Range of Motion Exercises Overview

Range of Motion Exercises

• Range of motion (ROM) is the amount of movement at joints in certain directions or the range a body part can move around a joint.
• It's a basic technique used for:
  • Examining movement (Goniometry)
  • Starting a therapeutic intervention program.

Physical and Physiologic Considerations Related to Joint ROM

• Intrinsic Factors:

  • Shape and congruency of articulating bony surfaces
  • Pliability of joint capsule, ligaments, and collagenous tissues
  • Strength and flexibility of musculature acting on or crossing the joint

• Extrinsic Factors:

  • Aging decreases joint ROM
  • Body segment size is related to muscle and adipose bulk within the segment
  • Disease, injury, overuse, and immobilization affect joint tissues and ROM.

Types of ROM Exercises

• Passive ROM (PROM)
• Active ROM (AROM)
• Active-Assistive ROM (A-AROM)

Passive ROM (PROM)

• Definition: Movement of a segment within the unrestricted ROM produced entirely by an external force, without voluntary muscle contraction by the patient.
• Sources of external force:
  • Gravity
  • Machine (Continuous Passive Motion)
  • Another individual
  • Another part of the individual's body.

Types of External Forces

• Manual:
  • Therapist
  • Patient (unaffected body part)
  • Gravity
• Mechanical:
  • Continuous Passive Motion (CPM)

Uses of Passive Range of Motion (PROM)

• Relaxed Passive Movement: Maintain full range of motion without restriction.
• Passive Movement for Mobilization: Breakdown adhesions, increase range of motion.
• Passive Movement for Stretching: Lengthen pathologically shortened soft tissue structures to increase joint range.

Indications of Passive Range of Motion (PROM)

• Coma
• Paralysis
• Immobilized joint
• Muscle re-education (teaching desired movement)
• Used before passive stretching
• Examination

Goals for PROM

• Main goal: Decrease complications of immobilization (cartilage degeneration, adhesion, contracture formation, sluggish circulation).
• Specific goals:
  • Maintain joint and connective tissue mobility
  • Minimize effects of contracture formation
  • Maintain mechanical elasticity of muscle
  • Assist circulation and vascular dynamics
  • Enhance synovial movement for cartilage nutrition
  • Decrease or inhibit pain
  • Assist in healing after injury or surgery
  • Maintain patient's awareness of movement

Limitations of PROM

• Does not prevent muscle atrophy
• Does not increase strength or endurance
• Does not assist circulation as effectively as active voluntary muscle contraction

Precautions and Contraindications to PROM Exercises

• When the motion is disruptive to healing (unhealed fracture, open wound at the fracture site)
• When too much or wrong motion increases pain and inflammation
• At the site of effusion and swelling
• Immediately after ligament or tendon tear
• Uncontrolled high blood pressure

Principles and Procedures for Applying ROM Techniques

• Examination, Evaluation, and Treatment Planning:
  • History taking (patient report, relative report)
  • General examination (Active ROM, Passive ROM, muscle strength)
  • Select appropriate technique (AROM, PROM, AAROM)
  • Monitoring the patient (response to exercise, vital signs, pain, ROM quality, warmth & color)
  • Document and communicate findings & interventions
  • Re-evaluation of the intervention as necessary

Patient Preparation

• Communicate with the patient
• Free region from restrictive clothing, linen, splints, dressings
• Cover other parts
• Position patient comfortably with proper body alignment & stability, allowing movement through available ROM
• Position yourself for proper body mechanics.

Application of Techniques

• To control movement, grasp extremity proximal and distal to target joint; grasp should be firm but not harmful.
• Support areas of poor structural integrity (hypermobile joint, recent fracture, paralyzed limb) so patient feels confident and relaxed.
• Move segment through complete pain-free range to tissue resistance; do not force beyond range (forces motion becomes stretching).
• Perform motions smoothly and rhythmically with 5-10 repetitions.

Characteristics of Relaxed Passive Movement

• Slowly
• Rhythmically
• Regular
• Through full range of motion (available)

Continuous Passive Motion (CPM)

• 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

• Prevents adhesions and contractures, thus preventing joint stiffness
• Stimulates healing of tendons and ligaments
• Enhances healing of incisions over the moving joint
• Increases synovial fluid lubrication, increasing intra-articular cartilage healing and regeneration
• Prevents the degrading effects of immobilization
• Provides a quicker return of ROM
• Decreases postoperative pain.

