Understanding Complex Systems

Range of Motion (ROM)

• Range of motion is the amount of movement at each joint in specific directions, or the range a body part can move around a joint.
• It's a fundamental technique used for:
  • Assessing movement (Goniometry).
  • Initiating therapies.

Physical and Physiological Considerations Related to Joint ROM

• Intrinsic Factors:
  • Shape and congruence of articulating bony surfaces.
  • Flexibility of the joint capsule, ligaments, and other connective tissues.
  • Strength and flexibility of the muscles acting on or crossing the joint.
• Extrinsic Factors:
  • Aging: reduces joint ROM.
  • Body segment size: impacts muscle/fat bulk.
  • Effects of disease, injury, overuse, and immobility on the 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 body segment within its unrestricted range of motion (ROM) entirely by an external force, with no voluntary muscle contraction from the patient.
• External Force Sources:
  • Gravity.
  • Machines (Continuous Passive Motion - CPM).
  • Another individual.
  • Another body part of the individual.

Types of External Forces

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

Uses of Passive Range of Motion

• Relaxed Passive Movement: Maintains full unrestricted ROM.
• Passive Movement for Mobilization: Breaks down adhesions, increasing ROM.
• Passive Movement for Stretching: Lengthens shortened soft tissues, improving joint range.

Indications of Passive Range of Motion

• Coma.
• Paralysis.
• Immobilized joint.
• Muscle re-education (teaching desired movement).
• Before passive stretching techniques.
• Examinations.

Goals for PROM

• Decrease immobilization complications (e.g., cartilage degeneration, adhesions, contracture formation, sluggish circulation).
• Maintain joint and connective tissue mobility.
• Minimize contracture formation.
• Maintain muscle elasticity.
• Assist circulation and vascular dynamics.
• Enhance synovial movement for cartilage nutrition.
• Decrease or inhibit pain.
• Assist the healing process after injury or surgery.
• Maintain patient awareness of movement.

Limitations of Passive Motion

• Does not prevent muscle atrophy.
• Does not increase strength or endurance.
• Assists circulation to the degree of active, voluntary muscle contraction.

Precautions and Contraindications to PROM Exercises

• Motion disruptive to healing process (e.g., unhealed fracture, open wound).
• Excessive/improper movement causing pain and inflammation.
• Effusion and swelling sites.
• Immediately after ligament/tendon tears.
• Uncontrolled high blood pressure.

Principles and Procedures for Applying ROM Techniques

• Examination, Evaluation, and Treatment Planning:
  • Taking patient history (patient and relative input).
  • General examination (including active ROM, passive ROM, muscle strength).
  • Choosing appropriate techniques (AROM, PROM, AAROM).
• Re-evaluation: Reassess and modify the intervention as needed.
• Monitoring the patient:
  • Assess the patient's response to exercise (before and after).
  • Monitor vital signs, pain, ROM, movement quality, warmth, and skin color.
• Document and communicate findings and intervention:
  • Note the observed pattern of applying ROM techniques such as single, combined, or functional patterns.

Patient Preparation

• Communicate with the patient.
• Remove restrictive clothing, splints, and dressings from the affected area.
• Cover the unaffected parts of the body.
• Position the patient comfortably with proper body alignment and stabilization, allowing for full ROM.
• Position yourself for proper ergonomic practices.

Application of Techniques

• Grasp extremities proximal and distal to target joint for control, firm but non-harmful grip.
• Support areas of poor structural integrity (hypermobile joints, recent fractures, paralyzed limbs) to promote relaxation and confidence in the patient.
• Move the segment smoothly and rhythmically through full pain-free range of motion, to point of tissue resistance.
• Perform with 5-10 repetitions, adjusting based on individual needs and the response to treatment.
• Follow established rhythmic and regular patterns.

Characteristics of Relaxed Passive Movement

• Slowly.
• Rhythmically.
• Regularly.
• Through the full available ROM.

Active Movement (ROM)

• Movements performed within the unrestricted range of motion.
• Controlled by voluntary muscle contractions.

Classification of Active Movement

• Free Exercise: Working muscles are solely under the influence of gravity.
• Assisted Exercise: Used when muscle strength is insufficient, external force (manual or mechanical) provides assistance.
• Resisted Exercise: External forces (manual or mechanical) increase resistance against the working muscles to build strength and endurance.

Active-Assistive ROM (AAROM)

• Performed within unrestricted ROM.
• Voluntary muscle contractions provide most of the movement.
• Outside force (manual or mechanical) assists as needed when muscle strength is limited.
• Muscle grade less than 3 on manual muscle testing.

The Principles of Active Assisted Exercises

• Insufficient voluntary muscle contraction to control movement.
• External force to complete the range.
• Force application in the direction of muscle action.
• Force to augment, not replace, muscular action.
• Assistance decreases proportionately as muscular power increases.

