RANGE OF MOTION

EXERCISE
 DEFINITON OF ROM AND OTHER
RELATED TERMS
Range of motion – is the full motion
possible in a joint.
 PASSIVE ROM
 ACTIVE ROM
 ACTIVE ASSISTIVE ROM
 FUNCTIONAL EXCURSION
 ACTIVE INSUFFICIENCY
 PASSIVE INSUFFICIENCY
INDICATIONS FOR ROM EXERCISES

Passive ROM exercise

Indicated in the following patients:
 Comatose and completely paralyzed and
immobilized patients or body part.
 On complete bed rest where any active
contraction is contraindicated.
 Where there is an acute inflammatory
reaction.
INDICATIONS FOR ROM EXERCISES

 Used in evaluating joint and soft tissue

injury.
 Used to demonstrate a desired motion or
test to a patient.
 Used as preparatory to passive stretching.
 Used for muscle grade to zero and trace.
 INDICATIONS FOR ROM
EXERCISES
Active and active – assistive ROM
 Used for muscle graded poor to fair minus.
 Used to provide enough assistance to muscles
in a carefully controlled manner so that that
muscle can function at its maximum level and
progressively be strengthened.
 Used when there is no contraindication to
active movement.
  
EFFECTS OF ROM EXERCISES

Passive ROM exercises

 Maintain joint and soft tissue integrity.
 Prevent contractures.
 Maintain muscle elasticity and prevent
adaptive shortening.
 Assist circulation and vascular dynamics
EFFECTS OF ROM EXERCISES

 Enhance synovial movement for the cartilage

nutrition and diffusion of materials in the
joint.
 Decrease or inhibit pain.
 Assist with the healing process following
injury or surgery.
 Help maintain the patient’s awareness of
movement.
EFFECTS OF ROM EXERCISES

Active and active – assisted ROM

 Maintain muscle elasticity and contractility.
 Provide sensory feedback from contracting
muscle.
 Provide stimulus for bone integrity.
EFFECTS OF ROM EXERCISES

 Increase circulation and prevent thrombus

formation.
 Develop coordination and motor skills for
functional activities.
 Improve cardiovascular and respiratory
responses.
 LIMITATION OF ROM EXERCISES

Passive ROM exercises

 Difficult to achieve in innervated muscles and
conscious patients.
 It will not prevent atrophy.
 It will not increase strength and endurance.
 It will not improve or assist circulation to the
extent that active muscle contraction does.
LIMITATION OF ROM EXERCISES

Active ROM
 It will not maintain or increase strength.
 It will not develop skill or coordination except
in the movement pattern used.
 It may encourage compensatory rather than
normal movement patterns
PRECAUTIONS AND CONTRAINDICATION
TO ROM EXERCISES
 When motion disrupts the healing process as
in acute joint inflammations and immediately
after skin graft etc.
 Immediately following acute tears, fractures
and surgery.
 Unstable cardiovascular conditions.
 Signs of too much or wrong motion include
increased pain and increased
inflammations(greater swelling, heat ,redness)
 PRINCIPLES AND PROCEDURE FOR
APPLYING ROM TECHNIQUES
 Determine whether PROM, AAROM, or AROM will meet the
goals based on evaluation of the patient’s impairment and
level of function.
 Place the patient in a comfortable position that will allow you
to move the segment through the available ROM(patient has
proper body alignment)
 Position yourself so that proper body mechanics can be used.
 Support areas of poor structural integrity such as hyper
mobile joint, recent fracture site or paralyzed limb.
 Move the segment through its complete pain – free range( do
not force beyond the available range – it becomes stretching
technique)
 PRINCIPLES AND PROCEDURE FOR
APPLYING ROM TECHNIQUES
 Perform the motion smoothly and rhythmically
 ROM techniques may be performed in the :
1. Anatomical planes of ROM
2. Muscle range of elongation
3. Combined patterns
4. Functional patterns
 Monitor the patient’s general condition during and after
the procedure.
 Document observable and measurable reactions to the
treatment.
 Modify or progress the treatment as necessary.
ROM TECHNIQUES

 UPPER EXTREMITY
1.Shoulder : flexion and extension
Hand Placement and Motion
 grasp the patient’s arm under the elbow with your lower
hand.
 with the top hand, cross over and grasp the wrist and palm
of the patient’s hand.
 Lift the arm through the available range and return. Note:
for normal motion, the scapula should free to rotate
upward as the shoulder flexes. If the motion of only the
glenohumeral joint is desired, the scapula is stabilized.
 Shoulder : extension(hyperextension)
Alternate Position
 Extension is possible if the patient’s shoulder
is at the edge of the bed when supine or if the
patient positioned side- lying or prone.
 Shoulder :abduction and adduction
Hand Placement and Motion
 use the same hand placement as with flexion,
but move the arm out to the side. The elbow
may be flexed.
 
