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P A R !
^pplled Sclence ol
lxerclse and 1echnlques
kanqe ol Mollon
C h A P ! L R
lN0lCAJl0NS AN0 00ALS F0P P0M 44
Passìvc P0M 44
Acfìvc and Acfìvc-Assìsfìvc P0M 44
Lìmìfafìons of Passìvc Mofìon 45
Lìmìfafìons of Acfìvc P0M 45
Examìnafìon, Evaluafìon, and Jrcafmcnf
Plannìng 45
Pafìcnf Prcparafìon 48
Applìcafìon of Jcchnìqucs 48
Applìcafìon of PP0M 48
Applìcafìon of AP0M 48
uppcr Exfrcmìfy 47
Lowcr Exfrcmìfy 52
Ccrvìcal Spìnc 55
Lumhar Spìnc 55
Comhìncd Paffcrns of Mofìon 58
Sclf-Assìsfancc 57
Wand (J-8ar} Excrcìscs 50
Wall Clìmhìng 80
0vcrhcad Pullcys 80
Skafc 8oardjPowdcr 8oard 81
Pccìprocal Excrcìsc unìf 81
C0NJlNu0uS PASSlvE M0Jl0N 81
8cncfìfs of CPM 81
0cncral 0uìdclìncs for CPM 82
Range oI motion is a basic technique used Ior the exami-
nation oI movement and Ior initiating movement into a
program oI therapeutic intervention. Movement that is nec-
essary to accomplish Iunctional activities can be viewed, in
its simplest Iorm, as muscles or external Iorces moving
bones in various patterns or ranges oI motions. When a
person moves, the intricate control oI the muscle activity
that causes or controls the motion comes Irom the central
nervous system. Bones move with respect to each other at
the connecting joints. The structure oI the joints, as well
as the integrity and Ilexibility oI the soIt tissues that pass
over the joints, aIIects the amount oI motion that can occur
between any two bones. The Iull motion possible is called
the range of motion (ROM). When moving a segment
through its ROM, all structures in the region are aIIected:
muscles, joint surIaces, capsules, ligaments, Iasciae, ves-
sels, and nerves. ROM activities are most easily described
in terms oI joint range and muscle range. To describe
joint range, terms such as Ilexion, extension, abduction,
adduction, and rotation are used. Ranges oI available
joint motion are usually measured with a goniometer
and recorded in degrees.
Muscle range is related to the
Iunctional excursion oI muscles.
Functional excursion is the distance a muscle is
capable oI shortening aIter it has been elongated to its
In some cases the Iunctional excursion, or
range oI a muscle, is directly inIluenced by the joint it
crosses. For example, the range Ior the brachialis muscle is
limited by the range available at the elbow joint. This is
true oI one-joint muscles (muscles with their proximal and
distal attachments on the bones on either side oI one joint).
For two-joint or multijoint muscles (those muscles that
cross over two or more joints), their range goes beyond the
limits oI any one joint they cross. An example oI a two-
joint muscle Iunctioning at the elbow is the biceps brachii
muscle. II it contracts and moves the elbow into Ilexion
and the Iorearm into supination while simultaneously mov-
ing the shoulder into Ilexion, it shortens to a point known
as active insufficiencv, where it can shorten no more. This
is one end oI its range. The muscle is lengthened Iull range
by extending the elbow, pronating the Iorearm, and simul-
taneously extending the shoulder. When Iully elongated it
is in a position known as passive insufficiencv. Two-joint or
multijoint muscles normally Iunction in the midportion oI
their Iunctional excursion, where ideal length-tension rela-
tions exist.
To maintain normal ROM, the segments must be
moved through their available ranges periodically, whether
it is the available joint range or muscle range. It is recog-
nized that many Iactors can lead to decreased ROM, such
as systemic, joint, neurological, or muscular diseases; sur-
gical or traumatic insults; or simply inactivity or immobi-
lization Ior any reason. Therapeutically, ROM activities are
administered to maintain joint and soIt tissue mobility to
minimize loss oI tissue Ilexibility and contracture Iorma-
Extensive research by Salter has provided evidence
oI the beneIits oI movement on the healing oI tissues in
various pathological conditions in both the laboratory and
clinical settings.
The principles oI ROM described in this chapter do
not encompass stretching to increase range. Principles and
techniques oI stretching and joint mobilization Ior treating
impaired mobility are described in Chapters 4 and 5.
Passive ROM. Passive ROM (PROM) is movement oI a
segment within the unrestricted ROM that is produced
entirely by an external force; there is little to or no vol-
untary muscle contraction. The external Iorce may be
Irom gravity, a machine, another individual, or another
part oI the individual`s own body.
PROM and passive
stretching are not synonymous (see Chapter 4 Ior deIini-
tions and descriptions oI passive stretching).
Active ROM. Active ROM (AROM) is movement oI
a segment within the unrestricted ROM that is pro-
duced by active contraction oI the muscles crossing
that joint.
Active-Assistive ROM. Active-assistive ROM (A-
AROM) is a type oI AROM in which assistance is pro-
vided manually or mechanically by an outside Iorce
because the prime mover muscles need assistance to
complete the motion.
Passìvc P0M
lndìcafìons for PP0M
In the region where there is acute, inIlamed tissue, pas-
sive motion is beneIicial; active motion would be detri-
mental to the healing process. InIlammation aIter injury
or surgery usually lasts 2 to 6 days.
When a patient is not able to or not supposed to actively
move a segment or segments oI the body, as when coma-
tose, paralyzed, or on complete bed rest, movement is
provided by an external source.
0oals for PP0M
The primary goal Ior PROM is to decrease the complica-
tions that would occur with immobilization, such as carti-
lage degeneration, adhesion and contracture Iormation, and
sluggish circulation.
SpeciIically, the goals are to:
Maintain joint and connective tissue mobility
Minimize the eIIects oI the Iormation oI contractures
Maintain mechanical elasticity oI muscle
Assist circulation and vascular dynamics
Enhance synovial movement Ior cartilage nutrition and
diIIusion oI materials in the joint
Decrease or inhibit pain
Assist with the healing process aIter injury or surgery
Help maintain the patient`s awareness oI movement
0fhcr uscs for PP0M
When a therapist is examining inert structures, PROM is
used to determine limitations oI motion, to determine
joint stability, and to determine muscle and other soIt tis-
sue elasticity.
When a therapist is teaching an active exercise program,
PROM is used to demonstrate the desired motion.
When a therapist is preparing a patient Ior stretching,
PROM is oIten used preceding the passive stretching
Acfìvc and Acfìvc-Assìsfìvc P0M
lndìcafìons for AP0M
Whenever a patient is able to contract the muscles
actively and move a segment with or without assistance,
AROM is used.
When a patient has weak musculature and is unable to
move a joint through the desired range (usually against
gravity), A-AROM is used to provide enough assistance
to the muscles in a careIully controlled manner so the
muscle can Iunction at its maximum level and be pro-
gressively strengthened. Once patients gain control oI
their ROM, they are progressed to manual or mechanical
resistance exercises to improve muscle perIormance Ior a
return to Iunctional activities (see Chapter 6).
AROM can be used Ior aerobic conditioning programs
(see Chapter 7).
44 lN0lCAJl0NS AN0 00ALS F0P P0M
It is imperative that the therapist recognizes the value
as well as potential abuse oI motion and stays within the
range, speed, and tolerance oI the patient during the acute
recovery stage.
Additional trauma to the part is contraindi-
cated. Signs oI too much or the wrong motion include
increased pain and increased inIlammation (greater
swelling, heat, and redness). See Chapter 10 Ior principles
oI when to use the various types oI passive and active
motion therapeutically.
Usually, AROM oI the upper extremities and limited
walking near the bed are tolerated as early exercises aIter
myocardial inIarction, coronary artery bypass surgery, and
percutaneous transluminal coronary angioplasty.
monitoring oI symptoms, perceived exertion, and blood
pressure is necessary. II the patient`s response or the condi-
tion is liIe-threatening, PROM may be careIully initiated to
the major joints along with some AROM to the ankles and
Ieet to avoid venous stasis and thrombus Iormation. Indi-
vidualized activities are initiated and progress gradually as
the patient tolerates.
Examìnafìon, Evaluafìon, and
Jrcafmcnf Plannìng
1. Examine and evaluate the patient`s impairments and
level oI Iunction, determine any precautions and pro-
gnosis, and plan the intervention.
When a segment oI the body is immobilized Ior a period
oI time, AROM is used on the regions above and below
the immobilized segment to maintain the areas in as nor-
mal a condition as possible and to prepare Ior new activ-
ities, such as walking with crutches.
0oals for AP0M
II there is no inIlammation or contraindication to active
motion, the same goals oI PROM can be met with AROM.
In addition, there are physiological beneIits that result Irom
active muscle contraction and motor learning Irom volun-
tary muscle control. SpeciIic goals are to:
Maintain physiological elasticity and contractility oI the
participating muscles
Provide sensory Ieedback Irom the contracting muscles
Provide a stimulus Ior bone and joint tissue integrity
Increase circulation and prevent thrombus Iormation
Develop coordination and motor skills Ior Iunctional
Lìmìfafìons of Passìvc Mofìon
True passive, relaxed ROM may be diIIicult to obtain when
muscle is innervated and the patient is conscious. Passive
motion aoes not.
Prevent muscle atrophy
Increase strength or endurance
Assist circulation to the extent that active, voluntary
muscle contraction does
Lìmìfafìons of Acfìvc P0M
For strong muscles, active ROM aoes not maintain or
increase strength. It also aoes not develop skill or coordi-
nation except in the movement patterns used.
Although both PROM and AROM are contraindicated
under any circumstance when motion to a part is disruptive
to the healing process (Box 3.1), complete immobility
leads to adhesion and contracture Iormation, sluggish cir-
culation, and a prolonged recovery time. In light oI
research by Salter
and others,
early, continuous PROM
within a pain-Iree range has been shown to be beneIicial to
the healing and early recovery oI many soIt tissue and joint
lesions (discussed later in the chapter). Historically, ROM
has been contraindicated immediately aIter acute tears,
Iractures, and surgery; but because the beneIits oI con-
trolled motion have demonstrated decreased pain and an
increased rate oI recovery, early controlled motion is used
so long as the patient`s tolerance is monitored.
C R A P J E P 8 Panqe of Molion 45
80X 8.1 Summary of Prccaufìons and Confraìn-
dìcafìons fo Pangc of Mofìon Excrcìscs
R0M slould nol bc donc wlcn molion is disiuplivc lo llc
lcaling pioccss.
- Caicfully conliollcd molion willin llc limils of pain-ficc
molion duiing caily plascs of lcaling las bccn slown lo
bcncfil lcaling and caily iccovciy.
- Signs of loo mucl oi llc wiong molion includc
incicascd pain and inflammalion.
R0M slould nol bc donc wlcn palicnl icsponsc oi llc
condilion is lifc-llicalcning.
- PR0M may bc caicfully inilialcd lo majoi joinls and
AR0M lo anklcs and fccl lo minimizc vcnous slasis and
lliombus foimalion.
- Aflci myocaidial infaiclion, coionaiy ailciy bypass
suigciy, oi pciculancous liansluminal coionaiy angio-
plasly, AR0M of uppci cxlicmilics and limilcd walk-
ing aic usually lolcialcd undci caicful moniloiing of
N01E. R0M is nol synonymous will sliclcling. Foi piccaulions and
conliaindicalions lo passivc and aclivc sliclcling lcclniqucs, scc
Claplcis 4 and ¯.
2. Determine the ability oI the patient to participate in the
ROM activity and whether PROM, A-AROM, or AROM
can meet the immediate goals.
3. Determine the amount oI motion that can be saIely
applied Ior the condition oI the tissues and health oI the
4. Decide what patterns can best meet the goals. ROM
techniques may be perIormed in the
a. Anatomic planes of motion: Irontal, sagittal, transverse
b. Muscle range of elongation: antagonistic to the line oI
pull oI the muscle
c. Combinea patterns: diagonal motions or movements
that incorporate several planes oI motion
d. Functional patterns: motions used in activities oI
daily living (ADL)
5. Monitor the patient`s general condition and responses
during and aIter the examination and intervention; note
any change in vital signs, any change in the warmth and
color oI the segment, and any change in the ROM, pain,
or quality oI movement.
6. Document and communicate Iindings and intervention.
7. Re-evaluate and modiIy the intervention as necessary.
Pafìcnf Prcparafìon
1. Communicate with the patient. Describe the plan and
method oI intervention to meet the goals.
2. Free the region Irom restrictive clothing, linen, splints,
and dressings. Drape the patient as necessary.
3. Position the patient in a comIortable position with prop-
er body alignment and stabilization but that also allows
you to move the segment through the available ROM.
4. Position yourselI so proper body mechanics can be
Applìcafìon of Jcchnìqucs
1. To control movement, grasp the extremity around the
joints. II the joints are painIul, modiIy the grip, still pro-
viding support necessary Ior control.
2. Support areas oI poor structural integrity, such as a
hypermobile joint, recent Iracture site, or paralyzed limb
3. Move the segment through its complete pain-Iree range
to the point oI tissue resistance. Do not Iorce beyond the
available range. II you Iorce motion, it becomes a
stretching technique.
4. PerIorm the motions smoothly and rhythmically, with 5
to 10 repetitions. The number oI repetitions depends on
the objectives oI the program and the patient`s condition
and response to the treatment.
Applìcafìon of PP0M
1. During PROM the Iorce Ior movement is external, being
provided by a therapist or mechanical device. When
appropriate, a patient may provide the Iorce and be
taught to move the part with a normal extremity.
2. No active resistance or assistance is given by the
patient`s muscles that cross the joint. II the muscles
contract, it becomes an active exercise.
3. The motion is carried out within the Iree ROM, that is,
the range that is available without Iorced motion or pain.
Applìcafìon of AP0M
1. Demonstrate the motion desired using PROM; then ask
the patient to perIorm the motion. Have your hands in
position to assist or guide the patient iI needed.
2. Provide assistance only as needed Ior smooth motion.
When there is weakness, assistance may be required
only at the beginning or the end oI the ROM, or when
the eIIect oI gravity has the greatest moment arm
3. The motion is perIormed within the available ROM.
The descriptions oI positions and ROM techniques in this
section may be used Ior PROM as well as A-AROM and
AROM. When making the transition Irom PROM to
AROM, gravity has a signiIicant impact especially in indi-
viduals with weak musculature. When the segment moves
up against gravity, it may be necessary to provide assis-
tance to the patient. However, when moving parallel to
the ground (gravity eliminated or gravity neutral), the part
may need only to be supported while the muscles take the
part through the range. When the part moves downward,
with gravity causing the motion, muscles antagonist to the
motion become active and may need assistance in control-
ling the descent oI the part. The therapist must be aware
oI these eIIects and modiIy the patient`s position iI needed
to meet desired goals Ior A-AROM and AROM. Principles
and techniques Ior progression to manual and mechanical
resistance ROM to develop strength are described in
Chapter 6.
The Iollowing descriptions are, Ior the most part, with
the patient in the supine position. Alternate positions Ior
many motions are possible and, Ior some motions, neces-
sary. For eIIiciency, perIorm all motions possible in one
position; then change the patient`s position and perIorm all
appropriate motions in that position, progressing the treat-
ment with minimal turning oI the patient. Individual body
types or environmental limitations might necessitate varia-
tions oI the suggested hand placements. Use oI good body
mechanics by the therapist while applying proper stabiliza-
tion and motion to the patient to accomplish the goals and
avoid injury to weakened structures is the primary consid-
N 0 J L : !he lern nppcr cr tcp |crJ neans lhe hand
of lhe lheraµisl lhal is loward lhe µalienl's head; Icttcr
cr |cwcr |crJ refers lo lhe hand loward lhe µalienl's fool.
Anlaqonislic P0Ms are qrouµed loqelher for ease of aµµli-
uppcr Exfrcmìfy
Shouldcr: Flcxìon and Exfcnsìon (Fìg. 8.1}
Hand Placement and Procedure
Grasp the patient`s arm under the elbow with your lower
With the top hand, cross over and grasp the wrist and
palm oI the patient`s hand.
LiIt the arm through the available range and return.
N 0 J L : For nornal nolion, lhe scaµula should be free lo
rolale uµward as lhe shoulder flexes. lf nolion of only lhe
qlenohuneral |oinl is desired, lhe scaµula is slabilized as
described in lhe chaµler on slrelchinq (see Chaµler 4).
C R A P J E P 8 Panqe of Molion 47
Fl0uPE 8.1 hand µ|aceuen¦ and µos|¦|ons ¦or (} |n|¦|a¦|nç and (} couµ|e¦-
|nç s|ou|der ¦|ez|on.
Fl0uPE 8.2 h,µerez¦ens|on o¦ ¦|e s|ou|der (} w|¦| ¦|e µa¦|en¦ a¦ ¦|e edçe
o¦ ¦|e ued and (} w|¦| ¦|e µa¦|en¦ s|de-|,|nç.
Shouldcr: Exfcnsìon (Rypcrcxfcnsìon} (Fìg. 8.2}
Alternate Positions
Extension past zero is possible iI the patient`s shoulder is
at the edge oI the bed when supine or iI the patient is posi-
tioned side-lying, prone, or sitting.
Shouldcr: Ahducfìon and Adducfìon (Fìg. 8.8}
Hand Placement and Procedure
Use the same hand placement as with Ilexion, but move the
arm out to the side. The elbow may be Ilexed.
Scapula: Elcvafìonj0cprcssìon, ProfracfìonjPcfracfìon,
and upwardj0ownward Pofafìon (Fìg. 8.8}
Alternate Positions
The patient should be prone, with his or her arm at the
side, or side-lying, with the patient Iacing the therapist
and the patient`s arm draped over the therapist`s bottom
arm (see Fig. 3.6B).
N 0 J L : !o reach full ranqe of abduclion, lhere nusl be
exlernal rolalion of lhe hunerus and uµward rolalion of
lhe scaµula.
Shouldcr: Rorìzonfal Ahducfìon (Exfcnsìon}
and Adducfìon (Flcxìon} (Fìg. 8.5}
Patient Position
The patient`s shoulder must be at the edge oI the table to
reach Iull horizontal abduction. Begin with the arm either
Ilexed or abducted 90 .
Hand Placement and Procedure
Hand placement is the same as with Ilexion, but turn your
body and Iace the patient`s head as you move the patient`s
arm out to the side and then across the body.
Fl0uPE 8.5 hor|zon¦a| (} auduc¦|on and (} adduc¦|on o¦ ¦|e s|ou|der.
Fl0uPE 8.4 !|e 90|90 µos|¦|on ¦or |n|¦|a¦|nç (} |n¦erna| and (} ez¦erna|
ro¦a¦|on o¦ ¦|e s|ou|der.
Shouldcr: lnfcrnal (Mcdìal} and Exfcrnal
(Lafcral} Pofafìon (Fìg. 8.4}
Patient Position
II possible, the arm is abducted to 90 , the elbow is Ilexed
to 90 , and the Iorearm is held in neutral position. Rotation
may also be perIormed with the patient`s arm at the side oI
the thorax, but Iull internal rotation is not possible in this
Hand Placement and Procedure
Grasp the hand and the wrist with your index Iinger
between the patient`s thumb and index Iinger.
Place your thumb and the rest oI your Iingers on either
side oI the patient`s wrist, thereby stabilizing the wrist.
With the other hand, stabilize the elbow.
Rotate the humerus by moving the Iorearm like a spoke
on a wheel.
Fl0uPE 8.8 Auduc¦|on o¦ ¦|e s|ou|der w|¦| ¦|e e|uow ¦|ezed.
Hand Placement and Procedure
Cup the top hand over the acromion process and place
the other hand around the inIerior angle oI the scapula.
For elevation, depression, protraction, and retraction, the
clavicle also moves as the scapular motions are directed
at the acromion process.
For rotation, direct the scapular motions at the inIerior
angle oI the scapula while simultaneously pushing the
acromion in the opposite direction to create a Iorce cou-
ple turning eIIect.
C R A P J E P 8 Panqe of Molion 40
Fl0uPE 8.7 L|uow ¦|ez|on and ez¦ens|on w|¦| ¦|e ¦orearu suµ|na¦ed.
Fl0uPE 8.8 R0V o¦ ¦|e scaµu|a w|¦| ¦|e µa¦|en¦ (} µrone and w|¦| ¦|e
µa¦|en¦ (} s|de-|,|nç.
Elhow: Flcxìon and Exfcnsìon (Fìg. 8.7}
Hand Placement and Procedure
Hand placement is the same as with shoulder Ilexion
except the motion occurs at the elbow as it is Ilexed and
N 0 J L : Conlrol forearn suµinalion and µronalion wilh
your finqers around lhe dislal forearn. Perforn elbow flex-
ion and exlension wilh lhe forearn µronaled as well as
suµinaled. !he scaµula should nol liµ forward when lhe
elbow exlends, as il disquises lhe lrue ranqe.
Elongafìon of Jwo-1oìnf 8ìccps 8rachìì Musclc
Patient Position
To extend the shoulder beyond zero, position the patient`s
shoulder at the edge oI the table when supine or position
the patient prone lying, sitting, or standing.
Hand Placement and Procedure
First pronate the patient`s Iorearm by grasping the wrist
and extend the elbow while supporting it.
Then extend (hyperextended) the shoulder to the point oI
tissue resistance in the anterior arm region. At this point,
Iull available lengthening oI the two-joint muscle is
Elongafìon of Jwo-1oìnf Long Rcad
of fhc Jrìccps 8rachìì Musclc (Fìg. 8.8}
Alternate Positions
When near-normal range oI the triceps brachii muscle is
available, the patient must be sitting or standing to reach
the Iull ROM. With marked limitation in muscle range,
ROM can be perIormed in the supine position.
Wrìsf: Flcxìon (Palmar Flcxìon} and Exfcnsìon
(0orsìflcxìon}; Padìal (Ahducfìon} and ulnar
(Adducfìon} 0cvìafìon (Fìg. 8.10}
Hand Placement and Procedure
For all wrist motions, grasp the patient`s hand just distal to
the joint with one hand and stabilize the Iorearm with your
other hand.
N 0 J L : !he ranqe of lhe exlrinsic nuscles lo lhe finqers
affecl lhe ranqe al lhe wrisl if lension is µlaced on lhen. !o
oblain full ranqe of lhe wrisl |oinl, allow lhe finqers lo
nove freely as you nove lhe wrisl.
Forcarm: Pronafìon and Supìnafìon (Fìg. 8.0}
Hand Placement and Procedure
Grasp the patient`s wrist, supporting the hand with the
index Iinger and placing the thumb and the rest oI the
Iingers on either side oI the distal Iorearm.
Stabilize the elbow with the other hand.
The motion is a rolling oI the radius around the ulna at
the distal radius.
Alternate Hand Placement
Sandwich the patient`s distal Iorearm between the palms oI
both hands.
N 0 J L : Pronalion and suµinalion should be µerforned
wilh lhe elbow bolh flexed and exlended.
P ß L L A u J I 0 N : 0o nol slress lhe wrisl by lwislinq
lhe hand; conlrol lhe µronalion and suµinalion nolion by
novinq lhe radius around lhe ulna.
Fl0uPE 8.10 R0V a¦ ¦|e wr|s¦. S|own |s wr|s¦ ¦|ez|on, no¦e ¦|a¦ ¦|e ¦|nçers
are ¦ree ¦o uove |n resµonse ¦o µass|ve ¦ens|on |n ¦|e ez¦r|ns|c ¦endons.
Fl0uPE 8.0 Prona¦|on o¦ ¦|e ¦orearu.
Fl0uPE 8.8 Lnd R0V ¦or ¦|e |onç |ead o¦ ¦|e ¦r|ceµs urac||| uusc|e.
Hand Placement and Procedure
First, Iully Ilex the patient`s elbow with one hand on the
distal Iorearm.
Then Ilex the shoulder by liIting up on the humerus with
the other hand under the elbow.
Full available range is reached when discomIort is expe-
rienced in the posterior arm region.
Rand: Cuppìng and Flaffcnìng fhc Arch
of fhc Rand af fhc Carpomcfacarpal
and lnfcrmcfacarpal 1oìnfs (Fìg. 8.11}
Hand Placement and Procedure
Face the patient`s hand; place the Iingers oI both oI your
hands in the palms oI the patient`s hand and your thenar
eminences on the posterior aspect.
Roll the metacarpals palmarward to increase the arch,
and dorsalward to Ilatten it.
Alternate Hand Placement
One hand is placed on the posterior aspect oI the patient`s
hand, with the Iingers and thumb cupping the
N 0 J L : Exlension and abduclion of lhe lhunb al lhe
carµonelacarµal |oinl are inµorlanl for nainlaininq lhe
web sµace for funclional novenenl of lhe hand. lsolaled
flexion-exlension and abduclion-adduclion P0M of lhis
|oinl should be µerforned by novinq lhe firsl nelacarµal
while slabilizinq lhe lraµeziun.
C R A P J E P 8 Panqe of Molion 51
Fl0uPE 8.12 R0V ¦o ¦|e ue¦acarµoµ|a|ançea| ¦o|n¦ o¦ ¦|e ¦|uuu.
Fl0uPE 8.11 R0V ¦o ¦|e arc| o¦ ¦|e |and.
1oìnfs of fhc Jhumh and Fìngcrs: Flcxìon and Exfcn-
sìon and Ahducfìon and Adducfìon (Fìg. 8.12}
The joints oI the thumbs and Iingers include the metacar-
pophalangeal and interphalangeal joints.
Hand Placement and Procedure
Depending on the position oI the patient, stabilize the
Iorearm and hand on the bed or table or against your
Move each joint oI the patient`s hand individually by sta-
bilizing the proximal bone with the index Iinger and
thumb oI one hand and moving the distal bone with the
index Iinger and thumb oI the other hand.
Alternate Procedure
Several joints can be moved simultaneously iI proper stabi-
lization is provided. Example: To move all the metacar-
pophalangeal joints oI digits 2 through 5, stabilize the
metacarpals with one hand and move all the proximal pha-
langes with the other hand.
N 0 J L : !o acconµlish full |oinl P0M, do nol µlace len-
sion on lhe exlrinsic nuscles qoinq lo lhe finqers. !ension
on lhe nuscles can be relieved by allerinq lhe wrisl µosilion
as lhe finqers are noved.
Elongafìon of Exfrìnsìc Musclcs of fhc Wrìsf and Rand:
Flcxor and Exfcnsor 0ìgìforum Musclcs (Fìg. 8.18}
General Technique
To minimize compression oI the small joints oI the Iingers,
begin the motion with the distalmost joint. Elongate the
muscles 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. This is particularly critical
is there is restricted Ilexibility in the extrinsic musculature.
Hand Placement and Procedure
First move the distal interphalangeal joint and stabilize
it; then move the proximal interphalangeal joint.
Hold both these joints at the end oI their range; then
move the metacarpophalangeal joint to the end oI the
available range.
Stabilize all the Iinger joints and begin to extend the
wrist. When the patient Ieels discomIort in the Iorearm,
the muscles are Iully elongated.
Fl0uPE 8.14 (} ln|¦|a¦|nç and (} couµ|e¦|nç couu|ned ||µ and
|nee ¦|ez|on.
Rìp: Exfcnsìon (Rypcrcxfcnsìon} (Fìg. 8.15}
Alternate Positions
Prone or side-lying must be used iI the patient has near-
normal or normal motion.
Hand Placement and Procedure
II the patient is prone, liIt the thigh with the bottom hand
under the patient`s knee; stabilize the pelvis with the top
hand or arm.
II the patient is side-lying, bring the bottom hand under
the thigh and place the hand on the anterior surIace; sta-
bilize the pelvis with the top hand. For Iull range oI hip
extension, do not Ilex the knee Iull range, as the two-
joint rectus Iemoris would then restrict the range.
Fl0uPE 8.18 Lnd o¦ rançe ¦or ¦|e (} ez¦r|ns|c ¦|nçer ¦|ezors and
(} ez¦ensors.
Lowcr Exfrcmìfy
Comhìncd Rìp and Kncc: Flcxìon
and Exfcnsìon (Fìg. 8.14}
Hand Placement and Procedure
Support and liIt the patient`s leg with the palm and Iin-
gers oI the top hand under the patient`s knee and the
lower hand under the heel.
As the knee Ilexes Iull range, swing the Iingers to the
side oI the thigh.
N 0 J L : !o reach full ranqe of hiµ flexion, lhe knee nusl
also be flexed lo release lension on lhe hanslrinq nuscle
qrouµ. !o reach full ranqe of knee flexion, lhe hiµ nusl be
flexed lo release lension on lhe reclus fenoris nuscle.
Elongafìon of fhc Jwo-1oìnf Pccfus Fcmorìs Musclc
Alternate Positions
The patient is supine, with knee Ilexed over the edge oI the
treatment table, or prone.
Hand Placement and Procedure
When supine, stabilize the lumbar spine by Ilexing the
hip and knee oI the opposite lower extremity and placing
the Ioot on the treatment table (hook lying).
When prone, stabilize the pelvis with the top hand (see
Fig. 4.31)
Flex the patient`s knee until tissue resistance is Ielt in the
anterior thigh, which means the Iull available range is
Rìp: Ahducfìon and Adducfìon (Fìg. 8.17}
Hand Placement and Procedure
Support the patient`s leg with the upper hand under the
knee and the lower hand under the ankle.
For Iull range oI 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 perIormed.
Elongafìon of fhc Jwo-1oìnf Ramsfrìng
Musclc 0roup (Fìg. 8.18}
Hand Placement and Procedure
Place the lower hand under the patient`s heel and the
upper hand across the anterior aspect oI the patient`s
Keep the knee in extension as the hip is Ilexed.
II the knee requires support, cradle the patient`s leg in
your lower arm with your elbow Ilexed under the calI
and your hand across the anterior aspect oI the patient`s
knee. The other hand provides support or stabilization
where needed.
II the hamstrings are so tight as to limit the knee Irom
going into extension, the available range oI the muscle is
reached simply by extending the knee as Iar as the muscle
allows and not moving the hip.
C R A P J E P 8 Panqe of Molion 58
Fl0uPE 8.15 h|µ ez¦ens|on w|¦| ¦|e µa¦|en¦ s|de-|,|nç.
Fl0uPE 8.18 R0V ¦o ¦|e |aus¦r|nç uusc|e çrouµ.
Fl0uPE 8.17 Auduc¦|on o¦ ¦|e ||µ, ua|n¦a|n|nç ¦|e ||µ |n ez¦ens|on and
neu¦ra| ¦o ro¦a¦|on.
Rìp: lnfcrnal (Mcdìal} and Exfcrnal (Lafcral} Pofafìon
Hand Placement and Procedure 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
Roll the thigh inward and outward.
Hand Placement and Procedure for Rotation
With the Hip and Knee Flexed (Fig. 3.18)
Flex the patient`s hip and knee to 90 ; support the knee
with the top hand.
II the knee is unstable, cradle the thigh and support the
proximal calI and knee with the bottom hand.
Rotate the Iemur by moving the leg like a pendulum.
This hand placement provides some support to the
knee but should be used with caution iI there is knee
Suhfalar (Lowcr Anklc} 1oìnf: lnvcrsìon
and Evcrsìon (Fìg. 8.20}
Hand Placement and Procedure
Using the bottom hand, place the thumb medial and the
Iingers lateral to the joint on either side oI the heel.
Turn the heel inward and outward.
N 0 J L : Suµinalion of lhe fool nay be conbined wilh
inversion, and µronalion nay be conbined wilh eversion.
Jransvcrsc Jarsal 1oìnf
Hand Placement and Procedure
Stabilize the patient`s talus and calcaneus with one hand.
With the other hand, grasp around the navicular and
Gently rotate the midIoot by liIting and lowering the
Fl0uPE 8.10 0ors|¦|ez|on o¦ ¦|e an||e.
Fl0uPE 8.20 lnvers|on o¦ ¦|e suu¦a|ar ¦o|n¦.
Anklc: 0orsìflcxìon (Fìg. 8.10}
Hand Placement and Procedure
Stabilize around the malleoli with the top hand.
Cup the patient`s heel with the bottom hand and place
the Iorearm along the bottom oI the Ioot.
Pull the calcaneus distalward with the thumb and Iingers
while pushing upward with the Iorearm.
N 0 J L : lf lhe knee is flexed, full ranqe of lhe ankle |oinl
can be oblained. lf lhe knee is exlended, lhe lenqlhened
ranqe of lhe lwo-|oinl qaslrocnenius nuscle can be
oblained, bul lhe qaslrocnenius linils full ranqe of dorsi-
flexion. Aµµly dorsiflexion in bolh µosilions of lhe knee lo
µrovide ranqe lo bolh lhe |oinl and lhe nuscle.
Anklc: Planfarflcxìon
Hand Placement and Procedure
Support the heel with the bottom hand.
Place the top hand on the dorsum oI the Ioot and push it
into plantarIlexion.
N 0 J L : ln bed-bound µalienls, lhe ankle lends lo assune
a µlanlarflexed µosilion fron lhe weiqhl of lhe blankels and
lhe µull of qravily, so lhis nolion nay nol need lo be µer-
Fl0uPE 8.18 Ro¦a¦|on o¦ ¦|e ||µ w|¦| ¦|e ||µ µos|¦|oned |n 90 o¦ ¦|ez|on.
Ccrvìcal Spìnc
Position of Therapist and Hand Placement
Standing at the end oI the treatment table, securely grasp
the patient`s head by placing both hands under the occipital
Flcxìon (Forward 8cndìng} (Fìg. 8.22A}
LiIt the head as though it were nodding (chin towards
larynx) to Ilex the head on the neck.
Once Iull nodding is complete, continue to Ilex the cer-
vical spine and liIt the head toward the sternum.
Exfcnsìon (8ackward 8cndìng or Rypcrcxfcnsìon}
Tip the head backward.
N 0 J L : lf lhe µalienl is suµine, only lhe head and uµµer
cervical sµine can be exlended; lhe head nusl clear lhe end
of lhe lable lo exlend lhe enlire cervical sµine. !he µalienl
nay also be µrone or sillinq.
1oìnfs of fhc Jocs: Flcxìon and Exfcnsìon and Ahduc-
fìon and Adducfìon (Mcfafarsophalangcal and lnfcr-
phalangcal 1oìnfs} (Fìg. 8.21}
Hand Placement and Procedure
Stabilize the bone proximal to the joint that is to be
moved with one hand, and move the distal bone with the
other hand.
The technique is the same as Ior ROM oI the Iingers.
Alternate Procedure
Several joints oI the toes can be moved simultaneously iI
care is taken not to stress any structure.
C R A P J E P 8 Panqe of Molion 55
Fl0uPE 8.21 Lz¦ens|on o¦ ¦|e ue¦a¦arsoµ|a|ançea| ¦o|n¦ o¦ ¦|e |arçe ¦oe.
Fl0uPE 8.22 Cerv|ca| (} ¦|ez|on and (} ro¦a¦|on.
Lafcral Flcxìon (Sìdc 8cndìng}
and Pofafìon (Fìg. 8.228}
Maintain the cervical spine neutral to Ilexion and extension
as you direct the head and neck into side bending (approxi-
mate the ear toward the shoulder) and rotation (rotate Irom
side to side).
Lumhar Spìnc
Flcxìon (Fìg. 8.28}
Hand Placement and Procedure
Bring both oI the patient`s knees to the chest by liIting
under the knees (hip and knee Ilexion).
Flexion oI the spine occurs as the hips are Ilexed Iull
range and the pelvis starts to rotate posteriorly.
Greater range oI Ilexion can be obtained by liIting
under the patient`s sacrum with the lower hand.
Alternate Position
The patient is prone.
Hand Placement and Procedure
With hands under the thighs, liIt the thighs upward until
the pelvis rotates anteriorly and the lumbar spine extends.
Comhìncd Paffcrns of Mofìon
EIIective and eIIicient ROM can be administered by com-
bining several joint motions that transect several planes
resulting in oblique or diagonal patterns. For example,
wrist Ilexion may be combined with ulnar deviation, or
shoulder Ilexion may be combined with abduction and lat-
eral rotation so movement Iollows Iunctional patterns. Pro-
prioceptive neuromuscular Iacilitation (PNF) patterns oI
movement Iollow speciIic guidelines and may be eIIective-
ly used Ior PROM, A-AROM, or AROM techniques (see
Chapter 6 Ior descriptions oI these patterns).
Patient involvement in selI-care should begin as soon as
the individual is able to understand and learn what to do.
Even with weakness or paralysis, the patient can learn
how to move the involved part and be instructed in the
importance oI movement within saIe parameters. AIter
surgery or traumatic injury, selI-assisted ROM (S-AROM)
is used to protect the healing tissues when more intensive
muscle contraction is contraindicated. A variety oI devices
as well as use oI a normal extremity may be used to
meet the goals oI PROM or A-AROM. Incorporation oI
S-AROM then becomes a part oI the home exercise pro-
gram (Box 3.2).
Fl0uPE 8.24 Ro¦a¦|on o¦ ¦|e |uuuar sµ|ne resu|¦s w|en ¦|e ¦|oraz |s s¦au|-
||zed and ¦|e µe|v|s ||¦¦s o¦¦ ¦|e ¦au|e as ¦ar as a||owed.
80X 8.2 Sclf-Assìsfcd Pangc of Mofìon
Forms oI SclI-Assistcd R0M
- Manual
- Fquipmcnl
- Wand oi 1-bai
- Fingci laddci, wall climbing, ball iolling
- Pullcys
- Skalc boaid|powdci boaid
- Rccipiocal cxcicisc dcviccs
Cuidclincs Ior 1caching SclI-Assistcd R0M
- Fducalc llc palicnl on llc valuc of llc molion.
- 1cacl llc palicnl coiiccl body alignmcnl and slabili-
- 0bscivc palicnl pcifoimancc and coiiccl any subslilulc
oi unsafc molions.
- lf cquipmcnl is uscd, bc suic all lazaids aic climinalcd
foi applicalion lo bc safc.
- Piovidc diawings and clcai guidclincs foi numbci of
icpclilions and ficqucncy.
Rcvicw llc cxciciscs al a follow-up scssion. Modify
oi piogicss llc cxcicisc piogiam bascd on llc palicnl
icsponsc and licalmcnl plan foi mccling llc oulcomc
Fl0uPE 8.28 Luuuar ¦|ez|on |s ac||eved u, ur|nç|nç ¦|e µa¦|en¦'s ||µs |n¦o
¦|ez|on un¦|| ¦|e µe|v|s ro¦a¦es µos¦er|or|,.
Pofafìon (Fìg. 8.24}
Alternate Position
The patient is hook-lying.
Hand Placement and Procedure
Push both oI the patient`s knees laterally in one direction
until the pelvis on the opposite side comes up oII the
treatment table.
Stabilize the patient`s thorax with the top hand.
Repeat in the opposite direction.
Shoulder horizontal abduction and adduction. Begin-
ning with the arm abducted 90 , 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 90 and
elbow Ilexed 90 , the patient rotates the Iorearm with
the uninvolved extremity (Fig. 3.26). It is important to
emphasize rotating the humerus, not merely Ilexing and
extending the elbow.
With cases oI unilateral weakness or paralysis, or during
early stages oI recovery aIter trauma or surgery, the patient
can be taught to use the uninvolved extremity to move the
involved extremity through ranges oI motion. These exer-
cises may be done supine, sitting, or standing. The eIIects
oI gravity change with patient positioning, so when liIting
the part against gravity, gravity provides a resistive Iorce
against the prime motion and thereIore the prime mover
requires assistance. When the extremity moves downward,
gravity causes the motion; and the antagonists need assis-
tance to control the motion eccentrically.
Arm and Forcarm
Instruct the patient to reach across the body with the unin-
volved (or assisting) extremity and grasp the involved
extremity around the wrist, supporting the wrist and hand
(Fig. 3.25).
Shoulder flexion and extension. The patient liIts the
involved extremity over the head and returns it to the
side (Fig. 3.25).
C R A P J E P 8 Panqe of Molion 57
Fl0uPE 8.25 Pa¦|en¦ ç|v|nç se|¦-ass|s¦ed R0V ¦o s|ou|der ¦|ez|on and ez¦en-
s|on. hor|zon¦a| auduc¦|on and adduc¦|on can ue aµµ||ed w|¦| ¦|e saue |and
Fl0uPE 8.28 Aru µos|¦|on o¦ µa¦|en¦ ¦or ç|v|nç se|¦-ass|s¦ed R0V ¦o |n¦er-
na| and ez¦erna| ro¦a¦|on o¦ s|ou|der.
Fl0uPE 8.27 Pa¦|en¦ aµµ|,|nç se|¦-ass|s¦ed wr|s¦ ¦|ez|on and ez¦ens|on, w|¦|
no µressure aça|ns¦ ¦|e ¦|nçers.
Elbow flexion and extension. The patient bends the
elbow until the hand is near the shoulder and then moves
the hand down toward the side oI the leg.
Pronation and supination of the forearm. Beginning
with the Iorearm resting across the body, the patient
rotates the radius around the ulna; emphasize to the
patient not to twist the hand at the wrist joint.
Wrìsf and Rand
The patient moves the uninvolved Iingers to the dorsum oI
the hand and the thumb into the palm oI the hand.
Wrist flexion and extension and radial and ulnar devi-
ation. The patient moves the wrist in all directions,
applying no pressure against the Iingers (Fig. 3.27).
1humb flexion with opposition and extension with
reposition. The patient cups the uninvolved Iingers
around the radial border oI the thenar eminence oI the
involved thumb and places the uninvolved thumb along
the palmar surIace oI the involved thumb to extend it
(Fig. 3.29). To Ilex and oppose the thumb, the patient
cups the normal hand around the dorsal surIace oI the
involved hand and pushes the Iirst metacarpal toward
the little Iinger.
Finger flexion and extension. The patient uses the unin-
volved thumb to extend the involved Iingers and cups the
normal Iingers over the dorsum oI the involved Iingers to
Ilex them (Fig. 3.28).
Hip abduction and adduction. It is diIIicult Ior the weak
patient to assist the lower extremities into abduction and
adduction when supine owing to the weight oI the leg
and he Iriction oI the bed surIace. It is necessary, though,
Ior the individual to move a weak lower extremity Irom
side to side Ior bed mobility. To practice this Iunctional
activity as an exercise, instruct the patient to slide the
normal Ioot Irom the knee down to the ankle and then
move the involved extremity Irom side to side. S-AROM
can be perIormed sitting by using the hands to assist
moving the thigh outward and inward.
Combined hip abduction with external rotation. The
patient is sitting on the Iloor or on a bed with the back
supported and the involved hip and knee Ilexed and
Ioot resting on the surIace. The knee is moved outward
(toward the table/bed) and back inward, with assistance
Irom the upper extremity (Fig. 3.31).
Fl0uPE 8.20 Pa¦|en¦ aµµ|,|nç se|¦-ass|s¦ed ¦|uuu ez¦ens|on.
Fl0uPE 8.81 Se|¦-ass|s¦ed ||µ auduc¦|on and ez¦erna| ro¦a¦|on.
Fl0uPE 8.80 Se|¦-ass|s¦ed ¦|ez|on o¦ ¦|e ||µ.
Fl0uPE 8.28 Pa¦|en¦ aµµ|,|nç se|¦-ass|s¦ed ¦|nçer ¦|ez|on and ez¦ens|on.
Rìp and Kncc
Hip and knee flexion. With the patient supine, instruct
the patient to initiate the motion by liIting up the
involved knee with a strap or belt under the involved
knee (Fig. 3.30). The patient can then grasp the knee
with one or both hands to bring the knee up toward the
chest to complete the range. With the patient sitting, he
or she may liIt the thigh with the hands and Ilex the knee
to the end oI its available range.
wand Irom side to side across the trunk while main-
taining the elbows at the side (Fig. 3.33C). The rotation
should occur in the humerus; do not allow elbow Ilexion
and extension. To prevent substitute motions as well as
provide a slight distraction Iorce to the glenohumeral
joint, a small towel roll may be placed in the axilla with
instruction to the patient to 'keep the roll in place.``
Alfcrnafc Posìfìon
The patient`s shoulders are abducted 90 and the elbows
Ilexed 90 . For external rotation, the wand is moved toward
the patient`s head; Ior internal rotation, the wand is moved
toward the waistline.
Anklc and Jocs
The 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 dorsiIlexion, plantarIlexion, inversion, and eversion,
and toe Ilexion and extension (Fig. 3.32).
C R A P J E P 8 Panqe of Molion 50
Fl0uPE 8.82 Pos|¦|on o¦ µa¦|en¦ and |and µ|aceuen¦ ¦or se|¦-ass|s¦ed an||e
and ¦oe uo¦|ons, s|own |s |nvers|on and evers|on.
Fl0uPE 8.88 Pa¦|en¦ us|nç a wand ¦or se|¦-ass|s¦ed s|ou|der (} ¦|ez|on, (}
|or|zon¦a| auduc¦|on|adduc¦|on (} ro¦a¦|on.
Wand (J-8ar} Excrcìscs
When a patient has voluntary muscle control in an involved
upper extremity but needs guidance or motivation to com-
plete the ROM in the shoulder or elbow, a wand (dowel
rod, cane, wooden stick, T-bar, or similar object) can be
used to provide assistance (Fig. 3.33).
The choice oI position is based on the patient`s level
oI Iunction. Most oI the techniques can be perIormed
supine iI maximum protection is needed. Sitting or stand-
ing requires greater control. Choice oI position is also
guided by the eIIects oI gravity on the weak muscles.
Initially, guide the patient through the proper motion Ior
each activity to ensure that he or she does not use substi-
tute motions. The patient grasps the wand with both hands,
and the normal extremity guides and controls the motions.
Shoulder flexion and return. The wand is grasped with
the hands a shoulder-width apart. The wand is liIted Ior-
ward and upward through the available range, with the
elbows kept in extension iI possible (Fig. 3.33A). Scapu-
lohumeral motion should be smooth; do not allow scapu-
lar elevation or trunk movement.
Shoulder horizontal abduction and adduction. The
wand is liIted to 90 shoulder Ilexion. Keeping the
elbows extended, the patient pushes and pulls the wand
back and Iorth across the chest through the available
range (Fig. 3.33B). Do not allow trunk rotation.
Shoulder internal and external rotation. The patient`s
arms are at the sides, and the elbows are Ilexed 90 .
Rotation oI the arms is accomplished by moving the
Elbow flexion and extension. The patient`s Iorearms
may be pronated or supinated; the hands grasp the wand
a shoulder-width apart. Instruct the patient to Ilex and
extend the elbows.
Shoulder hyperextension. The patient may be standing
or prone. He or she places the wand behind the buttocks,
grasps the wand with hands a shoulder-width apart, and
then liIts the wand backward away Irom the trunk. The
patient should avoid trunk motion.
Jariations and combinations of movements. For exam-
ple, the patient begins with the wand behind the buttocks
and then moves the wand up the back to achieve scapular
winging, shoulder internal rotation, and elbow Ilexion.
Wall Clìmhìng
Wall climbing (or use oI a device such as a Iinger ladder)
can provide the patient with objective reinIorcement and,
thereIore, motivation Ior perIorming shoulder ROM. Wall
markings may also be used to provide visual Ieedback Ior
the height reached. The arm may be moved into Ilexion or
abduction (Fig. 3.34). The patient steps closer to the wall
as the arm is elevated.
P ß L L A u J I 0 N : !he µalienl nusl be lauqhl lhe
µroµer nolions and nol allowed lo subslilule wilh lrunk
side bendinq, loe raisinq, or shoulder shruqqinq.
ous passive motion machines (described later in the chap-
ter), so this Iorm oI assistance should be used only when
muscle activity is desired.
For home use, a single pulley may be attached to a
strap that is held in place by closing the strap in a door.
A pulley may also be attached to an overhead bar or
aIIixed to the ceiling. The patient should be set up so the
pulley is directly over the joint that is moving or so the line
oI pull is eIIectively moving the extremity and not just
compressing the joint surIaces together. The patient may be
sitting, standing, or supine.
Shouldcr P0M (Fìg. 8.85}
Instruct the patient to hold one handle in each hand and,
with the normal hand, pull the rope and liIt the involved
extremity Iorward (Ilexion), out to the side (abduction), or
in the plane oI the scapula (scaption is 30 Iorward oI the
Irontal plane). The patient should not shrug the shoulder
(scapular elevation) or lean the trunk. Guide and instruct
the patient so there is smooth motion.
P ß L L A u J I 0 N : Assislive µulley aclivilies for lhe
shoulder are easily nisused by lhe µalienl, resullinq in con-
µression of lhe hunerus aqainsl lhe acronion µrocess. Con-
linual conµression leads lo µain and decreased funclion.
Proµer µalienl seleclion and aµµroµriale inslruclion can
avoid lhis µroblen. lf a µalienl cannol learn lo use lhe µul-
ley wilh µroµer shoulder nechanics, lhese exercises should
nol be µerforned. 0isconlinue lhis aclivily if lhere is
increased µain or decreased nobilily.
Fl0uPE 8.84 wa|| c||uu|nç ¦or s|ou|der e|eva¦|on.
Fl0uPE 8.85 Use o¦ over|ead µu||e,s ¦o ass|s¦ s|ou|der e|eva¦|on.
0vcrhcad Pullcys
II properly taught, pulley systems can be eIIectively used
to assist an involved extremity in perIorming ROM. The
pulley has been demonstrated to utilize signiIicantly more
muscle activity than therapist-assisted ROM and continu-
Elhow Flcxìon
With the arm stabilized along the side oI the trunk, the
patient liIts the Iorearm and bends the elbow.
the research by Robert Salter, who demonstrated that con-
tinual passive motion has beneIicial healing eIIects on dis-
eased or injured joint structures and soIt tissues in animal
and clinical studies.
Since the development oI CPM,
many studies have been done to determine the parameters
oI application; but because the devices are used Ior many
conditions, and studies have used various protocols with
varying research designs, no deIinitive delineation has
been established.
8cncfìfs of CPM
CPM has been reported to be eIIective in lessening the
negative eIIects oI joint immobilization in conditions such
as arthritis, contractures, and intra-articular Iractures; it has
also improved the recovery rate and ROM aIter a variety oI
surgical procedures.
Basic research and clinical
studies reported by Salter have demonstrated the eIIective-
ness oI CPM in a number oI areas.
Prevents development oI adhesions and contractures and
thus joint stiIIness
Provides a stimulating eIIect on the healing oI tendons
and ligaments
Enhances healing oI incisions over the moving joint
Increases synovial Iluid lubrication oI the joint and thus
increases the rate oI intra-articular cartilage healing and
Prevents the degrading eIIects oI immobilization
Provides a quicker return oI ROM
Decreases postoperative pain
Focus on Evidence
Recent studies have compared short- and long-term out-
comes oI CPM use aIter various types oI surgery using
Skafc 8oardjPowdcr 8oard
Use oI a Iriction-Iree surIace may encourage movement
without the resistance oI gravity or Iriction. II available, a
skate with rollers may be used. Other methods include
using powder on the surIace or placing a towel under the
extremity so it can slide along the smooth surIace oI the
board. Any motion can be done, but most common are
abduction/adduction oI the hip while supine and horizontal
abduction/adduction oI the shoulder while sitting.
Pccìprocal Excrcìsc unìf
Several devices, such as a bicycle, upper body, or lower
body ergometer, or a reciprocal exercise unit can be set
up to provide some Ilexion and extension to an involved
extremity using the strength oI the normal extremity.
Movable devices are available that can be attached to a
patient`s bed, wheelchair, or standard chair. The circumIer-
ence oI motion as well as excursion oI the extremities can
be adjusted. A reciprocal exercise unit has additional exer-
cise beneIits in that it can be used Ior reciprocal patterning,
endurance training, and strengthening by changing the
parameters oI the exercise and monitoring the heart rate
and Iatigue. (See Chapter 3 Ior principles oI resistance
exercise and Chapter 6 Ior principles oI aerobic exercise.)
Continuous passive motion (CPM) reIers to passive
motion perIormed by a mechanical device that moves
a joint slowly and continuously through a controlled
ROM. The mechanical devices that exist Ior nearly every
joint in the body (Fig. 3.36) were developed as a result oI
C R A P J E P 8 Panqe of Molion 81
Fl0uPE 8.88 CV-100 Con¦|nuous Vo¦|on
0ev|ce. (Cour¦es, o¦ Luµ|, S¦. Pau|, VN.}
various parameters as well as CPM with other methods oI
early movement and positioning.
studies have shown no signiIicant diIIerence between
patients undergoing CPM and those undergoing PROM or
other Iorms oI early motion.
Many studies support
the short-term beneIits oI CPM use aIter surgery in that
patients gain ROM more quickly and thereIore may experi-
ence earlier discharge Irom the hospital when CPM is used
compared with other Iorms oI intervention. However, long-
term Iunctional gains are reported to be no diIIerent Irom
those in patients who underwent other Iorms oI early
Some studies have identiIied detrimental eIIects, such as
the need Ior greater analgesic intervention and increased
postoperative blood drainage, when using CPM
in con-
trast to claims that CPM decreases postoperative pain and
postoperative complications.
Cost-eIIectiveness oI
the CPM equipment, patient compliance, utilization and
supervision oI equipment by trained personnel, length oI
hospital stay, speed oI recovery, and determination oI
appropriate patient populations become issues to consider
when making the choice oI whether or not to utilize CPM
0cncral 0uìdclìncs for CPM
General guidelines Ior CPM are as Iollows.
1. The device may be applied to the involved extremity
immediately aIter surgery while the patient is still under
anesthesia or as soon as possible iI bulky dressings pre-
vent early motion.
2. The arc oI motion Ior the joint is determined. OIten a
low arc oI 20 to 30 is used initially and progressed
10 to 15 per day as tolerated. The portion oI the range
used initially is based on the range available and patient
tolerance. One study looked at accelerating the range
oI knee Ilexion aIter total knee arthroplasty and Iound
that a greater range and earlier discharge was attained
Ior that group oI patients,
although there was no diI-
Ierence between the groups at 4 weeks.
3. The rate oI motion is determined; usually 1 cycle/45 sec
or 2 min is well tolerated.
4. The amount oI time on the CPM machine varies Ior
diIIerent protocols: anywhere Irom continuous Ior 24
hours to continuous Ior 1 hour three times a day.
The longer periods oI time per day reportedly result in a
shorter hospital stay, Iewer postoperative complications,
and greater ROM at discharge,
although no signiIicant
diIIerence was Iound in a study comparing CPM Ior
5 hr/day with CPM Ior 20 hr/day.
A recent study com-
pared short-duration CPM (3 to 5 hr/day) with long
duration CPM (10 to 12 hr/day) and Iound that patient
compliance and the most gained range occurred with a
CPM duration oI 4 to 8 hours.
5. Physical therapy treatments are usually initiated during
periods when the patient is not on CPM, including
active-assistive and muscle-setting exercises. It is impor-
tant that patients learn to use and develop motor control
oI the ROM as motion improves.
6. The duration minimum Ior CPM is usually less than 1
week or when a satisIactory range oI motion is reached.
Because CPM devices are portable, home use is possible
in cases where the therapist or physician deems addi-
tional time would be beneIicial. In these cases, the
patient, a Iamily member, or a caregiver is instructed in
proper application.
7. CPM machines are designed to be adjustable, easily
controlled, versatile, and portable. Some are battery
operated (with rechargeable batteries) to allow the indi-
vidual to wear the device Ior up to 8 hours while Iunc-
tioning with daily activities.
To accomplish motion through Iunctional patterns, Iirst
determine what pattern oI movement is desired and then
move the extremity through that pattern using manual
assistance, mechanical assistance iI it is appropriate, or
selI-assistance Irom the patient. Functional patterning
can be beneIicial in initiating the teaching oI ADL and
instrumental activities oI daily living (IADL) as well as
in instructing patients with visual impairments in Iunction-
al activities. Utilizing Iunctional patterns helps the patient
recognize the purpose and value oI ROM exercises and
develop motor patterns that can be used in daily activities
as strength and endurance improves. Box 3.3 identiIies
some examples and the basic motions that are utilized.
When the patient no longer requires assistance to perIorm
the pattern saIely and correctly, the activity is incorporated
into his or her daily activities so motor learning is rein-
Iorced and the motion becomes Iunctional.
C R A P J E P 8 Panqe of Molion 88
your partner placed in the Iollowing positions: prone,
side-lying, sitting.
a. What are the advantages and disadvantages oI each oI
the positions Ior some oI the ranges, such as shoulder
and hip extension, knee Ilexion with the hip extended,
rotation oI the hip?
b. Progress the PROM to A-AROM and AROM and
determine the eIIects oI gravity and the eIIort
required in these positions compared to that in the
supine position.
2. Compare the ROMs oI the hip, knee, and ankle when
each oI the two joint muscles is elongated over its
respective joint versus when each oI the muscles is
Crìfìcal Jhìnkìng and 0ìscussìon
1. Analyze a variety oI Iunctional activities, such as
grooming, dressing, and bathing, and determine the
Iunctional ranges needed to perIorm each task.
2. Look at the eIIects oI gravity or other Iorces on the
ROM Ior each activity in #1. II you had a patient who
was unable to do the activity because oI an inability to
control the range needed, determine how you would
establish an exercise program to begin preparing the
individual to develop the desired Iunction.
Lahorafory Pracfìcc
1. PerIorm PROM oI the upper and lower extremities with
l h 0 E P E h 0 E h ! L E A P h l h 6 A C ! l v l ! l E S
R L l L R L N C L S
1. AlIredson, H, Lorentzon, R: Superior results with continuous passive
motion compared to active motion aIter periosteal transplantation: a
retrospective study oI human patella cartilage deIect treatment. Knee
Surg Sports Traumatol Arthrosc 7(4):232, 1999.
2. Basso, DM, Knapp, L: Comparison oI two continuous passive motion
protocols Ior patients with total knee implants. Phys Ther 67:360,
3. Chiarello, CM, Gunersen, L, O`Halloran, T: The eIIect oI continuous
passive motion duration and increment on range oI motion in total
knee arthroplasty patients. J Orthop Sports Phys Ther 25(2):119,
4. Denis, M, MoIIet, H, Caron, F, et al: EIIectiveness oI continuous
passive motion and conventional physical therapy aIter total knee
arthroplasty: a randomized clinical trial. Phys Ther 86(2):174185,
5. Dockery, ML, Wright, TW, LaStayo, P: Electromyography oI the
shoulder: an analysis oI passive modes oI exercise. Orthopedics
11:1181, 1998.
6. Donatelli, R, Owens-Burckhart, H: EIIects oI immobilization on the
extensibility oI periarticular connective tissue. J Orthop Sports Phys
Ther 3:67, 1981.
7. Fletcher, GF, et al: Exercise Standards: A Statement Ior Health ProIes-
sionals. American Heart Association, Dallas, 1991.
8. Frank, C, et al: Physiology and therapeutic value oI passive joint
motion. Clin Orthop 185:113, 1984.
9. Gose, J: Continuous passive motion in the postoperative treatment oI
patients with total knee replacement. Phys Ther 67:39, 1987.
10. Guidelines Ior Exercise Testing and Prescription, ed 4. American Col-
lege oI Sports Medicine, Lea & Febiger, Philadelphia, 1991.
11. Kumar, PJ, McPherson, EJ, et al: Rehabilitation aIter total knee
arthroplasty: a comparison oI 2 rehabilitation techniques. Clin Orthop
331:93, 1996.
12. LaStayo, PC, Wright T, et al: Continuous passive motion aIter repair
oI the rotator cuII: a prospective outcome study. J Bone Joint Surg Am
80(7):1002, 1998.
13. LaStayo, PC: Continuous passive motion Ior the upper extremity. In
Hunter, JM, MacKin, EJ, Callahan AD (eds) Rehabilitation oI the
Hand: Surgery and Therapy, ed 4. Mosby, St/ Louis, 1995.
14. McCarthy, MR, et al: The clinical use oI continuous passive motion in
physical therapy. J Orthop Sports Phys Ther 15:132, 1992.
80X 8.8 Funcfìonal Pangc of Mofìon Acfìvìfìcs
Faily R0M liaining foi funclional uppci cxlicmily and ncck
pallcins may includc aclivilics sucl as
- Ciasping an caling ulcnsil, ulilizing fingci cxlcnsion and
- Faling (land lo moull), ulilizing clbow flcxion and foic-
aim supinalion and somc slouldci flcxion, abduclion, and
lalcial iolalion
- Rcacling lo vaiious slclf lciglls, ulilizing slouldci flcx-
ion and clbow cxlcnsion
- Biusling oi combing back of laii, ulilizing slouldci
abduclion and lalcial iolalion, clbow flcxion, and ccivical
- Eolding a plonc lo llc cai, slouldci lalcial iolalion, foic-
aim supinalion, and ccivical sidc bcnd
- Ponning oi doffing a sliil oi jackcl, ulilizing slouldci
cxlcnsion, lalcial iolalion, clbow flcxion and cxlcnsion
- Rcacling oul a cai window lo an A1M maclinc, ulilizing
slouldci abduclion, lalcial iolalion, clbow cxlcnsion, and
somc lalcial bcnding of llc liunk
Faily R0M liaining foi funclional lowci cxlicmily and liunk
pallcins may includc aclivilics sucl as
- Coing fiom supinc lo silling al llc sidc of a bcd, ulilizing
lip abduclion and adduclion followcd by lip and kncc
- Slanding up|silling down and walking, ulilizing lip and
kncc flcxion and cxlcnsion, anklc doisi and planlai flcx-
ion and somc lip iolalion
- Pulling on socks and slocs, ulilizing lip cxlcinal iolalion
and abduclion, kncc flcxion and anklc doisi and planlai
flcxion, and liunk flcxion
15. Nadler, SF, Malanga, GA, Jimmerman, JR: Continuous passive
motion in the rehabilitation setting: a retrospective study. Am J Phys
Med Rehabil 72(3):162, 1993.
16. Norkin, CC, White, DJ: Measurement oI Joint Motion: A Guide to
Goniometry, ed 3. FA Davis, Philadelphia, 2003.
17. O`Driscoll, SW, Giori, NJ: Continuous passive motion (CPM) theory
and principles oI clinical application. J Rehabil Res Dev 37(2):179,
18. Pope, RO, Corcoran, S, et al: Continuous passive motion aIter primary
total knee arthroplasty: does it oIIer any beneIits? J Bone Joint Surg
Br 79(6):914, 1997.
19. Rosen, MA, Jackson, DW, Atwell, EA: The eIIicacy oI continuous
passive motion in the rehabilitation oI anterior cruciate ligament
reconstructions. Am J Sports Med 20(2):122, 1992.
20. Salter, RB: History oI rest and motion and the scientiIic basis Ior early
continuous passive motion. Hand Clin 12(1):1, 1996.
21. Salter, RB, Simmens, DF, Malcolm, BW: The biological eIIects oI
continuous passive motion on the healing oI Iull thickness deIects in
articular cartilage. J Bone Joint Surg Am 62:1232, 1980.
22. Salter, RB: The prevention oI arthritis through the preservation oI car-
tilage. J Can Assoc Radiol 31:5, 1981.
23. Salter, RB, Bell, RS, Keely, FW: The protective eIIect oI continuous
passive motion on living cartilage in acute septic arthritis. Clin Orthop
159:223, 1981.
24. Salter, RB: Textbook oI Disorders and Injuries oI the Musculoskeletal
System, ed 3. Williams & Wilkins, Baltimore, 1999.
25. Salter, RB, et al: Clinical application oI basic research on continuous
passive motion Ior disorders and injuries oI synovial joints. J Orthop
Res 1:325, 1984.
26. Smith, LK, Weiss, EL, Lehmkuhl, LD: Brunnstrom`s Clinical Kinesi-
ology, ed 5. FA Davis, Philadelphia, 1996.
27. Stap, LJ, WoodIin, PM: Continuous passive motion in the treatment oI
knee Ilexion contractures: a case report. Phys Ther 66:1720, 1986.
28. Wasilewski, SA, Woods, LC, et al: Value oI continuous passive
motion in total knee arthroplasty. Orthopedics 13(3):291, 1990.
29. Witherow, GE, Bollen, SR, Pinczewski, LA: The use oI continuous
passive motion aIter arthroscopically assisted anterior cruciate liga-
ment reconstruction: help or hindrance? Knee Surg Sports Traumatol
Arthrosc 1(2):68, 1993.
30. Yashar, AA, Venn Watson, E, et al: Continuous passive motion with
accelerated Ilexion aIter total knee arthroplasty. Clin Orthop 345:38,
Slrelchlnq lor
lmpalred Moblllly
The term mobilitv can be described based on two diIIerent
but interrelated parameters. It is oIten deIined as the ability
oI structures or segments oI the body to move or be moved
to allow the presence oI range oI motion Ior Iunctional
activities (functional ROM).
It can also be deIined as
the ability oI an individual to initiate, control, or sustain
active movements oI the body to perIorm simple to com-
plex motor skills (functional mobilitv).
as it relates to Iunctional ROM, is associated with joint
integrity as well as the flexibilitv (i.e., extensibilitv oI soIt
tissues that cross or surround jointsmuscles, tendons,
Iascia, joint capsules, ligaments, nerves, blood vessels,
skin), which are necessary Ior unrestricted, pain-Iree move-
ments oI the body during Iunctional tasks oI daily living.
The ROM needed Ior the perIormance oI Iunctional activi-
ties does not necessarily mean Iull or 'normal¨ ROM.
SuIIicient mobility oI soIt tissues and ROM oI joints
must be supported by a requisite level oI muscle strength
and endurance and neuromuscular control to allow the
body to accommodate to imposed stresses placed upon it
during Iunctional movement and thus to enable an individ-
ual to be Iunctionally mobile. Furthermore, soIt tissue
mobility, neuromuscular control, and muscular endurance
and strength consistent with demand are thought to be an
important Iactor in the prevention oI injury or reinjury oI
the musculoskeletal system.
Hvpomobilitv (restricted motion) caused by adaptive
shortening oI soIt tissues can occur as the result oI many
disorders or situations. Factors include (1) prolonged
immobilization oI a body segment, (2) sedentary liIestyle,
(3) postural malalignment and muscle imbalances, (4)
impaired muscle perIormance (weakness) associated with
C h A P ! L R
Flcxìhìlìfy 88
Rypomohìlìfy 88
Confracfurc 88
Jypcs of Confracfurc 87
lnfcrvcnfìons fo lncrcasc Mohìlìfy of Soff
Jìssuc 88
Sclccfìvc Sfrcfchìng 80
0vcrsfrcfchìng and Rypcrmohìlìfy 80
Mcchanìcal Propcrfìcs of Confracfìlc Jìssuc 70
Ncurophysìologìcal Propcrfìcs of Confracfìlc
Jìssuc 72
Mcchanìcal Propcrfìcs of Nonconfracfìlc Soff
Jìssuc 78
Alìgnmcnf and Sfahìlìzafìon 77
lnfcnsìfy of Sfrcfch 70
0urafìon of Sfrcfch 70
Spccd of Sfrcfch 81
Frcqucncy of Sfrcfch 81
Modc of Sfrcfch 82
Proprìoccpfìvc Ncuromuscular Facìlìfafìon
Sfrcfchìng Jcchnìqucs 85
lnfcgrafìon of Funcfìon ìnfo Sfrcfchìng 87
Examìnafìon and Evaluafìon of fhc Pafìcnf 88
Prcparafìon for Sfrcfchìng 80
Applìcafìon of Manual Sfrcfchìng Proccdurcs 80
Affcr Sfrcfchìng 00
0cncral Prccaufìons 00
Spccìal Prccaufìons for Mass-Markcf Flcxìhìlìfy
Programs 01
Pclaxafìon Jraìnìng 02
Rcaf 02
Massagc 08
8ìofccdhack 08
1oìnf Jracfìon or 0scìllafìon 08
uppcr Exfrcmìfy Sfrcfchìng 04
Lowcr Exfrcmìfy Sfrcfchìng 00
an array oI musculoskeletal or neuromuscular disorders,
(5) tissue trauma resulting in inIlammation and pain, and
(6) congenital or acquired deIormities. Any Iactor that lim-
its mobility, that is, causes decreased extensibility oI soIt
tissues, may also impair muscular perIormance.
mobility, in turn, can lead to Iunctional limitations and
disability in a person`s liIe.
Just as strength and endurance exercises are essential
interventions to improve impaired muscle perIormance or
prevent injury, when restricted mobility adversely aIIects
Iunction and increases the risk oI injury, stretching inter-
ventions become an integral component oI the individual-
ized rehabilitation program. Stretching exercises are also
thought to be an important element oI Iitness and condi-
tioning programs designed to promote wellness and reduce
the risk oI injury and reinjury. Stretching is a general term
used to describe any therapeutic maneuver designed to
increase the extensibility oI soIt tissues, thereby improving
Ilexibility by elongating (lengthening) structures that have
adaptively shortened and have become hypomobile over
Only through a systematic examination, evaluation,
and diagnosis oI a patient`s presenting problems can a ther-
apist determine what structures are restricting motion and
iI, when, and what types oI stretching procedures are indi-
cated. Early in the rehabilitation process manual stretching
and joint mobilization, which involve direct, 'hands-on¨
intervention by a practitioner, may be the most appropriate
techniques. Later, selI-stretching exercises perIormed inde-
pendently by a patient aIter careIul instruction and close
supervision may be a more suitable intervention. In some
situations the use oI mechanical stretching devices are indi-
cated, particularly when manual therapies have been ineI-
Iective. Regardless oI the types oI stretching procedures
selected Ior an exercise program, iI the gain in ROM is to
become permanent it must be complemented by an appro-
priate level oI strength and endurance and used on a regu-
lar basis in Iunctional activities.
The stretching interventions described in this chapter
are designed to elongate the contractile and noncontractile
components oI muscle.-tendon units and periarticular
structures. The eIIicacy oI these interventions is explored
throughout the chapter. In addition to the stretching pro-
cedures Ior the extremities illustrated in this chapter,
selI-stretching exercises Ior each region oI the body are
described and illustrated in Chapters 16 through 22. Joint
mobilization and manipulation procedures oI extremity
joints are described and illustrated in Chapter 5.
Flexibilitv is the ability to move a single joint or series
oI joints smoothly and easily through an unrestricted,
pain-Iree ROM.
Muscle length in conjunction with
joint integrity and the extensibility oI periarticular soIt
tissues determine Ilexibility.
Flexibility is related to
the extensibility oI musculotendinous units that cross a
joint, based on their ability to relax or deIorm and yield
to a stretch Iorce. The arthrokinematics oI the moving
joint (the ability oI the joint surIaces to roll and slide) as
well as the ability oI periarticular connective tissues to
deIorm also aIIect joint ROM and an individual`s overall
0ynamìc and Passìvc Flcxìhìlìfy
Dynamic flexibility. This Iorm oI Ilexibility, also reIer-
red to as active mobility or active ROM, is the degree to
which an active muscle contraction moves a body seg-
ment through the available ROM oI a joint. It is depen-
dent on the degree to which a joint can be moved by a
muscle contraction and the amount oI tissue resistance
met during the active movement.
Passive flexibility. This aspect oI Ilexibility, also reIerred
to as passive mobility or passive ROM, is the degree to
which a joint can be passively moved through the available
ROM and is dependent on the extensibility oI muscles and
connective tissues that cross and surround a joint. Passive
Ilexibility is a prerequisite Ior but does not ensure dynamic
Hvpomobilitv reIers to decreased mobility or restricted
motion. A wide range oI pathological processes can restrict
movement and impair mobility. There are many Iactors
that may contribute to hypomobility and stiIIness oI soIt
tissues, the potential loss oI ROM, and the development
oI contractures. These Iactors are summarized in Table 4.1.
Restricted motion can range Irom mild muscle shortening
to irreversible contractures. Contracture is deIined as the
adaptive shortening oI the muscle-tendon unit and other
soIt tissues that cross or surround a joint that results in
signiIicant resistance to passive or active stretch and
limitation oI ROM, and it may compromise Iunctional
There is no clear delineation oI how much limtation
oI motion Irom loss oI soIt tissue extensibility must exist
to designate the limitation oI motion as a contracture. In
one reIerence,
contracture is deIined as an almost com-
plete loss oI motion, whereas the term shortness is used
to denote partial loss oI motion. The same resource dis-
courages the use oI the term tightness to describe restricted
motion due to adaptive shortening orI soIt tissue despite
its common usage in the clinical and Iitness settings to
describe mild muscle shortening. However, another
uses the term muscle tightness to denote adap-
tive shortening oI the contractile and noncontractile ele-
ments oI muscle.
cause a pseudomyostatic contracture. In both situations
the involved muscles appear to be in a constant state oI
contraction, giving rise to excessive resistance to passive
stretch. Hence, the term pseuaomvostatic contracture or
apparent contracture is used. II inhibition procedures to
reduce muscle tension temporarily are applied, Iull, pas-
sive elongation oI the apparently shortened muscle is
then possible.
Arfhrogcnìc and Pcrìarfìcular Confracfurcs
An arthrogenic contracture is the result oI intra-articular
pathology. These changes may include adhesions, synovial
proliIeration, joint eIIusion, irregularities in articular carti-
lage, or osteophyte Iormation.
A periarticular contracture
develops when connective tissues that cross or attach to a
joint or the joint capsule lose mobility, thus restricting
normal arthrokinematic motion.
Fìhrofìc Confracfurc and lrrcvcrsìhlc Confracfurc
Fibrous changes in the connective tissue oI muscle and
periarticular structures can cause adherence oI these tissues
and subsequent development oI a Iibrotic contracture.
Although it is possible to stretch a Iibrotic contracture
and eventually increase ROM, it is oIten diIIicult to re-
establish optimal tissue length.
Permanent loss oI extensibility oI soIt tissues that
cannot be reversed by nonsurgical intervention may occur
when normal muscle tissue and organized connective
tissue are replaced with a large amount oI relatively nonex-
tensible, Iibrotic adhesions and scar tissue
or even hetero-
topic bone. These changes can occur aIter long periods oI
immobilization oI tissues in a shortened position or aIter
tissue trauma and the subsequent inIlammatory response.
The longer a Iibrotic contracture exists or the greater the
replacement oI normal muscle and connective tissue with
nonextensible adhesions and scar tissue or bone, the more
diIIicult it becomes to regain optimal mobility oI soIt
0csìgnafìon of Confracfurcs hy Locafìon
Contractures are described by identiIying the action oI
the shortened muscle. II a patient has shortened elbow
Ilexors and cannot Iully extend the elbow, he or she is
said to have an elbow Ilexion contracture. When a patient
cannot Iully abduct the leg because oI shortened adductors
oI the hip, he or she is said to have an adduction contrac-
ture oI the hip.
Confracfurc vcrsus Confracfìon
The terms contracture and contraction (the process oI
tension developing in a muscle during shortening or
lengthening) are not synonymous and should not be
used interchangeably.
Jypcs of Confracfurc
One way to clariIy what is meant by the term contracture
is to describe contractures by the pathological changes in
the diIIerent types oI soIt tissues involved.
Myosfafìc Confracfurc
In a myostatic (myogenic) contracture, although the mus-
culotendinous unit has adaptively shortened and there is a
signiIicant loss oI ROM, there is no speciIic muscle patho-
logy present.
From a morphological perspective, although
there may be a reduction in the number oI sarcomere units
in series, there is no decrease in individual sarcomere
length. Myostatic contractures can be resolved in a rela-
tively short time with stretching exercises.
Pscudomyosfafìc Confracfurc
Impaired mobility and limited ROM may also be the result
oI hypertonicity (i.e., spasticity or rigidity) associated
with a central nervous system lesion such as a cerebral
vascular accident, a spinal cord injury, or traumatic brain
Muscle spasm or guarding and pain may also
C R A P J E P 4 Slrelchinq for lnµaired Mobilily 87
JA8LE 4.1 Facfors Jhaf Confrìhufc fo Pcsfrìcfcd Mofìon
LonIrìhuIìng FacIors Lxamp|cs
Prolonged immobilization
Casts and splints
Skeletal traction
Joint inflammation and effusion
Muscle, tendon, or fascial disorders
Skin disorders
Bony block
Vascular disorders
Sedentary lifestyle and habitual faulty
or asymmetrical postures
Paralysis, tonal abnormalities, and muscle
Postural malalignment: congenital or acquired
Fractures, osteotomy, soft tissue trauma or repair
Microtrauma or macrotrauma; degenerative diseases
Joint diseases or trauma
Myositis, tendonitis, fasciitis
Burns, skin grafts, scleroderma
Osteophytes, ankylosis, surgical fusion
Peripheral lymphedema
Confinement to bed or a wheelchair; prolonged positioning
associated with occupation or work environment
Neuromuscular disorders and diseases: CNS or PNS dysfunction
(spasticity, rigidity, flaccidity, weakness, muscle guarding, spasm)
Scoliosis, kyphosis
tissues and the more likely it is that the contracture will
become irreversible.
lnfcrvcnfìons fo lncrcasc
Mohìlìfy of Soff Jìssucs
Many therapeutic interventions have been designed to
improve the mobility oI soIt tissues and consequently
increase ROM and Ilexibility. Stretching and mobilization
are general terms that describe any therapeutic maneuver
that increases the extensibility oI restricted soIt tissues.
There are situations in which stretching interventions are
approriate and saIe; however, there are also instances
when stretching should not be implemented. Boxes 4.1
and 4.2 list indications and contraindications Ior the use
oI stretching interventions.
The Iollowing are terms that describe a number oI pro-
cedures designed to increase soIt tissue and joint mobility,
only some oI which are addressed in depth in this chapter.
Manual or McchanìcaljPassìvc or Assìsfcd Sfrcfchìng
A sustained or intermittent external, end-range stretch
Iorce, applied with overpressure and by manual contact
or a mechanical device, elongates a shortened muscle-
tendon unit and periarticular connective tissues by moving
a restricted joint just past the available ROM. II the patient
is as relaxed as possible, it is called passive stretching. II
the patient assists in moving the joint through a greater
range, it is called assistea stretching.
Any stretching exercise that is carried out independently
by a patient aIter instruction and supervision by a therapist
is reIerred to as self-stretching. The terms selI-stretching
and flexibilitv exercises are oIten used interchangeably.
However, some practitioners preIer to limit the deIinition
oI Ilexibility exercises to ROM exercises that are part
oI a general conditioning and Iitness program carried
out by individuals without mobility impairment. Active
stretching is another term sometimes used to denote
selI-stretching procedures. However, stretching exercises
that incorporate inhibition or Iacilitation techniques into
stretching maneuvers have also been reIerred to as active
Ncuromuscular Facìlìfafìon and lnhìhìfìon Jcchnìqucs
Neuromuscular Iacilitation and inhibition procedures are
purported to relax tension in shortened muscles reIlexively
prior to or during muscle elongation. Because the use oI
inhibition techniques to assist with muscle elongation is
associated with an approach to exercise known as pro-
prioceptive neuromuscular Iacilitation (PNF),
clinicians and some authors reIer to these combined
inhibition/muscle lengthening procedures as PNF stretch-
active inhibition,
active stretching,
Iacilitated stretching.
Stretching procedures based on
principles oI PNF are discussed in a later section oI this
Musclc Encrgy Jcchnìqucs
Muscle energy techniques are manipulative procedures
that have evolved out oI osteopathic medicine and are
designed to lengthen muscle and Iascia and to mobilize
The procedures employ voluntary
muscle contractions by the patient in a precisely con-
trolled direction and intensity against a counterIorce
applied by the practitioner. Because principles oI neuro-
muscular inhibition are incorporated into this approach,
another term used to describe these techniques is post-
isometric relaxation.
1oìnf MohìlìzafìonjManìpulafìon
Joint mobilization/manipulation methods are manual thera-
py techniques speciIically applied to joint structures and
are used to stretch capsular restrictions or reposition a sub-
luxed or dislocated joint.
Basic techniques Ior the
extremity joints are described and illustrated in detail in
Chapter 5. Mobilization with movement techniques Ior the
extremities are described and illustrated throughout the
regional chapters (see Chapters 17 to 22).
80X 4.1 lndìcafìons for usc of Sfrcfchìng
- R0M is limilcd bccausc sofl lissucs lavc losl llcii cxlcn-
sibilily as llc icsull of adlcsions, conliacluics, and scai
lissuc foimalion, causing funclional limilalions oi dis-
- Rcsliiclcd molion may lcad lo sliucluial dcfoimilics llal
aic ollciwisc picvcnlablc.
- 1lcic is musclc wcakncss and sloilcning of opposing
- May bc uscd as pail of a lolal filncss piogiam dcsigncd
lo picvcnl musculoskclclal injuiics.
- May bc uscd piioi lo and aflci vigoious cxcicisc polcn-
lially lo minimizc poslcxcicisc musclc soicncss.
80X 4.2 Confraìndìcafìons fo Sfrcfchìng
- A bony block limils joinl molion.
