Range of Motion

Exercises

By:
Dr. Ahmed Abd El-Moneim
Lecturer of Physical Therapy
Beni-Suef University
 Range of motion

 Range of motion is the amount of movement you have

at each joints in certain directions or the range you can
move a body part around a joint.

 It is a basic technique used for:

1) Examination of movement (Goniometry).
2) Initiating movement into a program of therapeutic
intervention.
 Physical and Physiologic Considerations
Related to Joint ROM

Intrinsic Factors Extrinsic Factors

1) The shape and Congruency of 1) Aging: can decrease joint ROM.
the articulating bony surfaces 2) Body segment size: it is related
2) Pliability of the joint capsule, to muscle or adipose tissue bulk
ligaments, and other collagenous within the segment.
tissues.
3) Effects of disease, injury,
3) The strength and flexibility of overuse, and immobilization on
musculature acting on or joint tissues and joint ROM.
crossing the joint.
 Types of ROM Exercises

• Passive ROM (PROM)

• Active ROM (AROM)

• Active-Assistive ROM (A-AROM)

 Passive ROM (PROM)

 Definition

The movement of a segment within the unrestricted ROM,

produced entirely by an external force without voluntary
muscle contraction done by the patient.
 Sources of external force:

1) Gravity
2) Machine (Continuous Passive Motion)
3) Another individual
4) Another part of the individual’s own body.
 Types of External Forces
1) Manual
 Therapist
 Patient (unaffected part of the body)
 Gravity

2) Mechanical
 Continuous Passive Motion (CPM)
 Uses of Passive Range of Motion

1)Relaxed Passive Movement

Used to maintain full range of motion without restriction.

2)Passive Movement for Mobilization

Used to breakdown adhesions and to increase range of motion.

3)Passive Movement for Stretching

Used to lengthen pathologically shortened soft tissues structures to
increase joint range.
Indications of Passive Range of Motion

 Coma
 Paralysis
 Immobilized joint
 Muscle Re-education (Teaching patient the desired
movement).
 Used before the passive stretching technique
 Examination
 Goals for PROM
The main goal: to decrease the complications of immobilization (cartilage
degeneration, adhesion and contracture formation, and sluggish
circulation).
Specific goals:
 Maintain joint and connective tissue mobility.
 Minimize the effects of the formation of contractures.
 Maintain mechanical elasticity of muscle.
 Assist circulation and vascular dynamics.
 Enhance synovial movement for cartilage nutrition
 Decrease or inhibit pain.
 Assist with the healing process after injury or surgery.
 Maintain the patient’s awareness of movement.
 Limitations of Passive Motion

Passive motion does not:

 Prevent muscle atrophy.

 Increase strength or endurance.

 Assist circulation to the extent that active,

voluntary muscle contraction does.
 Precautions and Contraindications to
PROM Exercises
1) When the motion is disruptive to the healing process
(unhealed fracture, open wound, at the site of
fracture).
2) When too much or wrong motion increased pain and
inflammation.
3) At the site of effusion and swelling.
4) Immediately after ligament or tendon tear.
5) Uncontrolled high blood pressure.
 Principles and Procedures for Applying
ROM Techniques
1) Examination,Evaluation,and Treatment Planning

Select the appropriate

History Taking General Examination
technique

• From patient’s • Active ROM • AROM

report • Passive ROM • PROM
• From the • Muscle strength • AAROM
patient
• From relatives
1)Examination,Evaluation,and Treatment Planning

Document and
Pattern of applying Monitoring the
communicate findings
ROM technique patient
and intervention

• Single pattern • Response to exercise

(before and after)
• Combined
• Vital signs
pattern • Pain, ROM, and

• Functional quality of movement

• Warmth and color of

pattern
the segment
1) Examination,Evaluation,and Treatment Planning

Re-evaluation
Re-evaluate and modify
the intervention as
necessary.
2)Patient Preparation
1. Communicate with the patient.