 Note: to reach the full range of abduction,
there must be external rotation of the
humerus and upward rotation of the scapula.
 Shoulder: internal (medial) and
external(lateral) rotation
Initial Position of the Arm
 If possible the arm is abducted 90⁰, the elbow
is flexed to 90⁰ and forearm is held in neutral
position. Rotation may also be performed
with the patient’s arm at the side of thorax,
but full internal rotation will not be possible.
Hand Placement and Motion
 Grasp the hand and the wrist with your index
finger between the patient’s thumb and index
finger.
 Place your thumb and the rest of your fingers on
either side of the patient’s wrist, thus stabilizing
the wrist.
 With the other hand, stabilize the elbow. Rotate
the humerus by moving the forearm like a spoke
in a wheel.
 Shoulder: horizontal abduction(extension) and
adduction(flexion)
Position of the Arm
 to reach the full horizontal abduction, the shoulder
must be at the edge of the table. Begin with the
arm either flexed or abducted 90⁰.
Hand Placement and Motion
 -same as with flexion, but the therapist turn his or
her body and faces the patient’s head as the patient
arm is moved out to the side then across the body.
Scapula: elevation/depression, protraction/retraction, and
upward/downward rotation
Alternate Position
 prone , with the patient’s arm at the side, or side lying, with
the patient facing the therapist and the patient’s arm draped
over the therapist bottom arm.
 
Hand Placement and Motion
 cup the top hand over the acromion process and place the
other hand around the inferior angle of the scapula.
 For elevation, depression, protraction, retraction, the clavicle
also moves as the scapular motions are directed at the
acromion process.
 For rotation, direct the scapular motions at the inferior angle.
 Elbow: flexion and extension
Hand Placement and Motion
 same as with shoulder flexion except the motion
occurs at the elbow as it is flexed and extended.
 
Note: control forearm supination and pronation
with your fingers around the wrist. Perform
elbow flexion and extension with forearm
pronated as well as supinated. The shoulder
should not protract when the elbow extends:
this disguises the true range.
 Elongation of two joint muscle crossing the shoulder and elbow
 Biceps brachii muscle
Position of the Patient
 supine with the shoulder at the edge of the treatment table so
that shoulder can be extended past the neutral position. 
 
Hand Placement and Motion
 -first pronate the patient’s forearm by grasping around the
wrist, and extend the elbow by supporting under the elbow.
 -The shoulder is then extended (hyperextended) until the
patient experiences discomfort in the anterior arm region. At
this point, full available lengthening of the two joint muscles is
reached.
 Long head of the triceps brachii muscle
Alternate Position
 when near normal range of this muscle is available, the
patient must be sitting or standing to reach the full
ROM. With marked limitation in muscle range, ROM can
be performed in supine position.
 
Hand Placement and Motion
 First, flex the patient’s elbow full range with one hand
on the distal forearm
 Then flex the shoulder by lifting up on the humerus with
the other hand under the elbow.
 Full available range is reached when discomfort is
experienced in the posterior arm region.
 Forearm: pronation and supination
Hand Placement and Motion
 grasp the patient’s wrist, supporting the hand with the index finger and
placing the thumb and the rest of the finger on either side of the distal
forearm.
 The motion is a rolling of the radius around the ulna at the distal
radius.
 Stabilize the elbow with the other hand. 
Alternate Hand Placement
 sandwich the patient’s distal forearm between the palms of both hand.

Note: pronation and supination should be performed with the elbow

both flexed and extended.
Caution: do not stress the wrist by twisting the hand; control the
pronation and supination motion by moving the radius around the
ulna.
 Wrist: flexion(palmar flexion) and extension
(dorsiflexion), radial and ulnar deviation
Hand Placement and Motion
 for all wrist motions, grasp the patient’s hand just distal
to the joint with one hand, and stabilize the forearm
with the other hand.
 