- 1lcic was a icccnl fiacluic, and bony union is incom-
- 1lcic is cvidcncc of an aculc inflammaloiy oi infcc-
lious pioccss (lcal and swclling) oi sofl lissuc lcaling
could bc disiuplcd in llc ligll lissucs and suiiounding
- 1lcic is slaip, aculc pain will joinl movcmcnl oi musclc
- A lcmaloma oi ollci indicalion of lissuc liauma is
- Eypcimobilily alicady cxisls.
- Sloilcncd sofl lissucs piovidc ncccssaiy joinl slabilily
in licu of noimal sliucluial slabilily oi ncuiomusculai
- Sloilcncd sofl lissucs cnablc a palicnl will paialysis oi
scvcic musclc wcakncss lo pcifoim spccific funclional
skills ollciwisc nol possiblc.
0vcrsfrcfchìng and Rypcrmohìlìfy
Overstretching is a stretch well beyond the normal length
oI muscle and ROM oI a joint and the surrounding soIt
resulting in hvpermobilitv (excessive mobility).
Creating selective hypermobility by overstretching may
be necessary Ior certain healthy individuals with normal
strength and stability participating in sports that require
extensive Ilexibility.
Overstretching becomes detrimental and creates joint
instabilitv when the supporting structures oI a joint and
the strength oI the muscles around a joint are insuIIicient
and cannot hold a joint in a stable, Iunctional position
during activities. Instability oI a joint oIten causes pain
and may predispose a person to musculoskeletal injury.
The ability oI the body to move Ireely, that is, without
restrictions and with control during Iunctional activities, is
dependent on the passive mobility oI soIt tissues as well as
active neuromuscular control. Motion is necessary Ior the
health oI tissues in the body.
As mentioned previously,
the soIt tissues that can become restricted and impair
mobility are muscles with their contractile and noncontrac-
tile elements and various types oI connective tissue (ten-
dons, ligaments, joint capsules, Iascia, skin). For the most
part, decreased extensibility oI connective tissue, not the
contractile elements oI muscle tissue, is the primary cause
oI restricted ROM in both healthy individuals and patients
with impaired mobility as the result oI injury, disease, or
Morphological adaptations oI tissues oIten accompany
immobilization. Each type oI soIt tissue has unique proper-
ties that aIIect its response to immobilization and its abil-
ity to regain extensibility aIter immobilization. When
stretching procedures are applied to these soIt tissues, the
direction, velocity, intensity (magnitude), duration, and
Irequency oI the stretch Iorce as well as tissue temperature
aIIect the responses oI the various types oI soIt tissue.
Mechanical characteristics oI contractile and noncon-
tractile soIt tissue and the neurophysiological properties
oI contractile tissue aIIect tissue lengthening. Most oI the
inIormation on the biomechanical, biochemical, and neuro-
physiological responses oI soIt tissues to immobilization
and remobilization is derived Irom animal studies; and as
such, the exact physiological mechanism by which stretch-
ing procedures produce an increase in the extensibility oI
human tissues is still unclear. Despite this, an understand-
ing oI the properties oI these tissues and their responses to
immobilization and stretch is the basis Ior selecting and
applying the saIest, most eIIective stretching procedures
in a therapeutic exercise program Ior patients with
impaired mobility.
Soff Jìssuc Mohìlìzafìon and Manìpulafìon
SoIt tissue mobilization/manipulation techniques are
designed to improve muscle extensibility and involve
the application oI speciIic and progressive manual Iorces
(e.g., by means oI sustained manual pressure or slow, deep
stroking) to eIIect change in the myoIascial structures that
can bind soIt tissues and impair mobility. Techniques,
including friction massage,
mvofascial release,
and trigger point therapv,
designed to improve tissue mobility by mobilizing and
manipulating connective tissue that binds soIt tissues.
Although they are useIul adjuncts to manual stretching
procedures, speciIic techniques are not described in this
Ncural Jìssuc Mohìlìzafìon
(Ncuromcnìngcal Mohìlìzafìon}
AIter trauma or surgical procedures, adhesions or scar tis-
sue may Iorm around the meninges and nerve roots or at
the site oI injury at the plexus or peripheral nerves. Tension
placed on the adhesions or scar tissue leads to pain or neu-
rological symptoms. AIter tests to determine neural tissue
mobility are conducted, the neural pathway is mobilized
through selective procedures.
These maneuvers are
described in Chapter 13.
Sclccfìvc Sfrcfchìng
Selective stretching is a process whereby the overall Iunc-
tion oI a patient may be improved by applying stretching
techniques selectively to some muscles and joints but
allowing limitation oI motion to develop in other muscles
or joints. When determining which muscles to stretch and
which to allow to become slightly shortened, the therapist
must always keep in mind the Iunctional needs oI the
patient and the importance oI maintaining a balance
between mobility and stability Ior maximum Iunctional
The decision to allow restrictions to develop in select-
ed musculotendon units and joints is usually made in
patients with permanent paralysis. For example:
In a patient with spinal cord injury, stability oI the trunk
is necessary Ior independence in sitting. With thoracic
and cervical lesions, the patient does not have active
control oI the back extensors. II the hamstrings are rou-
tinely stretched to improve or maintain their extensibility
and moderate hypomobility is allowed to develop in the
extensors oI the low back, this enables a patient to lean
into the slightly shortened structures and have some
trunk stability Ior long-term sitting. However, the patient
must still have enough Ilexibility Ior independence in
dressing and transIers. Too much limitation oI motion in
the low back can decrease Iunction.
Allowing slight hypomobility to develop in the long
Ilexors oI the Iingers while maintaining Ilexibility oI
the wrist enables the patient with spinal cord injury
who lacks innervation oI the intrinsic Iinger muscles
to develop grasp ability through a tenodesis action.
C R A P J E P 4 Slrelchinq for lnµaired Mobilily 80
When soIt tissue is stretched, elastic, viscoelastic, or
plastic changes occur. Elasticitv is the ability oI soIt tissue
to return to its prestretch resting length directly aIter a
short-duration stretch Iorce has been removed.
coelasticitv is a time-dependent property oI soIt tissue that
initially resists deIormation, such as a change in length, oI
the tissue when a stretch Iorce is Iirst applied. II a stretch
Iorce is sustained, viscoelasticity allows a change in the
length oI the tissue and then enables the tissue to return
gradually to its prestretch state aIter the stretch Iorce has
been removed.
Plasticitv is the tendency oI soIt tis-
sue to assume a new and greater length aIter the stretch
Iorce has been removed.
Both contractile and non-
contractile tissues have elastic and plastic qualities; how-
ever, only connective tissues, not the contractile elements
oI muscle, have viscoelastic properites.
Mcchanìcal Propcrfìcs of Confracfìlc Jìssuc
Muscle is composed oI both contractile and noncontractile
connective tissues. The contractile elements oI muscle
(Fig. 4.1) give it the characteristics oI contractility and
The noncontractile connective tissue in and around
muscle (Fig. 4.2) has the same properties as all connec-
tive tissue, including the ability to resist deIorming
The connective tissue structures, which
act as a 'harness¨ oI a muscle, are the enaomvsium,
which is the innermost layer that separates individual
muscle Iibers and myoIibrils; the perimvsium, which
encases Iiber burrelles; and the epimvsium, which is
the enveloping Iascial sheath around the entire muscle.
It is the connective tissue Iramework oI muscle that is
the primary source oI a muscle`s resistance to passive
When contractures develop, adhe-
sions in and between collagen Iibers resist and restrict
Confracfìlc Elcmcnfs of Musclc
Individual muscles are composed oI many muscle
fibers that lie in parallel with one another. A single
muscle Iiber is made up oI many mvofibrils. Each
myoIibril is composed oI even smaller structures
called sarcomeres, which lie in series within a myo-
Iibril. The sarcomere is the contractile unit oI the
myoIibril and is composed oI overlapping mvofila-
ments oI actin and myosin that Iorm cross-bridges.
The sarcomere gives a muscle its ability to contract
and relax. When a motor unit stimulates a muscle to
contract, the actin-myosin Iilaments slide together,
and the muscle actively shortens. When a muscle
relaxes, the cross-bridges slide apart slightly, and the
muscle returns to its resting length (Fig. 4.3).
Fl0uPE 4.1 S¦ruc¦ure o¦ s|e|e¦a| uusc|e.
Muscle fibers
Muscle nuclei
Fl0uPE 4.2 Vuscu|ar connec¦|ve ¦|ssue. Cross-sec¦|ona| v|ew o¦ ¦|e
connec¦|ve ¦|ssue |n a uusc|e s|ows |ow ¦|e µer|u,s|uu |s con¦|nuous
w|¦| ¦|e ou¦er |a,er o¦ eµ|u,s|uu. (|rcr |-vcrji- crc Ncr|ir,
j. 08, wi:|
Iorce must be maintained over an extended period oI
Response to Immobilization and Remobilization
Morphological changes. II a muscle is immobilized
Ior a prolonged period oI time, the muscle is not used
during Iunctional activities, and consequently the phy-
sical stresses placed on the muscle are substantially
dimished. This results in decay oI contractile protein
in the immobilized muscle, a decrease in muscle Iiber
diameter, a decrease in the number oI myoIibrils, and a
decrease in intramuscular capillary density, the outcome
oI which is muscle atrophv and weakness (decreased
muscle Iorce).
11,17,32,60,61,64,81,84, 91,111,131,141
As the immo-
bilized muscle atrophies, an increase in Iibrous and Iatty
tissue in muscle also occurs.
The composition oI muscle aIIects its response to
immobilization, with atrophy occurring more quickly and
more extensively in tonic (slow-twitch) postural muscle
Iibers than in phasic (Iast-twitch) Iibers.
The duration
and position oI immobilization also aIIect the extent oI
atrophy and loss oI strength and power. The longer the
duration oI immobilization, the greater is the atrophy oI
muscle and loss oI Iunctional strength. Atrophy can begin
within as little as a Iew days to a week.
Not only
is there a decrease in the cross-sectional size oI muscle
Iibers over time, an even more signiIicant deterioration in
motor unit recruitment occurs as reIlected by electromyo-
graphic activity.
Both compromise the Iorce-producing
capabilities oI the muscle.
Immobilization in a shortened position. When a muscle
is immobilized in a shortened position Ior several weeks,
which is oIten necessary aIter a Iracture or surgical repair
oI a muscle tear or tendon rupture, there is a reduction in
the length oI the muscle and its Iibers and in the number
oI sarcomeres in series within myoIibrils as the result oI
sarcomere absorption.
This absorption occurs
at a Iaster rate than the muscle`s ability to regenerate
sarcomeres in an attempt to restore itselI. The decrease
in the overall length oI the muscle Iibers and their in-
series sarcomeres, in turn, contributes to muscle atrophy
and weakness. It has also been suggested that a muscle
immobilized in a shortened position atrophies and weakens
at a Iaster rate than iI it is held in a lengthened position
over time.
There is a shiIt to the leIt in the lengthtension
curve oI a shortened muscle, which decreases the
muscle`s capacity to produce maximum tension at its
normal resting length as it contracts.
The increased
proportion oI Iibrous tissue and subcutaneous Iat in
muscle that occurs with immobilization contributes
to the decreased extensibility oI the shortened muscle
but may also serve to protect the weakened muscle
when it stretches.
Mcchanìcal Pcsponsc of fhc Confracfìlc
unìf fo Sfrcfch and lmmohìlìzafìon
There are a number oI changes that occur over time in
the anatomical structure and physiological Iunction oI the
contractile units (sarcomeres) in muscle iI a muscle is
stretched during an exercise or iI it is immobilized in eit-
her a lengthened or shortened position Ior an extended
period oI time and then remobilized. A discussion oI these
changes Iollows. OI course, the noncontractile structures
in and around muscle also aIIect a muscle`s response to
stretch and immobilization.
Those responses and
adaptations are discussed later in the chapter.
Response to Stretch
When a muscle is stretched and elongates, the stretch Iorce
is transmitted to the muscle Iibers via connective tissue
(endomysium and perimysium) in and around the Iibers.
It is hypothesized that molecular interactions link these
noncontractile elements to the contractile unit oI muscle,
the sarcomere.
During passive stretch both longitudinal and lateral
Iorce transduction occurs.
When initial lengthening
occurs in the series elastic (connective tissue) component,
tension rises sharply. AIter a point, there is mechanical
disruption (inIluenced by neural and biochemical changes)
oI the cross-bridges as the Iilaments slide apart, leading
to abrupt lengthening oI the sarcomeres,
reIerred to as sarcomere give.
When the stretch Iorce
is released, the individual sarcomeres return to their rest-
ing length
(see Fig. 4.3). As noted previously, the
tendency oI muscle to return to its resting length aIter
short-term stretch is called elasticity.
II more perma-
nent (plastic) length increases are to occur, the stretch
C R A P J E P 4 Slrelchinq for lnµaired Mobilily 71
Fl0uPE 4.8 A uode| o¦ u,o¦||auen¦ s||d|nç. L|onça¦|on and s|or¦en|nç o¦
¦|e sarcouere, ¦|e con¦rac¦||e un|¦ o¦ uusc|e.
Immobilization in a lengthened position. Sometimes a
muscle is immobilized in a position oI maximum available
length Ior a prolonged period oI time. This occurs with the
application oI a series oI positional casts (serial casts)
the use oI a dynamic splint to stretch a long-standing con-
tracture and increase ROM.
There is some evidence
Irom animal studies
to suggest that iI a muscle is
held in a lengthened position Ior an extended time period,
it adapts by increasing the number oI sarcomeres in series
) to maintain the greatest Iunctional
overlap oI actin and myosin Iilaments. This may lead to a
relatively permanent (plastic) Iorm oI muscle lengthening
iI the newly gained length is used on a regular basis in
Iunctional activities.
The minimum time Irame necessary Ior a stretched
muscle (Iiber) to become a longer muscle (Iiber) by add-
ing sarcomeres in series is not known. In animal studies
that have reported increased muscle length as the result
oI myoIibrillogenesis, the stretched muscle was continu-
ously immobilized in a lengthened position Ior several
There is speculation that this same pro-
cess contributes to gains in ROM associated with use oI
serial casts
and dynamic splints
and possibly as the
result oI stretching exercises.
The adaptation oI the contractile units oI muscle (an
increase or decrease in the number oI sarcomeres) to pro-
longed positioning in either lengthened or shortened posi-
tions is transient, lasting only 3 to 5 weeks iI the muscle
resumes its preimmobilization use and degree oI lengthen-
ing Ior Iunctional activities.
In clinical situations, this
underscores the need Ior patients to use Iull-range motions
during a variety oI Iunctional activities to maintain the Iull
available ROM.
Ncurophysìologìcal Propcrfìcs
of Confracfìlc Jìssuc
The neurophysiological properites oI the muscle-tendon
unit also inIluence a muscle`s response to stretch and the
eIIectiveness oI stretching interventions to elongate mus-
cle. In particular, two sensory organs oI muscle-tendon
units, the muscle spinale and the Golgi tenaon organ,
are mechanoreceptors that convey inIormation to the
central nervous system about what is occurring in a
muscle-tendon unit and aIIect a muscle`s response to
Musclc Spìndlc
The muscle spindle is the major sensory organ oI muscle
and is senstive to quick and sustained (tonic) stretch (Fig.
4.4). The main Iunction oI muscle spindles is to receive
and convey inIormation about changes in the length oI a
muscle and the velocity oI the length changes.
Muscle spindles are small, encapsulated receptors
composed oI aIIerent sensory Iiber endings, eIIerent motor
Iiber endings, and specialized muscle Iibers called intra-
fusal fibers. IntraIusal muscle Iibers are bundled together
and lie between and parallel to extraIusal muscle Iibers
that make up the main body oI a skeletal muscle.
Because intraIusal muscle Iibers connect at their ends
to extraIusal muscle Iibers, when a muscle is stretched,
intraIusal Iibers are also stretched. Only the ends (polar
regions), not the central portion (equatorial region), oI an
intraIusal Iiber is contractile. Consequently, when an intra-
Iusal muscle Iiber is stimulated and contracts, it lengthens
the central portion. Small-diameter motor neurons, known
as gamma motor neurons, innervate the contractile polar
regions oI intraIusal muscle Iibers and adjust the sensitivity
oI muscle spindles. Large-diameter alpha motor neurons
innervate extraIusal Iibers.
There are two general types oI intraIusal Iiber: nuclear
bag fibers and nuclear chain fibers, so named because oI
Fl0uPE 4.4 Vusc|e sµ|nd|e. 0|açrau s|ows |n¦ra¦usa| and ez¦ra¦usa|
uusc|e ¦|uers. !|e uusc|e sµ|nd|e ac¦s as a s¦re¦c| receµ¦or. (|rcr |-r|0||,
|0, Sri:|, ||. 3r0rr·:rcr´· C|iricc| |ir-·ic|cjy, -c 4. |/ 0cvi·, ||i|cc-|j|ic, 1088,
j 07, wi:| j-rri··icr.}
applied, low-intensity, prolonged stretch is considered preI-
ereable to a quickly applied, short-duration stretch.
In contrast, the GTO, as it monitors tension in the
muscle Iibers being stretched, has an inhibitory impact on
the level oI muscle tension in the muscle-tendon unit in
which it lies, particularly iI the stretch Iorce is prolonged.
This eIIect is called autogenic inhibition.
tion oI the contractile components oI muscle by the GTO
contributes to reIlexive muscle relaxation during a stretch-
ing maneuver, enabling a muscle to be elongated against
less muscle tension. It is thought that iI a low-intensity,
slow stretch Iorce is applied to muscle, the stretch reIlex
is less likely to be activated as the GTO Iires and inhibits
tension in the muscle, allowing the parallel elastic compo-
nent (the sarcomeres) oI the muscle to remain relaxed and
to lengthen.
That being said, improvement in muscle extensibility
attributed to stretching procedures are more likely due to
tensile stresses placed on the noncontractile connective tis-
sue in and around muscle than to inhibition oI the contrac-
tile elements oI muscle.
A discussion oI the eIIects
oI stretching on noncontractile soIt tissue Iollows.
Mcchanìcal Propcrfìcs of
Nonconfracfìlc Soff Jìssuc
Noncontractile soIt tissue permeates the entire body and is
organized into various types oI connective tissue to support
the structures oI the body. Ligaments, tendons, joint cap-
sules, Iasciae, noncontractile tissue in muscles (see Fig.
4.2), and skin have connective tissue characteristics that
can lead to the development oI adhesions and contractures
and thus aIIect the Ilexibility oI the tissues crossing joints.
When these tissues restrict ROM and require stretching, it
is important to understand how they respond to the intensi-
ty and duration oI stretch Iorces and to recognize that the
only way to increase the extensibility oI connective tissue
is to remodel its basic architecture.
Composìfìon of Connccfìvc Jìssuc
Connective tissue is composed oI three types oI Iiber:
collagen, elastin and reticulin, and nonIibrous ground
Collagen fibers. Collagen Iibers are responsible Ior the
strength and stiIIness oI tissue and resist tensile deIorma-
tion. Tropocollagen crystals Iorm the building blocks oI
collagen microIibrils. Each additional level oI composition
oI the Iibers is arranged in an organized relationship and
dimension (Fig. 4.5). There are six classes with 19 types
oI collagen; the Iibers oI tendons and ligaments mostly
contain type I collagen, which is highly resistant to ten-
As collagen Iibers develop and mature, they bind
together, initially with unstable hydrogen bonding, which
then converts to stable covalent bonding. The stronger the
bonds, the greater is the mechanical stability oI the tissue.
Tissue with a greater proportion oI collagen provides
greater stability.
the arrangement oI their nuclei in the central portions oI
the Iibers. Primary (type Ia Iiber) aIIerent endings, which
arise Irom nuclear bag Iibers, sense and cause muscle to
respond to both quick and sustained (tonic) stretch. How-
ever, secondary (type II) aIIerents Irom the nuclear chain
Iibers are sensitive only to tonic stretch. Primary and sec-
ondary Iibers synapse on the alpha or gamma motoneu-
rons, which when stimulated cause excitation oI their own
extraIusal and intraIusal Iibers, respectively. There are
essentially two ways to stimulate these sensory Iibers by
means oI stretch; one is by overall lengthening oI the mus-
cle, and the other is by stimulating contraction oI intraIusal
Iibers via the gamma eIIerent neural pathways.
0olgì Jcndon 0rgan
The Golgi tendon organ (GTO) is a sensory organ located
near the musculotendinous junctions oI extraIusal muscle
Iibers. The Iunction oI a GTO is to monitor changes in ten-
sion oI muscle-tendon units. These encapsulated nerve
endings are woven among collagen strands oI a tendon and
transmit sensory inIormation via Ib Iibers. These sensory
organs are sensitive to even slight changes oI tension on a
muscle-tendon unit as the result oI passive stretch oI a
muscle or with active muscle contractions during normal
When tension develops in a muscle, the GTO Iires,
inhibits alpha motoneuron activity, and decreases tension
in the muscle-tendon unit being stretched.
respect to the neuromuscular system, inhibition is a state
oI decreased neuronal activity and altered synaptic poten-
tial, which reIlexively diminishes the capacity oI a muscle
to contract.
Originally, the GTO was thought to Iire and inhibit
muscle activation only in the presence oI high levels oI
muscle tension as a protective mechanism. However, the
GTO has since been shown to have a low threshold Ior Iir-
ing (Iires easily) so it can continuously monitor and adjust
the Iorce oI active muscle contractions during movement
or the tension in muscle during passive stretch.
Ncurophysìologìcal Pcsponsc of Musclc fo Sfrcfch
When a stretch Iorce is applied to a muscle-tendon unit
either quickly or over a prolonged period oI time, the pri-
mary and secondary aIIerents oI intraIusal muscle Iibers
sense the length changes and activate extraIusal muscle
Iibers via alpha motor neurons in the spinal cord, thus acti-
vating the stretch reIlex and increasing (Iacilitating) ten-
sion in the muscle being stretched. The increased tension
causes resistance to lengthening and, in turn, is thought to
compromise the eIIectiveness oI the stretching procedure.
When the stretch reIlex is activated in a muscle being
lengthened, decreased activity (inhibition) in the muscle on
the opposite side oI the joint, reIerred to as reciprocal inhi-
bition, may also occur.
However, this phenomenon has
been documented only in studies using animal models. To
minimize activation oI the stretch reIlex and the subse-
quent increase in muscle tension and reIlexive resistance to
muscle lengthening during stretching procedures, a slowly
C R A P J E P 4 Slrelchinq for lnµaired Mobilily 78
Elastin fibers. Elastin Iibers provide extensibility. They
show a great deal oI elongation with small loads and Iail
abruptly without deIormation at higher loads. Tissues with
greater amounts oI elastin have greater Ilexibility.
Reticulin fibers. Reticulin Iibers provide tissue with bulk.
Cround substance. Ground substance is made up oI pro-
teoglycans (PGs) and glycoproteins. The PGs Iunction to
hydrate the matrix, stabilize the collagen networks, and
resist compressive Iorces. (This is most important in carti-
lage and intervertebral discs.) The type and amount oI PGs
are proportional to the types oI compressive and tensile
stress the tissue undergoes.
The glycoproteins provide
linkage between the matrix components and between the
cells and matrix opponents. In essence, the ground sub-
stance is mostly an organic gel containing water that
reduces Iriction between Iibers, transports nutrients and
metabolites, and may help prevent excessive cross-linking
between Iibers by maintaining space between Iibers.
Mcchanìcal 8chavìor of Nonconfracfìlc Jìssuc
The mechanical behavior oI the various noncontractile
tissues is determined by the proportion oI collagen and
elastin Iibers and by the structural orientation oI the Iibers.
The proportion oI proteoglycans (PGs) also inIluences the
mechanical properties oI connective tissue. Those high in
collagen and low in PGs are designed to resist high tensile
loads; those tissues that withstand greater compressive
loads have greater concentrations oI PGs.
Collagen is the structural element that absorbs most
oI the tensile stress. Collagen Iibers elongate quickly
under light loads (wavy Iibers align and straighten). With
increased loads, tension in the Iibers increases, and the
Iibers stiIIen. The Iibers strongly resist the tensile Iorce,
but with continued loading the bonds between collagen
Iibers begin to break. When a substantial number oI bonds
are broken, the Iibers Iail. When tensile Iorces are applied
the maximum elongation oI collagen is less than 10°,
whereas elastin may lengthen 150° and return to its
original conIiguration. Collagen is Iive times as strong
as elastin. The alignment oI collagen Iibers in various
tissues reIlects the tensile Iorces acting on that tissue
(see Fig. 4.5).
In tendons, collagen Iibers are parallel and can resist the
greatest tensile load. They transmit Iorces to the bone
created by the muscle.
In skin, collagen Iibers are random and weakest in resist-
ing tension.
In ligaments, joint capsules, and Iasciae, the collagen
Iibers vary between the two extremes, and they resist
multidirectional Iorces. Ligaments that resist major joint
stresses have a more parallel orientation oI collagen
Iibers and a larger cross-sectional area.
lnfcrprcfìng Mcchanìcal 8chavìor of
Connccfìvc Jìssuc: Jhc Sfrcss-Sfraìn Curvc
The stressstrain curve illustrates the mechanical strength
oI structures (Fig. 4.6) and is used to interpret what is hap-
pening to connective tissue under stress loads.
Elastic Range Plastic Range
Elastic Limit Necking
(% deformation)
X' Y'
Skin Ligament Tendon
Fl0uPE 4.5 Couµos|¦|on o¦ co||açen ¦|uers s|ow|nç ¦|e aççreça¦|on o¦
¦roµoco||açen cr,s¦a|s as ¦|e uu||d|nç u|oc|s o¦ co||açen. 0rçan|za¦|on o¦
¦|e ¦|uers |n connec¦|ve ¦|ssue |s re|a¦ed ¦o ¦|e ¦unc¦|on o¦ ¦|e ¦|ssue. !|ssues
w|¦| µara||e| ¦|uer or|en¦a¦|on, suc| as ¦endons, are au|e ¦o w|¦|s¦and çrea¦er
¦ens||e |oads ¦|an ¦|ssue suc| as s||n, w|ere ¦|e ¦|uer or|en¦a¦|on aµµears
uore randou.
Fl0uPE 4.8 S¦ress-s¦ra|n curve. w|en s¦ressed, |n|¦|a||, ¦|e wav, co||açen
¦|uers s¦ra|ç|¦en (¦oe reç|on}. w|¦| add|¦|ona| s¦ress, recoverau|e de¦orua¦|on
occurs |n ¦|e e|as¦|c rançe. 0nce ¦|e e|as¦|c ||u|¦ |s reac|ed, seuuen¦|a| ¦a||ure
o¦ ¦|e co||açen ¦|uers and ¦|ssue occurs |n ¦|e µ|as¦|c rançe, resu|¦|nç |n
re|ease o¦ |ea¦ (|,s¦eres|s} and new |enç¦| w|en ¦|e s¦ress |s re|eased. !|e
|enç¦| ¦rou ¦|e s¦ress µo|n¦ (/} resu|¦s |n a new |enç¦| w|en re|eased (/ },
¦|e |ea¦ re|eased |s reµresen¦ed u, ¦|e area under ¦|e curve ue¦ween ¦|ese
¦wo µo|n¦s (|,s¦eres|s |ooµ}. (Y ¦o Y reµresen¦s add|¦|ona| |enç¦| ¦rou add|-
¦|ona| s¦ress w|¦| uore |ea¦ re|eased.} Nec||nç |s ¦|e reç|on |n w||c| ¦|ere |s
cons|derau|e wea|en|nç o¦ ¦|e ¦|ssue and |ess ¦orce |s needed ¦or de¦orua-
¦|on. !o¦a| ¦a||ure uu|c||, ¦o||ows even under sua||er |oads.
stretching because as the tissue begins necking, iI the
stress is maintained, there could be complete tearing oI
the tissue. Experimentally, maximum tensile deIormation
oI isolated collagen Iibers prior to Iailure is 7° to 8°.
Whole ligaments may withstand strain oI 20° to 40°.
Failure. Rupture oI the integrity oI the tissue is called
Structural stiffness. Tissues with greater stiIIness have a
higher slope in the elastic region oI the curve, indicating
that there is less elastic deIormation with greater stress.
Contractures and scar tissue have greater stiIIness, proba-
bly because oI a greater degree oI bonding between colla-
gen Iibers and their surrounding matrix.
Connccfìvc Jìssuc Pcsponscs fo Loads
Creep. When a load is applied Ior an extended period oI
time, the tissue elongates, resulting in permanent deIorma-
tion (Fig. 4.7A). It is related to the viscosity oI the tissue
and is thereIore time-dependent. The amount oI deIorma-
tion depends on the amount oI Iorce and the rate at which
the Iorce is applied. Low-magnitude loads, usually in the
elastic range and applied Ior long periods, increase the
deIormation oI connective tissue and allow gradual
rearrangement oI collagen Iiber bonds (remodeling) and
redistribution oI water to surrounding tissues.
Increasing the temperature oI the part increases the creep
and thereIore the distensibility oI the tissue.
plete recovery Irom creep may occur over time, but not as
rapidly as a single strain. Patient reaction dictates the time
a speciIic load is tolerated.
Stress and Strain
Stress is Iorce per unit area. Mechanical stress is the inter-
nal reaction or resistance to an external load. There are
three kinds oI stress.
Tension: a Iorce applied perpendicular to the cross-
sectional area oI the tissue in a direction away Irom
the tissue. A stretching Iorce is a tension stress.
Compression: a Iorce applied perpendicular to the cross-
sectional area oI the tissue in a direction toward the tis-
sue. Muscle contraction and loading oI a joint during
weight bearing cause compression stresses in joints.
Shear: a Iorce applied parallel to the cross-sectional area
oI the tissue.
Strain: the amount oI deIormation or lengthening that
occurs when a load (stress) or stretch Iorce is applied.
Regions of the Stress-Strain Curve
1oe region. That area oI the stressstrain curve where there
is considerable deIormation without the use oI much Iorce
is called the toe region. This is the range where most Iunc-
tional activity normally occurs. Collagen Iibers at rest are
wavy and are situated in a three-dimensional matrix, so
some distensibility in the tissue occurs by straightening
and aligning the Iibers.
Elastic range/linear phase. Strain is directly proportional
to the ability oI tissue to resist the Iorce. This occurs when
tissue is taken to the end oI its ROM, and gentle stretch is
applied. With stress in this phase the collagen Iibers line up
with the applied Iorce, the bonds between Iibers and
between the surrounding matrix are strained, some micro-
Iailure between the collagen bonds begins, and some water
may be displaced Irom the ground substance. There is
complete recovery Irom this deIormation, and the tissue
returns to its original size and shape when the load is
released iI the stress is not maintained Ior any length oI
time (see the Iollowing discussion on creep and stress-
relaxation Ior prolonged stretch).
Elastic limit. The point beyond which the tissue does not
return to its original shape and size is the elastic limit.
Plastic range. The range beyond the elastic limit extending
to the point oI rupture is the plastic range. Tissue strained
in this range has permanent deIormation when the stress is
released. In this range there is sequential Iailure oI the
bonds between collagen Iibrils and eventually oI collagen
Iibers. Heat is released and absorbed in the tissue. Because
collagen is crystalline, individual Iibers do not stretch but,
instead, rupture. In the plastic range it is the rupturing oI
Iibers that results in increased length.
Ultimate strength. The greatest load the tissue can sustain
is its ultimate strength. Once this load is reached, there is
increased strain (deIormation) without an increase in stress
required. The region of necking is reached in which there is
considerable weakening oI the tissue, and it rapidly Iails.
The therapist must be cognizant oI the tissue Ieel when
C R A P J E P 4 Slrelchinq for lnµaired Mobilily 75
Tissue creep with
constant load
Stress relaxation with
constant tissue length
Fl0uPE 4.7 !|ssue resµonse ¦o µro|onçed s¦re¦c| ¦orces as a resu|¦ o¦ v|s-
coe|as¦|c µroµer¦|es. (/} L¦¦ec¦s o¦ creeµ. A cons¦an¦ |oad, aµµ||ed over ¦|ue,
resu|¦s |n |ncreased ¦|ssue |enç¦| un¦|| euu|||ur|uu |s reac|ed. (3} L¦¦ec¦s o¦
s¦ress-re|aza¦|on. A |oad aµµ||ed w|¦| ¦|e ¦|ssue |eµ¦ a¦ a cons¦an¦ |enç¦|
resu|¦s |n decreased |n¦erna| ¦ens|on |n ¦|e ¦|ssue un¦|| euu|||ur|uu |s reac|ed.
Stress-relaxation. When a Iorce (load) is applied to stretch
a tissue and the length oI the tissue is kept cons-
tant, aIter the initial creep there is a decrease in the Iorce
required to maintain that length, and the tension in the
tissue decreases
(Fig. 4.7B). This, like creep, is related
to the viscoelastic qualities oI the connective tissue and
redistribution oI the water content. Stress-relaxation is
the underlying principle used in prolonged stretching
procedures where the stretch position is maintained Ior
several hours or days. Recovery (i.e., no change) versus
permanent changes in length is dependent on the amount
oI deIormation and the length oI time the deIormation is
Cyclic loading and connective tissue fatigue. Repetitive
loading oI tissue increases heat production and may cause
Iailure below the yield point. The greater the applied load,
the Iewer number oI cycles needed Ior Iailure. This princi-
ple can be used Ior stretching by applying repetitive
(cyclic) loads at a submaximal level on successive days.
The intensity oI the load is determined by the patient`s
tolerance. A minimum load is required Ior this Iailure.
Below the minimum load an apparently inIinite number
oI cycles do not cause Iailure. This is the enaurance
limit. Examples oI connective tissue Iatigue Irom cyclic
loading are stress Iractures and overuse syndromes,
neither oI which is desired as a result oI stretching.
ThereIore, periodically, time is allowed between bouts
oI cyclic stretching to allow Ior remodeling and healing
in the new range.
Summary of Mcchanìcal Prìncìplcs
for Sfrcfchìng Connccfìvc Jìssuc
Connective tissue deIormation (stretch) occurs to diIIer-
ent degrees at diIIerent intensities oI Iorce. It requires
breaking oI collagen bonds and realignment oI the Iibers
Ior there to be permanent elongation or increased Ilexi-
bility. Failure oI tissue begins as microIailure oI Iibrils
and Iibers beIore complete Iailure oI the tissue occurs.
Complete tissue Iailure can occur as a single maximal
event (acute tear Irom a traumatic injury or manipulation
that exceeds the Iailure point) or Irom repetitive submax-
imal stress (Iatigue or stress Iailure Irom cyclic loading).
MicroIailure (needed Ior permanent lengthening) also
occurs with creep, stress-relaxation, and controlled
cyclic loading.
Healing and adaptive remodeling capabilities allow the
tissue to respond to repetitive and sustained loads iI time
is allowed between bouts. This is important Ior increas-
ing both Ilexibility and tensile strength oI the tissue. II
healing and remodeling time is not allowed, a break-
down oI tissue (Iailure) occurs as in overuse syndromes
and stress Iractures. Intensive stretching is usually not
done every day in order to allow time Ior healing. II the
inIlammation Irom the microruptures is excessive, addi-
tional scar tissue is laid down, which could become more
It is imperative that the individual use any newly gained
range to allow the remodeling oI tissue and to train the
muscle to control the new range, or the tissue eventually
returns to its shortened length.
Changcs ìn Collagcn Affccfìng Sfrcss-Sfraìn Pcsponsc
Effects of Immobilization
There is weakening oI the tissue because oI collagen
turnover and weak bonding between the new, nonstressed
Iibers. There is also adhesion Iormation because oI greater
cross-linking between disorganized collagen Iibers and
because oI decreased eIIectiveness oI the ground substance
maintaining space and lubrication between the Iibers.
The rate oI return to normal tensile strength is slow. For
example, aIter 8 weeks oI immobilization, the anterior
cruciate ligament in monkeys Iailed at 61° oI maximum
load; aIter 5 months oI reconditioning, it Iailed at 79°;
aIter 12 months oI reconditioning, it Iailed at 91°.
There was also a reduction in energy absorbed and an
increase in compliance (decreased stiIIness) prior to
Iailure Iollowing immobilization. Partial and near-
complete recovery Iollowed the same 5-month and
12-month pattern.
Effects of Inactivity (Decrease of Normal Activity)
There is a decrease in the size and amount oI collagen
Iibers, resulting in weakening oI the tissue. There is a
proportional increase in the predominance oI elastin
Iibers, resulting in increased compliance. Recovery
takes about 5 months oI regular cyclic loading. Physical
activity has a beneIicial eIIect on the strength oI
connective tissue.
Effects of Age
There is a decrease in the maximum tensile strength
and the elastic modulus, and the rate oI adaptation to
stress is slower.
There is an increased tendency Ior
overuse syndromes, Iatigue Iailures, and tears with
Effects of Corticosteroids
There is a long-lasting deleterious eIIect on the mecha-
nical properties oI collagen with a decrease in tensile
There is Iibrocyte death next to the injection
site with delay in reappearance up to 15 weeks.
Effects of Injury
Excessive tensile loading can lead to rupture oI ligaments
and tendons at musculotendinous junctions. Healing Iol-
lows a predictable pattern (see Chapter 10), with bridging
oI the rupture site with newly synthesized type III colla-
gen. This is structurally weaker than mature type I colla-
gen. Remodeling progresses, and eventually collagen
matures to type I. Remodeling usually begins about 3
weeks postinjury and continues Ior several months to a
year, depending on the size oI the connective tissue struc-
ture and magnitude oI the tear.
- A||qnmcni: posilioning a limb oi llc body sucl llal llc
sliclcl foicc is diicclcd lo llc appiopiialc musclc gioup
- Siab|||zai|on: fixalion of onc silc of allaclmcnl of llc
musclc as llc sliclcl foicc is applicd lo llc ollci bony
- Inicns|iy o] siìcich: magniludc of llc sliclcl foicc
- Duìai|on o] siìcich: lcngll of limc llc sliclcl foicc is
applicd duiing a sliclcl cyclc
- S¡ccd o] siìcich: spccd of inilial applicalion of llc
sliclcl foicc
- Fìcqucncy o] siìcich. numbci of sliclcling scssions pci
day oi pci wcck
- Modc o] siìcich: foim oi mannci in wlicl llc sliclcl
foicc is applicd (slalic, ballislic, cyclic), dcgicc of palicnl
pailicipalion (passivc, assislcd, aclivc), oi llc souicc of
llc sliclcl foicc (manual, mcclanical, sclf)
bility and increase ROM, but recommended protocols vary
substantially. Some oI this research is highlighted in this
section. Injury prevention or risk reduction, prevention or
reduction oI postexercise muscle soreness, and enhanced
physical perIormance also are eIIects that have been attrib-
uted to stretching interventions. However, the evidence to
support these claims, Ior the most part, is mixed.
Focus on Evidence
Many oI the investigations comparing the intensity, dura-
tion, Irequency, and mode oI stretching have been carried
out with healthy, young adults as subjects. The Iindings
and recommendations oI these studies are diIIicult to gen-
eralize and apply to patients with long-standing contrac-
tures or other Iorms oI tissue restriction. ThereIore, many
decisions, particularly those related to the type, intensity,
duration, and Irequency oI stretching, must continue to be
based on a balance oI scientiIic evidence and sound clini-
cal judgments by the therapist.
Alìgnmcnf and Sfahìlìzafìon
Just as appropriate alignment and eIIective stabilization are
Iundamental components oI muscle testing and goniometry
as well as ROM and strengthening exercises, they are also
essential elements oI eIIective stretching.
Proper alignment or positioning oI the patient and the spe-
ciIic muscles and joints to be stretched is necessary Ior
patient comIort and stability during stretching. Alignment
inIluences the amount oI tension present in soIt tissue and
consequently aIIects the ROM available in joints. Align-
ment oI the muscles and joint to be stretched as well as the
alignment oI the trunk and adjacent joints must all be con-
sidered. For example, to stretch the rectus Iemoris (a mus-
cle that crosses two joints) eIIectively, as the knee is Ilexed
and the hip extended, the lumbar spine and pelvis should
be aligned in a neutral position. The pelvis should not tilt
anteriorly nor should the low back hyperextend; the hip
should not abduct or remain Ilexed (Fig. 4.8). When a
As with other Iorms oI therapeutic exercise, such as
strengthening exercises and endurance training, there are a
number oI essential elements that determine the eIIective-
ness oI stretching interventions. The elements (determi-
nants) oI stretching, all oI which are interrelated, include
alignment and stabili:ation oI the body during stretching;
the intensitv (magnituae), auration, speea, frequencv, and
moae oI stretch; and the integration oI neuromuscular inhi-
bition or Iacilitation and Iunctional activities into stretching
programs. By manipulating the determinants oI stretching
interventions, which are deIined in Box 4.3, a therapist has
many options Irom which to choose when designing
stretching programs that are saIe and eIIective and meet
many patients` needs, Iunctional goals, and capabilities.
Each oI these determinants is discussed in this section oI
the chapter.
There are Iour broad categories oI stretching exer-
cises: static stretching, cyclic stretching, ballistic stretch-
ing, and stretching techniques based on the principles
oI proprioceptive neuromuscular Iacilitation.
Each oI these approaches to stretching can be carried out
in various mannersthat is, manually or mechanically,
passively or actively, and by a therapist or independently
by a patientgiving rise to many terms that are used in
the literature to describe stretching interventions. The
stretching interventions listed in Box 4.4 are deIined
and discussed in this section.
Extensive evidence Irom numerous research studies
has shown that stretching interventions can improve Ilexi-
C R A P J E P 4 Slrelchinq for lnµaired Mobilily 77
80X 4.8 0cfcrmìnanfs of Sfrcfchìng lnfcrvcnfìons 80X 4.4 Jypcs of Sfrcfchìng
- Slalic sliclcling
- Cyclic|inlcimillcnl sliclcling
- Ballislic sliclcling
- Piopiioccplivc ncuiomusculai facililalion sliclcling pio-
ccduics (PNF sliclcling)
- Manual sliclcling
- Mcclanical sliclcling
- Sclf-sliclcling
- Passivc sliclcling
- Aclivc sliclcling
patient is selI-stretching to increase shoulder Ilexion, the
trunk should be erect, not slumped (Fig. 4.9B).
To achieve an eIIective stretch oI a speciIic muscle or
muscle group and associated periarticular structures, it is
imperative to stabilize (Iixate) either the proximal or distal
attachment site oI the muscle-tendon unit being elongated.
Either site may be stabilized, but Ior manual stretching it is
common Ior a therapist to stabilize the proximal attachment
and move the distal segment, as shown in Figure 4.10A.
Fl0uPE 4.8 (/} Correc¦ a||çnuen¦ w|en s¦re¦c||nç ¦|e rec¦us ¦euor|s. ¦|e
|uuuar sµ|ne, µe|v|s, and ||µ are |e|d |n a neu¦ra| µos|¦|on as ¦|e |nee |s
¦|ezed. (3} lncorrec¦ µos|¦|on o¦ ¦|e ||µ |n ¦|ez|on. ln add|¦|on, avo|d an¦er|or
µe|v|c ¦||¦, |,µerez¦ens|on o¦ ¦|e |uuuar sµ|ne, and auduc¦|on o¦ ¦|e ||µ.
Fl0uPE 4.0 (/} Correc¦ a||çnuen¦ w|en s¦re¦c||nç ¦o |ncrease s|ou|der ¦|ez-
|on. ¦|e cerv|ca| and ¦|orac|c sµ|ne |s erec¦. (3} lncorrec¦ a||çnuen¦. ¦orward
|ead and rounded sµ|ne.
Fl0uPE 4.10 (/} !|e µroz|ua| a¦¦ac|uen¦ (¦euur and µe|v|s} o¦ ¦|e uusc|e
ue|nç s¦re¦c|ed (¦|e uuadr|ceµs} |s s¦au|||zed as ¦|e d|s¦a| seçuen¦ |s uoved
¦o |ncrease |nee ¦|ez|on.
For selI-stretching procedures, a stationary object,
such as a chair or a doorIrame, or active muscle contrac-
tions by the patient may provide stabilization oI one seg-
ment as the other segment moves. During selI-stretching, it
is oIten the distal attachment that is stabilized as the proxi-
mal segment moves (Fig. 4.10B).
Fl0uPE 4.10 (3} 0ur|nç ¦||s se|¦-s¦re¦c| o¦ ¦|e uuadr|ceµs, ¦|e d|s¦a| seç-
uen¦ (¦|u|a} |s s¦au|||zed ¦|rouç| ¦|e ¦oo¦ as ¦|e µa¦|en¦ uoves ¦|e µroz|ua|
seçuen¦ (¦euur} u, |unç|nç ¦orward.
N 0 J E : !hrouqhoul lhis and laler chaµlers, reconnenda-
lions for aµµroµriale aliqnnenl and µosilioninq durinq
slrelchinq µrocedures are idenlified. lf il is inµossible for
a µalienl lo be µlaced in or assune lhe reconnended
µoslures because of disconforl, reslriclions of nolion of
ad|acenl |oinls, inadequale neuronuscular conlrol, or
cardioµulnonary caµacily, lhe lheraµisl nusl crilically
analyze lhe silualion lo delernine an allernalive µosilion.
Despite numerous studies, there continues to be a lack
oI agreement on the 'ideal¨ combination oI the duration oI
a single cycle and the number oI repetitions oI stretch that
should be applied in a daily stretching program to achieve
the greatest and most sustained stretch-induced gains in
ROM. The duration oI stretch must be put in context with
other stretching parameters, including intensity, Irequency,
and mode oI stretch. Key Iindings Irom several studies are
summarized in Box 4.5 on the Iollowing page.
Numerous descriptors are used to diIIerentiate
between a long-duration versus a short-duration stretch.
Terms such as static, sustainea, maintainea, and prolongea
are all used to describe a long-duration stretch, whereas
terms such as cvclic, intermittent, or ballistic are used to
characterize a short-duration stretch. There is no speciIic
time period assigned to any oI these descriptors, nor is
there a time Irame that distinguishes a long-duration
Irom a short-duration stretch.
Sfafìc Sfrcfchìng
Static stretching
is a commonly used method oI stretching
in which soIt tissues are elongated just past the point oI
tissue resistance and then held in the lengthened position
with a sustained stretch Iorce over a period oI time. Other
terms used interchangeably are sustained, maintained, or
prolonged stretching. The duration oI static stretch is pre-
determined prior to stretching or is based on the patient`s
tolerance and response during the stretching procedure.
In research studies the term 'static stretching¨ has
been linked to durations oI a single stretch cycle ranging
Irom as Iew as 5 seconds to 5 minutes per repetition when
either a manual stretch or selI-stretching procedure is
II a mechanical device provides the static
stretch, the time Irame can range Irom almost an hour to
several days or weeks.
(See additional
inIormation on mechanical stretching later in this section.)
Focus on Evidence
In a systematic review oI the literature (28 studies)
on hamstring stretching,
a 30-second manual or selI-
stretching procedure perIormed Ior one or more repetitions
was the most Irequently used duration per repetition oI
stretch in static stretching programs. A 30-second stretch
per repetition was also identiIied as the median duration
oI stretch in a review oI the literature oI studies on calI
muscle stretching.
Static stretching is well accepted as an eIIective Iorm
oI stretching to increase Ilexibility
and has been
considered a saIer Iorm oI stretching than ballistic stretch-
ing (described in the next section on speed oI stretch) Ior
many years.
Research has shown that tension created in
muscle during static stretching is approximately halI that
created during ballistic stretching.
This is consistent with
Stabilization oI multiple segments oI a patient`s body
also helps maintain the proper alignment necessary Ior an
eIIective stretch. For example, when stretching the iliop-
soas, the pelvis and lumbar spine must maintain a neutral
position as the hip is extended to avoid stress to the low
back region. Sources oI stabilization include manual con-
tacts, body weight, or a Iirm surIace such as a table, wall,
or Iloor.
lnfcnsìfy of Sfrcfch
The intensity (magnitude) oI a stretch Iorce is determined
by the load placed on soIt tissue to elongate it. There is
general agreement among clinicians and researchers that
stretching should be applied at a low intensitv by means
oI a low loaa.
Low-intensity stretch-
ing in comparison to high-intensity stretching makes the
stretching maneuver more comIortable Ior the patient and
minimizes voluntary or involuntary muscle guarding so a
patient can either remain relaxed or assist with the stretch-
ing maneuver.
Low-intensity stretching (coupled with a long duration
oI stretch) results in optimal rates oI improvement in ROM
without exposing tissues, possibly weakened by immo-
bilization, to excessive loads and potential injury.
Low-intensity stretching has also been shown to elongate
dense connective tissue, a signiIicant component oI chronic
contractures, more eIIectively and with less soIt tissue
damage and post-exercise soreness than a high-intensity
0urafìon of Sfrcfch
One oI the most important decisions a therapist must make
when selecting and implementing a stretching intervention
(stretching exercises or use oI a mechanical stretching
device) is to determine the duration oI stretch that is
expected to be saIe, eIIective, practical, and eIIicient Ior
each situation.
The duration oI stretch reIers to the period oI time a
stretch Iorce is applied and shortened tissues are held in
a lengthened position. Duration most oIten reIers to how
long a single cvcle oI stretch is applied. II more than one
repetition oI stretch (stretch cvcle) is carried out during a
treatment session (which is most oIten the case), the cumu-
lative time oI all the stretch cycles is also considered an
aspect oI duration.
In general, the shorter the duration oI a single stretch
cycle, the greater the number oI repetitions applied during
a stretching session. Any number oI combinations have
been studied. For example, in a study by Cipriani et al.,
two repetitions oI 30-second hamstring stretches were
Iound to be equally eIIective compared to six repetitions
oI 10-second stretches. However, Roberts and Wilson
Iound that over the course oI a 5-week period three
15-second hamstring stretches each day yielded signiIi-
cantly greater stretch-induced gains in ROM than nine
daily 5-second stretches.
C R A P J E P 4 Slrelchinq for lnµaired Mobilily 70
* See reIerences 4,5,6,13,14,25,35,39,40,50,55,58,86,95,101,112,124,
f See reIerences 4,5,6,12,13,14,25,50,96,124,126,151,161,163.
our understanding oI the viscoelastic properties oI connec-
tive tissue, which lies in and around muscles, as well as
the neurophysiological properties oI the contractile ele-
ments oI muscle. As discussed in the previous section oI
this chapter, noncontractile soIt tissues are known to yield
more readily to a low-intensity, continuously applied
stretch Iorce, as used in static stretching.
Furthermore, during static stretching it is thought that
the GTO, which monitors tension created by stretch oI a
muscle-tendon unit, may contribute to muscle elongation
by overriding any Iacilitative impulses Irom the primary
aIIerents oI the muscle spindle (Ia aIIerent Iibers) and may
contribute to muscle relaxation by inhibiting tension in the
contractile units oI the muscle being stretched. For these
reasons clinicians believe that static stretching, iI applied at
a low intensity, generates less tissue trauma and less post-
exercise muscle soreness than ballistic stretching.
Sfafìc Progrcssìvc Sfrcfchìng
Static progressive stretching is another term that describes
how static stretch is applied Ior maximum eIIectiveness.
The shortened soIt tissues are held in a comIortably length-
ened position until a degree oI relaxation is Ielt by the
patient or therapist. Then the shortened tissues are incre-
mentally lengthened even Iurther and again held in the
new end-range position Ior an additional duration oI
This approach involves continuous displace-
ment oI a limb by varying the stretch Iorce (stretch load).
This approach to stretching capitalizes on the stress-
relaxation properties oI soIt tissue
(see Fig. 4.7B).
Most studies that have explored the merits oI static
progressive stretching have examined the eIIectiveness oI a
dynamic orthosis (see Fig. 4.13, below), which allows the
patient to control the degree oI displacement oI the
Manual stretching and selI-stretching procedures
are also routinely applied in this manner.
Cyclìc (lnfcrmìffcnf} Sfrcfchìng
A relatively short-duration stretch Iorce that is repeatedly
but gradually applied, released, and then reapplied is
described as a cyclic (intermittent) stretch.
stretching, by its very nature, is applied Ior multiple repeti-
tions (stretch cycles) during a single treatment session.
With cyclic stretching the end-range stretch Iorce is
80X 4.5 lnfcnsìfy, 0urafìon, Frcqucncy, and Modc of Sfrcfch-lnfcrrclafìonshìps and lmpacf
on Sfrcfchìng 0ufcomcs
- 1lcic is an invcisc iclalionslip bclwccn inlcnsily and
duialion as wcll as bclwccn inlcnsily and ficqucncy of
- 1lc lowci llc inlcnsily of sliclcl, llc longci llc limc llc
palicnl will lolcialc sliclcling and llc sofl lissucs can bc
lcld in a lcngllcncd posilion.
- 1lc liglci llc inlcnsily, llc lcss ficqucnlly llc sliclcl-
ing inlcivcnlion can bc applicd lo allow limc foi lissuc
lcaling and icsolulion of icsidual musclc soicncss.
- A low-load (low-inlcnsily), long-duialion sliclcl is consid-
cicd llc safcsl foim of sliclcl and yiclds llc mosl signifi-
canl, claslic dcfoimalion and long-lcim, plaslic clangcs in
sofl lissucs.
- Manual sliclcling and sclf-sliclcling in lypomobilc
bul lcallly subjccls
and piolongcd mcclanical
sliclcling in palicnls will clionic conliacluics
yicld significanl sliclcl-induccd gains in R0M.
- ln llc wcll cldcily, sliclcl cyclcs of 1¯, 20, and 60 scconds
applicd lo llc lamsliings foi foui icpclilions lavc all bccn
slown lo pioducc significanl gains in R0M will llc gical-
csl and longcsl-lasling impiovcmcnls occuiiing will llc
usc of 60-sccond sliclcl cyclcs.
- ln lcallly young and|oi middlc-agc adulls
- Sliclcl duialions of 1¯, 20, 4¯, oi 60 scconds oi 2 min-
ulcs lo lowci cxlicmily musculaluic pioduccd significanl
gains in R0M.
- Sliclcl cyclcs of 20- and 60-sccond duialion applicd lo
llc lamsliings foi onc icpclilion daily aic boll moic
cffcclivc llan onc icpclilion daily of a 1¯-sccond sliclcl
cyclc bul aic cqually cffcclivc wlcn compaicd lo cacl
- 1wo icpclilions daily of a 20-sccond slalic sliclcl of llc
lamsliings yicld significanl gains in lamsliing flcxibili-
ly similai lo llosc sccn will six icpclilions of 10-sccond
slalic sliclclcs daily.

- Slalic sliclclcs of llc lip adduclois foi 1¯ scconds oi 2
minulcs pioducc cqual impiovcmcnls in R0M.
- 1lcic sccms lo bc no addilional bcncfil lo lolding cacl
sliclcl cyclc bcyond 60 scconds.
- 1licc cyclcs of 20-sccond and 1-minulc sliclclcs aic no
moic cffcclivc foi impioving R0M llan onc cyclc of
cacl duialion of sliclcl.
- Wlcn llc lolal duialion of sliclcl is cqual, cyclic sliclcl-
ing is cqually cffcclivc and possibly moic comfoilablc
llan slalic sliclcling.
- ln palicnls will clionic, fibiolic conliacluics.
- Common duialions of manual sliclcling oi sclf-
sliclcling may nol bc cffcclivc.
- Usc of piolongcd slalic sliclcl will splinls oi casls is
moic cffcclivc.
- Ficqucncy of sliclcling nccds lo occui a minimum of
lwo limcs pci wcck
foi lcallly lypomobilc individ-
uals, bul moic ficqucnl sliclcling is ncccssaiy foi
palicnls will sofl lissuc pallology lo aclicvc gains
in R0M.
- Alllougl sliclcl-induccd gains in R0M oflcn pcisisl foi
scvcial wccks lo a monll in lcallly adulls aflci ccssalion
of a sliclcling piogiam, pcimancnl impiovcmcnl in
mobilily can bc aclicvcd only by usc of llc ncwly gaincd
R0M in funclional aclivilics and|oi will a mainlcnancc
sliclcling piogiam.
It is characterized by the use oI
quick, bouncing movements that create momentum to carry
the body segment through the ROM to stretch shortened
structures. Although both static stretching and ballistic
stretching have been shown to improve Ilexibility equally,
ballistic stretching is thought to cause greater trauma to
stretched tissues and greater residual muscle soreness than
static stretching.
Consequently, although ballistic stretching has been
shown to increase ROM saIely in young, healthy subjects
participating in a conditioning program,
it is, Ior the most
part, not recommended Ior elderly or sedentary individuals
or patients with musculoskeletal pathology or chronic con-
tractures. The rationale Ior this recommendation is
Tissues, weakened by immobilization or disuse, are easi-
ly injured.
Dense connective tissue Iound in chronic contractures
does not yield easily with high-intensity, short-duration
stretch; rather, it becomes more brittle and tears more
Rìgh-vclocìfy Sfrcfchìng ìn Condìfìonìng
Programs and Advanccd-Phasc Pchahìlìfafìon
Although somewhat controversial, certain practitioners and
authors believe there are situations when high-velocity
stretching is appropriate Ior careIully selected individu-
For example, a highly trained athlete involved in a
sport such as gymnastics that requires signiIicant dynamic
Ilexibility may need to incorporate high-velocity stretching
in a conditioning program. Also, a young, active patient in
the Iinal phase oI rehabilitation who wishes to return to
high-demand, recreational activities aIter a musculoskeletal
injury may need to perIorm careIully progressed, high-
velocity stretching activities prior to beginning plyometric
training or simulated, sport-speciIic exercises or drills.
II high-velocity stretching is employed, rapid, but low-
loaa (low-intensitv) stretches are recommemded, paying
close attention to eIIective stabilization. The Iollowing
selI-stretching sequence, reIerred to as a Progressive Veloc-
ity Flexibility Program, has been suggested Ior a saIe tran-
sition and progression Irom static stretching to ballistic
stretching to improve dynamic Ilexibility.
Static stretching Slow, short end-range stretching
Slow, Iull-range stretching Fast, short end-range
stretching Fast, Iull-range stretching.
The stretch Iorce is initiated by having the patient active-
ly contract the muscle group opposite the muscle and
connective tissues to be stretched.
Frcqucncy of Sfrcfch
Frequency oI stretching reIers to the number of bouts (ses-
sions) per aav or per week a patient carries out a stretching
The recommended Irequency oI stretching is
oIten based on the underlying cause oI impaired mobility,
the quality and level oI healing oI tissues, the chronicity
and severity oI a contracture, as well as a patient`s age, use
applied at a slow velocity, in a controlled manner, and at
relatively low intensity. For these reasons, cyclic stretching
is not synonymous with ballistic stretching, which is char-
acterized by high-velocity movements.
The diIIerentiation between cyclic stretching and static
stretching based on the duration that each stretch is applied
is not clearly deIined in the literature. According to some
authors, Ior cyclic stretching each cycle oI stretch is held
between 5 and 10 seconds.
However, investigtors in
other studies reIer to stretching that involves 5- and 10-
second stretch cycles as static stretching.
There is also
no consensus on the optimal number oI repetitions oI cyclic
stretching during a treatment session. Rather, this determi-
nation is oIten based on the patient`s response to stretching.
Based on clinical experience, some therapists hold the
opinion that appropriately applied, end-range cyclic
stretching is as eIIective and more comIortable Ior a
patient than a static stretch oI comparable intensity, partic-
ularly iI the static stretch is appled continuously Ior more
than 30 seconds. There is some evidence to support this
opinion. Although there have been Iew studies on cyclic or
intermittent stretching (aside Irom those on ballistic
stretching), cyclic loading has been shown to increase Ilex-
ibility as or more eIIectively than static stretching.
Focus on Evidence
In a study oI nonimpaired young adults, 60 seconds oI
cyclic stretching oI calI muscles caused tissues to yield at
slightly lower loads than one 60-second, two 30-second, or
Iour 15-second static stretches, possibly due to decreased
muscle stiIIness.
In another study that compared cyclic
and static stretching,
the authors speculated that heat
production might occur because oI the movement inherent
in cyclic stretching and cause soIt tissues to yield more
readily to stretch. The authors oI the latter study also con-
cluded that cyclic stretching was more comIortable than a
prolonged static stretch.
Spccd of Sfrcfch
lmporfancc of a Slowly Applìcd Sfrcfch
To ensure optimal muscle relaxation and prevent injury
to tissues, the speed oI stretch should be slow.
The stretch Iorce should be applied and released graauallv.
A slowly applied stretch is less likely to increase tensile
stresses on connective tissues
or to activate the
stretch reIlex and increase tension in the contractile struc-
tures oI the muscle being stretched.
Remember, the Ia
Iibers oI the muscle spindle are sensitive to the velocitv oI
muscle lengthening. A stretch Iorce applied at a low veloc-
ity is also easier Ior the therapist or patient to control and
is thereIore saIer than a high-velocity stretch. In addition,
a slow rate stretch aIIects the viscoelastic properties oI
connective tissue, making them more compliant.
8allìsfìc Sfrcfchìng
A rapia, forceful intermittent stretchthat is, a high-speed
ana high-intensity stretchis commonly called ballistic
C R A P J E P 4 Slrelchinq for lnµaired Mobilily 81
oI corticosteroids, and previous response to stretching.
Because Iew studies have attempted to determine the opti-
mal Irequency oI stretching within a day or a week,
it is
not possible to draw evidence-based guidelines Irom the
literature. As with decisions on the most appropriate num-
ber oI repetitions oI stretch in an exercise session, most
suggestions are based on opinion. Frequency on a weekly
basis ranges Irom two to Iive sessions, allowing time Ior
rest between sessions Ior tissue healing and to minimize
postexercise soreness. Ultimately, the decision is based on
the clinical discretion oI the therapist and the response and
needs oI the patient.
A therapist must be aware oI any breakdown oI tissues
with repetitive stretch. A Iine balance between collagen tis-
sue breakdown and repair is needed to allow an increase in
soIt tissue lengthening. II there is excessive Irequency oI
loading, tissue breakdown exceeds repair; and ultimate tis-
sue Iailure is a possibility. In addition, iI there is progres-
sive loss oI ROM over time rather than a gain in range,
continued low-grade inIlammation Irom repetitive stress
can cause excessive collagen Iormation and hypertrophic
Modc of Sfrcfch
The mode oI stretch reIers to the Iorm oI stretch or the
manner in which stretching exercises are carried out. Mode
oI stretch can be deIined by who or what is applying the
stretch Iorce or whether the patient is actively participating
in the stretching maneuver. Categories include but are not
limited to manual and mechanical stretching or self-
stretching as well as passive, assistea, or active stretching.
Regardless oI the Iorm oI stretching selected and imple-
mented, it is imperative that the shortened muscle remains
relaxed and that the restricted connective tissues yield as
easily as possible to the stretch. To accomplish this,
stretching procedures should be preceded by either low-
intensity active exercise or therapeutic heat to warm up the
tissues that are to be lengthened.
There is no best Iorm oI stretching. What is important
is that the therapist and patient have many modes oI
stretching Irom which to choose. Box 4.6 lists some ques-
tions a therapist needs to answer to determine which Iorms
oI stretching are most appropriate and most eIIective Ior
each patient at diIIerent stages oI a rehabilitation program.
Manual Sfrcfchìng
During manual stretching a therapist or other trained prac-
titioner or caregiver applies an external Iorce to move the
involved body segment slightlv bevona the point oI tissue
resistance and available ROM. The therapist manually con-
trols the site oI stabilization as well as the direction, speed,
intensity, and duration oI stretch. As with ROM exercises
(described in Chapter 3), manual stretching can be per-
Iormed passivelv, with assistance from the patient, or even
inaepenaentlv bv the patient.
N 0 J E : Penenber, slrelchinq and P0M exercises are nol
synonynous lerns. Slrelchinq lakes sofl lissue slruclures
IcycrJ lheir available lenqlh lo ircrcc·c P0M. P0M exer-
cises slay wilhin lhe linils of lissue exlensibilily lo rcir-
tcir lhe available lenqlh of lissues. Fiqures 4.1ß lhrouqh
4.8ß of lhis chaµler deµicl nanual slrelchinq lechniques
of lhe exlrenilies.
Manual stretching usually employs a controlled, end-
range, static, progressive stretch applied at an intensity
consistent with the patient`s comIort level, held Ior 15 to
60 seconds and repeated Ior at least several repetitions.
When compared to mechanical stretching, manual stretch-
ing could be categorized as a high-intensity, short-duration
Despite widespread use in the clinical setting, the
eIIectiveness oI manual passive stretching Ior increasing
the extensibility oI range-limiting muscle-tendon units is
debatable. Some investigators
have Iound that man-
ual passive stretching increases muscle length and ROM
in nonimpaired subjects. However, the short duration oI
stretch that typically occurs with manual stretching may be
why other investigators have reported that the eIIect oI a
manual passive stretching program is negligible,
ly in the presence oI long-standing contractures associated
with tissue pathology.
The Iollowing are points to consider about the use oI
manual stretching.
Manual stretching may be most appropriate in the early
stages oI a stretching program when a therapist wants to
determine how a patient responds to varying intensities
or durations oI stretch and when optimal stabilization is
most critical.
Manual stretching perIormed passivelv is an appropriate
choice Ior a therapist or caregiver iI a patient cannot per-
Iorm selI-stretching owing to a lack oI neuromuscular
control oI the body segment to be stretched.
80X 4.8 Consìdcrafìons for Sclccfìng Mcfhods
of Sfrcfchìng
- Bascd on llc icsulls of youi cxaminalion, wlal lissucs
aic involvcd and impaiiing mobilily?
- ls llcic cvidcncc of pain oi inflammalion?
- Eow long las llc lypomobilily cxislcd?
- Wlal is llc slagc of lcaling of icsliiclcd lissucs?
- Wlal foim(s) of sliclcling lavc bccn implcmcnlcd picvi-
ously? Eow did llc palicnl icspond?
- Aic llcic any undcilying discascs, disoidcis, oi dcfoimi-
lics llal migll affccl llc cloicc of sliclcling pioccduics?
- Pocs llc palicnl lavc llc abilily lo aclivcly pailicipalc
in, assisl will, oi indcpcndcnlly pcifoim llc cxciciscs?
Considci llc palicnl`s plysical capabililics, agc, abilily lo
coopcialc, oi abilily lo follow and icmcmbci insliuclions.
- ls assislancc fiom a llciapisl oi caicgivci ncccssaiy lo
cxcculc llc sliclcling pioccduics and appiopiialc slabi-
lizalion? lf so, wlal is llc sizc and slicngll of llc llcia-
pisl oi llc caicgivci wlo is assisling llc palicnl will a
sliclcling piogiam?
used as the source oI the stretch Iorce to elongate the
shortened muscle-tendon unit (Fig. 4.11B).
Neuromuscular inhibition, using PNF stretching tech-
niques, can be integrated into selI-stretching proce-
dures to promote relaxation in the muscle that is being
Low-intensity acitve stretching (reIerred to by some as
avnamic ROM
), using repeated, short-duration, end-
range active muscle contractions oI the muscle opposite
the shortened muscle is another Iorm oI selI-stretching
II a patient has control oI the body segment to be
stretched, it is oIten helpIul to ask the patient to assist
the therapist with the manual stretching maneuver, par-
ticularly iI the patient is apprehensive and is having
diIIiculty relaxing. For example, iI the patient concen-
trically contracts the muscle opposite the short muscle
and assists with joint movement, the range-limiting
muscle tends to relax reIlexively, thus decreasing
muscle tension interIering with elongation. This is
one oI several stretching procedures based on proprio-
ceptive neuromuscular Iacilitation techniques that are
discussed later in this chapter.
Using procedures and hand placements similar to those
described Ior selI-ROM exercises (see Chapter 3), a
patient can also independently lengthen range-limiting
muscles and periarticular tissues with manual stretching.
As such, this Iorm oI stretching is usually reIerred to as
self-stretching and is discussed in more detail as the next
topic in this section.
N 0 J E : Sµecific quidelines for lhe aµµlicalion of nanual
slrelchinq, as well as descriµlions and illuslralions of
nanual slrelchinq lechniques for lhe exlrenilies are
µresenled in laler seclions of lhis chaµler.
SelI-stretching (also reIerred to as flexibilitv exercises or
active stretching) is a type oI stretching procedure a patient
carries out independently aIter careIul instruction and
supervised practice. SelI-stretching enables a patient to
maintain or increase the ROM gained as the result oI direct
intervention by a therapist. This Iorm oI stretching is oIten
an integral component oI a home exercise program and is
necessary Ior long-term selI-management oI many muscu-
loskeletal and neuromuscular disorders.
Teaching a patient to carry out selI-stretching procedu-
res correctlv and safelv is Iundamental Ior preventing rein-
jury or Iuture dysIunction. Proper alignment oI the body
or body segments is critical Ior eIIective selI-stretching.
SuIIicient stabilization oI either the proximal or distal
attachment oI a shortened muscle is necessary but can be
diIIicult to achieve with selI-stretching. Every eIIort should
be made to see that restricted structures are stretched speci-
Iically and that adjacent structures are not overstretched.
The guidelines Ior the intensity, speed, duration, and
Irequency oI stretch that apply to manual stretching are
also appropriate Ior selI-stretching procedures. Static
stretching with a 30- to 60-second duration per repetition is
considered the saIest type oI stretching Ior a selI-stretching
SelI-stretching exercises can be carried out in several
Using positions Ior selI-ROM exercises described in
Chapter 3, a patient can passively move the distal seg-
ment oI a restricted joint with one or both hands to elon-
gate a shortened muscle while stabilizing the proximal
segment (Fig. 4.11A).
II the distal attachment oI a shortened muscle is Iixed
(stabilized) on a support surIace, body weight can be
C R A P J E P 4 Slrelchinq for lnµaired Mobilily 88
Fl0uPE 4.11 (/} w|en uanua||, se|¦-s¦re¦c||nç ¦|e adduc¦ors and |n¦erna|
ro¦a¦ors o¦ ¦|e ||µ, ¦|e µa¦|en¦ uoves ¦|e d|s¦a| seçuen¦ (¦euur} w|||e s¦au|-
||z|nç ¦|e µroz|ua| seçuen¦ (µe|v|s} w|¦| uod, we|ç|¦.
Fl0uPE 4.11 (3} w|en se|¦-s¦re¦c||nç ¦|e |aus¦r|nçs, ¦|e d|s¦a| seçuen¦
(¦|u|a} |s s¦au|||zed ¦|rouç| ¦|e ¦oo¦ on ¦|e sur¦ace o¦ a c|a|r as ¦|e µa¦|en¦
uends ¦orward and uoves ¦|e µroz|ua| seçuen¦. !|e we|ç|¦ o¦ ¦|e uµµer
uod, |s ¦|e source o¦ ¦|e s¦re¦c| ¦orce.
Mcchanìcal Sfrcfchìng
There are many ways to use equipment to stretch shortened
tissues and increase ROM. The equipment can be as simple
as a cuII weight or weight-pulley system or as sophisti-
cated as some adjustable orthoses or automated stretching
These mechanical stretching devices provide
either a constant load with variable displacement or con-
stant displacement with variable loads. Studies
the eIIicacy oI these two categories oI mechanical stretch-
ing devices base their eIIectiveness on the soIt tissue pro-
perties oI either creep or stress-relaxation, which occur
within a short period oI time, as well as plastic deIorma-
tion, which occurs over an extended period oI time.
It is oIten the responsibility oI a therapist to recom-
mend the type oI stretching device that is most suitable and
teach a patient how to saIely use the equipment and moni-
tor its use in the home setting. A therapist may also be
involved in the Iabrication oI serial casts or splints.
Mechanical stretching devices apply a very low-
intensity stretch Iorce (low load) over a prolonged period
oI time to create relatively permanent lengthening oI soIt
tissues, presumably due to plastic deIormation.
N 0 J E : 8e caulious of sludies or µroducl infornalion
lhal reµorl "µernanenl" lenqlheninq as lhe resull of use
of nechanical slrelchinq devices. Pernanenl nay nean lhal
lenqlh increases were nainlained for as lillle as a few days
or a week afler use of a slrelchinq device has been discon-
linued. Lonq-lern follow-uµ nay indicale lhal lissues have
relurned lo lheir shorlened slale if lhe newly qained nolion
has nol been used reqularly in daily aclivilies.
Each oI the Iollowing Iorms oI mechanical stretching
has been shown to be eIIective, particularly in reducing
long-standing contractures.
An eIIective stretch load applied with a cuII weight
(Fig. 4.12) can be as low as a Iew pounds.
Some devices, such as the Joint Active Systems¹
adjustable orthosis (Fig. 4.13), allow a patient to
control and adjust the load (stretch Iorce) during a
stretching session.
With other devices the load is preset prior to the app-
lication oI the splint, and the load remains constant
while the splint is in place.
Duration of Mechanical Stretch
Mechanical stretching involves a substantially longer
overall duration oI stretch than is practical with manual
stretching or selI-stretching exercises. The duration oI
mechanical stretch reported in the literature ranges Irom
15 to 30 minutes
to as long as 8 to 10 hours at a time
or continuous throughout the day except Ior time out oI
the device Ior hygiene and exercise.
Serial casts are
worn Ior days or weeks at a time beIore being removed
and then reapplied.
The time Irame is dependent on
the type oI device employed, the cause and severity oI
impairment, and patient tolerance. The longer durations
oI stretch are required Ior patients with chronic contrac-
tures as the result oI neurological or musculoskeletal
disorders than Ior healthy subjects with only mild hypo-
Focus on Evidence
Light and colleagues
studied nonambulatory, elderly
nursing home residents with long-standing bilateral knee
Ilexion contractures and compared the eIIects oI mechani-
cal and manual stretching. Over a 4-week period twice-
daily stretching sessions occurred 5 days per week.
Low-intensity, prolonged mechanical stretching (a 5-
to 12-lb poundstretch Iorce applied by a weight-pulley
system Ior 1 hour each session) was applied to one knee,
and manual passive stretching was applied to the other
knee by a therapist (three repetitions oI 1-minute static
stretches per stretching session). At the conclusion oI
the study, the mechanical stretching procedure was Iound
Fl0uPE 4.12 Low-|oad uec|an|ca| s¦re¦c| w|¦| a cu¦¦ we|ç|¦ and se|¦-
s¦au|||za¦|on o¦ ¦|e µroz|ua| |uuerus ¦o s¦re¦c| ¦|e e|uow ¦|ezors and
|ncrease end-rançe e|uow ez¦ens|on.
Fl0uPE 4.18 JAS or¦|os|s |s a µa¦|en¦-d|rec¦ed dev|ce ¦|a¦ aµµ||es a s¦a¦|c
µroçress|ve s¦re¦c|. (Cour¦es, o¦ Jo|n¦ Ac¦|ve S,s¦eus, L¦¦|nç|au, lL.}
* See reIerences 10, 15, 79, 89, 91, 96, 100, 106, 127, 131, 132, 149, 150.
Jypcs of PNF Sfrcfchìng
There are several types oI PNF stretching procedures. They
Holdrelax (HR) or contractrelax (CR)
Agonist contraction (AC)
Holdrelax with agonist contraction (HR-AC).
With classic PNF, these techniques are perIormed
with combined muscle groups acting in diagonal pat-
but have been modiIied in a number oI studies
and resources
by stretching in anatomical
planes or opposite the line oI pull oI a speciIic muscle
group. (For a description oI the PNF diagonal patterns,
reIer to Chapter 6.)
Hold-Relax and Contract-Relax
With the holdrelax (HR) procedure,
the range-
limiting muscle is Iirst lengthened to the point oI limitation
or to the extent that is comIortable Ior the patient. The
patient then perIorms a prestretch, ena-range, isometric
contraction (Ior 5 to 10 seconds) Iollowed by voluntary
relaxation oI the tight muscle. The limb is then passively
moved into the new range as the range-limiting muscle is
elongated. A sequence Ior using the HR technique to
stretch shortened pectoralis major muscles bilaterally and
increase horizontal abduction oI the shoulders is illustrated
in Figure 4.14.
N0JE: ln lhe clinical sellinq and in a nunber of invesliqa-
lions lhe lerns conlracl-relax (CP) and hold-relax (RP) are
oflen used inlerchanqably. Rowever, il should be noled lhal
for classic PhF lhe lechniques are nol idenlical. Allhouqh
bolh lechniques are µerforned in diaqonal µallerns, for lhe
CP lechnique lhe rolalors of lhe linb are allowed lo con-
lracl concenlrically whereas all olher nuscle qrouµs con-
lracl isonelrically durinq lhe µreslrelch conlraclion of lhe
reslriclinq nuscles.
For lhe RP lechnique, lhe µre-
slrelch conlraclion is isonelric in all nuscles of lhe diaqo-
nal µallern.
Practitioners in the clinical and athletic training set-
tings have reported that the HR and CR techniques appear
to make passive elongation oI muscles more comIortable
Ior a patient than manual passive stretching.
It has been
assumed that the sustained, prestretch contraction is Iol-
lowed by reIlexive relaxation accompanied by a decrease
in electromyographic (EMG) activity in the range-limiting
muscle, possibly as the result oI autogenic inhibition.
This assumption has been challenged in one study but sup-
ported in a later study. In the earlier study,
a postcontrac-
tion sensory discharge (increased EMG activity) was
identiIied in the muscle to be stretched, suggesting that
there was lingering tension in the muscle aIter the pre-
stretch isometric contraction and that the muscle to be
stretched was not eIIectively relaxed. In the later study, no
postcontraction elevation in EMG activity was Iound with
the use oI the HR or CR techniques.
Consequently, clini-
cians must evaluate the eIIectiveness oI the HR and CR
to be considerably more eIIective than the manual stretch-
ing procedure Ior increasing knee extension. The patients
also reported that the prolonged mechanical stretch was
more comIortable than the manual stretching procedure,
which tended to be applied at a higher intensity. The
investigators recognized that the total duration oI mecha-
nical stretch (40 hours) was substantially longer over
the course oI the study than the total duration oI manual
stretch (2 hours) but believed that the manual stretch-
ing sessions were typical and practical in the clinical
Proprìoccpfìvc Ncuromuscular
Facìlìfafìon Sfrcfchìng Jcchnìqucs
Proprioceptive neuromuscular Iacilitation techniques used
Ior stretching (PNF stretching),
also reIerred
to as active stretching
or facilitative stretching,
grate active muscle contractions into stretching maneu-
vers purportedly to Iacilitate or inhibit muscle activation
and to increase the likelihood that the muscle to be length-
ened remains as relaxed as posssible as it is stretched.
It is believed that when muscle Iibers are reIlexively
inhibited through autogenic or reciprocal inhibition,
there is less resistance to elongation by the contractile
elements oI the muscle.
However, inhibition tech-
niques are designed to relax only the contractile struc-
tures oI muscle, not the connective tissue in and around
shortened muscles.
N 0 J E : !he PhF slrelchinq lechniques described in
lhis seclion require nornal innervalion and volunlary
conlrol of eilher lhe shorlened nuscle or lhe nuscle
on lhe oµµosile side of lhe |oinl. As such, lhese lech-
niques cannol be used effeclively in µalienls wilh
µaralysis or sµaslicily resullinq fron neuronuscular
diseases or in|ury. Furlhernore, because PhF slrelchinq
µrocedures are desiqned lo affecl lhe conlraclile ele-
nenls of nuscle, nol nonconlraclile conneclive lissues,
lhey are nore aµµroµriale when nuscle sµasn linils
nolion and less aµµroµriale for slrelchinq fibrolic con-
The PNF stretching techniques, most oI which have
been adapted Irom the PNF techniques originally described
by Knott and Voss,
have been used Ior many years in
the clinical setting as an adjunct to manual stretching or
selI-stretching. Although the eIIicacy oI the neurophysio-
logical principles on which PNF was Iounded has come
into question, the results oI numerous studies have demon-
strated that the various PNF stretching techniques eIIec-
tively increase Ilexibility and ROM.
However, there is no consensus on whether one PNF tech-
nique is consistently superior to another or whether PNF
stretching is more, less, or equally eIIective as static
C R A P J E P 4 Slrelchinq for lnµaired Mobilily 85
techniques and determine their eIIectiveness with individ-
ual patients.
P P E C A u J l 0 N : ll is nol necessary for lhe µalienl lo
µerforn a naxinal isonelric conlraclion of lhe liqhl nuscle
µrior lo slrelch. Mulliµle reµelilions of naxinal µreslrelch
isonelric conlraclions have been shown lo resull in an
acule increase in arlerial blood µressure, nosl nolably afler
lhe lhird reµelilion.
!o nininize lhe adverse effecls of lhe
valsalva naneuver (elevalion in blood µressure), have lhe
µalienl brealhe reqularly while µerforninq subnaxinal
(low-inlensily) isonelric conlraclions held for 6 lo 10 sec-
onds wilh each reµelilion of lhe slrelchinq µrocedure. A
subnaxinal conlraclion is also easier for lhe lheraµisl lo
conlrol if lhe µalienl is slronq.
Agonist Contraction
Another PNF stretching technique is the agonist contrac-
tion (AC) procedure. This term has been used by several
but can be misunderstood. The 'agonist¨
reIers to the muscle opposite the range-limiting muscle.
