Techniques for Treating a Stiff Wrist: Nordic Kalternborn-Evienth Concept Mobilization

Written by:

Sabine Klüss, PT, OMT 

Finland 

VHSF Fellow 24-25 

The story of the OMT Nordic System began in the 1940’s when Norwegian Freddy Kaltenborn became frustrated in his attempts to treat patients with joint dysfunction. His professional training, first as a physical educator and athletic trainer in 1945, and later as a physical therapist in 1949, included mobilization techniques and primitive manipulative thrusts as well as exercise but he recognized that these treatments only had limited effects. 

In 1952 Kaltenborn went to London with his colleague R. Stensnes, to observe the joint mobilization techniques of Dr. Mennell and to study with Dr. Cyriax. Upon his return to Norway, Kaltenborn demonstrated his newly acquired skill at the Medical Association for Physical Medicine, which then agreed to cosponsor the first course on the Cyriax approach taught by Kaltenborn in 1954. Cyriax, Cramer and Stoddard worked with Kaltenborn for many years to determine which evaluation and treatment tools from orthopedic medicine, chiropractic and osteopathy should be a part of OMT for physicians and physical therapists. Kaltenborn began to develop his own theories and techniques and to incorporate these into his evolving MT system. His integrated approach became known as “Manual Therapy (MT) ad modum Kaltenborn” or “The Kaltenborn Method.” And later Physicians and Physical Therapists whom graduated from his training programs were known as Orthopedic Manipulative Therapists (OMT). Kaltenborn passed away in 2019 but my OMT Class of 2004-2007 had the opportunity to meet and learn joint mobilization and manipulation under his watchful eyes. 

Among Kaltenborn’s contributions were an emphasis on translatoric (linear) joint play movements in  relation to a treatment plane for evaluating and mobilizing joints, the use of grades of movement, the  convex-concave rule, three-dimensional pre-positioning for joint movement, protecting adjacent  nontreated joints during procedures, self-treatment, and ergonomic principles applied to protect the  therapist. 

Olaf Evjenth, OMT, a skilled Norwegian clinician with a background in physical education, athletic training and physical therapy, joined Kaltenborn in 1968. Evjenth expanded Kaltenborn’s approach with specialized techniques for muscle stretching and coordination training. In particular, Evjenth 

believed in more intensive training for patients and developed programs that, in addition to monitoring  pain and range of movement, assessed performance. Evjenth also modified specific exercises for patient use at home with automobilization, autostabilization, and autostretching. Evjenth and Kaltenborn, together with members of the Norwegian Medical Manipulation Group, began to develop additional self-treatment techniques, equipment for home treatment, and ergonomic innovations including mobilization wedges, fixation belts, and grips to make treatments more effective and less physically stressful for the therapist (always a concern in the Kaltenborn-Evjenth Concept). 

We know that 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. These joint play movements can be highlighted during passive movements and include; 

• Distraction 

• Sliding 

• Compression 

• Rolling 

• Spinning of joint surfaces. 

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. 

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. 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. 

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. 

• 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. 

There are also three grades of translatoric movement specific for traction and gliding that 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. 

A stiff wrist is most often caused by injuries, including fractures, sprains, and strains from falls or  repetitive stress, as well as inflammatory conditions like arthritis (osteoarthritis, rheumatoid arthritis,  or psoriatic arthritis). Other potential causes could be ganglion cysts, infections, and conditions like Kienbock's disease, which affects wrist bones, along with the stiffness resulting from a poorly healed

fracture or prolonged immobility. Indications of a stiff wrist may include difficulty with simple tasks, such as turning doorknobs or lifting objects, a limited range of motion in the wrist joint, and a "catching" or "popping" sensation when moving the wrist. Other symptoms may include pain, swelling, weakness, clicking or crackling sounds, and numbness or tingling. 

Common Signs & Symptoms include: 

• Reduced Range of Motion (ROM): You may find it hard to fully bend or extend your wrist. 

• Difficulty with Daily Tasks: Stiffness can make it challenging to grip items, open jars, or perform other routine hand movements. 

• "Catching" or "Popping" Sensations: A feeling of a "catch" or popping sound when you move your wrist can indicate stiffness or inflammation. 

•Pain and Tenderness: The wrist may feel tender to the touch or ache, especially during or after activity. 

• Swelling: The wrist may appear swollen, particularly around the joints or the base of the fingers.  •Weakness: You may notice a weakness in your grip or hand strength. 

•Numbness or Tingling: In some cases, especially with conditions like carpal tunnel syndrome, you might experience tingling or pins and needles. 

• Sounds: A clicking, grinding, or crackling sound may occur when you move your wrist. 

