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Norse Articulation Course

Overview

Articulations have been a used as part of manual therapy for many years. Osteopaths, chiropractors, and physiotherapist have been using them over the last hundred and fifty years. Prior to that Thai massage uses a form of articulation which has been around for roughly 2500 years. According to Gyer, Michael & Calvert-Painter (2016) articulation is a corner stone of manual therapy.

The rise in the Sports Therapy & Sports Massage industry has led to many more people practicing manual medicine. Massage is a very powerful tool in treating muscular skeletal pain. However, articulation has a fundamental part to play in a manual therapist arsenal. For example, if you picture a 70-year-old patent with the onset of osteoarthritis in his spine and hips. He has restricted movement through his thoracic spine, neck and the anterior capsule of his hips are very tight. He then struggles to lengthen his stride while walking and sitting for long periods of time causes neck pain. Soft tissue techniques like massage or soft tissue release are beneficial, but do not challenge the reduced range of movement at these joints. However, coupling soft tissue techniques with a variety of articulations can improve quality of movement, range of movement and thus pain.

Generations have shown that articulation techniques can relieve pain and increase the range of movement of joints (Maitland, 1986, Kaltenborn & Evjenth, 1989). Furthermore, articulations have been shown to reduce; pain, stiffness, disorders directly related to a specific diagnosis, improve range of movement, and increase the speed of recovery (Maitland et al, 2005, Ledermann, 1997).

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Technique

Articulation, mobilization, and manipulation are all terms that are used to describe the active movement of a joint, up to or beyond the restrictive barrier by a therapist. It is important to define each of these terms because many professionals use them interchangeably.

Articulation and mobilization are very similar terms. Mobilization is defined as the passive joint movement for increasing range of movement and decreasing pain. They are applied at varying speeds and amplitudes using physiological and accessory motion (London College of Osteopathy, 2020).

The term manipulation normally refers to a high velocity low amplitude thrust, or grade V manipulation. In this case the thrust is applied beyond the restrictive barrier of the joint, normally it results in a cavitation or the classic pop. Manipulations are not the focus of this module.

Osteopathic viewpoint

Articulation or mobilization from an osteopathic view, relates to the use of repetitive passive movement, usually employing a lever and fulcrum (Hartman, 2001). The operator is consistently sensing the tissues under the hands and adjusting the pressure accordingly.

The articulation can be applied over a broad arc or at a small amplitude depending on the requirements. A common method is to add a small emphasis of movement at the end of range. This can produce a more rapid effect on tissue texture and aids accurate assessment.

The direction of movement can be applied in a single plane or multiple planes. With regards to the spine, osteopaths use the principle of joint locking, this can also be applied during articulations to reduce unwanted side effects on the tissue. Working with this manufactured barrier causes faster changes in mobility, reduces discomfort of capsular stretch, while positively effecting joint receptor mechanisms (Hartman, 2001).

The precise application of joint articulation has been researched, proposing that four sets of 30 to 60 movements provides a significant effect on range of movement and pain threshold (Pentelka et al, 2012).

Physiotherapy viewpoint

Physiotherapist like Maitland have developed articulation techniques, refining them down to specific movements. From a certain point of view, they are more specific than the traditional osteopathic articulation. According to Hengeveld & Banks (2005) Mobilization and manipulation from a physiotherapy point of view is divided into five grades.

Grade 1 – A slow smooth oscillatory movement of a small amplitude performed at the beginning range of movement.

Grade 2 – A larger amplitude movement performed within the resistance free aspect of the range of movement. Grades 1 and 2 are aimed at achieving tissue healing and relieving pain (Gyer, Michael & Calvert-Painter, 2016).

Grade 3 – A larger amplitude movement performed up to the limit of available range of movement.

Grade 4 – A small amplitude movement performed into the limit or up to the limit of available range.  Grades 3 and 4 are aimed at increasing joint range of movement (Gyer, Michael & Calvert-Painter, 2016).