Definition of Active-Assistive ROM (AAROM)

• Movement performed within unrestricted ROM controlled by voluntary muscle contraction, with assistance from outside force (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 ROM control, they progress to AROM.

The principles of active assisted exercises

• When voluntary muscle contraction is insufficient to produce movement.
• An external force may be added to complete the range
• Force is applied in the direction of muscle action.
• The assisting force magnitude is only sufficient to augment, not substitute, muscular action
• As muscular power increases, assistance decreases proportionally.

Types of Assistance

• Manual: Provided by therapist or patient
• Mechanical: Uses equipment (wand, T-bar, finger ladder, wall climbing, ball rolling, pulleys, skate board/powder board, reciprocal exercise devices)

Effects and uses of AAROM

• When patient has weakness (poor to fair minus muscle test grade)
• Maintain physiologic elasticity and contractility of participating muscles
• Provide sensory feedback for early neuromuscular re-education
• Provide stimulus for bone and joint tissue integrity
• Develop coordination and motor skills for functional activities
• Build patient confidence and cooperation
• Prevent Deep Vein Thrombosis (DVT)

Indications of AAROM

• Muscle weakness (disuse, after plaster cast)
• Muscle re-education
• Inability to do Activities of Daily Living (ADL)
• To increase ROM
• Following tendon or muscle transplantation

Contraindications of AAROM

• Swelling, fever and redness
• Immediately following myocardial infarction
• If active assisted exercises induce severe pain during movement
• Cardiopulmonary dysfunction
• Unhealed or unprotected recent fracture or recent surgical site
• In cases of deep vein thrombosis (DVT)

Precautions for ROM Exercises

• Avoid proximity and distally to the injured or immobilized joint to minimize venous and thrombus formation.

Technique of Assisted Exercise

• Starting position: Ensure patient's concentration on movement pattern and effort required
• Pattern of movement: Explain by performing it passively or actively on sound limb.
• Fixation: Fix proximal part of prime movers to improve efficiency; avoid trick movements
• Support: Support moved part to reduce load on muscles (pillows, boards, slings, manual support), countering gravity effect
• Traction: Preliminary stretching of weak muscle provides a powerful stimulus to the contraction (myotatic reflex) initiating movement.
• Antagonistic muscle: Select starting position to reduce tension in antagonistic muscles
• Assistance force: Apply force in direction of movement by therapist's hands
• Movement character: Smooth
• Repetitions: Depends on patient condition
• Patient cooperation: Encourage maximum effort

Active Free Exercise (AROM)

• Performed by patient's own muscular efforts within the unrestricted ROM.
• No assistance or resistance other than gravity.

AROM Classification

• Localized: strengthening specific muscle groups
• Generalized: using numerous muscles of the body.

Uses of AROM

• Relaxation: Induced by rhythmic or pendulum exercises
• Joint mobility: Maintains normal range of motion in the full range of movement
• Power and Endurance enhancement in working muscles

Goals for AROM

• Maintain participating muscle's physiologic elasticity and contractility.
• Provide sensory feedback from contracting muscles.
• Stimulate bone and joint integrity
• Increase circulation and prevent thrombus formation
• Develop coordination.

Technique of Active Free Exercise

• Starting position: Select and teach to maximize postural efficiency. Give instructions to gain interest & cooperation
• Speed: Depends on required effects
• Duration: Depends on patient capacity without reaching fatigue.
• Demonstration: Demonstrate the desired motion with PROM, and then guide the patient

Effects of Immobilization

• Fractures, surgery, paralysis, muscle spasticity, arthritis, and pain can result in extended periods of immobilization

Effects of Immobilization (details)

• Loss of bone density: Lack of muscle contraction & weight bearing leads to regional osteoporosis, delayed or incomplete recovery
• Articular cartilage: Reduces thickness & stiffness, impairing absorption and dissipation of joint forces
• Collagenous tissue: Fibrosis and adhesion caused by excessive collagen fiber cross-links
• Muscle tissue: Atrophy (reduction in muscle size & contractile force), especially in slow-twitch fibers.