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TECHNIQUE

Osteopathic Joint Articulation

Definition of Osteopathic Articulation

The word articulation originates from the latin meaning ‘jointed’ or ‘divided into joints’. Articulation is the cornerstone of most manual therapies, including osteopathy, physiotherapy, chiropractic, sports therapy and massage therapy.

Articulation uses a low amplitude (short distance) and low to moderate velocity (speed) of movement within the patients pain free range of motion while in dysfunction. This aids the bodies natural lubricating system (synovial fluid) to embalm the joint which increased range of motion, decreased pain or both (ideally).

Articulation techniques have been shown to help relieve pain and increase range of motion in joints.

Osteopathic Articulation™ has been shown to be effective for;

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Osteopathic Articulation™ of joints has also been observed to;

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Treatment of Pain and Movement

Human joints bear considerable forces resulting from the day-to-day activities of daily living. Our joint tissues help the body to protect against and withstand these forces. When these tissues are stretched due to movement and stress, they undergo an elastic phase of deformation. However, if the tissues are stressed beyond the greatest capacity of the elastic phase, this leads to the plastic phase of deformation 13.

The plastic deformation of tissues in the joint often causes a number of problems, these include Tissue thickening, a tear of the tissue, loss of tissue elasticity, shortening of the tissue, joint stiffness and a loss of range of motion in joints.

Healthy movement through the joint tissues can assist in tissue repair and recovery. This healing mechanism of tissues is thought to promote by a process known as mechanotransduction, any of various mechanical and structural cues that encourage cell behaviour 8. Joint articulation techniques can influence the mechanotransduction process, enabling the patient to return to normal physical activity 6.

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The early, accurate application of these techniques can aid the damaged tissues and structures of the joints by:

Encouraging faster tissue repair and recovery

Promoting healthy cellular homeostasis

Reducing musculoskeletal pain and discomfort

Increasing joint movement by stretching fibrous tissue and affecting the stretch reflex excitability

Increasing the vascular circulation in and out of the joint

Improving structural stability and integrity of the intervertebral disc

Preventing degenerative changes to the articular surfaces

Inhibiting the build-up of fluid and distension forces upon the tissues and joint

Aiding the removal of metabolic waste products

Influencing the sympathetic nervous system activity, thus affecting blood flow, blood pressure, heart rate or respiratory rate

However, joint articulation techniques that involve considerable movements should be avoided, as they may:

Exceed the natural motion barrier

Stress the tissues excessively

Force the tissues to undergo the plastic deformation

Synovial joints

Synovial joints allow friction-free, smooth movement to the articulating bones at their point of contact. This gives the bones of a joint the freedom to move freely in various planes. The articular cartilage plays a significant role in the increased joint mobility. It serves as the load-bearing material for synovial joints, allowing distribution of contact forces and reducing friction and wear.

However, articular cartilage is an avascular structure, thus depends predominately on the synovial fluid for the nutritional supply. The continuous supply of nutrition to the cartilage ensures faster recovery from an injury. It is also important for the smooth lubrication of the articular surfaces. A lack of lubrication at the articular cartilage causes reduced nutritional input during joint immobility 17.

Therefore, movement through the joint, whether active or passive, is essential for the optimal functioning of articular cartilage  1, 14. The application of articulation techniques through injury and recovery can aid the lubrication of the joint, encouraging the trans-synovial pump 2.

In the optimization of synovial elements, this pump plays three major roles:

Fluctuation of the intra-articular pressure

Regulation of blood flow to the joint

Facilitation of fluid drainage in and out of the joint.

Taken together, it can be said that by encouraging the trans-synovial pump, joint articulation can:

Potentially enhance the healing mechanism within the joint

Aid the fluid circulation to and from the joint

Tendons & Ligaments

Ligaments and tendons are connective tissues made of almost parallel collagen fibres, they provide:

Stability to the bones of the joint

Ensure rigidity when needed, and

Assist in the guiding of movement through the joint.

When tendons and ligaments are placed under stress, they change their shape to absorb the pressures applied on them within their physical limits 6. They toughen and become stiffer with increased strain but weaken with less strain 15.

Therefore, the application of either passive or active movement through connective tissues is important following a trauma. The movement is essential not only for the nutritional and vascular health of tissues but also for the tissue repair and recovery  5, 12.