2. Free the region from restrictive clothing, linen, splints, and

dressings.

3. Cover the other parts.

4. Position the patient in a comfortable position with proper

body alignment and stabilization but that also allows you to

move the segment through the available ROM.

5. Position yourself so proper body mechanics can be used.

3)Application of Techniques
1. To control movement, grasp the extremity proximal

and distal to the target joint, grasp should be firm

but not harmful.

2. Support areas of poor structural integrity, such as a

hypermobile joint, recent fracture site, or paralyzed

limb segment, so that the patient get confidence and

remain relaxed.
3)Application of Techniques
3. Move the segment through its complete pain-free range to the

point of tissue resistance. Do not force beyond the available

range. If you force motion, it becomes a stretching technique.

4. Perform the motions smoothly and rhythmically, with 5 to 10

repetitions. The number of repetitions depends on the

objectives of the program and the patient’s condition and

response to the treatment.

 Characteristics of relaxed passive
movement
 Slowly

 Rhythmic

 Regular

 Through full range of motion (available)

 Continuous Passive Motion
 Continuous passive motion (CPM) refers to passive motion
performed by a mechanical device that moves a joint slowly
and continuously through a controlled ROM.
 Benefits of CPM
1) Prevents development of adhesions and contractures and thus joint
stiffness

2) Provides a stimulating effect on the healing of tendons and ligaments

3) Enhances healing of incisions over the moving joint

4) Increases synovial fluid lubrication of the joint and thus increases the rate
of intra-articular cartilage healing and regeneration

5) Prevents the degrading effects of immobilization

6) Provides a quicker return of ROM

7) Decreases postoperative pain

 Definition of AAROM
• Movement performed within the unrestricted ROM
controlled by the voluntary contraction of the muscle,
in which assistance is provided by an outside force,
either manual or mechanical when muscle strength is
inadequate to complete the motion.

• Muscle strength is less than grade 3 by manual

muscle testing. Once patients gain control of their
ROM, they are progressed to AROM.
The principles of active assisted exercises
1) When the voluntary contraction of the muscle is
insufficient to produce movement.
2) An external force may be added to complete range.
3) This external force must be applied in the direction
of the muscle action.
4) The magnitude of the assisting force must be
sufficient only to augment the muscular action but
not allowed to act as a substitute for it.
5) As the muscular power is increasing, the assistance
given must be decreased proportionally.
 Types of Assistance

1) Manual Assistance

When the assistance is provided by:

a) The P.T
b) The patient’s sound limb (self assisted)
2)Mechanical Assistance

• Equipment

• Wand or T-bar

• Finger ladder, wall climbing, ball rolling

• Pulleys

• Skate board/ Powder board

• Reciprocal exercise devices

 Effects and uses of AAROM

1) When the patient has weakness, not paralyzed musculature

(poor to fair minus muscle test grade).

2) Maintain physiologic elasticity and contractility of the

participating muscles.

3) Provide sensory feedback from the contracting muscle to be

used in early stages of neuromuscular re-education.

4) Provide stimulus for bone integrity and joint tissue integrity.

5) Develop coordination and motor skills for functional
activities as the repetitive assisted exercises on the
correct pattern learn the patient to control the
movement by himself, so helping in training
coordination.

6) Confidence of the patient in his ability to move and

helping to co-operate.

7) Prevent DVT.

8) Improve blood circulation.

9) Can increase metabolism to help lose weight
and decrease stress and pain.

10) A decrease in the risk of heart disease and

heart attack is another benefit of regular
exercises as it reduces blood pressure and
cholesterol level.
 Indications
1) Muscle weakness as result of disuse or after
plaster cast
2) Muscle re-education
3) Inability to do Activities of Daily Living (ADL)
4) To increase ROM
5) Following tendon or muscle transplantation
 Contraindications of AAROM
1) Swelling, fever and redness
2) Immediately following myocardial infarction
3) If active assisted exercises induced sever pain during
movement
4) Cardiopulmonary dysfunction
5) Unhealed or unprotected recent fracture or recent surgical
site
6) In cases of DVT
 Precautions
 ROM exercises proximal and distal to the
injured and/or immobilized joint to minimize
venous and thrombus formation.
 Technique of Assisted Exercise
1) Starting position: Stability of the body is important to ensure
that the patient’s attention is concentrated on the pattern of
the movement and the effort required to perform it.