Note: the range of the extrinsics muscle to the finger will
affect the range at the wrist if tension is placed on
them. To get full range of the wrist joint, allow the
fingers to move freely as you move the wrist.
 Hand : cupping and flattening the arch of the hand at
carpometacarpal and intermetacarpal joints
Hand Placement and Motion
 face the patient’s hand; place the fingers in the palms of the
patient’s hand and the thumbs on the posterior aspect.
 Roll the metacarpal to increase the arch, then flattened it.
 
Alternate Hand Placement
 one hand is placed on the posterior aspect of the patient’s hand
with the fingers and thumb cupping around the metacarpals.
 
Note: extension and abduction of the thumb at the
carpometacarpal joint are important in maintaining the web
space for functional movement of the hand.
 Joints of the Thumb and Fingers: flexion and extension and abduction
and adduction(of the metacarpophalangeal joints of the fingers)
Hand Placement and Motion
 each joint of the patient’s hand can be moved individually by stabilizing
the proximal bone with the index finger and thumb with one hand and
moving the distal bone with the index finger and thumb of the other
hand depending on the position of the patient, the forearm and hand
can be stabilized on the bed or table or against therapist body.
 Alternate Method
 several joints can be moved simultaneously if proper stabilization is
provided. Example: to move all the metacarpophalangeal joints of digits
2 through 5, stabilize the metacarpals with one hand and move all the
proximal phalanges with the other hand.
 Note: to accomplish full joint range of motion, do not place tension on
the extrinsic muscle going to the fingers. Tension on the muscle can be
relieved by altering the wrist position as the fingers are moved.
 Elongation of the extrinsic muscles of the wrist and hand
General Technique
 to minimize compression of the small joints of the fingers,
begin the motion with the distal most joint, then elongate the
muscle over one joint at a time, stabilize that joint then
elongate the muscle over the next joint until the multijoint
muscles are at maximum length.
 Hand Placement and Motion
 First move the distal IP joint
 hold both these joint at the end of their range; then move the
metacarpophalangeal joint to the end of the available range.
 stabilize all the finger joints and begin to extend the wrist.
When patient feels discomfort in the forearm, the muscles are
fully elongated.
 LOWER EXTREMITY

 Combined Hip and Knee: flexion and Extension

Hand Placement and Motion
 support and lift the patient’s leg with the palm and fingers of
the top hand under the patient’s knee and the lower hand
under the heel.
 as the knee flexes full range, swing the fingers to the side of
the thigh.
 
Note: to reach full range of hip flexion, the knee must also be
flexed to release tension on the hamstring muscle group. To
reach the full range of knee flexion, the hip must be flexed to
release tension on the rectus femoris muscle.
 Hip: extension ( hyperxtension)
Alternate Position
 prone or side –lying must be used if the patient has a
near normal or normal motion.
Hand Placement and Motion
 if the patient is prone, lift the thigh with the bottom
hand under the patient’s knee; stabilize the pelvis with
the top hand or arm.
 if the patient is side-lying, bring the bottom hand under
the thigh and place the hand on the anterior surface;
stabilize the pelvis with the top hand. For full range of
hip extension, do not flex the knee full range, as the
two-joint rectus femoris would then restrict the range.
 Elongation of two-joint Hamstring Muscle
Group
Hand Placement and Motion
 place the lower hand under the patient’s heel
and the upper hand across the anterior aspect of
the patient’s knee.
 keep the knee in extension as the hip is flexed.
 if the knee requires support, cradle the patient’s
leg in your elbow flexed under the calf and your
hand across the anterior aspect of the patient’s
knee. The hand provides support or stabilization
where needed.
 Elongation of the two-joint Rectus Femoris Muscle
Alternate Position
 supine, with knee flexed over the edge of the treatment
table, or prone.
Hand Placement and Motion
 when supine, stabilize lumbar spine by flexing the hip
and knee of the opposite lower extremity and placing
the foot on the treatment table(hook lying)
 when prone, stabilize the pelvis with the top hand.
 flex the patient’s knee until tissue resistance is felt in the
anterior thigh, which means full available range is
reached.
 Hip: Abduction and Adduction
Hand Placement and Motion
 support the patient’s leg with the upper hand
under the knee and lower hand under the ankle.
 for full range of adduction, the opposite leg
needs to be in a partially abducted position.
 keep the patient’s hip and knee in extension
and neutral to rotation as abduction and
adduction are performed.
 Hip: Internal (medial) and External( lateral) Rotation
Hand Placement and Motion with the Hip and Knee Extended
 grasp just proximal to the patient’s knee with the top hand
and just proximal to the ankle with the bottom hand.
 roll thigh inward and outward.
 Hand Placement and Motion with the Hip and Knee Extended
 flex the patient’s hip and knee to 90⁰; support the knee with
the top hand.
 If the knee is unstable, cradle the thigh and support the
proximal calf and knee with the bottom hand.
 rotate the femur by moving the leg like a pendulum.
 Ankle: Dorsiflexion
Hand Placement and Motion
 stabilize around the malleoli with the top hand.
 cup the patient’s heel with the bottom hand and place
the forearm along the bottom of the foot.
 pull the calcaneus distal ward with the thumb and
fingers while pushing upward with the forearm.