Grade 5 – A small amplitude high velocity thrust localized to a single joint movement at the end of the range of movement.

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Research

General

There is a significant body of evidence that suggests that articulation can provide a variety of benefits including reducing pain, speeding up recovery, improving range of movement. The exact mechanism for these benefits is not entirely clear but we have provided an overview of the research.

In the event of an injury the deformation that tissue requires to remain healthy ceases, this results in inhibiting joints from regenerating optimally. This causes tissue thickening, insufficient water in the tissue matrix, loss of tissue elasticity, collagen cross bridging and shortening of tissue (Threlkeld, 1992).

We know that healthy movement through a joint can aid tissue repair and recovery (Gyer, Michael & Calvert-Painter, 2016). Therefore, it seems logical that controlled joint movement in the form of articulation can be therapeutic.  More specifically, joint articulation has been shown to be effective at reducing muscular skeletal pain (Shum et al, 2012). They have been shown to increase range of movement, by stretching fibrous tissue and by affecting stretch reflex excitability (Cooke, 2007).  

Articulations can aid the reduction of swelling because rhythmical movement cause a pumping action within the joint which influences the intra – articular pressure (Rice & McNair, 2009). Furthermore, articulations of the joint can increase the vascular circulation of the joint (Saunders & Saunders, 2004). These effects help the body process the swelling as early introduction of movement helps in fluid drainage, preventing the build up of fluid and distension forces upon the tissue and joint (Lederman, 1997). This confirms the findings by a study by Green et al (2001) showing that passive articulation to a sprained ankle greatly improved the recovery of pain free movement. This builds the case for early articulation of an acute injury.

 Joint restriction

Going back to the example of the 70-year-old patient in the introduction, it is clear to see that joint restrictions that occur after an injury or over time have a negative affect on the body. Specifically, joint restrictions or lack of movement have been linked to degeneration (Rapperport et al, 1985, Salter, 1989, Responte et al, 2012). It is proposed that joints with osteoarthritis have increased friction due to a lack of lubrication, the suggestion is that articulation increases lubrication and is thus beneficial (Basalo et al, 2004, 2005).

Soft tissue response

Articulations also influence tendons and ligaments. These structures require movement to remain healthy. As we know connective and muscular tissue responds to certain levels of mechanical stress by strengthening (Veigel et al, 2003).

Furthermore, placing stress on connective tissue is important for the nutritional and vascular health of that tissue (Noel et al, 2000, Schild & Trueb, 2002, Heinemeier et al, 2007). Some authorities suggest that early articulation develops higher tensile strength of the ligaments (Takai et al, 1991), increases range of movement by stretching fibrous tissue (Refshauge & Gass, 2004), and reduces formation of adhesions between the tendon and its sheath (Thomopoulos et al, 2009).

In the event of a joint sprain early articulation is the manual treatment of choice. This promotes ligament strength, vascular health and reduces the chances of adhesion formation. To create connective tissue lengthening, joints need to be articulated towards the end of range of movement (Threlkeld, 1992). If tendons and ligaments are placed under careful stress, they can remodel within their anatomical limits (Herzog & Gal, 1999).

Neurological response

Research has shown that articulating a joint cause a neurological response and alters the perception of pain. When joints or tissues are moved beyond their normal limits, nociceptors are activated and cause the brain to register pain.

It has been shown that joint articulation decreases pain response and increase pain free movement. Movements such as articulation stimulates other receptors called mechanoreceptors, when this happens according to the pain gating theory it counters the nociceptors, thus reducing pain. Moss et al (2007) showed that articulation of arthritic joints provided a hypoalgesic effect.

The precise application of joint articulation has been researched, proposing that four sets of 30 to 60 movements provides a significant effect on range of movement and pain threshold (Pentelka et al, 2012).

Summary

In summary, joint articulation has a variety of effects on pain modulation, range of movement, soft tissue health and swelling. Carefully applied articulations are a very safe and effective treatment

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