Musculoskeletal Interventions

Physical therapy interventions for musculoskeletal conditions span from passive techniques like joint mobilization to active approaches like therapeutic exercise. The NPTE tests your ability to select the most appropriate intervention based on the patient's presentation and phase of healing.

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Joint Mobilization

Maitland Mobilization Grades

Joint mobilization uses oscillatory or sustained movements applied to a joint to restore normal arthrokinematic motion:

Clinical Application:

• Grades I and II are used primarily for pain relief (they stimulate mechanoreceptors that inhibit pain signals via the gate control theory)
• Grades III and IV are used to increase joint mobility by stretching restricted joint capsule or periarticular tissues
• Grade V (thrust manipulation) is used to restore joint play; it requires additional training and is regulated by state practice acts

Applying the Concave-Convex Rule in Mobilization

When performing mobilization to increase ROM:

• Convex surface restricted (e.g., humeral head on glenoid) → Glide in the opposite direction of the restricted osteokinematic motion
• Concave surface restricted (e.g., tibia on femur) → Glide in the same direction as the restricted osteokinematic motion

Example: To improve shoulder flexion (humeral head is convex on concave glenoid), apply an inferior glide (opposite direction of the upward bone movement).

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Therapeutic Exercise

Exercise Progression Continuum

Rehabilitation exercises follow a progression from passive to resistive:

1. PROM (Passive Range of Motion) — Therapist moves the joint; used in acute/post-operative phase
2. AAROM (Active-Assistive ROM) — Patient initiates, therapist assists through range
3. AROM (Active ROM) — Patient moves independently through range against gravity
4. Isometric exercise — Muscle contraction without joint movement; used when motion is restricted or painful
5. Isotonic concentric — Muscle shortens against resistance
6. Isotonic eccentric — Muscle lengthens against resistance (generates more force, good for tendinopathy rehab)
7. Isokinetic exercise — Resistance matches effort at a constant speed (requires specialized equipment)

Progressive Resistive Exercise (PRE)

Two classic PRE protocols for strength training:

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Soft Tissue Techniques

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PNF (Proprioceptive Neuromuscular Facilitation)

PNF Diagonal Patterns

PNF uses diagonal, spiral movement patterns that mirror functional activities:

Upper Extremity:

• D1 Flexion: Shoulder flexion, adduction, external rotation (reaching across to opposite shoulder)
• D1 Extension: Shoulder extension, abduction, internal rotation (reverse of D1 flexion)
• D2 Flexion: Shoulder flexion, abduction, external rotation (reaching up and out)
• D2 Extension: Shoulder extension, adduction, internal rotation (pulling down across body)

Lower Extremity:

• D1 Flexion: Hip flexion, adduction, external rotation
• D1 Extension: Hip extension, abduction, internal rotation
• D2 Flexion: Hip flexion, abduction, internal rotation
• D2 Extension: Hip extension, adduction, external rotation

PNF Stretching Techniques