Note: if knee is flexed, full range of the ankle joint can be

obtained. If the knee is extended, the lengthened range
of the two-joint gastrocnemius muscle limits full range
of dorsiflexion.apply dorsiflexion in both positions of the
knee to provide range to both the joint and the muscle.
 Ankle: Plantarflexion
Hand Placement and Motion
 support the heel with the bottom hand.
 place the top hand on the dorsum of the foot
and push it into plantarflexion.
Note: in bed-bound patient’s, the ankle tends to
assume a plantarflexed position from the
weight of the blankets and the pull of the
gravity, so this motion may not need to
performed.
 Subtalar(lower ankle) Joint: Inversion and
Eversion
Hand Placement and Motion
 using the bottom hand, place the thumb
medial and the fingers lateral to the joint on
either side of the heel.
 turn the heel inward and outward.
Note: supination of the foot may be combined
with inversion, and pronation may be
combined with eversion.
 Transverse Tarsal Joint
Hand Placement and Motion
 stabilize the patient’s talus and calcaneus
with one hand
 with the other hand, grasp around the
navicular and cuboid.
 gently rotate the midfoot by lifting and
lowering the arch.
 Joints of the Toes: Flexion and Extension and
Abduction and Adduction (Metatarsophalangeal
and Interphalangeal Joint)
Hand Placement and Motion
 stabilize the bone proximal to the joint that is to be
moved aith the other hand, and move the distal bone
with the other hand.
 the technique is the same as for ROM of the fingers.
Alternate Procedure
 several joints of the toes can be moved
simultaneously if care is taken not to stress any
structure.
CERVICAL SPINE
Position of the therapist and Hand Placement
 standing at the end of the treatment table,
securely grasp the patient’s head by placing
hands under the occiput.
Flexion (Forward Bending)
 lift the head as though it were nodding(chin
towards larynx) to flex the head on the neck.
 once full nodding is complete, continue to
flex the cervical spine and lift the head toward
the sternum.
Flexion (Forward Bending)
 lift the head as though it were nodding(chin
towards larynx) to flex the head on the neck.
 once full nodding is complete, continue to
flex the cervical spine and lift the head toward
the sternum.
Extension (Backward Bending or
Hyperextension)
 tip the head backward.
Note: if the patient is supine, only the head and
the upper cervical spine can be extended; the
head must clear the end of the table to
extend the entire cervical spine. The patient
may also be prone or sitting.
Lateral Flexion(Side Bending)
 Maintain the cervical spine neutral to flexion
and extension as you direct the head and
neck into side bending(approximate the ear
toward the shoulder) and rotation(rotate
from side to side)
LUMBAR SPINE

Flexion
 bring both the patient’s knees to the chest by
lifting under the knees(hip and knee flexion)
 flexion of the spine occurs as the hips are
flexed full range and the pelvis starts to rotate
posteriorly.
 greater range of flexion can be obtained by
lifting under the patient’s sacrum with the
lower hand.
Extension
 the patient is prone
 with hands under the thigh, lift the thighs
upward until the pelvis rotates anteriorly and
the lumbar spine extends.
Rotation
 the patient is hook lying.
 push both of the patient’s thorax with the top
hand
 repeat in the opposite direction.
SELF- ASSISTED ROM

