Kaltenborn of Hand

'"Orginal Editor'"- Jacintha McGahan '"Top Contributors'" -

Purpose[edit | edit source]

The Kaltenborn method, also referred to as Orthopedic Manual Physical Therapy (OMT), is a Nordic System of Manual Therapy derived by Freddy Kaltenborn and Olaf Evjenth over several years. This Nordic system seeks to repair usual joint mechanics[1].

All joints have positions that provide a degree of freedom or create a low level of laxity of the capsule and ligaments that allows little, accurate movements of joint play. This is the result of internal and external movement forces on the body. These joint play movements are referred to as accessory movements and are not under conscious control, but they are essential to permissive, painless functioning of active movement[2]. These joint play movements can be highlighted during passive movements and include;

  • Distraction
  • Sliding
  • Compression
  • Rolling
  • Spinning of joint surfaces.

The term arthrokinematics describes these motions of the bone surfaces inside the joint. OMT Kaltenborn-Evjenth Concept uses translatoric (linear) joint play movements in association to the treatment plane in both assessment and treatment. Translatoric traction, compression and gliding joint play movements are applied to assess joint function and translatoric gliding and traction mobilisations are used to restore joint play[2].

The Kaltenborn Treatment Plane passes through the joint and exists at a right angle to a line positioned from the axis of rotation in the convex bony partner, to the deepest position of the articulating concave surface. Therefore, the treatment plane remains with the concave joint surface despite the moving joint partner being concave or convex[2].

Technique[edit | edit source]

Assessment[2][3][edit | edit source]

There are two procedures that can determine the direction of restricted glides;

  • Glide test; involves the application of passive translatoric gliding movements in all achievable directions and ascertain in which directions joint gliding is reduced. The glide test is the preferred procedure, as it gives the most accurate information about the degree and nature of a gliding restriction, including its end-feel.
  • Kaltenborn Convex-Concave Rule: First decide which bone rotations are reduced and if the moving joint partner is convex or concave. Then gather the direction of reduced joint gliding by applying the Convex-Concave Rule.

Kaltenborn established the Convex-Concave Rule to allow ease in identifying the direction of limitation and subsequently the direction that treatment is to be applied.

  • When a convex joint surface is moving, the roll and glide transpire in the opposite direction. The therapist moves a convex joint surface opposite to the direction of reduced movement to instigate the capsule in the same direction as the glide.
  • When a concave joint surface is moving the roll and the glide takes place in the same direction. The therapist moves a concave joint surface in the same direction of the reduced movement. The reverse capsule is provoked[4].

[5]

Traction and Compression tests can be utilised as part of the assessment;

Traction Compression
Relieves Joint pain Aggravates joint pain
If positive in normal resting position, then locate a position of greater discomfort and reassess the patient's reaction to traction. If negative this test should be conducted in several three-dimensional positions.

Joint compression should be assessed separately and prior resisted tests, as resisted tests also provoke pain.

Grades of translatoric movement[2][3][edit | edit source]

Three grades of translatoric movement specific for traction and gliding are described by OMT. The grades are deduced by the extent of joint slack (looseness and resistance) in the joint. This slack is taken up when assessing and treating joints with a glide or traction and allows the therapist to sense the end feel.

  • Grade I (loosen); Equalises joint pressure without actual surface separation, provides pain relief by reducing compressive forces and friction between joint surfaces.
  • Grade II (slack zone & transitional zone, i.e. tightens); Separates articulating surfaces by taking up slack or removes play within joint capsule. Is used initially to identify joint sensitivity and can be used to increase or maintain range.
  • Grade III (stretch); Involves stretching of soft tissue surrounding joint and to increase joint play in hypomobile joint.

Joint pathology will affect the quality of end-feel and grades of movement. For instance, the presence of notable hypomobility, the slack is taken up sooner than normal and greater force may be required to overcome intra-articular compression forces. In comparison to hypermobility the slack is taken up later than normal and less force may be necessary to achieve Grade I traction.

Using translatoric movement[edit | edit source]
  • Grade I; Relieve pain with vibratory and oscillatory movements.
  • Grade II: To relieve pain the treatment takes place in the Slack Zone, and not in the Transition Zone. Relaxation mobilisation can be applied within the entire Grade II range, including the Transition Zone.
  • Grade III; Tests joint play end-feel and is used to increase mobility and joint play by stretching shortened tissues.

In Grade I and II the slack zone range demonstrates little to no resistance on palpation. In Grade II Transition Zone range a gradual rise in resistance is felt by the therapist. At the first stop, the therapist will palpate notable resistance as the slack is now taken up and all tissues become taut. Stretching happens past this point.

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Evidence[edit | edit source]

Villafañe et al conducted a double-blind, randomized controlled trial to appraise the outcome of Kaltenborn manual therapy on sensory and motor function of elderly patients diagnosed with secondary carpometacarpal osteoarthritis (CMC OA). Twenty-nine female patients (70-90 years old) with secondary CMC OA were randomised into Kaltenborn manual therapy and sham groups. Therapy comprised of Kaltenborn mobilisation of posterior-anterior gliding with distraction in grade 3 of the carpometacarpal (CMC) joint of the dominant hand for 6 sessions over 2 weeks. Pain was recorded by algometry, as the pressure pain threshold (PPT) at the CMC joint and tubercle of the scaphoid bone. Pinch strength and grip strength were recorded by grip dynamometer. All outcomes were recorded prior to treatment and after 1 week and 2 weeks. The study concluded that Kaltenborn manual therapy reduced pain in the CMC joint and scaphoid bone areas of elderly female patients; however, it did not demonstrate any improvement in motor function in patients with CMC OA[8].