2) Pattern of movement: This can be explained to the patient by

performing it passively or actively on the sound limb.

3) Fixation: Fixation of the proximal part of the prime movers

improves their efficiency. Avoid trick movements to occur by
proper fixation.
4) Support: The moved part should be supported to reduce the
load on the muscle (pillows, boards, slings & manual
support)→ eliminate any force orb load on the weak muscle
by counterbalancing the effect of gravity (eliminate effect of
gravity).

5) Traction: Preliminary stretching of the weak muscle provides

a powerful stimulus to contraction because it stimulate the
muscle spindle (myotatic reflex) which helps in the initiation
of movement.
6) The antagonistic muscle: A proper starting position
should be selected to reduce the tension in the
antagonistic muscles, e.g. a position in which the knee
flexed is suitable for assisted dorsiflexion of the foot.

7) The assistance force: The force used in assisting the

action of the muscle must be applied in the direction
of the movement by the PT hands.
8) The character of the movement: Movement is
performed smoothly.

9) Repetitions: Repetition of the movement depends

on the condition of the patient.

10)The cooperation of the patient: This is essential

during this type of exercise. The patient should be
encouraged to exert maximum effort.
 Active Free Exercise (AROM)

AROM: are those which are performed by the

patient’s own muscular efforts within the unrestricted
ROM without assistance or resistance of any external
force other than gravity.
AROM classified into:

• Localized: to strengthen muscle group.

• Generalized: to use many muscles all over

the body.
This type of exercise can be used to obtain
the following:
1) Relaxation: can be induced by exercises which
are rhythmical or pendulum (swinging) in
character.
2) Joint mobility: normal range of joint motion is
maintained by exercises performed in full range.
3) The power and endurance of the working
muscles.
4) Co-ordination

5) Confidence

6) Circulatory and respiratory cooperation:

during prolonged exercise, the depth of
respiration is increased leading to production
of heat and increasing circulation.
 Goals for AROM
1) Maintain physiologic elasticity and contractility of the
participating muscles.

2) Provide sensory feedback from the contracting muscles.

3) Provide a stimulus for bone and joint integrity.

4) Increase circulation and prevent thrombus formation.

5) Develop coordination.
 Technique of active free exercise
1) The starting position: is selected and taught with care to ensure the

maximum postural efficiency as a basis for movement.

Instruction: is given to gain interest and cooperation of the patient.

2) The speed: at which the exercise is done depends on the effect required.

3) The duration of the exercise: depends very largely on the patient’s

capacity without reaching fatigue.

4) Demonstrate to the patient the motion desired using PROM, then ask the

patient to perform the motion. Have your hands in position to assist or

guide the patient if needed.

 Effects of Immobilization

 Fractures, surgery, paralysis, muscle spasticity,

various forms of arthritis, and even pain can result in
extended periods of immobilization.
1) loss of bone density
Because of lack of muscle contraction and weight bearing
forces and immobilization continues for several months,
regional osteoporosis will occur and full recovery of bone
mass, volume, and strength may be delayed or incomplete.
2) Articular cartilage,being largely avascular
 Cartilage will reduce the thickness and stiffness of the tissue
and result in a reduced ability to absorb and dissipate joint
forces without injury to the cartilage.
3) Collagenous tissue fibrosis and adhesion
caused by the formation of excessive collagen fiber
cross-links.

4)Muscle tissue atrophy and contracture

 A reduction in muscle tissue size and contractile force.

 Slow-twitch fibers exhibiting greater atrophy than

those composed of fast-twitch fibers.
ThankYou