Arm and Forearm

 instruct the patient to reach across the body with the
uninvolved(or assisting)extremity and grasp the involved
extremity around the wrist, supporting the wrist and hand.
Shoulder Flexion and Extension
 patient lifts the involved extremity over the head and
returns it to the side.
Shoulder Horizontal Abduction and Adduction
 beginning with the ram abducted to 90⁰, the patient pulls
the extremity across the chest and returns it out to the
side.
 Shoulder Rotation
 beginning with the arm at the patient’s side in
slight abduction or abducted 90⁰ and elbow
flexed 90⁰, the patient rotates the forearm with
the uninvolved extremity.
 it is important to emphasized rotating the
humerus, not merely flexing and extending the
elbow.
Elbow flexion and Extension
 patient bends the elbow until the hand is near
the shoulder and then moves the hand down
toward the side of the leg.
Pronation and Supination of the Forearm
 with the forearm resting across the body, the
patient rotates the radius around the ulna;
emphasized to the patient not to twist the
hand at the wrist joint.
Wrist and Hand

Wrist flexion and Extension and Radial and

Ulnar deviation
 patient moves the wrist in all directions,
applying no pressure against the fingers.
Finger Flexion and Extension
 patient uses the uninvolved thumb to extend
the involved fingers and cups the normal
fingers over the dorsum of the involved
fingers to flex them.
Thumb Flexion with Opposition and extension
with reposition
 patient cups the uninvolved fingers around the
radial border of the thenar eminence of the
involved thumb and places uninvolved thumb to
extend it.
 to flex and oppose the thumb, the patient cups
the normal hand around the dorsal surface of the
involved hand and pushes the first metacarpal
toward the little finger.
Hip and Knee

Hip and knee flexion

 with the patient supine, instruct the patient to
initiate the motion by lifting up the involved knee
with strap or belt under the knee. The patient can
then grasp the knee with one or both hands to bring
the knee up toward the chest to complete the range.
Hip abduction and Adduction
 instruct the patient to slide the normal foot from the
knee down to the ankle and then move the involved
extremity from side to side.
Combined Hip abduction with external
rotation
 patient is sitting on the floor or on abed with
the back supported and the involved hip and
knee flexed and foot resting on the surface.
 the knee is moved outward and back inward
with assistance from the upper extremity.
Ankle and Toes

 patient sits with the involved extremity

crossed over the uninvolved one so the distal
leg rests on the normal knee.
 The uninvolved hand moves the involved
ankle into dorsiflexion, plantarflexion,
inversion and eversion and toe flexion and
extension.
 TECHNIQUES OF ROM USING
MECHANICAL ASSISTANCE
SUSPENSION SYSTEM
 Vertical fixation
 Axial fixation
 Benefits of suspension for
ROM exercises
 Active participation is required, thus the
patient learns to use the appropriate muscles
for the desired movement.
 It promotes relaxation through secure
support and smooth, rhythmic motion
 Little work is required for stabilization
 Modifications can be made to the system to
provide grades of exercise resistance.
 Patient can work independently.
 CONTINOUS PASSIVE MOTION(CPM)
Indication and procedure of CPM
 Patient’s response, surgical procedure or disease entity
may necessitate modifying the range, time, and duration
of CPM application.
 CPM may be used or applied to the involved extremity
immediately after surgery while patient is still under
anesthesia or within 3 days if bulky dressings limit
movement.
 A low arc of 20 to 30 degrees may be used immediately
after surgery and ma progress the patient’s range as
tolerated.
 May be used for one hour 3x a day or for 24 hours
Benefits of CPM
Lessens negative effects of joint immobilization in arthritis,
contractures and intra-articular fractures
Decrease the frequency of postoperative complication
Prevent development of adhesions and decrease contracture
formation
Decrease post operative pain
Improve circulation to enhance nutritional status of extremity
Increase synovial fluid lubrication of the joint
Decrease joint effusion and wound edema thus improving wound
healing
Increase the rate of intra-articular cartilage healing regeneration
provide a quicker return of ROM