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.

This quiz explores key concepts related to complex systems, focusing on their challenges and properties. Participants will answer questions about system performance and methods of analysis. Test your knowledge on how complexity impacts systems and their emergent behaviors.