Early articulation of joints in a controlled manner following injuries can:

Help ligaments to develop greater tensile strength

Inhibit adhesion of the tendon with its sheath

Prolong the strength and resistance of the tissues

Reduce the formation of fibrous tissue

Neurological effects

Articulation of the joints can result in stimulation of mechanoreceptors in joint tissues, ligaments and the joint capsule 2. When a joint is articulated within its anatomical limits, the large myelinated A-beta fibres are activated, which are responsible for the ‘closing’ of the gating system 11. This, in turn, generates the pain threshold lowering effects, neutralising the transmission of pain signals by the small neurofibres, A-δ and C fibres.

In addition, a number of studies have shown that the application of joint articulation techniques can:

Increase extensibility of targeted joint tissues

Produce hypoalgesic effects, both locally and distally

Decrease pain and muscle spasm in the chronically inflamed joint and muscle areas

Enhance pain-free mobility of joints and better joint alignment

Amplitude of articulation

There are no absolute values for the duration, amplitude, and frequency of articulation. They should be personalised depending on the individual patient, joint and practitioner  10. The amplitude of articulation should be less enough to cause pain but ample to generate movement. Research has shown that three cycles of 60-second articulations can achieve both local and widespread analgesia 4, 9, 16. The amplitude can be slowly increased with the subsiding of symptoms.

In conclusion, it can be said that early articulation of joints can significantly contribute to the treatment of pain and immobility. If the articulation techniques are applied skilfully and accurately, they can profoundly lower the pain threshold, increase the range of motion of joints, and promote faster recovery of tissues.

REFERENCES

1. Bertone AL (2008). Joint physiology: responses to exercise and training. In: KW Hinchcliff, RJ Geor, AJ Kaneps eds. Equine Exercise Physiology. Elsevier Limited; 132-142. 2. Dutton M (2002). Manual Therapy of the Spine: an integrated approach. New York: McGraw-Hill. 3. Fernandez C, Arendt-Nielsen L, Gerwin R (2010). Tension-type and Cervicogenic Headache: Pathophysiology, Diagnosis, and Management. Burlington, MA:Jones & Bartlett Learning. 4. Goodsell M, Lee M, Latimer J (2000). Short-term effects of lumbar posteroanterior mobilisation in individuals with low back pain. Journal of Manipulative and Physiological Therapeutics, 23(5):332-342. 5. Heinemeier KM, Olesen JL, Haddad F et al (2007). Expression of collagen and related growth factors in rat tendon and skeletal muscle in response to specific contraction types. Journal of Physiology, 582:1303-1316. 6. Herzog W, Gal J (1999). Tendon. In: BM Nigg, W Herzog eds. Biomechanics of the Musculoskeletal System, 2nd ed. New York: John Wiley & Sons; 127-147. 7. Huang C, Holfeld J, Schaden W et al (2013). Mechanotherapy: revisiting physical therapy and recruiting mechanobiology for a new era in medicine. Trends in Molecular Medicine, 19(9):555-564. 8. Ingber DE (2006). Cellular mechanotransduction: putting all the pieces together again. FASEB Journal, 20(7):811-827. 9. Krouwel O, Hebron C, Willett E (2010). An investigation into the potential hypoalgesic effects of different amplitudes of PA mobilisations on the lumbar spine as measured by pressure pain thresholds (PPT). Manual Therapy, 15:7-12. 10. Maitland GD, Hengeveld E, Banks K et al (2005). Vertebral Manipulation, 7th ed. London: Butterworth–Heinemann. 11. Melzack R, Wall PD (1965). Pain mechanisms: a new theory. Science, 150 (3699):971-979. 12. Sawhney RK, Howard J (2002). Slow local movements of collagen fibers by fibroblasts drive the rapid global self-organization of collagen gels. Journal of Cell Biology, 157(6):1083-1092. doi: 10.1083/ jcb.200203069. 13. Threlkeld A (1992). The effects of manual therapy on connective tissue. Physical Therapy, 72(12):893-902. 14. Viitanen MJ, Wilson AM, McGuigan HP et al (2003). Effect of foot balance on the intra articular pressure in the distal interphalangeal joint in vitro. Equine Veterinary Journal, 35(2):184-189. 15. Wang JH, Guo Q, Li B (2012). Tendon biomechanics and mechanobiology – a mini review of basic concepts and recent advancements. Journal of Hand Therapy, 25(2):133-141. 16. Willett E, Hebron C, Krouwel O (2010). The initial effects of different rates of lumbar mobilisations on pressure pain thresholds in asymptomatic subjects. Manual Therapy, 15(2):173-178. 17. Zappone B, Greene GW, Oroudjev E et al (2007). Molecular aspects of boundary lubrication by human lubricin: effect of disulfide bonds and enzymatic digestion. Langmuir, 24(4):1495-1508.