'Antagonist,¨ thereIore, reIers to the range-limiting
Think oI it as the short muscle (the antagonist)
preventing the Iull movement oI the prime mover (the
agonist). Dvnamic range of motion (DROM)
and active
are terms that have been used to describe the
AC procedure.
To perIorm the AC procedure the patient concentri-
callv contracts (shortens) the muscle opposite the range-
limiting muscle and then holds the end-range position Ior
at least several seconds.
The movement oI the limb
is independently controlled by the patient and is deliberate
and slow, not ballistic. In most instances the shortening
contraction is perIormed without the addition oI resistance.
For example, iI the hip Ilexors are tight, the patient can
perIorm end-rage, prone leg liIts by contracting the hip
extensors concentrically; the end-range contraction is held
Ior a number oI seconds. AIter a brieI rest period, the
patent repeats the procedure.
It has been suggested that when the agonist is acti-
vated and contracts concentrically, the antagonist (the
range- limiting muscle) is reciprocally inhibited, allowing
it to relax and lengthen more easily.
However, the
theoretical mechanism oI receiprocal inhibition has been
substantiated only in animal studies, not in studies oI
Focus on Evidence
Several studies have evaluated the eIIectiveness oI the ago-
nist contraction procedure Ior improving Ilexibility and
ROM. Two studies compared the eIIect oI the AC proce-
dure, reIerred to as DROM, to static stretching oI the ham-
strings oI healthy subjects who participated in 6-week
stretching programs. In one study
DROM was Iound to
be as eIIective as static stretching, but in the other study
one daily repetition oI a 30-second static stretch was
almost three times as eIIective in increasing hamstring
Ilexibility as six repetitions daily (with a 5-second, end-
range hold) oI DROM.
Fl0uPE 4.14 (3} !|e µa¦|en¦ re|azes, and ¦|e ¦|eraµ|s¦ µass|ve|, |enç¦|ens
¦|e µec¦ora||s ua¦or uusc|es u, |or|zon¦a||, auduc¦|nç ¦|e s|ou|ders |n¦o ¦|e
new|, ça|ned rançe. A¦¦er a 10-second res¦ w|¦| ¦|e uusc|e ua|n¦a|ned |n a
cou¦or¦au|, |enç¦|ened µos|¦|on, ¦|e en¦|re seuuence |s reµea¦ed.
Fl0uPE 4.14 ho|d-re|az (hR} µrocedure ¦o s¦re¦c| ¦|e µec¦ora||s ua¦or uus-
c|es u||a¦era||,. (/} !|e ¦|eraµ|s¦ |or|zon¦a||, auduc¦s ¦|e s|ou|ders u||a¦era||,
¦o a cou¦or¦au|e µos|¦|on. !|e µa¦|en¦ |soue¦r|ca||, con¦rac¦s ¦|e µec¦ora||s
ua¦or uusc|es aça|ns¦ ¦|e ¦|eraµ|s¦'s res|s¦ance ¦or o ¦o 10 seconds.
P P E C A u J l 0 N S : Follow lhe sane µrecaulions as
described for bolh lhe RP and AC µrocedures.
lnfcgrafìon of Funcfìon ìnfo Sfrcfchìng
lmporfancc of Sfrcngfh and Musclc Endurancc
As previously discussed, the strength oI soIt tissue is
altered when it is immoblized Ior a period oI time.
The magnitude oI peak tension produced by muscle
decreases, and the tensile strength oI noncontractile
tissues decreases. A muscle group that has been over-
stretched because its opposing muscle group has been
in a shortened state Ior an extended period oI time also
becomes weak.
ThereIore, it is critical to begin low-
load resistance exercises to improve muscle perIormance
(strength and endurance) as early as possible in a stretch-
ing program.
Initially, it is important to place emphasis on develop-
ing neuromuscular control and strength oI the agonist, the
muscle group opposite the muscle that is being stretched.
For example, iI the elbow Ilexors are the range-limiting
muscle group, emphasize contraction oI the elbow exten-
sors in the gained range. Complement stretching the ham-
strings to reduce a knee Ilexion contracture by using the
quadriceps in the new range. Early use oI the agonist
enables the patient to elongate the hypomobile structures
actively and use the recently gained ROM.
As ROM approaches a 'normal,¨ or Iunctional,
level, the muscles that were shortened and then stretched
must also be strengthened to maintain an appropriate
balance oI strength between agonists and antagonists
throughout the ROM. Manual and mechanical resistance
exercises are eIIective ways to load and strengthen mus-
cles, but Iunctional weight-bearing activities, such as
those mentioned below also strengthen antigravity
muscle groups.
usc of lncrcascd Mohìlìfy for Funcfìonal Acfìvìfìcs
As mentioned previously, gains in Ilexibility and ROM
achieved as the result oI a stretching program are transient,
lasting only about 4 weeks aIter cessation oI stretching.
The most eIIective means oI achieving permanent
increases in ROM and reducing Iunctional limitations
is to integrate Iunctional activities into a stretching pro-
gram to use the gained range on a regular basis. Use oI
Iunctional activities to maintain mobility lends diversity
and interest to a stretching program.
Active movements should be within the pain-Iree
ROM. Examples oI movements oI the upper or lower
extremities or spine that are components oI daily acti-
vities include reaching, grasping, turning, twisting,
bending, pushing, pulling, and squatting to name just
a Iew. As soon as even small increases in tissue extensi-
bility and ROM have been achieved, have the patient
use the gained range by perIorming motions that simulate
Iunctional activities. Later have the patient use all oI the
available ROM while actually doing speciIic Iunctional
Functional movements that are practiced should com-
plement the stretching program. For example, iI a patient
In a study oI young adults with hypomobile hip Ilexors
and periodic lumbar or lower-quarter pain, investigators
compared 'active stretching¨ using the AC procedure
to static passive stretching.
Both techniques resulted
in increased hip extension with no signiIicant diIIerence
between the active and passive stretching groups.
In addition to the results oI studies on the the AC
stretching procedure, clinicians have observed the
The AC technique seems to be especially eIIective when
signiIicant muscle guarding restricts muscle lengthening
and joint movement and is less eIIective in reducing
chronic contractures.
This technique is also useIul when a patient cannot gen-
erate a strong, pain-Iree contraction oI the range-limiting
muscle, which must be done during the HR procedure.
This technique is also useIul Ior initiating neuromus-
cular control in the newly gained range to re-establish
dynamic Ilexibility.
The AC technique is least eIIective iI a patient has close
to normal Ilexibility.
P P E C A u J l 0 N S : Avoid full-ranqe, balllislic nove-
nenls when µerforninq concenlric conlraclions of lhe aqo-
nisl nuscle qrouµ. Pesl afler each reµelilion lo avoid
nuscle cranµinq when lhe aqonisl is conlraclinq in lhe very
shorlened µorlion of ils ranqe.
Hold-Relax with Agonist Contraction
The HR-AC stretching technique combines the HR and
AC procedures. The HR-AC technique is also reIerred to
as the slow reversal holdrelax technique.
To perIorm
the HR-AC procedure, move the limb to the point that tis-
sue resistance is Ielt in the tight (range-limiting) muscle;
then have the patient perIorm a resisted, prestretch isomet-
ric contraction oI the range-limiting muscle followea by
relaxation oI that muscle and an immediate concentric con-
traction oI the muscle opposite the tight mus-
For example, to stretch knee Ilexors, extend the
patient`s knee to a comIortable position and then have the
patient perIorm an isometric contraction oI the knee Ilex-
ors against resistance Ior 5 to 10 seconds. Tell the patient
to relax the knee Ilexors and then actively extend the knee
as Iar as possible, holding the newly gained range Ior sev-
eral seconds.
Focus on Evidence
Studies comparing two PNF stretching procedures pro-
duced diIIering results. In one study,
the HR-AC tech-
nique produced a greater increase in ankle dorsiIlexion
range than did the HR technique. Both PNF techniques
produced a greater increase in range oI ankle dorsiIlexion
than did manual passive stretching. However, in another
study, there was no signiIicant diIIerence between the use
oI the HR and HR-AC techniques.
C R A P J E P 4 Slrelchinq for lnµaired Mobilily 87
has been perIorming stretching exercises to increase
shoulder mobility, have the patient Iully use the available
ROM by reaching as Iar as possible behind the back and
overhead when grooming or dressing or by reaching Ior
or placing objects on a high shelI (Fig. 4.15). Gradually
increase the weight oI objects placed on or removed
Irom a shelI to strengthen shoulder musculature simul-
II the Iocus oI a stretching program has been to
increase knee Ilexion aIter removal oI a long-leg cast,
emphasize Ilexing both knees beIore standing up Irom
a chair or when stooping to pick up an object Irom the
Iloor. These weight-bearing activities also strengthen
the quadriceps that became weak while the leg was
immobilized and the quadricepts was held in a shortened
The Iollowing guidelines are central to the development
and implementation oI stretching interventions. The results
oI an examination and evaluation oI a patient`s status
determine the need Ior and types oI stretching procedures
that will be most eIIective in a patient`s plan oI care. This
section identiIies general guidelines to be addressed beIore,
during, and aIter stretching procedures as well as guide-
lines speciIic to the application oI manual stretching. Spe-
cial considerations Ior teaching selI-stretching exercises
and using mechanical stretching devices are listed in
Boxes 4.7 and 4.8.
Examìnafìon and Evaluafìon of fhc Pafìcnf
CareIully review the patient`s history and perIorm a
thorough systems review.
Select and perIorm appropriate tests and measure-
ments. Determine the ROM available in involved and
adjacent joints and iI either active or passive mobility
is impaired.
Determine iI hypomobility is related to other impair-
ments and iI it is causing Iunctional limitations or
Ascertain iI, and iI so, which soIt tissues are the source
oI the impaired mobility. In particular, diIIerentiate
between joint capsule, periarticular noncontractile tis-
sue, and muscle length restrictions as the cause oI
limited ROM. Be sure to assess joint play and Iascial
Evaluate the irritability oI the involved tissues and
determine their stage oI healing. When moving the
patient`s extremities or spine, pay close attention to the
patient`s reaction to movements. This not only helps
identiIy the stage oI healing oI involved tissues, it helps
determine the probable dosage (such as intensity and
duration) oI stretch that stays within the patient`s com-
Iort range.
Assess the underlying strength oI muscles in which
there is limitation oI motion and realistically consider
the value oI stretching the range-limiting structures.
An individual must have the capability oI developing
adequate strength to control and saIely use the new
Be sure to determine what outcome goals (i.e., Iunc-
tional improvements) the patient is seeking to achieve
as the result oI the intervention program and determine
iI those goals are realistic.
Analyze the impact oI any Iactors that could adver-
sely aIIect the projected outcomes oI the stretching
Fl0uPE 4.15 (/, 3} S¦re¦c||nç-|nduced ça|ns |n R0V are used dur|nç da||,
Prcparafìon for Sfrcfchìng
Review the goals and desired outcomes oI the stretching
program with the patient. Obtain the patient`s consent to
initiate treatment.
Select the stretching techniques that will be most eIIec-
tive and eIIicient.
Warm up the soIt tissues to be stretched by the applica-
tion oI local heat or by active, low-intensity exercises.
Warming up tight structures may increase their extensi-
bility and may decrease the risk oI injury Irom stretch-
Have the patient asssume a comIortable, stable position
that allows the correct plane oI motion Ior the stretching
procedure. The airection of stretch is exactlv opposite the
airection of the foint or muscle restriction.
Explain the procedure to the patient and be certain he or
she understands.
Free the area to be stretched oI any restrictive clothing,
bandages, or splints.
Explain to the patient that it is important to be as relaxed
as possible or assist when requested. Also explain that
the stretching procedures are geared to his or her toler-
ance level.
Applìcafìon of Manual Sfrcfchìng Proccdurcs
Move the extremity slowly through the Iree range to the
point oI tissue restriction.
Grasp the areas proximal and distal to the joint in which
motion is to occur. The grasp should be Iirm but not
uncomIortable Ior the patient. Use padding, iI necessary,
in areas with minimal subcutaneous tissue, reduced sen-
C R A P J E P 4 Slrelchinq for lnµaired Mobilily 80
80X 4.7 Spccìal Consìdcrafìons for Jcachìng Sclf-Sfrcfchìng Excrcìscs
- Bc suic lo caicfully lcacl llc palicnl all clcmcnls of sclf-
sliclcling pioccduics, including appiopiialc alignmcnl and
slabilizalion, inlcnsily, duialion, and ficqucncy of sliclcl-
ing. Bccausc many sclf-sliclcling cxciciscs aic pcifoimcd
using a poilion of llc body wcigll as llc sliclcl foicc (by
moving llc body ovci a fixcd dislal scgmcnl), cmplasizc
llc impoilancc of pcifoiming a slow, suslaincd sliclcl,
nol a ballislic sliclcl llal cicalcs momcnlum and may
lcngllcn bul can polcnlially injuic lypomobilc sofl lissucs.
- Makc suic llal llc palicnl is laugll lo caiiy oul sliclcling
cxciciscs on a fiim, slablc, comfoilablc suifacc lo mainlain
piopci alignmcnl.
- Supcivisc llc palicnl and makc suggcslions oi coiicclions
lo bc ccilain llc palicnl pcifoims cacl cxcicisc using safc
biomcclanics llal piolccl joinls and ligamcnls, cspccially
al llc cnd of llc R0M. Pay pailiculai allcnlion lo main-
laining posluial alignmcnl and cffcclivc slabilizalion. Foi
cxamplc, wlilc sclf-sliclcling llc lamsliings in a long-
silling posilion oi wlilc slanding will onc lcg icsling on a
lablc, bc suic llal llc palicnl knows lo kccp llc lloiaco-
lumbai scgmcnls of llc spinc in cxlcnsion and lo bcnd
foiwaid al llc lips lo picvcnl poslciioi pclvic lill and
ovcisliclcl of llc low back.
- Fmplasizc llc impoilancc of waiming up llc lissucs will
low-inlcnsily, ilyllmic aclivilics, sucl as cycling, piioi lo
sliclcling. Sliclcling slould nol bc llc fiisl aclivily in an
cxcicisc ioulinc bccausc cold lissuc is moic biilllc and
moic casily loin.
- lf appiopiialc and possiblc, lcacl llc palicnl low lo incoi-
poialc ncuiomusculai inlibilion lcclniqucs indcpcndcnlly,
sucl as llc lold-iclax (ER) pioccduic, inlo sclcclcd
sliclcling cxciciscs.
- Piovidc wiillcn insliuclions will illuslialions lo wlicl llc
palicnl can icfci wlcn indcpcndcnlly pcifoiming llc sclf-
sliclcling cxciciscs.
- Pcmonslialc low ilcms commonly found aiound llc
lousc, sucl as a lowcl, bcll, bioomslick, oi lomcmadc
wcigll, can bc uscd lo assisl will sliclcling aclivilics.
- Fmplasizc llc impoilancc of using llc gaincd R0M duiing
appiopiialcly piogicsscd funclional aclivilics.
80X 4.8 Spccìal Consìdcrafìons for usc
of Mcchanìcal Sfrcfchìng 0cvìccs
- Bccomc lloiouglly familiai will llc manufacluici`s
pioducl infoimalion.
- Bccomc familiai will sliclcling piolocols iccommcndcd
by llc manufacluici, scck oul icscaicl sludics llal pio-
vidc cvidcncc of llc cfficacy of llc cquipmcnl oi piolo-
- Pclciminc if modifying a suggcslcd piolocol is waiianlcd
lo mccl youi palicnl`s nccds. Foi cxamplc, slould llc
suggcslcd inlcnsily of sliclcl oi iccommcndcd wcaiing
limc (duialion and ficqucncy) bc modificd?
- Clcck llc fil of a dcvicc bcfoic scnding il lomc will a
palicnl. 1cacl llc palicnl low lo apply and safcly adjusl
llc dcvicc and low lo mainlain il in good woiking oidci.
Bc suic llal llc palicnl knows wlo lo conlacl if llc
cquipmcnl appcais lo bc dcfcclivc.
- 1cacl llc palicnl wlcic and low lo inspccl llc skin lo
dclccl aicas of cxccssivc picssuic fiom llc sliclcling
dcvicc and polcnlial skin iiiilalion.
- lf llc mcclanical sliclcling dcvicc is ¨lomcmadc,¨ sucl
as a cuff wcigll, clcck lo scc if llc cquipmcnl is safc
and cffcclivc.
- Eavc llc palicnl kccp a daily iccoid of using llc sliclcl-
ing dcvicc.
- Rc-cxaminc and ic-cvalualc llc palicnl and cquipmcnl
pciiodically lo dclciminc llc cffcclivcncss of llc
mcclanical sliclcling piogiam and lo modify and
piogicss llc piogiam as ncccssaiy.
- Bc suic llc palicnl complcmcnls llc usc of mcclanical
sliclcling will aclivc cxciciscs.
position, increases in ROM are more readily
Regardless oI the type oI stretching intervention used,
have the patient perIorm active ROM and strengthening
exercises through the gained range immediately aIter
stretching. With your supervision and Ieedback, have the
patient use the gained range by perIorming simulated
Iunctional movement patterns that are part oI daily liv-
ing, occupational, or recreational tasks.
Develop a balance in strength in the antagonistic muscles
in the new range so there is adequate neuromuscular
control and stability as Ilexibility increases.
There are a number oI general precautions that apply to all
Iorms oI stretching interventions. In addition, some special
precautions must be taken when advising patients about
stretching exercises that are part oI community-based Iit-
ness programs or commercially available exercise products
marketed to the general public.
0cncral Prccaufìons
Do not passively Iorce a joint beyond its normal ROM.
Remember, normal (typical) ROM varies among individ-
uals. In adults, Ilexibility is greater in women than in
When treating older adults, be aware oI age-
related changes in Ilexibility.
Focus on Evidence.
Some studies suggest that Ilexibility decreases with age,
particularly when coupled with decreased activity lev-
However, the results oI a study oI more than 200
adults ages 20 to 79 who regularly exercised demonstrated
that hamstring length did not signiIicantly decrease with
Use extra caution in patients with known or suspected
osteoporosis due to disease, prolonged bed rest, age, or
prolonged use oI steroids.
Protect newly united Iractures; be certain there is appro-
priate stabilization between the Iracture site and the joint
in which the motion takes place.
Avoid vigorous stretching oI muscles and connective
tissues that have been immobilized Ior an extended
period oI time. Connective tissues, such as tendons and
ligaments, lose their tensile strength aIter prolonged
immobilization. High-intensity short-duration stretch-
ing procedures tend to cause more trauma and resulting
weakness oI soIt tissues than low-intensity, long-duration
Progress the dosage (intensity, duration, and Irequency)
oI stretching interventions gradually to minimize soIt tis-
sue trauma and postexercise muscle soreness. II a patient
sation, or over a bony surIace. Use the broad surIaces oI
your hands to apply all Iorces.
Firmly stabilize the proximal segment (manually or with
equipment) and move the distal segment.
To stretch a multijoint muscle, stabilize either the proxi-
mal or distal segment to which the range-limiting muscle
attaches. Stretch the muscle over one joint at a time and
then over all joints simultaneously until the optimal
length oI soIt tissues is achieved. To minimize compres-
sive Iorces in small joints, stretch the distal joints Iirst
and proceed proximally.
Consider incorporating a prestretch, isometric contrac-
tion oI the range-limiting muscle (the holdrelax proce-
dure) to relax the muscle reIlexively prior to stretching it.
To avoid joint compression during the stretching proce-
dure, apply gentle (grade I) distraction to the moving
Apply a low-intensity stretch in a slow, sustained man-
ner. Remember, the direction oI the stretching movement
is directly opposite the line oI pull oI the range-limiting
muscle. Ask the patient to assist you with the stretch or
apply a passive stretch to lengthen the tissues. Take the
hypomobile soIt tissues to the point oI Iirm tissue resist-
ance and then move just beyond that point. The Iorce
must be enough to place tension on soIt tissue structures
but not so great as to cause pain or injure the structures.
The patient should experience a pulling sensation, but
not pain, in the structures being stretched. When stretch-
ing adhesions oI a tendon within its sheath, the patient
may experience a 'stinging¨ sensation.
Maintain the stretched position Ior 30 seconds or longer.
During this time, the tension in the tissues should slowly
decrease. When tension decreases, move the extremity or
joint a little Iarther to progressively lengthen the hypo-
mobile tissues.
Gradually release the stretch Iorce and allow the patient
and therapist to rest momentarily while maintaining the
range-limiting tissues in a comIortably elongated posi-
tion. Then repeat the sequence several times.
II the patient does not seem to tolerate a sustained
stretch, use several very slow, gentle, intermittent
stretches with the muscle in a lengthened position.
II deemed appropriate, apply selected soIt tissue mobi-
lization procedures, such as Iascial massage or cross-
Iiber Iriction massage, at or near the sites oI adhesion
during the stretching maneuver.
N 0 J E : 0o nol allenµl lo qain lhe full ranqe in one or
lwo lrealnenl sessions. Pesolvinq nobilily inµairnenl is a
slow, qradual µrocess. ll nay lake several weeks of slrelch-
inq lo see siqnificanl resulls.
Affcr Sfrcfchìng
Apply cold to the soIt tissues that have been stretched
and allow these structures to cool in a lengthened posi-
tion. Cold may minimize poststretch muscle soreness
that can occur as the result oI microtrauma during
stretching. When soIt tissues are cooled in a lengthened
oI stretch. An eIIective Ilexibility routine should be pro-
gressed gradually and should not cause pain or excessive
stress to tissues.
Abnormal biomechanics. Some popular stretching exercis-
es do not respect the biomechanics oI the region. For
example, the 'hurdler`s¨ stretch is designed to stretch uni-
laterally the hamstrings oI one lower extremity and the
quadriceps oI the opposite extremity but imposes unsaIe
stresses on the medial capsule and ligaments oI the Ilexed
Insufficient information about age-related differences.
One Ilexibility program does not Iit all age groups. As a
result oI the normal aging process, mobility oI connective
tissues diminishes.
Consequently, elderly individuals,
whose physical activity level has diminished with age, typ-
ically exhibit less Ilexibility than young adults. Even an
adolescent aIter a growth spurt temporarily exhibits
restricted Ilexibility, particularly in two-joint muscle
groups. Flexibility programs marketed to the general public
may not be sensitive to these normal, age-related diIIer-
ences in Ilexibility and may Ioster unrealistic expectations.
Sfrafcgìcs for Pìsk Pcducfìon
Whenever possible, assess the appropriateness and saIety
oI exercises in a 'prepackaged¨ Ilexibility program.
II a patient you are treating is participating in a commu-
nity-based Iitness class, review the exercises in the pro-
gram and determine their appropriateness and saIety Ior
your patient.
Stay up-to-date on current exercise programs, products,
and trends by monitoring the content and saIety and your
patient`s use oI home exercise videotapes.
Determine whether a class or video is geared Ior individ-
uals oI the same age or with similar pathological condi-
Eliminate or modiIy those exercises that are inconsistent
with the intervention plan you have developed Ior your
See that the Ilexibility program maintains a balance oI
mobility between antagonistic muscle groups and
emphasizes stretching those muscle groups that oIten
become shortened with age, Iaulty posture, or sedentary
Teach your patient basic principles oI selI-stretching and
how to apply those principles to select saIe and appropri-
ate stretching exercises and to avoid those that perpetu-
ate impairments or have no value.
Make sure your patient understands the importance oI
warming up prior to stretching. Give suggestions on how
to warm up beIore stretching.
Be certain that the patient knows how to provide eIIec-
tive selI-stabilization to isolate stretch to speciIic muscle
Teach your patient how to determine the appropriate
intensity oI stretch; be sure your patient knows that, at
most, postexercise muscle soreness should be mild and
last no more than 24 hours.
experiences joint pain or muscle soreness lasting more
than 24 hours aIter stretching, too much Iorce has been
used during stretching, causing an an inIlammatory
response. This, in turn, causes increased scar tissue Ior-
mation. Patients should experience no more residual dis-
comIort than a transitory Ieeling oI tenderness.
Avoid stretching edematous tissue, as it is more suscepti-
ble to injury than normal tissue. Continued irritation oI
edematous tissue usually causes increased pain and
Avoid overstretching weak muscles, particularly those
that support body structures in relation to gravity.
Spccìal Prccaufìons for Mass-
Markcf Flcxìhìlìfy Programs
In an eIIort to develop and maintain a desired level oI Iit-
ness, many people, young and old, participate in physical
conditioning programs at home or in the community. Flexi-
bility (selI-stretching) exercises are an integral component
oI these programs. As a result, individuals Irequently learn
selI-stretching procedures in Iitness classes or Irom popu-
lar videos or television programs. Although much oI the
inIormation in these resources is usually saIe and accurate,
there may be some errors and potential problems in Ilexi-
bility programs designed Ior the mass market.
Common Errors and Pofcnfìal Prohlcms
Aonselective or poorly balanced stretching activities.
General Ilexibility programs may include stretching
regions oI the body that are already mobile or even hyper-
mobile but may neglect regions that are tight Irom Iaulty
posture or inactivity. For example, in the sedentary popula-
tion, some degree oI hypomobility tends to develop in the
hip Ilexors, trunk Ilexors, shoulder extensors and internal
rotators, and scapular protractors Irom sitting in a slumped
posture. Yet many commercially available Ilexibility rou-
tines overemphasize exercises that stretch posterior muscle
groups, already overstretched, and Iail to include exercises
to stretch the tight anterior structures. Consequently, Iaulty
postures may worsen rather than improve.
Insufficient warm-up. Individuals involved in Ilexibility
programs oIten Iail to warm up prior to stretching.
Ineffective stabilization. Programs oIten lack eIIective
methods oI selI-stabilization. ThereIore, an exercise may
Iail to stretch the intended tight structures and may transIer
the stretch Iorce to structures that are already mobile or
even hypermobile.
Use of ballistic stretching. Although a less common prob-
lem than in the past, some exercise routines still demon-
strate stretches using ballistic maneuvers. Because this
Iorm oI stretching is not well controlled, it increases the
likelihood oI postexercise muscle soreness and signiIicant
injury to soIt tissues.
Excessive intensity. The phrase 'no pain, no gain¨ is
oIten used inappropriately as the guideline Ior intensity
C R A P J E P 4 Slrelchinq for lnµaired Mobilily 01
Interventions that promote general or local relaxation can
complement a stretching program. Therapists managing
patients with impairments, including chronic pain, muscle
guarding, or imbalances, and restricted mobility may Iind
it useIul to integrate relaxation exercises into a patient`s
plan oI care. SuperIicial or deep heat, massage, bioIeed-
back, and joint traction also are useIul adjuncts to stretch-
ing procedures.
Pclaxafìon Jraìnìng
Relaxation training, using methods oI general relaxation
(total body relaxation), has been used Ior many years by a
variety oI practitioners
to help patients learn
to relieve or reduce pain, muscle tension, anxiety or stress,
and associated physical impairments including tension
headaches, high blood pressure, and respiratory distress.
Volumes have been written by health proIessionals Irom
many disciplines on topics such as chronic pain manage-
ment, progressive relaxation, bioIeedback, stress and anxi-
ety management, and imagery. A brieI overview oI
techniques is presented in this section.
Common Elcmcnfs of Pclaxafìon Jraìnìng
Relaxation training involves a reduction in muscle tension
in the entire body or the region that is painIul or restricted
by conscious eIIort and thought. Training occcurs in a
quiet environment with low lighting and soothing music
or an auditory cue on which the patient may Iocus. The
patient perIorms deep breathing exercises or visualizes
a peaceIul scene. When giving instructions the therapist
uses a soIt tone oI voice.
Examplcs of Approachcs fo Pclaxafìon Jraìnìng
Autogenic training. This approach, advocated by Schultz
and colleagues,
involves conscious relaxation through
autosuggestion and a progression oI exercises as well as
Progressive relaxation. This technique, developed by
uses systematic, distal to proximal progression
oI voluntary contraction and relaxation oI muscles. It is
sometimes incorporated into childbirth education.
Awareness through movement. The system oI therapy
developed by Feldenkrais
combines sensory awareness,
movements oI the limbs and trunk, deep breathing, con-
scious relaxation procedures, and selI-massage to alter
muscle imbalances and abnormal postural alignment to
remediate muscle tension and pain.
Scqucncc for Progrcssìvc Pclaxafìon Jcchnìqucs
Place the patient in a quiet area and in a comIortable
position, and be sure that restrictive clothing is loosened.
Have the patient breathe in a deep, relaxed manner.
Ask the patient to contract the distal musculature in the
hands or Ieet voluntarily Ior several (5 to 7) seconds
and then consciously relax those muscles Ior 20 to 30
Suggest that the patient try to Ieel a sense oI heaviness
in the hands or Ieet and a sense oI warmth in the mus-
cles just relaxed.
Progress to a more proximal area oI the body and have
the patient actively contract and actively relax the more
proximal musculature. Eventually have the patient iso-
metrically contract and consciously relax the entire
Suggest to the patient that he or she should Ieel a sense
oI relaxation and warmth throughout the entire limb and
eventually throughout the whole body.
lndìcafors of Pclaxafìon
There are a number oI physiological, behavioral, cognitive,
and emotional responses that occur during total body relax-
These key indicators are summarized in Box 4.9.
Warming up prior to stretching is a common practice in
rehabilitation and Iitness programs.
It is well docu-
mented in human and animal studies that as intramuscular
temperature increases the extensibility oI contractile and
noncontractile soIt tissues likewise increases. In addition,
as the temperature oI muscle increases, the amount oI Iorce
required and the time the stretch Iorce must be applied
There is also a decrease in the rate
oI Iiring oI the type II eIIerents Irom the muscle spindles
and an increase in the sensitivity oI the GTO, which makes
it more likely to Iire.
In turn, it is believed that when tis-
sues relax and more easily lengthen, stretching is associat-
ed with less muscle guarding and is more comIortable Ior
the patient.
It has also been suggested that warming up
prior to exercise reduces postexercise muscle sorenesss and
the risk oI injury to soIt tissues.
However, not all oI
these assumptions about the clinical application oI heat are
well supported by evidence.
P P E C A u J l 0 N : Allhouqh slrelchinq is oflen lhouqhl
of as a warn-uµ aclivily µerforned µrior lo viqorous exer-
cise, an aµµroµriale warn-uµ nusl also occur in µreµaralion
for slrelchinq.
80X 4.0 lndìcafors of Pclaxafìon
- Pccicascd musclc lcnsion
- Lowcicd lcail and icspiialoiy ialcs and blood picssuic
- lncicascd skin lcmpcialuic in llc cxlicmilics associalcd
will vasodilalion
- Consliiclcd pupils
- Lilllc lo no body movcmcnl
- Fycs closcd and flal facial cxpicssion
- 1aw and lands iclaxcd will palms opcn
- Pccicascd disliaclabilily
some approaches to stress and anxiety or pain manage-
ment, selI-massage, using light stroking techniques
(eIIleurage), is perIormed during the relaxation process.
In sports and conditioning programs,
massage has been
used Ior general relaxation purposes or to enhance recov-
ery aIter strenuous physical activity, although the eIIicacy
oI the latter is not well Iounded.
Because massage has
been shown to increase circulation to muscles and decrease
muscle spasm, it is a useIul adjunct to stretching exercises.
Soff Jìssuc Mohìlìzafìon Jcchnìqucs
Another broad category oI massage is soIt tissue mobiliza-
tion. Although soIt tissue mobilization and manipulation
techniques involve various Iorms oI deep massage, the pri-
mary purpose oI these techniques is not relaxation but,
rather, increasing the mobility oI adherent or shortened
connective tissues including Iascia, tendons, and
There are many techniques and explanations as to their
eIIects on connective tissues, including the mechanical
eIIects oI stress and strain. Stresses are applied long
enough Ior creep and stress-relaxation oI tissues to occur.
With mvofascial massage,
stretch Iorces are applied
across Iascial planes or between muscle and septae. With
friction massage,
deep circular or cross-Iiber mas-
sage is applied to break up adhesions or minimize rough
surIaces between tendons and their synovial sheaths. Fric-
tion massage is also used to increase the mobility oI scar
tissue in muscle as it heals. Theoretically, it applies stresses
to scar tissue as it matures to align collagen Iibers along
the lines oI stress Ior normal mobility. These Iorms oI con-
nective tissue massage as well as many other approaches
and techniques oI soIt tissue mobilization are useIul inter-
ventions Ior patients with restricted mobility.
BioIeedback is another tool to help a patient learn and
practice the process oI relaxation. A patient, iI properly
trained, can electronically monitor and learn to reduce the
amount oI tension in muscles, as well as heart rate and
blood pressure, through bioIeedback instrumentation.
Through visual or auditory Ieedback, a patient can begin to
sense or Ieel what muscle relaxation is. By reducing mus-
cle tension, pain can be decreased and Ilexibility increased.
N 0 J E : 8iofeedback is also a useful neans lo helµ a
µalienl learn how lo aclivale a nuscle, ralher lhan relax il,
such as when learninq how lo µerforn quadriceµs sellinq
exercises afler knee surqery.
1oìnf Jracfìon or 0scìllafìon
Slight manual distraction oI joint surIaces prior to or in
conjunction with joint mobilization or muscle-tendon
stretching techniques can be used to inhibit joint pain and
spasm oI muscles around a joint (see Chapter 5).
Pendular motions oI a joint use the weight oI the limb to
distract the joint surIaces and simultaneously oscillate and
Mcfhods of Warm-up
SuperIicial heat (hot packs, paraIIin) or deep-heating
modalities (ultrasound, shortwave diathermy) provide diI-
Ierent mechanisms to heat tissues.
These thermal
agents are used primarily to heat small areas such as
individual joints, muscle groups, or tendons and may be
applied prior to or during the stretching procedure.
There is no consensus whether heating modalities should
be applied prior to or during the stretching procedure.
Low-intensity, active exercises, which generally
increase circulation and core body temperature, also have
been used as a mechanism to warm up large muscle groups
prior to stretching.
Some common warm-up
exercises are a brieI walk, nonIatiguing cycling on a sta-
tionary bicycle, use oI a stair-stepping machine, active heel
raises, or a Iew minutes oI active arm exercises.
Effccfìvcncss of Warm-up Mcfhods
The use oI heat alone (a thermal agent or warm-up exer-
cises) without stretching has been shown to have either
little or no eIIect on improving muscle Ilexibility.
Although a body oI knowledge indicates that heat com-
bined with stretching produces greater long-term gains
in tissue length than stretching alone,
the results
oI other studies have shown comparable improvement
in ROM with no signiIicant diIIerences between
N 0 J E : !he aµµlicalion of cold µrior lo slrelchinq
(cryoslrelchinq) conµared lo heal has been sludied.
Advocales suqqesl ils use lo decrease nuscle lone and nake
lhe nuscle less sensilive durinq slrelch in heallhy sub|ecls
and in µalienls wilh sµaslicily or riqidily secondary lo uµµer
nolor neuron lesions.
!he use of cold innedialely afler
sofl lissue in|ury effeclively decreases µain and nuscle
Rowever, once sofl lissue healinq and scar
fornalion beqin, cold nakes healinq lissues less exlensible
and nore susceµlible lo nicrolrauna durinq slrelch-
Coolinq sofl lissues in a lenqlhened µosilion
cItcr slrelchinq has been shown lo µronole nore laslinq
increases in sofl lissue lenqlh and nininize µoslslrelch
nuscle soreness.
To summarize, the authors oI this text recommend that
cold be applied to injured soIt tissues during the Iirst 24 to
48 hours aIter injury to minimize swelling, muscle spasm,
and pain. Remember, stretching is contraindicated in the
presence oI inIlammation that occurs during the acute phase
oI tissue healing (see Chapter 10). When inIlammation sub-
sides and stretching is indicated, the authors advocate
warming soIt tissues prior to or during a stretching maneu-
ver. AIter stretching, cold should be applied to soIt tissues
held in a lengthened position to minimize poststretch mus-
cle soreness and to promote longer-lasting gains in ROM.
Massagc for Pclaxafìon
Local muscle relaxation can be enhanced by massage, par-
ticularly with light or deep stroking techniques.
C R A P J E P 4 Slrelchinq for lnµaired Mobilily 08
relax the limb. The joint may be Iurther distracted by add-
ing a 1- or 2-lb weight to the extremity, which causes a
stretch Iorce on joint tissues.
As with the ROM exercises described in Chapter 3, the
manual stretching techniques in this section are described
with the patient in a supine position. Alternate patient posi-
tions such as prone or sitting are indicated Ior some
motions and are noted when necessary. Manual stretching
procedures in an aquatic environment are described in
Chapter 9.
EIIective manual stretching techniques require ade-
quate stabilization oI the patient and suIIicient strength and
good body mechanics oI the therapist. Depending on the
size (height and weight) oI the therapist and the patient,
modiIications in the patient`s position and suggested hand
placements Ior stretching or stabilization may have to be
made by the therapist.
Each description oI a stretching technique is identi-
Iied by the anatomical plane oI motion that is to be
increased Iollowed by a notation oI the muscle group
being stretched. Limitations in Iunctional ROM usually
are caused by shortening oI multiple muscle groups and
periarticular structures, and they aIIect movement in com-
bined (as well as anatomical) planes oI motion. In this
situation, however, stretching multiple muscle groups
simultaneously using diagonal patterns (i.e., D
and D
Ilexion and extension oI the upper or lower extremities as
described in Chapter 6) is not recommended and thereIore
is not described in this chapter. The authors believe that
combined, diagonal patterns are appropriate Ior maintain-
ing available ROM with passive and active exercises and
increasing strength in multiple muscle groups but are ineI-
Iective Ior isolating a stretch Iorce to speciIic muscles or
muscle groups oI the extremities that are shortened and
restricting ROM. Special considerations Ior each region
being stretched are also noted in this section.
Prolonged passive stretching techniques using
mechanical equipment are applied using the same points
oI stabilization as manual stretching. The stretch Iorce is
applied at a lower intensity and is applied over a much
longer period than with manual stretching. The stretch
Iorce is provided by weights or splints rather than the
strength or endurance oI a therapist. The patient is stabi-
lized with belts, straps, or counterweights.
N 0 J E : Manual slrelchinq µrocedures for lhe nusculalure
of lhe cervical, lhoracic, and lunbar sµine nay be found in
Chaµler 1ß. Selecled self-slrelchinq lechniques of lhe
exlrenilies and sµine lhal a µalienl can do wilhoul assis-
lance fron a lheraµisl are nol described in lhis chaµler.
!hese exercises are for each |oinl of lhe exlrenilies nay be
found in Chaµlers 1ß lhrouqh 22.
uppcr Exfrcmìfy Sfrcfchìng
Jhc Shouldcr: Spccìal Consìdcrafìons
Many muscles involved with shoulder motion attach to
the scapula rather than the thorax. ThereIore, when most
muscles oI the shoulder girdle are stretched, it is impera-
tive to stabilize the scapula. Without scapular stabilization
the stretch Iorce is transmitted to the muscles that normally
stabilize the scapula during movement oI the arm. This
subjects these muscles to possible overstretching and dis-
guises the true ROM oI the glenohumeral joint.
When the scapula is stabilized and not allowed to abduct
or upwardly rotate, only 120 oI shoulder Ilexion and
abduction can occur at the glenohumeral joint.
The humerus must be externally rotated to gain Iull
ROM oI abduction.
Muscles most apt to become shortened are those that
prevent Iull shoulder Ilexion, abduction, and external
rotation. It is rare to Iind restrictions in structures that
prevent shoulder adduction and extension to neutral.
Flcxìon of fhc Shouldcr
To increase flexion of the shoulaer (to stretch the shoulder
extensors) (Fig. 4.16).
Fl0uPE 4.18 (/} hand µ|aceuen¦ and s¦au|||za¦|on o¦ ¦|e scaµu|a ¦o s¦re¦c|
¦|e ¦eres ua¦or and |ncrease s|ou|der ¦|ez|on.
Patient Position
Place the patient in a prone position.
Hand Placement and Procedure
Support the Iorearm and grasp the distal humerus.
Stabilize the posterior aspect oI the scapula to prevent
substitute movements.
Move the patient`s arm into Iull hyperextension oI the
shoulder to elongate the shoulder Ilexors.
Ahducfìon of fhc Shouldcr
To increase abauction of the shoulaer (to stretch the
adductors) (Fig. 4.18).
Hand Placement and Procedure
Grasp the posterior aspect oI the distal humerus, just
above the elbow.
Stabilize the axillary border oI the scapula to stretch the
teres major, or stabilize the lateral aspect oI the thorax
and superior aspect oI the pelvis to stretch the latissimus
Move the patient`s arm into Iull shoulder Ilexion to elon-
gate the shoulder extensors.
Rypcrcxfcnsìon of fhc Shouldcr
To increase hvperextension of the shoulaer (to stretch the
shoulder Ilexors) (Fig. 4.17).
C R A P J E P 4 Slrelchinq for lnµaired Mobilily 05
Fl0uPE 4.18 (3} hand µ|aceuen¦ and s¦au|||za¦|on o¦ ¦|e µe|v|s ¦o s¦re¦c|
¦|e |a¦|ss|uus dors| and |ncrease s|ou|der ¦|ez|on.
Fl0uPE 4.17 hand µ|aceuen¦ and s¦au|||za¦|on o¦ ¦|e scaµu|a ¦o |ncrease
ez¦ens|on o¦ ¦|e s|ou|der ue,ond neu¦ra|.
Fl0uPE 4.18 hand µ|aceuen¦ and s¦au|||za¦|on o¦ ¦|e scaµu|a ¦or ¦|e
s¦re¦c||nç µrocedure ¦o |ncrease s|ou|der auduc¦|on.
Hand Placement and Procedure
With the elbow Ilexed to 90 , grasp the distal humerus.
Stabilize the axillary border oI the scapula.
Move the patient into Iull shoulder abduction to lengthen
the adductors oI the shoulder.
Adducfìon of fhc Shouldcr
To increase aaauction of the shoulaer (to stretch the
abductors). It is rare when a patient is unable to adduct the
shoulder Iully to 0 (so the upper arm is at the patient`s
side). Even iI a patient has worn an abduction splint aIter a
soIt tissue or joint injury oI the shoulder, when he or she is
upright the constant pull oI gravity elongates the shoulder
abductors so the patient can adduct to a neutral position.
Exfcrnal Pofafìon of fhc Shouldcr
To increase external rotation of the shoulaer (stretch the
internal rotators) (Fig. 4.19).
Hand Placement and Procedure
Abduct the shoulder to a comIortable positioninitially
30 or 45 and later to 90 iI the glenohumoral (GH)
joint is stableor place the arm at the patient`s side.
Flex the elbow to 90 so the Iorearm can be used as a
Grasp the volar surIace oI the mid-Iorearm with one
Stabilization oI the scapula is provided by the table on
which the patient is lying.
Externally rotate the patient`s shoulder by moving the
patient`s Iorearm closer to the table. This Iully lengthens
the internal rotators.
P P E C A u J l 0 N : 8ecause il is necessary lo aµµly lhe
slrelch forces across lhe inlernediale elbow |oinl when
elonqalinq lhe inlernal and exlernal rolalors of lhe shoul-
der, be sure lhe elbow |oinl is slable and µain-free. ln addi-
lion, keeµ lhe inlensily of lhe slrelch force very low,
µarlicularly in µalienls wilh osleoµorosis.
lnfcrnal Pofafìon of fhc Shouldcr
To increase internal rotation of the shoulaer (stretch the
external rotators) (Fig. 4.20).
Hand Placement and Procedure
Abduct the shoulder to a comIortable position that
allows internal rotation to occur without the thorax
blocking the motion (initially to 45 and eventually
to 90 ).
Flex the elbow to 90 so the Iorearm can be used as a
Grasp the dorsal surIace oI the midIorearm with one
hand, and stabilize the anterior aspect oI the shoulder
and support the elbow with your other Iorearm and hand.
Move the patient`s arm into internal rotation to lengthen
the external rotators oI the shoulder.
Rorìzonfal Ahducfìon of fhc Shouldcr
To increase hori:ontal abauction of the shoulaer (stretch
the pectoralis muscles) (Fig. 4.21).
Fl0uPE 4.10 S|ou|der µos|¦|on (s||ç|¦|, auduc¦ed and ¦|ezed} and |and
µ|aceuen¦ a¦ ¦|e u|d ¦o µroz|ua| ¦orearu ¦o |ncrease ez¦erna| ro¦a¦|on o¦ ¦|e
s|ou|der. A ¦o|ded ¦owe| |s µ|aced under ¦|e d|s¦a| |uuerus ¦o ua|n¦a|n ¦|e
s|ou|der |n s||ç|¦ ¦|ez|on. !|e ¦au|e s¦au|||zes ¦|e scaµu|a.
Fl0uPE 4.20 hand µ|aceuen¦ and s¦au|||za¦|on o¦ ¦|e s|ou|der ¦o |ncrease
|n¦erna| ro¦a¦|on o¦ ¦|e s|ou|der.
Fl0uPE 4.21 hand µ|aceuen¦ and s¦au|||za¦|on o¦ ¦|e an¦er|or asµec¦ o¦
¦|e s|ou|der and c|es¦ ¦o |ncrease |or|zon¦a| auduc¦|on o¦ ¦|e s|ou|der µas¦
neu¦ra| (¦o s¦re¦c| ¦|e µec¦ora||s ua¦or}.
Patient Position
To reach Iull horizontal abduction in the supine position,
the patient`s shoulder must be at the edge oI the table.
Begin with the shoulder in 60 to 90 oI abduction. The
patient`s elbow may also be Ilexed.
Hand Placement and Procedure
Grasp the anterior aspect oI the distal humerus.
Stabilize the anterior aspect oI the shoulder.
Move the patient`s arm below the edge oI the table into
Iull horizontal abduction to stretch the horizontal adduc-
N 0 J E : !he horizonlal adduclors are usually liqhl bilal-
erally. Slrelchinq lechniques can be aµµlied bilalerally by
lhe lheraµisl, or a bilaleral self-slrelch can be done by
lhe µalienl by usinq a corner or wand (see Fiqs. 17.80
lhrouqh 17.82).
Scapular Mohìlìfy
To have Iull shoulder motion, a patient must have normal
scapular mobility. (See scapular mobilization techniques in
Chapter 5.)
Hand Placement and Procedure
Grasp the distal Iorearm.
With the upper arm at the patient`s side supported on the
table. stabilize the scapula and anterior aspect oI the
proximal humerus.
Extend the elbow just past the point oI tissue resistance
to lengthen the elbow Ilexors.
N 0 J E : 8e sure lo do lhis wilh lhe forearn in suµinalion,
µronalion, and neulral µosilion lo slrelch each of lhe elbow
To increase elbow extension with the shoulaer
extenaea (stretch the long head oI the biceps).
Patient Position, Hand Placement, and Procedure
With the patient lying supine close to the side oI the
table, stabilize the anterior aspect oI the shoulder or with
the patient lying prone, stabilize the scapula.
Pronate the Iorearm, extend the elbow, and then extend
the shoulder.
P P E C A u J l 0 N : ll has been reµorled lhal heleroloµic
ossificalion (lhe aµµearance of ecloµic bone in lhe sofl
lissues around a |oinl) can develoµ around lhe elbow
afler lraunalic or burn in|uries.

ll is believed lhal viçcr-
cn·, IcrciI|c µassive slrelchinq of lhe elbow flexors nay
increase lhe risk of lhis condilion develoµinq. Passive or
assisled slrelchinq, lherefore, should be aµµlied very
qenlly and qradually in lhe elbow reqion. bse of aclive
slrelchinq, such as aqonisl conlraclion, niqhl also be
Supìnafìon or Pronafìon of fhc Forcarm
To increase supination or pronation of the forearm.
Hand Placement and Procedure
With the patient`s humerus supported on the table and
the elbow Ilexed to 90 , grasp the distal Iorearm.
Stabilize the humerus.
Jhc Elhow and Forcarm: Spccìal Consìdcrafìons
Several muscles that cross the elbow, such as the biceps
brachii and brachioradialis, also inIluence supination
and pronation oI the Iorearm. ThereIore, when stretch-
ing the elbow Ilexors and extensors, the techniques
should be perIormed with the Iorearm pronated as well
as supinated.
Elhow Flcxìon
To increase elbow flexion (stretch the one-joint elbow
Hand Placement and Procedure
Grasp the distal Iorearm just proximal to the wrist.
With the arm at the patient`s side supported on the table,
stabilize the proximal humerus.
Flex the patient`s elbow just past the point oI tissue
resistance to lengthen the elbow extensors.
To increase elbow flexion with the shoulaer flexea
(stretch the long head oI the triceps) (Fig. 4.22).
C R A P J E P 4 Slrelchinq for lnµaired Mobilily 07
Fl0uPE 4.22 hand µ|aceuen¦ and s¦au|||za¦|on ¦o |ncrease e|uow ¦|ez|on
w|¦| s|ou|der ¦|ez|on (¦o s¦re¦c| ¦|e |onç |ead o¦ ¦|e ¦r|ceµs urac|||}.
Patient Position, Hand Placement, and Procedure
With the patient sitting or lying supine with the arm at
the edge oI the table, Ilex the patient`s shoulder as Iar
as possible.
While maintaining shoulder Ilexion, grasp the distal
Iorearm and Ilex the elbow as Iar as possible.
Elhow Exfcnsìon
To increase elbow extension (to stretch the elbow Ilexors)
(Fig. 4.23).
Fl0uPE 4.28 hand µ|aceuen¦ and s¦au|||za¦|on o¦ ¦|e scaµu|a and µroz|ua|
|uuerus ¦or s¦re¦c||nç µrocedures ¦o |ncrease e|uow ez¦ens|on.
Supinate or pronate the Iorearm just beyond the point oI
tissue resistance.
Be sure the stretch Iorce is applied to the radius rotating
around the ulna. Do not twist the hand, thereby avoiding
stress to the wrist articulations.
Repeat the procedure with the elbow extended. Be sure
to stabilize the humerus to prevent internal or external
rotation oI the shoulder.
Jhc Wrìsf and Rand: Spccìal Consìdcrafìons
The extrinsic muscles oI the Iingers cross the wrist joint
and thereIore may inIluence the ROM oI the wrist. Wrist
motion may also be inIluenced by the position oI the elbow
and Iorearm because the wrist Ilexors and extensors attach
proximally on the epicondyles oI the humerus.
When stretching the musculature oI the wrist, the
stretch Iorce should be applied proximal to the metacar-
pophalangeal (MCP) joints, and the Iingers should be
Patient Position
When stretching the muscles oI the wrist and hand, have
the patient sit in a chair adjacent to you with the Iorearm
supported on a table to stabilize the Iorearm eIIectively.
Wrìsf Flcxìon
To increase wrist flexion.
Hand Placement and Procedure
The Iorearm may be supinated, in midposition, or
Stabilize the Iorearm against the table and grasp the dor-
sal aspect oI the patient`s hand.
To elongate the wrist extensors, Ilex the patient`s wrist
and allow the Iingers to extend passively.
To Iurther elongate the wrist extensors, extend the
patient`s elbow.
Wrìsf Exfcnsìon
To increase wrist extension (Fig. 4.24).
Hand Placement and Procedure
Pronate the Iorearm or place it in midposition, and grasp
the patient at the palmar aspect oI the hand. II there is a
severe wrist Ilexion contracture, it may be necessary to
place the patient`s hand over the edge oI the treatment
Stabilize the Iorearm against the table.
To lengthen the wrist Ilexors, extend the patient`s wrist,
allowing the Iingers to Ilex passively.
Padìal 0cvìafìon
To increase raaial aeviation.
Hand Placement and Procedure
Grasp the ulnar aspect oI the hand along the IiIth
Hold the wrist in midposition.
Stabilize the Iorearm.
Radially deviate the wrist to lengthen the ulnar deviators
oI the wrist.
ulnar 0cvìafìon
To increase ulnar aeviation.
Hand Placement and Procedure
Grasp the radial aspect oI the hand along the second
metacarpal, not the thumb.
Stabilize the Iorearm.
Deviate the wrist ulnarly to lengthen the radial deviators.
Jhc 0ìgìfs: Spccìal Consìdcrafìons
The complexity oI the relationships among the joint struc-
tures and the intrinsic and multijoint extrinsic muscles oI
the digits requires careIul examination and evaluation oI
the Iactors that contribute to loss oI Iunction in the hand
because oI limitation oI motion. The therapist must deter-
mine iI a limitation is Irom restriction oI joints, decreased
muscle Ilexibility, or adhesions oI tendons or ligaments.
The digits should always be stretched individually, not
simultaneously. II an extrinsic muscle limits motion,
lengthen it over one joint while stabilizing the other joints.
Then hold the lengthened position and stretch it over the
second joint, and so Iorth, until normal length is obtained.
As noted in Chapter 3, begin the motion with the most dis-
tal joint to minimize shearing and compressive stresses to
the surIaces oI the small joints oI the digits. SpeciIic meth-
ods oI intervention Ior dealing with adhesions oI tendons
are described in Chapter 19.
CMC 1oìnf of fhc Jhumh
To increase flexion, extension, abauction, or aaauction of
the carpometacarpal (CMC) foint of the thumb.
Hand Placement and Procedure
Stabilize the trapezium with your thumb and index Iinger.
Grasp the Iirst metacarpal (not the Iirst phalanx) with
your other thumb and index Iinger.
Move the Iirst metacarpal in the desired direction
to increase CMC Ilexion, extension, abduction, and
Fl0uPE 4.24 hand µ|aceuen¦ and s¦au|||za¦|on o¦ ¦|e ¦orearu ¦or s¦re¦c||nç
µrocedure ¦o |ncrease ez¦ens|on o¦ ¦|e wr|s¦.
Hand Placement and Procedure
With the patient`s knee Iully extended, support the
patient`s lower leg with your arm or shoulder.
Stabilize the opposite extremity along the anterior aspect
oI the thigh with your other hand or a belt or with the
assistance oI another person.
With the knee at 0 extension, and the hip in neutral
rotation, Ilex the hip as Iar as possible.
N 0 J E : Exlernally rolale lhe hiµ µrior lo hiµ flexion lo
isolale lhe slrelch force lo lhe nedial hanslrinqs and
inlernally rolale lhe hiµ lo isolale lhe slrelch force lo
lhe laleral hanslrinqs.
MCP 1oìnfs of fhc 0ìgìfs
To increase flexion, extension, abauction, or aaauction of
the MCP foints of the aigits.
Hand Placement and Procedure
Stabilize the metacarpal with your thumb and index
Grasp the proximal phalanx with your other thumb and
index Iinger.
Keep the wrist in midposition.
Move the MCP joint in the desired direction Ior stretch.
Allow the interphalangeal (IP) joints to Ilex or extend
PlP and 0lP 1oìnfs
To increase flexion or extension of the proximal (PIP) ana
aistal (DIP) interphalangeal foints.
Hand Placement and Procedure
Grasp the middle or distal phalanx with your thumb and
Stabilize the proximal or middle phalanx with your other
thumb and Iinger.
Move the PIP or DIP joint in the desired direction Ior
Sfrcfchìng Spccìfìc Exfrìnsìc
and lnfrìnsìc Musclcs of fhc Fìngcrs
Elongation oI extrinsic and intrinsic muscles oI the hand is
described in Chapter 3. To stretch these muscles beyond
their available range, the same hand placement and stabi-
lization are used as with passive ROM. The only diIIerence
in technique is that the therapist moves each segment into
the stretch range.
Lowcr Exfrcmìfy Sfrcfchìng
Jhc Rìp: Spccìal Consìdcrafìons
Because muscles oI the hip attach to the pelvis or lum-
bar spine, the pelvis must always be stabilized when
lengthening muscles about the hip. II the pelvis is not
stabilized, the stretch Iorce is transIerred to the lumbar
spine, in which unwanted compensatory motion then
Flcxìon of fhc Rìp
To increase flexion of the hip with the knee flexea (stretch
the gluteus maximus).
Hand Placement and Procedure
Flex the hip and knee simultaneously.
Stabilize the opposite Iemur in extension to prevent pos-
terior tilt oI the pelvis.
Move the patient`s hip and knee into Iull Ilexion to
lengthen the one-joint hip extensor.
Flcxìon of fhc Rìp wìfh Kncc Exfcnsìon
To increase flexion of the hip with the knee extenaea
(stretch the hamstrings) (Fig. 4.25).
C R A P J E P 4 Slrelchinq for lnµaired Mobilily 00
Fl0uPE 4.25 (/, 3} hand µ|aceuen¦ and s¦au|||za¦|on o¦ ¦|e oµµos|¦e ¦euur
¦o s¦au|||ze ¦|e µe|v|s and |ow uac| ¦or s¦re¦c||nç µrocedures ¦o |ncrease ||µ
¦|ez|on w|¦| |nee ez¦ens|on (s¦re¦c| ¦|e |aus¦r|nçs} w|¦| ¦|e ¦|eraµ|s¦ s¦and-
|nç u, ¦|e s|de o¦ ¦|e ¦au|e or |nee||nç on ¦|e ¦au|e.
Alternate Therapist Position
Kneel on the mat and place the patient`s heel or distal tibia
against your shoulder. Place both oI your hands along the
anterior aspect oI the distal thigh to keep the knee extend-
ed. The opposite extremity is stabilized in extension by a
belt or towel around the distal thigh and held in place by
the therapist`s knee.
Exfcnsìon of fhc Rìp
To increase hip extension (to stretch the iliopsoas)
(Fig. 4.26).
Alternate Position
The patient can lie prone (Fig. 4.27).
Fl0uPE 4.28 hand µ|aceuen¦ and s¦au|||za¦|on o¦ ¦|e µe|v|s ¦o |ncrease
ez¦ens|on o¦ ¦|e ||µ (s¦re¦c| ¦|e |||oµsoas} w|¦| ¦|e µa¦|en¦ |,|nç suµ|ne. l|ez-
|nç ¦|e |nee w|en |n ¦||s µos|¦|on a|so e|onça¦es ¦|e rec¦us ¦euor|s.
Patient Position
Have the patient close to the edge oI the treatment table so
the hip being stretched can be extended beyond neutral.
The opposite hip and knee are Ilexed toward the patient`s
chest to stabilize the pelvis and spine.
Hand Placement and Procedure
Stabilize the opposite leg against the patient`s chest with
one hand, or iI possible have the patient assist by grasp-
ing around the thigh and holding it to the chest to pre-
vent an anterior tilt oI the pelvis during stretching.
Move the hip to be stretched into extension or hyperex-
tension by placing downward pressure on the anterior
aspect oI the distal thigh with your other hand. Allow the
knee to extend so the two-joint rectus Iemoris does not
restrict the range.
Fl0uPE 4.27 hand µ|aceuen¦ and s¦au|||za¦|on ¦o |ncrease |,µerez¦ens|on
o¦ ¦|e ||µ w|¦| ¦|e µa¦|en¦ |,|nç µrone.
Hand Placement and Procedure
Support and grasp the anterior aspect oI the patient`s
distal Iemur.
Stabilize the patient`s buttocks to prevent movement
oI the pelvis.
Extend the patient`s hip by liIting the Iemur oII the
Exfcnsìon of fhc Rìp wìfh Kncc Flcxìon
To increase hip extension ana knee flexion simultaneouslv
(stretch the rectus Iemoris).
Patient Position
Use either oI the positions previously described Ior
increasing hip extension in the supine or prone positions
(see Figs. 4.26 and 4.27).
Hand Placement and Procedure
With the hip held in Iull extension on the side to be
stretched, move your hand to the distal tibia and gently
Ilex the knee oI that extremity as Iar as possible.
Do not allow the hip to abduct or rotate.
Ahducfìon of fhc Rìp
To increase abauction of the hip (stretch the adductors)
(Fig. 4.28).
Hand Placement and Procedure
Support the distal thigh with your arm and Iorearm.
Stabilize the pelvis by placing pressure on the opposite
anterior iliac crest or by maintaining the opposite lower
extremity in slight abduction.
Abduct the hip as Iar as possible to stretch the adductors.
N 0 J E : You nay aµµly your slrelch force cauliously al
lhe nedial nalleolus only if lhe knee is slable and µain-free.
!his creales a qreal deal of slress lo lhe nedial suµµorlinq
slruclures of lhe knee and is qenerally nol reconnended by
lhe aulhors.
Adducfìon of fhc Rìp
To increase aaauction of the hip |stretch the tensor Iasciae
latae and iliotibial (IT) band| (Fig. 4.29).
C R A P J E P 4 Slrelchinq for lnµaired Mobilily 101
Fl0uPE 4.20 Pa¦|en¦ µos|¦|oned s|de-|,|nç. hand µ|aceuen¦ and µrocedure
¦o s¦re¦c| ¦|e ¦ensor ¦asc|ae |a¦ae and l! uand.
Fl0uPE 4.80 (/} hand µ|aceuen¦ and s¦au|||za¦|on o¦ ¦|e µe|v|s ¦o |ncrease
ez¦erna| ro¦a¦|on o¦ ¦|e ||µ.
Fl0uPE 4.28 hand µ|aceuen¦ and s¦au|||za¦|on o¦ ¦|e oµµos|¦e ez¦reu|¦, (or
µe|v|s} ¦or ¦|e s¦re¦c||nç µrocedure ¦o |ncrease auduc¦|on o¦ ¦|e ||µ.
Patient Position
Place the patient in a side-lying position with the hip to
be stretched uppermost. Flex the bottom hip and knee to
stabilize the patient.
Hand Placement and Procedure
Stabilize the pelvis at the iliac crest with your proximal
Flex the knee and extend the patient`s hip to neutral or
into slight hyperextension, iI possible.
Let the patient`s hip adduct with gravity and apply
an additional stretch Iorce with your other hand to
the lateral aspect oI the distal Iemur to Iurther adduct
the hip.
N 0 J E : lf lhe µalienl's hiµ cannol be exlended lo neulral,
lhe hiµ flexors nusl be slrelched before lhe lensor fasciae
lalae can be slrelched.
Exfcrnal Pofafìon of fhc Rìp
To increase external rotation of the hip (stretch the internal
rotators) (Fig. 4.30A).
Patient Position
Place the patient in a prone position, hips extended and
knee Ilexed to 90 .
Hand Placement and Procedure
Grasp the distal tibia oI the extremity to be stretched.
Stabilize the pelvis by applying pressure with your other
hand across the buttocks.
Apply pressure to the lateral malleolus or lateral aspect
oI the tibia, and externally rotate the hip as Iar as
Alternate Position and Procedure
Sitting at the edge oI a table with hips and knees Ilexed
to 90 .
Stabilize the pelvis by applying pressure to the iliac crest
with one hand.
Apply the stretch Iorce to the lateral malleolus or lat-
eral aspect oI the lower leg, and externally rotate the
N 0 J E : When you aµµly lhe slrelch force aqainsl lhe
lower leq in lhis nanner, lhus crossinq lhe knee |oinl,
lhe knee nusl be slable and µain-free. lf lhe knee is nol
slable, il is µossible lo aµµly lhe slrelch force by qrasµinq
lhe dislal lhiqh, bul lhe leveraqe is µoor and lhere is a
lendency lo lwisl lhe skin.
lnfcrnal Pofafìon of fhc Rìp
To increase internal rotation of the hip (stretch the external
rotators) (Fig. 4.30B).
Patient Position and Stabilization
Position the patient the same as when increasing external
rotation, described previously.
Hand Placement and Procedure
Apply pressure to the medial malleolus or medial aspect oI
the tibia, and internally rotate the hip as Iar as possible.
Jhc Kncc: Spccìal Consìdcrafìons
The position oI the hip during stretching inIluences the
Ilexibility oI the Ilexors and extensors oI the knee. The
Ilexibility oI the hamstrings and the rectus Iemoris must
be examined and evaluated separately Irom the one-joint
muscles that aIIect knee motion.
Kncc Flcxìon
To increase knee flexion (stretch the knee extensors)
(Fig. 4.31).
Fl0uPE 4.80 (confìnucd} (3} hand µ|aceuen¦ and s¦au|||za¦|on o¦ ¦|e
µe|v|s ¦o |ncrease |n¦erna| ro¦a¦|on o¦ ¦|e ||µ w|¦| ¦|e µa¦|en¦ µrone.
Fl0uPE 4.81 hand µ|aceuen¦ and s¦au|||za¦|on ¦o |ncrease |nee ¦|ez|on
(s¦re¦c| ¦|e rec¦us ¦euor|s and uuadr|ceµs} w|¦| ¦|e µa¦|en¦ |,|nç µrone.
Patient Position
Have the patient assume a prone position.
Hand Placement and Procedure
Stabilize the pelvis by applying downward pressure
across the buttocks.
Grasp the anterior aspect oI the distal tibia, and Ilex the
patient`s knee.
P P E C A u J l 0 N : Place a rolled lowel under lhe lhiqh
|usl above lhe knee lo µrevenl conµression of lhe µalella
aqainsl lhe lable durinq lhe slrelch. Slrelchinq lhe knee
exlensors loo viqorously in lhe µrone µosilion can lrauna-
lize lhe knee |oinl and cause swellinq.
Alternate Position and Procedure
Have the patient sit with the thigh supported on the treat-
ment table and leg Ilexed over the edge as Iar as possible.
Patient Position
Place the patient in a prone position and put a small, rolled
towel under the patient`s distal Iemur, just above the patella.
Hand Placement and Procedure
Grasp the distal tibia with one hand and stabilize the but-
tocks to prevent hip Ilexion with the other hand.
Slowly extend the knee to stretch the knee Ilexors.
End-Pangc Kncc Exfcnsìon
To increase ena-range knee extension (Fig. 4.33).
Stabilize the anterior aspect oI the proximal Iemur with
one hand.
Apply the stretch Iorce to the anterior aspect oI the distal
tibia and Ilex the patient`s knee as Iar as possible.
N 0 J E : !his µosilion is useful when workinq in lhe 0 lo
100 ranqe of knee flexion. !he µrone µosilion is besl for
increasinq knee flexion fron 00 lo 186 .
Kncc Exfcnsìon
To increase knee extension in the miarange (stretch the
knee Ilexors) (Fig. 4.32).
C R A P J E P 4 Slrelchinq for lnµaired Mobilily 108
Fl0uPE 4.82 hand µ|aceuen¦ and s¦au|||za¦|on ¦o |ncrease u|d-rançe |nee
ez¦ens|on w|¦| ¦|e µa¦|en¦ |,|nç µrone.
Fl0uPE 4.88 hand µ|aceuen¦ and s¦au|||za¦|on ¦o |ncrease ¦eru|na| |nee
Fl0uPE 4.84 hand µ|aceuen¦ and µrocedure ¦o |ncrease dors|¦|ez|on o¦ ¦|e
an||e w|¦| ¦|e |nee ez¦ended (s¦re¦c||nç ¦|e ças¦rocneu|us}.
Patient Position
Patient assumes a supine position.
Hand Placement and Procedure
Grasp the distal tibia oI the knee to be stretched.
Stabilize the hip by placing your hand or Iorearm across
the anterior thigh. This prevents hip Ilexion during
Apply the stretch Iorce to the posterior aspect oI the dis-
tal tibia, and extend the patient`s knee.
Jhc Anklc and Foof: Spccìal Consìdcrafìons
The ankle and Ioot are composed oI multiple joints. Con-
sider the mobility oI these joints (see Chapter 5) as well as
the multijoint muscles that cross these joints when increas-
ing ROM oI the ankle and Ioot.
0orsìflcxìon of fhc Anklc
To increase aorsiflexion of the ankle with the knee
extenaea (stretch the gastrocnemius muscle) (Fig. 4.34).
Hand Placement and Procedure
Grasp the patient`s heel (calcaneus) with one hand,
maintain the subtalar joint in a neutral position, and
place your Iorearm along the plantar surIace oI the Ioot.
Stabilize the anterior aspect oI the tibia with your other
DorsiIlex the talocrural joint oI the ankle by pulling the
calcaneus in an inIerior direction with your thumb and
Iingers while gently applying pressure in a superior
direction just proximal to the heads oI the metatarsals
with your Iorearm.
To increase aorsiflexion of the ankle with the knee
flexea (stretch the soleus muscle). To eliminate the eIIect
oI the two-joint gastrocnemius muscle, the knee must be
Ilexed. Hand placement, stabilization, and stretch Iorce
are the same as when stretching the gastrocnemius.
P P E C A u J l 0 N : When slrelchinq lhe qaslrocnenius or
soleus nuscles, avoid µlacinq loo nuch µressure aqainsl lhe
heads of lhe nelalarsals and slrelchinq lhe lonq arch of lhe
fool. 0verslrelchinq lhe lonq arch of lhe fool can cause a
flal fool or a rocker-bollon fool.
Planfarflcxìon of fhc Anklc
To increase plantarflexion of the ankle.
Hand Placement and Procedure
Support the posterior aspect oI the distal tibia with one
Grasp the Ioot along the tarsal and metatarsal areas.
Apply the stretch Iorce to the anterior aspect oI the
Ioot, and plantarIlex the Ioot as Iar as possible.
lnvcrsìon and Evcrsìon of fhc Anklc
To increase inversion ana eversion of the ankle. Inversion
and eversion oI the ankle occur at the subtalar joint as a
component oI pronation and supination. Mobility oI the
subtalar joint (with appropriate strength) is particularly
important Ior walking on uneven surIaces.
Hand Placement and Procedure
Stabilize the talus by grasping just distal to the malleoli
with one hand.
Grasp the calcaneus with your other hand, and move it
medially and laterally at the subtalar joint.
Sfrcfchìng Spccìfìc Musclcs of fhc Anklc and Foof
Hand Placement and Procedure
Stabilize the distal tibia with your proximal hand.
Grasp around the Ioot with your other hand and align the
motion and Iorce opposite the line oI pull oI the tendons.
Apply the stretch Iorce against the bone to which the
muscle attaches distally.
· To stretch the tibialis anterior (which inverts and dor-
siIlexes the ankle): Grasp the dorsal aspect oI the Ioot
across the tarsals and metatarsals and plantarIlex and
abduct the Ioot.
· To stretch the tibialis posterior (which plantarIlexes
and inverts the Ioot): Grasp the plantar surIace oI the
Ioot around the tarsals and metatarsals and dorsiIlex
and abduct the Ioot.
· To stretch the peroneals (which evert the Ioot): Grasp
the lateral aspect oI the Ioot at the tarsals and
metatarsals and invert the Ioot.
Flcxìon and Exfcnsìon of fhc Jocs
To increase flexion ana extension of the toes. It is best to
stretch any musculature that limits motion in the toes indi-
vidually. With one hand, stabilize the bone proximal to the
restricted joint, and with the other hand move the phalanx
in the desired direction.
Ncck and Jrunk
Stretching techniques to increase mobility in the cervical,
thoracic, and lumbar spine may be Iound in Chapter 16.
Sclf-Sfrcfchìng Jcchnìqucs
Examples oI selI-stretching techniques, perIormed inde-
pendently by the patient aIter appropriate instruction, may
be Iound in Chapters 17 through 22 (upper and lower
extremities) and Chapter 16 (neck and trunk).
l h 0 E P E h 0 E h ! L E A P h l h 6 A C ! l v l ! l E S
Crìfìcal Jhìnkìng and 0ìscussìon
1. What physical Iindings Irom an examination oI a patient
would lead you to decide that stretching exercises were
an appropriate intervention?
2. Discuss the advantages and disadvantages oI various
stretching exercises, speciIically manual stretching, selI-
stretching, and mechanical stretching. Under what cir-
cumstances would one Iorm be a more appropriate
choice than another?
3. Discuss how the eIIectiveness oI a program oI stretching
activities is inIluenced by the responses oI contractile
and noncontractile soIt tissues to stretch. Consider such
Iactors as intensity, speed, duration, and Irequency oI
4. Discuss how your approach to and application oI
stretching would diIIer when developing stretching exer-
cises Ior a healthy young adult with limited mobility in
the (a) shoulder, (b) knee, or (c) ankle in contrast to an
elderly individual with osteoporosis and limited motion
in the same regions.
5. Explain the procedures Ior and rationale behind each
oI the Iollowing types oI neuromuscular inhibition: HR,
HR-AC, CR, and AC. Under what circumstances would
you choose one technique over another?
6. Select a popular exercise videotape. Review and critique
the Ilexibility exercises on the tape. Was there a balance
in the Ilexibility exercises in the program? Were the
exercises executed saIely and correctly? Were the exer-
cises appropriate Ior the target population?
Lahorafory Pracfìcc
1. Manually stretch as many major muscle groups oI the
upper and lower extremities as is safe and practical
with the patient in prone-lying, side-lying, or seated
2. While considering individual muscle actions and lines
oI pull, demonstrate how to speciIically and Iully elon-
gate the Iollowing muscles: pectoralis major, biceps
brachii, brachioradialis, brachialis, triceps, extensor or
Ilexor carpi ulnaris or radialis, Ilexor digitorum superIi-
5. Design an eIIective and eIIicient series oI selI-stretching
exercises that a person who works at a desk most oI the
day should incorporate into a daily home Iitness routine.
Demonstrate and teach each selI-stretching exercise to
your laboratory partner.
6. IdentiIy a recreational/sport activity that your partner
enjoys (i.e., tennis, golI, cycling, jogging, etc.) and
design and demonstrate a program oI selI-stretching
exercises to prepare your partner Ior the activity and
reduce the risk oI injury.
7. Design a program oI progressive relaxation exercises Ior
total body relaxation. Then implement the relaxation
training sequence with your partner.
cialis or proIundus, rectus Iemoris versus the iliopsoas,
gastrocnemius versus soleus, and the tibialis anterior and
3. Teach your partner how to stretch major muscle groups
oI the upper and lower extremities using either body
weight or a cuII weight as the stretch Iorce. Be sure to
include eIIective stabilization procedures Ior these
stretching techniques whenever possible.
4. Using either the hold-relax or contract-relax and the
hold-relax agonist contraction neuromuscular inhibition
techniques, elongate at least two major muscle groups at
the shoulder, elbow, wrist, hip, knee, and ankle. Be sure
to position, align, and stabilize your partner properly.
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160. Wolpe, J: Psychotherapy by Reciprocal Inhibition. StanIord Univer-
sity Press, StanIord, CA, 1958.
161. Worrell, T, McCullough, M, PIeiIIer, A: EIIect oI Ioot position on
gastrocnemius/soleus stretching in subjects with normal Ilexibility. J
Orthop Sports Phys Ther 19:352356, 1994.
162. Worrell, TW, Smith, TL, Winegardner, J: EIIect oI hamstring stretch-
ing on hamstring muscle perIormance. J Orthop Sports Phys Ther
20:154159, 1994.
163. Youdas, JW, Krause, DA, Egan, KS, et al: The eIIect oI static
stretching oI the calI muscle-tendon unit on active ankle dorsiIlecion
range oI motion. J Orthop Sports Phys Ther 33(7):408417, 2003.
164. Youdas, JW, Krause, DA, Hollman, JH, et al: The inIluence oI gen-
der and age on hamstring muscle length in healthy adults. J Orthop
Sports Phys Ther 35(4):246252. 2005.
165. Zachazewski, JE: Flexibility in sports. In Sanders, B (ed): Sports
Physical Therapy. Appleton & Lange, Norwalk, CT, 1990, pp
166. Zarins, B: SoIt tissue injury and repair: biomechanical aspects. Int J
Sports Med 3:9, 1982.
Perlpheral 1olnl
0EFlNlJl0NS 0F JEPMS 110
MohìlìzafìonjManìpulafìon 110
Sclf-Mohìlìzafìon (Aufo-mohìlìzafìon} 110
Mohìlìzafìon wìfh Movcmcnf 110
Physìologìcal Movcmcnfs 110
Acccssory Movcmcnfs 110
Jhrusf 110
Manìpulafìon undcr Ancsfhcsìa 110
Musclc Encrgy 110
1oìnf Shapcs 110
Jypcs of Mofìon 111
Passìvc-Angular Sfrcfchìng vcrsus 1oìnf-
0lìdc Sfrcfchìng 118
0fhcr Acccssory Mofìons fhaf Affccf
fhc 1oìnf 118
Effccfs of 1oìnf Mofìon 114
lN0lCAJl0NS F0P 10lNJ M08lLlZAJl0N 114
Paìn, Musclc 0uardìng, and Spasm 114
Pcvcrsìhlc 1oìnf Rypomohìlìfy 114
Posìfìonal FaulfsjSuhluxafìons 114
Progrcssìvc Lìmìfafìon 114
Funcfìonal lmmohìlìfy 114
LlMlJAJl0NS 0F 10lNJ M08lLlZAJl0N
JECRNl0uES 115
Rypcrmohìlìfy 115
1oìnf Effusìon 115
lnflammafìon 115
Condìfìons Pcquìrìng Spccìal Prccaufìons
for Sfrcfchìng 115
M08lLlZAJl0N JECRNl0uES 118
Examìnafìon and Evaluafìon 118
0radcs or 0osagcs of Movcmcnf 118
Posìfìonìng and Sfahìlìzafìon 117
Jrcafmcnf Forcc and 0ìrccfìon of Movcmcnf 118
lnìfìafìon and Progrcssìon of Jrcafmcnf 118
Spccd, Phyfhm, and 0urafìon of Movcmcnfs 110
Pafìcnf Pcsponsc 110
Jofal Program 110
0F APPLlCAJl0N 120
Prìncìplcs of MWM ìn Clìnìcal Pracfìcc 120
Paìn as fhc 0uìdc 120
Jcchnìqucs 120
Jhcorcfìcal Framcwork 121
Shouldcr 0ìrdlc Complcx 121
Elhow and Forcarm Complcx 127
Wrìsf Complcx 181
Rand and Fìngcr 1oìnfs 188
Rìp 1oìnf 185
Kncc and Lcg 187
Anklc and Foof 1oìnfs 141
Joint mobilization reIers to manual therapy techniques that
are used to modulate pain and treat joint dysIunctions that
limit range oI motion (ROM) by speciIically addressing the
altered mechanics oI the joint. The altered joint mechanics
may be due to pain and muscle guarding, joint eIIusion,
contractures or adhesions in the joint capsules or support-
ing ligaments, or malalignment or subluxation oI the bony
surIaces. Joint mobilization stretching techniques diIIer
Irom other Iorms oI passive or selI-stretching (described in
Chapter 4) in that they speciIically address restricted cap-
sular tissue by replicating normal joint mechanics while
minimizing abnormal compressive stresses on the articular
cartilage in the joint.
To use joint mobilization Ior treatment eIIectively, the
practitioner must know and be able to examine the anato-
my, arthrokinematics, and pathology oI the neuromuscu-
loskeletal system and to recognize when the techniques are
indicated or when other techniques would be more eIIec-
tive Ior regaining lost motion. Indiscriminate use oI joint
mobilization techniques, when not indicated, could lead to
potential harm to the patient`s joints. We assume that prior
to learning the joint mobilization techniques presented here
the student or therapist has had (or will be concurrently
taking) a course in orthopedic examination and evaluation
and thereIore will be able to choose appropriate, saIe tech-
niques Ior treating the patient`s Iunctional limitation. The
C h A P ! L R
reader is reIerred to several resources Ior additional study
oI evaluation procedures.
When indicated, joint
mobilization is a saIe, eIIective means oI restoring or
maintaining joint play within a joint and can also be
used Ior treating pain.
Mobilization and manipulation are two words that have
come to have the same meaning
and are thereIore inter-
changeable. They are passive, skilled manual therapy tech-
niques applied to joints and related soIt tissues at varying
speeds and amplitudes using physiological or accessory
motions Ior therapeutic purposes.
The varying speeds and
amplitudes could range Irom a small-amplitude Iorce
applied at high velocity to a large-amplitude Iorce applied
at slow velocity; that is, there is a continuum oI intensities
and speeds at which the technique could be applied.
Sclf-Mohìlìzafìon (Aufo-mohìlìzafìon}
SelI-mobilization reIers to selI-stretching techniques that
speciIically use joint traction or glides that direct the
stretch Iorce to the joint capsule. SelI-mobilization tech-
niques are described in the chapters on speciIic regions oI
the body.
Mohìlìzafìon wìfh Movcmcnf
Mobilization with movement (MWM) is the concurrent
application oI sustained accessory mobilization applied
by a therapist and an active physiological movement to
end range applied by the patient. Passive end-oI-range
overpressure, or stretching, is then delivered without
pain as a barrier. The techniques are always applied in
a pain-Iree direction and are described as correcting
joint tracking Irom a positional Iault.
Brian Mulligan
oI New Zealand originally described these techniques.
Physìologìcal Movcmcnfs
Physiological movements are movements the patient
can do voluntarily (e.g., the classic or traditional move-
ments, such as Ilexion, abduction, and rotation). The
term osteokinematics is used when these motions oI
the bones are described.
Acccssory Movcmcnfs
Accessory movements are movements in the joint and
surrounding tissues that are necessary Ior normal ROM
but that cannot be actively perIormed by the patient.
Terms that relate to accessory movements are compo-
nent motions and joint play.
