Range of Motion Exercises PDF

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 aro...

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