PT Classroom - When Exercises Aren't Enough ׀ by Eric Mason, PT

Following injury or surgery, exercise is often prescribed to rehabilitate patients to their previous level of functional independence. Much emphasis is placed on exercise as a treatment modality because it creates physical improvements and has wide-ranging psychological benefits to our patients. Exercise restores strength in muscles, flexibility in tissues and range of motion in joints. Many times, exercise can help restore proper muscle balance around the joints. However, it may not be enough to restore proper joint mechanics.

To the untrained eye, joint motion may appear simplistic in nature. But it is quite to the contrary. There is no single joint that moves in only one plane of motion. For example, when the knee extends, it does not simply roll in one plane. In the standing position, the femur rolls forward, glides backward and spins medially in relationship to the tibia. These motions are referred to as accessory joint motions and are essential to prevent undue stress on the joint and surrounding tissues.

A manual physical therapist is able to assess joint biomechanics and is trained how to manipulate the joints and surrounding tissues. This treatment allows restoration of all the necessary component motions and can relieve pain from abnormal stress. In the knee example, the therapist may have to work on restoring the glide and spin components of joint motion between the femur and tibia to regain full range of knee extension.

Another instance demonstrating the importance of assessing proper joint mechanics can be a joint that appears to have full range of motion but continues to be painful. For example, a painful finger might have full range of classic motion, but when the manual therapist assesses the joint, there can be a slight decrease in the accessory joint glide on one side of the joint. Performing the appropriate accessory joint manipulation can, in most cases, restore the proper mechanics within the joint and allow heal. If proper arthrokinematics are not restored over a period of some years, the patient can develop arthritis or tendonitis due to abnormal stress on the joint cartilage and tendons.

The spine is probably the most complex biomechanical structure, displaying many planes of motion between the multiple joints and vertebrae or between the vertebrae and the ribs. It takes countless hours of training to understand spinal mechanics and its components. Treatment of such areas should be left to those with the appropriate skills and expertise. Many studies have shown that manipulation
and exercise can be extremely effective in treatment of neck or back pain, even herniated discs.

So if you have a patient that does not seem to be responding to their physical therapy as you might have expected, it may be there is a component of their treatment that is being overlooked. Joint mobilization/manipulation may be the missing link.

Last revised: February, 11 2009
by Eric Mason, PT