Component motions are those motions that accompany
active motion but are not under voluntary control. The
term is oIten used synonymously with accessory move-
ment. For example, motions such as upward rotation
oI the scapula and rotation oI the clavicle, which occur
with shoulder Ilexion, and rotation oI the Iibula, which
occurs with ankle motions, are component motions.
Joint plav describes the motions that occur between
the joint surIaces and also the distensibility or 'give¨
in the joint capsule, which allows the bones to move.
The movements are necessary Ior normal joint Iunc-
tioning through the ROM and can be demonstrated
passively, but they cannot be perIormed actively by
the patient.
The movements include distraction, slid-
ing, compression, rolling, and spinning oI the joint
surIaces. The term arthrokinematics is used when
these motions oI the bone surIaces within the joint
are described.
N 0 J E : Procedures lo dislracl or slide lhe |oinl surfaces
lo decrease µain or reslore |oinl µlay are lhe fundanenlal
|oinl nobilizalion lechniques described in lhis lexl.
Thrust is a high-velocity, short-amplitude motion such
that the patient cannot prevent the motion.
The motion
is perIormed at the end oI the pathological limit oI the
joint and is intended to alter positional relationships, snap
adhesions, or stimulate joint receptors.
limit means the end oI the available ROM when there
is restriction.
Manìpulafìon undcr Ancsfhcsìa
Manipulation under anesthesia is a medical procedure
used to restore Iull ROM by breaking adhesions around
a joint while the patient is anesthetized. The technique
may be a rapid thrust or a passive stretch using physio-
logical or accessory movements.
Musclc Encrgy
Muscle energy techniques use active contraction oI deep
muscles that attach near the joint and whose line oI pull
can cause the desired accessory motion. The technique
requires the therapist to provide stabilization to the seg-
ment on which the distal aspect oI the muscle attaches.
A command Ior an isometric contraction oI the muscle
is given that causes accessory movement oI the joint.
These techniques are not described in this text.
1oìnf Shapcs
The type oI motion occurring between bony partners in
a joint is inIluenced by the shape oI the joint surIaces.
The shape may be described as ovoia or sellar.
The surIaces are incongruent.
New points on one surIace meet new points on the
opposing surIace.
Rolling results in angular motion oI the bone (swing).
Rolling is always in the same direction as the swinging
bone motion whether the surIace is convex (Fig. 5.3A)
or concave (Fig. 5.3B).
Rolling, iI it occurs alone, causes compression oI the
surIaces on the side to which the bone is swinging and
separation on the other side. Passive stretching using
bone angulation alone may cause stressIul compressive
Iorces to portions oI the joint surIace, potentially leading
to joint damage.
In normally Iunctioning joints, pure rolling does not
occur alone but in combination with joint sliding and
In ovoid joints one surIace is convex, the other is con-
cave (Fig. 5.1A).
In sellar joints, one surIace is concave in one direction
and convex in the other, with the opposing surIace con-
vex and concave, respectively; similar to a horseback
rider being in complementary opposition to the shape
oI a saddle (Fig. 5.1B).
C R A P J E P 5 Periµheral Joinl Mobilizalion 111
Fl0uPE 5.2 Reµresen¦a¦|on o¦ one sur¦ace ro|||nç on ano¦|er. New µo|n¦s on
one sur¦ace uee¦ new µo|n¦s on ¦|e oµµos|nç sur¦ace.
Fl0uPE 5.4 Reµresen¦a¦|on o¦ one sur¦ace s||d|nç on ano¦|er, w|e¦|er
(/} ¦|a¦ or (3} curved. !|e saue µo|n¦ on one sur¦ace coues |n¦o con¦ac¦
w|¦| new µo|n¦s on ¦|e oµµos|nç sur¦ace.
Fl0uPE 5.1 (/} w|¦| ovo|d ¦o|n¦s, one sur¦ace |s convez, and ¦|e o¦|er
|s concave. (3} w|¦| se||ar ¦o|n¦s, one sur¦ace |s concave |n one d|rec¦|on
and convez |n ¦|e o¦|er, w|¦| ¦|e oµµos|nç sur¦ace convez and concave,
Jypcs of Mofìon
As a bony lever moves about an axis oI motion, there is
also movement oI the bone surIace on the opposing bone
surIace in the joint.
The movement oI the bony lever is called swing and is
classically described as Ilexion, extension, abduction,
adduction, and rotation. The amount oI movement can
be measured in degrees with a goniometer and is called
Motion oI the bone surIaces in the joint is a variable
combination oI rolling and sliaing, or spinning.
These accessory motions allow greater angulation oI the
bone as it swings. For the rolling, sliding, or spinning to
occur, there must be adequate capsule laxity or joint play.
Characteristics oI one bone rolling on another (Fig. 5.2)
are as Iollows.
Fl0uPE 5.8 Ro|||nç |s a|wa,s |n ¦|e saue d|rec¦|on as uone uo¦|on, w|e¦|er
¦|e uov|nç uone |s (/} convez or (3} concave.
Characteristics oI one bone sliding (translating) across
another include the Iollowing.
For a pure slide, the surIaces must be congruent, either
Ilat (Fig. 5.4A) or curved (Fig. 5.4B).
The same point on one surIace comes into contact with
the new points on the opposing surIace.
Pure sliding does not occur in joints because the
surIaces are not completely congruent.
The direction in which sliding occurs depends on
whether the moving surIace is concave or convex.
Sliding is in the opposite direction oI the angular
movement oI the bone iI the moving joint surIace
is convex (Fig. 5.5A). Sliding is in the same direc-
tion as the angular movement oI the bone iI the
moving surIace is concave (Fig. 5.5B).
Comhìncd Poll-Slìdìng ìn a 1oìnf
The more congruent the joint surIaces are, the more
sliding there is oI one bony partner on the other with
The more incongruent the joint surIaces are, the more
rolling there is oI one bony partner on the other with
When muscles actively contract to move a bone, some
oI the muscles may cause or control the sliding move-
ment oI the joint surIaces. For example, the caudal
sliding motion oI the humeral head during shoulder
abduction is caused by the rotator cuII muscles, and
the posterior sliding oI the tibia during knee Ilexion
is caused by the hamstring muscles. II this Iunction
is lost, the resulting abnormal joint mechanics may
cause microtrauma and joint dysIunction.
The joint mobilization techniques described in this chap-
ter use the sliding component oI joint motion to restore
joint play and reverse joint hypomobility. Rolling (pas-
sive angular stretching) is not used to stretch tight joint
capsules because it causes joint compression.
N 0 J E . When lhe lheraµisl µassively noves lhe arliculal-
inq surface usinq lhe slide conµonenl of |oinl nolion, lhe
lechnique is called lranslaloric qlide, lranslalion, or sinµly
ll is used lo conlrol µain when aµµlied qenlly or
lo slrelch lhe caµsule when aµµlied wilh a slrelch force.
Characteristics oI one bone spinning on another include the
There is rotation oI a segment about a stationary
mechanical axis (Fig. 5.6).
The same point on the moving surIace creates an arc
oI a circle as the bone spins.
Fl0uPE 5.5 Reµresen¦a¦|on o¦ ¦|e concave-convez ru|e. (/} l¦ ¦|e sur¦ace o¦
¦|e uov|nç uone |s convez, s||d|nç |s |n ¦|e d|rec¦|on oµµos|¦e ¦o ¦|a¦ o¦ ¦|e
ançu|ar uoveuen¦ o¦ ¦|e uone. (3} l¦ ¦|e sur¦ace o¦ ¦|e uov|nç uone |s con-
cave, s||d|nç |s |n ¦|e saue d|rec¦|on as ¦|e ançu|ar uoveuen¦ o¦ ¦|e uone.
N 0 J E . !his nechanical relalionshiµ is known as lhe
ccrvcx-ccrccvc rn|c and is lhe basis for delernininq lhe
direclion of lhe nobilizinq force when |oinl nobilizalion
qlidinq lechniques are used.
Focus on Evidence
Several studies
have examined the translational
movement oI the humeral head with shoulder motions and
have documented translations opposite to what is predicted
by the convex-concave rule. Hsu et al.
proposed that this
apparent contradiction to the convex-concave rule is the
result oI asymmetrical tightening oI the shoulder joint cap-
sule during movement resulting in translation oI the mov-
ing bone opposite to the direction oI capsular tightening.
They documented that stretching the tight capsule with
translations that aIIect the restricting tissues leads to
greater ROM in cadaver shoulder joints.
Fl0uPE 5.8 Reµresen¦a¦|on o¦ sµ|nn|nç. !|ere |s ro¦a¦|on o¦ a seçuen¦ auou¦
a s¦a¦|onar, uec|an|ca| az|s.
0fhcr Acccssory Mofìons
fhaf Affccf fhc 1oìnf
Compression is the decrease in the joint space between
bony partners.
Compression normally occurs in the extremity and spinal
joints when weight bearing.
Some compression occurs as muscles contract, which
provides stability to the joints.
As one bone rolls on the other (see Fig. 5.3), some com-
pression also occurs on the side to which the bone is
Normal intermittent compressive loads help move
synovial Iluid and thus help maintain cartilage health.
Abnormally high compression loads may lead to
articular cartilage changes and deterioration.
Traction and distraction are not synonymous. Traction is
a longitudinal pull. Distraction is a separation, or pulling
Separation oI the joint surIaces (distraction) does not
always occur when a traction Iorce is applied to the
long axis oI a bone. For example, iI traction is applied
to the shaIt oI the humerus, it results in a glide oI the
joint surIace (Fig. 5.8A). Distraction oI the glenohumer-
al joint requires a pull at right angles to the glenoid
Iossa (Fig. 5.8B).
For clarity, whenever there is pulling on the long axis
oI a bone, the term long-axis traction is used. Whenever
the surIaces are to be pulled apart, the term aistraction,
foint traction, or foint separation is used.
Spinning rarely occurs alone in joints but in combination
with rolling and sliding.
Three examples oI spin occurring in joints oI the body
are the shoulder with Ilexion/extension, the hip with
Ilexion/extension, and the radiohumeral joint with
pronation/supination (Fig. 5.7).
C R A P J E P 5 Periµheral Joinl Mobilizalion 118
Fl0uPE 5.7 Lzauµ|es o¦ ¦o|n¦ sµ|n |oca¦|on |n ¦|e uod,. (/} huuerus w|¦|
¦|ez|on|ez¦ens|on. (3} leuur w|¦| ¦|ez|on|ez¦ens|on. (C} head o¦ ¦|e rad|us
w|¦| µrona¦|on|suµ|na¦|on.
Fl0uPE 5.8 (/} !rac¦|on aµµ||ed ¦o ¦|e s|a¦¦ o¦ ¦|e |uuerus resu|¦s |n cau-
da| ç||d|nç o¦ ¦|e ¦o|n¦ sur¦ace. (3} 0|s¦rac¦|on o¦ ¦|e ç|eno|uuera| ¦o|n¦
reuu|res seµara¦|on a¦ r|ç|¦ anç|es ¦o ¦|e ç|eno|d ¦ossa.
Passìvc-Angular Sfrcfchìng
vcrsus 1oìnf-0lìdc Sfrcfchìng
Passive-angular stretching procedures,
as when the bony
lever is used to stretch a tight joint capsule, may cause
increased pain or joint trauma because:
The use oI a lever signiIicantly magniIies the Iorce at
the joint.
The Iorce causes excessive joint compression in the
direction oI the rolling bone (see Fig. 5.3).
The roll without a slide does not replicate normal joint
Joint glide (mobilization) stretching procedures,
as when the translatoric slide component oI the bones
is used to stretch a tight capsule, are saIer and more
selective because:
The Iorce is applied close to the joint surIace and
controlled at an intensity compatible with the
The direction oI the Iorce replicates the sliding compo-
nent oI the joint mechanics and does not compress the
The amplitude oI the motion is small yet speciIic to
the restricted or adherent portion oI the capsule or
ligaments. Thus, the Iorces are selectively applied
to the desired tissue.
N 0 J E : For |oinl nobilizalion lechniques, dislraclion is
used lo conlrol or relieve µain when aµµlied qenlly or lo
slrelch lhe caµsule when aµµlied wilh a slrelch force.
A sliqhl dislraclion force is used when aµµlyinq qlidinq
Effccfs of 1oìnf Mofìon
Joint motion stimulates biological activity by moving syn-
ovial Iluid, which brings nutrients to the avascular articular
cartilage oI the joint surIaces and intra-articular Iibrocarti-
lage oI the menisci.
Atrophy oI the articular cartilage
begins soon aIter immobilization is imposed on joints.
Extensibility and tensile strength oI the articular and
periarticular tissues are maintained with joint motion. With
immobilization there is IibroIatty proliIeration, which caus-
es intra-articular adhesions as well as biochemical changes
in tendon, ligament, and joint capsule tissue, which in turn
causes joint contractures and ligamentous weakening.
AIIerent nerve impulses Irom joint receptors transmit
inIormation to the central nervous system and thereIore
provide awareness oI position and motion. With injury
or joint degeneration, there is a potential decrease in an
important source oI proprioceptive Ieedback that may
aIIect an individual`s balance response.
Joint motion
provides sensory input relative to
Static position and sense oI speed oI movement (type I
receptors Iound in the superIicial joint capsule)
Change oI speed oI movement (type II receptors Iound
in deep layers oI the joint capsule and articular Iat pads)
Sense oI direction oI movement (type I and III receptors;
type III Iound in joint ligaments)
Regulation oI muscle tone (type I, II, and III receptors)
Nociceptive stimuli (type IV receptors Iound in the
Iibrous capsule, ligaments, articular Iat pads, periosteum,
and walls oI blood vessels)
lN0lCAJl0NS F0P 10lNJ
Paìn, Musclc 0uardìng, and Spasm
PainIul joints, reIlex muscle guarding, and muscle spasm
can be treated with gentle foint-plav techniques to stimu-
late neurophysiological and mechanical eIIects.
Ncurophysìologìcal Effccfs
Small-amplitude oscillatory and distraction movements are
used to stimulate the mechanoreceptors that may inhibit
the transmission oI nociceptive stimuli at the spinal cord or
brain stem levels.
Mcchanìcal Effccfs
Small-amplitude distraction or gliding movements oI the
joint are used to cause synovial Iluid motion, which is the
vehicle Ior bringing nutrients to the avascular portions oI
the articular cartilage (and intra-articular Iibrocartilage
when present). Gentle joint-play techniques help maintain
nutrient exchange and thus prevent the painIul and degen-
erating eIIects oI stasis when a joint is swollen or painIul
and cannot move through the ROM.
N 0 J E : !he snall-anµlilude |oinl lechniques used lo
lreal µain, nuscle quardinq, or nuscle sµasn should nol
µlace slrelch on lhe reaclive lissues (see seclions on Con-
lraindicalions and Precaulions).
Pcvcrsìhlc 1oìnf Rypomohìlìfy
Reversible joint hypomobility can be treated with progres-
sivelv vigorous foint-plav stretching techniques to elongate
hypomobile capsular and ligamentous connective tissue.
Sustained or oscillatory stretch Iorces are used to distend
the shortened tissue mechanically.
Posìfìonal FaulfsjSuhluxafìons
Malposition oI one bony partner with respect to its oppos-
ing surIace may result in limited motion or pain. This can
occur with a traumatic injury, aIter periods oI immobility,
or with muscle imbalances. The malpositioning may be
perpetuated with maladapted neuromuscular control across
the joint so whenever attempting active ROM there is
Iaulty tracking oI the joint surIaces resulting in pain or lim-
ited motion. MWM techniques attempt to realign the bony
partners while the person actively moves the joint through
its ROM.
Manipulations are used to reposition an obvious
subluxation, such as a pulled elbow or capitate-lunate sub-
Progrcssìvc Lìmìfafìon
Diseases that progressively limit movement can be treated
with joint-play techniques to maintain available motion or
retard progressive mechanical restrictions. The dosage oI
distraction or glide is dictated by the patient`s response to
treatment and the state oI the disease.
Funcfìonal lmmohìlìfy
When a patient cannot Iunctionally move a joint Ior a peri-
od oI time, the joint can be treated with nonstretch gliding
or distraction techniques to maintain available joint play
and prevent the degenerating and restricting eIIects oI
Focus on Evidence
summarized evidence on the eIIectiveness oI
manual therapy (primarily mobilization and manipulation)
on patients with somatic pain syndromes in the low back
region and concluded that there was signiIicantly greater
improvement in patients receiving manual therapy than in
controls. Boissonnault et al.
cited several studies that
demonstrated the eIIectiveness oI manual therapy interven-
tions (deIined as 'a continuum oI skilled passive move-
114 lN0lCAJl0NS F0P 10lNJ M08lLlZAJl0N
Do not stretch a swollen joint with mobilization or
passive stretching techniques. The capsule is already
on a stretch by being distended to accommodate the
extra Iluid. The limited motion is Irom the extra
Iluid and muscle response to pain, not Irom shortened
Gentle oscillating motions that do not stress or stretch
the capsule may help block the transmission oI a pain
stimulus so it is not perceived and may also help
improve Iluid Ilow while maintaining available joint
II the patient`s response to gentle techniques results in
increased pain or joint irritability, the techniques were
applied too vigorously or should not have been done
with the current state oI pathology.
Whenever inIlammation is present, stretching increases
pain and muscle guarding and results in greater tissue dam-
age. Gentle oscillating or distraction motions may tem-
porarily inhibit the pain response. See Chapter 10 Ior an
appropriate approach to treatment when inIlammation is
Condìfìons Pcquìrìng Spccìal
Prccaufìons for Sfrcfchìng
In most cases, joint mobilization techniques are saIer than
passive angular stretching, in which the bony lever is used
to stretch tight tissue and joint compression results. Mobi-
lization may be used with extreme care in the Iollowing
conditions iI the signs and the patient`s response are
Bone disease detectable on radiographs
Unhealed Iracture (depends on the site oI the Iracture
and stabilization provided)
Excessive pain (determine the cause oI pain and modiIy
treatment accordingly)
Hypermobility in associated joints (associated joints
must be properly stabilized so the mobilization Iorce is
not transmitted to them)
Total joint replacements (the mechanism oI the replace-
ment is selI-limiting, and thereIore the mobilization glid-
ing techniques may be inappropriate)
Newly Iormed or weakened connective tissue such as
immediately aIter injury, surgery, or disuse or when the
patient is taking certain medications such as corticos-
teroids (gentle progressive techniques within the toler-
ance oI the tissue help align the developing Iibrils, but
IorceIul techniques are destructive)
Systemic connective tissue diseases such as rheumatoid
arthritis, in which the disease weakens the connective
tissue (gentle techniques may beneIit restricted tissue,
but IorceIul techniques may rupture tissue and result in
ments to the joints and/or related soIt tissues that are
applied at varying speeds and amplitudes¨) in patients with
not only low back pain but also shoulder impingement,
knee osteoarthritis, and cervical pain. However, there is a
lack oI randomized, controlled studies on the eIIects oI
mobilization/manipulation Ior all the peripheral joints.
Case studies that describe patient selection and/or interven-
tions using joint mobilization/manipulation techniques are
identiIied in various chapters in this text (see Chapters 15,
17 to 22).
LlMlJAJl0NS 0F 10lNJ
Mobilization techniques cannot change the disease process
oI disorders such as rheumatoid arthritis or the inIlamma-
tory process oI injury. In these cases, treatment is directed
toward minimizing pain, maintaining available joint play,
and reducing the eIIects oI any mechanical limitations (see
Chapter 11).
The skill oI the therapist aIIects the outcome. The
techniques described in this text are relatively saIe iI direc-
tions are Iollowed and precautions are heeded; but iI these
techniques are used indiscriminately on patients not prop-
erly examined and screened Ior such maneuvers or iI they
are applied too vigorously Ior the condition, joint trauma
or hypermobility may result.
The only true contraindications to stretching techniques are
hypermobility, joint eIIusion, and inIlammation.
The joints oI patients with potential necrosis oI the liga-
ments or capsule should not be stretched.
Patients with painIul hypermobile joints may beneIit
Irom gentle joint-play techniques iI kept within the lim-
its oI motion. Stretching is not done.
1oìnf Effusìon
There may be joint swelling (eIIusion) due to trauma or
disease. Rapid swelling oI a joint usually indicates bleed-
ing in the joint and may occur with trauma or diseases
such as hemophilia. Medical intervention is required Ior
aspiration oI the blood to minimize its necrotizing eIIect on
the articular cartilage. Slow swelling (more than 4 hours)
usually indicates serous eIIusion (a buildup oI excess syn-
ovial Iluid) or edema in the joint due to mild trauma, irrita-
tion, or a disease such as arthritis.
C R A P J E P 5 Periµheral Joinl Mobilizalion 115
Elderly individuals with weakened connective tissue
and diminished circulation (gentle techniques within
the tolerance oI the tissue may be beneIicial to increase
PASSlvE 10lNJ M08lLlZAJl0N
Examìnafìon and Evaluafìon
II the patient has limited or painIul motion, examine and
decide which tissues are limiting Iunction and the state oI
pathology. Determine whether treatment should be directed
primarily toward relieving pain or stretching a joint or soIt
tissue limitation.
0ualìfy of paìn
The quality oI pain when testing the ROM helps determine
the stage oI recovery and the dosage oI techniques used Ior
treatment (see Fig. 10.2).
II pain is experienced before tissue limitationsuch as
the pain that occurs with muscle guarding aIter an acute
injury or during the active stage oI a diseasegentle
pain-inhibiting joint techniques may be used. The same
techniques can also help maintain joint play (see next
section on Grades or Dosages oI Movement). Stretching
under these circumstances is contraindicated.
II pain is experienced concurrentlv with tissue limita-
tionsuch as the pain and limitation that occur when
damaged tissue begins to healthe limitation is treated
cautiously. Gentle stretching techniques speciIic to the
tight structure are used to improve movement gradually
yet not exacerbate the pain by reinjuring the tissue.
II pain is experienced after tissue limitation is met
because oI stretching oI tight capsular or periarticular
tissue, the stiII joint can be aggressively stretched with
joint-play techniques and the periarticular tissue with the
stretching techniques described in Chapter 4.
Capsular Pcsfrìcfìon
The joint capsule is limiting motion and should respond
to mobilization techniques iI the Iollowing signs are
The passive ROM Ior that joint is limited in a capsular
pattern (these patterns are described Ior each peripheral
joint under the respective sections on joint problems in
Chapters 17 through 22).
There is a Iirm capsular end-Ieel when overpressure is
applied to the tissues limiting the range.
There is decreased joint-play movement when mobility
tests (articulations) are perIormed.
An adhered or contracted ligament is limiting motion iI
there is decreased joint play and pain when the Iibers oI
the ligament are stressed; ligaments oIten respond to
joint mobilization techniques iI applied speciIic to their
line oI stress.
Suhluxafìon or 0ìslocafìon
Subluxation or dislocation oI one bony part on another and
loose intra-articular structures that block normal motion
may respond to thrust techniques. Some oI the simpler
manipulations are described in appropriate sections in this
text. Others require more advanced training and are beyond
the scope oI this book.
0radcs or 0osagcs of Movcmcnf
Two systems oI grading dosages Ior mobilization are
0radcd 0scìllafìon Jcchnìqucs (Fìg. 5.0}
Grade I: Small-amplitude rhythmic oscillations are
perIormed at the beginning oI the range.
Grade II: Large-amplitude rhythmic oscillations
are perIormed within the range, not reaching the
Grade III: Large-amplitude rhythmic oscillations are
perIormed up to the limit oI the available motion and
are stressed into the tissue resistance.
Grade IV: Small-amplitude rhythmic oscillations are
perIormed at the limit oI the available motion and
stressed into the tissue resistance.
Grade V: A small-amplitude, high-velocity thrust tech-
nique is perIormed to snap adhesions at the limit oI
the available motion. Thrust techniques used Ior this
purpose require advanced training and are beyond
the scope oI this book.
Fl0uPE 5.0 Reµresen¦a¦|on o¦ çraded osc|||a¦|on ¦ec|n|uues. (/ccj:-c frcr
Gentle grade II distraction applied intermittently may
be used to inhibit pain. Grade II glides may be used
to maintain joint play when ROM is not allowed.
Grade III distractions or glides are used to stretch
the joint structures and thus increase joint play.
This grading system describes only joint-play techniques
that separate (distract) or glide/translate (slide) the joint
When using either grading system, dosages I and II are low
intensity and so do not cause a stretch Iorce on the joint
capsule or surrounding tissue, although, by deIinition, sus-
tained grade II techniques take up the slack oI the tissues
whereas grade II oscillation techniques stay within the
slack. Grades III and IV oscillations and grade III sus-
tained stretch techniques are similar in intensity in that
they all are applied with a stretch Iorce at the limit oI
motion. The diIIerences are related to the rhythm or
speed oI repetition oI the stretch Iorce.
For clarity and consistency, when reIerring to dosages in
this text, the notation graaea oscillations means to use
the dosages as described in the section on graded oscilla-
tion techniques. The notation sustainea graae means to
use the dosages as described in the section on sustained
translatory joint-play techniques.
The choice oI using oscillating or sustained techniques
depends on the patient`s response.
· When dealing with managing pain, either grade I or II
oscillation techniques or slow intermittent grade I or II
sustained joint distraction techniques are recommend-
ed; the patient`s response dictates the intensity and Ire-
quency oI the joint-play technique.
· When dealing with loss oI joint play and thus de-
creased Iunctional range, sustained techniques ap-
plied in a cyclic manner are recommended; the
longer the stretch Iorce can be maintained, the
greater the creep and plastic deIormation oI the
connective tissue.
· When attempting to maintain available range by using
joint-play techniques, either grade II oscillating or sus-
tained grade II techniques can be used.
Posìfìonìng and Sfahìlìzafìon
The patient and the extremity to be treated should be
positioned so the patient can relax. To relax the muscles
crossing the joint, techniques oI inhibition (see Chapter
4) may be appropriately used prior to or between joint
mobilization techniques.
Examination oI joint play and the Iirst treatment are ini-
tially perIormed in the resting position Ior that joint so
the greatest capsule laxity is possible. In some cases,
the position to use is the one in which the joint is least
Grades I and II are primarily used Ior treating joints
limited by pain. The oscillations may have an inhi-
bitory eIIect on the perception oI painIul stimuli by
repetitively stimulating mechanoreceptors that block
nociceptive pathways at the spinal cord or brain stem
These nonstretch motions help move syn-
ovial Iluid to improve nutrition to the cartilage.
Grades III and IV are primarily used as stretching
The oscillations may be perIormed using physiological
(osteokinematic) motions or joint-play (arthrokinematic)
Susfaìncd Jranslafory 1oìnf-Play Jcchnìqucs (Fìg. 5.10}
Grade I (loosen): Small-amplitude distraction is applied
where no stress is placed on the capsule. It equalizes
cohesive Iorces, muscle tension, and atmospheric pres-
sure acting on the joint.
Grade II (tighten): Enough distraction or glide is
applied to tighten the tissues around the joint.
called this 'taking up the slack.¨
Grade III (stretch): A distraction or glide is applied
with an amplitude large enough to place stretch on the
joint capsule and surrounding periarticular structures.
C R A P J E P 5 Periµheral Joinl Mobilizalion 117
Fl0uPE 5.10 Reµresen¦a¦|on o¦ sus¦a|ned ¦rans|a¦or, ¦o|n¦-µ|a, ¦ec|n|uues.
(/ccj:-c frcr |c|:-r¹crr.
Grade I distraction is used with all gliding motions and
may be used Ior relieI oI pain.
Grade II distraction is used Ior the initial treatment to
determine how sensitive the joint is. Once the joint reac-
tion is known, the treatment dosage is increased or
decreased accordingly.
painIul. With progression oI treatment, the joint is posi-
tioned at or near the end oI the available range prior to
application oI the mobilization Iorce. This places the
restricting tissue in its most lengthened position where
the stretch Iorce can be more speciIic and eIIective.
Firmly and comIortably stabilize one joint partner, usual-
ly the proximal bone. A belt, one oI the therapist`s
hands, or an assistant holding the part may provide stabi-
lization. Appropriate stabilization prevents unwanted
stress to surrounding tissues and joints and makes the
stretch Iorce more speciIic and eIIective.
Jrcafmcnf Forcc and 0ìrccfìon of Movcmcnf
The treatment Iorce (either gentle or strong) is applied as
close to the opposing joint surIace as possible. The larg-
er the contact surIace, the more comIortable is the
patient with the procedure. For example, instead oI Iorc-
ing with your thumb, use the Ilat surIace oI your hand.
The direction oI movement during treatment is either
parallel or perpendicular to the treatment plane. Treat-
ment plane was described by Kaltenborn
as a plane
perpendicular to a line running Irom the axis oI rotation
to the middle oI the concave articular surIace. The plane
is in the concave partner, so its position is determined by
the position oI the concave bone (Fig. 5.11).
Distraction techniques are applied perpendicular to the
treatment plane. The entire bone is moved so the joint
surIaces are separated.
Gliding techniques are applied parallel to the treat-
ment plane. The direction oI gliding is easily deter-
mined by using the convex-concave rule (described
earlier in the chapter). II the surIace oI the moving
bony partner is convex, the treatment glide should be
opposite to the direction in which the bone swings.
II the surIace oI the moving bony partner is concave,
the treatment glide should be in the same direction
(see Fig. 5.5).
The entire bone is moved so there is gliding oI one joint
surIace on the other. The bone should not be used as a
lever; it should have no arcing motion (swing), which
would cause rolling and thus compression oI the joint
lnìfìafìon and Progrcssìon
of Jrcafmcnf (Fìg. 5.12}
1. The initial treatment is the same whether treating
to decrease pain or increase joint play. The purpose
is to determine joint reactivity beIore proceeding.
Use a sustained grade II distraction oI the joint
surIaces with the joint held in resting position
or the position oI greatest relaxation.
Note the
immediate joint response relative to irritability and
2. The next day, evaluate joint response or have the patient
report the response at the next visit.
· II there is increased pain and sensitivity, reduce the
amplitude oI treatment to grade I oscillations.
· II the joint is the same or better, perIorm either oI the
Iollowing: Repeat the same maneuver iI the goal oI
treatment is to maintain joint play, or progress the
maneuver to stretching techniques iI the goal oI treat-
ment is to increase joint play.
3. To maintain joint play by using gliding techniques when
ROM techniques are contraindicated or not possible Ior
a period oI time, use sustained grade II or grade II oscil-
lation techniques.
4. To progress the stretch technique, move the bone to
the end oI the available ROM, then apply a sustained
grade III distraction or glide technique. Progressions
include prepositioning the bone at the end oI the avail-
able range and rotating it prior to applying grade III
distraction or glide techniques. The direction oI the
glide and rotation is dictated by the joint mechanics.
For example, laterally rotate the humerus as shoulder
abduction is progressed; medially rotate the tibia as
knee Ilexion is progressed.
Distraction Distraction
Fl0uPE 5.11 !rea¦uen¦ µ|ane (!.P.} |s a¦ r|ç|¦ anç|es ¦o a ||ne drawn ¦rou
¦|e az|s o¦ ro¦a¦|on ¦o ¦|e cen¦er o¦ ¦|e concave ar¦|cu|a¦|nç sur¦ace and ||es
|n ¦|e concave sur¦ace. Jo|n¦ ¦rac¦|on (d|s¦rac¦|on} |s aµµ||ed µerµend|cu|ar ¦o
and ç||des µara||e| ¦o ¦|e ¦rea¦uen¦ µ|ane.
Grades II and III are smooth, regular oscillations at 2 or
3 per second Ior 1 to 2 minutes.
Vary the speed oI oscillations Ior diIIerent eIIects such
as low amplitude and high speed to inhibit pain or slow
speed to relax muscle guarding.
For painIul joints, apply intermittent distraction Ior 7
to 10 seconds with a Iew seconds oI rest in between Ior
several cycles. Note the response and either repeat or
For restricted joints, apply a minimum oI a 6-second
stretch Iorce Iollowed by partial release (to grade I or II),
then repeat with slow, intermittent stretches at 3- to 4-
second intervals.
Pafìcnf Pcsponsc
Stretching maneuvers usually cause soreness. PerIorm
the maneuvers on alternate days to allow the soreness to
decrease and tissue healing to occur between stretching
sessions. The patient should perIorm ROM into any
newly gained range during this time. II there is increased
pain aIter 24 hours, the dosage (amplitude) or duration
oI treatment was too vigorous. Decrease the dosage or
duration until the pain is under control.
The patient`s joint and ROM should be reassessed aIter
treatment and again beIore the next treatment. Alter-
ations in treatment are dictated by the joint response.
Jofal Program
Mobilization techniques are one part oI a total treatment
program when there is decreased Iunction. II muscles or
connective tissues are also limiting motion, inhibition and
Focus on Evidence
A cadavaric study demonstrated improvement in gleno-
humeral abduction ROM when dorsal and ventral transla-
tional glides were applied at the end oI the range but not
when applied in the resting position.
5. Hints
· Warm the tissue around the joint prior to stretching.
Modalities, massage, or gentle muscle contractions
increase the circulation and warm the tissues.
· Muscle relaxation techniques and oscillation techniques
may inhibit muscle guarding and should be alternated
with the stretching techniques, iI necessary.
· When using grade III gliding techniques, a grade I
distraction should be used with it. A grade II or III
distraction should not be used with a grade III glide
to avoid excessive trauma to the joint.
· II gliding in the restricted direction is too painIul, begin
gliding mobilizations in the painless direction. Progress
to gliding in the restricted direction when mobility
improves a little and it is not painIul.
· When applying stretching techniques, move the bony
partner through the available range oI joint play Iirst,
that is, 'take up the slack.¨ When tissue resistance is
Ielt, apply the stretch Iorce against the restriction.
· Incorporate MWM techniques (described later in the
chapter) as part oI the total approach to treatment.
Spccd, Phyfhm, and 0urafìon of Movcmcnfs
Grades I and IV are usually rapid oscillations, like man-
ual vibrations.
C R A P J E P 5 Periµheral Joinl Mobilizalion 110
Ìnitial Treatment:
Day Two: Patient Response
Sustained Grade ll Joint Traction in R.P.
Ìncreased pain
or inflammation
same or better
Grade l oscillations in R.P.
to control pain
Sustained Grade ll
traction or glides in
R.P. to maintain joint
D.C. when patient
can move own
Ìf gliding in
restricted direction
painful, glide in
painless direction
Sustained Grade lll
techniques to increase
joint play
Ìf restricted without
pain glide in restricted
direction at end of
available range
Progress by adding
rotation prior to
traction or glide
Grade ll oscillations
Fl0uPE 5.12 ln|¦|a¦|on and µroçress|on o¦ ¦rea¦uen¦.
passive stretching techniques are alternated with joint
mobilization during the same treatment session. Therapy
should also include appropriate ROM, strengthening, and
Iunctional exercises so the client learns eIIective control
and use oI the gained mobility (Box 5.1).
Brian Mulligan`s concept oI mobilization with movement
(MWM) is the natural continuance oI progression in the
development oI manual therapy Irom active selI-stretching
exercises, to therapist-applied passive physiological move-
ment, to passive accessory mobilization techniques.
Mobilization with movement is the concurrent application
oI pain-Iree accessory mobilization with active and/or pas-
sive physiological movement.
Passive end-range over-
pressure or stretching is then applied without pain as a
barrier. These techniques are applicable when:
No contraindication Ior manual therapy exists (described
earlier in the chapter).
A Iull orthopedic scanning examination has been com-
pleted, and evaluation oI the results indicate local mus-
culoskeletal pathology.
A speciIic biomechanical analysis reveals localized loss
oI movement and/or pain associated with Iunction.
No pain is produced during or immediately aIter applica-
tion oI the technique.
Prìncìplcs of MWM ìn Clìnìcal Pracfìcc
One or more comparable signs are identiIied during the
A comparable sign is a positive test sign
that can be repeated aIter a therapeutic maneuver to
determine the eIIectiveness oI the maneuver. For exam-
ple, a comparable sign may include loss oI joint play
movement, loss oI ROM, or pain associated with move-
ment during speciIic Iunctional activities such as lat-
eral elbow pain with resisted wrist extension, painIul
restriction oI ankle dorsiIlexion, or pain with overhead
A passive joint mobilization is applied as described in
the previous section Iollowing the principles oI
This accessory glide or distraction per-
Iormed parallel or perpendicular to the treatment plane
must be pain-Iree.
Utilizing knowledge oI joint anatomy and mechanics,
a sense oI tissue tension, and sound clinical reasoning,
the therapist investigates various combinations oI paral-
lel or perpendicular accessory glides to Iind the pain-Iree
direction and grade oI accessory movement. This may be
a glide, spin, distraction, or combination oI movements.
While the therapist sustains the pain-Iree accessory
mobilization, the patient is requested to perIorm the
comparable sign. The comparable sign should now be
signiIicantly improved; that is, there should be increased
ROM, and the motion should be free of the original
The therapist must continuously monitor the patient`s
reaction to ensure no pain is produced. Failure to
improve the comparable sign would indicate that the
therapist has not Iound the correct direction oI accessory
mobilization or the grade oI movement or that the tech-
nique is not indicated.
The previously restricted and/or painIul motion or activ-
ity is repeated 6 to 10 times by the patient while the
therapist continues to maintain the appropriate accessory
mobilization. Further gains are expected with repetition
during a treatment session, particularly when pain-free
passive overpressure is applied to achieve end-range
Paìn as fhc 0uìdc
SuccessIul MWM techniques should render the compara-
ble sign painless while signiIicantly improving Iunction
during the application oI the technique. SelI-treatment is
oIten possible using MWM principles with sports-type
adhesive tape and/or the patient providing the mobilization
component oI the MWM concurrent with the active physi-
ological movement.
Having restored articular Iunction
with MWMs, the therapist progresses the client through
the ensuing rehabilitation sequences oI the recovery
oI muscular power, endurance, and neural control. Sus-
tained improvements are necessary to justiIy ongoing
Techniques applicable to the extremity joints are described
throughout this text in the treatment sections Ior various
conditions (see Chapters 17 through 22).
80X 5.1 Suggcsfcd Scqucncc of Jrcafmcnf fo
0aìn and Pcìnforcc Funcfìonal Mohìlìfy
1. Waim llc lissucs.
2. Rclax llc musclcs.
- Eold-iclax inlibilion lcclniquc
- Ciadc l oi ll joinl oscillalion lcclniqucs
J. 1oinl mobilizalion sliclclcs.
- Posilion and dosagc foi lcvcl of lissuc lolciancc
4. Passivc sliclcl pciiailiculai lissucs.
5. Palicnl aclivcly uscs ncw iangc.
- Rccipiocal inlibilion
- Aclivc R0M
- Funclional aclivilics
6. Mainlain ncw iangc, palicnl insliuclion.
- Sclf-sliclcling
- Aulo-mobilizalion
- Aclivc, icsislivc R0M
- Funclional aclivilics using llc ncw iangc
Resting Position
The shoulder is abducted 55 , horizontally adducted 30 ,
and rotated so the Iorearm is in the horizontal plane.
Treatment Plane
The treatment plane is in the glenoid Iossa and moves with
the scapula.
Fixate the scapula with a belt or have an assistant help.
0lcnohumcral 0ìsfracfìon (Fìg. 5.14}
Testing; initial treatment (sustained grade II); pain control
(grade I or II oscillations); general mobility (sustained
grade III).
Jhcorcfìcal Framcwork
Mulligan postulated a positional Iault model to explain
the results gained through his concept. Alternately, inap-
propriate joint tracking mechanisms due to an altered
instantaneous axis oI rotation and neurophysiological
response models have also been considered.
Iurther details oI the application oI the Mulligan concept
as it applies to the spine and extremities, reIer to Manual
Therapv, 'NAGS,` 'SNAGS,` 'MWMs,` Etc.
Focus on Evidence
Early research on the MWM approach conIirms its bene-
Iits; however, the mechanism by which it aIIects the mus-
culoskeletal system, whether mechanical or physiological,
has yet to be Iully determined.
A study by
Paungmail et al.
measured a signiIicant reduction in pain,
increased grip strength, and increased sympathetic nervous
system response immediately Iollowing MWM Ior chronic
lateral epicondylalgia compared with a placebo interven-
tion, results that were similar to studies oI spinal manipula-
tion. They interpreted this to imply that there is a
multisystem response to manipulation whether the spine or
the elbow is manipulated.
The Iollowing are suggested joint distraction and gliding
techniques Ior use by entry-level therapists and those
attempting to gain a Ioundation in joint mobilization. A
variety oI adaptations can be made Irom these techniques.
Some adaptations are described in the respective chapters
where speciIic impairments and interventions are discussed
(see Chapters 17 through 22). The distraction and glide
techniques should be applied with respect to the dosage,
Irequency, progression, precautions, and procedures as
described in the previous sections.
N 0 J E . !erns such as µroxinal hand, dislal hand, laleral
hand, or olher descriµlive lerns indicale lhal lhe lheraµisl
should use lhe hand lhal is nore µroxinal, dislal, or laleral
lo lhe µalienl or lhe µalienl's exlrenily.
Shouldcr 0ìrdlc Complcx (Fìg. 5.18}
N 0 J E . !o qain full elevalion of lhe hunerus, lhe accessory
and conµonenl nolions of clavicular elevalion and rolalion,
scaµular rolalion, and exlernal rolalion of lhe hunerus as
well as adequale |oinl µlay anleriorly and inferiorly are nec-
essary. !he clavicular and scaµular lechniques are described
followinq lhe qlenohuneral |oinl lechniques. For a review of
lhe nechanics of lhe shoulder conµlex, see Chaµler 17.
0lcnohumcral 1oìnf
The concave glenoid Iossa receives the convex humeral
C R A P J E P 5 Periµheral Joinl Mobilizalion 121
Fl0uPE 5.18 bones and ¦o|n¦s o¦ ¦|e s|ou|der ç|rd|e couµ|ez.
Fl0uPE 5.14 C|eno|uuera| ¦o|n¦. d|s¦rac¦|on |n res¦|nç µos|¦|on. No¦e ¦|a¦
¦|e ¦orce |s µerµend|cu|ar ¦o ¦|e ¦rea¦uen¦ µ|ane |n ¦|e ç|eno|d ¦ossa.
Patient Position
Supine, with arm in the resting position. Support the Iore-
arm between your trunk and elbow.
Hand Placement
Use the hand nearer the part being treated (e.g., leIt hand
iI treating the patient`s leIt shoulder) and place it in the
patient`s axilla with your thumb just distal to the joint
margin anteriorly and Iingers posteriorly.
Your other hand supports the humerus Irom the lateral
Mobilizing Force
With the hand in the axilla, move the humerus laterally.
N 0 J E . !he enlire arn noves in a lranslaloric nolion
away fron lhe µlane of lhe qlenoid fossa. 0islraclions nay
be µerforned wilh lhe hunerus in any µosilion (see Fiqs.
6.17, 6.10, and 17.20). You nusl be aware of lhe anounl of
scaµular rolalion and ad|usl lhe dislraclion force aqainsl
lhe hunerus so il is µerµendicular lo lhe µlane of lhe qle-
noid fossa.
0lcnohumcral Caudal 0lìdc, Pcsfìng Posìfìon (Fìg. 5.15}
To increase abduction (sustained grade III); to reposition
the humeral head iI superiorly positioned.
Mobilizing Force
With the superiorly placed hand, glide the humerus in an
inIerior direction.
0R Caudal 0lìdc: Alfcrnafc
Hand Placement
Same as Ior distraction (see Fig. 5.14).
Mobilizing Force
The Iorce comes Irom the hand around the arm,
pulling caudally as you shiIt your body weight
N 0 J E . !his qlide is also called lonq-axis lraclion.
0lcnohumcral Caudal 0lìdc Progrcssìon (Fìg. 5.18}
To increase abduction.
Fl0uPE 5.15 C|eno|uuera| ¦o|n¦. cauda| ç||de |n ¦|e res¦|nç µos|¦|on. No¦e
¦|a¦ ¦|e d|s¦rac¦|on ¦orce |s aµµ||ed u, ¦|e |and |n ¦|e az|||a, and ¦|e cauda|
ç||de ¦orce |s ¦rou ¦|e |and suµer|or ¦o ¦|e |uuera| |ead.
Patient Position
Same as Ior distraction.
Hand Placement
Place one hand in the patient`s axilla to provide a grade
I distraction.
The web space oI your other hand is placed just distal to
the acromion process.
Fl0uPE 5.18 C|eno|uuera| ¦o|n¦. cauda| ç||de w|¦| ¦|e s|ou|der near 90 .
Patient Position
Supine or sitting, with the arm abducted to the end oI its
available range.
External rotation oI the humerus should be added to the
end-range position as the arm approaches and goes
beyond 90 .
Therapist Position and Hand Placement
With the patient supine, stand Iacing the patient`s Ieet
and stabilize the patient`s arm against your trunk with
the hand Iarthest Irom the patient. Slight lateral motion
Mobilizing Force
With the hand on the proximal humerus, glide the
humerus in a progressively anterior direction against the
inIerior Iolds oI the capsule in the axilla.
The direction oI Iorce with respect to the patient`s body
depends on the amount oI upward rotation and protrac-
tion oI the scapula.
0lcnohumcral Posfcrìor 0lìdc,
Pcsfìng Posìfìon (Fìg. 5.18}
To increase Ilexion; to increase internal rotation.
oI your trunk provides grade I distraction. With the
patient sitting, Iace the patient and cradle the distal
humerus with the hand closest to the patient; this hand
provides a grade I distraction.
Place the web space oI your other hand just distal to the
acromion process on the proximal humerus.
Mobilizing Force
With the hand on the proximal humerus, glide the humerus
in an inIerior direction.
0lcnohumcral Elcvafìon Progrcssìon (Fìg. 5.17}
To increase elevation beyond 90 oI abduction.
C R A P J E P 5 Periµheral Joinl Mobilizalion 128
Fl0uPE 5.18 C|eno|uuera| ¦o|n¦. µos¦er|or ç||de |n ¦|e res¦|nç µos|¦|on.
Fl0uPE 5.17 C|eno|uuera| ¦o|n¦. e|eva¦|on µroçress|on |n ¦|e s|¦¦|nç µos|-
¦|on. !||s |s used w|en ¦|e rançe |s çrea¦er ¦|an 90 . No¦e ¦|e ez¦erna||,
ro¦a¦ed µos|¦|on o¦ ¦|e |uuerus, µressure aça|ns¦ ¦|e |ead o¦ ¦|e |uuerus |s
¦oward ¦|e az|||a.
Patient Position
Supine or sitting, with the arm abducted and externally
rotated to the end oI its available range.
Therapist Position and Hand Placement
Hand placement is the same as Ior caudal glide pro-
Adjust your body position so the hand applying the
mobilizing Iorce is aligned with the treatment plane.
With the hand grasping the elbow, apply a grade I
distraction Iorce.
Patient Position
Supine, with the arm in resting position.
Therapist Position and Hand Placement
Stand with your back to the patient, between the
patient`s trunk and arm.
Support the arm against your trunk, grasping the distal
humerus with your lateral hand. This position provides
grade I distraction to the joint.
Place the lateral border oI your top hand just distal
to the anterior margin oI the joint, with your Iingers
pointing superiorly. This hand gives the mobilizing
Mobilizing Force
Glide the humeral head posteriorly by moving the entire
arm as you bend your knees.
Patient Position
Supine, with the arm Ilexed to 90 and internally rotated
and with the elbow Ilexed. The arm may also be placed in
horizontal adduction.
Hand Placement
Place padding under the scapula Ior stabilization.
Place one hand across the proximal surIace oI the
humerus to apply a grade I distraction.
Place your other hand over the patient`s elbow.
A belt placed around your pelvis and the patient`s
humerus may be used to apply the distraction Iorce.
Mobilizing Force
Glide the humerus posteriorly by pushing down at the
elbow through the long axis oI the humerus.
0lcnohumcral Anfcrìor 0lìdc,
Pcsfìng Posìfìon (Fìg. 5.20}
To increase extension; to increase external rotation.
Fl0uPE 5.20 C|eno|uuera| ¦o|n¦. an¦er|or ç||de |n ¦|e res¦|nç µos|¦|on.
Fl0uPE 5.10 C|eno|uuera| ¦o|n¦. µos¦er|or ç||de µroçress|on. 0ne |and (/}
or a ue|¦ (3} |s used ¦o ezer¦ a çrade 1 d|s¦rac¦|on ¦orce.
0lcnohumcral Posfcrìor 0lìdc Progrcssìon (Fìg. 5.10}
To increase posterior gliding when Ilexion approaches 90 ;
to increase horizontal adduction.
Patient Position
Prone, with the arm in resting position over the edge oI the
treatment table, supported on your thigh. Stabilize the
acromion with padding. Supine position may also be used.
Because oI the danger oI subluxation when applying an
anterior glide with the humerus externally rotated, use a
distraction progression or elevation progression to gain
Distraction progression: Begin with the shoulder in rest-
ing position; externally rotate the humerus to end range
and then apply a grade III distraction perpendicular to
the treatment plane in the glenoid Iossa.
Elevation progression (see Fig. 5.17). This technique
incorporates end-range external rotation.
Acromìoclavìcular 1oìnf: Anfcrìor 0lìdc (Fìg. 5.22}
To increase mobility oI the joint.
Therapist Position and Hand Placement
Stand Iacing the top oI the table with the leg closer to
the table in a Iorward stride position.
Support the patient`s arm against your thigh with your
outside hand; the arm positioned on your thigh provides
a grade I distraction.
Place the ulnar border oI your other hand just distal to
the posterior angle oI the acromion process, with your
Iingers pointing superiorly; this hand gives the mobiliz-
ing Iorce.
Mobilizing Force
Glide the humeral head in an anterior and slightly medial
direction. Bend both knees so the entire arm moves
P P E C A u J l 0 N . 0o nol lifl lhe arn al lhe elbow
and lhereby cause anqulalion of lhe hunerus: Such
anqulalion could lead lo anlerior subluxalion or dislo-
calion of lhe huneral head. 0o nol use lhis µosilion lo
µroqress exlernal rolalion. Placinq lhe shoulder in 00
abduclion wilh exlernal rolalion and aµµlyinq an
anlerior qlide nay cause anlerior subluxalion of lhe
huneral head.
0lcnohumcral Exfcrnal Pofafìon
Progrcssìons (Fìg. 5.21}
To increase external rotation.
C R A P J E P 5 Periµheral Joinl Mobilizalion 125
Fl0uPE 5.21 C|eno|uuera| ¦o|n¦. d|s¦rac¦|on ¦or ez¦erna| ro¦a¦|on µro-
çress|on. No¦e ¦|a¦ ¦|e |uuerus |s µos|¦|oned |n ¦|e res¦|nç µos|¦|on w|¦|
uaz|uuu ez¦erna| ro¦a¦|on µr|or ¦o ¦|e aµµ||ca¦|on o¦ d|s¦rac¦|on s¦re¦c|
Fl0uPE 5.22 Acrou|oc|av|cu|ar ¦o|n¦. an¦er|or ç||de.
Fixate the scapula with your more lateral hand around the
acromion process.
Patient Position
Sitting or prone.
Hand Placement
With the patient sitting, stand behind the patient and sta-
bilize the acromion process with the Iingers oI your lat-
eral hand.
The thumb oI your other hand pushes downward through
the upper trapezius and is placed posteriorly on the clav-
icle, just medial to the joint space.
With the patient prone, stabilize the acromion with a
towel roll under the shoulder.
Mobilizing Force
Your thumb pushes the clavicle anteriorly.
Sfcrnoclavìcular 1oìnf
The proximal articulating surIace oI the clavicle is convex
superiorly/inIeriorly and concave anteriorly/posteriorly.
Patient Position and Stabilization
Supine; the thorax provides stability to the sternum.
Sfcrnoclavìcular Posfcrìor 0lìdc
and Supcrìor 0lìdc (Fìg. 5.28}
Posterior glide to increase retraction; superior glide to
increase depression oI the clavicle.
Hand Placement
Your Iingers are placed superiorly and thumb inIeriorly
around the clavicle.
Mobilizing Force
The Iingers and thumb liIt the clavicle anteriorly Ior an
anterior glide.
The Iingers press inIeriorly Ior a caudal glide.
Scapulofhoracìc Mohìlìzafìon (Fìg. 5.25}
The scapulothoracic articulation is not a true joint, but the
soIt tissue is stretched to obtain normal shoulder girdle
Fl0uPE 5.25 Scaµu|o¦|orac|c ar¦|cu|a¦|on. e|eva¦|on, deµress|on, µro¦rac¦|on,
re¦rac¦|on, uµward and downward ro¦a¦|ons, and w|nç|nç.
Fl0uPE 5.28 S¦ernoc|av|cu|ar ¦o|n¦. µos¦er|or and suµer|or ç||des. (/} Press
down w|¦| ¦|e ¦|uuu ¦or µos¦er|or ç||de. (3} Press uµward w|¦| ¦|e |ndez ¦|n-
çer ¦or suµer|or ç||de.
Fl0uPE 5.24 S¦ernoc|av|cu|ar ¦o|n¦. an¦er|or and |n¦er|or ç||des. (/} Pu|| ¦|e
c|av|c|e uµward ¦or an an¦er|or ç||de. (3} Press cauda|ward w|¦| ¦|e cur|ed
¦|nçers ¦or an |n¦er|or ç||de.
Hand Placement
Place your thumb on the anterior surIace oI the proximal
end oI the clavicle.
Flex your index Iinger and place the middle phalanx
along the caudal surIace oI the clavicle to support the
Mobilizing Force
Posterior glide: Push with your thumb in a posterior
Superior glide: Push with your index Iinger in a superior
Sfcrnoclavìcular Anfcrìor 0lìdc
and Caudal (lnfcrìor} 0lìdc (Fìg. 5.24}
Anterior glide to increase protraction; caudal glide to
increase elevation oI the clavicle.
Treatment Plane
The treatment plane is in the olecranon Iossa, angled ap-
proximately 45 Irom the long axis oI the ulna (Fig. 5.27).
To increase scapular motions oI elevation, depression, pro-
traction, retraction, rotation, upward and downward rota-
tions, and winging.
Patient Position
II there is considerable restriction in mobility, begin
prone and progress to side-lying, with the patient
Iacing you.
Support the weight oI the patient`s arm by draping it
over your inIerior arm and allowing it to hang so the
scapular muscles are relaxed.
Hand Placement
Place your superior hand across the acromion process to
control the direction oI motion.
With the Iingers oI your inIerior hand, scoop under the
medial border and inIerior angle oI the scapula.
Mobilizing Force
Move the scapula in the desired direction by liIting Irom
the inIerior angle or by pushing on the acromion process.
Elhow and Forcarm Complcx (Fìg. 5.28}
N 0 J E : !he elbow and forearn conµlex consisls of four
|oinls: huneroulnar, huneroradial, µroxinal radioulnar and
dislal radioulnar. For full elbow flexion and exlension,
accessory nolions of varus and valqus (wilh radial and ulnar
qlides) are necessary. !he lechniques for each of lhe |oinls
as well as accessory nolions are described in lhis seclion.
For a review of lhe |oinl nechanics, see Chaµler 18.
C R A P J E P 5 Periµheral Joinl Mobilizalion 127
Fl0uPE 5.28 bones and ¦o|n¦s o¦ ¦|e e|uow couµ|ez.
Fl0uPE 5.27 La¦era| v|ew o¦ ¦|e |uuerou|nar ¦o|n¦, deµ|c¦|nç ¦|e ¦rea¦uen¦
µ|ane (!.P.}.
Fixate the humerus against the treatment table with a belt
or use an assistant to hold it. The patient may roll onto his
or her side and Iixate the humerus with the contralateral
hand iI muscle relaxation can be maintained around the
elbow joint being mobilized.
Rumcroulnar 0ìsfracfìon and Progrcssìon (Fìg. 5.28A}
Testing; initial treatment (sustained grade II); pain control
(grade I or II oscillation); to increase Ilexion or extension
(grade III or IV).
Rumcroulnar Arfìculafìon
The convex trochlea articulates with the concave olecranon
Resting Position
Elbow is Ilexed 70 , and Iorearm is supinated 10 .
Fl0uPE 5.28 huuerou|nar ¦o|n¦. (/} d|s¦rac¦|on and
Patient Position
Supine, with the elbow over the edge oI the treatment table
or supported with padding just proximal to the olecranon
process. Rest the patient`s wrist against your shoulder,
allowing the elbow to be in resting position Ior the initial
treatment. To stretch into either Ilexion or extension, posi-
tion the joint at the end oI its available range.
Hand Placement
When in the resting position or at end-range Ilexion, place
the Iingers oI your medial hand over the proximal ulna on
the volar surIace; reinIorce it with your other hand. When
at end-range extension, stand and place the base oI your
proximal hand over the proximal portion oI the ulna and
support the distal Iorearm with your other hand.
Mobilizing Force
Force against the proximal ulna at a 45 angle to the shaIt
oI the bone.
Rumcroulnar 0ìsfal 0lìdc (Fìg. 5.288}
To increase Ilexion.
Rumcroulnar Padìal 0lìdc
To increase varus. This is an accessory motion oI the joint
that accompanies elbow Ilexion and is thereIore used to
progress Ilexion.
Patient Position
Side-lying on the arm to be mobilized, with the shoul-
der laterally rotated and the humerus supported on the
Begin with the elbow in resting position; progress to
end-range Ilexion.
Hand Placement
Place the base oI your proximal hand just distal to the
elbow; support the distal Iorearm with your other hand.
Mobilizing Force
Force against the ulna in a radial direction.
Rumcroulnar ulnar 0lìdc
To increase valgus. This is an accessory motion oI the joint
that accompanies elbow extension and is thereIore used to
progress extension.
Patient Position
Same as Ior radial glide except a block or wedge is
placed under the proximal Iorearm Ior stabilization
(using distal stabilization).
Initially, the elbow is placed in resting position and is
progressed to end-range extension.
Mobilizing Force
Force against the distal humerus in a radial direction, caus-
ing the ulna to glide ulnarly.
Rumcroradìal Arfìculafìon
The convex capitulum articulates with the concave radial
head (see Fig. 5.26).
Resting Position
Elbow is extended, and Iorearm is supinated to the end oI
the available range.
Treatment Plane
The treatment plane is in the concave radial head perpendi-
cular to the long axis oI the radius.
Fixate the humerus with one oI your hands.
Rumcroradìal 0ìsfracfìon (Fìg. 5.20}
To increase mobility oI the humeroradial joint; to mani-
pulate a pushed elbow (proximal displacement oI the
Fl0uPE 5.28 (confìnucd} (3} d|s¦rac¦|on w|¦| d|s¦a| ç||de (scooµ uo¦|on}.
Patient Position and Hand Placement
Supine, with the elbow over the edge oI the treatment
table. Begin with the elbow in resting position. Progress by
positioning it at the end range oI Ilexion. Place the Iingers
oI your medial hand over the proximal ulna on the volar
surIace; reinIorce it with your other hand.
Mobilizing Force
First apply a distraction Iorce to the joint at a 45 angle to
the ulna, then while maintaining the distraction, direct the
Iorce in a distal direction along the long axis oI the ulna
using a scooping motion.
Patient Position
Supine or sitting with the elbow extended and supinated to
the end oI the available range.
Hand Placement
Stabilize the humerus with your hand that is on the
medial side oI the patient`s arm.
Place the palmar surIace oI your lateral hand on the
volar aspect and your Iingers on the dorsal aspect oI the
radial head.
Mobilizing Force
Move the radial head dorsally with the palm oI your
hand or volarly with your Iingers.
II a stronger Iorce is needed Ior the volar glide, realign
your body and push with the base oI your hand against
the dorsal surIace in a volar direction.
Rumcroradìal Comprcssìon (Fìg. 5.81}
To reduce a pulled elbow subluxation.
Patient Position
Supine or sitting, with the arm resting on the treatment
Therapist Position and Hand Placement
Position yourselI on the ulnar side oI the patient`s Iore-
arm so you are between the patient`s hip and upper
Stabilize the patient`s humerus with your superior hand.
Grasp around the distal radius with the Iingers and
thenar eminence oI your inIerior hand. Be sure your are
not grasping around the distal ulna.
Mobilizing Force
Pull the radius distally (long-axis traction causes joint
Rumcroradìal 0orsaljvolar 0lìdcs (Fìg. 5.80}
Dorsal glide head oI the radius to increase elbow exten-
sion; volar glide to increase Ilexion.
C R A P J E P 5 Periµheral Joinl Mobilizalion 120
Fl0uPE 5.20 huuerorad|a| ¦o|n¦. d|s¦rac¦|on.
Fl0uPE 5.80 huuerorad|a| ¦o|n¦. dorsa| and vo|ar ç||des. !||s ua, a|so ue
done s|¦¦|nç, as |n l|çure o.32, w|¦| ¦|e e|uow µos|¦|oned |n ez¦ens|on and ¦|e
|uuerus s¦au|||zed u, ¦|e µroz|ua| |and (ra¦|er ¦|an ¦|e u|na}.
Fl0uPE 5.81 huuerorad|a| ¦o|n¦. couµress|on uan|µu|a¦|on. !||s |s a uu|c|
¦|rus¦ w|¦| s|uu|¦aneous suµ|na¦|on and couµress|on o¦ ¦|e rad|us.
Patient Position
Sitting or supine.
Hand Placement
Approach the patient right hand to right hand, or leIt
hand to leIt hand. Stabilize the elbow posteriorly with
the other hand. II supine, the stabilizing hand is under
the elbow supported on the treatment table.
Place your thenar eminence against the patient`s thenar
eminence (locking thumbs).
Mobilizing Force
Simultaneously, extend the patient`s wrist, push against the
thenar eminence, and compress the long axis oI the radius
while supinating the Iorearm.
N 0 J E . !o reµlace an acule subluxalion, a quick nolion
(lhrusl) is used.
Proxìmal Padìoulnar 1oìnf,
0orsaljvolar 0lìdcs (Fìg. 5.82}
The convex rim oI the radial head articulates with the con-
cave radial notch on the ulna (see Fig. 5.26).
Mobilizing Force
Force the radial head volarly by pushing with your palm
or dorsally by pulling with your Iingers.
II a stronger Iorce is needed Ior the dorsal glide, move
around to the other side oI the patient, switch hands, and
push Irom the volar surIace with the base oI your hand
against the radial head.
0ìsfal Padìoulnar 1oìnf, 0orsaljvolar 0lìdcs (Fìg. 5.88}
The concave ulnar notch oI the radius articulates with the
convex head oI the ulna.
Fl0uPE 5.82 Proz|ua| rad|ou|nar ¦o|n¦. dorsa| and vo|ar ç||des.
Resting Position
The elbow is Ilexed 70 and the Iorearm supinated 35 .
Treatment Plane
The treatment plane is in the radial notch oI the ulna, par-
allel to the long axis oI the ulna.
Proximal ulna is stabilized.
Dorsal glide to increase pronation; volar glide to increase
Patient Position
Sitting or supine, with the elbow and Iorearm in resting
Progress by placing the Iorearm at the limit oI the range
oI pronation prior to administering the dorsal glide or at
the limit oI the range oI supination prior to administering
the volar glide.
Hand Placement
Fixate the ulna with your medial hand around the medial
aspect oI the Iorearm.
Place your other hand around the head oI the radius with
the Iingers on the volar surIace and the palm on the dor-
sal surIace.
Fl0uPE 5.88 0|s¦a| rad|ou|nar ¦o|n¦. dorsa| and vo|ar ç||des.
Resting Position
The resting position is with the Iorearm supinated 10 .
Treatment Plane
The treatment plane is the articulating surIace oI the
radius, parallel to the long axis oI the radius.
Distal ulna.
Dorsal glide to increase supination; volar glide to increase
Patient Position
Sitting, with the Iorearm on the treatment table. Begin in
the resting position and progress to end-range pronation or
Hand Placement
Stabilize the distal ulna by placing the Iingers oI one hand
on the dorsal surIace and the thenar eminence and thumb
on the volar surIace. Place your other hand in the same
manner around the distal radius.
Mobilizing Force
Glide the distal radius dorsally or volarly parallel to the
Patient Position
Sitting, with the Iorearm supported on the treatment table,
wrist over the edge oI the table.
Hand Placement
With the hand closest to the patient, grasp around the
styloid processes and Iixate the radius and ulna against
the table.
Grasp around the distal row oI carpals with your other
Mobilizing Force
Pull in a distal direction with respect to the arm.
Padìocarpal 1oìnf, 0cncral 0lìdcs, and Progrcssìon
Dorsal glide to increase Ilexion (Fig. 5.36A); volar glide
to increase extension (Fig. 5.36B); radial glide to increase
Wrìsf Complcx (Fìg. 5.84}
N 0 J E . When nobilizinq lhe wrisl, beqin wilh qeneral
dislraclions and qlides lhal include lhe µroxinal row and
dislal row of carµals as a qrouµ. For full P0M, individual
carµal nobilizalionsjnaniµulalions nay be necessary.
!hey are described followinq lhe qeneral nobilizalions.
For a review of lhe nechanics of lhe wrisl conµlex, see
Chaµler 10.
Padìocarpal 1oìnf
The concave distal radius articulates with the convex proxi-
mal row oI carpals, which is composed oI the scaphoid,
lunate, and triquetrum.
C R A P J E P 5 Periµheral Joinl Mobilizalion 181
Articular disc
Fl0uPE 5.84 bones and ¦o|n¦s o¦ ¦|e wr|s¦ and |and.
Fl0uPE 5.85 wr|s¦ ¦o|n¦. çenera| d|s¦rac¦|on.
Fl0uPE 5.88 wr|s¦ ¦o|n¦. çenera| uou|||za¦|on. (/} 0orsa| ç||de.
Resting Position
The resting position is a straight line through the radius
and third metacarpal with slight ulnar deviation.
Treatment Plane
The treatment plane is in the articulating surIace oI the
radius perpendicular to the long axis oI the radius.
Distal radius and ulna.
Padìocarpal 0ìsfracfìon (Fìg. 5.85}
Testing; initial treatment; pain control; general mobility oI
the wrist.
ulnar deviation; ulnar glide to increase radial deviation
(Fig. 5.37).
Ior the radial and ulnar techniques. Progress by moving
the wrist to the end oI the available range and glide in
the deIined direction. SpeciIic carpal gliding techniques
described in the next sections are used to increase mobil-
ity at isolated articulations.
Mobilizing Force
The mobilizing Iorce comes Irom the hand around the
distal row oI carpals.
Spccìfìc Carpal 0lìdìng (Fìgs. 5.88, 5.80}
N 0 J E : Sµecific lechniques lo nobilize individual
carµal bones nay be necessary lo qain full P0M of lhe
wrisl. Sµecific bionechanics of lhe radiocarµal and inler-
carµal |oinls are described in Chaµler 10. !o qlide one
carµal on anolher or on lhe radius, ulilize lhe followinq
Fl0uPE 5.88 (confìnucd} (3} vo|ar ç||de.
Fl0uPE 5.87 wr|s¦ ¦o|n¦. çenera| uou|||za¦|on÷u|nar ç||de.
Patient Position and Hand Placement
Sitting with Iorearm resting on the table in pronation Ior
the dorsal and volar techniques and in mid-range position
Fl0uPE 5.88 Sµec|¦|c carµa| uou|||za¦|ons. s¦au|||za¦|on o¦ ¦|e d|s¦a| uone
and vo|ar ç||de o¦ ¦|e µroz|ua| uone. S|own |s s¦au|||za¦|on o¦ ¦|e scaµ|o|d
and |una¦e w|¦| ¦|e |ndez ¦|nçers and a vo|ar ç||de ¦o ¦|e rad|us w|¦| ¦|e
¦|uuus ¦o |ncrease wr|s¦ ¦|ez|on.
By mobilizing Irom the dorsal surIace, pressure against
the nerves, blood vessels, and tendons in the carpal tun-
nel and Guyon`s canal is minimized, and a stronger
mobilizing Iorce can be used without pain.
To increase Ilexion.
Glide the concave radius volarly on the stabilized
Glide the concave radius volarly on the stabilized lunate
(see Fig. 5.38).
Glide the concave trapezium-trapezoid unit volarly on
the stabilized scaphoid.
Glide the concave lunate volarly on the stabilized capi-
Glide the concave triquetrum volarly on the stabilized
To increase extension.
Glide convex scaphoid volarly on the stabilized radius.
Glide convex lunate volarly on the stabilized radius.
Glide convex scaphoid volarly on the stabilized
trapezium-trapezoid unit.
Glide convex capitate volarly on the stabilized lunate
(see Fig. 5.39).
Glide convex hamate volarly on the stabilized triquetrum.
ulnar-Mcnìscal Jrìqucfral Arfìculafìon
To unlock the articular disk, which may block motions oI
the wrist or Iorearm; apply a glide oI the ulna volarly on a
Iixed triquetrum (see Fig. 19.7).
Rand and Fìngcr 1oìnfs
Carpomcfacarpal and lnfcrmcfacarpal 1oìnfs
of 0ìgìfs ll-v: 0ìsfracfìon (Fìg. 5.40}
To increase mobility oI the hand.
Patient and Therapist Positions
The patient sits.
You stand and grasp the patient`s hand so the elbow
hangs unsupported.
The weight oI the arm provides slight distraction to the
joint (grade I), so you then need only to apply the glides.
Hand Placement
IdentiIy the speciIic articulation to be mobilized and place
your index Iingers on the volar surIace oI the bone to be
stabilized. Place the overlapping thumbs on the dorsal sur-
Iace oI the bone to be mobilized. The rest oI your Iingers
hold the patient`s hand so it is relaxed.
To increase extension, the stabilizing index Iingers are
placed under the bone that is concave (on the volar sur-
Iace), and the mobilizing thumbs are overlapped on the
dorsal surIace oI the bone that is convex.
To increase flexion, the stabilizing index Iingers are
placed under the bone that is convex (on the volar sur-
Iace), and the mobilizing thumbs are overlapped on the
dorsal surIace oI the bone that is concave.
Mobilizing Force
In each case, the Iorce comes Irom the overlapping
thumbs on the dorsal surIace.
C R A P J E P 5 Periµheral Joinl Mobilizalion 188
Fl0uPE 5.40 Carµoue¦acarµa| ¦o|n¦. d|s¦rac¦|on.
Fl0uPE 5.80 Sµec|¦|c carµa| uou|||za¦|ons. s¦au|||za¦|on o¦ ¦|e µroz|ua| uone
and vo|ar çu|de o¦ ¦|e d|s¦a| uone. S|own |s s¦au|||za¦|on o¦ ¦|e |una¦e w|¦|
¦|e |ndez ¦|nçers and vo|ar ç||de ¦o ¦|e caµ|¦a¦e w|¦| ¦|e ¦|uuus ¦o |ncrease
Stabilization and Hand Placement
Stabilize the respective carpal with thumb and index Iinger
oI one hand. With your other hand, grasp around the proxi-
mal portion oI a metacarpal.
Mobilizing Force
Apply long-axis traction to the metacarpal to separate the
joint surIaces.
Carpomcfacarpal and lnfcrmcfacarpal: volar 0lìdc
To increase mobility oI the arch oI the hand.
Stabilization and Hand Placement
Stabilize the carpals with the thumb and index Iinger oI
one hand; place the thenar eminence oI your other hand
along the dorsal aspect oI the metacarpals to provide the
mobilization Iorce.
Mobilizing Force
Glide the proximal portion oI the metacarpal volar ward.
See also the stretching technique Ior cupping and Ilattening
the arch oI the hand described in Chapter 4.
Carpomcfacarpal 1oìnf of fhc Jhumh
The CMC oI the thumb is a saddle joint. The trapezium is
concave, and the proximal metacarpal is convex Ior abduc-
tion/adduction. The trapezium is convex, and the proximal
metacarpal is concave Ior Ilexion/extension.
Resting Position
The resting position is midway between Ilexion and exten-
sion and between abduction and adduction.
Fixate the trapezium with the hand that is closer to the
Treatment Plane
The treatment plane is in the trapezium Ior abduction-
adduction and in the proximal metacarpal Ior Ilexion-
Carpomcfacarpal 0ìsfracfìon (Jhumh}
Testing; initial treatment; pain control; general mobility.
Patient Position
The patient is positioned with Iorearm and hand resting on
the treatment table.
Hand Placement
Fixate the trapezium with the hand that is closer to the
Grasp the patient`s metacarpal by wrapping your Iingers
around it (similar to Fig. 6.41A).
Mobilizing Force
Apply long-axis traction to separate the joint surIaces.
Carpomcfacarpal 0lìdcs (Jhumh} (Fìg. 5.41}
Ulnar glide to increase Ilexion; radial glide to increase
extension; dorsal glide to increase abduction; volar glide
to increase adduction.
Fl0uPE 5.41 Carµoue¦acarµa| ¦o|n¦ o¦ ¦|e ¦|uuu. (/} U|nar ç||de ¦o |ncrease
¦|ez|on. (3} Rad|a| ç||de ¦o |ncrease ez¦ens|on. (C} 0orsa| ç||de ¦o |ncrease
auduc¦|on. (0} vo|ar ç||de ¦o |ncrease adduc¦|on. No¦e ¦|a¦ ¦|e
¦|uuu o¦ ¦|e ¦|eraµ|s¦ |s µ|aced |n ¦|e weu sµace ue¦ween ¦|e |ndez and
¦|uuu o¦ ¦|e µa¦|en¦'s |and ¦o aµµ|, a vo|ar ç||de.
Mobilizing Force
Apply long-axis traction to separate the joint surIace.
Mcfacarpophalangcal and lnfcrphalangcal
0lìdcs and Progrcssìon
Volar glide to increase Ilexion (Fig. 5.43); dorsal glide to
increase extension; radial or ulnar glide (depending on Iin-
ger) to increase abduction or adduction.
Patient Position and Hand Placement
The trapezium is stabilized by grasping it directly or by
wrapping your Iingers around the distal row oI carpals.
Place the thenar eminence oI your other hand against the
base oI the patient`s Iirst metacarpal on the side opposite
the desired glide. For example, as pictured in Fig. 5.41A,
the surIace oI the thenar eminence is on the radial side
oI the metacarpal to cause an ulnar glide.
Mobilizing Force
The Iorce comes Irom your thenar eminence against the
base oI the metacarpal. Adjust your body position to line
up the Iorce as illustrated in Figure 5.41AD.
Mcfacarpophalangcal and lnfcrphalangcal
1oìnfs of fhc Fìngcrs
In all cases, the distal end oI the proximal articulating sur-
Iace is convex, and the proximal end oI the distal articulat-
ing surIace is concave.
N 0 J E . 8ecause all lhe arliculalinq surfaces are lhe sane
for lhe diqils, all lechniques are aµµlied in lhe sane nanner
lo each |oinl.
Resting Position
The resting position is in light Ilexion Ior all joints.
Treatment Plane
The treatment plane is in the distal articulating surIace.
Rest the Iorearm and hand on the treatment table; Iixate the
proximal articulating surIace with the Iingers oI one hand.
Mcfacarpophalangcal and lnfcrphalangcal
0ìsfracfìon (Fìg. 5.42}
Testing; initial treatment; pain control; general mobility.
Hand Placement
Use your proximal hand to stabilize the proximal bone;
wrap the Iingers and thumb oI your other hand around the
distal bone close to the joint.
C R A P J E P 5 Periµheral Joinl Mobilizalion 185
Fl0uPE 5.42 Ve¦acarµoµ|a|ançea| ¦o|n¦. d|s¦rac¦|on.
Fl0uPE 5.48 Ve¦acarµoµ|a|ançea| ¦o|n¦. vo|ar ç||de.
Fl0uPE 5.44 bones and ¦o|n¦s o¦ ¦|e µe|v|s and ||µ.
Mobilizing Force
The glide Iorce is applied by the thumb against the
proximal end oI the bone to be moved. Progress by
taking the joint to the end oI its available range and
applying slight distraction and the glide Iorce.
Rotation may be added prior to applying the gliding
Rìp 1oìnf (Fìg. 5.44}
The concave acetabulum receives the convex Iemoral
head. Biomechanics oI the hip joint are reviewed in
Chapter 20.
Resting Position
The resting position is hip Ilexion 30 , abduction 30 , and
slight external rotation.
Fixate the pelvis to the treatment table with belts.
Rìp 0ìsfracfìon of fhc Wcìghf-8carìng
Surfacc, Caudal 0lìdc (Fìg. 5.45}
N 0 J E : 8ecause of lhe deeµ confiquralion of lhis |oinl,
lraclion aµµlied µerµendicular lo lhe lrealnenl µlane causes
laleral qlide of lhe suµerior, weiqhl-bearinq surface. !o
oblain seµaralion of lhe weiqhl-bearinq surface, caudal
qlide is used.
Alfcrnafc Posìfìon for Rìp Caudal 0lìdc
To apply distraction to the weight-bearing surIace oI the
hip joint when there is knee dysIunction.
Patient Position
Supine, with the hip and knee Ilexed.
Therapist Position and Hand Placement
Wrap your hands around the epicondyles oI the Iemur and
distal thigh. Do not compress the patella.
Mobilizing Force
The Iorce comes Irom your hands and is applied in a cau-
dal direction as you lean backward.
Rìp Posfcrìor 0lìdc (Fìg. 5.48}
To increase Ilexion; to increase internal rotation.
Fl0uPE 5.45 h|µ ¦o|n¦. d|s¦rac¦|on o¦ ¦|e we|ç|¦-uear|nç sur¦ace.
Testing; initial treatment; pain control; general mobility.
Patient Position
Supine, with the hip in resting position and the knee
P P E C A u J l 0 N . ln lhe µresence of knee dysfunclion,
lhis µosilion should nol be used; see allernale µosilion
Therapist Position and Hand Placement
Stand at the end oI the treatment table; place a belt around
your trunk, then cross the belt over the patient`s Ioot and
around the ankle. Place your hands proximal to the malle-
oli, under the belt. The belt allows you to use your body
weight to apply the mobilizing Iorce.
Mobilizing Force
Long-axis traction is applied by pulling on the leg as you
lean backward.
Fl0uPE 5.48 h|µ ¦o|n¦. µos¦er|or ç||de.
Patient Position
Supine, with hips at the end oI the table.
The patient helps stabilize the pelvis and lumbar spine
by Ilexing the opposite hip and holding the thigh against
the chest with the hands.
Initially, the hip to be mobilized is in resting position;
progress to the end oI the range.
Therapist Position and Hand Placement
Stand on the medial side oI the patient`s thigh.
Place a belt around your shoulder and under the patient`s
thigh to help hold the weight oI the lower extremity.
Push against the posterior aspect oI the greater
trochanter in an anterior direction with your caudal hand.
Kncc and Lcg (Fìg. 5.48}
Jìhìofcmoral Arfìculafìon
The concave tibial plateaus articulate on the convex
Iemoral condyles. Biomechanics oI the knee joint are
described in Chapter 21.
Place your distal hand under the belt and distal thigh.
Place your proximal hand on the anterior surIace oI the
proximal thigh.
Mobilizing Force
Keep your elbows extended and Ilex your knees; apply the
Iorce through your proximal hand in a posterior direction.
Rìp Anfcrìor 0lìdc (Fìg. 5.47}
To increase extension; to increase external rotation.
C R A P J E P 5 Periµheral Joinl Mobilizalion 187
Fl0uPE 5.47 h|µ ¦o|n¦. an¦er|or ç||de (/} µrone
Fl0uPE 5.48 bones and ¦o|n¦s o¦ ¦|e |nee and |eç.
Pcsfìng Posìfìon
The resting position is 25 Ilexion.
Treatment Plane
The treatment plane is along the surIace oI the tibial
plateaus; thereIore, it moves with the tibia as the knee
angle changes.
In most cases, the Iemur is stabilized with a belt or by the
Patient Position
Prone, with the trunk resting on the table and hips over the
edge. The opposite Ioot is on the Iloor.
Therapist Position and Hand Placement
Stand on the medial side oI the patient`s thigh.
Place a belt around your shoulder and the patient`s thigh
to help support the weight oI the leg.
With your distal hand, hold the patient`s leg.
Place your proximal hand posteriorly on the proximal
thigh just below the buttock.
Mobilizing Force
Keep your elbow extended and Ilex your knees; apply
the Iorce through your proximal hand in an anterior
Alternate Position (Fig. 5.47B)
Position the patient side-lying with the thigh comIortably
Ilexed and supported by pillows.
Stand posterior to the patient and stabilize the pelvis
across the anterior superior iliac spine with your cranial
Fl0uPE 5.47 (3} s|de-|,|nç.
Jìhìofcmoral 0ìsfracfìon, Long-Axìs Jracfìon (Fìg. 5.40}
Testing; initial treatment; pain control; general mobility.
Patient Position
Sitting, supine, or prone, beginning with the knee in the
resting position.
Progress to positioning the knee at the limit oI the range
oI Ilexion or extension.
Rotation oI the tibia may be added prior to apply-
ing the traction Iorce. Use internal rotation at end-
range Ilexion and external rotation at end-range
Hand Placement
Grasp around the distal leg, proximal to the malleoli with
both hands.