• Sprains and Strains: These injuries result from falls or repetitive activities and can lead to  constricted connective tissue and stiffness. Occur from overstretching or tearing ligaments, muscles, or tendons due to falls or heavy lifting. Tasks involving frequent, forceful, or awkward wrist movements, such as typing or manual labor, can lead to overuse and inflammation. 

• Fractures: A broken wrist bone, especially if it has not healed properly, can lead to significant stiffness. 

• Arthritis: Inflammation of the wrist joint, which can be caused by the wear-and-tear of osteoarthritis or the autoimmune nature of rheumatoid arthritis, leads to pain and stiffness. Osteoarthritis, rheumatoid arthritis, and psoriatic arthritis can cause inflammation, swelling, and stiffness in the wrist joint. 

• Carpal Tunnel Syndrome: This occurs when the median nerve in the wrist is compressed, causing pain, tingling, and stiffness. 

• Tendinitis: Inflammation of the tendons in the wrist, often a result of overuse or repetitive activities. 

• Ganglion Cysts: Non-cancerous, fluid-filled sacs that can develop near joints or tendons and cause stiffness. These growths on the wrist can cause discomfort, stiffness, and instability. 

• Cartilage Injuries: Damage or wear-and-tear of the cartilage cushioning the bones in the wrist can result in stiffness and pain. 

• Kienbock's Disease: A condition affecting the lunate bone in the wrist, causing pain and stiffness, particularly in the dominant hand. 

•Infections: Infections from bites or cellulitis can also contribute to wrist stiffness.

Before treating and mobilizing a stiff wrist you mut be aware of the contraindications for wrist  mobilization which include unhealed fractures, unstable joints, active infection, acute inflammation,  osteoporosis, malignancy, open wounds, and excessive pain or spasm. Other considerations are an unclear diagnosis, conditions involving hyperligamentous laxity, and potentially the presence of fibromyalgia-type syndromes or widespread symptoms without a clear explanation. It is crucial to consult a healthcare professional to determine if a stiff wrist is safe to mobilize. 

Absolute Contraindications (Signs of serious underlying pathology)  

• Fractures: or unstable fracture fragments 

• Infection: affecting the bone or joint 

• Malignancy: (cancer) of the bone or surrounding tissues 

• Acute inflammation: or an acute episode of rheumatoid arthritis 

• Open wounds: or actively bleeding tissues 

Conditions Requiring Caution or Relative Contraindications  

• Osteoporosis: or impaired bone density, which can weaken bone and increase fracture risk 

• Hyperligamentous laxity: or hypermobility disorders, as mobilization could potentially cause further instability 

• Excessive pain, severe muscle spasm, or an "empty end-feel," which can indicate a more serious issue 

• Unstable joints 

• Unclear diagnosis: or working hypothesis for the stiffness 

• Fibromyalgia-type syndromes: where symptoms lack a clear explanation 

• Chronic pain: and conditions that make it difficult to determine the cause of stiffness 

General Principles of mobilisation  

• Consult a professional: before attempting mobilization, especially if you have any health concerns.  • Stop if pain worsens: or if the movement feels excessive. 

• Mobilization should not be aggressive, particularly with early trauma, to avoid re-initiating inflammation or damaging healing tissues. 

Once you have determined that there are no contraindications for mobilizing a stiff wrist and you have determined the direction of the movement limitation, you are then ready to start manual treatments.

1. Mobilization of the Wrist-Traction 

- The therapist’s hand grips the patient’s forearm just proximal to the wrist joint 

- The pronated forearm is fixated against the wedge by the therapist. 

- The therapist’s thenar eminence fixates just proximal and the hand grips just distal to the wrist joint.  - The therapist moves the hand distally producing traction in the wrist joint. 

2. Mobilization of the Wrist Palmar Glide for restricted dorsiflexion: to increase wrist dorsal flexion range-of movement (convex rule) 

- The therapist’s hand grips the dorsal side of the patient’s distal forearm (or the proximal row of carpals) fixating it against the wedge. 

-The therapist’s hand grips from the dorsal side of the patient’s wrist (or the distal row of carpals.) 

- The carpals are moved in the palmar direction, palmar glide movement to the distal joint partners.

- Modify your grip to apply more specific mobilization between the radius and proximal row of carpals, or between the proximal and distal row of carpals. 

Progression: Apply palmar glide with the targeted wrist joints positioned close to the end range-of - motion into dorsal flexion (convex rule) 

3. Mobilization of the Wrist Dorsal Glide for restricted palmar flexion: to increase wrist palmar flexion range-of-motion (convex rule) 

- The therapist’s hand grips from the ventral side of the patient’s distal forearm (or the proximal row of carpals) fixating it against the wedge. 

