In Phil’s case, the lower-quadrant sequence was applied.

1. The session began with Phil lying supine on the treatment table. Depending on the affected areas, patients will lie in a supine, prone, or side-lie position, whichever is most comfortable.

2. Next, I grasped the affected leg above the ankle. You may need to grasp above the knee if a knee problems exists or at the iliac crest if a total hip replacement exists.

3. I gently internally rotated the right leg to lock the ankle, knee, and hip joints to isolate the forces to the right iliosacral joint. Hip adduction or abduction along with leg traction would be used to specifically line up tension to the right iliosacral joint. Each motion would be taken to the first sign of resistance or barrier then backed off to the interbarrier zone.

4. Once at the interbarrier zone, I had Phil lift the right hip superiorly while I resisted this movement, creating an isometric contraction lasting three to five seconds.

5. Time was allowed for complete relaxation following each contraction. I then asked Phil to take a deep breath. On exhalation the leg traction was increased to the next barrier. This was repeated three to five times as needed. On the final exhalation, a quick, abrupt pull was performed.

By using the exact methods Phil’s body needed, he experienced significant relief and restored function in his right upslip. It is not uncommon for restoration to occur quickly in cases such as this where the dysfunction is contained to one area. The key is thorough, whole-body evaluation and a Total Body Balancing treatment approach to release the underlying lines of tension. This is followed by a specific evaluation and a targeted treatment most effective to the underlying dysfunction.

I find the value of Joint Balancing techniques to be inestimable for their efficiency and effectiveness—all of which translates to restored health and reduced treatment time for patients.

*Name changed to protect patient confidentiality

Last revised: November 18, 2014
by Dr. Kerry D’Ambrogio, DOM, AP, PT, DO-MTP

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