Mobilizing Force
Pull on the long axis oI the tibia to separate the joint sur-
Jìhìofcmoral Posfcrìor 0lìdc (Fìg. 5.50}
Testing; to increase Ilexion.
Fl0uPE 5.40 !|u|o¦euora| ¦o|n¦. d|s¦rac¦|on (/} s|¦¦|nç, (3} suµ|ne, and (C}
Fl0uPE 5.50 !|u|o¦euora| ¦o|n¦. µos¦er|or ç||de (drawer}.
Patient Position
Supine, with the Ioot resting on the table. The position Ior
the drawer test can be used to mobilize the tibia either
anteriorly or posteriorly, although no grade I distraction
can be applied with the glides.
Therapist Position and Hand Placement
Sit on the table with your thigh Iixating the patient`s Ioot.
With both hands, grasp around the tibia, Iingers pointing
posteriorly and thumbs anteriorly.
Mobilizing Force
Extend your elbows and lean your body weight Iorward;
push the tibia posteriorly with your thumbs.
Patient Position
Prone, beginning with the knee in resting position;
progress to the end oI the available range.
The tibia may also be positioned in lateral rotation.
Place a small pad under the distal Iemur to prevent
patellar compression.
Hand Placement
Grasp the distal tibia with the hand that is closer to it and
place the palm oI the proximal hand on the posterior aspect
oI the proximal tibia.
Mobilizing Force
Force with the hand on the proximal tibia in an anterior
direction. The Iorce may be directed to the lateral or medi-
al tibial plateau to isolate one side oI the joint.
Alternate Position
II the patient cannot be positioned prone, position
him or her supine with a Iixation pad under the
The mobilizing Iorce is placed against the Iemur in a
posterior direction.
N 0 J E . !he drawer lesl µosilion can also be
used. !he nobilizinq force cones fron lhe finqers
on lhe µoslerior libia as you lean backward (see
Fiq. 6.60).
Jìhìofcmoral Posfcrìor 0lìdc: Alfcrnafc
Posìfìons and Progrcssìon (Fìg. 5.51}
To increase Ilexion.
Patient Position
Sitting, with the knee Ilexed over the edge oI the treat-
ment table, beginning in the resting position (Fig. 5.51).
Progress to near 90 Ilexion with the tibia positioned in
internal rotation.
Once the knee Ilexes past 90 , position the patient prone;
place a small rolled towel proximal to the patella to min-
imize compression Iorces against the patella during the
C R A P J E P 5 Periµheral Joinl Mobilizalion 180
Fl0uPE 5.51 !|u|o¦euora| ¦o|n¦. µos¦er|or ç||de, s|¦¦|nç.
Fl0uPE 5.52 !|u|o¦euora| ¦o|n¦. an¦er|or ç||de.
When progressing with medial rotation oI the tibia at the
end oI the range oI Ilexion, the Iorce is applied in a pos-
terior direction against the medial side oI the tibia.
Jìhìofcmoral Anfcrìor 0lìdc (Fìg. 5.52}
To increase extension.
Therapist Position and Hand Placement
When in resting position, stand on the medial side oI the
patient`s leg. Hold the distal leg with your distal hand
and place the palm oI your proximal hand along the
anterior border oI the tibial plateaus.
When near 90 sit on a low stool; stabilize the leg
between your knees and place one hand on the anterior
border oI the tibial plateaus.
When prone, stabilize the Iemur with one hand and place
the other hand along the border oI the tibial plateaus.
Mobilizing Force
Extend your elbow and lean your body weight onto the
tibia, gliding it posteriorly.
Pafcllofcmoral 1oìnf, 0ìsfal 0lìdc (Fìg. 5.58}
To increase patellar mobility Ior knee Ilexion.
Patient Position
Supine, with knee extended; progress to positioning the
knee at the end oI the available range in Ilexion.
Hand Placement
Stand next to the patient`s thigh, Iacing the patient`s Ieet.
Place the web space oI the hand that is closer to the thigh
around the superior border oI the patella. Use the other
hand Ior reinIorcement.
Mobilizing Force
Glide the patella in a caudal direction, parallel to the Iemur.
P P E C A u J l 0 N : 0o nol conµress lhe µalella inlo lhe
fenoral condyles while µerforninq lhis lechnique.
Pafcllofcmoral Mcdìal-Lafcral 0lìdc (Fìg. 5.54}
To increase patellar mobility.
Patient Position
Supine with the knee extended. Side-lying may be used to
apply a medial glide (see Fig. 21.3)
Hand Placement
Place the heel oI your hand along either the medial or lat-
eral aspect oI the patella. Stand on the opposite side oI the
table to position your hand along the medial border and on
the same side oI the table to position your hand along the
lateral border. Place the other hand under the Iemur to sta-
bilize it.
Mobilizing Force
Glide the patella in a medial or lateral direction, against the
Proxìmal Jìhìofìhular Arfìculafìon: Anfcrìor (vcnfral}
0lìdc (Fìg. 5.55}
To increase movement oI the Iibular head; to reposition a
posteriorly positioned head.
Fl0uPE 5.58 Pa¦e||o¦euora| ¦o|n¦. d|s¦a| ç||de.
Fl0uPE 5.54 Pa¦e||o¦euora| ¦o|n¦. |a¦era| ç||de.
Fl0uPE 5.55 Proz|ua| ¦|u|o¦|uu|ar ¦o|n¦. an¦er|or ç||de.
Patient Position
Side-lying, with the trunk and hips rotated partially
toward prone.
The top leg is Ilexed Iorward so the knee and lower leg
are resting on the table or supported on a pillow.
Therapist Position and Hand Placement
Stand behind the patient, placing one oI your hands
under the tibia to stabilize it.
Place the base oI your other hand posterior to the head
oI the Iibula, wrapping your Iingers anteriorly.
Treatment Plane
The treatment plane is in the mortise, in an anterior-
posterior direction with respect to the leg.
The tibia is strapped or held against the table.
Jalocrural 0ìsfracfìon (Fìg. 5.58}
Testing; initial treatment; pain control; general mobility.
Mobilizing Force
The Iorce comes Irom the heel oI your hand against the
posterior aspect oI the Iibular head, in an anterior-lateral
0ìsfal Jìhìofìhular Arfìculafìon: Anfcrìor
(vcnfral} or Posfcrìor (0orsal} 0lìdc (Fìg. 5.58}
To increase mobility oI the mortise when it is restricting
ankle dorsiIlexion.
C R A P J E P 5 Periµheral Joinl Mobilizalion 141
Fl0uPE 5.58 0|s¦a| ¦|u|o¦|uu|ar ar¦|cu|a¦|on. µos¦er|or ç||de.
Patient Position
Supine or prone.
Hand Placement
Working Irom the end oI the table, place the Iingers oI
the more medial hand under the tibia and the thumb
over the tibia to stabilize it. Place the base oI your
other hand over the lateral malleolus, with the Iingers
Mobilizing Force
Press against the Iibula in an anterior direction when prone
and in a posterior direction when supine.
Anklc and Foof 1oìnfs (Fìg. 5.57}
Biomechanics oI the ankle and Ioot are summarized in
Chapter 22.
Jalocrural 1oìnf (uppcr Anklc 1oìnf}
The convex talus articulates with the concave mortise made
up oI the tibia and Iibula.
Resting Position
The resting position is 10 plantarIlexion.
Fl0uPE 5.57 (/} An¦er|or v|ew o¦ ¦|e uones and ¦o|n¦s o¦ ¦|e |ower |eç and
an||e. (3} Ved|a| v|ew. (C} La¦era| v|ew o¦ ¦|e uones and ¦o|n¦ re|a¦|ons||µs o¦
¦|e an||e and ¦oo¦.
Fl0uPE 5.58 !a|ocrura| ¦o|n¦. d|s¦rac¦|on.
Patient Position
Supine, with the lower extremity extended. Begin with the
ankle in resting position. Progress to the end oI the avail-
able range oI dorsiIlexion or plantarIlexion.
Therapist Position and Hand Placement
Stand at the end oI the table; wrap the Iingers oI both
hands over the dorsum oI the patient`s Ioot, just distal to
the mortise.
Place your thumbs on the plantar surIace oI the Ioot to
hold it in resting position.
Mobilization Force
Pull the Ioot away Irom the long axis oI the leg in a distal
direction by leaning backward.
Jalocrural 0orsal (Posfcrìor} 0lìdc (Fìg. 5.50}
To increase dorsiIlexion.
Mobilizing Force
Glide the talus posteriorly with respect to the tibia by
pushing against the talus.
Jalocrural vcnfral (Anfcrìor} 0lìdc (Fìg. 5.80}
To increase plantarIlexion.
Fl0uPE 5.50 !a|ocrura| ¦o|n¦. µos¦er|or ç||de.
Patient Position
Supine, with the leg supported on the table and the heel
over the edge.
Therapist Position and Hand Placement
Stand to the side oI the patient.
Stabilize the leg with your cranial hand or use a belt to
secure the leg to the table.
Place the palmar aspect oI the web space oI your other
hand over the talus just distal to the mortise.
Wrap your Iingers and thumb around the Ioot to main-
tain the ankle in resting position. Grade I distraction
Iorce is applied in a caudal direction.
Fl0uPE 5.80 !a|ocrura| ¦o|n¦. an¦er|or ç||de.
Patient Position
Prone, with the Ioot over the edge oI the table.
Therapist Position and Hand Placement
Working Irom the end oI the table, place your lateral
hand across the dorsum oI the Ioot to apply a grade
I distraction.
Place the web space oI your other hand just distal to
the mortise on the posterior aspect oI the talus and
Mobilizing Force
Push against the calcaneus in an anterior direction (with
respect to the tibia); this glides the talus anteriorly.
Alternate Position
Patient is supine. Stabilize the distal leg anterior to the
mortise with your proximal hand.
The distal hand cups under the calcaneus.
When you pull against the calcaneus in an anterior direc-
tion, the talus glides anteriorly.
Suhfalar 1oìnf (Jalocalcancal}, Posfcrìor Comparfmcnf
The calcaneus is convex, articulating with a concave talus
in the posterior compartment.
Resting Position
The resting position is midway between inversion and
Therapist Position and Hand Placement
Align your shoulder and arm parallel to the bottom oI
the Ioot.
Stabilize the talus with your proximal hand.
Place the base oI the distal hand on the side oI the calca-
neus medially to cause a lateral glide and laterally to
cause a medial glide.
Wrap the Iingers around the plantar surIace.
Mobilizing Force
Apply a grade I distraction Iorce in a caudal direction, then
push with the base oI your hand against the side oI the cal-
caneus parallel to the planter surIace oI the heel.
Treatment Plane
The treatment plane is in the talus, parallel to the sole oI
the Ioot.
Suhfalar 0ìsfracfìon (Fìg. 5.81}
Testing; initial treatment; pain control; general mobility Ior
C R A P J E P 5 Periµheral Joinl Mobilizalion 148
Fl0uPE 5.82 Suu¦a|ar ¦o|n¦. |a¦era| ç||de. (/} µrone and (3} s|de-|,|nç.
Fl0uPE 5.81 Suu¦a|ar (¦a|oca|canea|} ¦o|n¦. d|s¦rac¦|on.
Patient and Therapist Positions
The patient is placed in a supine position, with the leg
supported on the table and heel over the edge.
The hip is externally rotated so the talocrural joint
can be stabilized in dorsiIlexion with pressure Irom
your thigh against the plantar surIace oI the patient`s
Hand Placement
The distal hand grasps around the calcaneus Irom the pos-
terior aspect oI the Ioot. The other hand Iixes the talus and
malleoli against the table.
Mobilizing Force
Pull the calcaneus distally with respect to the long axis oI
the leg.
Suhfalar Mcdìal 0lìdc or Lafcral 0lìdc (Fìg. 5.82}
Medial glide to increase eversion; lateral glide to increase
Patient Position
The patient is side-lying or prone, with the leg supported
on the table or with a towel roll.
Alternate Position
Same as the position Ior distraction, moving the calcaneus
in the medial or a lateral direction with the base oI the
lnfcrfarsal and Jarsomcfafarsal 1oìnfs
When moving in a dorsal-plantar direction with respect to
the Ioot, all oI the articulating surIaces are concave and
convex in the same direction. For example, the proximal
articulating surIace is convex and the distal articulating
surIace is concave. The technique Ior mobilizing each joint
is the same. The hand placement is adjusted to stabilize the
proximal bone partner so the distal bone partner can be
lnfcrfarsal and Jarsomcfafarsal
Planfar 0lìdc (Fìg. 5.88}
To increase plantarIlexion accessory motions (necessary
Ior supination).
Hand Placement
To mobilize the tarsal joints along the medial aspect oI
the Ioot, position yourselI on the lateral side oI the Ioot.
Place the proximal hand on the dorsum oI the Ioot with
the Iingers pointing medially so the index Iinger can be
wrapped around and placed under the bone to be stabi-
Place your thenar eminence oI the distal hand over the
dorsal surIace oI the bone to be moved and wrap the Iin-
gers around the plantar surIace.
To mobilize the lateral tarsal joints, position yourselI on
the medial side oI the Ioot, point your Iingers laterally,
and position your hands around the bones as just
Mobilizing Force
Push the distal bone in a plantar direction Irom the dorsum
oI the Ioot.
lnfcrfarsal and Jarsomcfafarsal 0orsal 0lìdc (Fìg. 5.84}
To increase the dorsal gliding accessory motion (necessary
Ior pronation).
Fl0uPE 5.84 0orsa| ç||d|nç o¦ a d|s¦a| ¦arsa| on a µroz|ua| ¦arsa|. S|own |s
¦|e cuuo|d uone on ¦|e ca|caneus.
Fl0uPE 5.88 P|an¦ar ç||de o¦ a d|s¦a| ¦arsa| uone on a s¦au|||zed µroz|ua|
uone. S|own |s ¦|e cune|¦oru uone on ¦|e nav|cu|ar.
Patient Position
Supine, with hip and knee Ilexed, or sitting, with knee
Ilexed over the edge oI the table and heel resting on
your lap.
Fixate the more proximal bone with your index Iinger on
the plantar surIace oI the bone.
Patient Position
Prone, with knee Ilexed.
Fixate the more proximal bone.
Hand Placement
To mobilize the lateral tarsal joints (e.g., cuboid on
calcaneus), position yourselI on the medial side oI the
is Iorced in a plantar direction. This is a relative motion
oI the distal bone moving in a dorsal direction.
lnfcrmcfarsal, Mcfafarsophalangcal,
and lnfcrphalangcal 1oìnfs
The intermetatarsal, metatarsophalangeal, and interpha-
langeal joints oI the toes are stabilized and mobilized in
the same manner as the Iingers. In each case, the articulat-
ing surIace oI the proximal bone is convex, and the articu-
lating surIace oI the distal bone is concave. It is easiest to
stabilize the proximal bone and glide the surIace oI the dis-
tal bone either plantarward Ior Ilexion, dorsalward Ior
extension, and medially or laterally Ior adduction and
patient`s leg and wrap your Iingers around the lateral
side oI the Ioot (as in Fig. 5.64).
To mobilize the medial bones (e.g., navicular on talus),
position yourselI on the lateral side oI the patient`s leg
and wrap your Iingers around the medial aspect oI the
Place your second metacarpophalangeal joint against the
bone to be moved.
Mobilizing Force
Push Irom the plantar surIace in a dorsal direction.
Alternate Technique
Same position and hand placements as Ior plantar glides,
except the distal bone is stabilized and the proximal bone
C R A P J E P 5 Periµheral Joinl Mobilizalion 145
l h 0 E P E h 0 E h ! L E A P h l h 6 A C ! l v l ! l E S
Crìfìcal Jhìnkìng and 0ìscussìon
1. An individual is immobilized in a cast Ior 4 to 6 weeks
Iollowing a Iracture. In general, what structures lose
their elasticity, and what restrictions do you Ieel when
testing range oI motion, joint play, and Ilexibility?
2. Describe the normal arthrokinematic relationships Ior
the extremity joints and deIine the location oI the treat-
ment plane Ior each joint.
3. Using the inIormation Irom item 1, deIine a speciIic
Iracture, such as a Colle`s Iracture oI the distal Iorearm.
IdentiIy what techniques are necessary to gain joint
mobility and range oI motion in the related joints such
as the wrist, Iorearm, and elbow joints, connective tis-
sues, and muscles. Practice using each oI the techniques.
4. Explain the rationale Ior using passive joint techniques
to treat patients with limitations because oI pain and
muscle guarding or to treat patients with restricted cap-
sular or ligamentous tissue. What is the diIIerence in the
way the techniques are applied in each case?
5. Describe how joint mobilization techniques Iit into the
total plan oI therapeutic intervention Ior patients with
impaired joint mobility.
6. Explain the diIIerence between passive joint mobiliza-
tion techniques and mobilization with movement tech-
Lahorafory Pracfìcc
With a partner, practice mobilizing each joint in the upper
and lower extremities.
Precaution: Do not practice on an individual with a
hypermobile or unstable joint.
1. Begin with the joint in its resting position and apply dis-
traction techniques at each intensity (sustained grades I,
II, and III) to develop a Ieel Ior 'very gentle,¨ 'taking up
the slack,¨ and 'stretch.¨ Do not apply a vigorous stretch
to someone with a normal joint. Be sure to use appropri-
ate stabilization.
2. With the joint in its resting position, practice all appro-
priate glides Ior that joint. Be sure to use a grade I dis-
traction with each gliding technique. Vary the techniques
between sustained and oscillation.
3. Practice progressing each technique by taking the joint
to a point that you determine to be the 'end oI the
range¨ and:
· Apply a distraction technique with the extremity in that
· Apply the appropriate glide at that range (be sure to
apply a grade I distraction with each glide).
· Add rotation (e.g., external rotation Ior shoulder abduc-
tion) and then apply the appropriate glide.
R L l L R L N C L S
1. Akeson, WH, et al: EIIects oI immobilization on joints. Clin Orthop
219:28, 1987.
2. American Physical Therapy Association. Guide to physical therapist
practice, ed 2. Phys Ther 81:9746, 2001.
3. Backstrom, KM: Mobilization with movement as an adjunct interven-
tion in a patient with complicated DeQuervain`s tenosynovitis: a case
report. J Orthop Sports Phys Ther 32(3):8697, 2002.
4. Boissonnault, W, Bryan, JM, Fox, KJ: Joint manipulation curricula in
physical therapist proIessional degree programs. J Orthop Sports Phys
Ther 34(4):171181, 2004.
5. Cyriax, J: Textbook oI Orthopaedic Medicine. Vol I. The Diagnosis oI
SoIt Tissue Lesions, ed 8. Bailliere & Tindall, London, 1982.
6. DiFabio, RP: EIIicacy oI manual therapy. Phys Ther 72:853864,
7. Donatelli, R, Owens-Burkhart, H: EIIects oI immobilization on the
extensibility oI periarticular connective tissue. J Orthop Sports Phys
Ther 3:67, 1981.
8. Enneking, WF, Horowitz, M: The intra-articular eIIects oI immo-
bilization on the human knee. J Bone Joint Surg Am 54:978,
9. Exelby, L: Mobilizations with movement, a personal view. Physi-
otherapy 81(12):724, 1995.
10. Harryman, DT, Sidles, JA, et al: Translation oI the humeral head on
the glenoid with passive glenohumeral motion. J Bone Joint Surg Am
72:13341343, 1990.
11. Howell, SM, Galinat, BJ, et al: Normal and abnormal mechanics oI
the glenohumeral jont in the horizontal plane. J Bone Joint Surg Am
70:227232, 1988.
12. Hsu, AT, Hedman, T, Chang, TH, et al: Changes in abduction and
rotation range oI motion in response to simulated dorsal and ventral
translational mobilization oI the glenohumeral joint. Phys Ther
82(6):544556, 2002.
13. Itoi, E, Motzkin, NE, et al: Contribution oI axial arm rotation to the
humeral head translation. Am J Sports Med 22:499503, 1994.
14. Kaltenborn, FM: The Kaltenborn Method oI Joint Examination and
Treatment. Vol I. The Extremities, ed 5. OlaI Norlis Bokhandel, Oslo,
15. Kavanagh, J: Is there a positional Iault at the inIerior tibioIibular joint
in patients with acute or chronic ankle sprains compared to normals?
Manual Ther 4(1):19, 1999.
16. Magee, DJ: Orthopedic Physical Assessment, ed 3. WB Saunders,
Philadelphia, 1997.
17. Maitland, GD: Peripheral Manipulation, ed 3. Butterworth-
Heinemann, Boston, 1991.
18. McDavitt, S: Practice aIIairs corner; a revision Ior the Guide to Physi-
cal Therapist Practice; mobilization or manipulation? Yes! That is my
Iinal answer! Orthop Phys Ther Pract 12(4), 2000.15.
19. Meadows, J: Orthopedic DiIIerential Diagnosis in Physical Therapy:
A Case Study Approach. McGraw-Hill, Toronto, 1999.
20. Miller, J: The Mulligan conceptthe next step in the evolution oI
manual therapy. Orthop Division Rev 2:9, 1999.
21. Mulligan, BR: Manual Therapy 'NAGS,¨ 'SNAGS,¨ 'MWM`S: Etc.,
ed 4. Plane View Press, Wellington, 1999.
22. Mulligan, BR: Mobilizations with movement (MWM`S). J Manual
Manipulative Ther 1(4):154, 1993.
23. Norkin, C, Levangie, P: Joint Structure and Function: A Comprehen-
sive Analysis, ed 2. FA Davis, Philadelphia, 1992.
24. O`Brien, T, Vincenzino, B: A study oI the eIIects oI Mulligan`s
mobilization with movement oI lateral ankle pain using a case study
design. Manual Ther 3(2):78, 1998.
25. Paris, SV: Mobilization oI the spine. Phys Ther 59:998, 1979.
26. Paungmali, A, O`Leary, S, et al: Hypoalgesic and sympathoexcitatory
eIIects oI mobilization with movement Ior lateral epicondylalgia. Phys
Ther 83(4):374383, 2003.
27. Smith, LK, Weiss, EL, Lehmkuhl, LD: Brunnstrom`s Clinical Kinesi-
ology, ed 5. FA Davis, Philadelphia, 1996.
28. Vincenzino, B, Wright, A: EIIects oI a novel manipulative physiother-
apy technique on tennis elbow: a single case study. Manual Ther
1(1):30, 1995.
29. Warwick, R, Williams, S (eds): Arthrology. In Gray`s Anatomy, 35th
British ed. WB Saunders, Philadelphia, 1973.
30. Wegener, L, Kisner, C, Nichols, D: Static and dynamic balance
responses in persons with bilateral knee osteoarthritis. J Orthop
Sports Phys Ther 25:13, 1997.
31. Wilson, E. Mobilizations with movement and adverse neutral tension:
an exploration oI possible links. Manipulative Phys Ther 27(1):40,
32. Wyke, B: The neurology oI joints. Ann R Coll Surg 41:25, 1967.
33. Wyke, B: Articular neurology: a review. Physiotherapy March:94,
34. Wyke, B: Neurological aspects oI pain Ior the physical therapy clini-
cian. Physical Therapy Forum 1982. Lecture presented at Columbus,
Ohio, 1982.
keslslance lxerclse lor lmpalred
Muscle Perlormance
0EFlNlJl0NS AN0 0ul0lN0 PPlNClPLES 148
Sfrcngfh 140
Powcr 140
Endurancc 140
0vcrload Prìncìplc 150
SAl0 Prìncìplc 150
Pcvcrsìhìlìfy Prìncìplc 150
Facfors fhaf lnflucncc Jcnsìon 0cncrafìon ìn
Normal Skclcfal Musclc 151
Physìologìcal Adapfafìons fo Pcsìsfancc
Excrcìsc 157
Alìgnmcnf and Sfahìlìzafìon 180
lnfcnsìfy 181
volumc 182
Excrcìsc 0rdcr 188
Frcqucncy 188
0urafìon 188
Pcsf lnfcrval (Pccovcry Pcrìod} 184
Modc of Excrcìsc 184
vclocìfy of Excrcìsc 185
Pcrìodìzafìon 188
lnfcgrafìon of Funcfìon 188
Manual and Mcchanìcal Pcsìsfancc Excrcìsc 187
lsomcfrìc Excrcìsc (Sfafìc Excrcìsc} 188
0ynamìc Excrcìsc-Conccnfrìc and Ecccnfrìc 170
0ynamìc Excrcìsc-Consfanf and varìahlc
Pcsìsfancc 172
lsokìncfìc Excrcìsc 172
0pcn-Chaìn and Closcd-Chaìn Excrcìsc 174
Examìnafìon and Evaluafìon 180
Prcparafìon for Pcsìsfancc Excrcìscs 181
Applìcafìon of Pcsìsfancc Excrcìscs 181
valsalva Mancuvcr 182
Suhsfìfufc Mofìons 188
0vcrfraìnìng and 0vcrwork 188
Excrcìsc-lnduccd Musclc Sorcncss 184
Pafhologìcal Fracfurc 185
Paìn 188
lnflammafìon 188
Scvcrc Cardìopulmonary 0ìscasc 188
0cfìnìfìon and usc 188
0uìdclìncs and Spccìal Consìdcrafìons 187
Jcchnìqucs-0cncral 8ackground 188
uppcr Exfrcmìfy 188
Lowcr Exfrcmìfy 102
0ìagnonal Paffcrns 108
8asìc Proccdurcs wìfh PNF Paffcrns 108
uppcr Exfrcmìfy 0ìagonal Paffcrns 107
Lowcr Exfrcmìfy 0ìagonal Paffcrns 200
Spccìal Jcchnìqucs wìfh PNF 202
usc ìn Pchahìlìfafìon 204
usc ìn Condìfìonìng Programs 204
Spccìal Consìdcrafìons for Chìldrcn and 0ldcr
Adulfs 204
Progrcssìvc Pcsìsfancc Excrcìsc 208
Cìrcuìf Wcìghf Jraìnìng 207
Plyomcfrìc Jraìnìng-Sfrcfch-Shorfcnìng
0rìlls 208
lsokìncfìc Pcgìmcns 210
Frcc Wcìghfs and Sìmplc Wcìghf-Pullcy
Sysfcms 218
varìahlc-Pcsìsfancc Machìncs 215
Elasfìc Pcsìsfancc 8ands and Juhìng 218
Equìpmcnf for Closcd-Chaìn Jraìnìng 210
Pccìprocal Excrcìsc Equìpmcnf 220
Equìpmcnf for 0ynamìc Sfahìlìzafìon
Jraìnìng 221
lsokìncfìc Jcsfìng and Jraìnìng Equìpmcnf 222
C h A P ! L R
Muscle performance reIers to the capacity oI a muscle
to do work (Iorce distance).
Despite the simplicity oI
the deIinition, muscle perIormance is a complex compo-
nent oI Iunctional movement and is inIluenced by all oI
the body systems. Factors that aIIect muscle perIormance
include the morphological qualities oI muscle; neurologi-
cal, biochemical, and biomechanical inIluences; and meta-
bolic, cardiovascular, respiratory, cognitive, and emotional
Iunction. For a person to anticipate, respond to, and control
the Iorces applied to the body and carry out the physical
demands oI everyday liIe in a saIe and eIIicient manner,
the body`s muscles must be able to produce, sustain, and
regulate muscle tension to meet these demands.
The key elements oI muscle perIormance are strength,
power, and enaurance.
II any one or more oI these areas
oI muscle perIormance is impaired, Iunctional limitations
and disability or increased risk oI dysIunction may ensue.
Many Iactors, such as injury, disease, immobilization, dis-
use, and inactivity, may result in impaired muscle perIorm-
ance, leading to weakness and muscle atrophy.
When deIicits in muscle perIormance place a person at risk
Ior injury or hinder Iunction, the use oI resistance exercise
is an appropriate therapeutic intervention to improve the
integrated use oI strength, power, and muscular endurance
during Iunctional movements, reduce the risk oI injury or
reinjury, and enhance physical perIormance.
Resistance exercise is any Iorm oI active exercise in
which dynamic or static muscle contraction is resisted by
an outside Iorce applied manually or mechanically.
Resistance exercise, also reIerred to as resistance train-
is an essential element oI rehabilitation pro-
grams Ior persons with impaired Iunction and an integral
component oI conditioning programs Ior those who wish
to promote or maintain health and physical well-being,
potentially enhance perIormance oI motor skills, and
prevent or reduce the risk oI injury and disease.
A comprehensive examination and evaluation oI a
patient or client is the basis on which a therapist deter-
mines whether a program oI resistance exercise is warrant-
ed and can improve a person`s current level oI Iunction or
prevent potential dysIunction. Many Iactors inIluence how
appropriate, eIIective, or saIe resistance training is and how
the exercises are designed, implemented, and progressed.
Factors such as the underlying pathology, the extent and
severity oI muscle perIormance impairments, the presence
oI other deIicits, the stage oI tissue healing aIter injury or
surgery, and a patient`s or client`s age, overall level oI
Iitness, and the ability to cooperate and learn all must be
considered. Once a program oI resistance exercise is devel-
oped and prescribed to meet speciIic Iunctional goals and
outcomes, direct intervention by a therapist initially to
implement the exercise program or to begin to teach and
supervise the prescribed exercises Ior a smooth transition
to an independent, home-based program is imperative.
This chapter provides a Ioundation oI inIormation on
resistance exercise, identiIies the determinants oI resistance
training programs, summarizes the principles and guide-
lines Ior application oI manual and mechanical resistance
exercise, and addresses a variety oI regimens Ior resistance
training. It also addresses the scientiIic evidence, when
available, oI the relationship between improvements in
muscle perIormance and enhanced Iunctional abilities.
The speciIic techniques described and illustrated in this
chapter Iocus on manual resistance exercise Ior the extrem-
ities, primarily used during the early phase oI rehabilita-
tion. Additional exercises perIormed independently by a
patient or client using resistance equipment are described
and illustrated in Chapters 17 to 22. The use oI resistance
exercise Ior spinal conditions is presented in Chapter 16.
AN0 0ul0lN0 PPlNClPLES
The three elements oI muscle perIormance
power, and endurancecan be enhanced by some Iorm oI
resistance exercise. To what extent each oI these elements
is altered by exercise depends on how the principles oI
resistance training are applied and how Iactors such as the
intensity, Irequency, and duration oI exercise are manipu-
lated. Because the physical demands oI work, recreation
and everyday living usually involve all three aspects oI
muscle perIormance, most resistance training programs
seek to achieve a balance oI strength, power, and muscular
endurance to suit an individual`s needs and goals. In addi-
tion to having a positive impact on muscle perIormance,
resistance training can produce many other beneIits.
These potential beneIits are listed in Box 6.1. AIter a brieI
80X 8.1 Pofcnfìal 8cncfìfs of Pcsìsfancc
- Fnlanccd musclc pcifoimancc. icsloialion, impiovcmcnl
oi mainlcnancc of musclc slicngll, powci, and cnduiancc
- lncicascd slicngll of conncclivc lissucs. lcndons,
ligamcnls, inliamusculai conncclivc lissuc
- Cicalci bonc mincial dcnsily oi lcss bonc dcmincializa-
- Pccicascd slicss on joinls duiing plysical aclivily
- Rcduccd iisk of sofl lissuc injuiy duiing plysical aclivily
- Possiblc impiovcmcnl in capacily lo icpaii and lcal
damagcd sofl lissucs duc lo posilivc impacl on lissuc
- Possiblc impiovcmcnl in balancc
- Fnlanccd plysical pcifoimancc duiing daily living,
occupalional, and iccicalional aclivilics
- Posilivc clangcs in body composilion. lcan musclc
mass oi body fal
- Fnlanccd fccling of plysical wcll-bcing
- Possiblc impiovcmcnl in pciccplion of disabilily and
qualily of lifc
increasing the work a muscle must perIorm during a
speciIied period oI time or reducing the amount oI time
required to produce a given Iorce. The greater the inten-
sity oI the exercise and the shorter the time period taken
to generate Iorce, the greater is the muscle power.
For power training regimens, such as plvometric training
or stretch-shortening arills the speed oI movement is the
variable that is most oIten manipulated.
Endurance is a broad term that reIers to the ability to
perIorm low-intensity, repetitive, or sustained activities
over a prolonged period oI time. Caraiopulmonarv
enaurance (total boav enaurance) is associated with
repetitive, dynamic motor activities such as walking,
cycling, swimming, or upper extremity ergometry,
which involve use oI the large muscles oI the body.
This aspect oI endurance is explored in Chapter 7.
Muscle enaurance (sometimes reIerred to as local
enaurance) is the ability oI a muscle to contract repeatedly
against a load (resistance), generate and sustain tension,
and resist Iatigue over an extended period oI time.
The term aerobic power is sometimes used inter-
changeably with muscle endurance.
oI balance and proper alignment oI the body segments
requires sustained control (endurance) by the postural
muscles. In Iact, almost all daily living tasks require some
degree oI muscle and cardiopulmonary endurance.
Although strength and muscle endurance, as elements
oI muscle perIormance, are associated, they do not always
correlate well with each other. Just because a muscle group
is strong, it does not preclude the possibility that muscular
endurance is impaired. For example, an individual in the
workplace who is strong has no diIIiculty liIting a 10-
pound object several timesbut does the worker have
suIIicient muscle endurance in the upper extremities and
the stabilizing muscles oI the trunk and lower extremities
to liIt 10-pound objects several hundred times during the
course oI a day`s work without excessive Iatigue or poten-
tial injury?
Endurance training. Enaurance training (enaurance exer-
cise) is characterized by having a muscle contract and liIt
or lower a light load Ior many repetitions or sustain a mus-
cle contraction Ior an extended period oI time.
key elements oI endurance training are low-intensity mus-
cle contractions, a large number oI repetitions, and a pro-
longed time period. Unlike strength training, muscles adapt
to endurance training by increases in their oxidative and
metabolic capacities, which allows better delivery and use
oI oxygen. For many patients with impaired muscle per-
Iormance, endurance training has a more positive impact
on improving Iunction than strength training. In addition,
using low levels oI resistance in an exercise program mini-
mizes adverse Iorces on joints, produces less irritation to
soIt tissues, and is more comIortable than heavy resistance
description oI the three elements oI muscle perIormance,
guiding principles oI exercise prescription and training are
discussed in this section.
Muscle strength is a broad term that reIers to the ability oI
contractile tissue to produce tension and a resultant Iorce
based on the demands placed on the muscle.
speciIically, muscle strength is the greatest measurable
Iorce that can be exerted by a muscle or muscle group to
overcome resistance during a single maximum eIIort.
Functional strength relates to the ability oI the neuromus-
cular system to produce, reduce, or control Iorces, contem-
plated or imposed, during Iunctional activities, in a
smooth, coordinated manner.
InsuIIicient muscular
strength can contribute to major Iunctional losses oI even
the most basic activities oI daily living.
Strength training. The development oI muscle strength
is an integral component oI most rehabilitation or condi-
tioning programs Ior individuals oI all ages and all ability
Strength training (strengthening exercise)
is deIined as a systematic procedure oI a muscle or mus-
cle group liIting, lowering, or controlling heavy loads
(resistance) Ior a relatively low number oI repetitions
or over a short period oI time.
The most common
adaptation to heavy resistance exercise is an increase in
the maximum Iorce-producing capacity oI muscle, that
is, an increase in muscle strength, primarily as the result
oI neural adaptations and an increase in muscle Iiber
Muscle power, another aspect oI muscle perIormance, is
related to the strength and speed oI movement and is
deIined as the work (Iorce distance) produced by a mus-
cle per unit oI time (Iorce distance/time).
In other words, it is the rate oI perIorming work. The rate
at which a muscle contracts and produces a resultant Iorce
and the relationship oI Iorce and velocity are Iactors that
aIIect muscle power.
Because work can be produced
over a very brieI or an extended period oI time, power can
be expressed by either a single burst oI high-intensity
activity (such as liIting a heavy piece oI luggage onto an
overhead rack or perIorming a high jump) or by repeated
bursts oI less intense muscle activity (such as climbing a
Ilight oI stairs). The terms anaerobic power and aerobic
power, respectively, are sometimes used to diIIerentiate
these two aspects oI power.
Power training. Many motor skills in our lives are com-
posed oI movements that are explosive and involve both
strength and speed. ThereIore, re-establishing muscle
power may be an important priority in a rehabilitation pro-
gram. Muscle strength is a necessary Ioundation Ior devel-
oping muscle power. Power can be enhanced by either
C R A P J E P 8 Pesislance Exercise For lnµaired Muscle Perfornance 140
0vcrload Prìncìplc
A guiding principle oI exercise prescription that has been
one oI the Ioundations on which the use oI resistance exer-
cise to improve muscle perIormance is based is the over-
loaa principle. Simply stated, iI muscle perIormance is to
improve, a load that exceeds the metabolic capacity oI the
muscle must be applied; that is, the muscle must be chal-
lenged to perIorm at a level greater than that to which it is
II the demands remain constant
aIter the muscle has adapted, the level oI muscle perIorm-
ance can be maintained but not increased.
Applìcafìon of fhc 0vcrload Prìncìplc
The overload principle Iocuses on the progressive loading
oI muscle by manipulating, Ior example, the intensity or
volume oI exercise. Intensitv oI resistance exercise reIers
to how much weight (resistance) is imposed on the muscle,
whereas volume encompasses variables such as repetitions,
sets, or Irequency oI exercise, any one or more oI which
can be gradually adjusted to increase the demands on the
In a strength training program, the amount of resistance
applied to the muscle is incrementally and progressively
For endurance training, more emphasis is placed on
increasing the time a muscle contraction is sustained or
the number of repetitions perIormed than on increasing
P R L C A U ! l 0 N . !o ensure safely, lhe exlenl and µro-
qression of overload nusl always be aµµlied in lhe conlexl
of lhe underlyinq µalholoqy, aqe of lhe µalienl, slaqe of lis-
sue healinq, falique, and lhe overall abililies and qoals of
lhe µalienl. !he nuscle and relaled body syslens nusl be
qiven line lo cJcpt lo lhe denands of an increased load or
reµelilions before lhe load or nunber of reµelilions is aqain
SAl0 Prìncìplc
The SAID principle (speciIic adaptation to imposed
suggests that a Iramework oI speciIicity is
a necessary Ioundation on which exercise programs
should be built. This principle applies to all body systems
and is an extension oI WolII`s law (body systems adapt
over time to the stresses placed on them). The SAID prin-
ciple helps therapists determine the exercise prescription
and which parameters oI exercise should be selected to cre-
ate speciIic training eIIects that best meet speciIic Iunc-
tional needs and goals.
Spccìfìcìfy of Jraìnìng
Specificitv of training, also reIerred to as specificitv of
exercise, is a widely accepted concept suggesting that the
adaptive eIIects oI training, such as improvement oI
strength, power, and endurance, are highly speciIic to the
training method employed.
Whenever possible, exercis-
es incorporated in a program should mimic the anticipated
Iunction. For example, iI the desired Iunctional activity
requires greater muscular endurance than strength, the
intensity and duration oI exercises should be geared to
improve muscular endurance.
SpeciIicity oI training should also be considered rela-
tive to mode (type) and velocity oI exercise
well as patient or limb position (joint angle)
the movement pattern during exercise. For example, iI the
desired Iunctional outcome is the ability to ascend and
descend stairs, exercise should be perIormed eccentrically
and concentrically in a weight-bearing pattern and pro-
gressed to the desired speed. Regardless oI the simplicity
or complexity oI the motor task to be learned, task-speciIic
practice must always be emphasized. It has been suggested
that the basis oI speciIicity oI training is related to morpho-
logical and metabolic changes in muscle as well as neural
adaptations to the training stimulus associated with motor
Jransfcr of Jraìnìng
In contrast to the SAID principle, carryover oI training
eIIects Irom one variation oI exercise or task to another
has also been reported. This phenomenon is called transfer
of training, overflow, or cross-training. TransIer oI training
has been reported to occur on a verv limitea basis with
respect to the velocity oI training
and the type or
mode oI exercise.
It has also been suggested that a cross-
training eIIect can occur Irom an exercised limb to a
nonexercised, contralateral limb in a resistance training
A program oI exercises designed to develop muscle
strength has also been shown to improve muscular
endurance at least moderately. In contrast, endurance train-
ing has little to no cross-training eIIect on strength.
Strength training at one speed oI exercise has been shown
to provide some improvement in strength at higher or
lower speeds oI exercise. However, the overIlow eIIects are
substantially less than the training eIIects resulting Irom
speciIicity oI training.
Despite the evidence that a small degree oI transIer oI
training does occur in resistance exercise programs, most
studies support the importance oI designing an exercise
program that most closely replicates the desired Iunctional
activities. As many variables as possible in the exercise
program should match the requirements and demands
placed on a patient during speciIic Iunctional activities.
Pcvcrsìhìlìfy Prìncìplc
Adaptive changes in the body`s systems, such as increased
strength or endurance, in response to a resistance exercise
program are transient unless training-induced improve-
ments are regularly used Ior Iunctional activities or unless
an individual participates in a maintenance program oI
resistance exercises.
nalion on nuscle slruclure and funclion, nunerous
resources are available.
Diverse but interrelated Iactors aIIect the tension-
generating capacity oI normal skeletal muscle necessary
to control the body and perIorm motor tasks. Determinants
and correlates include morphological, biomechanical,
neurological, metabolic, and biochemical Iactors. All con-
tribute to the magnituae, auration, and speea oI Iorce pro-
duction as well as how resistant or susceptible a muscle
is to Iatigue. Properties oI muscle itselI as well as key
neural Iactors and their impact on tension generation
during an active muscle contraction are summarized in
Table 6.1.
Additional Iactors such as the energy stores available
to muscle, the inIluence oI Iatigue and recovery Irom exer-
cise, and a person`s age, gender, and psychological/cogni-
tive status, as well as many other Iactors, aIIect a muscle`s
ability to develop and sustain tension. A therapist must rec-
ognize that these Iactors aIIect a patient`s perIormance dur-
ing exercise and the potential outcomes oI the exercise
Encrgy Sforcs and 8lood Supply
Muscle needs adequate sources oI energy (Iuel) to contract,
generate tension, and resist Iatigue. The predominant Iiber
type Iound in the muscle and the adequacy oI blood sup-
ply, which transports oxygen and nutrients to muscle and
removes waste products, aIIect the tension-producing
capacity oI a muscle and its resistance to Iatigue.
three main energy systems (ATP-PC system, anaerobic/gly-
colytic/lactic acid system, aerobic system) are reviewed in
Chapter 7.
Detraining, reIlected by a reduction in muscle per-
Iormance, begins within a week or two aIter the cessation
oI resistance exercises and continues until training eIIects
are lost.
For this reason, it is imperative that gains in
strength and endurance are incorporated into daily activi-
ties as early as possible in a rehabilitation program. It is
also advisable Ior patients to participate in a maintenance
program oI resistance exercises as an integral component
oI a liIelong Iitness program.
Knowledge oI the Iactors that inIluence the Iorce-
producing capacity oI normal muscle during an active
contraction is Iundamental to understanding how the
neuromuscular system adapts as the result oI resistance
training. This knowledge, in turn, provides a basis on
which a therapist is able to make sound clinical decisions
when designing a resistance exercise program Ior patients
with weakness and Iunctional limitations as the result oI
injury or disease or to enhance physical perIormance and
prevent or reduce the risk oI injury in healthy individuals.
Facfors fhaf lnflucncc Jcnsìon
0cncrafìon ìn Normal Skclcfal Musclc
N 0 ! L . For a brief review of lhe slruclure of skelelal nus-
cle, refer lo Chaµler 4 of lhis lexlbook. For in-deµlh infor-
C R A P J E P 8 Pesislance Exercise For lnµaired Muscle Perfornance 151
JA8LE 8.1 0cfcrmìnanfs and Corrclafcs fhaf Affccf Jcnsìon 0cncrafìon of Skclcfal Musclc
FacIor Inf|ucncc
Cross-section and size of the muscle (includes muscle
fiber number and size)
Fiber arrangement and fiber length (also relates to
cross-sectional diameter of the muscle)
Fiber-type distribution of muscle: type Ì (tonic, slow-
twitch) and type ÌÌA & ÌÌB (phasic, fast-twitch)
Length-tension relationship of muscle at time of
Recruitment of motor units
Frequency of firing of motor units
Type of muscle contraction
Speed of muscle contraction (force-velocity relationship)
The larger the muscle diameter, the greater its tension-
producing capacity
Short fibers with pinnate and multipinnate design in high
force producing muscles (ex. quadriceps, gastrocnemius,
deltoid, biceps brachii)
Long parallel design in muscles with high rate of shortening
but less force production (ex. sartorius, lumbricals)
High percentage of type Ì fibers: low force production, slow
rate of maximum force development, resistant to fatigue
High percentage of type ÌÌA and ÌÌB fibers: rapid high force
production; rapid fatigue
Muscle produces greatest tension when it is near or at the
physiological resting position at the time of contraction
The greater the number and synchronization of motor units
firing, the greater the force production
The higher the frequency of firing, the greater the tension
Force output from greatest to least: eccentric, isometric,
concentric muscle contraction
Concentric contraction: speed tension. Eccentric
contraction: speed tension
Fatigue is a complex phenomenon that aIIects muscle per-
Iormance and must be considered in a resistance training
program. Fatigue has a variety oI deIinitions that are based
on the type oI Iatigue being addressed.
Muscle (local) fatigue. Most relevant to resistance
exercise is the phenomenon oI skeletal muscle Iatigue.
Muscle (local) Iatiguethe diminished response oI
muscle to a repeated stimulusis reIlected in a progres-
sive decrement in the amplitude oI motor unit poten-
This occurs during exercise when a muscle
repeatedly contracts statically or dynamically against an
imposed load.
This acute physiological response to exercise is nor-
mal and reversible. It is characterized by a gradual decline
in the Iorce-producing capacity oI the neuromuscular sys-
tem, that is, a temporarv state oI exhaustion (Iailure), lead-
ing to a decrease in muscle strength.
The diminished response oI the muscle is caused by a
combination oI Iactors, which include:
Disturbances in the contractile mechanism oI the muscle
itselI because oI a decrease in energy stores, insuIIicient
oxygen, and a build-up oI H
Inhibitory (protective) inIluences Irom the central nerv-
ous system
Possibly a decrease in the conduction oI impulses at
the myoneural junction, particularly in Iast-twitch
The Iiber-type distribution oI a muscle, which can
be divided into two broad categories (type I and type II),
aIIects how resistant it is to Iatigue.
Type II
(phasic, Iast-twitch) muscle Iibers are Iurther divided
into two additional classiIications (types IIA and IIB)
based on contractile and Iatigue characteristics. Some
resources subdivide type II Iibers into three classiIica-
In general, type II Iibers generate a great amount
oI tension within a short period oI time, with type IIB
being geared toward anaerobic metabolic activity and
having a tendency to Iatigue more quickly than type IIA
Iibers. Type I (tonic, slow-twitch) muscle Iibers generate
a low level oI muscle tension but can sustain the con-
traction Ior a long time. These Iibers are geared toward
aerobic metabolism, as are type IIA Iibers. However,
type I Iibers are more resistant to Iatigue than type IIA.
Table 6.2 compares the characteristics oI muscle Iiber
Because diIIerent muscles are composed oI varying
proportions oI tonic and phasic Iibers, their Iunction
becomes specialized. For example, a heavy distribution oI
type I (tonic) Iibers is Iound in postural muscles, which
allows muscles such as the soleus to sustain a low level oI
tension Ior extended periods oI time to hold the body erect
against gravity or stabilize against repetitive loads. On
the other end oI the Iatigue spectrum, muscles with a
large distribution oI type IIB (phasic) Iibers, such as the
gastrocnemius or biceps brachii, produce a great burst
oI tension to enable a person to liIt the entire body weight
or to liIt, lower, push, or pull a heavy load but Iatigue
Clinical signs oI muscular Iatigue during exercise are
summarized in Box 6.2. When these signs and symptoms
develop during resistance exercise, it is time to decrease
the load on the exercising muscle or stop the exercise and
shiIt to another muscle group to allow time Ior the Iatigued
muscle to rest and recover.
Cardiopulmonary (general) fatigue. This type oI Iatigue is
the diminished response oI an individual (the entire body)
as the result oI prolonged physical activity, such as walk-
ing, jogging, cycling, or repetitive liIting or digging.
It is related to the body`s ability to use oxygen eIIiciently.
Cardiopulmonary Iatigue associated with endurance train-
ing is probably caused by a combination oI the Iollowing
JA8LE 8.2 Musclc Fìhcr Jypcs and Pcsìsfancc
fo Fafìguc
LharacIcrìsIìcs Jypc I Jypc IIA Jypc II8
to fatigue
Capillary density
Energy system
Twitch rate
Maximum muscle-
80X 8.2 Sìgns and Sympfoms of Musclc
- An uncomfoilablc scnsalion in llc musclc, cvcn pain and
- 1icmulousncss in llc conliacling musclc
- Aclivc movcmcnls jciky, nol smooll
- lnabilily lo complclc llc movcmcnl pallcin lliougl llc
full iangc of availablc molion duiing dynamic cxcicisc
againsl llc samc lcvcl of icsislancc
- Usc of subslilulc molions÷llal is, incoiiccl movcmcnl
pallcins÷lo complclc llc movcmcnl pallcin
- lnabilily lo conlinuc low-inlcnsily plysical aclivily
- Pcclinc in pcak loiquc duiing isokinclic lcsling
Lactic acid is removed Irom skeletal muscle and blood
within approximately 1 hour aIter exercise.
Glycogen is replaced over several days.
Focus on Evidence
It has been known Ior some time that iI light exercise is
perIormed during the recovery period (active recoverv),
recovery Irom exercise occurs more rapidly than with total
rest (passive recoverv).
Faster recovery with
light exercise is probably the result oI neural as well as
circulatory inIluences.
P R L C A U ! l 0 N S . 0nly if a µalienl is allowed adequale
line lo recover fron falique afler each exercise session does
lonq-lern nuscle µerfornance (slrenqlh, µower, or
endurance) inµrove.
lf a sufficienl resl inlerval is nol a
recurrinq conµonenl of a resislance exercise µroqran, a
µalienl's µerfornance µlaleaus or deleriorales. Evidence of
overlraininq or overwork weakness nay becone aµµarenl
(see addilional discussion in a laler seclion of lhis chaµler).
ll has also been shown lhal faliqued nuscles are nore sus-
ceµlible lo acule slrains.
Muscle perIormance changes throughout the liIe span.
Whether the goal oI a resistance training program is to
remediate impairments and Iunctional limitations or
enhance Iitness and perIormance oI physical activities, an
understanding oI 'typical¨ changes in muscle perIormance
and response to exercise during each phase oI liIe Irom
early childhood through the advanced years oI liIe is nec-
essary to prescribe eIIective, saIe resistance exercises Ior
individuals oI all ages. Key aspects oI how muscle per-
Iormance changes throughout liIe are discussed in this sec-
tion and summarized in Box 6.3.
Early Childhood and Preadolescence
In absolute terms, muscle perIormance (speciIically
strength), which in part is related to the development oI
muscle mass, increases linearlv with chronological age
in both boys and girls Irom birth through early and mid-
dle childhood to puberty.
Muscle endurance also
increases linearly during the childhood years.
Iiber number is essentially determined prior to or shortly
aIter birth,
although there is speculation that Iiber num-
ber may continue to increase into early childhood.
rate oI Iiber growth (increase in cross-sectional area) is
relatively consistent Irom birth to puberty. Change in
Iiber type distribution is relatively complete by the age
oI 1, shiIting Irom a predominance oI type II Iibers to
Decrease in blood sugar (glucose) levels
Decrease in glycogen stores in muscle and liver
Depletion oI potassium, especially in the elderly patient
1hreshold for fatigue. Threshold Ior Iatigue is the level
oI exercise that cannot be sustained indeIinitely.
patient`s threshold Ior Iatigue could be noted as the length
oI time a contraction is maintained or the number oI repeti-
tions oI an exercise that initially can be perIormed. This
sets a baseline Irom which adaptive changes in physical
perIormance can be measured.
Factors that influence fatigue. Factors that inIluence
Iatigue are diverse. A patient`s health status, diet, or
liIestyle (sedentary or active) all inIluence Iatigue. In
patients with neuromuscular, cardiopulmonary, oncologic,
inIlammatory, or psychological disorders, the onset oI
Iatigue is oIten abnormal.
For instance, it may occur
abruptly, more rapidly, or at predictable intervals.
It is advisable Ior a therapist to become Iamiliar with
the patterns oI Iatigue associated with diIIerent diseases
and medications. In multiple sclerosis, Ior example, the
patient usually awakens rested and Iunctions well during
the early morning. By mid-aIternoon, however, the patient
reaches a peak oI Iatigue and becomes notably weak.
Then by early evening the Iatigue diminishes, and strength
returns. Patients with cardiac, peripheral vascular, and
pulmonary diseases, as well as patients with cancer under-
going chemotherapy or radiation therapy, all have deIicits
that compromise the oxygen transport system. ThereIore,
these patients Iatigue more readily and require a longer
period oI time Ior recovery Irom exercise.
Environmental Iactors, such as outside or room tem-
perature, air quality, and altitude, also inIluence how
quickly the onset oI Iatigue occurs and how much time is
required Ior recovery Irom exercise.
Pccovcry from Excrcìsc
Adequate time Ior recovery Irom Iatiguing exercise must
be built into every resistance training program. This applies
to both intrasession and intersession recovery. AIter vigor-
ous exercise, the body must be given time to restore itselI
to a state that existed prior to the exhaustive exercise.
Recovery Irom acute exercise, where the Iorce-producing
capacity oI muscle returns to 90° to 95° oI the pre-
exercise capacity, usually takes 3 to 4 minutes, with the
greatest proportion oI recovery occurring in the Iirst
Changes that occur in muscle during recovery are:
Oxygen stores are replenished in muscles.
Energy stores are replenished.
C R A P J E P 8 Pesislance Exercise For lnµaired Muscle Perfornance 158
a more balanced distribution oI type I and type II
Throughout childhood, boys have slightly greater
absolute and relative muscle mass (kilograms oI muscle
per kilogram oI body weight) than girls, with boys approx-
imately 10° stronger than girls Irom early childhood to
This diIIerence may be associated with diIIer-
ences in relative muscle mass, although social expecta-
tions, especially by mid-childhood, also may contribute to
the observed diIIerence in muscle strength.
There is no question that an appropriately designed
resistance exercise program can improve muscle strength
in children above and beyond gains attributable to typical
growth and development. A review oI the literature
many studies that support this statement. However, there is
concern that children who participate in resistance training
may be at risk Ior injuries, such as an epiphyseal Iracture
or avulsion Iracture, because the musculoskeletal system
is immature.
The American Academy oI Pedi-
and the American College oI Sports Medicine
support youth participation in resistance training programs
iI they are designed appropriately and careIully supervised
(Fig. 6.1). With this in mind, two important questions need
to be addressed: (1) At what point during childhood is a
resistance training program appropriate? (2) What consti-
tutes a saIe training program?
80X 8.8 Summary of Agc-Pclafcd Changcs ìn Musclc and Musclc Pcrformancc
InIancy, Early Childhood, and Prcadolcsccncc
- Al biill, musclc accounls foi aboul 2¯% of body wcigll.
- 1olal numbci of musclc fibcis is cslablislcd piioi lo oi
caily duiing infancy.
- Poslnalal clangcs in disliibulion of lypc l and lypc ll
fibcis in musclc aic iclalivcly complclc by llc cnd of llc
fiisl ycai of lifc.
- Musclc fibci sizc and musclc mass incicasc lincaily fiom
infancy lo pubcily.
- Musclc slicngll and musclc cnduiancc incicasc lincaily
will clionological agc in boys and giils lliougloul clild-
lood unlil pubcily.
- Musclc mass (absolulc and iclalivc) and musclc slicngll is
jusl sligllly gicalci (appioximalcly 10%) in boys llan giils
fiom caily clildlood lo pubcily.
- 1iaining-induccd slicngll gains occui cqually in boll
scxcs duiing clildlood willoul cvidcncc of lypcilioply
unlil pubcily.
- Rapid accclcialion in musclc fibci sizc and musclc mass,
cspccially in boys. Puiing pubcily, musclc mass incicascs
moic llan 20% pci ycai.
- Rapid incicasc in musclc slicngll in boll scxcs.
- Maikcd diffcicncc in slicngll lcvcls dcvclops in boys and
- ln boys, musclc mass and body lcigll and wcigll pcak
bcfoic musclc slicngll, in giils, slicngll pcaks bcfoic
body wcigll.
- Rclalivc slicngll gains as llc icsull of icsislancc liaining
aic compaiablc bclwccn llc scxcs, will significanlly
gicalci musclc lypcilioply in boys.
Young and Middlc Adulthood
- Musclc mass pcaks in womcn bclwccn 16 and 20 ycais of
agc, musclc mass in mcn pcaks bclwccn 18 and 2¯ ycais
of agc.
- Pccicascs in musclc mass occui as caily as 2¯ ycais of agc.
- Musclc mass conslilulcs appioximalcly 40% of lolal body
wcigll duiing caily adulllood, will mcn laving sligllly
moic musclc mass llan womcn.
- Slicngll conlinucs lo dcvclop inlo llc sccond dccadc,
cspccially in mcn.
- Musclc slicngll and cnduiancc icacl a pcak duiing llc
sccond dccadc, cailici foi womcn llan mcn.
- By somclimc in llc lliid dccadc, slicngll dcclincs bc-
lwccn 8% and 10% pci dccadc lliougl llc fifll oi
sixll dccadc.
- Slicngll and musclc cnduiancc dclciioialc lcss iapidly in
plysically aclivc vcisus scdcnlaiy adulls.
- lmpiovcmcnls in slicngll and cnduiancc aic possiblc will
only a modcsl incicasc in plysical aclivily.
Iatc Adulthood
- Ralc of dcclinc of musclc slicngll accclcialcs lo 1¯% lo
20% pci dccadc duiing llc sixll and scvcnll dccadcs and
incicascs lo 20% pci dccadc llcicaflci.
- Loss of musclc mass conlinucs, by llc ciglll dccadc,
skclclal musclc mass las dccicascd by ¯0% compaicd lo
pcak musclc mass duiing young adulllood.
- Musclc fibci sizc (cioss-scclional aica), lypc l and lypc ll
fibci numbcis, and llc numbci of alpla moloncuions all
dccicasc. Picfcicnlial alioply of lypc ll musclc fibcis
- Pccicasc in llc spccd of musclc conliaclions and pcak
- Ciadual bul piogicssivc dccicasc in cnduiancc and maxi-
mum oxygcn uplakc.
- Loss of flcxibilily icduccs llc foicc-pioducing capacily of
- Minimal dcclinc in pcifoimancc of funclional skills duiing
llc sixll dccadc.
- Significanl dclciioialion in funclional abililics by llc
ciglll dccadc associalcd will a dcclinc in musculai
- Will a icsislancc liaining piogiam, a significanl impiovc-
mcnl in musclc slicngll, powci, and cnduiancc is possiblc
duiing lalc adulllood.
- Fvidcncc of llc impacl of icsislancc liaining on llc lcvcl
of pcifoimancc of funclional moloi skills is mixcd bul
els gradually return to a pretraining level, as occurs in
This suggests that some maintenance level oI
training could be useIul in children as with adults.
In addition, although evidence to suggest that a struc-
tured resistance training program Ior children (in addi-
tion to a general sports conditioning program) reduces
injuries or enhances sports perIormance is inconclusive,
other health-related beneIits have been noted, including
increased cardiopulmonary Iitness, decreased blood lipids
levels, and improved psychological well-being.
These Iindings suggest that participation in a resistance
training program during the later childhood (preadoles-
cent) years may, indeed, be oI value iI the program is
perIormed at an appropriate level (low loads and repeti-
tions) and is closely supervised.
At puberty, as hormonal levels change, there is rapid accel-
eration in the development oI muscle strength, especially
in boys. During this phase oI development, typical strength
levels become markedly diIIerent in boys and girls, which
in part are caused by hormonal diIIerences between the
sexes. Longitudinal studies
oI adolescent boys indicate
that strength increases about 30° per year between ages
10 and 16, with muscle mass peaking beIore muscle
strength. In adolescent girls, peak strength develops beIore
peak weight.
Overall, during the adolescent years, muscle
mass increases more than 5-Iold in boys and approximately
3.5-Iold in girls.
Although most longitudinal studies oI
growth stop at age 18, strength continues to develop, par-
ticularly in males, well into the second and even into the
third decade oI liIe.
As with prepubescent children, resistance training
during puberty also results in signiIicant strength gains.
During puberty these gains average 30° to 40° above that
which is expected as the result oI normal growth and matu-
BeneIits oI strength training noted during puberty
are similar to those noted in prepubescent children.
Young and Middle Adulthood
Although data on typical strength and endurance levels
during the second through the IiIth decades oI liIe are more
oIten Irom studies oI men than women, a Iew generaliza-
tions can be made that seem to apply to both sexes.
Strength reaches a maximal level earlier in women than
men, with women reaching a peak during the second
decade and in most men by age 30. Strength then declines
approximately 1° per year,
or 8° per decade.
decline in strength appears to be minor until about age
and tends to occur at a later age or slower rate in
active adults versus those who are sedentary.
potential Ior improving muscle perIormance with a resist-
ance training program (Fig. 6.2 A&B) or by participation
in even moderately demanding activities several times a
week is high during this phase oI liIe. Guidelines Ior
young and middle-aged adults participating in resistance
training have been published by the American College oI
Sports Medicine (ACSM).
There is general consensus that during the toddler, pre-
school, and even the early elementary school years, Iree
play and organized but age-appropriate physical activities
are eIIective methods to promote Iitness and improve mus-
cle perIormance, rather than structured resistance training
programs. The emphasis throughout most or all oI the Iirst
decade oI liIe should be on recreation and learning motor
However, there is lack oI agreement on when and
under what circumstances resistance training is an appro-
priate Iorm oI exercise. During the past two decades it has
become popular Ior older (preadolescent) boys and girls to
participate in resistance training programs, in theory, to
enhance athletic perIormance and reduce the risk oI sport-
related injury. In addition, prepubescent children who sus-
tain injuries during everyday activities may require
rehabilitation that may include resistance exercises. Conse-
quently, an understanding oI the eIIects oI exercise in this
age group Iounded on current research must be the basis
Ior establishing a saIe program with realistic goals.
Focus on Evidence
In the preadolescent age group many studies have shown
that improvements in strength and muscular endurance
occur on a relative basis similar to training-induced gains
in young adults.
It is also important to point out
that, although only a Iew studies have looked at the eIIects
oI detraining in children, when training ceases strength lev-
C R A P J E P 8 Pesislance Exercise For lnµaired Muscle Perfornance 155
Fl0uPE 8.1 Res|s¦ance ¦ra|n|nç, |¦ |n|¦|a¦ed dur|nç ¦|e µreado|escen¦
,ears, s|ou|d ue µer¦orued us|nç uod, we|ç|¦ or ||ç|¦ we|ç|¦s and care-
¦u||, suµerv|sed.
Late Adulthood
The rate oI decline in the tension-generating capacity oI
muscle in most cases accelerates to approximately 15° to
20° per decade in men and women in their sixties and
seventies, and it increases to 30° per decade there-
However, the rate oI decline may be signiIicant-
ly less (only 0.3° decrease per year) in elderly men and
women who maintain a high level oI physical activity.
These disparate Iindings and others suggest that loss oI
muscle strength during the advanced years may be due, in
part, to progressively greater inactivity and disuse.
oI muscle strength during late adulthood, particularly dur-
ing the eighties and beyond, is associated with a gradual
increase in Iunctional limitations as well as an increase in
the Irequency oI Ialling.
The decline in muscle strength and endurance in the
elderly is associated with many Iactors in addition to pro-
gressive disuse and inactivity. It is diIIicult to determine iI
these Iactors are causes or eIIects oI age-related deteriora-
tion in strength. Neuromuscular Iactors include a decrease
in muscle mass (atrophy), decrease in the number oI type I
and II muscle Iibers with a corresponding increase in con-
nective tissue in muscle, a decrease in the cross-sectional
size oI muscle, selective atrophy oI type II Iibers, and
change in the lengthtension relationship oI muscle associ-
ated with loss oI Ilexibility, more so than deIicits in motor
unit activation and Iiring rate.
decline in the number oI motor units appears to begin aIter
age 60.
All oI these changes have an impact on strength
and physical perIormance.
In addition to decreases in muscle strength, declines
in speed oI muscle contraction, muscle endurance, and
the ability to recover Irom muscular Iatigue occur with
advanced age.
The time needed to produce the same
absolute and relative levels oI torque output and the time
necessary to achieve relaxation aIter a voluntary contrac-
tion are lengthened in the elderly compared to younger
Consequently, as velocity oI movement declines,
so does the ability to generate muscle power during activi-
ties that require quick responses, such as rising Irom a low
chair or adjusting one`s balance to prevent a Iall.
InIormation on changes in muscle endurance with
aging is limited. There is some evidence to suggest that the
ability to sustain low-intensity muscular eIIort also
declines with age, in part because oI reduced blood supply
and capillary density in muscle, decreased mitochondrial
density, changes in enzymatic activity level, and decreased
glucose transport.
As a result, muscle Iatigue may tend
to occur more readily in the elderly. In the healthy and
active (community-dwelling) elderly population, the
decline in muscle endurance appears to be minimal well
into the seventies.
During the past Iew decades, as the health care com-
munity and the public have become more aware oI the ben-
eIits oI resistance training during late adulthood, more and
more older adults are participating in Iitness programs that
include resistance exercises (Fig. 6.3). ACSM has also pub-
Fl0uPE 8.2 Cond|¦|on|nç and ¦|¦ness µroçraus ¦or ac¦|ve ,ounç and
u|dd|e-açe adu|¦s |nc|ude res|s¦ance ¦ra|n|nç w|¦| a ua|ance o¦ (/} uµµer
ez¦reu|¦, and (3} |ower ez¦reu|¦, s¦renç¦|en|nç ezerc|ses.
Fl0uPE 8.8 lncorµora¦|nç res|s¦ance ¦ra|n|nç |n¦o a ¦|¦ness µroçrau
|as uan, uene¦|¦s ¦or o|der adu|¦s.
vant inIormation Irom the environment and to respond to
internal cues Irom the body. Both are necessary when Iirst
learning an exercise and later when carrying out an exer-
cise program independently. Attention to Iorm and tech-
nique during resistance training is necessary Ior patient
saIety and optimal long-term training eIIects.
Motivation and Feedback
II a resistance exercise program is to be eIIective, a patient
must be willing to put Iorth and maintain suIIicient eIIort
and adhere to an exercise program over time to improve
muscle perIormance Ior Iunctional activities. Use oI activi-
ties that are meaningIul and are perceived as having poten-
tial useIulness or periodically modiIying an exercise
routine help maintain a patient`s interest in resistance train-
ing. Charting or graphing a patient`s strength gains, Ior
example, also helps sustain motivation. Incorporating gains
in muscle perIormance into Iunctional activities as early as
possible in a resistance exercise program puts improve-
ments in strength to practical use, thereby making those
improvements meaningIul.
The importance oI Ieedback Ior learning an exercise
or a motor skill is discussed in Chapter 1. In addition,
Ieedback can have a positive impact on a patient`s motiva-
tion and subsequent adherence to an exercise program. For
example, some computerized equipment, such as isokinetic
dynamometers, provide visual or auditory signals that let
the patient know iI each muscle contraction during a par-
ticular exercise is in a zone that causes a training eIIect.
Documenting improvements over time, such as the amount
oI weight (exercise load) used during various exercises or
changes in walking distance or speed, also provides posi-
tive Ieedback to sustain a patient`s motivation in a resist-
ance exercise program.
Physìologìcal Adapfafìons
fo Pcsìsfancc Excrcìsc
The use oI resistance exercise in rehabilitation and condi-
tioning programs has a substantial impact on all systems
oI the body. Resistance training is equally important Ior
patients with impaired muscle perIormance and individuals
who wish to improve or maintain their level oI Iitness,
enhance perIormance, or reduce the risk oI injury. When
body systems are exposed to a greater than usual but
appropriate level oI resistance in an exercise program,
they initially react with a number oI acute physiological
and then later adapt. That is, body systems
accommodate over time to the newly imposed physical
Training-induced adaptations to resist-
ance exercise, known as chronic physiological responses,
that aIIect muscle perIormance are summarized in Table
6.3 and discussed in this section. Key diIIerences in adap-
tations Irom strength training versus endurance training
are noted.
Adaptations to overload create changes in muscle per-
Iormance and, in part, determine the eIIectiveness oI a
resistance training program. The time course Ior these
adaptations to occur varies Irom one individual to another
lished guidelines Ior resistance training Ior healthy adults
over 60 to 65 years oI age.
Focus on Evidence
A review oI the literature indicates that when healthy
or Irail elderly individuals participate in a resistance train-
ing program oI appropriate duration and intensity, muscle
strength and endurance increase.
Some oI these studies
have also measured pretraining and post-training levels
oI Iunctional abilities, such as balance, stair climbing,
walking speed, and chair rise. The eIIect oI strength and
endurance training on Iunctional abilities is promising but
still inconclusive, with most but not all
demonstrating a positive impact.
disparity oI outcomes among investigations underscores
the point that resistance training has a direct impact on
muscle perIormance but only an indirect impact on Iunc-
tional perIormance, a more complex variable. Studies oI
elderly individuals have also shown that iI resistance train-
ing is discontinued, detraining gradually occurs; and subse-
quently strength and Iunctional capabilities deteriorate
close to pretraining levels.
In summary, evidence indi-
cates that the decline in muscle strength and Iunctional
abilities that occurs during late adulthood can be slowed or
at least partially reversed with a resistance training pro-
gram. However, as in other age groups, iI these training-
induced improvements are to be maintained, some degree
oI resistance training must be continued.
Psychologìcal and Cognìfìvc Facfors
An array oI psychological Iactors can positively or nega-
tively inIluence muscle perIormance and how easily, vigor-
ously, or cautiously a person moves. Just as injury and
disease adversely aIIect muscle perIormance, so can one`s
mental status. For example, Iear oI pain, injury, or reinjury,
depression related to physical illness, or impaired attention
or memory as the result oI age, head injury, or the side
eIIects oI medication can adversely aIIect the ability to
develop or sustain suIIicient muscle tension Ior execution
or acquisition oI Iunctional motor tasks. In contrast, psy-
chological Iactors can also positively inIluence physical
The principles and methods employed to maximize
motor perIormance and learning as Iunctions oI eIIective
patient education are discussed in Chapter 1. These princi-
ples and methods should be applied in a resistance training
program to develop a requisite level oI muscle strength,
power, and endurance Ior Iunctional activities. The Iollow-
ing interrelated psychological Iactors as well as other
aspects oI motor learning may inIluence muscle perIorm-
ance and the eIIectiveness oI a resistance training program.
A patient must be able to Iocus on a given task (exercise)
to learn how to perIorm it correctly. Attention involves the
ability to process relevant data while screening out irrele-
C R A P J E P 8 Pesislance Exercise For lnµaired Muscle Perfornance 157
* See reIerences 35, 36, 43, 120, 145, 179, 203, 213, 248,
267, 270, 304
and is dependent on a person`s health status and previous
level oI participation in a resistance exercise program.
Ncural Adapfafìons
It is well accepted that in a resistance training program the
initial, rapid gain in the tension-generating capacity oI
skeletal muscle is largely attributed to neural responses,
not adaptive changes in muscle itselI.
This is
reIlected by an increase in electromyographic (EMG)
activity during the Iirst 4 to 8 weeks oI training with little
to no evidence oI muscle Iiber hypertrophy. It is also possi-
ble that increased neural activity is the source oI additional
gains in strength late in a resistance training program even
aIter muscle hypertrophy has reached a plateau.
Neural adaptations are attributed to motor learning and
improved coordination
and include increasea
recruitment in the number oI motor units Iiring as well as
an increasea rate ana svnchroni:ation oI Iiring.
It is speculated that these changes are caused by a decrease
in the inhibitory Iunction oI the central nervous system
(CNS), decreased sensitivity oI the Golgi tendon organ
(GTO), or changes at the myoneural junction oI the motor
Skclcfal Musclc Adapfafìons
As noted previously, the tension-producing capacity oI
muscle is directly related to the physiological cross-
sectional area oI the individual muscle Iibers. Hvpertrophv
is an increase in the size (bulk) oI an individual muscle
Iiber caused by an increase in myoIibrillar volume.
AIter an extended period oI moderate- to high-intensity
resistance training, usually by 4 to 8 weeks
possibly as early as 2 to 3 weeks with very high-intensity
resistance training,
hypertrophy becomes an increas-
ingly important adaptation that accounts Ior strength
gains in muscle.
Although the mechanism oI hypertrophy is complex
and the stimulus Ior growth is not clearly understood,
hypertrophy oI skeletal muscle appears to be the result oI
an increase in protein (actin and myosin) synthesis and a
decrease in protein degradation. Hypertrophy is also asso-
ciated with biochemical changes that stimulate uptake oI
amino acids.
The greatest increases in protein synthesis and
thereIore hypertrophy are associated with high-volume,
moderate-resistance exercise perIormed eccentrically.
In addition, it is the type IIB muscle Iibers that appear to
increase in size most readily with resistance training.
Although the topic has been debated Ior many years and
evidence oI the phenomenon is sparse, there is some
thought that a portion oI the increase in muscle size that
occurs with heavy resistance training is caused by hvper-
plasia, an increase in the number oI muscle Iibers. It has
been suggested that this increase in Iiber number, observed
in laboratory animals,
is the result oI longitudinal
splitting oI Iibers.
It has been postulated that Iiber
splitting occurs when individual muscle Iibers increase in
size to a point where they are ineIIicient, then subsequently
split to Iorm two distinct Iibers.
JA8LE 8.8 Physìologìcal Adapfafìons fo Pcsìsfancc Excrcìsc
varìah|c SIrcngIh Jraìnìng AdapIaIìons Lndurancc Jraìnìng AdapIaIìons
Skeletal muscle structure
Neural system
Metabolic system
Body composition
Connective tissue
Hypertrophy of muscle fibers; greater in type
ÌÌ fibers
Hyperplasia (possibly) of muscle fibers
Fiber type composition: remodeling of type
ÌÌB to type ÌÌA; no change in type Ì to type
ÌÌ distribution (i.e., no conversion)
Capillary bed density: or no change
Mitochondrial density and volume:
Motor unit recruitment: # motor units firing
Rate of firing: ( twitch contraction time)
Synchronization of firing:
ATP and CP storage:
Myoglobin storage:
Stored triglycerides: not known
Creatine phosphokinase:
Lean body (fat-free) mass:
% body fat:
Tensile strength of tendons, ligaments, and
connective tissue in muscle:
Bone: bone mineral density; no change or
possible in bone mass
Hypertrophy: minimal or no change
Capillary bed density:
Mitochondrial density and volume:
ATP and CP storage:
Myoglobin storage:
Stored triglycerides:
Lean body (fat-free) mass: no change
% body fat:
Tensile strength of tendons, ligaments,
and connective tissue in muscle:
Bone: mineralization with weight-
bearing activities
It is also thought that noncontractile soIt tissue strength
may develop more rapidly with eccentric resistance train-
ing than with other types oI resistance exercises.
Numerous sources indicate there is a high correlation
between muscle strength and the level oI physical activity
across the liIe span with bone mineral density.
quently, physical activities and exercises, particularly those
perIormed in weight-bearing positions, are typically rec-
ommended to minimize or prevent age-related bone loss.
They are also prescribed to reduce the risk oI Iractures or
improve bone density when osteopenia or osteoporosis is
already present.
Focus on Evidence
Although the evidence Irom prospective studies is limited
and mixed, resistance exercises perIormed with adequate
intensity and with site-speciIic loading through weight
bearing oI the bony area to be tested has been shown to
increase or maintain bone mineral density.
contrast, a number oI studies in young, healthy women
and postmenopausal women
have reported that there
was no signiIicant increase in bone mineral density with
resistance training. However, the resistance exercises in
these studies were not combined with site-speciIic weight
bearing. In addition, the intensity oI the weight training
programs may not have been high enough to have an
impact on bone density.
The time course oI the exer-
cise program also may not have been long enough. It has
been suggested that it may take as long as 9 months to a
year oI exercise Ior detectable and signiIicant increases
in bone mass to occur.
In the spine, although studies to
date have not shown that resistance training prevents spinal
Iractures, there is some evidence to suggest that the
strength oI the back extensors closely correlates with bone
mineral density oI the spine.
Research continues to determine the most eIIective
Iorms oI exercise to enhance bone density and prevent
age-related bone loss and Iractures. For additional inIor-
mation on prevention and management oI osteoporosis,
reIer to Chapter 11.
Many elements (variables) determine whether a resistance
exercise program is appropriate, eIIective, and saIe. This
holds true when resistance training is a part oI a rehabilita-
tion program Ior individuals with known or potential
impairments in muscle perIormance or when it is incorpo-
rated into a general conditioning program to improve the
level oI Iitness oI healthy individuals.
Each oI the interrelated elements discussed in this sec-
tion should be addressed to improve one or more aspects oI
Critics oI the concept oI hyperplasia suggest that evi-
dence oI Iiber splitting may actually be caused by inappro-
priate tissue preparation in the laboratory.
The general
opinion in the literature is that hyperplasia either does not
occur; or iI it does occur to a slight degree, its impact is
In a recent review article it was the
authors` opinion that iI hyperplasia is a valid Iinding, it
probably accounts Ior a very small proportion (less than
5°) oI the increase in muscle size that occurs with resist-
ance training.
Muscle Fiber Type Adaptation
As previously mentioned, type II (phasic) muscle Iibers
preIerentially hypertrophy with heavy resistance training.
In addition, a substantial degree oI plasticity exists in mus-
cle Iibers with respect to contractile and metabolic proper-
TransIormation oI type IIB to type IIA is common
with endurance training,
as well as during the early
weeks oI heavy resistance training,
making the type II
Iibers more Iatigue-resistant. There is some evidence that
demonstrates type I to type II Iiber type conversion in the
denervated limbs oI laboratory animals,
in humans
with spinal cord injury, and aIter an extended period oI
weightlessness associated with space Ilight.
there is little to no evidence oI type II to type I conversion
under training conditions in rehabilitation or Iitness pro-
vascular and Mcfaholìc Adapfafìons
Adaptations oI the cardiovascular and respiratory systems
as the result oI low-intensity, high-volume resistance train-
ing are discussed in Chapter 7. Opposite to what occurs
with endurance training, when muscles hypertrophy with
high-intensity, low-volume training, capillary bed density
actually decreases because oI an increase in the number
oI myoIilaments per Iiber.
Athletes who participate in
heavy resistance training actually have Iewer capillaries per
muscle Iiber than endurance athletes and even untrained
Other changes associated with metabo-
lism, such as a decrease in mitochondrial density, also
occur with high-intensity resistance training.
This is
associated with reduced oxidative capacity oI muscle.
Adapfafìons of Connccfìvc Jìssucs
Although the evidence is limited, it appears that the tensile
strength oI tendons and ligaments as well as bone increases
with resistance training designed to improve the strength or
power oI muscles.
Tendons, Ligaments, and Connective
Tissue in Muscle
Strength improvement in tendons probably occurs at the
musculotendinous junction, whereas increased ligament
strength may occur at the ligamentbone interIace. It is
believed that tendon and ligament tensile strength increases
in response to resistance training to support the adaptive
strength and size changes in muscle.
The connective tis-
sue in muscle (around muscle Iibers) also thickens, giving
more support to the enlarged Iibers.
strong ligaments and tendons may be less prone to injury.
C R A P J E P 8 Pesislance Exercise For lnµaired Muscle Perfornance 150
muscle perIormance and achieve desired Iunctional out-
comes. Appropriate alignment and stabili:ation are always
basic elements oI any exercise designed to improve muscle
perIormance. A suitable aosage oI exercise must also be
determined. In resistance training, dosage includes intensi-
tv, volume, frequencv, and auration oI exercise and rest
interval. Each Iactor is a mechanism by which the muscle
can be progressively overloaded to improve muscle per-
Iormance. The velocitv oI exercise and the moae oI exer-
cise must also be considered. These elements are
summarized in Box 6.4.
Consistent with the SAID principle discussed in the
Iirst section oI this chapter, these elements oI resistance
exercise must be speciIic to the patient`s desired Iunctional
goals. Other Iactors, such as the underlying cause or causes
oI the deIicits in muscle perIormance, the extent oI impair-
ment, and the patient`s age, medical history, mental status,
and social situation also aIIect the design and implementa-
tion oI a resistance exercise program.
Alìgnmcnf and Sfahìlìzafìon
Just as correct alignment and eIIective stabilization are
basic elements oI manual muscle testing and dynamometry,
they are also crucial in resistance exercise. To strengthen a
speciIic muscle or muscle group eIIectively and avoid sub-
stitute motions, appropriate positioning oI the body and
alignment oI a limb or body segment are essential. Substi-
tute motions are compensatory movement patterns caused
by muscle action oI a stronger adjacent agonist or a muscle
group that normally serves as a stabilizer (Iixator).