- The therapist’s hand grips from the palmar side around the patient’s wrist (all the carpals or just the distal row) 

- The carpals are moved in the dorsal direction. Modify your grip to apply more specific mobilization between the radius and proximal row of carpals, or between the proximal and distal row of carpals. 

Progression: Apply dorsal glide with targeted joints positioned close to their end range-of motion into palmar flexion (convex rule) 

4. Mobilization of the Capitate-Lunate Palmar Glide to increase wrist dorsal flexion range-of motion (concex rule) 

- The lunate is fixated against the wedge. 

- Support the patient’s hand and thumb in your hand with your thumb on the capitate: use your other hand to supplement your grip. 

- The therapist’s hypotenar eminence is placed over the thumb 

- The lunate is moved in a palmar direction in relation to the capitate. 

Progression: Apply palmar glide joint play movement to the capitate near the end range-of -motion into wrist dorsal flexion (convex rule) 

Lunate-Radius mobilization: fixate the radius and apply palmar glide to the lunate (convex rule) 

5. Mobilization of Capitate-Lunate dorsal glide for restricted palmar flexion to increase wrist palmar flexion range-of-motion (convex rule)

- The lunate is fixated against the wedge. 

- Support the patient’s hand and thumb in your hand with your thumb on the capitate. Use your other hand to supplement your grip. 

- Apply dorsal glide to the capitate. 

Progression: Apply dorsal glide joint lay movement near the end range-of-motion into wrist palmar flexion (convex rule) 

Radius-Lunate mobilization: Fixate the radius, apply dorsal glide to the lunate (convex rule) 

6. Mobilization of the Scaphoid-radius palmar glide for restricted dorsal flexion to increase wrist dorsal and radial flexion range-of-motion (convex rule) 

- The therapist’s hand grips around the patient’s distal forearm from the radial side with then thenar eminence dorsal and fingers palmar. 

- The radius is fixated against the wedge. 

- The therapist’s hand grips from the radial side of the patient’s hand with the thenar eminence dorsal against the scaphoid. 

- The scaphoid is moved palmar in a palmar direction in relation to the radius. 

7. Mobilization of the Carpal Joints Dorsal Glide of the two Trapezii for restricted dorsal and radial flexion of the wrist and when decreased dorsal gliding of the Trapezii in relation to  the Scaphoid is present. (concave rule)

- The Scaphoid is fixated against the wedge. 

- The therapist’s hand grips from the radial side around the patient’s wrist with the thumb palmar and the index finger dorsal on the trapezii. 

- The therapist’s hypothenar eminence is placed over their thumb 

- The two trapezii are moved dorsally in relation to the scaphoid. 

Scaphoid-radius dorsal glide for restricted dorsal flexion: fixate radius and apply dorsal glide to the scaphoid (convex rule) 

8. Mobilization of the Carpal Joints Palmar Glide of Triquetrum for restricted wrist movements  with decreased gliding between Triquetrum and ulna or with restricted forearm pronation and  supination. (convex rule) 

- The Ulna is fixated against the wedge. 

- The therapist’s hand grips from the ulnar side with the thumb dorsal and the index finger palmar around the triquetrum. 

- The therapist’s hypothenar eminence is placed over their thumb 

- Apply palmar glide to the triquetral.

References: 

Manual Mobilization of the Extremity Joints. Basic Examination and Treatment Techniques by Freddy  M. Kaltenborn in cooperation with Olaf Evijenth. 4^th and 7^th edition 

Orthopedic manual therapy for physical therapists Nordic system: OMT Kaltenborn-Evjenth concept  FM Kaltenborn - Journal of Manual & Manipulative Therapy, 1993 - Taylor & Francis 

Kaltenborn of Hand - Physiopedia. Cite article Kaltenborn of Hand Jump to: navigation, search  '"Orginal Editor'"- Jacintha McGahan '"Top Contributors'" - Jacintha McGahan , Rachael Lowe , Admin  Kim Jackson , Shaimaa Eldib and Anas Mohamed Contents 1 Purpose 2 Technique 2.1 Assessment  2.2Grades of translatoric movement. 

Manual Therapy – Physiopedia to evidence. 1st. ed. Philadelphia: F.A. Davis Company, 2015. ↑  Physiopedia. Kaltenborn of Hand (last accessed 29 April. 2023). ↑ IMTA. Programme details. Available  from: https://www.imta.ch/course-system/ (last accessed 29 April 2023). ↑ Physiopedia, Maitland  Mobilisations (last accessed 29 April 2023