Villafañe et al then carried out a secondary analysis of data previously reported in 2011 randomized controlled trial. Once more twenty-nine females (age 70–90) with dominant hand thumb CMC osteoarthritis took part, and were randomized into 2 groups. The test group received a Kaltenborn mobilisation, and the placebo group received a non-therapeutic dose of intermittent ultrasound. Pressure pain thresholds at the thumb CMC joint, scaphoid bone and hamate bone and pinch strength were recorded prior and post the intervention, and 1 week and 2 weeks post the intervention. The Kaltenborn mobilisation group obtained therapy of posterior-anterior gliding with Grade 3 distraction of the thumb CMC joint of the dominant hand. Grade 3 distraction was applied to avoid touch between the articular surfaces and to stimulate hypoalgesic effects. The treatment lasted for 6 sessions over a period of 2 weeks. The mobilisation was performed over a course of 3 minutes with a 1-minute break, and repeated three times. The physiotherapist held the right thumb metacarpal bone of the patient with their right thumb and index finger and applied a precise Kaltenborn mobilisation of posterior-anterior gliding, with a brief amplitude and distraction of the thumb CMC joint. In summary, this secondary analysis identified that Kaltenborn mobilisation for the symptomatic hand decreased pressure pain sensitivity and produced motor changes in the contralateral non-treated hand in contrast with the placebo group. This contralateral motor responses post unilateral manual therapy may advocate the idea of a centrally-mediated response. However, it is important to note that in both of these studies a confined intervention for the symptomatic joint was used and this does not constitute a usual clinical practice. Additionally, sample sizes were small and the advancing age of the patient sample, with likely other comorbidities, could influence the results[9].

Finally, Levitsky et al conducted a small randomized crossover trial of 12 patients with Rheumatoid Arthritis (RA) and 8 patients with hand osteoarthritis. One hand per patient was randomised to undergo weekly low-grade (I-II) Kaltenborn manual mobilisation, using passive steady stretch of the metacarpophalangeal (MCP) joints II to V. Post a fortnight, the randomised treated hand was crossed over to control (untreated) for weeks 3 to 4 and vice versa. Outcomes encompassed pain via visual analog scale, tender or swollen joint count, presence of Doppler signal or synovial fluid and radiographic joint space by ultrasound. The results found that the RA patients, both the primarily randomised treated hand and the contralateral hand improved markedly from baseline to crossover to follow-up at 2 months (pain outcomes and Doppler signal, P < .050; synovial fluid and MCP joint space, P ≤ .001). Hand pain and MCP joint space also improved markedly in OA. There were no reported harmful incidents in either the RA or OA group[10].

Resources[edit | edit source]

The Kaltenborn Concept

Kaltenborn Manual Therapy Hand

References[edit | edit source]

  1. Kaltenborn FM. Orthopedic manual therapy for physical therapists Nordic system: OMT Kaltenborn-Evjenth concept. Journal of Manual & Manipulative Therapy. 1993 Jan 1;1(2):47-51.
  2. 2.0 2.1 2.2 2.3 2.4 University of Sargodha. Translatoric joint play, Grades of Kaltenborn and Cocave-convex rule. Available from: https://lms.su.edu.pk/lesson/156/translatoric-joint-play-grades-of-kaltenborn-and-cocave-convex-rule (accessed 12 October 2020)
  3. 3.0 3.1 Sreeraj S R. Kaltenborn Manual Mobilisation. Available from: https://www.slideshare.net/sreerajsr/kaltenborn-manual-mobilizations-srs [last accessed 13 October 2020]
  4. Manual Mobilisations. Kaltenborn Concept. Available from:https://manualmobilization.wordpress.com/kaltenbornconcept/ (accessed 13 October 2020)
  5. Alexandra Kopelovich. CONVEX-CONCAVE RULE: Easy animation and explanation. Available from: https://www.youtube.com/watch?v=pkXIADrBuVc [Last accessed 13/10/2020)
  6. Student Assistent. PHALANGES ASSESSMENT horizontal plane. Available from: https://www.youtube.com/watch?v=ymYEiHxkylY [Last accessed 13/10/2020)
  7. Student Assistent. CMC1 AB sagittal plane. Available from: https://www.youtube.com/watch?v=LT5VvtpfdRY [Last accessed 13/10/2020)
  8. Villafañe JH, Silva GB, Diaz-Parreño SA, Fernandez-Carnero J. Hypoalgesic and motor effects of kaltenborn mobilization on elderly patients with secondary thumb carpometacarpal osteoarthritis: a randomized controlled trial. Journal of manipulative and physiological therapeutics. 2011 Oct 1;34(8):547-56.
  9. Villafañe JH, de-las-Peñas CF, Silva GB, Negrini S. Contralateral sensory and motor effects of unilateral kaltenborn mobilization in patients with thumb carpometacarpal osteoarthritis: a secondary analysis. Journal of physical therapy science. 2014;26(6):807-12.
  10. Levitsky A, Kisten Y, Lind S, Nordström P, Hultholm H, Lyander J, Hammelin V, Gentline C, Giannakou I, Faustini F, Skillgate E. Joint mobilization of the hands of patients with rheumatoid arthritis: results from an assessor-blinded, randomized crossover trial. Journal of Manipulative and Physiological Therapeutics. 2019 Jan 1;42(1):34-46.