II the
principles oI alignment and stabilization Ior manual muscle
are applied whenever possible during resist-
ance exercise, substitute motions can usually be avoided.
Alignment and muscle action. Proper alignment is deter-
mined by the direction oI muscle Iibers and the line oI pull
oI the muscle to be strengthened. The patient or a body
segment must be positioned so the direction oI movement
oI a limb or segment oI the body replicates the action oI
the muscle or muscle groups to be strengthened. For exam-
ple, to strengthen the gluteus medius, the hip must remain
slightly extended, not Ilexed; and the pelvis must be rotat-
ed slightly Iorward as the patient abducts the lower extrem-
ity against the applied resistance. II the hip is Ilexed as the
leg abducts, the adjacent tensor Iasciae latae becomes the
prime mover and is strengthened.
Alignment and gravity. The alignment or position oI the
patient or the limb with respect to gravity may also be
important during some Iorms oI resistance exercises, par-
ticularly iI body weight or Iree weights (dumbbells, bar-
bells, cuII weights) are the source oI resistance. The patient
or limb should be positioned so the muscle being strength-
ened acts against the resistance oI gravity and the weight.
This, oI course, is contingent on the comIort and mobility
oI the patient.
Staying with the example oI strengthening the gluteus
medius, iI a cuII weight is placed around the lower leg, the
patient must assume the side-lying position so abduction
occurs through the Iull ROM against gravity and the addi-
tional resistance oI the cuII weight. II the patient rolls
toward the supine position, the resistance Iorce is applied
primarily to the hip Ilexors, not the abductors.
Stabilization reIers to holding down a body segment or
holding the body steady.
To maintain appropriate align-
ment, ensure the correct muscle action and movement pat-
tern, and avoid unwanted substitute motions during
resistance exercise, eIIective stabilization is imperative.
Exercising on a stable surface, such as a Iirm treatment
table, helps hold the body steady. Boav weight may also
provide a source oI stability during exercise, particularly in
the horizontal position. It is most common to stabilize the
proximal attachment oI the muscle being strengthened, but
sometimes the distal attachment is stabilized as the muscle
Stabilization can be achieved externally or internally.
External stabili:ation can be applied manually by the
therapist or sometimes by the patient with equipment,
such as belts and straps, or by a Iirm support surIace,
such as the back oI a chair or the surIace oI the treat-
ment table.
Internal stabili:ation is achieved by an isometric con-
traction oI an adjacent muscle group that does not enter
into the movement pattern but holds the body segment oI
the proximal attachment oI the muscle being strength-
80X 8.4 0cfcrmìnanfs of a Pcsìsfancc
Excrcìsc Program
- /|içrrcrt of scgmcnls of llc body duiing cxcicisc
- StcIi|izcticr of pioximal oi dislal joinls lo picvcnl subsli-
- |rtcr·ity. llc cxcicisc load (lcvcl of icsislancc)
- vc|nrc. llc lolal numbci of icpclilions and scls in an
cxcicisc scssion mulliplicd by llc icsislancc uscd
- |xcrci·c crJcr. llc scqucncc in wlicl musclc gioups aic
cxciciscd duiing an cxcicisc scssion
- |rcqncrcy. llc numbci of cxcicisc scssions pci day oi pci
- Bc·t irtcrvc|. limc allollcd foi iccupcialion bclwccn scls
and scssions of cxcicisc
- 0nrcticr. lolal limc fiamc of a icsislancc liaining pio-
- McJc of cxcicisc. lypc of musclc conliaclion, posilion of
llc palicnl, foim (souicc) of icsislancc, aic of movcmcnl,
oi llc piimaiy cncigy syslcm ulilizcd
- vc|ccity of cxcicisc
- PcricJizcticr. vaiialion of inlcnsily and volumc duiing
spccific pciiods of icsislancc liaining
- |rtcçrcticr cI cxcrci·c· irtc Inrcticrc| cctivitic·. usc of
icsislancc cxciciscs llal appioximalc oi icplicalc func-
lional dcmands
For otherwise healthy adults in the aavancea phase oI a
rehabilitation program aIter a musculoskeletal injury in
preparation Ior returning to high-demand occupational or
recreational activities
In a conditioning program Ior individuals with no known
For individuals training Ior competitive weight liIting or
body building
P R L C A U ! l 0 N . !he inlensily of exercise should
never be so qreal as lo cause µain. As lhe inlensily of
exercise increases and a µalienl exerls a naxinun or near-
naxinun efforl, cardiovascular risks subslanlially increase.
A µalienl needs lo be conlinually reninded lo incorµorale
rhylhnic brealhinq inlo each reµelilion of an exercise lo
nininize lhese risks.
lnìfìal Lcvcl of Pcsìsfancc (Load}
and 0ocumcnfafìon of Jraìnìng Effccfs
It is always challenging to estimate how much resistance to
apply manually or how much weight a patient should use
during resistance exercises to improve muscle strength par-
ticularly at the beginning oI a strengthening program. With
manual resistance exercise the decision is entirely subjec-
tive, based on the therapist`s judgment during exercise. In
an exercise program using mechanical resistance the deter-
mination can be made quantitatively.
Repetition Maximum
One method oI measuring the eIIectiveness oI a resistance
exercise program and calculating an appropriate exercise
load Ior training is to determine a repetition maximum.
This term was Iirst reported decades ago by DeLorme in
his investigations oI an approach to resistance training
called progressive resistive exercise (PRE).
A repetition
maximum (RM) is deIined as the greatest amount oI weight
(load) a muscle can move through the available range oI
motion (ROM) a speciIic number oI times.
Use of a repetition maximum. There are two main reasons
Ior determining a repetition maximum: (1) to document a
baseline measurement oI the dynamic strength oI a muscle
or muscle group against which exercise-induced improve-
ments in strength can be compared and (2) to identiIy an
exercise load (amount oI weight) to be used during exer-
cise Ior a speciIied number oI repetitions. DeLorme report-
ed use oI a 1 RM (the greatest amount oI weight a subject
can liIt through the available ROM just one time) as the
baseline measurement oI a subject`s maximum eIIort but
used a 10 RM (the amount oI weight that could be liIted
and lowered exactly 10 times) during training.
In the clinical setting, a practical, time-saving way to
establish a baseline RM Ior a particular muscle group is Ior
a therapist to select a speciIic amount oI resistance
(weight) and document how many repetitions can be com-
pleted through the Iull range beIore the muscle begins to
Iatigue. Remember, a sign oI Iatigue is the inability to
complete the available ROM against the applied resistance.
Despite criticism that establishing a 1 RM involves
some trial and error, it is a Irequently used method Ior
ened Iirmly in place. For example, when perIorming a
bilateral straight leg raise, the abdominals contract to sta-
bilize the pelvis and lumbar spine as the hip Ilexors raise
the legs. This Iorm oI stabilization is eIIective only iI the
Iixating muscle group is strong enough or not Iatigued.
The intensitv oI exercise in a resistance training program is
the amount oI resistance (weight) imposed on the contract-
ing muscle during each repetition oI an exercise. The
amount oI resistance is also reIerred to as the exercise loaa
(training load), that is, the extent to which the muscle is
loaded or how much weight is liIted, lowered, or held.
Remember, consistent with the overload principle, to
improve muscle perIormance the muscle must be loaded to
an extent greater than loads usually incurred. One way to
overload a muscle progressively is to gradually increase
the amount oI resistance used in the exercise pro-
The intensity oI exercise and the degree to
which the muscle is overloaded is also dependent on the
volume, Irequency, and order oI exercise or the length oI
rest intervals.
Suhmaxìmal vcrsus Maxìmal Excrcìsc Loads
Many Iactors, including the goals and expected Iunctional
outcomes oI the exercise program, the cause oI deIicits in
muscle perIormance, the extent oI impairment, the stage oI
healing oI injured tissues, the patient`s age, general health,
and Iitness level, and other Iactors determine whether the
exercise is carried out against submaximal or maximal mus-
cle loading. In general, the level oI resistance is oIten lower
in rehabilitation programs Ior persons with impairments
than in conditioning programs Ior healthy individuals.
Submaximal loading. Exercise at moderate to low intensi-
ties is indicated:
At the beginning oI an exercise program to evaluate the
patient`s response to resistance exercise, especially aIter
extended periods oI inactivity
In the early stages oI soIt tissue healing when injured tis-
sues must be protected
AIter periods oI immobilization when the articular carti-
lage is not able to withstand large compressive Iorces or
when bone demineralization may have occurred, increas-
ing the risk oI pathological Iracture
For most children or older adults
When the goal oI exercise is to improve muscle
To warm up and cool down prior to and aIter a session
oI exercise
During slow-velocity isokinetic training to minimize
compressive Iorces on joints
Aear maximal or maximal loading. High-intensity exer-
cise is indicated:
When the goal oI exercise is to increase muscle strength
and power and possibly increase muscle size
C R A P J E P 8 Pesislance Exercise For lnµaired Muscle Perfornance 181
measuring muscle strength in research studies and has
been shown to be a saIe and reliable measurement tool
with healthy young adults and athletes
as well as
active older adults prior to beginning conditioning pro-
P R L C A U ! l 0 N . bse of a 1 PM as a baseline neasure-
nenl of dynanic slrenqlh is inaµµroµriale for sone µalienl
µoµulalions because il requires one naxinun efforl. ll is
nol safe for µalienls, for exanµle, wilh |oinl inµairnenls,
µalienls who are recoverinq fron or who are al risk for sofl
lissue in|ury, or µalienls wilh known or al risk for osleo-
µorosis or cardiovascular µalholoqy.
Alternative Methods of Determining Baseline
Strength and a Beginning Exercise Load
Cable tensiometry
and isokinetic or handheld dynamom-
are alternatives to a repetition maximum Ior estab-
lishing a baseline measurement oI strength. A percentage
oI body weight also has been proposed to estimate how
much resistance (load) should be used in a strengthening
Some examples Ior diIIerent exercises are list-
ed in Box 6.5. The percentages indicated are meant as
guidelines Ior the advanced stage oI rehabilitation and are
based on 10 repetitions oI each exercise at the beginning
oI an exercise program. Percentages vary Ior diIIerent
muscle groups.
Training Zone
AIter establishing the baseline RM, the amount oI resist-
ance (exercise load) to be used at the initiation oI resist-
ance training is oIten calculated as a percentage oI a 1 RM
Ior a particular muscle group. At the beginning oI an exer-
cise program the percentage necessary to achieve training-
induced adaptations in strength is low (30° to 40°) Ior
sedentary, untrained individuals or very high (80° to 95°)
Ior those already highly trained. For healthy but untrained
adults, a typical training zone usually Ialls between 60°
and 70° oI an RM.
The lower percentage oI this range is
saIer at the beginning oI a program to enable an individual
to Iocus on learning exercise Iorm and technique.
Exercising at a low to moderate percentage oI the
established RM is also recommended Ior children and
the elderly.
For patients with signiIicant deIicits in
muscle strength or to train Ior muscular endurance, using
a low load, possibly at the 30° to 50° level, is saIe yet
In resistance training the volume oI exercise is the summa-
tion oI the total number oI repetitions and sets oI a particu-
lar exercise during a single exercise session multiplied by
the resistance used.
The same combination oI repeti-
tions and sets is not and should not be used Ior all muscle
There is an inverse relationship between the number
oI repetitions perIormed and the intensity oI the resistance.
The higher the intensity (load), the lower the number oI
repetitions that are possible; and conversely, the lower the
load, the greater the number oI repetitions possible. There-
Iore, the exercise load directly dictates how many repeti-
tions and sets are possible.
Pcpcfìfìons and Scfs
Repetitions. The number oI repetitions in a dynamic exer-
cise program reIers to the number oI times a particular
movement is repeated. More speciIically, it is the number
oI muscle contractions perIormed to move the limb
through a series oI continuous and complete excursions
against a speciIic exercise load.
II the RM designation is used, the number oI repeti-
tions at a speciIic exercise load is reIlected in the designa-
tion. For example, 10 repetitions at a particular exercise
load is a 10 RM. II a 1 RM has been established as a base-
line level oI strength, a percentage oI the 1 RM used as the
exercise load inIluences the number oI repetitions a patient
is able to perIorm. The 'average,¨ untrained adult, when
exercising with a load that is equivalent to 75° oI the 1
RM, is able to complete approximately 10 repetitions
beIore needing to rest.
At 60° intensity about 15 repe-
titions are possible, and at 90° intensity only 4 or 5 repeti-
tions are usually possible.
For practical reasons, aIter a beginning exercise load is
selected, the target number oI repetitions perIormed Ior
each exercise beIore a brieI rest is oIten within a range
rather than an exact number oI repetitions. For example, a
patient might be able to complete between 8 and 10 repeti-
tions against a speciIied load beIore resting. This is some-
times reIerred to as a RM :one
; it gives the patient a goal
but builds in some Ilexibility.
The number oI repetitions selected depends on the
patient`s status and whether the goal oI the exercise is to
improve muscle strength or endurance. No optimal number
Ior strength training or endurance training has been identi-
Iied. Training eIIects (greater strength) have been reported
employing 2 to 3 RM to 15 RM.
Sets. A predetermined number oI repetitions grouped
together is known as a set or bout. AIter each set oI a spec-
iIied number oI repetitions, there is a brieI interval oI rest.
For example, during a single exercise session to strengthen
a particular muscle group, a patient might be directed to
liIt a load 8 to 10 times, rest, and then liIt the load 8 to 10
more times. That would be two sets oI an 8 to 10 RM
80X 8.5 Pcrccnfagc of 8ody Wcìghf
as an lnìfìal Excrcìsc Load
- Univcisal bcncl picss. 20% body wcigll
- Univcisal lcg cxlcnsion. 20% body wcigll
- Univcisal lcg cuil. 10% lo 1¯% body wcigll
- Univcisal lcg picss. ¯0% body wcigll
sity exercises should be perIormed beIore lower intensity
Frequencv in a resistance exercise program reIers to the
number oI exercise sessions per day or per week.
with other aspects oI dosage, Irequency is dependent on
other determinants, such as intensity and volume as well as
the patient`s goals, general health status, previous partici-
pation in a resistance exercise program, and response to
training. The greater the intensity and volume oI exercise,
the more time is needed between exercise sessions to
recover Irom the temporarily Iatiguing eIIects oI exercise.
A common cause oI a decline in perIormance Irom over-
training (see discussion later in the chapter) is excessive
Irequency, inadequate rest, and progressive Iatigue. Some
Iorms oI exercise should be perIormed less Irequently than
others because they require greater recovery time. High-
intensity eccentric exercise, Ior example, is associated with
greater microtrauma to soIt tissues and a higher incidence
oI delayed-onset muscle soreness than other modes oI
ThereIore, rest intervals between exercise
sessions are longer and the Irequency oI exercise is less
than with other Iorms oI exercise.
Although an optimal Irequency per week has not been
determined, a Iew generalizations can be made. Initially in
an exercise program, so long as the intensity and number
oI repetitions are low, short sessions oI exercises some-
times can be perIormed on a daily basis several times per
day. This Irequency is oIten indicated Ior early postsurgical
patients when the operated limb is immobilized and the
extent oI exercise is limited to low-intensity isometric (set-
ting) exercises to prevent or minimize atrophy. As the
intensity and volume oI exercise increases, every other day
or up to Iive exercise sessions per week is common.
Frequency is again reduced Ior a maintenance program,
usually to two times per week. With prepubescent chil-
and the very elderly,
Irequency is usually limited
to two to three sessions per week. Highly trained athletes
involved in body building, power liIting, and weight liIting
who know their own response to exercise oIten train at a
high intensity and volume up to 6 days per week.
Exercise auration is the total number oI weeks or months
during which a resistance exercise program is carried out.
Depending on the cause oI an impairment in muscle per-
Iormance, some patients require only a month or two oI
training to return to the desired level oI Iunction or activity,
whereas others need to continue the exercise program Ior a
liIetime to maintain optimal Iunction.
As noted earlier in the chapter, strength gains,
observed early in a resistance training program (aIter 2
to 3 weeks) are the result oI neural adaptation. For signiIi-
As with repetitions, there is no optimal number oI sets
per exercise session. As Iew as one set and as many as six
sets have yielded positive training eIIects.
Single-set exer-
cises at low intensities are most common in the very early
phases oI a resistance exercise program or in a mainte-
nance program. Multiple-set exercises are used to progress
the program and have been shown to be superior to single-
set regimens in advanced training.
Jraìnìng fo lmprovc Sfrcngfh or Endurancc:
lmpacf of Excrcìsc Load and Pcpcfìfìons
Overall, because many variations oI intensity and volume
cause positive training-induced adaptations in muscle per-
Iormance, there is a substantial amount oI latitude Ior
selecting an exercise load/repetition and set scheme Ior
each exercise. The question is: Is the goal to improve
strength, muscular endurance, or both?
To Improve Muscle Strength
In DeLorme`s early studies
three sets oI a 10 RM per-
Iormed Ior 10 repetitions over the training period led to
gains in strength. Current recommendations are to use an
exercise load that causes Iatigue aIter 6 to 12 repetitions
Ior two to three sets (6 to 12 RM).
When Iatigue no
longer occurs aIter the target number oI repetitions has
been completed, the level oI resistance is increased to once
again overload the muscle.
To Improve Muscle Endurance
Training to improve local endurance involves perIorming
many repetitions oI an exercise against a submaximal
For example, as many as three to Iive sets oI 40
to 50 or more repetitions against a low amount oI weight
or a light grade oI elastic resistance might be used. When
increasing the number oI repetitions or sets becomes ineIIi-
cient, the load can be increased slightly.
Endurance training can also be accomplished by main-
taining an isometric muscle contraction Ior incrementally
longer periods oI time. Because endurance training is per-
Iormed against very low levels oI resistance, it can and
should be initiated very early in a rehabilitation program
without risk oI injury to healing tissues. Remember, when
injured muscles are immobilized, type I (slow twitch)
Iibers atrophy at a Iaster rate than type II (Iast twitch)
This underscores the need Ior early initiation
oI endurance training.
Excrcìsc 0rdcr
The sequence in which exercises are perIormed during an
exercise session has an impact on muscle Iatigue and the
adaptive training eIIects. When multiple muscle groups
are exercised in a single session, as is oIten the case in
rehabilitation or conditioning programs, large muscle
groups should be exercised beIore small muscle groups
and multijoint muscles beIore single-joint muscles.
In addition, aIter an appropriate warm-up, higher inten-
C R A P J E P 8 Pesislance Exercise For lnµaired Muscle Perfornance 188
cant changes to occur in muscle, such as hypertrophy or
increased vascularization, at least 6 to 12 weeks oI resist-
ance training is required.
Pcsf lnfcrval (Pccovcry Pcrìod}
Purposc of Pcsf lnfcrvals
Rest is a critical element oI a resistance training program
and is necessary to allow time Ior the body to recuperate
Irom the acute eIIects oI exercise associated with muscle
Iatigue or to oIIset adverse responses, such as exercise-
induced, delayed-onset muscle soreness. Only with an
appropriate balance oI progressive loading and adequate
rest intervals can muscle perIormance improve. ThereIore,
rest between sets oI exercise and between exercise sessions
must be addressed.
lnfcgrafìon of Pcsf ìnfo Excrcìsc
Rest intervals Ior each exercising muscle group are
dependent on the intensity and volume oI exercise. In gen-
eral, the higher the intensity oI exercise the longer the rest
interval. For moderate-intensity resistance training, a 2- to
3-minute rest period aIter each set is recommended. A
shorter rest interval is adequate aIter low-intensity exercise;
longer rest intervals (4 to 5 minutes) are appropriate with
high-intensity resistance training, particularly when exer-
cising large, multijoint muscles, such as the hamstrings,
which tend to Iatigue rapidly.
While the muscle group
that was just exercised is resting, resistance exercises can
be perIormed by another muscle group in the same extrem-
ity or by the same muscle group in the opposite extremity.
Patients with pathological conditions that make them
more susceptible to Iatigue, as well as children and the eld-
erly, should rest at least 3 minutes between sets by per-
Iorming an unresisted exercise, such as low-intensity
cycling, or perIorming the same exercise with the opposite
extremity. Remember, active recovery is more eIIicient
than passive recovery Ior neutralizing the eIIects oI muscle
Rest between exercise sessions must also be consid-
ered. When strength training is initiated at moderate inten-
sities (typically in the intermediate phase oI a rehabilitation
program aIter soIt tissue injury) a 48-hour rest interval
between exercise sessions (that is, training every other day)
allows the patient adequate time Ior recovery.
Modc of Excrcìsc
The moae oI exercise in a resistance exercise program
reIers to the Iorm oI exercise, the type oI muscle contrac-
tion that occurs, and the manner in which the exercise is
carried out. For example, a patient may perIorm an exer-
cise dynamically or statically or in a weight-bearing or
non-weight-bearing position. Mode oI exercise also
encompasses the Iorm oI resistance, that is, how the exer-
cise load is applied. Resistance can be applied manually
or mechanically.
As with other determinants oI resistance training, the
modes oI exercise selected are based on a multitude oI Iac-
tors already highlighted throughout this section. A brieI
overview oI the various modes oI exercise is presented in
this section. An in-depth explanation and analysis oI each
oI these types oI exercise can be Iound in the next section
oI the chapter and in Chapter 7.
Jypc of Musclc Confracfìon
Figure 6.4 depicts the types oI muscle contraction that may
be perIormed in a resistance exercise program and their
relationships to each other and to muscle perIormance.
Fl0uPE 8.4 !,µes o¦ uusc|e con¦rac¦|ons. ¦|e|r re|a¦|ons||µs ¦o uusc|e µer-
¦oruance and ¦|e|r ¦ens|on-çenera¦|nç caµac|¦|es.
Isometric (static) or avnamic muscle contractions are
two broad categories oI exercise.
Dynamic resistance exercises can be perIormed using
concentric (shortening) or eccentric (lengthening) con-
tractions, or both.
When the velocity oI limb movement is held consistent
by a rate-controlling device, the term isokinetic contrac-
tion is sometimes used.
An alternative perspective is
that this is simply a dynamic (shortening or lengthening)
contraction that occurs under controlled conditions.
Posìfìon for Excrcìsc: Wcìghf-8carìng
or Non-Wcìghf-8carìng
The patient`s body position or the position oI a limb in
non-weight-bearing or weight-bearing positions also alters
the mode oI exercise. When a non-weight-bearing position
is assumed and the distal segment (Ioot or hand) moves
Ireely during exercise, the term open-chain exercise is
oIten used. When a weight-bearing position is assumed
and the body moves over a Iixed distal segment, the term
closea-chain exercise is commonly used.
associated with this approach to classiIying exercises and
deIinitions oI this terminology are addressed later in the
to avoid a painIul arc oI motion or a portion oI the range
where the joint is unstable or to protect healing tissues
aIter injury or surgery.
Modc of Excrcìsc and Applìcafìon fo Funcfìon
Mode-speciIic training is essential iI a resistance training
program is to have a positive impact on Iunction. When tis-
sue healing allows, the type oI muscle contractions per-
Iormed or the position in which an exercise is carried out
should mimic the desired Iunctional activity.
vclocìfy of Excrcìsc
The velocity at which a muscle contracts signiIicantly
aIIects the tension that the muscle produces and subse-
quently aIIects muscular strength and power.
The veloc-
ity oI exercise is Irequently manipulated in a resistance
training program to prepare the patient Ior a variety oI
Iunctional activities that occur across a range oI slow to
Iast velocities.
Forcc-vclocìfy Pclafìonshìp
The Iorce-velocity relationship is diIIerent during con-
centric and eccentric muscle contractions, as depicted in
Figure 6.6.
Forms of Pcsìsfancc
Manual resistance and mechanical resistance are the two
broad methods by which resistance can be applied.
A constant or variable load can be imposed using
mechanical resistance (e.g., Iree weights or weight
Accommoaating resistance
can be implemented by use
oI an isokinetic dynamometer that controls the velocity
oI active movement during exercise.
Boav weight or partial body weight is also a source oI
resistance iI the exercise occurs in an antigravity posi-
tion. Although an exercise perIormed against only the
resistance oI the weight oI a body segment (and no addi-
tional external resistance) is deIined as an active rather
than an active-resistive exercise, a substantial amount oI
resistance Irom the weight oI the body can be imposed
on contracting muscles by altering a patient`s position.
For example, progressive loads can be placed on upper
extremity musculature during push-ups by starting with
wall push-ups while standing, progressing to push-ups
while leaning against a countertop, push-ups in a hori-
zontal position (Fig. 6.5), and Iinally push-ups Irom a
head-down position on an incline board.
C R A P J E P 8 Pesislance Exercise For lnµaired Muscle Perfornance 185
Fl0uPE 8.5 bod, we|ç|¦ serves as ¦|e source o¦ res|s¦ance dur|nç
a µus|-uµ.
Encrgy Sysfcms
Modes oI exercise can also be classiIied by the energy sys-
tems used during the exercise. Anaerobic exercise involves
high-intensity (near-maximal) exercise carried out Ior a
very Iew number oI repetitions because muscles rapidly
Iatigue. Strengthening exercises Iall into this category. Aer-
obic exercise is associated with low-intensity, repetitive
exercise oI large muscle groups perIormed over an extend-
ed period oI time. This mode oI exercise primarily increas-
es muscular and cardiopulmonary endurance (reIer to
Chapter 7 Ior an in-depth explanation).
Pangc of Movcmcnf: Shorf-Arc or Full-Arc Excrcìsc
Resistance through the Iull, available range oI movement
(full-arc exercise) is necessary to develop strength through
the ROM. Sometimes resistance exercises are executed
through only a portion oI the available range. This is
known as short-arc exercise. This Iorm oI exercise is used
Fl0uPE 8.8 lorce-ve|oc|¦, curve ¦or concen¦r|c and eccen¦r|c ezerc|se. (|rcr
|-vcrji-, ||, Ncr|ir, CC. 1cir: S:r0c:0r- crc |0rc:icr÷/ Ccrjr-|-r·iv- /rc|y·i·, -c. 8. |/
0cvi·, ||i|cc-|j|ic, 2001, j 07, wi:| j-rri··icr.}
Concentric Muscle Contraction
As the velocity oI muscle shortening increases, the Iorce
the muscle can generate aecreases. EMG activity and
torque decrease as a muscle shortens at Iaster contractile
velocities, possibly because the muscle may not have suIIi-
cient time to develop peak tension.
Eccentric Muscle Contraction
Findings are less consistent Ior eccentric than concentric
muscle actions. During an eccentric contraction, as the
velocity oI active muscle lengthening increases, Iorce pro-
duction in the muscle initially also increases but then
quicklv levels off.
The initial increase in Iorce
production may be a protective response oI the muscle
when it is Iirst overloaded. It is thought that this increase
may be important Ior shock absorption or rapid decelera-
tion oI a limb during quick changes oI direction.
rise in tension may also be caused by stretch oI the non-
contractile tissue in muscle.
In contrast, other research
indicates that eccentric Iorce production is essentially unaI-
Iected by velocity and remains constant at slow and Iast
Applìcafìon fo Pcsìsfancc Jraìnìng
A range oI slow to Iast exercise velocities has a place in an
exercise program. Resistance training with Iree weights is
saIe and eIIective only at slow to medium velocities oI
limb movement so the patient can maintain control oI the
moving weight. Because many Iunctional activities involve
reasonably Iast velocities oI limb movement, training at
only slow velocities is inadequate. The development oI the
isokinetic dynamometer during the late 1960s
clinicians a tool to implement resistance training at Iast as
well as slow velocities. In recent years, some variable-
resistance exercise units (pneumatic and hydraulic) as well
as elastic resistance products also have aIIorded additional
options Ior saIely training at Iast velocities.
Speea-specific training is Iundamental to a successIul
rehabilitation program. Results oI numerous studies since
the 1970s have shown that training-induced strength gains
in a resistance exercise program primarily occur at the
training speeds,
with limited transIer oI training
(physiological overIlow) to other speeds oI move-
Accordingly, training velocities Ior resistance
exercises should be geared to match or approach the
demands oI the desired Iunctional activities.
Isokinetic training, using velocitv spectrum rehabilita-
tion regimens, and plvometric training, also known as
stretch-shortening arills, oIten emphasize high-speed train-
ing. These approaches to exercise are discussed later in the
Periodization, also known as perioai:ea training, is an
approach to resistance training that builds svstematic varia-
tion in exercise intensity and repetitions, sets, or Irequency
at regular intervals over a speciIied period oI time.
approach to training was developed Ior highly trained
athletes preparing Ior competitive weight-liIting or power-
liIting events. The concept was designed to prevent over-
training and psychological staleness prior to competition
and to optimize perIormance during competition.
In preparation Ior competition, the training calendar is
broken down into cycles, or phases, that sometimes extend
over an entire year. The idea is to prepare Ior a 'peak¨ per-
Iormance at the time oI competition. DiIIerent types oI
exercises at varying intensities, volume, Irequency, and rest
intervals are perIormed over a speciIic time period. Table
6.4 summarizes the characteristics oI each cycle.
Although periodized training is commonly implement-
ed prior to a competitive event, evidence to support the
eIIicacy oI periodization is limited.
Despite this,
periodized training has also been used on a limited basis in
the clinical setting Ior injured athletes during the advanced
stage oI rehabilitation.
lnfcgrafìon of Funcfìon
8alancc of Sfahìlìfy and Acfìvc Mohìlìfy
Control oI the body during Iunctional movement and the
ability to perIorm Iunctional tasks require a balance oI
active movement superimposed over a stable background
oI neuromuscular control. SuIIicient perIormance oI ago-
nist and antagonist muscles about a joint contributes to the
dynamic stability oI individual joints. For example, a per-
son must be able to hold the trunk erect and stabilize the
spine while liIting a heavy object. Stability is also neces-
sary to control quick changes oI direction during Iunctional
movements. Hence, a resistance exercise program must
address the static strength as well as the dynamic strength
oI the trunk and extremities.
8alancc of Sfrcngfh, Powcr, and Endurancc
Functional tasks related to daily living, occupational, and
recreational activities require many combinations oI mus-
cle strength, power, and endurance. Various motor tasks
require slow and controlled movements, rapid movements,
repeated movements, and long-term positioning. Analysis
oI the tasks a patient would like to be able to do provides
JA8LE 8.4 Characfcrìsfìcs of Pcrìodìzcd Jraìnìng
Pcrìod of Jraìnìng InIcnsìIy of Lxcrcìsc vo|umc and Frcqucncy of Lxcrcìsc
Lower loads
Higher loads (peaking just prior to
Gradual decrease in exercise loads
High number of reps and sets
More exercises per session
More frequent exercise sessions per day and per week
Decreased reps and sets
Fewer exercises per session
Less frequent exercise sessions per day per week
Additional decrease in reps, sets, number of exercises,
and frequency
analyzed and discussed. When available, supporting evi-
dence Irom the scientiIic literature is summarized. SpeciIic
regimens or systems oI resistance training, such as progres-
sive resistive exercise (PRE), circuit weight training, veloc-
ity spectrum rehabilitation, and plyometric training, are
addressed in a later section oI the chapter.
Manual and Mcchanìcal Pcsìsfancc Excrcìsc
From a broad perspective a load can be applied to a con-
tracting muscle in two ways: manually or mechanically.
The beneIits and limitations oI these two Iorms oI resist-
ance training are summarized in Boxes 6.13 and 6.14 (later
in the chapter).
Manual Pcsìsfancc Excrcìsc
Manual resistance exercise is a type oI active-resistive
exercise in which resistance is provided by a therapist or
other health proIessional. A patient can be taught how to
apply selI-resistance to selected muscle groups. Although
the amount oI resistance cannot be measured quantitative-
ly, this technique is useIul in the early stages oI an exercise
program when the muscle to be strengthened is weak and
can overcome only minimal to moderate resistance. It is
also useIul when the range oI joint movements needs to be
the Iramework Ior a task-speciIic resistance exercise
Jask-Spccìfìc Movcmcnf Paffcrns
0urìng Pcsìsfancc Excrcìsc
There is a place in a resistance exercise program Ior
strengthening isolated muscle groups as well as strengthen-
ing muscles in combined patterns. Applying resistance dur-
ing exercise in anatomical planes, diagonal patterns, and
combined task-speciIic movement patterns should be inte-
gral components oI a careIully progressed resistance exer-
cise program. Use oI simulated Iunctional movements
under controlled, supervised conditions is a means to
return a patient saIely to independent Iunctional activi-
Pushing, pulling, liIting, and holding activities, Ior
example, can Iirst be done against a low level oI resistance
Ior a limited number oI repetitions. Over time, a patient
can gradually return to using the same movements during
Iunctional activities in an unsupervised work or home set-
ting. The key to successIul selI-management is to teach a
patient how to judge the speed, level, and duration oI ten-
sion generation in muscle as well as the appropriate timing
that is necessary to perIorm a motor task saIely.
The types oI exercise selected Ior a resistance training
program are contingent on many Iactors, including the
cause and extent oI primary and secondary impairments.
DeIicits in muscle perIormance, the stage oI tissue heal-
ing, the condition oI joints and their tolerance to com-
pression and movement, the general abilities (physical
and cognitive) oI the patient, the availability oI equip-
ment, and oI course the patient`s goals and the intended
Iunctional outcomes oI the program must be considered.
A therapist has an array oI exercises Irom which to choose
to design a resistance exercise program to meet the indi-
vidual needs oI each patient. There is no one best Iorm
or type oI resistance training. Prior to selecting speciIic
types oI resistance exercise Ior a patient`s rehabilitation
program, a therapist may want to consider the questions
listed in Box 6.6.
Application oI the SAID principle based on the con-
cept oI speciIicity oI training is key to making sound exer-
cise decisions. In addition to selecting the appropriate
types oI exercise, a therapist must also make decisions
about the intensity, volume, order, Irequency, rest interval,
and other Iactors discussed in the previous section oI this
chapter to progress selected resistance exercises eIIectively.
Table 6.5 summarizes general guidelines Ior progression oI
The types oI exercise presented in this section are
static (isometric) and dynamic, concentric and eccentric,
isokinetic, and open-chain and closed-chain exercise, as
well as manual and mechanical and constant and variable
resistance exercises. The beneIits, limitations, and appli-
cations oI each oI these Iorms oI resistance exercise are
C R A P J E P 8 Pesislance Exercise For lnµaired Muscle Perfornance 187
80X 8.8 Consìdcrafìons for Sclccfìon
of Modcs of Pcsìsfancc Excrcìsc
- Bascd on llc icsulls of youi cxaminalion and cvalualion,
wlal aic llc lypc and cxlcnl of llc dcficils in musclc
- Bascd on llc undcilying pallology causing llc dcficils
in musclc pcifoimancc, would onc foim of icsislancc
liaining bc moic appiopiialc oi cffcclivc llan anollci?
- Wlal aic llc goals and anlicipalcd funclional oulcomcs
of llc icsislancc liaining piogiam?
- Wlicl lypcs of icsislancc cxcicisc aic moic compaliblc
will llosc goals?
- Aic llcic any limilalions on low llc palicnl is pcimillcd
oi ablc lo bc posilioncd duiing cxcicisc?
- ls wcigll bcaiing conliaindicalcd, icsliiclcd, oi fully
- ls llcic lypomobilily of affcclcd oi adjaccnl joinls (duc
lo pain oi conliacluic) llal could affccl low llc
palicnl is posilioncd duiing icsislancc cxcicisc?
- ls llcic a poilion of llc R0M in wlicl llc palicnl can-
nol safcly oi comfoilably pcifoim icsislancc
cxciciscs duc lo lypcimobilily?
- Aic llcic caidioicspiialoiy impaiimcnls llal could
affccl posilioning duiing cxcicisc?
- Will llc palicnl bc cxpcclcd lo pcifoim llc cxciciscs
indcpcndcnlly using mcclanical icsislancc, oi would
manual icsislancc applicd by llc llciapisl bc moic
appiopiialc al llis poinl in llc iclabililalion piogiam?
- Wlal lypcs of cquipmcnl will bc availablc oi nccdcd foi
careIully controlled. The amount oI resistance given is lim-
ited only by the strength oI the therapist.
N 0 ! L . !echniques for aµµlicalion of nanual resislance
exercises in analonical µlanes and diaqonal µallerns are
µresenled in laler seclions of lhe chaµler.
Mcchanìcal Pcsìsfancc Excrcìsc
Mechanical resistance exercise is a Iorm oI active-resistive
exercise in which resistance is applied through the use oI
equipment or mechanical apparatus. The amount oI resist-
ance can be measured quantitatively and incrementally pro-
gressed over time. It is also useIul when the amount oI
resistance necessary is greater than what the therapist can
apply manually.
N 0 ! L . Syslens and reqinens of resislance lraininq lhal
use nechanical resislance and advanlaqes and disadvan-
laqes of various lyµes of nechanical resislance equiµnenl
are addressed laler in lhe chaµler.
lsomcfrìc Excrcìsc (Sfafìc Excrcìsc}
Isometric exercise is a static Iorm oI exercise in which a
muscle contracts and produces Iorce without an apprecia-
ble change in the length oI the muscle and without visible
joint motion.
Although there is no mechanical
work done (Iorce distance), a measurable amount oI ten-
sion and Iorce output are produced by the muscle. Sources
oI resistance Ior isometric exercise include holding against
a Iorce applied manually, holding a weight in a particular
position, maintaining a position against the resistance oI
body weight, or pushing or pulling an immovable object.
During the 1950s and 1960s, isometric resistance
training became popular as an alternative to dynamic
resistance exercise and initially was thought to be a more
eIIective and eIIicient method oI muscle strengthen-
Based on the early research it was reported that
isometric strength gains oI 5° per week occurred when
healthy subjects perIormed a single, near-maximal isomet-
ric contraction everyday over a 6-week period.
replications oI this study reIuted some oI the original Iind-
ings, particularly the rapid rate oI strength gain, additional
studies during the 1960s showed that repetitive isometric
contractions (a set oI 20 per day) held Ior 6 seconds each
against near-maximal resistance consistently improved iso-
metric strength.
A cross-exercise eIIect (a limited
increase in strength oI the contralateral, unexercised mus-
cle group), as the result oI transIer oI training, has also
been observed with maximum isometric training.
Each oI
these early investigations concluded that isometric training
was a viable means oI improving muscle strength.
Pafìonalc for usc of lsomcfrìc Excrcìsc
The need Ior static strength and endurance is apparent in
almost all aspects oI control oI the body during Iunctional
activities. Loss oI static muscle strength occurs rapidly
with immobilization and disuse, with estimates Irom 8°
per week
to as much as 5° per day.
Functional demands oIten involve the need to hold a
position against either a high level oI resistance Ior a short
period oI time or a low level oI resistance over a prolonged
period oI time. OI these two aspects oI static muscle per-
Iormance, it has been suggested that muscular endurance
plays a more important role than muscle strength in main-
taining suIIicient postural stability and in preventing injury
during daily living tasks.
For example, the postural mus-
cles oI the trunk and lower extremities must contract iso-
metrically to hold the body erect against gravity and
provide a background oI stability Ior balance and Iunction-
al movements in an upright position.
Dynamic stabili-
JA8LE: 8.5 Progrcssìon of a Pcsìsfancc Jraìnìng Program: Facfors for Consìdcrafìon
FacIors Progrcssìon
Ìntensity (exercise load)
Body position (nonweight- or weight-bearing)
Repetitions and sets
Type of muscle contraction
Range of motion
Plane of movement
Speed of movement
Neuromuscular control
Functional movement patterns
Submaximal maximal (or near-maximal) intensity
Low load high load
Variable: depending on pathology and impairments, weight-bearing
restrictions (pain, swelling, instability) and goals of the
rehabilitation program
Low volume high volume
Variable: depends on intensity and volume of exercise
Static dynamic
Concentric and eccentric: variable progression
Short arc full arc
Stable portion of range unstable portion of range
Uniplanar multiplanar
Slow fast velocities
Proximal distal control
Simple complex
Single joint multijoint
Proximal control distal control
Stabilization exercises. This Iorm oI isometric exercise is
used to develop a submaximal but sustained level oI co-
contraction to improve postural stability or dynamic stabili-
ty oI a joint by means oI mid-range isometric contractions
against resistance in antigravity positions and in weight-
bearing postures iI weight bearing is permissible.
weight or manual resistance oIten are the sources oI resist-
ance. Variations terms are used to describe stabilization
exercises. They include rhvthmic stabili:ation and alter-
nating isometrics, two techniques associated with proprio-
ceptive neuromuscular Iacilitation (PNF) described later
in the chapter.
Stabilization exercises that Iocus on
trunk/postural control include avnamic, core, ana segmen-
tal stabili:ation exercises, described in Chapter 16.
Multiple-angle isometrics. This term reIers to a system oI
isometric exercise where resistance is applied, manually or
mechanically, at multiple joint positions within the avail-
able ROM.
This approach is used when the goal oI exer-
cise is to improve strength throughout the ROM when joint
motion is permissible but dynamic resistance exercise is
painIul or inadvisable.
Characfcrìsfìcs and Effccfs of lsomcfrìc Jraìnìng
EIIective use oI isometric exercise in a resistance training
program is Iounded on an understanding oI its characteris-
tics and its limitations.
Intensity of muscle contraction. The amount oI tension
that can be generated during an isometric muscle contrac-
tion depends in part on joint position and the length oI the
muscle at the time oI contraction.
It is suIIicient to
use an exercise intensity (load) oI 60° to 80° oI a mus-
cle`s Iorce-developing capacity to improve strength.
ThereIore, the amount oI resistance against which the mus-
cle is able to hold varies and needs to be adjusted at diIIer-
ent points in the range. Resistance must be progressively
increased to continue to overload the muscle as it becomes
Duration of muscle activation. To achieve adaptive
changes in static muscle perIormance, an isometric con-
traction should be held Ior 6 seconds and no more than
10 seconds because muscle Iatigue develops rapidly. This
allows suIIicient time Ior peak tension to develop and
Ior metabolic changes to occur in the muscle.
10-second contraction allows a 2-second rise time, a
6-second hold time, and a 2-second Iall time.
Repetitive contractions. Use oI repetitive contractions,
held Ior 6 to 10 seconds each, decreases muscle cramping
and increases the eIIectiveness oI the isometric regi-
1oint angle and mode specificity. Gains in muscle strength
occur only at or closely adjacent to the training
Physiological overIlow is minimal, occur-
ring no more than 10 in either direction in the ROM Irom
the training angle.
ThereIore, when perIorming multiple-
angle isometrics, resistance at Iour to six points in the
ROM is usually recommended. Isometric resistance train-
ty oI joints is achieved by activating and maintaining a low
level oI co-contraction, that is, concurrent isometric con-
tractions oI antagonist muscles that surround joints.
importance oI isometric strength and endurance in the
elbow, wrist, and Iinger musculature, Ior example, is
apparent when a person holds and carries a heavy object
Ior an extended period oI time.
With these examples in mind, there can be no doubt
that isometric exercises are an important part oI a rehabili-
tation program designed to improve Iunctional abilities.
The rationale and indications Ior isometric exercise in
rehabilitation are summarized in Box 6.7.
Jypcs of lsomcfrìc Excrcìsc
Several Iorms oI isometric exercise with varying degrees oI
resistance and intensity oI muscle contractions serve diIIer-
ent purposes during successive phases oI rehabilitation. All
but one type (muscle setting) incorporate some Iorm oI
signiIicant resistance and thereIore are used to improve
static strength or develop sustained muscular control
(endurance). Because no appreciable resistance is applied,
muscle setting technically is not a Iorm oI resistance exer-
cise but is included in this discussion to show a continuum
oI isometric exercise that can be used Ior multiIaceted
goals in a rehabilitation program.
Muscle-setting exercises. Setting exercises involve low-
intensity isometric contractions perIormed against little to
no resistance. They are used to decrease muscle pain and
spasm and to promote relaxation and circulation aIter
injury to soIt tissues during the acute stage oI healing. Two
common examples oI muscle setting are oI the quadriceps
and gluteal muscles.
Because muscle setting is perIormed against no appre-
ciable resistance, it does not improve muscle strength
except in very weak muscles. However, setting exercises
can retard muscle atrophy and maintain mobility between
muscle Iibers when immobilization oI a muscle is neces-
sary to protect healing tissues during the very early phase
oI rehabilitation.
C R A P J E P 8 Pesislance Exercise For lnµaired Muscle Perfornance 180
80X 8.7 lsomcfrìc Excrcìsc: Pafìonalc
and lndìcafìons
- 1o picvcnl oi minimizc musclc alioply wlcn joinl
movcmcnl is nol possiblc owing lo cxlcinal immobiliza-
lion (casls, splinls, skclclal liaclion)
- 1o aclivalc musclcs (facililalc musclc fiiing) lo bcgin lo
ic-cslablisl ncuiomusculai conliol bul piolccl lcaling
lissucs wlcn joinl movcmcnl is nol advisablc aflci sofl
lissuc injuiy oi suigciy
- 1o dcvclop posluial oi joinl slabilily
- 1o impiovc musclc slicngll wlcn usc of dynamic icsisl-
ancc cxcicisc could compiomisc joinl inlcgiily oi causc
joinl pain
- 1o dcvclop slalic musclc slicngll al pailiculai poinls in
llc R0M consislcnl will spccific lask-iclalcd nccds
ing is also mode-speciIic. It increases static strength but
has little to no impact on dynamic strength (concentric or
P R L C A U ! l 0 N S . !o avoid µolenlial in|ury lo lhe con-
lraclinq nuscle, aµµly and release lhe resislance qradually.
!his helµs lo qrade lhe nuscle lension and ensures lhal lhe
nuscle conlraclion is µain-free. ll also nininizes lhe risk of
unconlrolled |oinl novenenl.
8realh-holdinq connonly occurs durinq isonelric exercise,
µarlicularly when µerforned aqainsl subslanlial resislance.
!his is likely lo cause a µressor resµonse as lhe resull of lhe
valsalva naneuver, causinq a raµid increase in blood µres-
Phylhnic brealhinq, enµhasizinq exhalalion durinq
lhe conlraclion, should always be µerforned durinq isonel-
ric exercise lo nininize lhis resµonse.
C 0 N ! R A l N 0 l C A ! l 0 N . Riqh-inlensily isonelric
exercises nay be conlraindicaled for µalienls wilh a hislory
of cardiac or vascular disorders.
0ynamìc Excrcìsc-Conccnfrìc and Ecccnfrìc
A dynamic muscle contraction causes joint movement and
excursion oI a body segment as the muscle contracts and
shortens (concentric contraction) or lengthens under ten-
sion (eccentric contraction). As represented in Figure 6.7,
the term concentric exercise reIers to a Iorm oI dynamic
muscle loading where tension in a muscle develops and
physical shortening oI the muscle occurs as an external
Iorce (resistance) is overcome, as when liIting a weight. In
contrast, eccentric exercise involves dynamic loading oI a
muscle beyond its Iorce-producing capacity, causing physi-
cal lengthening oI the muscle as it attempts to control the
load, as when lowering a weight.
pulley system; (2) a weight machine that provides variable
resistance; or (3) an isokinetic device that controls the
velocity oI limb movement.
N 0 ! L . Allhouqh lhe lern i·ctcric (neaninq equal len-
sion) has been used for nany years lo describe a resisled,
dynanic nuscle conlraclion, aµµlicalion of lhis lerninoloqy
is incorrecl. ln facl, when a body seqnenl noves lhrouqh ils
available ranqe, lhe lension lhal lhe nuscle is caµable of
qeneralinq vcric· lhrouqh lhe ranqe as lhe nuscle shorlens
or lenqlhens. !his is due lo lhe chanqinq lenqlh-lension
relalionshiµ of lhe nuscle and lhe chanqinq lorque of lhe
!herefore, in lhis lexlbook "isolonic" is nol used
lo describe dynanic resislance exercise.
Pafìonalc for usc of Conccnfrìc and Ecccnfrìc Excrcìsc
Both concentric and eccentric exercise have distinct value
in rehabilitation and conditioning programs. Concentric
muscle contractions accelerate body segments, whereas
eccentric contractions decelerate body segments (e.g., dur-
ing sudden changes oI direction or momentum). Eccentric
contractions also act as a source oI shock absorption dur-
ing high-impact activities.
A combination oI concentric and eccentric muscle
action is evident in countless tasks oI daily liIe, such as
walking up and down inclines, ascending and descending
stairs, rising Irom a chair and sitting back down, or picking
up or setting down an object. Hence, it is advisable to
incorporate a variety oI concentric and eccentric resistance
exercises in a rehabilitation progression Ior patients with
impaired muscle perIormance to improve muscle strength,
power, or endurance and to meet necessary Iunctional
Eccentric training, in particular, is thought to be an
essential component oI a rehabilitation or conditioning pro-
gram to reduce the risk oI musculoskeletal injury or rein-
jury during activities that involve high-intensity
deceleration and quick changes oI direction.
chronic muscle-tendon disorders are commonly associated
with activities that involve repetitive, eccentric muscle con-
tractions, the progressive use oI eccentric resistance train-
ing is advocated during the advanced stage oI rehabilitaion,
and its eIIicacy is supported by evidence.
Regimens oI exercise that emphasize eccentric load-
ing, such as plvometric training (stretch-shortening arills)
or Iast-velocity, eccentric isokinetic training (both oI which
are discussed later in the chapter), are oIten used to prepare
a patient Ior high-demand sports or work-related activities.
In addition, high-intensity, eccentric exercise is thought to
improve physical perIormance, especially sport-related per-
Characfcrìsfìcs and Effccfs of
Conccnfrìc and Ecccnfrìc Excrcìsc
Exercise load. A maximum concentric contraction pro-
duces less Iorce than a maximum eccentric contraction
under the same conditions (see Fig. 6.6). In other words,
greater loads can be lowered than liIted. This diIIerence in
the magnitude oI loads that can be controlled by concentric
Fl0uPE 8.7 (/} Concen¦r|c and (3} eccen¦r|c s¦renç¦|en|nç o¦ ¦|e e|uow ¦|ez-
ors occurs as a we|ç|¦ |s ||¦¦ed and |owered.
During concentric and eccentric exercise, resistance
can be applied in several ways: (1) constant resistance,
such as body weight, a Iree weight, or a simple weight-
N 0 ! L . A connon error nade by sone weiqhlliflers dur-
inq hiqh-inlensily resislance lraininq is lo assune lhal if a
weiqhl is lifled quickly (concenlric conlraclion) and lowered
slowly (eccenlric conlraclion), lhe slow eccenlric conlrac-
lion qenerales qrealer lension. ln facl, if lhe load is con-
slanl, less lension is qeneraled durinq lhe eccenlric µhase.
!he only way lo develoµ qrealer lension is lo increase lhe
weiqhl of lhe aµµlied load durinq lhe eccenlric µhase of
each exercise cycle. !his usually requires assislance fron an
exercise µarlner lo helµ lifl lhe load durinq each concenlric
conlraclion. !his is a hiqhly inlense forn of exercise and
should be underlaken only by heallhy individuals lraininq
for hiqh-denand sµorls or weiqhlliflinq conµelilion. !his
lechnique is nol aµµroµriale for individuals recoverinq fron
nusculoskelelal in|uries.
Energy expenditure. Eccentric exercise consumes less
oxygen and energy stores than concentric exercise against
similar loads.
ThereIore, the use oI eccentric activities
such as downhill running may improve muscular
endurance more eIIiciently than similar concentric activi-
ties because muscle Iatigue occurs less quickly with eccen-
tric exercise.
Mode specificity. Opinions and results oI studies vary on
whether the eIIects oI training with concentric and eccen-
tric contractions in the exercised muscle group are mode-
speciIic. Although there is substantial evidence to support
speciIicity oI training,
there is also some evi-
dence to suggest that training in one mode leads to strength
gains, though less signiIicant, in the other mode.
Because transIer oI training is quite limited, selection oI
exercises that simulate the Iunctional movements needed
by a patient is a prudent choice.
Cross-training effect. Concentric
and eccentric
ing has been shown to cause a cross-training effect, that is,
a slight increase in strength in the same muscle group oI
the opposite, unexercised extremity. This eIIect, sometimes
reIerred to as cross-exercise, also occurs with high-intensity
exercise that involves a combination oI concentric and
eccentric contractions (liIting and lowering a weight). This
eIIect in the unexercised muscle group may be caused by
repeated contractions oI the unexercised extremity in an
attempt to stabilize the body during high-eIIort exercise.
Although cross-training is an interesting phenomenon,
there is no evidence to suggest that a cross-training eIIect
has a positive impact on a patient`s Iunctional capabilities.
Exercise-induced muscle soreness. Repeated and rapidly
progressed eccentric muscle contractions against resistance
are associated with a signiIicantly higher incidence and
severity oI delayed-onset muscle soreness (DOMS) than
resisted concentric exercise.
Why DOMS occurs
more readily with eccentric exercise is speculative, possi-
bly the result oI greater damage to muscle and connective
tissue when heavy loads are controlled and lowered.
should be noted that there is at least limited evidence to
suggest that iI the intensity and volume oI concentric and
eccentric exercise are equal, there is no signiIicant diIIer-
ence in the degree oI DOMS aIter exercise.
versus eccentric muscle contractions may be associated
with the contributions oI the contractile and noncontractile
components oI muscle. When a load is lowered, the Iorce
exerted by the load is controlled not only by the active,
contractile components oI muscle but also by the connec-
tive tissue in and around the muscle. In contrast, when a
weight is liIted, only the contractile components oI the
muscle liIt the load.
With a concentric contraction, greater numbers oI
motor units must be recruited to control the same load
compared to an eccentric contraction, suggesting that con-
centric exercise has less mechanical eIIiciency than eccen-
tric exercise.
Consequently, it requires more eIIort by a
patient to control the same load during concentric exercise
than during eccentric exercise. As a result, maximum
resistance during the concentric phase oI an exercise does
not provide a maximum load during the eccentric phase.
Although not practical, Ior maximum resistance during the
eccentric phase, an additional load must be applied.
Although greater loads can be used Ior eccentric
training than Ior concentric training, the relative adaptive
gains in eccentric and concentric strength appear to be
similar at the conclusion oI an concentric or eccentric
exercise program. It has been suggested that the higher
incidence oI delayed-onset muscle soreness associated
with high-intensity eccentric exercise may inIluence the
outcome oI these two modes oI training.
N 0 ! L . 6iven lhal eccenlric exercise requires recruilnenl
of fewer nolor unils lo conlrol a load lhan concenlric exer-
cise, when a nuscle is very weak÷less lhan a fair (8j6) nus-
cle qrade÷aclive eccenlric nuscle conlraclions aqainsl no
exlernal resislance (olher lhan qravily) can be used lo qen-
erale aclive nuscle conlraclions and develoµ a beqinninq
level of slrenqlh and neuronuscular conlrol. ln olher words,
in lhe µresence of subslanlial nuscle weakness, il nay be
easier lo conlrol lowerinq a linb aqainsl qravily lhan liflinq
lhe linb.
P R L C A U ! l 0 N S . !here is qrealer slress on lhe cardio-
vascular syslen (i.e., increased hearl rale and arlerial blood
µressure) durinq eccenlric exercise lhan durinq concenlric
µossibly because qrealer loads can be used for
eccenlric lraininq. !his underscores lhe need for rhylhnic
brealhinq durinq hiqh-inlensily exercise. (Pefer lo a laler
seclion of lhis chaµler for addilional infornalion on cardio-
vascular µrecaulions.)
Jelocity of exercise. The velocity at which concentric
or eccentric exercises are perIormed directly aIIects the
Iorce-generating capacity oI the neuromuscular unit.
At slow velocities with a maximum load, an eccentric
contraction generates greater tension than a concentric
contraction. At slow velocities, thereIore, a greater load
(weight) can be lowered (with control) than liIted. As
the velocity oI exercise increases, concentric contrac-
tion tension rapidly and consistently decreases, whereas
eccentric contraction Iorces increase slightly but then rap-
idly reach a plateau under maximum load conditions (see
Fig. 6.6).
C R A P J E P 8 Pesislance Exercise For lnµaired Muscle Perfornance 171
0ynamìc Excrcìsc-Consfanf
and varìahlc Pcsìsfancc
The most common system oI resistance training used with
dynamic exercise against constant or variable resistance is
progressive resistance exercise (PRE). A later section oI
the chapter, which covers systems oI training using
mechanical resistance, addresses PRE.
0ynamìc Consfanf Exfcrnal Pcsìsfancc Excrcìsc
Dynamic constant external resistance (DCER) exercise is
a Iorm oI resistance training where a limb moves through
a ROM against a constant external loaa, provided by Iree
weights such as a handheld or cuII weight, torque arm
units (Fig. 6.8), weight machines, or pulley systems.
This terminology (DCER exercise) is used in lieu oI the
term 'isotonic exercise¨ because although the imposed
load (weight) does not change the torque imposed by the
weight and the tension generated by the muscle do change
throughout the range oI movement.
II the load is less
than the torque generated by the muscle, the muscle con-
tracts concentrically and accelerates the load; iI the load
exceeds the muscle`s torque production, the muscle con-
tracts eccentrically to decelerate the load.
ing Ior training-induced improvements in muscle perIorm-
ance; and it is a mainstay oI resistance exercise programs.
varìahlc-Pcsìsfancc Excrcìsc
Variable-resistance exercise, a Iorm oI dynamic exercise,
addresses the primary limitation oI dynamic exercise
against a constant external load (DCER exercises). Special-
ly designed resistance equipment imposes varying levels oI
resistance to the contracting muscles to load the muscles
more eIIectively at multiple points in the ROM. The resist-
ance is altered throughout the range by means oI a weight-
cable system that moves over an asymmetrically shaped
cam, by a lever arm system, or by hydraulic or pneumatic
How eIIectively these machines vary the
resistance to match muscle torque curves is questionable.
Dynamic exercise with elastic resistance products
(bands and tubing) can also be thought oI in the broadest
sense as a variable-resistance exercise because oI the
inherent properties oI the material and its response to
Furthermore, when dynamic exercise
is perIormed against manual resistance, a skilled thera-
pist can vary the load applied to the contracting muscle
throughout the ROM. The therapist adjusts the resistance
based on the patient`s response so the muscle is appropri-
ately loaded at all portions oI the range.
Spccìal Consìdcrafìons for 0CEP
and varìahlc-Pcsìsfancc Excrcìsc
During either DCER or the variable-resistance exercise, the
velocity and excursion oI limb movement is controlled
exclusively by the patient (with the exception oI manual
resistance exercise and perIorming exercises on units that
have range-limiting devices). Exercises must be perIormed
at a relatively slow velocitv to avoid momentum and
uncontrolled movements, which could jeopardize the saIety
oI the patient.
N 0 ! L . Rydraulic and µneunalic variable-resislance
equiµnenl and elaslic resislance µroducls do allow safe,
hiqh-velocily resislance lraininq. 8ecause nosl daily livinq
and occuµalional aclivilies occur al noderale lo fasl veloci-
lies, lhe lraininq-induced inµrovenenls in nuscle slrenqlh
lhal occur only al slow velocilies nay nol µreµare lhe
µalienl for aclivilies lhal require raµid bursls of slrenqlh or
quick chanqes of direclion.
lsokìncfìc Excrcìsc
Isokinetic exercise is a Iorm oI dynamic exercise in which
the velocity oI muscle shortening or lengthening and
the angular limb velocity is predetermined and held con-
stant by a rate-limiting device known as an isokinetic
dynamometer (Fig. 6.9).
The term isokinetic
reIers to movement that occurs at an equal (constant)
velocity. Unlike DCER exercise where a speciIic weight
(amount oI resistance) is selected and superimposed on the
contracting muscle, in isokinetic resistance training the
velocitv oI limb movement, not the load, is manipulated.
The Iorce encountered by the muscle depends on the extent
oI Iorce applied to the equipment.
Fl0uPE 8.8 N-K Lzerc|se Un|¦ w|¦| ¦oruue aru and |n¦erc|ançeau|e
we|ç|¦s µrov|des cons¦an¦ ez¦erna| res|s¦ance. (Cc0r:-·y cf N-| |rcc0c:·
Ccrjcry, Scç0-|, C/.}
DCER exercise has an inherent limitation. When liIt-
ing or lowering a constant load, the contracting muscle is
challenged maximally at only one point in the ROM where
the maximum torque oI the resistance matches the maxi-
mum torque output oI the muscle. A therapist needs to be
aware oI the changing torque oI the exercise and the
changing lengthtension relationship oI the muscle and
modiIy body position and resistance accordingly to match
where in the range the maximum load needs to be applied.
Despite this limitation, constant external resistance has
been and continues to be an eIIective Iorm oI muscle load-
Irom 0 /sec up to 500 /sec. As shown in Table 6.6, these
training velocities are classiIied as slow, medium, and Iast.
This range theoretically provides a mechanism by which a
patient can prepare Ior the demands oI Iunctional activities
that occur at a range oI velocities oI limb movement.
Selection oI training velocities should be as speciIic
as possible to the demands oI the anticipated Iunctional
tasks. The Iaster training velocities appear to be similar to
or approaching the velocities oI limb movements inherent
in some Iunctional motor skills such as walking or liIt-
For example, the average angular velocity oI the
lower extremity during walking has been calculated at 230
to 240 /sec.
Nevertheless, the velocity oI limb
movements during many Iunctional activities Iar exceeds
the Iastest training velocities available.
The training velocities selected may also be based on
the mode oI exercise (concentric or eccentric) to be per-
Iormed. As noted in Table 6.6, the range oI training veloci-
ties advocated Ior concentric exercise is substantially
greater than Ior eccentric training.
Reciprocal versus isolated muscle training. Use oI recip-
rocal training oI agonist and antagonist muscles emphasiz-
ing quick reversals oI motion is possible on an isokinetic
dynamometer. For example, the training parameter can be
set so the patient perIorms concentric contraction oI the
quadriceps Iollowed by concentric contraction oI the ham-
strings. An alternative approach is to target the same mus-
cle in a concentric mode, Iollowed by an eccentric mode,
thus strengthening only one muscle group at a time.
Both oI these approaches have merit.
Specificity of training. Isokinetic training Ior the most part
is speea-specific,
with only limited evidence
oI signiIicant overIlow Irom one training speed to anoth-
Evidence oI mode-speciIicity (concentric vs.
eccentric) with isokinetic exercise is less clear.
isokinetic exercise tends to be speed-speciIic, patients typi-
Isokinetic exercise is also called accommoaating resist-
ance exercise.
Theoretically, iI an individual is putting
Iorth a maximum eIIort during each repetition oI exercise,
the contracting muscle produces variable but maximum
Iorce output, consistent with the muscle`s variable tension-
generating capabilities at all portions in the range oI move-
ment, not at only one small portion oI the range as occurs
with DCER training. Although early advocates oI isokinetic
training suggested it was superior to resistance training
with Iree weights or weight-pulley systems, this claim has
not been well supported by evidence. Today, use oI isoki-
netic training is regarded as one oI many tools that can be
integrated into the later stages oI rehabilitation.
Characfcrìsfìcs of lsokìncfìc Jraìnìng
A brieI overview oI the key characteristics oI isokinetic
exercise are addressed in this section. For more detailed
inIormation on isokinetic testing and training, a number oI
resources are available.
Constant velocity. Fundamental to the concept oI isokinet-
ic exercise is that the velocity oI muscle shortening or
lengthening is preset and controlled by the unit and
remains constant throughout the ROM.
Range and selection of training velocities. Isokinetic
training aIIords a wide range oI exercise velocities in reha-
bilitation Irom very slow to Iast velocities. Current
dynamometers manipulate the speed oI limb movement
C R A P J E P 8 Pesislance Exercise For lnµaired Muscle Perfornance 178
Fl0uPE 8.0 lso||ne¦|c s¦renç¦|en|nç o¦ ¦|e |n¦erna| and ez¦erna| ro¦a¦ors o¦
¦|e s|ou|der w|¦| ¦|e aru a¦ ¦|e s|de ¦o µro¦ec¦ a µo¦en¦|a||, uns¦au|e ç|eno-
|uuera| ¦o|n¦.
JA8LE 8.8 Classìfìcafìon of vclocìfy
of Jraìnìng ìn Conccnfrìc
lsokìncfìc Excrcìscs*
L|assìfìcaIìon Angu|ar vc|ocìIy
0 /sec
30 ÷60 /sec
60 ÷180 /sec
180 ÷360 /sec and above**
*Training velocities tend to be substantially slower for eccentric
training, ranging from 30 to 120 /sec with most eccentric training
usually initiated between 60 and 120 /sec.
**Although isokinetic equipment offers speed settings up to
500 /sec, training at velocities above 300 ÷360 /sec is not frequent-
ly used because the patient must accelerate the limb to the prede-
termined setting before ¨catching¨ the machine, that is, before
meeting resistance from the unit.
* See reIerences 11, 84, 122, 206, 241.
cally train at several medium and Iast velocities (between
90 and 360 /sec) using a system oI training known as
velocitv spectrum rehabilitation.
(This approach to
isokinetic training is discussed later in the chapter.)
Compressive forces on joints. During concentric exercise,
as Iorce output decreases, the compressive Iorces across
the moving joint are less at Iaster angular velocities than
at slow velocities.
Accommodation to fatigue. Because the resistance
encountered is directly proportional to the Iorce applied
to the resistance arm oI the isokinetic unit, as the contract-
ing muscle Iatigues, a patient is still able to perIorm addi-
tional repetitions even though the Iorce output oI the
muscle temporarily diminishes.
Accommodation to a painful arc. II a patient experiences
transient pain at some portion oI the arc oI motion during
isokinetic exercise, this Iorm oI training accommodates Ior
the painIul arc. The patient simply pushes less vigorously
against the resistance arm to move without pain through
that portion oI the range. II a patient needs to stop a resis-
ted motion because oI sudden onset oI pain, the resistance
is eliminated as soon as the patient stops pushing against
the torque arm oI the dynamometer.
Jraìnìng Effccfs and Carryovcr fo Funcfìon
Numerous studies have shown that isokinetic training is
eIIective Ior improving one or more oI the parameters oI
muscle perIormance.
In contrast, only a
limited number oI studies have investigated the relationship
between isokinetic training and improvement in the per-
Iormance oI Iunctional skills. Two such studies indicated
that the use oI high-velocity concentric and eccentric isoki-
netic training was associated with enhanced perIormance
(increased velocity oI serving in tennis and throwing a
Several Iactors inherent in the design oI most types oI
isokinetic equipment may limit the extent to which isoki-
netic training carries over to improvements in Iunctional
perIormance. Although isokinetic training aIIords a spec-
trum oI velocities Ior training, the velocity oI limb move-
ment during many daily living and sport-related activities
Iar exceeds the maximum velocity settings available on
isokinetic equipment. In addition, limb movements during
most Iunctional tasks occur at multiple velocities, not
at a constant velocity, depending on the conditions oI
the task.
Furthermore, isokinetic exercise usually isolates a sin-
gle muscle or opposite muscle groups, involves movement
oI a single joint, is uniplanar, and does not involve weight
bearing. Although isolation oI a single muscle can be bene-
Iicial in remediating strength deIicits in speciIic muscle
groups, most Iunctional activities require contractions oI
multiple muscle groups and movement oI multiple joints in
several planes oI motion, some in weight-bearing positions.
However, it is important to note that some oI these limita-
tions can be addressed by adapting the setup oI the equip-
ment to allow multiaxis movements in diagonal planes or
multijoint resisted movements with the addition oI an
attachment Ior closed-chain training.
Spccìal Consìdcrafìons for lsokìncfìc Jraìnìng
Availability of Equipment
From a pragmatic perspective, one limitation oI isokinetic
exercise is that a patient can incorporate this Iorm oI exer-
cise into a rehabilitation program only by going to a Iacili-
ty where the equipment is available. In addition, a patient
must be given assistance to set up the equipment and oIten
requires supervision during exercise. These considerations
contribute to high costs Ior the patient enrolled in a long-
term rehabilitation program.
Appropriate Setup
The setups recommended in the product manuals oIten
must be altered to ensure that the exercise occurs in a posi-
tion that is saIe Ior a particular joint. For example, even
though a manuIacturer may describe a 90 /90 position oI
the shoulder and elbow Ior strengthening the shoulder rota-
tors, exercising with the arm at the side may be a saIer,
more comIortable position (see Fig. 6.9).
Initiation and Progression of Isokinetic
Training During Rehabilitation
Isokinetic training is begun in the later stages oI rehabilita-
tion, when active motion through the Iull (or partial) ROM
is pain-Iree. Suggested guidelines Ior implementation and
progression are summarized in Box 6.8.
0pcn-Chaìn and Closcd-Chaìn Excrcìsc
Functional motor skills are composed oI an array oI move-
ments carried out in various positions in the environment.
80X 8.8 Progrcssìon of lsokìncfìc Jraìnìng
for Pchahìlìfafìon
- lnilially lo kccp icsislancc low, submaximal isokinclic
cxcicisc is implcmcnlcd bcfoic isokinclic cxcicisc will
maximal cffoil.
- Sloil-aic movcmcnls aic uscd bcfoic full-aic molions,
wlcn ncccssaiy, lo avoid movcmcnl in an unslablc oi
painful poilion of llc iangc. 1lis is accomplislcd by a
mcclanical iangc-limiling dcvicc oi will a compulciizcd
- Slow lo mcdium liaining vclocilics (60 -180 |scc) aic
incoipoialcd inlo llc cxcicisc piogiam bcfoic piogicss-
ing lo faslci vclocilics.
- Maximal conccnliic conliaclions al vaiious vclocilics aic
pcifoimcd bcfoic inlioducing ccccnliic isokinclic cxcicis-
cs foi llc following icasons.
- Conccnliic isokinclic cxcicisc is casici lo lcain and is
fully undci llc conliol of llc palicnl.
- Puiing ccccnliic isokinclic cxcicisc llc vclocily of
movcmcnl of llc icsislancc aim is iobolically con-
liollcd by llc dynamomclci, nol llc palicnl.
Ior a motion to be categorized as closed kinetic chain, but
many oI his examples oI closed-chain movements, particu-
larly in the lower extremities, involved weight bearing. In
the current literature, descriptions oI a closed kinetic chain
oIten do
but sometimes do not
include weight
bearing as a necessary element. One author suggested that
all weight-bearing exercises involve some elements oI
closed-chain motions, but not all closed-chain exercises are
perIormed in weight-bearing positions.
Another point oI ambiguity is whether the distal seg-
ment must be absolutely Iixed to a surIace and not moving
to be classiIied as a closed-chain motion. Steindler
described this as one oI the conditions oI a closed-chain
motion. However, another condition in his description oI
closed kinetic chain motions is that iI the 'considerable
external resistance¨ is overcome it results in movement oI
the peripheral segment. Examples Steindler cited were
pushing a cart away Irom the body and liIting a load. Con-
sequently, some investigators classiIy a bench press exer-
cise, a seated or reclining leg press exercise, or cycling as
closed-chain exercises because they involve pushing
motions and axial loading.
II these exercises Iit under
the closed-chain umbrella, does an exercise in which the
distal segment slides across the support surIace also qualiIy
as a closed-chain motion? Opinion is divided.
LiIting a handheld weight or pushing against the Iorce
arm oI an isokinetic dynamometer are consistently cited in
the literature as examples oI open-chain exercises.
Although there is no axial loading in these exercises, con-
sidering Steindler`s condition Ior closed-chain motion just
discussed, should these exercises more correctly be classi-
Iied as closed-chain rather than open-chain exercises in
that the distal segment is overcoming considerable external
resistance? Again, there is no consensus.
Given the complexity oI human movement, it is not
surprising that a single classiIication system cannot ade-
quately group the multitude oI movements Iound in Iunc-
tional activities and therapeutic exercise interventions.
Alfcrnafìvcs fo 0pcn-Chaìn and
Closcd-Chaìn Jcrmìnology
To address the unresolved issues associated with open-
chain and closed-chain terminology, several authors have
oIIered alternative or additional terms to classiIy exercises.
One suggestion is to use the terms aistallv fixatea and
nonaistallv fixatea in lieu oI closed chain and open
Another suggestion is to add a category dubbed
partial kinetic chain
to describe exercises in which
the distal segment (hand or Ioot) meets resistance but is not
absolutely stationary, such as using a leg press machine,
bicycle, stepping machine, or slide board. The term closed
kinetic chain is then reserved Ior instances when the termi-
nal segment does not move.
To avoid use oI the open- or closed-chain concepts,
another classiIication system categorizes exercises as either
foint isolation exercises (movement oI only one joint seg-
ment) or kinetic chain exercises (simultaneous movement
The cornerstone oI a functionallv relevant therapeutic
exercise program is the inclusion oI task-speciIic move-
ments and postural control associated with the necessary,
expected, and desired Iunctional demands in a patient`s
In the clinical setting and in the rehabilitation litera-
ture, Iunctional activities and exercises are commonly cate-
gorized as having weight-bearing or non-weight-bearing
characteristics. Another Irequently used method oI classiIy-
ing movements and exercises is based on 'open or closed
kinetic chain¨ and 'open or closed kinematic chain¨ con-
cepts. These concepts, which were introduced during the
1950s and 1960s in the human biomechanics and kinesiol-
ogy literature by Steindler
and Brunnstrom,
ly, were put Iorth to describe how segments (structures)
and motions oI the body are linked and how muscle
recruitment changes during diIIerent types oI movement
and in response to diIIerent loading conditions in the envi-
In his analysis oI human motion, Steindler
that the term 'open kinetic chain¨ applies to completely
unrestricted movement in space oI a peripheral segment oI
the body, as in waving the hand or swinging the leg. In
contrast, he suggested that during closed kinetic chain
movements the peripheral segment meets with 'consider-
able external resistance.¨ He stated that iI the terminal seg-
ment remains Iixed, the encountered resistance moves the
proximal segments over the stationary distal segments. He
also noted that in a closed kinetic chain motion in one joint
is accompanied by motions oI adjacent joints that occur in
reasonably predictable patterns.
Both Steindler and Brunnstrom pointed out that the
action oI a muscle changes when the distal segment is Iree
to move versus when it is Iixed in place. For example, in
an open chain the tibialis posterior muscle Iunctions to
invert and plantarIlex the Ioot and ankle. In contrast, dur-
ing the stance phase oI gait (during loading), when the Ioot
is planted on the ground the tibialis posterior contracts to
decelerate pronation oI the subtalar joint and to supinate
the Ioot to rotate the lower leg externally during the mid
and terminal stance.
During the late 1980s and early 1990s, clinicians and
researchers in rehabilitation, who were becoming Iamiliar
with the open and closed kinetic (or kinematic) chain
approach to classiIying human motion, began to describe
exercises based on these concepts.
Confrovcrsy and lnconsìsfcncy ìn usc
of 0pcn-Chaìn and Closcd-Chaìn Jcrmìnology
Although use oI open- and closed-chain terminology is
now prevalent in the clinical setting and in the rehabilita-
tion literature, as investigators have discussed and applied
open- and closed-chain concepts to exercise a lack oI
consensus has emerged about how, or even iI, this termi-
nology should be used and what constitutes an open-chain
versus a closed-chain exercise.
One source oI inconsistency is whether weight bearing
is an inherent component oI closed kinetic chain motions.
did not speciIy that weight bearing must occur
C R A P J E P 8 Pesislance Exercise For lnµaired Muscle Perfornance 175
* See reIerences 58, 59, 87, 101, 128, 229, 261, 299, 305.
oI multiple segments that are linked).
Boundaries oI
movement oI the peripheral segment (movable or station-
ary) or loading conditions (weight bearing or nonweight
bearing) are not parameters oI this terminology. However,
other, more complex classiIication systems do take these
conditions into account.
Although these alternative terms have been put Iorth,
open- and closed-chain terminology continues to be widely
used in the clinical setting and in the literature.
despite the many inconsistencies and shortcomings oI the
kinetic or kinematic chain terminology, and recognizing
that many exercises and Iunctional activities oIten involve
a combination oI open- and closed-chain motions or do not
Iit either open- or closed-chain deIinitions, the authors oI
this textbook have chosen to continue to use open- and
closed-chain terminology to describe exercises.
Characfcrìsfìcs of 0pcn-Chaìn
and Closcd-Chaìn Excrcìscs
The Iollowing operational deIinitions and characteristics
oI open- and closed-chain exercises are presented Ior clar-
ity and as the basis Ior the discussion oI open- and closed-
chain exercises described throughout this textbook. The
parameters oI the deIinitions are those most Irequently
noted in the current literature. Common characteristics
oI open- and closed-chain exercises are compared in
Table 6.7.
Open-Chain Exercises
Open-chain exercises involve motions in which the distal
segment (hand or Ioot) is Iree to move in space, without
necessarily causing simultaneous motions at adjacent
Limb movement only occurs aistal to
the moving joint. Muscle activation occurs in the muscles
that cross the moving joint. For example, during knee Ilex-
ion in an open-chain exercise (Fig. 6.10), the action oI the
hamstrings is independent oI recruitment oI other hip or
ankle musculature. Open-chain exercises also are typically
perIormed in non-weight-bearing positions.
addition, during resistance training, the exercise load
(resistance) is applied to the moving distal segment.
Closed-Chain Exercises
Closed-chain exercises involve motions in which the
body moves on a distal segment that is Iixed or stabilized
on a support surIace.
Movement at
one joint causes simultaneous motions at distal as well as
proximal joints in a relatively predictable manner. For
example, when a patient is perIorming a bilateral short-arc
squatting motion (mini-squat) (Fig. 6.11) and then return-
ing to an erect position, as the knees Ilex and extend, the
JA8LE 8.7 Characfcrìsfìcs of 0pcn-Chaìn and Closcd-Chaìn Excrcìscs
0pcn-Lhaìn Lxcrcìscs L|oscd-Lhaìn Lxcrcìscs
Distal segment moves in space
Ìndependent joint movement; no predictable joint motion in
adjacent joints
Movement of body segments only distal to the moving
Muscle activation occurs predominantly in the prime
mover and is isolated to muscles of the moving joint
Typically performed in non weight-bearing positions
Resistance is applied to the moving distal segment
Use of external rotary loading
External stabilization (manually or with equipment) usually
Distal segment remains in contact with or stationary (fixed
in place) on support surface
Ìnterdependent joint movements; relatively predictable
movement patterns in adjacent joints
Movement of body segments may occur distal and/or
proximal to the moving joint
Muscle activation occurs in multiple muscle groups, both
distal and proximal to the moving joint
Typically but not always performed in weight-bearing
Resistance is applied simultaneously to multiple moving
Use of axial loading
Ìnternal stabilization by means of muscle action, joint
compression, and congruency and postural control
Fl0uPE 8.10 0µen-c|a|n res|s¦ed |nee ¦|ez|on.
See reIerences 25, 30, 58, 59, 75, 84, 85, 125, 128, 150,
178, 195, 266, 305.
in the upper and lower extremities. However, oI the studies
reviewed, very Iew randomized, controlled trials demon-
strated that these improvements in muscle perIormance
were associated with a reduction oI Iunctional limitations
or improvement in physical perIormance.
A summary oI the beneIits and limitations oI open-
and closed-chain exercises and the rationale Ior their use
Iollows. Whenever possible, presumed beneIits and limita-
tions or comparisons oI both Iorms oI exercise are ana-
lyzed in light oI existing scientiIic evidence. Some oI the
reported beneIits and limitations are supported by evi-
dence, whereas others are oIten Iounded on opinion or
anecdotal reports. Evidence is presented as available.
N 0 ! L . Mosl reµorls and invesliqalions conµarinq or ana-
lyzinq closed- or oµen-chain exercises have focused on lhe
knee, in µarlicular lhe anlerior cruciale liqanenl (ACL) or
µalellofenoral |oinl. Far fewer arlicles have addressed lhe
aµµlicalion or inµacl of oµen- and closed-chain exercises
on lhe uµµer exlrenilies.
Isolation of Muscle Groups
Open-chain testing and training identiIies strength deIicits
and improves muscle perIormance oI individual muscles
or muscle groups more eIIectively than closed-chain exer-
cises. The possible occurrence oI substitute motions that
compensate Ior and mask strength deIicits oI individual
muscles is greater with closed-chain exercise than open-
chain exercise.
Focus on Evidence
In a study oI the eIIectiveness oI a closed-chain-onlv resist-
ance training program aIter ACL reconstruction, residual
muscle weakness oI the quadriceps Iemoris was identi-
The investigators suggested that this residual
strength deIicit, which altered gait, might have been avoid-
ed with the inclusion oI open-chain quadriceps training in
the postoperative rehabilitation program.
Control of Movements
During open-chain resisted exercises a greater level oI con-
trol is possible with a single moving joint than with multi-
ple moving joints as occurs during closed-chain training.
With open-chain exercises stabilization is usually applied
externally by a therapist`s manual contacts or with belts
or straps. In contrast, during closed-chain exercises the
patient most oIten uses muscular stabilization to control
joints or structures proximal and distal to the targeted joint.
The greater levels oI control aIIorded by open-chain train-
ing are particularly advantageous during the early phases
oI rehabilitation.