Types of Assistance

• Manual Assistance: Assistance provided by another person.
  • Therapist.
  • Patient's sound limb.
• Mechanical Assistance: Assistance provided by equipment.
  • Wand or T-bar.
  • Finger ladder, wall climbing, ball rolling.
  • Pulleys.
  • Skate board/ powder board.
  • Reciprocal exercise devices.

Effects and Uses of AAROM

• Strengthens when the patient has weakness (but not paralysis).
• Maintains physiologic elasticity and contractility of participating muscles.
• Helps sensory feedback during neuromuscular re-education.
• Provides stimulus to bone/joint integrity.
• Facilitates coordination and motor skills for functional activities (repetitive assisted exercises).
• Enhances patient confidence and cooperation.
• Prevents deep vein thrombosis (DVT).
• Improves blood circulation.
• Enhances metabolism and reduces stress/pain to aid weight loss.
• Reduces risk of heart disease/heart attack.

Contraindications of AAROM

• Gross swelling/inflammation.
• Recent myocardial infarction.
• Severe pain.
• Cardiopulmonary dysfunction.
• Unhealed fractures/recent surgeries.
• Acute tendon/ligament tears.
• Deep vein thrombosis (DVT).

Indications of AAROM

• Muscle weakness (disuse/after cast).
• Muscle re-education.
• Inability to complete activities of daily living (ADL).
• Improving ROM.
• Post-tendon/muscle transplantation.

Precautions for ROM Exercises

• Perform exercises proximal and distal from the injury/immobile joint to minimize venous and thrombus formation.

Technique of Assisted Exercise

• Starting position: Ensures patient attention and the appropriate effort for the exercise.
• Pattern of movement: Explained by performing passively/actively on a healthy limb.
• Fixation: Proximal fixation of prime movers improves their efficiency and prevents undesirable movements.
• Support: Supporting the moved body part (by pillows, boards, slings, or therapist's hands) reduces load on muscles, making the exercise easier.
• Traction: Pre-stretching of the weak muscle stimulates contractions via a myotatic reflex.
• Antagonistic Muscle: Selecting a starting position that reduces antagonistic muscle tension.
• Assistance force: Applying force in the direction of movement, adapting to different parts of ROM, to start, support and finish a movement.
• Character of movement: Smooth and rhythmic, focusing on efficient and consistent movement.
• Repetitions: Number of repetitions based on patient condition and fatigue rate.
• Patient cooperation: Encouraging maximal effort during the workout to aid in success.

Active Free Exercise (AROM)

• Exercises performed using the patient's muscles without assistance or resistance, other than gravity.
• Types of AROM:
  • Localized: strengthening specific muscle groups.
  • Generalized: utilizing many muscles throughout the body.

The Principles of Active Free Exercises

• Relaxation: Using rhythmic or pendulum-like exercises.
• Joint mobility: Maintaining normal range of motion through the complete range (exercises performed fully).
• Working muscle power/endurance: Building strength and endurance.
• Coordination: Improving the coordination of muscles.
• Confidence: Building confidence in the patient.
• Circulatory/respiratory co-operation: During prolonged exercise, respiration will become more intense.

Goals for AROM

• Maintain physiologic elasticity and contractility of participating muscles.
• Provide sensory feedback from contracting muscles.
• Provide stimulus for bone and joint integrity.
• Increase circulation and prevent thrombus formation.
• Develop coordination.

Technique of Active Free Exercise

• Starting position: Efficient posture is a key for effectiveness.
• Speed: Adjustment based on desired outcome.
• Duration: Patient's capacity is guiding factor, stopping short of fatigue.
• Demonstration/guidance: Demonstrating and guiding patients to perform movements.

Passive vs. Active ROM

• Passive ROM primarily stresses the ligament/joint capsule complex (stretching and/or compression).
• Active ROM stresses both the mover muscles and the ligament/joint capsule complex (muscle contraction creates the movement.
• Pain generation in active ROM is an indicator for musculoskeletal injury.
• Active ROM is useful as an initial screening for soft tissue injuries.

Manual Resistance

• Only mover musculature is stressed – no external force, maintaining the isometric contraction.
• Pain may occur if mover muscles/tendons are damaged.
• Ligaments and joint capsules are not impacted due to no active movement.

Effects of Immobilization

• Fractures, surgery, paralysis, muscle spasticity, various forms of arthritis, even pain can result from extended periods of immobilization.
• Loss of bone density: Reduced muscle contraction/weight-bearing forces can result in delayed/incomplete recovery of bone mass/volume/strength.
• Articular Cartilage: Reduces thickness, stiffness; diminishes ability to absorb/dissipate joint forces without injury.
• Collagen tissue fibrosis/adhesions: Caused by excessive collagen fiber cross-links.
• Muscle tissue atrophy/contracture: Leads to reduction in muscle size and force. Slow-twitch fibers impacted more than fast-twitch.