1oint Approximation
Almost all muscle contractions have a compressive com-
ponent that approximates the joint surIaces and provides
stability to the joint whether in open- or closed-chain situa-
Joint approximation also occurs during weight
hips and ankles move in a predictable pattern along with
the knees.
Closed-chain exercises are primarily perIormed in
weight-bearing positions.
Examples in the
upper extremities include balance activities in quadruped,
sitting press-ups, wall push-oIIs, or prone push-ups; exam-
ples in the lower extremities include lunges, squats, step-up
or step-down exercises, or heel rises to name a Iew.
N 0 ! L . ln lhis lexlbook, as in sone olher µublicalions,
inclusive in lhe scoµe of closed-chain exercises are
wciç|t-Iccrirç cctivitic· where lhe dislal seqnenl rcvc·
Int rcrcir· ir ccrtcct wit| t|c ·nppcrt ·nrIccc, as when
usinq a bicycle, cross-counlry ski nachine, or slair-sleµµinq
nachine. ln lhe uµµer exlrenilies a few non-weiqhl-bearinq
aclivilies qualify as closed-chain exercises, such as µull-uµs
on a lraµeze in bed or chin-uµs al an overhead bar.
Pafìonalc for usc of 0pcn-Chaìn
and Closcd-Chaìn Excrcìscs
The rationale Ior selecting open- or closed-chain exercises
is based on the goals oI an individualized rehabilitation
program and a critical analysis oI the potential beneIits and
limitations inherent in either Iorm oI exercise.
Iunctional activities involve many combinations and con-
siderable variations oI open- and closed-chain motions,
inclusion and integration oI task-speciIic open-chain and
closed-chain exercises into a rehabilitation or conditioning
program is both appropriate and prudent.
Focus on Evidence
Although oIten suggested, there is no evidence to support
the global assumption that closed-chain exercises are
'more Iunctional¨ than open-chain exercises. A review oI
the literature by Davies
indicated there is a substantial
body oI evidence that both open- and closed-chain exercis-
es are eIIective Ior reducing deIicits in muscle perIormance
C R A P J E P 8 Pesislance Exercise For lnµaired Muscle Perfornance 177
Fl0uPE 8.11 b||a¦era| c|osed-c|a|n res|s¦ed ||µ and |nee ez¦ens|on.
bearing and is associated with lower levels oI shear Iorces
at a moving joint. This has been demonstrated at the knee
(decreased anterior or posterior tibioIemoral transla-
and possibly at the glenohumeral joint.
joint approximation that occurs with the axial loading and
weight bearing during closed-chain exercises is thought to
cause an increase in joint congruency, which in turn con-
tributes to stability.
Co-activation and Dynamic Stabilization
Because most closed-chain exercises are perIormed in
weight-bearing positions, it has been assumed and com-
monly reported in the neurorehabilitation literature that
closed-chain exercises stimulate joint and muscle
mechanoreceptors, Iacilitate co-activation oI agonists and
antagonists (co-contraction), and consequently promote
dynamic stability.
During a standing squat, Ior
example, the quadriceps and hamstrings are thought to
contract concurrently to control the knee and hip, respec-
tively. In studies oI lower extremity closed-chain exercises
and activity oI the knee musculature, this assumption has
been both supported
and reIuted.
In the upper extremity, closed-chain exercises in
weight-bearing positions are also thought to cause co-
activation oI the scapular and glenohumeral stabilizers
and, thereIore, to improve dynamic stability oI the shoul-
der complex.
The assumption seems plausible, but
evidence oI co-contraction oI muscles oI the shoulder
girdle during weight-bearing exercises, such as a prone
push-up or a press-up in a chair, is just beginning to
making it diIIicult Ior clinicians to draw
conclusions or make evidence-based decisions at
this time.
There is also some thought that co-activation (co-
contraction) oI agonist and antagonist muscle groups may
occur with selected open-chain exercises. Exercise inter-
ventions, such as alternating isometrics associated with
some stretch-shortening drills perIormed
in non-weight-bearing positions,
use oI a BodyBlade
(see Fig. 6.55), and high-velocity isokinetic training, may
stimulate co-activation oI muscle groups to promote
dynamic stability. However, evidence oI this possibility is
In several studies oI open-chain, high-velocity, con-
centric isokinetic training oI knee musculature,
activation oI agonist and antagonist muscle groups was
noted brieIly at the end the range oI knee extension. Inves-
tigators speculated that the knee Ilexors Iired and contract-
ed eccentrically at the end oI the range oI knee extension
to decelerate the limb just beIore contact was made with
the ROM stop. However in another study, there was no evi-
dence oI co-activation oI knee musculature or decreased
anterior tibial translation with maximum-eIIort, slow-
velocity (60 /sec), open-chain training.
P R L C A U ! l 0 N . Riqh-load, oµen-chain exercise nay
have an adverse effecl on unslable, in|ured, or recenlly
reµaired |oinls, as denonslraled in lhe ACL-deficienl
Proprioception, Kinesthesia,
Neuromuscular Control, and Balance
Conscious awareness oI joint position or movement is one
oI the Ioundations oI motor learning during the early phase
oI training Ior neuromuscular control oI Iunctional move-
ments. AIter soIt tissue or joint injury, proprioception and
kinesthesia are disrupted and alter neuromuscular control.
Re-establishing the eIIective, eIIicient use oI sensory inIor-
mation to initiate and control movement is a high priority
in rehabilitation. Studies oI the ACL-reconstructed knee
have shown that proprioception and kinesthesia do improve
aIter rehabilitation.
It is thought that closed-chain training provides greater
proprioceptive and kinesthetic Ieedback than open-chain
training. Theoretically, because multiple muscle groups that
cross multiple joints are activated during closed-chain exer-
cise, more sensory receptors in more muscles and intra-arti-
cular and extra-articular structures are activated to control
motion than during open-chain exercises. The weight-bear-
ing element (axial loading) oI closed-chain exercises, which
causes joint approximation, is believed to stimulate
mechanoreceptors in muscles and in and around joints to
enhance sensory input Ior the control oI movement.
Focus on Evidence
Despite the assumption that joint position or movement
sense is enhanced to a greater extent under closed-chain
than open-chain conditions, the evidence is mixed. The
results oI one study
indicated that in patients with unsta-
ble shoulders kinesthesia improved to a greater extent with
a program oI closed-chain and open-chain exercises com-
pared to a program oI only open-chain exercises. In con-
trast, in a comparison oI the ability to detect knee position
during closed-chain versus open-chain conditions, no sig-
niIicant diIIerence was reported.
Finally, closed-chain positioning is the obvious choice
to improve balance and postural control in the upright posi-
tion. Balance training is believed to be an essential element
oI the comprehensive rehabilitation oI patients aIter mus-
culoskeletal injuries or surgery, particularly in the lower
extremities, to restore Iunctional abilities and prevent rein-
Activities and parameters to challenge the body`s
balance mechanisms are discussed in Chapter 8.
Carryover to Function and Injury Prevention
As already noted, there is ample evidence to demonstrate
that both open- and closed-chain exercises eIIectively
improve muscle strength, power, and endurance.
dence also suggests that iI there is a comparable level oI
loading (amount oI resistance) applied to a muscle group,
EMG activity is similar regardless oI whether open-chain
or closed-chain exercise is perIormed.
That being said, and consistent with the principle oI
motor learning and task-speciIic training, exercises should
be incorporated into a rehabilitation program that simulate
* See reIerences 128, 180, 181, 182, 183, 229, 253, 300.
discussed earlier in the chapter. Relevant Ieatures oI
closed-chain exercises and guidelines Ior progression
are summarized in Table 6.8.
Introduction of Open-Chain Training
Because open-chain training typically is perIormed in non-
weight-bearing postures, it may be the only option when
weight bearing is contraindicated or must be signiIicantly
restricted or when unloading in a closed-chain position is
not possible. SoIt tissue pain and swelling or restricted
motion oI any segment oI the chain may also necessitate
the use oI open-chain exercises at adjacent joints. AIter a
Iracture oI the tibia, Ior example, the lower extremity usu-
ally is immobilized in a long leg cast, and weight bearing
is restricted Ior at least a Iew weeks. During this period,
hip strengthening exercises in an open chain manner can
still be initiated and gradually progressed until partial
weight bearing and closed-chain activities are permissible.
Any activity that involves open-chain motions can
easily be replicated with open-chain exercises, Iirst by
developing isolated control and strength oI the weak mus-
culature and then by combining motions to simulate Iunc-
tional patterns.
Closed-Chain Exercises and Weight-Bearing
Restrictions-Use of Unloading
II weight bearing must be restricted, a saIe alternative to
open-chain exercises may be to perIorm closed-chain exer-
the desired Iunctions iI the selected exercises are to have
the most positive impact on Iunction.
Studies oI
lower extremity Iunctional tasks and open- and closed-
chain exercises support speciIicity oI training.
Focus on Evidence
In a study oI older women, stair-climbing abilities
improved to a greater extent in participants who perIormed
lower extremity strengthening exercises while standing
(closed-chain exercises) and wearing a weighted backpack
than those who perIormed traditional (open-chain) resist-
ance exercises.
In another study, squatting exercises
while standing, a closed-chain exercise, were shown to
enhance perIormance oI a jumping task more eIIectively
than open-chain isokinetic knee extension exercises.
Closed-chain training, speciIically a program oI jumping
activities, also has been shown to decrease landing Iorces
through the knees and reduce the risk oI knee injuries in
Iemale athletes.
lmplcmcnfafìon and Progrcssìon
of 0pcn- and Closcd-Chaìn Excrcìscs
Principles and general guidelines Ior the implementation
and progression oI open-chain and closed-chain exercises
are similar with respect to variables such as intensity, vol-
ume, Irequency, and rest intervals. These variables were
C R A P J E P 8 Pesislance Exercise For lnµaired Muscle Perfornance 170
JA8LE 8.8 Paramcfcrs and Progrcssìon of Closcd-Chaìn Excrcìscs
ParamcIcrs Progrcssìon
% Body weight
Base of support
Support surface
Exclusion of limb movement
Plane or direction of movement
Speed of movement or directional changes
Partial full weight-bearing
(LE: aquatic exercise, parallel bars, overhead harnessing; UE: wall
push-up modified prone push-up prone push-up)
Full weight bearing additional weight
(weighted vest or belt, handheld or cuff weights, elastic resistance)
Wide narrow
Bilateral unilateral
Fixed on support surface sliding on support surface
Stable unstable/moving
(LE: floor rocker board, wobble board, sideboard, treadmill)
(UE: floor, table or wall rocker or side board, ball)
Rigid soft
(Floor, table carpet, foam)
Height: ground level increasing height
(Low step high step)
With external support no external support
Eyes open eyes closed
Small large ranges
Short-arc full-arc (if appropriate)
Uniplanar multiplanar
Anterior posterior diagonal
(forward walking retrowalking; forward step-up backward step-up)
Sagittal frontal or transverse
(forward-backward sliding side to side sliding; forward or backward
step-up lateral step-up)
Slow fast
cises while partial weight bearing on the involved extremi-
ty. This is simple to achieve in the upper extremity; but in
the lower extremity, because the patient is in an upright
position during closed-chain exercises, axial loading in one
or both lower extremities must be reduced.
Use oI aquatic exercises, as described in Chapter 9, or
decreasing the percentage oI body weight borne on the
involved lower extremity in parallel bars are both Ieasible
unloading strategies even though each has limitations. It is
diIIicult to control the extent oI weight bearing when per-
Iorming closed-chain exercises in parallel bars. In addition,
lower limb movements while standing in the parallel bars
or in water tend to be slower than what typically occurs
during Iunctional tasks. An alternative is the use oI a har-
nessing system to unload the lower extremities.
This sys-
tem enables a patient to perIorm a variety oI closed-chain
exercises and to begin ambulation on a treadmill at Iunc-
tional speeds early in rehabilitation.
Progression of Closed-Chain Exercises
The parameters and suggestions Ior progression oI closed-
chain activities noted in Table 6.8 are not all-inclusive and
are Ilexible. As a rehabilitation program progresses, plyo-
metric training (discussed later in the chapter) and agility
drills, more advanced Iorms oI closed-chain training, can
be introduced.
The selection and progression oI activi-
ties should always be based on the discretion oI the thera-
pist and the patient`s Iunctional needs and response to
exercise interventions.
The principles oI resistance training presented in this sec-
tion apply to the use oI both manual and mechanical resist-
ance exercises Ior persons oI all ages, but these principles
are not 'set in stone.¨ There are many instances when they
may or should be modiIied based on the judgment oI the
therapist. Additional guidelines speciIic to the application
oI manual resistance exercise, proprioceptive neuromuscu-
lar Iacilitation, and mechanical resistance exercise are
addressed in later sections oI this chapter.
Examìnafìon and Evaluafìon
As with all Iorms oI therapeutic exercise, a comprehensive
examination and evaluation is the cornerstone oI an indi-
vidualized resistance training program. ThereIore, prior to
initiating any Iorm oI resistance exercise:
PerIorm a thorough examination oI the patient, including
a health history, systems review, and selected tests and
· Determine qualitative and quantitative baselines oI
strength, muscular endurance, ROM, and overall level
oI Iunctional perIormance against which progress can
be measured.
· Implement testing procedures, such as manual muscle
testing, determination oI a repetition maximum,
dynamometry, goniometry, quantitative Iunctional
perIormance tests, and assessment oI the patient`s
perceived level oI disability.
Interpret the Iindings to determine iI the use oI resist-
ance exercise is appropriate or inappropriate at this time.
Some questions that may need to be answered are noted
in Box 6.9. Be sure to identiIy the most Iunctionally rel-
evant impairments, the goals the patient is seeking to
achieve and the expected Iunctional outcomes oI the
exercise program.
Establish how resistance training will be integrated into
the plan oI care with other therapeutic exercise interven-
tions, such as stretching, joint mobilization techniques,
balance training, and cardiopulmonary conditioning
Re-evaluate periodically to document progress and deter-
mine iI and how the dosage oI exercises (intensity, vol-
ume, Irequency, rest) and the types oI resistance exercise
should be adjusted to continue to challenge the patient.
80X 8.0 ls Pcsìsfancc Jraìnìng Approprìafc?
0ucsfìons fo Consìdcr
- Wcic dcficils in musclc pcifoimancc idcnlificd? lf so, do
llcsc dcficils appcai lo bc conliibuling lo limilalions of
funclional abililics llal you lavc obscivcd oi llc palicnl
oi family las icpoilcd?
- Could idcnlificd dcficils causc fuluic impaiimcnl of func-
- Wlal is llc iiiilabilily and cuiicnl slagc of lcaling of
involvcd lissucs?
- ls llcic cvidcncc of lissuc swclling?
- ls llcic pain? (Al icsl oi will movcmcnl? Al wlal poi-
lion of llc R0M? ln wlal lissucs?)
- Aic llcic ollci dcficils (sucl as impaiicd mobilily, bal-
ancc, scnsalion, cooidinalion, oi cognilion) llal aic
advciscly affccling mucl of llc pcifoimancc?
- Wlal aic llc palicnl`s goals oi dcsiicd funclional oul-
comcs? Aic llcy icalislic in ligll of llc findings of llc
- Civcn llc palicnl`s cuiicnl slalus, aic icsislancc cxciciscs
indicalcd? Conliaindicalcd?
- Can llc idcnlificd dcficils in musclc pcifoimancc bc
climinalcd oi minimizcd will icsislancc cxciciscs?
- lf a dccision is madc lo picsciibc icsislancc cxciciscs in
llc licalmcnl plan, wlal icsislancc cxciciscs aic cxpccl-
cd lo bc mosl cffcclivc?
- Slould onc aica of musclc pcifoimancc bc cmplasizcd
ovci anollci?
- Will llc palicnl icquiic supcivision oi assislancc ovci llc
couisc of llc cxcicisc piogiam oi can llc piogiam bc
caiiicd oul indcpcndcnlly?
- Wlal is llc cxpcclcd ficqucncy and duialion of llc
icsislancc liaining piogiam? Will a mainlcnancc pio-
giam bc ncccssaiy?
- Aic llcic any piccaulions spccific lo llc palicnl`s plysi-
cal slalus, gcncial lcalll, oi agc llal may waiianl spc-
cial considcialion?
Stabilization is necessary to avoid unwanted, substitute
For non-weight-bearing resisted exercises, external stabi-
lization oI a segment is usually applied at the proximal
attachment oI the muscle to be strengthened. In the case
oI the biceps brachii muscle, Ior example, stabilization
should occur at the anterior shoulder as elbow Ilexion is
resisted (Fig. 6.13). Equipment such as belts or straps
are eIIective sources oI external stabilization.
During multijoint resisted exercises in weight-bearing
postures, the patient must use muscle control (internal
stabilization) to hold nonmoving segments in alignment.
Prcparafìon for Pcsìsfancc Excrcìscs
Select and prescribe the Iorms oI resistance exercise that
are appropriate and expected to be eIIective, such as
whether to implement manual or mechanical resistance
exercises, or both.
II implementing mechanical resistance exercise, deter-
mine what equipment is needed and available.
Review the anticipated goals and expected Iunctional
Explain the exercise plan and procedures. Be sure that
the patient and/or Iamily understands and gives consent.
Have the patient wear nonrestrictive clothing and
supportive shoes appropriate Ior exercise. II the patient
is wearing a hospital gown, use a sheet to drape Ior
II possible, select a Iirm but comIortable support surIace
Ior exercise.
Demonstrate each exercise and the desired movement
Applìcafìon of Pcsìsfancc Excrcìscs
N 0 ! L . !hese qeneral quidelines aµµly lo lhe use of
Jyrcric exercises aqainsl nanual cr nechanical resislance.
ln addilion lo lhese quidelines, refer lo sµecial considera-
lions and quidelines unique lo lhe aµµlicalion of nanual
and nechanical resislance exercises in lhe seclions of lhis
chaµler lhal follow.
Warm up
Prior to initiating resistance exercises, warm up with light,
repetitive, dynamic, site-speciIic movements without
applying resistance. For example, prior to lower extremity
resistance exercises, have the patient walk on a treadmill, iI
possible, Ior 5 to 10 minutes Iollowed by Ilexibility exer-
cises Ior the trunk and lower extremities.
Placcmcnf of Pcsìsfancc
Resistance is typically applied to the distal end oI the
segment in which the muscle to be strengthened attaches.
Distal placement oI resistance generates the greatest
amount oI external torque with the least amount oI man-
ual or mechanical resistance (load). For example, to
strengthen the anterior deltoid, resistance is applied to
the distal humerus as the patient Ilexes the shoulder
(Fig. 6.12).
Resistance may be applied across an intermediate joint
iI that joint is stable and pain-Iree and iI there is ade-
quate muscle strength supporting the joint. For example,
to strengthen the anterior deltoid using mechanical
resistance, a handheld weight is a common source oI
Revise the placement oI resistance iI pressure Irom the
load is uncomIortable.
0ìrccfìon of Pcsìsfancc
During concentric exercise resistance is applied in the
direction airectlv opposite to the desired motion, whereas
during eccentric exercise resistance is applied in the same
direction as the desired motion (see Fig. 6.12).
C R A P J E P 8 Pesislance Exercise For lnµaired Muscle Perfornance 181
Fl0uPE 8.12 Res|s¦ance (R} |s aµµ||ed ¦o ¦|e d|s¦a| end o¦ ¦|e seçuen¦ ue|nç
s¦renç¦|ened. Res|s¦ance |s aµµ||ed |n ¦|e cir-c:icr cjjc·i:- ¦o ¦|a¦ o¦ ||uu
uoveuen¦ ¦o res|s¦ a concen¦r|c uusc|e con¦rac¦|on and |n ¦|e ·cr- cir-c-
:icr as ||uu uoveuen¦ ¦o res|s¦ an eccen¦r|c con¦rac¦|on.
Fl0uPE 8.18 S¦au|||za¦|on |s aµµ||ed a¦ ¦|e µroz|ua| a¦¦ac|uen¦ o¦ ¦|e uus-
c|e ue|nç s¦renç¦|ened. ln ¦||s ¦|çure ¦|e µroz|ua| |uuerus and scaµu|a are
s¦au|||zed as e|uow ¦|ez|on |s res|s¦ed.
lnfcnsìfy of ExcrcìscjAmounf of Pcsìsfancc
N 0 ! L . !he inlensily of lhe exercise (subnaxinal lo near-
naxinal) nusl be consislenl wilh lhe inlended qoals of
resislance lraininq and lhe lyµe of nuscle conlraclion as
well as olher asµecls of dosaqe.
Initially, have the patient practice the movement pattern
against a minimal load to learn the correct pattern and
the exercise technique.
Have the patient exert a IorceIul but controlled and pain-
Iree eIIort. The level oI resistance should be such that
movements are smooth and nonballistic or tremulous.
Adjust the alignment, stabilization, or the amount oI
resistance iI the patient is unable to complete the avail-
able ROM, muscular tremor develops, or substitute
motions occur.
volumcjNumhcr of Pcpcfìfìons
and Scfs and Pcsf lnfcrvals
In general, Ior most adults, use 8 to 12 repetitions oI a
speciIic motion against a moderate exercise load. This
volume induces typical acute and chronic responses;
that is, muscular Iatigue and adaptive gains in muscular
strength, respectively.
Decrease the amount oI resistance iI the patient cannot
complete 8 to 12 repetitions.
AIter a brieI rest, perIorm additional repetitions: a sec-
ond set oI 8 to 12 repetitions, iI possible.
For progressive overloading, initially increase the num-
ber oI repetitions or sets; at a later point in the exercise
program, gradually increase the resistance.
vcrhal or Wrìffcn lnsfrucfìons
When teaching an exercise using mechanical resistance or
when applying manual resistance, use simple instructions
that are easily understood. Do not use medical terminology
or jargon. For example, tell the patient to 'Bend and
straighten your elbow¨ rather than 'Flex and extend your
elbow.¨ Be sure that descriptions oI resistance exercises to
be perIormed in a home program are written and clearly
Monìforìng fhc Pafìcnf
Assess the patient`s responses beIore, during, and aIter
exercise. It may be advisable to monitor the patient`s vital
signs. Adhere to relevant precautions discussed in the next
section oI the chapter.
Cool 0own
Cool down aIter a series oI resistance exercises with rhyth-
mic, unresisted movements, such as arm swinging, walk-
ing, or cycling. Gentle stretching is also appropriate aIter
resistance exercise.
Regardless oI the goals oI a resistance exercise program
and the types oI exercises prescribed and implemented,
the exercises must not only be eIIective but safe. The thera-
pist`s interpretation oI the examination`s Iindings deter-
mine the exercise prescription. Awareness oI precautions
maximizes patient saIety. General precautions Ior resist-
ance training are summarized in Box 6.10.
Additional inIormation about several oI these precau-
tions is presented in this section. Special considerations and
precautions Ior children and older adults who participate in
weight-training programs are addressed later in the chapter.
valsalva Mancuvcr
The Valsalva maneuver (phenomenon), which is deIined as
an expiratory eIIort against a closed glottis, must be avoid-
ed during resistance exercise. The Valsalva maneuver is
characterized by the Iollowing sequence. A deep inspira-
tion is Iollowed by closure oI the glottis and contraction oI
the abdominal muscles. This increases intra-abdominal and
intrathoracic pressures, which in turn Iorces blood Irom the
heart, causing an abrupt, temporary increase in arterial
blood pressure.
80X 8.10 0cncral Prccaufìons 0urìng
Pcsìsfancc Jraìnìng
- Kccp llc ambicnl lcmpcialuic of llc cxcicisc sclling
comfoilablc foi vigoious cxcicisc. Sclccl clolling foi
cxcicisc llal facililalcs lcal dissipalion and docs nol
impcdc swcal cvapoialion.
- Caulion llc palicnl llal pain slould rct occui Jnrirç
- Po nol inilialc icsislancc liaining al a maximal lcvcl of
icsislancc, pailiculaily will ccccnliic cxcicisc lo mini-
mizc dclaycd-onscl musclc soicncss (P0MS). Usc ligll lo
modcialc cxcicisc duiing llc iccovciy pciiod.
- Avoid usc of lcavy icsislancc duiing cxcicisc foi clil-
dicn, oldci adulls, and palicnls will oslcopoiosis.
- Po nol apply icsislancc acioss an unslablc joinl oi dislal
lo a fiacluic silc llal is nol complclcly lcalcd.
- Eavc llc palicnl avoid bicall-lolding duiing icsislcd
cxciciscs lo picvcnl llc Valsalva mancuvci, cmplasizc
cxlalalion duiing cxcilion.
- Avoid unconliollcd, ballislic movcmcnls as llcy compio-
misc safcly and cffcclivcncss.
- Picvcnl incoiiccl oi subslilulc molions by adcqualc sla-
bilizalion and an appiopiialc lcvcl of icsislancc.
- Avoid cxciciscs llal placc cxccssivc, uninlcndcd sccond-
aiy slicss on llc back.
- Bc awaic of mcdicalions a palicnl is using llal can allci
aculc and clionic icsponscs lo cxcicisc.
- Avoid cumulalivc faliguc duc lo cxccssivc ficqucncy
of cxcicisc and llc cffccls of ovciliaining oi ovciwoik
by incoipoialing adcqualc icsl inlcivals bclwccn cxci-
cisc scssions lo allow adcqualc limc foi iccovciy aflci
- Pisconlinuc cxciciscs if llc palicnl cxpciicnccs pain,
dizzincss, oi unusual oi piccipilous sloilncss of bicall.
0vcrfraìnìng and 0vcrwork
Exercise programs in which heavy resistance is applied or
exhaustive training is perIormed repeatedly must be pro-
gressed cautiously to avoid a problem known as overtrain-
ing or overwork. These terms reIer to deterioration in
muscle perIormance and physical capabilities (either tem-
porary or permanent) that can occur in healthy individuals
or in patients with certain neuromuscular disorders.
In most instances, the uncomIortable sensation associ-
ated with acute muscle Iatigue induces an individual to
cease exercising. This is not necessarily the case in highly
motivated athletes who are said to be overreaching in their
training program
or in patients who may not adequately
sense Iatigue because oI impaired sensation associated
with a neuromuscular disorder.
The term overtraining is commonly used to describe a
decline in physical perIormance in healthy individuals par-
ticipating in high-intensity, high-volume strength and
endurance training programs.
The terms chronic
fatigue, staleness, and burnout are also used to describe
this phenomenon. When overtraining occurs, the individual
progressively Iatigues more quickly and requires more time
to recover Irom strenuous exercise because oI physiologi-
cal and psychological Iactors.
Overtraining is brought on by inadequate rest inter-
vals between exercise sessions, too rapid progression oI
exercises, and inadequate diet and Iluid intake. Fortu-
nately, in healthy individuals, overtraining is a preventable,
reversible phenomenon that can be resolved by tapering
the training program Ior a period oI time by periodically
decreasing the volume and Irequency oI exercise (peri-
The term overwork, sometimes called overwork weakness,
reIers to progressive deterioration oI strength in muscles
already weakened by nonprogressive neuromuscular dis-
This phenomenon was Iirst observed more than
50 years ago in patients recovering Irom polio who were
actively involved in rehabilitation.
In many instances the
decrement in strength that was noted was permanent or
prolonged. More recently, overwork weakness has been
reported in patients with other nonprogressive neuromuscu-
lar diseases, such as Guillain-Barré syndrome.
syndrome is also thought to be related to long-term overuse
oI weak muscles.
Overwork weakness has been produced in labora-
tory animals,
which provides some insight to its
cause. When strenuous exercise was initiated soon aIter
a peripheral nerve lesion, the return oI Iunctional motor
strength was retarded. It was suggested that this could be
caused by excessive protein breakdown in the denervated
Prevention is the key to dealing with overwork weak-
ness. Patients in resistance exercise programs who have
impaired neuromuscular Iunction or a systemic, metabolic,
During exercise the Valsalva phenomenon occurs
most oIten with high-effort isometric
and dynamic
muscle contractions. It has been shown that the rise in
blood pressure induced by an isometric muscle contrac-
tion is proportional to the percentage oI maximum
voluntary Iorce exerted.
During isokinetic (concentric)
testing, iI a patient exerts maximum eIIort at increasing
velocities, the rise in blood pressure appears to be the
same at all velocities oI movement despite the Iact that
the Iorce output oI the muscle decreases.
occurrence oI the Valsalva phenomenon more oIten is
thought to be associated with isometric
and eccen-
resistance exercise, a recent study
indicated that
the rise in blood pressure appears to be based more on
extent oI eIIortnot strictly on the mode oI muscle con-
Af-Pìsk Pafìcnfs
The risk oI complications Irom a rapid rise in blood pres-
sure is particularly high in patients with a history oI coro-
nary artery disease, myocardial inIarction, cerebrovascular
disorders, or hypertension. Also at risk are patients who
have had neurosurgery or eye surgery or who have inter-
vertebral disc pathology. High-risk patients must be moni-
tored closely.
N 0 ! L . Allhouqh resislance lraininq is oflen reconnended
for individuals wilh a hislory of or who have a hiqh risk for
cardiovascular disorders,
il is inµorlanl lo dislinquish
lhose individuals for whon resislance lraininq is or is nol
safe and aµµroµriale. ln addilion lo connunicalinq wilh a
µalienl's µhysician, quidelines are available lo assisl wilh
lhis screeninq µrocess.
Prcvcnfìon 0urìng Pcsìsfancc Excrcìsc
Caution the patient about breath-holding.
Ask the patient to breathe rhythmically, count, or talk
during exercise.
Have the patient exhale with each resisted eIIort.
Be certain that high-risk patients avoid high-intensity
resistance exercises.
Suhsfìfufc Mofìons
II too much resistance is applied to a contracting muscle
during exercise, substitute motions can occur. When mus-
cles are weak because oI Iatigue, paralysis, or pain, a
patient may attempt to carry out the desired movements
that the weak muscles normally perIorm by any means
For example, iI the deltoid or supraspinatus
muscles are weak or abduction oI the arm is painIul, a
patient elevates the scapula (shrugs the shoulder) and later-
ally Ilexes the trunk to the opposite side to elevate the
arm. It may appear that the patient is abducting the arm,
but in Iact that is not the case. To avoid substitute motions
during exercise, an appropriate amount oI resistance must
be applied, and correct stabilization must be used with
manual contacts, equipment, or by means oI muscular
(internal) stabilization by the patient.
C R A P J E P 8 Pesislance Exercise For lnµaired Muscle Perfornance 188
or inIlammatory disease that increases susceptibility to
muscle Iatigue must be monitored closely, progressed
slowly and cautiously, and re-evaluated Irequently to deter-
mine their response to resistance training. These patients
should not exercise to exhaustion and should be given
longer and more Irequent rest intervals during and between
exercise sessions.
Excrcìsc-lnduccd Musclc Sorcncss
Almost every individual unaccustomed to exercise who
begins a resistance training program, particularly one that
includes eccentric exercise, experiences muscle soreness.
Exercise-induced muscle soreness Ialls into two categories:
acute and delayed onset.
Acufc Musclc Sorcncss
Acute muscle soreness develops during or directly aIter
strenuous exercise perIormed to the point oI muscle
This response occurs as a muscle becomes
Iatigued during acute exercise because oI the lack oI ade-
quate blood Ilow and oxygen (ischemia) and a temporary
buildup oI metabolites, such as lactic acid and potassium,
in the exercised muscle.
The sensation is characterized
as a Ieeling oI burning or aching in the muscle. It is
thought that the noxious metabolic waste products may
stimulate Iree nerve endings and cause pain. The muscle
pain experienced during intense exercise is transient and
subsides quickly aIter exercise when adequate blood Ilow
and oxygen are restored to the muscle. An appropriate
cool-down period oI low-intensity exercise (active recov-
ery) can Iacilitate this process.
0claycd-0nscf Musclc Sorcncss
AIter vigorous and unaccustomed resistance training or
any Iorm oI muscular overexertion, delayed-onset muscle
soreness (DOMS), which is noticeable in the muscle belly
or at the myotendinous junction,
begins to develop
approximately 12 to 24 hours aIter the cessation oI exer-
cise. As was already pointed out in the discussion oI con-
centric and eccentric exercise in this chapter, high-intensity
eccentric muscle contractions consistently cause the most
severe DOMS symptoms.
Box 6.11 lists the
signs and symptoms over the time course oI DOMS.
DOMS sensation usually intensiIies and peaks 24 to 48
hours aIter exercise. Although the time course varies, the
signs and symptoms, which can last up to 10 to 14 days,
gradually dissipate.
Etiology of DOMS. Despite years oI research dating back
to the early 1900s,
the underlying mechanism oI tissue
damage associated with DOMS is still unclear.
theories have been proposed, and some have subsequently
been reIuted. Early investigators proposed the metabolic
waste accumulation theorv, which suggested that both
acute and delayed-onset muscle soreness was caused by a
buildup oI lactic acid in muscle aIter exercise. Although
this is a source oI muscle pain with acute exercise, this the-
ory has been disproved as a cause oI DOMS.
studies have shown that it requires only about 1 hour oI
recovery aIter exercise to exhaustion to remove almost all
lactic acid Irom skeletal muscle and blood.
The muscle spasm theorv also was proposed as the
cause oI DOMS, suggesting that a Ieedback cycle oI pain
caused by ischemia and a buildup oI metabolic waste prod-
ucts during exercise led to muscle spasm.
This, it was
hypothesized, caused the DOMS sensation and an ongoing
reIlex painspasm cycle that lasted Ior several days aIter
exercise. The muscle spasm theory has been discounted in
subsequent research that showed no increase in EMG
activity and thereIore no evidence oI spasm in muscles
with delayed soreness.
Although studies on the speciIic etiology oI DOMS
continue, current research seems to suggest that DOMS is
linked to some Iorm oI contraction-induced, mechanical
disruption (microtrauma) oI muscle Iibers and/or connec-
tive tissue in and around muscle that results in degenera-
tion oI the tissue.
Evidence oI tissue damage such as
elevated blood serum levels oI creatine kinase, is present
Ior several days aIter exercise and is accompanied by
inIlammation and edema.
The temporary loss oI strength and the perception oI
soreness or aching associated with DOMS appear to occur
independently and Iollow diIIerent time courses. Strength
deIicits develop prior to the onset oI soreness and persist
aIter soreness has remitted.
Thus, Iorce production
deIicits appear to be the result oI muscle damage, possibly
myoIibrillar damage at the Z bands,
which directly
aIIects the structural integrity oI the contractile units oI
muscle, not neuromuscular inhibition as the result oI
Prevention and treatment of DOMS. Prevention and treat-
ment oI DOMS at the initiation oI an exercise program
aIter a short or long period oI inactivity has been either
ineIIective or, at best, marginally successIul. It is a com-
80X 8.11 0claycd-0nscf Musclc Sorcncss:
Clìnìcal Sìgns and Sympfoms
- Musclc soicncss and acling bcginning 12 lo 24 louis
aflci cxcicisc and pcaking al 48 lo 72 louis
- 1cndcincss will palpalion lliougloul llc involvcd mus-
clc bclly oi al llc myolcndinous junclion
- lncicascd soicncss will passivc lcngllcning oi aclivc
conliaclion of llc involvcd musclc
- Local cdcma and waimll
- Musclc sliffncss icflcclcd by sponlancous musclc sloil-
bcfoic llc onscl of pain
- Pccicascd R0M duiing llc limc couisc of musclc soic-
- Pccicascd musclc slicngll piioi lo onscl of musclc soic-
ncss llal pcisisls foi up lo 1 lo 2 wccks aflci soicncss
las icmillcd
* See reIerences 13, 40, 41, 70, 84, 104, 126, 144.
Pafhologìcal Fracfurc
When a patient with known (or at high risk Ior) osteoporo-
sis or osteopenia participates in a resistance exercise pro-
gram, the risk oI pathological Iracture must be addressed.
Osteoporosis, which is discussed in greater detail in Chap-
ter 11, is a systemic skeletal disease characterized by
reduced mineralized bone mass that is associated with an
imbalance between bone resorption and bone Iormation,
leading to Iragility oI bones. In addition to the loss oI bone
mass, there is also narrowing oI the bone shaIt and widen-
ing oI the medullary canal.
The changes in bone associated with osteoporosis
make the bone less able to withstand physical stress. Con-
sequently, bones become highly susceptible to pathological
Iracture. A pathological fracture (Iragility Iracture) is a
Iracture oI bone already weakened by disease that occurs
as the result oI minor stress to the skeletal sys-
Pathological Iractures most commonly
occur in the vertebrae, hips, wrists, and ribs.
Iore, to design and implement a saIe exercise program, a
therapist needs to know iI a patient has a history oI osteo-
porosis and, as such, an increased risk oI pathological Irac-
ture. II there is no known history oI osteoporosis, the
therapist must be able to recognize those Iactors that place
a patient at risk Ior osteoporosis.
As noted
in Chapter 11, postmenopausal women, Ior example, are at
high risk Ior primary (type I) osteoporosis. Secondary
(type II) osteoporosis is associated with prolonged immo-
bilization or disuse, restricted weight bearing, or extended
use oI certain medications, such as systemic corticosteroids
or immunosuppressants.
Prcvcnfìon of Pafhologìcal Fracfurc
As noted earlier in the chapter, evidence oI the positive
osteogenic eIIects oI resistance exercise is promising but
not yet clear. Despite this, resistance exercises have
become an essential element oI rehabilitation and condi-
tioning programs Ior patients with known, or who are at
risk Ior, osteoporosis.
ThereIore, patients who
are at risk Ior pathological Iracture oIten engage in resist-
ance training.
SuccessIul, saIe resistance training Ior these patients
imposes enough load (greater than what regularly occurs
with activities oI daily living) to achieve the goals oI the
exercise program (which include increasing bone density
as well as improving muscle perIormance and Iunctional
abilities) but not too heavy a load that could cause a patho-
logical Iracture. Precautions to prevent or reduce the risk
oI pathological Iracture are summarized in Box
There are only a Iew instances when resistance exercises
are contraindicated. Resistance training is most oIten con-
monly held opinion in clinical and Iitness settings that the
initial onset oI DOMS can be prevented or at least kept
to a minimum by progressing the intensity and volume
oI exercise graauallv,
by perIorming low-intensity
warm-up and cool-down activities,
or by gently
stretching the exercised muscles beIore and aIter strenu-
ous exercise.
Although these techniques are regu-
larly advocated and employed, little to no evidence in the
literature supports their eIIicacy in the prevention oI
There is some evidence to suggest that the use oI
repetitive concentric exercise prior to DOMS-inducing
eccentric exercise does not entirely prevent but reduces the
severity oI muscle soreness and other markers oI muscle
Paradoxically, the best prevention oI DOMS
appears to be a regular routine oI exercise, particularly
eccentric exercise, aIter an initial episode oI DOMS has
developed and remitted.
It may well be that with
repeated bouts oI the same level oI eccentric exercise or
activity that caused the initial episode oI DOMS the mus-
cle adapts to the physical stress, resulting in the prevention
oI additional episodes oI DOMS.
EIIective treatment oI DOMS once it has occurred is
continually being sought because, to date, the eIIicacy oI
DOMS treatment has been mixed. Evidence shows that
continuation oI a training program that has induced DOMS
does not worsen the muscle damage or slow the recovery
Light, high-speed (isokinetic), concentric
exercise has been reported to reduce muscle soreness and
hasten the remediation oI strength deIicits associated with
but other reports suggest no signiIicant improve-
ment in strength or relieI oI muscle soreness with light
The value oI therapeutic modalities and massage tech-
niques is also questionable. Electrical stimulation to reduce
soreness has been reported to be eIIective
Although cryotherapy (cold water immer-
sion) aIter vigorous eccentric exercise reduces signs oI
muscle damage (creatine kinase activity), it has been
reported to have no eIIect on the perpetuation oI muscle
tenderness or strength deIicit.
There is also no signiIicant
evidence that postexercise massage, despite its widespread
use in sports settings, reduces the signs and symptoms oI
In a prospective study
oI DOMS that was
induced by maximal eccentric exercise, the use oI a
compression sleeve over the exercised muscle group
resulted in no increase in circumIerential measurements
oI the upper arm (which could suggest prevention oI soIt
tissue swelling), more rapid reduction in the perception
oI muscle soreness, and more rapid amelioration oI deIicits
in peak torque than recovery Irom DOMS without the use
oI compression. Finally, topical salicylate creams, which
provide an analgesic eIIect, may also reduce the severity
oI and hasten the recovery Irom DOMS-related symp-
In summary, although some interventions Ior the
treatment oI DOMS appear to have potential, a deIinitive
treatment has yet to be determined.
C R A P J E P 8 Pesislance Exercise For lnµaired Muscle Perfornance 185
traindicated during periods oI acute inIlammation and
with some acute diseases and disorders.
By careIully
selecting the appropriate mode oI exercise (static vs.
dynamic; weight-bearing vs. non-weight-bearing) and
keeping the initial intensity oI the exercise at a very low
to moderate level, adverse eIIects Irom resistance training
can be avoided.
II a patient experiences severe joint or muscle pain during
active-Iree (unresisted) movements, dynamic resistance
exercises should not be initiated. During testing, iI a
patient experiences acute muscle pain during a resisted iso-
metric contraction, resistance exercises (static or dynamic)
should not be initiated. II a patient experiences pain that
cannot be eliminated by reducing the resistance, the exer-
cise should be stopped.
Dynamic and static resistance training is absolutely con-
traindicated in the presence oI inIlammatory neuromuscu-
lar disease. For example, in patients with acute anterior
horn cell disease (Guillain-Barré) or inIlammatory muscle
disease (polymyositis, dermatomyositis) resistance exercis-
es may actually cause irreversible deterioration oI strength
as the result oI damage to muscle. Dvnamic resistance
exercises are contraindicated in the presence oI acute
inIlammation oI a joint. The use oI dynamic resisted exer-
cise can irritate the joint and cause more inIlammation.
Gentle setting (static) exercises against negligible resist-
ance are appropriate.
Scvcrc Cardìopulmonary 0ìscasc
Severe cardiac or respiratory diseases or disorders associat-
ed with acute symptoms contraindicate resistance training.
For example, patients with severe coronary artery disease,
carditis, or cardiac myopathy should not participate in vig-
orous physical activities, including a resistance training
Resistance training should be postponed Ior up
to 12 weeks aIter myocardial inIarction or coronary artery
bypass graIt surgery or until the patient has clearance Irom
a physician.
0cfìnìfìon and usc
Manual resistance exercise is a Iorm oI active resistive
exercise in which the resistance Iorce is applied by the
therapist to either a dynamic or a static muscular con-
When joint motion is permissible, resistance is usu-
ally applied throughout the available ROM as the mus-
cle contracts and shortens or lengthens under tension.
Exercise is carried out in the anatomical planes oI
motion, in diagonal patterns associated with propriocep-
tive neuromuscular Iacilitation (PNF) techniques,
or in combined patterns oI movement that simulate Iunc-
tional activities.
A speciIic muscle may also be strengthened by resist-
ing the action oI that muscle, as described in manual
muscle-testing procedures.
In rehabilitation programs, manual resistance exercise,
which may be preceded by active-assisted and active
exercise, is part oI the continuum oI active exercises
available to a therapist Ior the improvement or restora-
tion oI muscular strength and endurance.
There are many advantages to the use oI manual
resistance exercises, but there are also disadvantages and
limitations to this Iorm oI resistance exercises. These
issues are summarized in Box 6.13.
80X 8.12 Prccaufìons fo Pcducc fhc Pìsk of
Pafhologìcal Fracfurc 0urìng Excrcìsc
- Avoid ligl-inlcnsily (ligl-load), ligl-volumc wcigll
liaining. Pcpcnding on llc scvciily of oslcopoiosis,
bcgin wcigll liaining al low inlcnsilics, inilially, pcifoim
only onc scl of scvcial cxciciscs and kccp llc inlcnsily
low foi llc fiisl 6 lo 8 wccks.
- Piogicss inlcnsily and volumc (icpclilions) giadually,
cvcnlually woik up lo llicc oi foui scls of cacl cxcicisc
al modcialc lcvcls of inlcnsily, if appiopiialc.
- Avoid ligl-impacl aclivilics sucl as jumping oi lopping.
Pcifoim mosl slicngllcning cxciciscs in wcigll-bcaiing
posluics llal involvc low impacl lo no impacl, sucl as
lungcs oi slcp-ups|slcp-downs againsl addilional icsisl-
ancc (land-lcld wciglls, a wcigllcd vcsl, oi claslic
- Avoid ligl-vclocily movcmcnls of llc spinc oi
- Avoid liunk flcxion will iolalion and cnd-iangc icsislcd
flcxion of llc spinc llal could placc cxccssivc loading on
llc anlciioi poilion of llc vcilcbiac, polcnlially icsulling
in anlciioi compicssion fiacluic, wcdging of llc vcilc-
bial body, and loss of lcigll.
- Avoid lowci cxlicmily wcigll-bcaiing aclivilics llal
involvc loisional movcmcnls of llc lips, pailiculaily if
llcic is cvidcncc of oslcopoiosis of llc pioximal fcmui.
- 1o avoid loss of balancc oi falling duiing lowci cxlicmi-
ly cxciciscs wlilc slanding, lavc llc palicnl lold onlo a
slablc suifacc sucl as a counlcilop foi balancc. lf llc
palicnl is al ligl iisk foi falling oi las a lisloiy of falls,
pcifoim cxciciscs in a claii lo piovidc wcigll bcaiing
lliougl llc spinc.
- ln gioup cxcicisc classcs kccp pailicipanl|insliucloi
ialios low, foi palicnls al ligl iisk foi falling oi will a
lisloiy of picvious fiacluic, considci diiccl supcivision
on a onc-lo-onc basis fiom anollci liaincd pcison.
patient`s bed, iI possible, to enhance use oI proper body
Assume a position close to the patient to avoid stresses
on your low back and to maximize control oI the
patient`s upper or lower extremity.
Use a wide base oI support to maintain a stable posture
while manually applying resistance; shiIt your weight to
move as the patient moves his or her limb.
Applìcafìon of Manual Pcsìsfancc and Sfahìlìzafìon
Review the principles and guidelines Ior placement and
direction oI resistance and stabilization (see Figs. 6.12
and 6.13). Stabilize the proximal attachment oI the con-
tracting muscle with one hand, when necessary, while
applying resistance distally to the moving segment. Use
appropriate hand placements (manual contacts) to pro-
vide tactile and proprioceptive cues to help the patient
better understand in which direction to move.
Grade and vary the amount oI resistance to equal the
abilities oI the muscle through all portions oI the avail-
able ROM.
N 0 ! L . ll requires well develoµed skills on lhe µarl of lhe
lheraµisl lo µrovide enouqh resislance lo challenqe bul nol
overµower lhe µalienl's efforls, esµecially when lhe µalienl
has siqnificanl weakness.
Gradually apply and release the resistance so movements
are smooth, not unexpected or uncontrolled.
Hold the patient`s extremity close to your body so some
oI the Iorce applied is Irom the weight oI your body not
just the strength oI your upper extremities. This allows
you to apply a greater amount oI resistance, particularly
as the patient`s strength increases.
When applying manual resistance to alternating isomet-
ric contractions oI agonist and antagonist muscles to
develop joint stability, maintain manual contacts at all
times as the isometric contractions are repeated. As a
transition is made Irom one muscle contraction to anoth-
er, no abrupt relaxation phase or joint movements should
occur between the opposing contractions.
vcrhal Commands
Coordinate the timing oI the verbal commands with the
application oI resistance to maintain control when the
patient initiates a movement.
Use simple, direct verbal commands.
Use diIIerent verbal commands to Iacilitate isometric,
concentric, or eccentric contractions. To resist an isomet-
ric contraction, tell the patient to 'Hold¨ or 'Don`t let
me move you¨ or 'Match my resistance.¨ To resist a
concentric contraction, tell the patient to 'Push¨ or
'Pull.¨ To resist an eccentric contraction, tell the patient
to 'Slowly let go as I push or pull you.¨
Numhcr of Pcpcfìfìons and Scfs; Pcsf lnfcrvals
As with all Iorms oI resistance exercise, the number oI
repetitions is dependent on the response oI the patient.
0uìdclìncs and Spccìal Consìdcrafìons
The general principles Ior the application oI resistance
exercises discussed in the preceding section oI this chapter
apply to manual resistance exercise. In addition, there are
some special guidelines that are unique to manual resist-
ance exercises that also should be Iollowed when using this
Iorm oI exercise. These guidelines apply to manual resist-
ance applied in anatomical planes oI motion, discussed in
this section, and to manual resistance used in association
with PNF, discussed in the Iollowing section.
8ody Mcchanìcs of fhc Jhcrapìsf
Select a treatment table on which to position the patient
that is a suitable height or adjust the height oI the
C R A P J E P 8 Pesislance Exercise For lnµaired Muscle Perfornance 187
80X 8.18 Manual Pcsìsfancc Excrcìsc:
Advanfagcs and 0ìsadvanfagcs
- Mosl cffcclivc duiing llc caily slagcs of iclabililalion
wlcn musclcs aic wcak (4|¯ oi lcss).
- Fffcclivc foim of cxcicisc foi liansilion fiom assislcd lo
mcclanically icsislcd movcmcnls.
- Moic fincly giadcd icsislancc llan mcclanical icsislancc.
- Rcsislancc is adjuslcd lliougloul llc R0M as llc llcia-
pisl icsponds lo llc palicnl`s cffoils oi a painful aic.
- Musclc woiks maximally al all poilions of llc R0M.
- 1lc iangc of joinl movcmcnl can bc caicfully conliollcd
by llc llciapisl lo piolccl lcaling lissucs oi lo picvcnl
movcmcnl inlo an unslablc poilion of llc iangc.
- Uscful foi dynamic oi slalic slicngllcning.
- Piiccl manual slabilizalion picvcnls subslilulc molions.
- Can bc pcifoimcd in a vaiicly of palicnl posilions.
- Placcmcnl of icsislancc is casily adjuslcd.
- Civcs llc llciapisl an oppoilunily foi diiccl inlciaclion
will llc palicnl lo moniloi llc palicnl`s pcifoimancc
- Fxcicisc load (amounl of icsislancc) is subjcclivc, il can-
nol bc mcasuicd oi quanlilalivcly documcnlcd foi pui-
poscs of cslablisling a basclinc and cxcicisc-induccd
impiovcmcnls in musclc pcifoimancc.
- Amounl of icsislancc is limilcd lo llc slicngll of llc
llciapisl, llcicfoic, icsislancc imposcd is nol adcqualc lo
slicngllcn alicady sliong musclc gioups.
- Lilllc valuc foi sliong musclc gioups.
- Spccd of movcmcnl is slow lo modcialc, wlicl may nol
caiiy ovci lo mosl funclional aclivilics.
- Cannol bc pcifoimcd indcpcndcnlly by llc palicnl lo
slicngllcn mosl musclc gioups.
- Nol uscful in lomc piogiam unlcss caicgivci assislancc
is availablc.
- Laboi- and limc-inlcnsivc foi llc llciapisl.
- lmpiaclical foi impioving musculai cnduiancc, loo limc-
For manual resistance exercise, the number oI repetitions
oI exercise is also contingent on the strength and
endurance oI the therapist.
Build in adequate rest intervals Ior the patient ana the
therapist; aIter 8 to 12 repetitions, both the patient and
the therapist begin to experience some degree oI muscu-
lar Iatigue.
Jcchnìqucs-0cncral 8ackground
The manual resistance exercise techniques described in this
section are Ior the upper and lower extremities, perIormed
concentrically in the anatomical planes oI motion. The
direction oI limb movement would be the opposite iI man-
ual resistance were applied to an eccentric contraction. The
exercises described are perIormed in non-weight-bearing
positions and involve movements to isolate individual mus-
cles or muscle groups.
Consistent with Chapter 3, most oI the exercises
described and illustrated in this section are perIormed with
the patient in a supine position. Variations in the therapist`s
position and hand placements may be necessary, depending
on the size and strength oI the therapist and the patient.
Alternate positions, such as prone or sitting, are described
when appropriate or necessary. Ultimately, a therapist must
be versatile and able to apply manual resistance with the
patient in all positions to meet the needs oI many patients
with signiIicant diIIerences in abilities, limitations, and
N 0 ! L . ln all illuslralions in lhis seclion, lhe direclion
in which resislance (P) is aµµlied is indicaled wilh a solid
Opposite motions, such as Ilexion/extension and
abduction/adduction, are oIten alternately resisted in an
exercise program in which strength and balanced neuro-
muscular control in both agonists and antagonists are
desired. Resistance to reciprocal movement patterns also
enhances a patient`s ability to reverse the direction oI
movement smoothly and quickly, a neuromuscular skill
that is necessary in many Iunctional activities. Reversal oI
direction requires muscular control oI both prime movers
and stabilizers and combines concentric and eccentric con-
tractions to decrease momentum and make a controlled
transition Irom one direction to the opposite direction oI
The use oI manual resistance in diagonal patterns oI
motion associated with PNF are described and illustrated
in the next section oI this chapter. Additional exercises to
increase strength, endurance, and neuromuscular control in
the extremities can be Iound in Chapters 17 through 22. In
these chapters many examples and illustrations oI resisted
eccentric exercises, exercises in weight-bearing (closed-
chain) positions, and exercises in Iunctional movement pat-
terns are included. Resistance exercises Ior the cervical,
thoracic, and lumbar spine are described and illustrated in
Chapter 16.
uppcr Exfrcmìfy
Flcxìon of fhc Shouldcr
Hand Placement and Procedure
Apply resistance to the anterior aspect oI the distal arm
or to the distal portion oI the Iorearm iI the elbow is sta-
ble and pain-Iree (Fig. 6.14).
Stabilization oI the scapula and trunk is provided by the
treatment table.
Fl0uPE 8.14 Res|s¦ed s|ou|der ¦|ez|on.
Exfcnsìon of fhc Shouldcr
Hand Placement and Procedure
Apply resistance to the posterior aspect oI the distal arm
or the distal portion oI the Iorearm.
Stabilization oI the scapula is provided by the table.
Rypcrcxfcnsìon of fhc Shouldcr
The patient may be in the supine position, close to the edge
oI the table, side-lying, or prone so hyperextension can
Hand Placement and Procedure
Apply resistance in the same manner as Ior extension oI
the shoulder.
Stabilize the anterior aspect oI the shoulder iI the patient
is supine.
II the patient is side-lying, adequate stabilization must be
given to the trunk and scapula. This can usually be done
iI the therapist places the patient close to the edge oI the
table and stabilizes the patient with the lower trunk.
II the patient is lying prone, manually stabilize the
lnfcrnal and Exfcrnal Pofafìon of fhc Shouldcr
Hand Placement and Procedure
Flex the elbow to 90 and position the shoulder in the
plane oI the scapula.
Apply resistance to the distal portion oI the Iorearm dur-
ing internal rotation and external rotation (Fig. 6.16A).
Stabilize at the level oI the clavicle during internal rota-
tion; the back and scapula are stabilized by the table dur-
ing external rotation.
Ahducfìon and Adducfìon of fhc Shouldcr
Hand Placement and Procedure
Apply resistance to the distal portion oI the arm with the
patient`s elbow Ilexed to 90 . To resist abduction (Fig.
6.15), apply resistance to the lateral aspect oI the arm.
To resist adduction, apply resistance to the medial aspect
oI the arm.
Stabilization (although not pictured in Fig. 6.15) is
applied to the superior aspect oI the shoulder, iI
necessary, to prevent the patient Irom initiating
abduction by shrugging the shoulder (elevation oI
the scapula).
C R A P J E P 8 Pesislance Exercise For lnµaired Muscle Perfornance 180
Fl0uPE 8.15 Res|s¦ed s|ou|der auduc¦|on.
P R L C A U ! l 0 N . Allow lhe qlenohunoral |oinl lo exler-
nally rolale when resislinq abduclion above 00 lo µrevenl
Elcvafìon of fhc Arm ìn fhc Planc
of fhc Scapula ("Scapfìon"}
Hand Placement and Procedure
Same as previously described Ior shoulder Ilexion.
Apply resistance as the patient elevates the arm in the
plane oI the scapula (30 to 40 anterior to the Irontal
plane oI the body).
N 0 ! L . Allhouqh "scaµlion" is nol a nolion of lhe shoul-
der lhal occurs in one of lhe analonical µlanes of lhe
body, resislance in lhe scaµular µlane is lhouqhl lo have
ils nerils. !he evidence is inconclusive
as lo whelher
lhe lorque-µroducinq caµabililies of lhe key nuscle qrouµs
of lhe qlenohuneral |oinl are qrealer when lhe arn ele-
vales in lhe µlane of lhe scaµula versus lhe fronlal or
saqillal µlanes; however, lhe qlenohuneral |oinl has been
shown lo be nore slable, and lhere is less risk of inµinqe-
nenl of sofl lissues when slrenqlh lraininq is µerforned
in lhe scaµular µlane.
(See addilional discussion in
Chaµler 17.)
Fl0uPE 8.18 (/} Res|s¦ed ez¦erna| ro¦a¦|on o¦ ¦|e s|ou|der w|¦| ¦|e s|ou|der
µos|¦|oned |n ¦|ez|on and auduc¦|on (aµµroac||nç ¦|e µ|ane o¦ ¦|e scaµu|a}.
(3} Res|s¦ed |n¦erna| ro¦a¦|on o¦ ¦|e s|ou|der w|¦| ¦|e s|ou|der |n 90 o¦
Alternate Procedure
Alternate alignment oI the humerus (Fig. 6.16B). II the
mobility and stability oI the glenohumeral joint permit,
the shoulder can be positioned in 90 oI abduction during
resisted rotation.
Rorìzonfal Ahducfìon and Adducfìon of fhc Shouldcr
Hand Placement and Procedure
Flex the shoulder and elbow to 90 and place the shoul-
der in neutral rotation.
Apply resistance to the distal portion oI the arm just
above the elbow during horizontal adduction and abduc-
Stabilize the anterior aspect oI the shoulder during hori-
zontal adduction. The table stabilizes the scapula and
trunk during horizontal abduction.
To resist horizontal abduction Irom 0 to 45 , the patient
must be close to the edge oI the table while supine or be
placed side-lying or prone.
Elcvafìon and 0cprcssìon of fhc Scapula
Hand Placement and Procedure
Have the patient assume a supine, side-lying, or sitting
Apply resistance along the superior aspect oI the shoul-
der girdle just above the clavicle during scapular eleva-
tion (Fig. 6.17).
patient has adequate strength, the exercise can be per-
Iormed to include weight bearing through the upper
extremity by having the patient sit on the edge oI a
low table and liIt the body weight with both hands.
Profracfìon and Pcfracfìon of fhc Scapula
Hand Placement and Procedure
Apply resistance to the anterior portion oI the shoul-
der at the head oI the humerus to resist protraction and
to the posterior aspect oI the shoulder to resist retrac-
Resistance may also be applied directly to the
scapula iI the patient sits or lies on the side, Iacing
the therapist.
Stabilize the trunk to prevent trunk rotation.
Flcxìon and Exfcnsìon of fhc Elhow
Hand Placement and Procedure
To strengthen the elbow Ilexors, apply resistance to the
anterior aspect oI the distal Iorearm (Fig. 6.18).
Fl0uPE 8.17 L|eva¦|on o¦ ¦|e s|ou|ders (scaµu|ae}, res|s¦ed u||a¦era||,.
Alternate Procedures: Scapular Depression
To resist unilateral scapular depression in the supine posi-
tion, have the patient attempt to reach down toward the Ieet
and push the hand into the therapist`s hand. When the
Fl0uPE 8.18 Res|s¦ed e|uow ¦|ez|on w|¦| µroz|ua| s¦au|||za¦|on.
The Iorearm may be positioned in supination, prona-
tion, and neutral to resist individual Ilexor muscles oI
the elbow.
To strengthen the elbow extensors, place the patient
prone (Fig. 6.19) or supine and apply resistance to the
distal aspect oI the Iorearm.
Stabilize the upper portion oI the humerus during both
Flcxìon and Exfcnsìon of fhc Wrìsf
Hand Placement and Procedure
Apply resistance to the volar and dorsal aspects oI the
hand at the level oI the metacarpals to resist Ilexion and
extension, respectively (Fig. 6.21).
Stabilize the volar or dorsal aspect oI the distal Iorearm.
Pronafìon and Supìnafìon of fhc Forcarm
Hand Placement and Procedure
Apply resistance to the radius oI the distal Iorearm with
the patient`s elbow Ilexed to 90 (Fig. 6.20) to prevent
rotation oI the humerus.
Do not apply resistance to the hand to avoid twisting
Iorces at the wrist.
C R A P J E P 8 Pesislance Exercise For lnµaired Muscle Perfornance 101
Fl0uPE 8.20 Res|s¦ed µrona¦|on o¦ ¦|e ¦orearu.
Fl0uPE 8.10 Res|s¦ed e|uow ez¦ens|on.
Fl0uPE 8.21 Res|s¦ed wr|s¦ ¦|ez|on and s¦au|||za¦|on o¦ ¦|e ¦orearu.
Padìal and ulnar 0cvìafìon of fhc Wrìsf
Hand Placement and Procedure
Apply resistance to the second and IiIth metacarpals
alternately to resist radial and ulnar deviation.
Stabilize the distal Iorearm.
Mofìons of fhc Fìngcrs and Jhumh
Hand Placement and Procedure
Apply resistance just distal to the joint that is moving.
Resistance is applied to one joint motion at a time (Figs.
6.22 and 6.23).
Stabilize the joints proximal and distal to the moving
Fl0uPE 8.22 Res|s¦ed ¦|ez|on o¦ ¦|e µroz|ua| |n¦erµ|a|ançea| (PlP} ¦o|n¦ o¦
¦|e |ndez ¦|nçer w|¦| s¦au|||za¦|on o¦ ¦|e ue¦acarµoµ|a|ançea| (VCP} and d|s-
¦a| |n¦erµ|a|ançea| (0lP} ¦o|n¦s.
Lowcr Exfrcmìfy
Flcxìon of fhc Rìp wìfh Kncc Flcxìon
Hand Placement and Procedure
Apply resistance to the anterior portion oI the distal
thigh (Fig. 6.24). Simultaneous resistance to knee Ilexion
may be applied at the distal and posterior aspect oI the
lower leg, just above the ankle.
Stabilization oI the pelvis and lumbar spine is provided
by adequate strength oI the abdominal muscles.
Exfcnsìon of fhc Rìp
Hand Placement and Procedure
Apply resistance to the posterior aspect oI the distal
thigh with one hand and to the inIerior and distal aspect
oI the heel with the other hand (Fig. 6.25).
Stabilization oI the pelvis and lumbar spine is provided
by the table.
Fl0uPE 8.28 Res|s¦ed oµµos|¦|on o¦ ¦|e ¦|uuu.
Fl0uPE 8.24 Res|s¦ed ¦|ez|on o¦ ¦|e ||µ w|¦| ¦|e |nee ¦|ezed.
Fl0uPE 8.25 Res|s¦ed ||µ and |nee ez¦ens|on w|¦| ¦|e |and µ|aced a¦ ¦|e
µoµ||¦ea| sµace ¦o µreven¦ |,µerez¦ens|on o¦ ¦|e |nee.
P R L C A U ! l 0 N . lf, when lhe oµµosile hiµ is exlended,
lhe µelvis rolales anleriorly, and lordosis in lhe lunbar sµine
increases durinq resisled hiµ flexion, have lhe µalienl flex
lhe oµµosile hiµ and knee and µlanl lhe fool on lhe lable lo
slabilize lhe µelvis and µrolecl lhe low back reqion.
Rypcrcxfcnsìon of fhc Rìp
Patient position: prone.
Hand Placement and Procedure
With patient in a prone position, apply resistance to the
posterior aspect oI the distal thigh (Fig. 6.26).
Stabilize the posterior aspect oI the pelvis to avoid
motion oI the lumbar spine.
Fl0uPE 8.28 Res|s¦ed end-rançe ||µ ez¦ens|on w|¦| s¦au|||za¦|on o¦ ¦|e
Hand Placement and Procedure
Apply resistance to the medial aspect oI the lower leg
just above the malleolus during external rotation and to
the lateral aspect oI the lower leg during internal rota-
Stabilize the anterior aspect oI the pelvis as the thigh is
supported to keep the hip in 90 oI Ilexion.
Patient position: prone, with the hip extended and the
knee Ilexed (Fig. 6.29).
Ahducfìon and Adducfìon of fhc Rìp
Hand Placement and Procedure
Apply resistance to the lateral and the medial aspects oI
the distal thigh to resist abduction (Fig. 6.27) and adduc-
tion, respectively, or to the lateral and medial aspects oI
the distal leg just above the malleoli iI the knee is stable
and pain-Iree.
Stabilization is applied to the pelvis to avoid hip-hiking
Irom substitute action oI the quadratus lumborum and to
keep the thigh in neutral position to prevent external
rotation oI the Iemur and subsequent substitution by the
C R A P J E P 8 Pesislance Exercise For lnµaired Muscle Perfornance 108
Fl0uPE 8.27 Res|s¦ed ||µ auduc¦|on.
lnfcrnal and Exfcrnal Pofafìon of fhc Rìp
Patient position: supine with the hip and knee extended.
Hand Placement and Procedure
Apply resistance to the lateral aspect oI the distal thigh
to resist external rotation and to the medial aspect oI the
thigh to resist internal rotation.
Stabilize the pelvis.
Patient position: supine with the hip and knee Ilexed
(Fig. 6.28).
Fl0uPE 8.28 Res|s¦ed ez¦erna| ro¦a¦|on o¦ ¦|e ||µ w|¦| ¦|e µa¦|en¦ |,|nç
Fl0uPE 8.20 Res|s¦ed |n¦erna| ro¦a¦|on o¦ ¦|e ||µ w|¦| ¦|e µa¦|en¦ |,|nç
Hand Placement and Procedure
Apply resistance to the medial and lateral aspects oI the
lower leg.
Stabilize the pelvis by applying pressure across the but-
Flcxìon of fhc Kncc
Resistance to knee Ilexion may be combined with resist-
ance to hip Ilexion, as described earlier with the patient
Patient position: prone with the hip extended
(Fig. 6.30).
II the patient is prone, place a rolled towel under the
anterior aspect oI the distal thigh; this allows the patella
to glide normally during knee extension.
II the patient is sitting, place a rolled towel under the
posterior aspect oI the distal thigh (Fig. 6.31).
Fl0uPE 8.80 Res|s¦ed |nee ¦|ez|on w|¦| s¦au|||za¦|on o¦ ¦|e ||µ.
Hand Placement
Apply resistance to the posterior aspect oI the lower leg
just above the heel.
Stabilize the posterior pelvis across the buttocks.
The patient may also be sitting at the edge oI a table
with the hips and knees Ilexed and the trunk supported and
Exfcnsìon of fhc Kncc
Alternate Patient Positions
II the patient is lying supine on a table, the hip must be
abducted and the knee Ilexed so the lower leg is over the
side oI the table. This position should not be used iI the
rectus Iemoris or iliopsoas is tight because it causes an
anterior tilt oI the pelvis and places stress on the low
Fl0uPE 8.81 Res|s¦ed |nee ez¦ens|on w|¦| ¦|e µa¦|en¦ s|¦¦|nç and s¦au|-
||z|nç ¦|e ¦run| w|¦| ¦|e uµµer ez¦reu|¦|es and ¦|e ¦|eraµ|s¦ s¦au|||z|nç
¦|e ¦||ç|.
Hand Placement and Procedure
Apply resistance to the anterior aspect oI the lower
Stabilize the Iemur, pelvis, or trunk as necessary.
0orsìflcxìon and Planfarflcxìon of fhc Anklc
Hand Placement and Procedure
Apply resistance to the dorsum oI the Ioot just above the
toes to resist dorsiIlexion (Fig. 6.32A) and to the plantar
surIace oI the Ioot at the metatarsals to resist plantarIlex-
ion (Fig. 6.32B).
Stabilize the lower leg.
Proprioceptive neuromuscular facilitation (PNF) is an
approach to therapeutic exercise that combines Iunction-
ally based diagonal patterns oI movement with techniques
oI neuromuscular Iacilitation to evoke motor responses
and improve neuromuscular control and Iunction. This
widely used approach to exercise was developed during
the 1940s and 1950s by the pioneering work oI Kabat,
Knott, and Voss.
Their work integrated the analysis
oI movement during Iunctional activities with then-
current theories oI motor development, control, and learn-
ing and principles oI neurophysiology as the Ioundations
oI their approach to exercise and rehabilitation. Long
associated with neurorehabilitation, PNF techniques also
have widespread application Ior rehabilitation oI patients
with musculoskeletal conditions that result in altered
neuromuscular control oI the extremities, neck, and
PNF techniques can be used to develop muscular
strength and endurance; Iacilitate stability, mobility, neuro-
muscular control, and coordinated movements; and lay a
Ioundation Ior the restoration oI Iunction. PNF techniques
are useIul throughout the continuum oI rehabilitation Irom
the early phase oI tissue healing when isometric techniques
are appropriate to the Iinal phase oI rehabilitation when
high-speed, diagonal movements can be perIormed against
maximum resistance.
Hallmarks oI this approach to therapeutic exercise are
the use oI diagonal patterns and the application oI sensory
cuesspeciIically proprioceptive, cutaneous, visual, and
auditory stimulito elicit or augment motor responses.
Embedded in this philosophy and approach to exercise is
that the stronger muscle groups oI a diagonal pattern Iacili-
tate the responsiveness oI the weaker muscle groups. The
Iocus oI discussion oI PNF in this chapter deals with the
use oI PNF patterns and techniques as an important Iorm
oI resistance exercise Ior the development oI strength,
muscular endurance, and dynamic stability.
Although PNF patterns Ior the extremities can be per-
Iormed unilaterally or bilaterally and in a variety oI
weight-bearing and non-weight-bearing positions, only
unilateral patterns with the patient in a supine position
are described and illustrated. In Chapter 4 oI this text, the
use oI PNF stretching techniquesspeciIically contract
relax and holdrelax techniques or other variations
to increase Ilexibility are described. As noted in Chap-
ter 3, diagonal patterns can also be used Ior passive and
active ROM. Additional application oI diagonal patterns
Ior the extremities and trunk, some using resistance equip-
ment, are described in the regional chapters later in this
lnvcrsìon and Evcrsìon of fhc Anklc
Hand Placement and Procedure
Apply resistance to the medial aspect oI the Iirst
metatarsal to resist inversion and to the lateral aspect oI
the IiIth metatarsal to resist eversion.
Stabilize the lower leg.
Flcxìon and Exfcnsìon of fhc Jocs
Hand Placement and Procedure
Apply resistance to the plantar and dorsal surIaces oI the
toes as the patient Ilexes and extends the toes.
Stabilize the joints above and below the joint that is
C R A P J E P 8 Pesislance Exercise For lnµaired Muscle Perfornance 105
Fl0uPE 8.82 (/} Res|s¦ed dors|¦|ez|on. (3} Res|s¦ed µ|an¦ar¦|ez|on o¦ ¦|e
0ìagonal Paffcrns
The patterns oI movement associated with PNF are com-
posed oI multifoint, multiplanar, aiagonal, and rotational
movements oI the extremities, trunk, and neck. Multiple
muscle groups contract simultaneously. There are two
pairs oI diagonal patterns Ior the upper and lower extremi-
ties: diagonal 1 (D
) and diagonal 2 (D
). Each oI these
patterns can be perIormed in either Ilexion or extension.
Hence, the terminology used is D
Flexion or D
sion and D
Flexion or D
Extension oI the upper or lower
extremities. The patterns are identiIied by the motions that
occur at proximal pivot pointsthe shoulder or the hip
joints. In other words, a pattern is named by the position
of the shoulaer or hip when the aiagonal pattern has
been completea. Flexion or extension oI the shoulder
or hip is coupled with abduction or adduction as well
as external or internal rotation. Motions oI body seg-
ments distal to the shoulder or hip also occur simultane-
ously during each diagonal pattern. Table 6.9 summa-
rizes the component motions oI each oI the diagonal
As mentioned, the diagonal patterns can be carried
out unilaterally or bilaterally. Bilateral patterns can be
done svmmetricallv (e.g., D
Flexion oI both extremities);
asvmmetricallv (D
Flexion oI one extremity coupled
with D
Flexion oI the other extremity); or reciprocallv
Flexion oI one extremity and D
Extension oI the
opposite extremity). Furthermore, there are patterns
speciIically Ior the scapula or pelvis and techniques that
integrate diagonal movements into Iunctional activities,
such as rolling, crawling, and walking. There are several
in-depth resources that describe and illustrate the many
variations and applications oI PNF techniques.
8asìc Proccdurcs wìfh PNF Paffcrns
A number oI basic procedures that involve the application
oI multiple types oI sensory cues are superimposed on the
diagonal patterns to elicit the best possible neuromuscular
Although the diagonal patterns can be
used with various Iorms oI mechanical resistance (e.g., Iree
weights, simple weight-pulley systems, elastic resistance,
or even an isokinetic unit), the interaction between the
patient and therapist, a prominent Ieature oI PNF, provides
the greatest amount and variety oI sensory input, particu-
larly in the early phases oI re-establishing neuromuscular
Manual Confacfs
The term manual contact reIers to how and where the ther-
apist`s hands are placed on the patient. Whenever possible,
manual contacts are placed over the agonist muscle groups
or their tendinous insertions. These contacts allow the ther-
apist to apply resistance to the appropriate muscle groups
and cue the patient as to the desired direction oI move-
ment. For example, iI wrist and Iinger extension is to be
resisted, manual contact is on the dorsal surIace oI the
hand and wrist. In the extremity patterns one manual con-
tact is placed distally (where movement begins). The other
manual contact can be placed more proximally, Ior exam-
ple, at the shoulder or scapula. Placement oI manual con-
tacts is adjusted based on the patient`s response and level
oI control.
JA8LE 8.0 Componcnf Mofìons of PNF Paffcrns: uppcr and Lowcr Exfrcmìfìcs
0ìagona| 1: F|cxìon 0ìagona| 1: LxIcnsìon 0ìagona| 2: F|cxìon 0ìagona| 2: LxIcnsìon
1oìnIs or ScgmcnIs (0
F|x) (0
LxI) (0
F|x) (0
U|||R |X¯R|||¯Y C0||0N|N¯ |0¯|0NS
Fingers and thumb
|0!|R |X¯R|||¯Y C0||0N|N¯ |0¯|0NS
external rotation
Elevation, abduction,
upward rotation
Flexion or extension
Flexion, radial
Flexion, adduction
external rotation
Flexion or extension
internal rotation
Depression, adduction,
downward rotation
Flexion or extension
Extension, ulnar
Extension, abduction
internal rotation
Flexion or extension
Plantarflexion, eversion
external rotation
Elevation, abduction,
upward rotation
Flexion or extension
Extension, radial
Extension, abduction
internal rotation
Flexion or extension
Dorsiflexion, eversion
internal rotation
Depression, adduction
downward rotation
Flexion or extension
Flexion, ulnar
Flexion, adduction
external rotation
Flexion or extension
Normal Jìmìng
A sequence oI distal to proximal, coordinated muscle con-
tractions occurs during the diagonal movement patterns.
The distal component motions oI the pattern should be
completed halIway through the pattern. Correct sequencing
oI movements promotes neuromuscular control and coordi-
nated movement.
Traction is the slight separation oI joint surIaces theoreti-
cally to inhibit pain and Iacilitate movement during execu-
tion oI the movement patterns.
Traction is most
oIten applied during Ilexion (antigravity) patterns.
The gentle compression oI joint surIaces by means oI
manual compression or weight bearing stimulates co-
contraction oI agonists and antagonists to enhance
dynamic stability and postural control via joint and
muscle mechanoreceptors.
vcrhal Commands
Auditory cues are given to enhance motor output. The tone
and volume oI the verbal commands are varied to help
maintain the patient`s attention. A sharp verbal command is
given simultaneously with the application oI the stretch
reIlex to synchronize the phasic, reIlexive motor response
with a sustained volitional eIIort by the patient. Verbal cues
then direct the patient throughout the movement patterns.
As the patient learns the sequence oI movements, verbal
cues can be more succinct.
vìsual Cucs
The patient is asked to Iollow the movement oI a limb to
Iurther enhance control oI movement throughout the ROM.
uppcr Exfrcmìfy 0ìagonal Paffcrns
N 0 ! L . All descriµlions for hand µlacenenls are for lhe
µalienl's riqhl (P) uµµer exlrenily. 0urinq each µallern lell
lhe µalienl lo walch lhe novinq hand. 8e sure lhal rolalion
shifls çrcJnc||y fron inlernal lo exlernal rolalion (or vice
versa) lhrouqhoul lhe ranqe. 8y nid-ranqe, lhe arn should
be in neulral rolalion. Manual conlacls (hand µlacenenls)
nay be allered fron lhe suqqesled µlacenenls as lonq as
conlacl renains on lhe aµµroµriale surfaces. Pesisl all µal-
lerns lhrouqh lhe full, available P0M.
Starting Position (Fig. 6.33A)
Position the upper extremity in shoulder extension, abduc-
tion, and internal rotation; elbow extension; Iorearm prona-
tion; and wrist and Iinger extension with the hand about 8
to 12 inches Irom the hip.
Maxìmal Pcsìsfancc
The amount oI resistance applied during dynamic concen-
tric muscle contractions is the greatest amount possible
that still allows the patient to move smoothly and without
pain through the available range. Resistance should be
adjusted throughout the pattern to accommodate to strong
and weak components oI the pattern.
Posìfìon and Movcmcnf of fhc Jhcrapìsf
The therapist remains positioned and aligned along the
diagonal planes oI movement with shoulders and trunk Iac-
ing in the direction oI the moving limb. Use oI eIIective
body mechanics is essential. Resistance should be applied
through body weight, not only through the upper extremi-
ties. The therapist must use a wide base oI support, move
with the patient, and pivot over the base oI support to
allow rotation to occur in the diagonal pattern.
Stretch stimulus. The stretch stimulus is the placing
oI body segments in positions that lengthen the muscles
that are to contract during the diagonal movement pattern.
For example, prior to initiating D
Flexion oI the lower
extremity, the lower limb is placed in D
Rotation is oI utmost consideration because it is the
rotational component that elongates the muscle Iibers and
spindles oI the agonist muscles oI a given pattern and
increases the excitability and responsiveness oI those mus-
cles. The stretch stimulus is sometimes described as 'wind-
ing up the part¨ or 'taking up the slack.¨
Stretch reflex. The stretch reIlex is Iacilitated by a rapid
stretch (overpressure) just past the point oI tension to an
already elongated agonist muscle. The stretch reIlex is usu-
ally directed to a distal muscle group to elicit a phasic
muscle contraction to initiate a given diagonal movement
pattern. The quick stretch is Iollowed by sustained resist-
ance to the agonist muscles to keep the contracting mus-
cles under tension. For example, to initiate D
Flexion oI
the upper extremity, a quick stretch is applied to the
already elongated wrist and Iinger Ilexors Iollowed by
application oI resistance. A quick stretch can also be
applied to any agonist muscle group at any point during the
execution oI a diagonal pattern to Iurther stimulate an ago-
nist muscle contraction or direct a patient`s attention to a
weak component oI a pattern. (See additional discussion oI
the use oI repeatea contractions in the next section, which
describes special PNF techniques.)
P R L C A U ! l 0 N . bse of a slrelch reflex, even µrior lo
resisled isonelric nuscle conlraclions, is nol advisable dur-
inq lhe early slaqes of sofl lissue healinq afler in|ury or sur-
qery. ll is also inaµµroµriale wilh acule or aclive arlhrilic
C R A P J E P 8 Pesislance Exercise For lnµaired Muscle Perfornance 107
Hand Placement
Place the index and middle Iingers oI your (R) hand in the
palm oI the patient`s hand and your leIt (L) hand on the
volar surIace oI the distal Iorearm or at the cubital Iossa oI
the elbow.
Verbal Commands
As you apply a quick stretch to the wrist and Iinger Ilex-
ors, tell the patient 'Squeeze my Iingers, turn your palm
up; pull your arm up and across your Iace,¨ as you resist
the pattern.
Ending Position (Fig. 6.33B)
Complete the pattern with the arm across the Iace in shoul-
der Ilexion, adduction, external rotation; partial elbow Ilex-
ion; Iorearm supination; and wrist and Iinger Ilexion.
Hand Placements
Grasp the dorsal surIace oI the patient`s hand and Iingers
with your (R) hand using a lumbrical grip. Place your (L)
hand on the extensor surIace oI the arm just proximal to
the elbow.
Verbal Commands
As you apply a quick stretch to the wrist and Iinger exten-
sors, tell the patient, 'Open your hand¨ (or 'Wrist and Iin-
gers up¨); then 'Push your arm down and out.¨
Fl0uPE 8.88 (/} S¦ar¦|nç µos|¦|on and (3} end|nç µos|¦|on ¦or 0
¦|ez|on o¦
¦|e uµµer ez¦reu|¦,.
Fl0uPE 8.84 (/} S¦ar¦|nç µos|¦|on and (3} end|nç µos|¦|on ¦or 0
o¦ ¦|e uµµer ez¦reu|¦,.
Starting Position (Fig. 6.34A)
Begin as described Ior completion oI D
Verbal Commands
As you apply a quick stretch to the wrist and Iinger exten-
sors, tell the patient, 'Open your hand and turn it to your
Iace¨; 'LiIt your arm up and out¨; 'Point your thumb out.¨
Ending Position (Fig. 6.35B)
Finish the pattern in shoulder Ilexion, abduction, and exter-
nal rotation; elbow extension; Iorearm supination; and
wrist and Iinger extension. The arm should be 8 to 10 inch-
es Irom the ear; the thumb should be pointing to the Iloor.
Starting Position (Fig. 6.36A)
Begin as described Ior completion oI D
Ending Position (Fig. 6.34B)
Finish the pattern in shoulder extension, abduction, internal
rotation; elbow extension; Iorearm pronation; and wrist and
Iinger extension.
Starting Position (Fig. 6.35A)
Position the upper extremity in shoulder extension, adduc-
tion, and internal rotation; elbow extension; Iorearm prona-
tion; and wrist and Iinger Ilexion. The Iorearm should lie
across the umbilicus.
C R A P J E P 8 Pesislance Exercise For lnµaired Muscle Perfornance 100
Fl0uPE 8.85 (/} S¦ar¦|nç µos|¦|on and (3} end|nç µos|¦|on ¦or 0
¦|ez|on o¦
¦|e uµµer ez¦reu|¦,.
Fl0uPE 8.88 (/} S¦ar¦|nç µos|¦|on and (3} end|nç µos|¦|on ¦or 0
o¦ ¦|e uµµer ez¦reu|¦,.
Hand Placement
Grasp the dorsum oI the patient`s hand with your (L) hand
using a lumbrical grip. Grasp the dorsal surIace oI the
patient`s Iorearm close to the elbow with your (R) hand.
Hand Placement
Place the index and middle Iingers oI your (R) hand in the
palm oI the patient`s hand and your (L) hand on the volar
surIace oI the Iorearm or distal humerus.
Verbal Commands
As you apply a quick stretch to the wrist and Iinger Ilex-
ors, tell the patient, 'Squeeze my Iingers and pull down
and across your chest.¨
Ending Position (Fig. 6.36B)
Complete the pattern in shoulder extension, adduction,
and internal rotation; elbow extension; Iorearm pronation;
and wrist and Iinger Ilexion. The Iorearm should cross the
Lowcr Exfrcmìfy 0ìagonal Paffcrns
N 0 ! L . Follow lhe sane quidelines wilh reqard lo rolalion
and resislance as µreviously described for lhe uµµer exlren-
ily. All descriµlions of hand µlacenenls are for lhe µalienl's
(P) lower exlrenily.
Starting Position (Fig. 6.37A)
Position the lower extremity in hip extension, abduction,
and internal rotation; knee extension; plantar Ilexion and
eversion oI the ankle; and toe Ilexion.
N 0 ! L . !his µallern nay also be inilialed wilh lhe knee
flexed and lhe lower leq over lhe edqe of lhe lable.
Hand Placement
Place your (R) hand on the dorsal and medial surIace oI
the Ioot and toes and your (L) hand on the anteromedial
aspect oI the thigh just proximal to the knee.
Verbal Commands
As you apply a quick stretch to the ankle dorsiIlexors and
invertors and toe extensors, tell the patient, 'Foot and toes
up and in; bend your knee; pull your leg over and across.¨
Ending Position (Fig. 6.37B)
Complete the pattern in hip Ilexion, adduction, and exter-
nal rotation; knee Ilexion (or extension); ankle dorsiIlexion
and inversion; toe extension. The hip should be adducted
across the midline, creating lower trunk rotation to the
patient`s (L) side.
Starting Position (Fig. 6.38A)
Begin as described Ior completion oI D
Fl0uPE 8.87 (/} S¦ar¦|nç µos|¦|on and (3} end|nç µos|¦|on ¦or 0
¦|ez|on o¦
¦|e |ower ez¦reu|¦,.
Fl0uPE 8.88 (/} S¦ar¦|nç µos|¦|on and (3} end|nç µos|¦|on ¦or 0
o¦ ¦|e |ower ez¦reu|¦,.
Hand Placement
Place your (R) hand along the dorsal and lateral surIaces oI
the Ioot and your (L) hand on the anterolateral aspect oI
the thigh just proximal to the knee. The Iingers oI your (L)
hand should point distally.
Verbal Commands
As you apply a quick stretch to the ankle dorsiIlexors and
evertors and toe extensors, tell the patient, 'Foot and toes
up and out; liIt your leg up and out.¨
Ending Position (Fig. 6.39B)
Complete the pattern in hip Ilexion, abduction, and internal
rotation; knee Ilexion (or extension); ankle dorsiIlexion
and eversion; and toe extension.
Starting Position (Fig. 6.40A)
Begin as described Ior the completion oI D
Hand Placement
Place your (R) hand on the plantar and lateral surIace
oI the Ioot at the base oI the toes. Place your (L) hand
(palm up) at the posterior aspect oI the knee at the
popliteal Iossa.
Verbal Commands
As you apply a quick stretch to the plantarIlexors oI the
ankle and toes, tell the patient, 'Curl (point) your toes;
push down and out.¨
Ending Position (Fig. 6.38B)
Finish the pattern in hip extension, abduction, and internal
rotation; knee extension or Ilexion; ankle plantarIlexion
and eversion; and toe Ilexion.
Starting Position (Fig. 6.39A)
Place the lower extremity in hip extension, adduction, and
external rotation; knee extension; ankle plantarIlexion and
inversion; and toe Ilexion.
C R A P J E P 8 Pesislance Exercise For lnµaired Muscle Perfornance 201
Fl0uPE 8.40 (/} S¦ar¦|nç µos|¦|on and (3} end|nç µos|¦|on ¦or 0
o¦ ¦|e |ower ez¦reu|¦,.
Fl0uPE 8.80 (/} S¦ar¦|nç µos|¦|on and (3} end|nç µos|¦|on ¦or 0
¦|ez|on o¦
¦|e |ower ez¦reu|¦,.
Hand Placement
Place your (R) hand on the plantar and medial surIace oI
the Ioot at the base oI the toes and your (L) hand at the
posteromedial aspect oI the thigh, just proximal to the
Verbal Commands
As you apply a quick stretch to the plantarIlexors and
invertors oI the ankle and toe Ilexors, tell the patient, 'Curl
(point) your toes down and in; push your leg down and in.¨
Ending Position (Fig. 6.40B)
Complete the pattern in hip extension, adduction, and
external rotation; knee extension; ankle plantarIlexion and
inversion; and toe Ilexion.
Spccìfìc Jcchnìqucs wìfh PNF
There are a number oI speciIic techniques that may be used
during the execution oI a PNF pattern to stimulate weak
muscles Iurther and enhance movement or stability. These
techniques are implemented selectively by the therapist to
evoke the best possible response Irom the patient and to
Iocus on speciIic treatment goals.
Phyfhmìc lnìfìafìon
Rhythmic initiation is used to promote the ability to initiate
a movement pattern. AIter the patient voluntarily relaxes,
the therapist moves the patient`s limb passivelv through the
available range oI the desired movement pattern several
times so the patient becomes Iamiliar with the sequence
oI movements within the pattern. It also helps the patient
understand the rate at which movement is to occur. Prac-
ticing assisted or active movements (without resistance)
also helps the patient learn a movement pattern.
Pcpcafcd Confracfìons
Repeated, dynamic contractions, initiated with repeated
quick stretches Iollowed by resistance, are applied at any
point in the ROM to strengthen a weak agonist component
oI a diagonal pattern.
Pcvcrsal of Anfagonìsfs
Many Iunctional activities involve quick reversals oI the
direction oI movement. This is evident in diverse activi-
ties such as sawing or chopping wood, dancing, playing
tennis, or grasping and releasing objects. The reversal oI
antagonists technique involves stimulation oI a weak ago-
nist pattern by Iirst resisting static or dynamic contractions
oI the antagonist pattern. The reversals oI a movement
pattern are instituted fust before the previous pattern has
been Iully completed. The reversal oI antagonists tech-
nique is based on Sherrington`s law oI successive inauc-
There are two categories oI reversal techniques
available to strengthen weak muscle groups.
Slow reversal. Slow reversal involves dynamic concen-
tric contraction oI a stronger agonist pattern immediately
Iollowed by dynamic concentric contraction oI the wea-
ker antagonist pattern. There is no voluntary relaxation
between patterns. This promotes rapid, reciprocal action
oI agonists and antagonists.
Slow reversal hold. Slow reversal hold adds an isometric
contraction at the end oI the range oI a pattern to enhance
end-range holding oI a weakened muscle. With no period
oI relaxation, the direction oI movement is then rapidly
reversed by means oI avnamic contraction oI the agonist
muscle groups quickly Iollowed by isometric contraction
oI those same muscles. This is one oI several techniques
used to enhance dynamic stability, particularly in proximal
muscle groups.
Alfcrnafìng lsomcfrìcs
Another technique to improve isometric strength and
stability oI the postural muscles oI the trunk or proximal
stabilizing muscles oI the shoulder girdle and hip is alter-
nating isometrics. Manual resistance is applied in a single
plane on one side oI a body segment and then on the other.
The patient is instructed to 'hold¨ his or her position as
resistance is alternated Irom one direction to the opposite
direction. No joint movement should occur. This procedure
isometrically strengthens agonists and antagonists; and it
can be applied to one extremity, to both extremities simul-
taneously, or to the trunk. Alternating isometrics can be
applied with the extremities in open-chain or closed-chain
For example, iI a patient assumes a side-lying posi-
tion, manual contacts are alternately placed on the anterior
aspect oI the trunk and then on the posterior aspect oI the
trunk. The patient is told to maintain (hold) the side-lying
position as the therapist Iirst attempts to push the trunk
posteriorly and then anteriorly (Fig. 6.41A). Manual con-
tacts are maintained on the patient as the therapist`s hands
are moved alternately Irom the anterior to posterior sur-
Iaces. Resistance is gradually applied and released. The
same can be done unilaterally or bilaterally in the extremi-
ties (Fig. 6.41B).
posterior aspect oI the body and the other hand simultane-
ously pushes against the anterior aspect oI the body
(Fig. 6.42). Manual contacts are then shiIted to the oppo-
site surIaces and isometric holding against resistance is
repeated. There is no voluntary relaxation between con-
Phyfhmìc Sfahìlìzafìon
Rhythmic stabilization is used as a progression oI alternat-
ing isometrics and is designed to promote stability through
co-contraction oI the proximal stabilizing musculature oI
the trunk as well as the shoulder and pelvic girdle regions
oI the body. Rhythmic stabilization is typically perIormed
in weight-bearing positions to incorporate joint approx-
imation into the procedure, hence Iurther Iacilitating co-
contraction. The therapist applies multidirectional, rather
than unidirectional, resistance by placing manual contacts
on opposite sides oI the body and applying resistance
simultaneouslv in opposite directions as the patient holds
the selected position. Multiple muscle groups around joints
must contract, most importantly the rotators, to hold the
For example, in the selected position, the patient is
told to hold that position as one hand pushes against the
C R A P J E P 8 Pesislance Exercise For lnµaired Muscle Perfornance 208
Fl0uPE 8.41 (/} Use o¦ a|¦erna¦|nç |soue¦r|cs ¦o |uµrove s¦a¦|c s¦renç¦| o¦
¦|e µroz|ua| uuscu|a¦ure u, a|¦erna¦e|, µ|ac|nç uo¦| |ands and aµµ|,|nç
res|s¦ance on ¦|e an¦er|or asµec¦ o¦ ¦|e uod, and ¦|en on ¦|e µos¦er|or
asµec¦ o¦ ¦|e uod,. (3} Use o¦ a|¦erna¦|nç |soue¦r|cs |n ¦|e uµµer ez¦reu|¦|es.
Fl0uPE 8.42 Use o¦ r|,¦|u|c s¦au|||za¦|on ¦o |uµrove s¦au|||¦, o¦ ¦|e ¦run|
u, s|uu|¦aneous|, aµµ|,|nç res|s¦ance |n oµµos|¦e d|rec¦|ons ¦o ¦|e an¦er|or
and µos¦er|or sur¦aces o¦ ¦|e ¦run|, euµ|as|z|nç |soue¦r|c con¦rac¦|ons o¦ ¦|e
¦run| ro¦a¦ors.
Use oI these special techniques, as well as others asso-
ciated with PNF gives the therapist a signiIicant variety oI
manual resistance exercise techniques to increase muscle
strength and to promote dynamic stability and controlled
mobility as the Ioundation oI and in preparation Ior initiat-
ing task-speciIic skilled movements in a rehabilitation
Mechanical resistance exercise is any Iorm oI exercise in
which resistance (the exercise load) is applied by means
oI some type oI exercise equipment. Frequently used
terms that denote the use oI mechanical resistance are
resistance training, weight training, and strength
Mechanical resistance exercise is an integral compo-
nent oI rehabilitation and conditioning programs Ior indi-
viduals oI all ages. However, use oI mechanical resistance
in an exercise program has some advantages and disadvan-
tages (Box 6.14). The positive and negative qualities oI
speciIic types oI exercise equipment are described in the
last section oI this chapter.
usc ìn Pchahìlìfafìon
Mechanical resistance exercise is commonly implemented
in rehabilitation programs to eliminate or reduce deIicits in
muscular strength, power, and endurance caused by an
array oI pathological conditions and to restore or improve
Iunctional abilities. Guidelines Ior integration oI mechani-
cal resistance exercises into an individualized rehabilitation
program Ior patients with speciIic conditions are detailed
in Chapters 16 through 22.
usc ìn Condìfìonìng Programs
There is a growing awareness through health promotion
and disease prevention campaigns that training with
weights or other Iorms oI mechanical resistance is an
important component oI comprehensive conditioning pro-
grams to improve or maintain physical Iitness and health
throughout most oI the liIe span. As in rehabilitation pro-
grams, resistance training complements aerobic training
and Ilexibility exercises in conditioning programs. Guide-
lines Ior a balanced resistance training program Ior the
healthy, but untrained adult (less than 50 to 60 years oI
age) recommended by the American College oI Sports
and other resources
are summarized in
Box 6.15.
Spccìal Consìdcrafìons for
Chìldrcn and 0ldcr Adulfs
As noted previously, children and older adults oIten wish
to, or may Iind it necessary to, engage in resistance train-
ing in a conditioning program to improve physical Iitness,
reduce health-related risk Iactors, or enhance physical
80X 8.14 Mcchanìcal Pcsìsfancc Excrcìsc: Advanfagcs and 0ìsadvanfagcs
- Fslablislcs a quanlilalivc basclinc mcasuicmcnl of musclc
pcifoimancc againsl wlicl impiovcmcnl can bc judgcd.
- Mosl appiopiialc duiing inlcimcdialc and advanccd plascs
of iclabililalion wlcn musclc slicngll is 4|¯ oi gicalci oi
wlcn llc slicngll of llc palicnl cxcccds llc llciapisl`s
- Ecavy cxcicisc loads, fai bcyond llal wlicl can bc
applicd manually by a llciapisl, can bc uscd lo inducc a
liaining cffccl foi alicady sliong musclc gioups.
- lncicascs in lcvcl of icsislancc can bc incicmcnlally and
quanlilalivcly documcnlcd.
- µuanlilalivc impiovcmcnl is an cffcclivc souicc of moliva-
lion foi llc palicnl.
- Uscful foi impioving dynamic oi slalic musculai slicngll.
- Adds vaiicly lo a icsislancc liaining piogiam.
- Piaclical foi impioving musculai cnduiancc.
- Somc cquipmcnl piovidcs vaiiablc icsislancc lliougl llc
- Eigl-vclocily icsislancc liaining is possiblc and safc will
somc foims of mcclanical icsislancc (lydiaulic and pncu-
malic vaiiablc icsislancc maclincs, isokinclic unils, claslic
icsislancc). Polcnlially bcllci caiiyovci lo funclional aclivi-
lics llan iclalivcly slow-vclocily manual icsislancc cxciciscs.
- Appiopiialc foi indcpcndcnl cxcicisc in a lomc piogiam
aflci caicful palicnl cducalion and a pciiod of supcivision.
- Nol appiopiialc wlcn musclcs aic vciy wcak oi sofl lis-
sucs aic in llc vciy caily slagcs of lcaling, will llc
cxccplion of somc cquipmcnl llal piovidcs assislancc,
suppoil, oi conliol againsl giavily.
- Fquipmcnl llal piovidcs conslanl cxlcinal icsislancc max-
imally loads llc musclc al only onc poinl in llc R0M.
- No accommodalion foi a painful aic (cxccpl will
lydiaulic, pncumalic, oi isokinclic cquipmcnl).
- Fxpcnsc foi puiclasc and mainlcnancc of cquipmcnl.
- Will ficc wciglls and wcigll maclincs, giadalion in
icsislancc is dcpcndcnl on llc manufacluici`s incicmcnls
of icsislancc.
80X 8.15 Summary of 0uìdclìncs for Pcsìsfancc
Jraìnìng ìn Condìfìonìng Programs
for Rcalfhy Adulfs ( 50-80 ycars
- Piioi lo icsislancc liaining, pcifoim waim-up aclivilics
followcd by flcxibilily cxciciscs.
- Pcifoim dynamic cxciciscs llal laigcl llc majoi musclc
gioups of llc body (appioximalcly 8-10 musclc gioups
of llc uppci and lowci cxlicmilics and liunk) foi lolal
body musculai filncss.
- Balancc flcxion-dominanl (pulling) cxciciscs will
cxlcnsion-dominanl (pusling) cxciciscs.
- Movc lliougl llc full, availablc, and pain-ficc R0M.
- lncludc boll conccnliic (lifling) and ccccnliic (lowciing)
musclc aclions.
- Usc modcìaic-inlcnsily cxciciscs. ai |casi 8 lo 12 icpcli-
lions pci scl.
- Pcifoim 1 lo 2 scls of cacl cxcicisc foi 8 lo 12 icpcli-
lions pci scl.
- Usc slow lo modcialc spccds of movcmcnl.
- Usc ilyllmic, conliollcd, nonballislic movcmcnls.
- Fxciciscs slould nol inlcifcic will noimal bicalling.
- lncludc icsl inlcivals of 2 lo 2 minulcs bclwccn scls.
Wlilc icsling onc musclc gioup, cxcicisc a diffcicnl
musclc gioup.
- Ficqucncy. lwo lo llicc limcs pci wcck.
- lncicasc inlcnsily giadually (incicmcnls of appioximalcly
¯%) lo piogicss llc piogiam as slicngll and musculai
cnduiancc impiovc.
- Wlcncvci possiblc, liain will a pailnci foi fccdback and
- Cool down aflci complclion of cxciciscs.
- Aflci a layoff of moic llan 1 lo 2 wccks, icducc llc
icsislancc and volumc wlcn icinilialing wcigll liaining.
children dissipate body heat less easily, Iatigue more
quickly, and may need more time to recover Irom exercise
than young adults.
Such diIIerences in response to
resistance exercise must be addressed when designing and
implementing strength training programs Ior children.
Accordingly, the American Academy oI Pediatrics,
the American College oI Sports Medicine,
and many
health proIessionals support youth involvement in resist-
ance trainingbut only iI a number oI special guidelines
and precautions are consistently Iollowed.
Although the risk oI injury Irom resistance training is quite
exercise-induced soIt tissue or growth-plate
injuries have been noted iI guidelines and precautions are
not Iollowed.
Special guidelines are summarized in Box
Consistent with adult guidelines, a bal-
anced program oI dynamic exercise Ior major muscle
groups includes warm-up and cool-down periods.
0ldcr Adulfs and Pcsìsfancc Jraìnìng
It is well known that muscle perIormance diminishes with
and deIicits in muscle strength, power, and
perIormance. Resistance training can be saIe and eIIective
iI exercise guidelines are modiIied to meet the unique
needs oI these two groups.
Chìldrcn and Pcsìsfancc Jraìnìng
Until the past decade or two, health proIessionals have
been reluctant to support preadolescent youth participation
in resistance training as a part oI Iitness programs because
oI concerns about possible adverse stress and injury to the
immature musculoskeletal system, in particular, growth-
plate injuries and avulsion Iractures. Furthermore, a com-
mon assumption was that the beneIits oI resistance training
were questionable in children.
There is now a growing body oI evidence that demon-
strates that children do achieve health-related beneIits
Irom resistance training and can saIely engage in closely
supervised weight-training programs.
Use oI body
weight as a source oI resistance and equipment speciIically
designed to Iit a child contributes to program saIety (Fig.
6.43). Training-induced strength gains in prepubescent
children have been documented,
but sports related
injury prevention remains oI questionable beneIit.
with adults, inIormation on the impact oI strength
training on the enhancement oI Iunctional motor skills
is limited.
C R A P J E P 8 Pesislance Exercise For lnµaired Muscle Perfornance 205
Fl0uPE 8.48 Us You¦| res|s¦ance ¦ra|n|nç on K|ds-N-Vo¦|on
(!r|ceµs-0|µ} sµec|¦|ca||, des|çned and s|zed ¦or a c|||d's use. (Cc0r:-·y cf Yc0:|
|i:r-·· |r:-rrc:icrc|, |crc|· Ccrr-r, SC, www.yc0:|fi:.ccr/.}
Focus on Evidence
Research has shown that, although some acute and chronic
responses oI children to exercise are similar to those oI
adults, other responses are quite diIIerent. For example,
80X 8.18 Pcsìsfancc Jraìnìng for Chìldrcn:
Spccìal 0uìdclìncs and Spccìal
- No foimal icsislancc liaining foi clildicn lcss llan 6 lo
7 ycais of agc.
- Al agc 6 lo 7, inlioducc llc conccpl of an cxcicisc scs-
sion inilially using cxciciscs willoul wciglls, llcn will
ligll (only 1- oi 2-pound) wciglls.
- Mainlain c|osc and coni|nuous su¡cìv|s|on by liaincd
pcisonncl oi a paicnl wlo las icccivcd insliuclion.
- Focus on piopci foim, cxcicisc lcclniquc, and safcly
(alignmcnl, slabilizalion, conliollcd molion).
- Fmplasizc |ow |nicns|iy lliougloul clildlood lo avoid
polcnlial injuiy lo a clild`s giowing skclclal syslcm and
lo joinls and suppoilivc sofl lissucs.
- Fmplasizc a vaiicly of sloil-duialion, play-oiicnlcd
cxciciscs lo picvcnl boicdom, ovcilcaling, and musclc
- Pcifoim waim-up aclivilics foi al lcasl ¯ lo 10 minulcs
bcfoic inilialing icsislancc cxciciscs.
- Sclccl low cxcicisc loads llal allow a m|n|mum of 8 lo
oi 12 lo 1¯
icpclilions. Fmplasizc mullijoinl,
combincd movcmcnls.
- Pcifoim only onc lo lwo scls of cacl cxcicisc, icsl al
lcasl 2 minulcs bclwccn scls of cxciciscs.
- lnilially piogicss icsislancc liaining by incicasing icpcli-
lions, nol icsislancc, oi by incicasing llc lolal numbci of
cxciciscs. Lalci, incicasc wcigll by no moic llan ¯% al a
- Limil llc ficqucncy lo lwo scssions pci wcck.
- Usc piopcily filling cquipmcnl llal is dcsigncd oi can bc
adaplcd foi a clild`s sizc. Many wcigll maclincs cannol
bc adcqualcly adjuslcd lo fil a clild`s slaluic.
endurance are associated with a higher incidence oI Iunc-
tional limitations and disability.
The extent to which
decreasing muscle strength is caused by the normal aging
process versus a sedentary liIestyle or an increasing inci-
dence oI age-related diseases, such as hypertension and
osteoarthritis, is not clear.
A major goal oI resistance training in older adults is
to maintain or improve their levels oI Iunctional independ-
and reduce the risk oI age-related dis-
As with young and middle-aged adults, older
adults (less than age 60 to 65) beneIit Irom regular exercise
that includes aerobic activity, Ilexibility exercises, and
resistance training. Even in previously sedentary older
adults or Irail elderly patients, a program oI weight training
has resulted in training-induced gains in muscle strength
and improvements in a number oI parameters oI physical
Iunction, such as balance, speed oI walking, and the ability
to rise Irom a chair.
It also has been sug-
gested that strength training in the elderly population may
minimize the incidence oI Ialls.
N 0 ! L . !he µosilive inµacl of resislance lraininq on bone
nineral densily and slowinq bone loss in older adulls exer-
cise is discussed in furlher delail in Chaµler 11.
Although many oI the guidelines Ior resistance train-
ing that apply to young and middle-aged adults (see Box
6.15) are applicable to healthy older adults, in general,
resistance training Ior older adults should be more closely
supervised and initially less rigorous than Ior younger pop-
ulations oI adults.
Accordingly, impaired balance, age-
related postural changes, and poor vision that can
compromise saIety must be addressed iI present. Also,
because oI age-related changes in connective tissue,
there is a higher incidence oI DOMS and greater muscle
Iiber damage in older versus young adults aIter heavy-
resistance, high-volume strength training.
Guidelines Ior saIe but eIIective resistance training Ior
older adults are listed in Box 6.17.
As with young
adult and youth guidelines, proper warm-up and cool-down
periods, a balanced program oI dynamic exercises, con-
trolled movements, and proper Iorm and technique are
equally important Ior older adults.
For the past 50 to 60 years practitioners and researchers
alike in rehabilitation and Iitness settings have taken great
interest in resistance exercise and Iunctional training. As a
result, many systems oI exercise have been developed to
improve muscle strength, power, and endurance. All oI
these systems are based on the overload principle, and
most use some Iorm oI mechanical resistance to load the
muscle. The driving Iorce behind the development oI these
regimens seems to be to design the 'optimal¨that is, the
most eIIective and eIIicientmethod to improve muscular
perIormance and Iunctional abilities.
Several Irequently used regimens oI resistance training
Ior the advanced phase oI rehabilitation and Ior condition-
ing programs have been selected Ior discussion in this sec-
tion. They are progressive resistive exercise (PRE), circuit
weight training, plyometric training (stretch-shortening
drills), and isokinetic training regimens.
Progrcssìvc Pcsìsfancc Excrcìsc
Progressive resistance exercise (PRE) is a system oI
dynamic resistance training in which a constant external
load is applied to the contracting muscle by some mechani-
cal means (usually a Iree weight or weight machine) and
incrementally increased. The repetition maximum (RM) is
used as the basis Ior determining and progressing the
* See reIerences 35, 36, 43, 120, 145, 179, 203, 213, 248,
267, 270, 304.
80X 8.17 Pcsìsfancc Jraìnìng for 0ldcr Adulfs
( 80-85 Ycars}: 0uìdclìncs and
Spccìal Consìdcrafìons
- Sccuic appioval lo inilialc cxcicisc fiom llc pailicipanl`s
- lnslilulc closc supcivision duiing llc caily plascs of
liaining lo cnsuic safcly.
- Moniloi vilal signs, pailiculaily wlcn llc piogiam is
- Pcifoim al lcasl ¯ lo 10 minulcs of waim-up aclivilics
bcfoic cacl scssion of icsislancc cxciciscs.
- Bcgin will low-icsislancc, low-icpclilion cxciciscs, cspc-
cially foi ccccnliic cxciciscs, lo minimizc loads on joinls
and lo allow limc foi conncclivc lissuc as wcll as musclc
lo adapl.
- Fmplasizc low lo modcialc lcvcls of icsislancc (al a lcvcl
llal pcimils 10-12 icpclilions) foi 6 lo 8 wccks. Piogicss
llc piogiam duiing llis limc by incicasing icpclilions.
Lalci, incicasc icsislancc by small incicmcnls.
- 1liougloul llc piogiam avoid ligl-icsislancc cxciciscs
lo avoid cxccssivc slicsscs on joinls.
- Pcifoim icsislancc liaining lwo lo llicc limcs wcckly,
allowing a 48-loui icsl inlcival bclwccn scssions.
- Modify cxciciscs foi agc-iclalcd posluial clangcs, sucl
as cxccssivc kyplosis, llal can allci llc biomcclanics of
an cxcicisc.
- Avoid flcxion-dominanl icsislancc liaining llal could
cmplasizc posluial clangcs.
- Wlcn possiblc, usc wcigll maclincs llal allow llc pai-
licipanl lo pcifoim cxciciscs in a scalcd posilion lo avoid
loss of balancc.
- Rcducc llc inlcnsily and volumc of wcigll liaining by
¯0% aflci a 1- lo 2-wcck layoff.
gression oI loading. In reality, an ideal combination oI
these variables does not exist. Extensive research has
shown that many combinations oI exercise load, repetitions
and sets, Irequency, and rest intervals signiIicantly improve
In general, training-induced strength gains
occur with two to three sets oI 6 to 12 repetitions oI a 6 to
12 RM.
This gives a therapist wide latitude
when designing an eIIective weight-training program.
0APPE Pcgìmcn
Knowing when and by how much to increase the resistance
in a PRE program to overload the muscle progressively is
oIten imprecise and arbitrary. A common guideline is to
increase the weight by 5° to 10° when all prescribed rep-
etitions and sets can be completed easily without signiIi-
cant Iatigue.
The Daily Adjustable Progressive
Resistive Exercise (DAPRE) technique
is more sys-
tematic and takes into account the diIIerent rates at which
individuals progress during rehabilitation or conditioning
programs. The system is based on a 6 RM working weight
(Table 6.11). The aafustea working weight, which is based
on the maximum number oI repetitions possible using the
working weight in Set #3 oI the regimen, determines the
working weight Ior the next exercise session (Table 6.12).
N 0 ! L . ll should be µoinled oul lhal lhe reconnended
increases or decrease in lhe ad|usled workinq weiqhl are
based on µroqressive loadinq of lhe quadriceµs nuscle qrouµ.
Cìrcuìf Wcìghf Jraìnìng
Another system oI training that employs mechanical resist-
ance is circuit weight training.
A pre-established
sequence (circuit) oI continuous exercises
is perIormed in
succession at individual exercise stations that target a vari-
ety oI major muscle groups (usually 8 to 12) as an aspect
oI total body conditioning. An example oI a circuit weight
training sequence is shown in Box 6.18.
Each resistance exercise is perIormed at an exercise
station Ior a speciIied number oI repetitions and sets. Typi-
cally, repetitions are higher and intensity (resistance) is
lower than in other Iorms oI weight training. For example,
two to three sets oI 8 to 12 repetitions at 90° to 100° 10
RM or 10 to 20 repetitions at 40° to 50° 1 RM are per-
Focus on Evidence
The results oI countless studies have demonstrated that
PRE programs improve the Iorce-generating capacity oI
muscle that may carry over to improvement in physical
perIormance. It is important to note that the participants in
many oI these studies have been young, healthy adults,
rather than patients with pathology and impairments.
However a systematic review oI the literature
2005 indicated that PRE also was beneIicial Ior patients
with a variety oI pathological conditions including muscu-
loskeletal injuries, osteoarthritis, osteoporosis, hyperten-
sion, adult-onset (type II) diabetes, and chronic obstructive
pulmonary disease. SpeciIic Iindings oI some oI the studies
identiIied in this systematic review are discussed in later
chapters oI this textbook
0clormc and 0xford Pcgìmcns
The concept oI PRE was introduced almost 60 years ago
by DeLorme,
who originally used the term heavv
resistance training
and later loaa-resisting exercise
describe a new system oI strength training. DeLorme pro-
posed and studied the use oI three sets oI a 10 RM with
progressive loaaing during each set. Other investigators
developed a regimen, the OxIord technique, with regressive
loaaing in each set (Table 6.10).
The DeLorme technique builds a warm-up period into
the protocol, whereas the OxIord technique diminishes the
resistance as the muscle Iatigues. Both regimens incorpo-
rate a rest interval between sets; both incrementally
increase the resistance over time; and both have been
shown to result in training-induced strength gains over
time. In a randomized study comparing the DeLorme and
OxIord regimens, no signiIicant diIIerence was Iound in
adaptive strength gains in the quadriceps muscle group in
older adults aIter a 9-week exercise program.
Since the DeLormer and OxIord systems oI training
were Iirst introduced, numerous variations oI PRE proto-
cols have been proposed and studied to determine an opti-
mal intensity oI resistance training, optimal number oI
repetitions and sets, optimal Irequency, and optimal pro-
C R A P J E P 8 Pesislance Exercise For lnµaired Muscle Perfornance 207
JA8LE 8.10 Comparìson or Jwo PPE Pcgìmcns
0cLormc ßcgìmcn 0xford ßcgìmcn
Determination of a
10 RM
10 reps @ 50% of
the 10 RM
10 reps @ 75% of
the 10 RM
10 reps @ 100% of
the 10 RM
Determination of a 10 RM
10 reps @ 100% of the 10 RM
10 reps @ 75% of the 10 RM
10 reps @ 50% of the 10 RM
JA8LE 8.11 0APPE Jcchnìquc
ScIs ßcpcIìIìons AmounI of ßcsìsIancc
Maximum possible
Maximum possible
50% 6 RM*
75% 6 RM
100% 6 RM
100% adjusted working
*6 RM working weight
**See Table 6.12 for calculation of the adjusted working weight.
with a minimum amount oI rest (15 to 20
seconds) between sets and stations. The program is pro-
gressed by increasing the number oI sets or repetitions, the
resistance, the number oI exercise stations, and the number
oI circuit revolutions.
Exercise oraer is an important consideration when set-
ting up a weight training circuit.
Exercises with Iree
weights or weight machines should alternate among upper
extremity, lower extremity, and trunk musculature and
between muscle groups involved in pushing or pulling
actions. This enables one muscle group to rest and recover
Irom exercise while exercising another group and, there-
Iore, minimizes muscle Iatigue. Ideally, larger muscle
groups should be exercised beIore smaller muscle groups.
Multijoint exercises that recruit multiple muscle groups
should be perIormed beIore exercises that recruit an
isolated muscle group to minimize the risk oI injury
Irom Iatigue.
Plyomcfrìc Jraìnìng-Sfrcfch-Shorfcnìng 0rìlls
High-intensity, high-velocity exercises emphasize the
development oI muscular power and coordination. Reactive
bursts oI Iorce in Iunctional movement patterns are oIten
necessary iI a patient is to return to high-demand occupa-
tional, recreational, or sport-related activities. Plyometric
training is integrated into the advanced phase oI rehabilita-
tion as a mechanism to train the neuromuscular system to
react quickly in order to prepare Ior activities that require
rapid starting and stopping movements. This Iorm oI train-
ing is appropriate only Ior careIully selected patients.
0cfìnìfìons and Characfcrìsfìcs
Plvometric training,
also called stretch-
shortening arills
or stretch-strengthening arills,
employs high-velocity eccentric to concentric muscle
loading, reIlexive reactions, and Iunctional movement pat-
terns. Plyometric training is deIined as a system oI high-
velocity resistance training characterized by a rapid
eccentric contraction during which the muscle elongates,
immediately Iollowed by a rapid reversal oI movement
with a resisted shortening contraction oI the same mus-
The rapid eccentric loading phase is the stretch
cvcle, and the concentric phase is the shortening cvcle. The
period oI time between the stretch and shortening cycles is
known as the amorti:ation phase. It is important that the
amortization phase is kept very brieI by a rapid reversal
oI movements to capitalize on the increased tension in the
Body weight or an external Iorm oI loading, such as
elastic bands or tubing or a weighted ball, are possible
sources oI resistance. An example oI a stretch-shortening
drill against the resistance oI body weight is represented
in Figure 6.44.
80X 8.18 Examplc of a Pcsìsfancc Jraìnìng
Slalion t1. Bcncl picss t2. Lcg picss oi squals t2.
Sil-ups t4. Upiigll iowing t¯. Eamsliing cuils
t6. Pionc liunk cxlcnsion t7. Slouldci picss t8.
Eccl iaiscs t9. Pusl-ups t10. Lcg lifls oi lowciing
Fl0uPE 8.44 P|,oue¦r|c ac¦|v|¦, aça|ns¦ ¦|e res|s¦ance o¦ uod, we|ç|¦.
(/} Pa¦|en¦ s¦ands on a |ow µ|a¦¦oru,
JA8LE 8.12 Calculafìon of fhc Ad|usfcd
Workìng Wcìghf for fhc
0APPE Pcgìmcn
Ad|usImcnI of Workìng WcìghI
Repetitions in
Set 3
11 or more
Set 4
5÷10 lb
0÷5 lb
Keep same weight
5÷10 lb
10÷15 lb
Next exercise
session 3
5÷10 lb
Same weight
5÷10 lb
5÷15 lb
10÷20 lb
Additional examples oI plyometric training Ior the
upper and lower extremities are noted in Box 6.19.
Ncurologìcal and 8ìomcchanìcal lnflucnccs
Plyometric training is thought to utilize the series-elastic
properties oI soIt tissues and the stretch reIlex oI the neu-
romuscular unit. The spring-like properties oI the series-
elastic components oI muscle-tendon units create elastic
energy during the initial phase (the stretch cycle) as the
muscle contracts eccentrically and lengthens while loaded.
This energy is brieIly stored and then retrieved Ior use dur-
ing the concentric contraction (shortening cycle) that Iol-
lows. The storage and release oI this elastic energy
augments the Iorce production oI the concentric muscle
Furthermore, the stretch-shortening cycle is thought
to stimulate the proprioceptors oI muscles, tendons, liga-
ments, and joints, increase the excitability oI the neuro-
muscular receptors, and improve the reactivity oI the
neuromuscular system. The term reactive neuromuscu-
lar training has also been used to describe this approach
to exercise. More speciIically, the loaded, eccentric con-
traction (stretch cycle) is thought to prepare the contractile
elements oI the muscle Ior a concentric contraction (short-
C R A P J E P 8 Pesislance Exercise For lnµaired Muscle Perfornance 200
80X 8.10 Plyomcfrìc Acfìvìfìcs for fhc uppcr
and Lowcr Exfrcmìfìcs
Uppcr Extrcmitics
- Calcling and lliowing a wcigllcd ball will a pailnci oi
againsl a wall. bilalcially llcn unilalcially
- Sliclcl-sloilcning diills will claslic lubing using
analomical and diagonal molions
- Piibbling a ball on llc flooi oi againsl a wall
- Piop pusl-ups. fiom boxcs lo flooi and back lo boxcs
- Clap pusl-ups
Iowcr Extrcmitics
- Rcpclilivc jumping on llc flooi. in placc, foiwaid|back-
waid, sidc lo sidc, diagonally lo foui coincis, jump will
iolalion, zigzag jumping, lalci, jump on foam
- Vcilical jumps and icaclcs
- Mulliplc jumps acioss a flooi (bounding)
- Box jumping. inilially off and ficczc, llcn off and back
on box incicasing spccd and lcigll
- Sidc lo sidc jumps (box lo flooi lo box)
- 1umping ovci objccls on llc flooi
- Eopping aclivilics. in placc, acioss a suifacc, ovci
objccls on llc flooi
- Pcpll jumps (advanccd). jump fiom a box, squal lo
absoib slock, and llcn jump and icacl as ligl as
Fl0uPE 8.44 (confìnucd} (3} ¦uuµs o¦¦ ¦|e µ|a¦¦oru ¦o ¦|e ¦|oor, con¦ro|||nç
¦|e |uµac¦ w|¦| a |oaded, |enç¦|en|nç con¦rac¦|on o¦ ¦|e ||µ and |nee ez¦en-
sors and µ|an¦ar¦|ezors÷¦|e s¦re¦c| µ|ase, and (C} ¦|en w|¦|ou¦ de|a, ¦uuµs
¦orward on¦o ¦|e nez¦ µ|a¦¦oru us|nç a concen¦r|c con¦rac¦|on o¦ ¦|e saue
uusc|e çrouµs÷¦|e s|or¦en|nç µ|ase.
ening cycle) by stimulation and activation oI the monosy-
naptic stretch reIlex.
Muscle spindles, the receptors
that lie in parallel with muscle Iibers, sense the length oI a
muscle and the velocity oI stretch applied to a muscle and
transmit this inIormation to the CNS via aIIerent pathways.
Impulses are then sent back to the muscle Irom the CNS,
which reIlexively Iacilitates activation oI a shortening
contraction oI the stretched muscle (the shortening
ThereIore, the more rapid the eccentric
muscle contraction (the stretch), the more likely it is that
the stretch reIlex will be activated.
It has been suggested that the ability to use this stored
elastic energy and neural Iacilitation is contingent on the
velocity and magnitude oI the stretch and the transition
time between the stretch and shortening phases (the amor-
tization phase).
During the amortization phase the muscle
must reverse its action, switching Irom deceleration to
acceleration oI the load. A decrease in the amortization
phase theoretically increases the Iorce output during the
shortening cycle.
Effccfs of Plyomcfrìc Jraìnìng
The evidence to support the eIIectiveness oI plyometric
training to enhance physical perIormance is somewhat
limited, with many resources citing opinion and anecdotal
evidence. However, there is evidence indicating that plyo-
metric training is associated with an increase in a muscle`s
ability to resist stretch, which may enhance the muscle`s
dynamic restraint capabilities.
There is also promising
evidence to suggest that plyometric training is associated
with a decreased incidence oI lower extremity
Focus on Evidence
In a prospective study by Hewett
two groups oI high
school-age Iemale athletes were monitored during a season
oI participation in one oI three sports (soccer, volleyball,
and basketball). One group (n 366) participated in a 6-
week preseason training program, whereas the other group
(n 463) did not. The preseason training Iocused on
jumping and landing techniques. At the end oI the sport
season there was a signiIicantly higher incidence (3.6 times
higher) oI knee injury in the untrained group than in the
trained group. The investigaators concluded that preseason
plyometric training may reduce the risk oI knee injury in
Iemale athletes possibly owing to increased dynamic knee
Applìcafìon and Progrcssìon of Plyomcfrìc Jraìnìng
Plyometric training is appropriate only in the later stage
oI rehabilitation oI active individuals who must achieve
a high level oI physical perIormance in speciIic, high-
demand activities.
Contraindications. Plyometrics should not be used iI
inIlammation, pain, or signiIicant joint instability is present.
Preparation for plyometrics. Prior to initiation oI plyomet-
ric training, a patient should have an adequate base oI mus-
cle strength and endurance as well as Ilexibility oI the
muscles to be exercised. Criteria to begin plyometric train-
ing usually include an 80° to 85° level oI strength and
90° to 95° ROM.
Specificity of training. A plyometric drill should be
designed with speciIic Iunctional activities in mind and
should include movement patterns that replicate the desired
Progression. Parameters oI plyometric training are pro-
gressed as Iollows.
Speed of drills. Drills should be perIormed rapidly but
saIely. The rate oI stretch oI the contracting muscle is
more important than the length oI the stretch.
sis should be placed on decreasing the reversal time Irom
an eccentric to a concentric contraction (decreasing the
amortization phase). This trains the muscle to generate
tension in the shortest time possible. II a jumping activ-
ity is perIormed, Ior example, progression oI the plyo-
metric activity should center on reducing the time on the
ground between each jump.
Intensity. Increase the resistance applied but not enough
to slow down the activity. Examples include use oI a
weighted vest, heavier Plyoballs (weighted balls), heav-
ier grade elastic resistance, double-leg to single-leg
jumping or hopping, or using higher height platIorms.
Intensity also involves progressing Irom simple to com-
plex movements.
Repetitions and frequency. Increase the number oI repe-
titions oI an activity so long as proper form (technique)
is maintainea, increase the number oI plyometric exer-
cises in a session; or increase the number oI plyometric
sessions in a week. A 48- to 72-hour recovery period is
Box 6.20 summarizes sample activities Ior upper
extremity plyometric training.
Programs, oI
course, must be individually designed and progressed to
meet each patient`s needs and goals. Note that prior to ini-
tiating plyometric activities a series oI warm-up exercises
must be perIormed.
P R L C A U ! l 0 N S . As wilh olher forns of hiqh-inlensily
resislance lraininq, sµecial µrecaulions nusl be followed lo
ensure µalienl safely.
!hese µrecaulions are lisled in
8ox ß.21.
lsokìncfìc Pcgìmcns
It is well established that isokinetic training improves mus-
cle perIormance. Its eIIectiveness in carryover to Iunctional
tasks is less clear. Studies support
and reIute
isokinetic training improves Iunction. Ideally, when isoki-
netic training is implemented in a rehabilitation program,
to have the most positive impact on Iunction it should be
perIormed at velocities that closely match or at least
approach the expected velocities oI movement oI speciIic
Iunctional tasks. Because many Iunctional movements
occur at a variety oI medium to Iast speeds, isokinetic
training is typically perIormed at medium and Iast veloci-
Current isokinetic technology makes it possible to
approximate training speeds to velocities oI movement dur-
ing some lower extremity Iunctions, such as walking.
In the upper extremities this is Iar less possible. Some
Iunctional movements in the upper extremities occur at
exceedingly rapid velocities (e.g., more than 1000 per sec-
ond Ior overhead throwing), which Iar exceed the capabili-
ties oI isokinetic dynamometers.
It is also widely accepted that isokinetic training is rel-
atively speed-speciIic, with only limited transIer oI training
(physiological overIlow causing improvements in muscle
perIormance at speeds other than the training speed).
ThereIore, speea-specific isokinetic training, similar to the
velocity oI a speciIic Iunctional task, is advocated.
vclocìfy Spccfrum Pchahìlìfafìon
To deal with the problem oI limited physiological overIlow
oI training eIIects Irom one training velocity to another, a
regimen called velocitv spectrum rehabilitation (VSR) has
been advocated.
With this system oI training, exer-
cises are perIormed across a range oI velocities.
N 0 ! L . !he quidelines for vSP lhal follow are for ccrccr-
tric isokinelic lraininq. 6eneral quidelines for eccenlric iso-
kinelics are idenlified al lhe conclusion of lhis seclion.
Selection of training velocities. Typically, medium (60 or
90 to 180 /sec) and Iast (180 to 360 /sec) angular veloci-
ties are selected. Although isokinetic units are designed Ior
testing and training at velocities Iaster than 360 per sec-
ond, the Iastest velocities usually are not used Ior training.
This is because the limb must accelerate to the very Iast,
preset speed beIore encountering resistance Irom the
torque arm oI the dynamometer. Hence, the contracting
muscles are resisted through only a small portion oI the
It has been suggested that the eIIects oI isokinetic
training (improvements in muscle strength, power, or
endurance) carry over only 15 per second Irom the train-
ing velocity.
ThereIore, some VSR protocols use 30
per second increments Ior medium and Iast velocity train-
ing. OI course, iI a patient trains at medium and Iast veloc-
ities (Irom 60 or 90 to 360 /sec) in one exercise session,
this strategy necessitates nine diIIerent training velocities,
giving rise to a time-consuming exercise session Ior one
agonist/antagonist combination oI muscle groups. A more
common protocol is to use as Iew as three training veloci-
Repetitions, sets, and rest. A typical VSR protocol might
have the patient perIorm one or two sets oI 8 to 10 or as
many as 20 repetitions oI agonist/antagonist muscle groups
C R A P J E P 8 Pesislance Exercise For lnµaired Muscle Perfornance 211
80X 8.20 Samplc Plyomcfrìc Scqucncc
for fhc uppcr Exfrcmìfìcs
- Waim-up aclivilics
- 1iunk cxciciscs lolding ligllwcigll ball. iolalion, sidc-
bcnding, wood-clopping
- Uppci cxlicmily cxciciscs in analomical and diagonal
plancs of molion will ligll-giadc claslic lubing
- Pionc pusl-ups
- 1liowing molions will a wcigllcd ball lo and fiom a
pailnci. bilalcial clcsl picss, bilalcial ovcilcad lliow,
bilalcial sidc lliow
- FR|lR againsl claslic lubing (90|90 posilion of slouldci
and clbow)
- Piagonal pallcins againsl claslic icsislancc
- Unilalcial lliowing molions will wcigllcd ball. bascball
lliow, sidc lliows
- Addilional cxciciscs
- 1iunk cxciciscs lolding wcigllcd ball. abdominal cuil-
ups, back cxlcnsion, sil-up and bilalcial lliow, long
silling lliows
- Clap pusl-ups
- Pionc pusl-ups fiom box lo flooi and back lo box
80X 8.21 Prccaufìons for Plyomcfrìc Jraìnìng
- lf ligl-slicss, slock-absoibing aclivilics aic nol pci-
missiblc, do nol incoipoialc plyomcliic liaining inlo
a palicnl`s iclabililalion piogiam.
- lf a dccision is madc lo includc plyomcliic aclivilics in
a iclabililalion piogiam foi clildicn oi cldcily palicnls,
sclccl only bcginning-lcvcl sliclcl-sloilcning diills
againsl ligll icsislancc. Po nol includc ligl-impacl,
lcavy-load aclivilics÷sucl as diop jumps oi wcigllcd
jumps÷llal could placc cxccssivc slicss on joinls.
- Bc suic llc palicnl las adcqualc flcxibilily and slicngll
bcfoic inilialing plyomcliic cxciciscs.
- Wcai slocs llal piovidc suppoil foi lowci cxlicmily ply-
- A|ways waim-up piioi lo plyomcliic liaining will a
sciics of aclivc, dynamic liunk and cxlicmily cxciciscs.
- Puiing jumping aclivilics, cmplasizc lcaining lcclniqucs
foi a safc landing bcfoic piogicssing lo icbounding.
- Piogicss icpclilions of an cxcicisc bcfoic incicasing
llc lcvcl of icsislancc uscd oi llc lcigll oi lcngll of
- Foi ligl-lcvcl alllclcs wlo piogicss lo ligl-inlcnsily
plyomcliic diills, incicasc llc icsl inlcivals bclwccn scls
and dccicasc llc ficqucncy of diills as llc inlcnsily of
llc diills incicascs.
- Allow adcqualc limc foi iccovciy will 48 lo 72 louis
bclwccn scssions of plyomcliic aclivilics.
- Slop an cxcicisc if a palicnl can no longci pcifoim llc
plyomcliic aclivily will good foim and landing lccl-
niquc bccausc of faliguc.
(reciprocal training) at multiple velocities.
For exam-
ple, at medium velocities (between 90 and 180 sec) train-
ing could occur at 90 , 120 , 150 , and 180 per second. A
second series would then be perIormed at decreasing
velocities: 180 , 150 , 120 , and 90 per second. Because
many combinations oI repetitions, sets, and diIIerent train-
ing velocities lead to improvement in muscle perIormance,
the therapist has many options when designing a VSR
program. A 15- to 20-second rest between sets and a 60-
second rest between exercise velocities has been recom-
The recommended Irequency Ior VSR is a
maximum oI three times per week.
Intensity. Submaximal eIIort is used Ior a brieI warm-up
period on the dynamometer. This is not a replacement Ior a
more general Iorm oI upper or lower body warm-up exer-
cises, such as cycling or upper-extremity ergometry. When
training to improve endurance, exercises are carried out at
a submaximal intensity (eIIort) but at a maximal intensity
to improve strength or power.
During the early stages oI isokinetic training, it is use-
Iul to begin with submaximal isokinetic exercise at inter-
mediate and slow velocities so the patient gets the 'Ieel¨ oI
the isokinetic equipment and at the same time protects the
muscle. As the program progresses, maximum eIIort can be
exerted at intermediate speeds. Slow-speed training is elim-
inated when the patient begins to exert maximum eIIort.
During the advanced stage oI rehabilitation, maximum-
eIIort, Iast-velocity training is emphasized, so long as exer-
cises are pain-Iree.
Additional aspects to a progression oI
isokinetic training regimens include short-arc to Iull-arc
exercises (iI necessary) and concentric to eccentric move-
P R L C A U ! l 0 N . Maxinun-efforl, slow-velocily lraininq
is rarely indicaled because of lhe excessive shear forces µro-
duced across |oinl surfaces.
Ecccnfrìc lsokìncfìc Jraìnìng: Spccìal Consìdcrafìons
As isokinetic technology evolved over several decades,
eccentric isokinetic training became possible,
Iew guidelines Ior eccentric isokinetic training and evi-
dence oI their eIIicacy are available. Guidelines developed
to date are primarily based on clinical opinion or anecdotal
evidence. Key diIIerences in eccentric versus concentric
isokinetic guidelines (intensity, repetitions, Irequency,
rest) are listed in Box 6.22. Several resources describe
pathology-speciIic guidelines Ior eccentric isokinetic
training based on clinical experience.
P R L C A U ! l 0 N S . Eccenlric isokinelic lraininq is aµµro-
µriale only durinq lhe final µhase of a rehabililalion µro-
qran lo conlinue lo challenqe individual nuscle qrouµs
when isolaled deficils in slrenqlh and µower µersisl.
8ecause of lhe robolic nalure of eccenlric isokinelic lrain-
inq, nediun ralher lhan fasl lraininq velocilies are consid-
ered safer. A sudden, raµid, nolor-driven novenenl of lhe
dynanoneler's lorque arn aqainsl a linb could in|ure heal-
inq lissue.
There seems to be an almost limitless selection oI exercise
equipment on the market that is designed Ior resistance
training. The equipment ranges Irom simple to complex,
compact to space-consuming, and inexpensive to expen-
sive. An assortment oI simple but versatile handheld and
cuII weights or elastic resistance products is useIul in clini-
cal and home settings, whereas multiple pieces oI variable
resistance equipment may be useIul Ior advanced-level
resistance training. Sources oI inIormation about new prod-
ucts on the market are the literature distributed by manu-
Iacturers, product demonstrations at proIessional meetings,
and studies oI these products reported in the research liter-
Although most equipment is loaa resisting (augments
the resistance oI gravity), a Iew pieces oI equipment can be
adapted to be loaa assisting (eliminates or diminishes the
resistance oI gravity) to improve the strength oI weak mus-
cles. Equipment can be used Ior static or dynamic, concen-
tric or eccentric, and open-chain or closed-chain exercises
to improve muscular strength, power, or endurance, neuro-
muscular stability or control, as well as cardiopulmonary
In the Iinal analysis, the choice oI equipment depends
primarily on the individual needs, abilities, and goals oI the
person using the equipment. Other Iactors that inIluence the
choice oI equipment are the availabilitv; the cost oI pur-
chase or maintenance by a Iacility or a patient; the ease of
use (application or setup) oI the equipment; the versatilitv
oI the equipment; and the space requirements oI the equip-
ment. Once the appropriate equipment has been selected,
its saIe and eIIective use is the highest priority. General
principles Ior use oI equipment are listed in Box 6.23.
80X 8.22 Kcy 0ìffcrcnccs ìn Ecccnfrìc vcrsus
Conccnfrìc lsokìncfìc Jraìnìng
Fcccnliic isokinclic cxcicisc is.
- lnlioduccd only a]icì max|ma| cffoil conccnliic iso-
kinclic cxcicisc can bc pcifoimcd willoul pain
- lmplcmcnlcd only aflci funclional R0M las bccn
- Pcifoimcd al slowci vclocilics acioss a naiiowci vclocily
spcclium llan conccnliic isokinclic cxcicisc. usually
bclwccn 60 and 120 pci sccond foi llc gcncial popula-
lion and up lo 180 pci sccond foi alllclcs
- Caiiicd oul al submaximal lcvcls foi a longci limc fiamc
lo avoid cxlcnsivc loiquc pioduclion and lcsscn llc iisk
of P0MS
- Mosl commonly pcifoimcd in a conlinuous conccnliic-
ccccnliic pallcin foi a musclc gioup duiing liaining
They include commercially available dumbbells, bar-
bells, weighted balls (Fig. 6.45), cuII weights, weigh-
ted vests, and even sandbags. Free weights can also
be Iashioned Ior a home exercise program Irom read-
ily available materials and objects Iound around the
Frcc Wcìghfs and Sìmplc
Wcìghf-Pullcy Sysfcms
Jypcs of Frcc Wcìghfs
Free weights are graduated weights that are handheld
or applied to the upper and lower extremities or trunk.
C R A P J E P 8 Pesislance Exercise For lnµaired Muscle Perfornance 218
80X 8.28 0cncral Prìncìplcs for fhc Sclccfìon and usc of Equìpmcnf
- Basc llc sclcclion of cquipmcnl on a compiclcnsivc
cxaminalion and cvalualion of llc palicnl.
- Pclciminc wlcn in llc cxcicisc piogiam llc usc of cquip-
mcnl slould bc inlioduccd and wlcn il slould bc allcicd
oi disconlinucd.
- Pclciminc if llc cquipmcnl could oi slould bc scl up and
uscd indcpcndcnlly by a palicnl.
- 1cacl appiopiialc cxcicisc foim bcfoic adding icsislancc
will llc cquipmcnl.
- 1cacl and supcivisc llc applicalion and usc of llc cquip-
mcnl bcfoic allowing a palicnl lo usc llc cquipmcnl indc-
- Adlcic lo all safcly piccaulions wlcn applying and using
llc cquipmcnl.
- Bc suic all allaclmcnls, cuffs, collais, and sliaps aic
sccuicly faslcncd and llal llc cquipmcnl is appiopiialcly
adjuslcd lo llc individual palicnl piioi lo llc cxcicisc.
- Apply padding foi comfoil, if ncccssaiy, cspccially ovci
bony piomincnccs.
- Slabilizc oi suppoil appiopiialc sliucluics lo picvcnl
unwanlcd movcmcnl and lo picvcnl unduc slicss on
body pails.
- lf cxcicisc maclincs aic uscd indcpcndcnlly, bc ccilain
llal scl-up and safcly insliuclions aic clcaily illuslialcd
and affixcd diicclly lo llc cquipmcnl.
- lf compaliblc will llc sclcclcd cquipmcnl, usc iangc-
limiling allaclmcnls if R0M musl bc icsliiclcd lo piolccl
lcaling lissucs oi unslablc sliucluics.
- lf llc palicnl is using llc cquipmcnl in a lomc piogiam,
givc cxplicil insliuclions on low, wlcn, and lo wlal
cxlcnl lo clangc oi adapl llc cquipmcnl lo piovidc a pio-
gicssivc ovciload.
- Wlcn making a liansilion fiom usc of onc lypc of icsisl-
ancc cquipmcnl lo anollci, bc ccilain llal llc ncwly
sclcclcd cquipmcnl and mcllod of scl-up inilially piovidcs
a similai lcvcl of loiquc pioduclion lo llc cquipmcnl pic-
viously cmploycd lo avoid insufficicnl oi cxccssivc loads.
- Wlcn llc cxcicisc las bccn complclcd.
- Piscngagc llc cquipmcnl and lcavc il in piopci condi-
lion foi fuluic usc.
- Ncvci lcavc biokcn oi polcnlially lazaidous cquipmcnl
foi fuluic usc.
- Scl up a icgulai ioulinc of mainlcnancc, icplaccmcnl, oi
safcly clccks foi all cquipmcnl.
Fl0uPE 8.45 (/, 3} ho|d|nç a we|ç|¦ed ua|| w|||e µer¦oru|nç couu|ned µa¦¦erns o¦ uoveuen¦ µrov|des res|s¦ance
¦o uµµer ez¦reu|¦, and ¦run| uusc|es and auçuen¦s ¦|e res|s¦ance o¦ uod, we|ç|¦ ¦o |ower ez¦reu|¦, uusc|e çrouµs
dur|nç we|ç|¦-uear|nç ac¦|v|¦|es.
Sìmplc Wcìghf-Pullcy Sysfcms
Free-standing or wall-mounted simple weight-pulley sys-
tems with weight-plates are commonly used Ior resisted
upper and lower extremity or trunk exercises (Fig. 6.46).
Permanent or interchangeable weights are available. Per-
manent weights are usually stacked with individual weight
plates oI 5- to 10-pound increments that can be easily
adjusted by changing the placement oI a single weight key.
torque. In addition, there is no accommodation Ior a
painIul arc.
When using Iree weights, it is possible to vary the
point in the ROM at which the maximum resistance load
is experienced by changing the patient`s position with
respect to gravity or the direction oI the resistance load.
For example, shoulder Ilexion may be resisted with the
patient standing or supine and holding a weight in the
Patient position. standing (Fig. 6.47): Maximum resist-
ance is experienced and maximum torque is produced
when the shoulder is at 90 oI Ilexion. Zero torque is
produced when the shoulder is at 0 oI Ilexion. Torque
again decreases as the patient liIts the weight Irom 90
to 180 oI Ilexion. In addition, when the weight is at
the side (in the 0 position oI the shoulder), it causes
traction Iorce on the humerus; and when overhead, it
causes compression Iorce through the upper extremity.
Fl0uPE 8.48 Vu|¦| Lzerc|se Pu||e, Un|¦ can ue used ¦o s¦renç¦|en a var|e¦,
o¦ uusc|e çrouµs. (Cc0r:-·y cf N-| |rcc0c:· Ccrjcry, |rc., Scç0-|, C/.}
Fl0uPE 8.47 w|en ¦|e µa¦|en¦ |s s¦and|nç and ||¦¦|nç a we|ç|¦. (/} Zero
¦oruue |s µroduced |n ¦|e s|ou|der ¦|ezors w|en ¦|e s|ou|der |s a¦ 0 o¦ ¦|ez-
|on. (3} Vaz|uuu ¦oruue |s µroduced w|en ¦|e s|ou|der |s a¦ 90 o¦ ¦|ez|on.
(C} !oruue aça|n decreases as ¦|e aru uoves ¦rou 90 ¦o 180 o¦ s|ou|der
N 0 ! L . !he sinµle weiqhl-µulley syslens described here
are lhose lhal inµose a relalively conslanl (fixed) load.
variable resislance weiqhl nachines, sone of which incor-
µorale µulleys inlo lheir desiqns, are discussed laler in lhis
Characfcrìsfìcs of Frcc Wcìghfs
and Sìmplc Wcìghf-Pullcy Sysfcms
Free weights and weight-pulley systems are resistance
equipment that impose a Iixed (constant) load. The weight
selected, thereIore, maximally challenges the contacting
muscle at only one portion oI the ROM when a patient is
in a particular position. The weight that is liIted or lowered
can be no greater than what the muscle can control at the
point in the ROM where the load provides the maximum
Patient position. supine (Fig. 6.48): Maximum resistance
is experienced and maximum torque is produced when
the shoulder is at 0 oI Ilexion. Zero torque is produced
at 90 oI shoulder Ilexion. In this position the entire load
creates a compression Iorce. The shoulder Ilexors are not
active between 90 and 180 oI shoulder Ilexion. Instead,
the shoulder extensors must contract eccentrically to
control the descent oI the arm and weight.
movements must be controlled entirely by the patient, it
may take more time Ior the patient to learn correct align-
ment and movement patterns.
A variety oI movement patterns is possible, incorporat-
ing single plane or multiplanar motions. An exercise can
be highly speciIic to one muscle or generalized to sever-
al muscle groups. Movement patterns that replicate Iunc-
tional activities can be resisted.
II a large enough assortment oI graduated Iree weights is
available, resistance can be increased by very small
increments, as little as 1 pound at a time. The weight
plates oI pulley systems have larger increments oI resist-
ance, usually a minimum oI 5 pounds per plate.
Most exercises with Iree weights and weight-pulley sys-
tems must be perIormed slowly to minimize acceleration
and momentum and prevent uncontrolled, end-range
movements that could compromise patient saIety. It is
thought that the use oI exclusively slow movements dur-
ing strengthening activities has less carryover to many
daily living activities than the incorporation oI slow-
and Iast-velocity exercises into a rehabilitation program.
However, a weighted ball can be used with catching
and throwing exercises as part oI plyometric training
during the advanced phase oI upper extremity rehabili-
Free weights with interchangeable disks, such as a bar-
bell, are versatile and can be used Ior patients with many
diIIerent levels oI strength, but they require patient or
personnel time Ior proper assembly.
Bilateral liIting exercises with barbell weights oIten
require the assistance oI a spotter to ensure patient saIe-
ty, thus increasing personnel time.
varìahlc-Pcsìsfancc Machìncs
Variable-resistance exercise equipment Ialls into two
broad categories: specially designed weight-cable (weight-
pulley) machines and hydraulic and pneumatic units. Both
categories oI equipment impose a variable load on the con-
tracting muscles consistent with the changing torque-
producing capabilities oI the muscles throughout the
available ROM.
varìahlc Pcsìsfancc Wcìghf-Cahlc Sysfcms
Variable-resistance weight-cable machines (Fig. 6.49) use a
cam in their design. The cam (an elliptical or kidney-
shaped disk) in the weight-cable system is designed to vary
the load (torque) applied to the contracting muscle even
though the weight selected remains the same. In theory, the
cam is conIigured to replicate the length-tension relation-
ship and resultant torque curve oI the contracting muscle
with the greatest amount oI resistance applied in the mid-
range. This system varies the external load imposed on the
contracting muscle based on the physical dimensions oI the
'average¨ individual. How eIIectively this design provides
truly accommodating resistance throughout the Iull ROM
is debatable.
The therapist must determine at which portion oI the
patient`s ROM maximum strength is needed and must
choose the optimum position in which the exercise should
be perIormed to gain maximum beneIit Irom the exercise.
Simple weight-pulley systems provide maximum
resistance when the angle oI the pulley is at right angles to
the moving bone. As the angle oI the pulley becomes more
acute, the load creates more compression through the mov-
ing bones and joints and less eIIective resistance.
Unlike many weight machines, neither Iree weights
nor pulleys provide external stabilization to guide the mov-
ing segment or restrict ROM. When a patient liIts or lowers
a weight to an overhead position, muscles oI the scapula
and shoulder abductors, adductors, and rotators must syn-
ergistically contract to stabilize the arm and keep it aligned
in the correct plane oI motion. The need Ior concurrent
contraction oI adjacent stabilizing muscle groups can be
viewed as an advantage or disadvantage. Because muscular
stabilization is necessary to control the plane or pattern oI
movement, less resistance can be controlled with Iree
weights than with a weight machine during the same
movement pattern.
Advanfagcs and 0ìsadvanfagcs of Frcc
Wcìghfs and Sìmplc Wcìghf-Pullcy Sysfcms
Exercises can be set up in many positions, such as
supine, side-lying, or prone in bed or on a cart, sitting in
a chair or on a bench, or standing. Many muscle groups
in the extremities and trunk can be strengthened by sim-
ply repositioning the patient.
Free weights and simple weight-pulley systems typically
are used Ior dynamic, non-weight-bearing exercises but
also can be set up Ior isometric exercise and resisted
weight-bearing activities.
Stabilizing muscle groups are recruited; however,
because there is no external source oI stabilization and
C R A P J E P 8 Pesislance Exercise For lnµaired Muscle Perfornance 215
Fl0uPE 8.48 w|en ¦|e µa¦|en¦ |s suµ|ne and ||¦¦|nç a we|ç|¦. (/} Vaz|uuu
¦oruue |s µroduced a¦ 0 o¦ s|ou|der ¦|ez|on. (3} Zero ¦oruue |s µroduced a¦
90 o¦ s|ou|der ¦|ez|on. (C} !|e s|ou|der ez¦ensors are ac¦|ve and con¦rac¦
eccen¦r|ca||, aça|ns¦ res|s¦ance ¦rou 90 ¦o 180 o¦ s|ou|der ¦|ez|on.
With each repetition oI an exercise, the same muscle
group contracts and is resisted concentrically and eccentri-
cally. As with simple weight-pulley systems and Iree
weights, exercises must be perIormed at relatively slow
velocities, thus compromising carryover to many Iunctional
Rydraulìc and Pncumafìc varìahlc-Pcsìsfancc unìfs
Other variable-resistance machines employ hydraulic or
pressurized pneumatic resistance to vary the resistance
throughout the ROM. These units allow concentric, recip-
rocal muscle work to agonist and antagonist muscle groups
but no eccentric work. Patients can saIely exercise at Iast
velocities with these units. These units also allow a patient
to accommodate Ior a pain-Iree arc.
Advanfagcs and 0ìsadvanfagcs
of varìahlc-Pcsìsfancc Machìncs
The obvious advantage oI these machines compared to
constant load equipment is that the eIIective resistance is
adjusted, at least to some extent, to a muscle`s tension-
generating capabilities throughout the ROM. The con-
tracting muscle is loaded maximally at multiple points in
the ROM, rather than just one small portion oI the range.
Most pieces oI equipment are designed to isolate and
exercise a speciIic muscle group. For example, resisted
squats are perIormed on one machine and hamstring curls
on another. Some units, such as a leg press or shoulder
press, strengthen multiple muscle groups simultaneously.
Unlike Iunctional movement, most machines allow only
single-plane movements, although some newer units now
oIIer a dual-axis design allowing multiplanar motions
that strengthen multiple muscle groups and more closely
resemble Iunctional movement patterns.
The equipment is adjustable to a certain extent to allow
individuals oI varying heights to perIorm each exercise
in a well aligned position.
Each unit provides substantial external stabilization to
guide or limit movements. This makes it easier Ior the
patient to learn how to perIorm the exercise correctly
and saIely and helps the patient maintain appropriate
alignment without assistance or supervision.
One oI the main disadvantages oI weight machines is the
initial expense and ongoing maintenance costs. Multiple
machines, usually 8 to 10 or more, must be purchased to
target multiple major muscle groups. Multiple machines
also require a large amount oI space in a Iacility.
Elasfìc Pcsìsfancc 8ands and Juhìng
The use oI elastic resistance products in therapeutic exer-
cise programs has become widespread in rehabilitation and
has been shown to be an eIIective method oI providing
resistance and improving muscle strength.
Despite the
popularity oI these products, not until the past 10 years has
quantitative inIormation been reported on the actual or rel-
ative resistance supplied by elastic products or the level oI
muscle activation during use.
studies suggest that the eIIective use oI elastic products Ior
resistance training requires not only the application oI bio-
mechanical principles but also an understanding oI the
physical properties oI elastic resistance material.
Jypcs of Elasfìc Pcsìsfancc
Elastic resistance products, speciIically designed Ior use
during exercise, Iall into two broad categories: elastic
bands and elastic tubing. Elastic bands and tubing are pro-
duced by several manuIacturers under diIIerent product
names, the most Iamiliar oI which is Thera-Band
Resistance Bands and Tubing (Hygenic Corp., Akron, OH).
Elastic bands are available in an assortment oI grades or
thicknesses. Tubing comes in graduated diameters and wall
thickness that provide progressive levels oI resistance.
Color-coding denotes the thickness oI the product and
grades oI resistance.
Propcrfìcs of Elasfìc Pcsìsfancc-
lmplìcafìons for Excrcìsc
A number oI studies describing the physical characteristics
oI elastic resistance have provided quantitative inIormation
about its material properties. Knowledge oI this inIorma-
tion enables a therapist to use elastic resistance more eIIec-
tively Ior therapeutic exercise programs.
Fl0uPE 8.40 C,uez|Laç|e l|¦ness S,s¦eus s|ou|der µress µrov|des var|au|e
res|s¦ance ¦|rouç|ou¦ ¦|e rançe o¦ uo¦|on. (Cc0r:-·y cf Cy¹-x, 0ivi·icr cf |0r-x,
Rcr|cr|crc, NY.}
only Iactor that must be considered. The amount oI torque
(Iorce distance) imposed by the elastic on the bony lever
is also an important consideration. Just because the tension
produced by an elastic band or tubing increases as it is
stretched, it does not mean that the imposed torque neces-
sarily increases Irom the beginning to the end oI an exer-
cise. In addition to the resistance (Iorce) imposed by the
elastic material as it is stretched, the Iactor oI the changing
length oI the moment arm as the angle oI the elastic
changes with respect to the moving limb aIIects the torque
imparted by the elastic material.
Studies have indicated
that bell-shaped torque curves occur, with the peak torque
near mid-range during exercises with elastic material.
CareIul scrutiny oI these studies is necessary to determine
iI the elastic resistance is at a 90 angle to the moving limb
at mid-range. As in all Iorms oI dynamic resistance exer-
cise, the lengthtension relationship oI the contracting
muscle also aIIects its ability to respond to the changing
Fatigue characteristics. It has been suggested that elastic
resistance products tend to Iatigue over time, which causes
the material to lose some oI its Iorce-generating proper-
That being said, the extent oI material fatigue is
dependent on the number oI times the elastic band or tub-
ing has been stretched (number oI stretch cycles) and the
percentage oI deIormation with each stretch.
Studies have shown that the decrease in tensile Iorce is
signiIicant but small, with much oI the decrease occurring
within the Iirst 20
or 50
stretch cycles. However, in
the Iormer study, investigators Iound that aIter this small
initial decrease in tensile Iorce occurred there was no
appreciable decrease in the Iorce-generating potential oI
the tubing aIter more than 5000 cycles oI stretch. In other
words, a patient could perIorm 10 repetitions each oI Iour
diIIerent exercises, three times a day on a daily basis Ior 6
weeks with the same piece oI tubing beIore needing to
replace it.
Elastic materials also display a property called vis-
coelastic creep. II a constant load is placed on elastic
material, in time it becomes brittle and eventually ruptures.
Environmental conditions, such as heat and humidity, also
aIIect the Iorce-generating potential oI elastic bands and
Applìcafìon of Elasfìc Pcsìsfancc
Selecting the appropriate grade of material. The thickness
(stiIIness) oI the material aIIects the level oI resistance.
A heavier grade oI elastic generates greater tension when
stretched and thereIore imparts a greater level oI resist-
As already noted, corresponding levels oI
resistance have been published Ior the diIIerent grades
oI bands and tubing.
There is a question oI whether similar colors oI bands
or tubing Irom diIIerent manuIacturers may or may not
provide similar levels oI tension under the same conditions.
Effect of elongation of elastic material. Elastic resistance
provides a Iorm oI variable resistance because the Iorce
generated changes as the material is elongated. SpeciIical-
ly, as it is stretched, the amount oI resistance (Iorce) pro-
duced by an elastic band or tubing increases depending on
the relative change in the length oI the material (percent-
age of elongation/aeformation) Irom the start to the end oI
elongation. There is a relatively predictable and linear rela-
tionship between the percentage oI elongation and the ten-
sile Iorce oI the material.
To determine the percentage oI elongation, the
stretched length must be compared to the resting length oI
the elastic material. The resting length oI a band or tubing
is its length when it is laid out Ilat and there is no stretch
applied. The actual length oI the material beIore it is
stretched has no eIIect on the Iorce imparted. Rather, it is
the percentage oI elongation that aIIects the tensile
The Iormula Ior calculating the percentage oI elonga-
tion/deIormation is
Percent oI elongation (stretched length
resting length) resting length 100
Using this Iormula, iI a 2-Ioot length oI red tubing, Ior
example, is stretched to 4 Ieet, the percentage oI elongation
is 100°. With this in mind, it is understandable why a 1-
Ioot length oI the same color tubing stretched to 2 Ieet
(100° elongation) generates the same Iorce as a 2-Ioot
length stretched to 4 Ieet.
Furthermore, the rate at which elastic material is
stretched does not seem to have a signiIicant eIIect on the
amount oI resistance encountered.
Consequently, when a
patient is perIorming a particular exercise, so long as the
percentage oI elongation oI the tubing is the same Irom
one repetition to the next, the resistance encountered is the
same regardless oI whether the exercise is perIormed at
slow or Iast velocity.
Determination and quantification of resistance. In order
to make decisions based on evidence, rather than solely on
clinical judgment, about the grade (color) oI elastic materi-
al to select Ior a patient`s exercise program, a number oI
studies have been done to quantiIy the resistance imparted
by elastic bands or tubing.
These studies
measured and compared the tensile Iorces generated by
various grades oI elastic bands or tubing in relation to the
percentage oI elongation oI the material. The Iorces
expected at speciIic percentages oI elongation oI each
grade oI tubing or bands can be calculated by means oI lin-
ear regression equations. Detailed speciIications about the
material properties oI one brand oI elastic resistance prod-
ucts, Thera-Band,
are available at www.thera-bandacade-
During exercise, the percentage oI deIormation and
resulting resistance (Iorce) Irom the material is not the
C R A P J E P 8 Pesislance Exercise For lnµaired Muscle Perfornance 217
In a study
comparing similar colors and lengths oI
Thera-Band and Cando tubing (Cando Fabrication Enter-
prises, White Plains, NY), investigators measured (by
means oI a strain gauge) the Iorces generated under similar
conditions. They Iound no appreciable diIIerences between
the two products except Ior the thinnest (yellow) and thick-
est (silver/gray) grades. In those two grades the Cando tub-
ing produced approximately 30° to 35° higher levels oI
Iorce than the Thera-Band product. Despite these small diI-
Ierences, it is prudent to use the same product with the
same patient.
Selecting the appropriate length. Elastic bands or tubing
come in large rolls and can be cut in varying lengths
depending on the speciIic exercise to be perIormed and the
height oI a patient or the length oI the extremities. The
length oI the elastic material should be suIIicient to attach
it securelv at both ends. It should be taut but not stretched
(resting length) at the beginning position oI an exercise.
Remember, the percentage oI elongation oI the materi-
al aIIects the tension produced. Accordingly, it is essential
that the same length oI elastic resistance is used each time
a particular exercise is perIormed. Otherwise, the imposed
load may be too little or too much Irom one exercise ses-
sion to the next even though the same grade (thickness) oI
elastic is used.
Securing bands or tubing. One end is oIten tied or
attached to a Iixed object (doorknob, table leg, or D-ring)
or secured by having the patient stand on one end oI the
material. The other end is grasped or Iastened to a nylon
loop, which is then placed around a limb segment. The
material can also be secured to a harness on a patient`s
trunk Ior resisted walking activities. The band or tubing
can also be held in both hands or looped under both Ieet
Ior bilateral exercise. Figure 6.50AC depicts upper or
lower extremity and trunk strengthening activities using
elastic resistance.
Setting up an exercise. With elastic resistance the mus-
cle receives the maximum resistive Iorce when the material
is on a stretch and angled 90 to the lever arm (moving
bone). The therapist should determine the limb position at
which maximum resistance is desired and anchor the elas-
tic material so it is at a right angle at that portion oI the
range. When the material is at an acute angle to the moving
bone, there is less resistance but greater joint compressive
It is important to consistently set up the exercise in the
same manner Irom one exercise session to the next. Each
time a patient perIorms a speciIic exercise, in addition to
using the same length oI elastic material the patient should
assume the same position. A resource by Page and Ellen-
described setups Ior numerous exercises using
elastic resistance.
Progressing exercises. Exercises can be progressed by
increasing the number oI repetitions oI an exercise with the
same grade oI resistance or by using the next higher grade
oI elastic band or tubing.
Fl0uPE 8.50 Use o¦ e|as¦|c res|s¦ance ¦o s¦renç¦|en (/} uµµer or (3} |ower
ez¦reu|¦, or (C} ¦run| uuscu|a¦ure.
The Iollowing equipment is designed speciIically Ior
closed-chain training and has Ieatures to improve muscle
perIormance across multiple joints.
8ody Wcìghf Pcsìsfancc-
Mulfìpurposc Excrcìsc Sysfcms
The Total Gym
system, Ior example, uses a glideboard,
which can be set at 10 incline angles, that enables a patient
to perIorm bilateral or unilateral closed-chain strengthen-
ing and endurance exercises in positions that range Irom
partially reclining to standing (Fig. 6.51 A&B). The level
oI resistance on the Total Gym apparatus is increased or
decreased by adjusting the angle oI the glideboard on
the incline.
Advanfagcs and 0ìsadvanfagcs of
Excrcìsc wìfh Elasfìc Pcsìsfancc
Elastic resistance products are portable and relatively
inexpensive, making them an ideal choice Ior home exer-
cise programs.
Because elastic resistance is not signiIicantly gravity-
dependent, elastic bands and tubing are extremely versa-
tile, allowing exercises to be perIormed in many
combinations oI movement patterns in the extremities
and trunk and in many positions.
It is saIe to exercise at moderate to Iast velocities with
elastic resistance because the patient does not have to
overcome the inertia oI a rapidly moving weight. As
such, it is appropriate Ior plyometric training.
One oI the most signiIicant drawbacks to the use oI elas-
tic resistance is the need to reIer to a table oI Iigures Ior
quantitative inIormation about the level oI resistance Ior
each color-coded grade oI material. This makes it diIIi-
cult to know which grade to select initially and to what
extent changing the grade oI the band or tubing changes
the level oI resistance.
As with Iree weights, there is no source oI stabilization
or control oI extraneous movements when an elastic
band or tubing is used Ior resistance. The patient must
use muscular stabilization to ensure that the correct
movement pattern occurs.
Although the eIIects oI material Iatigue are small with
typical clinical use (up to 300° deIormation in most
exercises), elastic bands and tubing should be replaced
on a routine basis to ensure patient saIety.
II many
individuals use the same precut lengths oI bands or tub-
ing, it may be diIIicult to determine how much use has
Some elastic products contain latex, thus eliminating use
by individuals with an allergy to latex. However, there
are latex-Iree products on the market at a relatively com-
parable cost.
Equìpmcnf for Closcd-Chaìn Jraìnìng
Many closed-chain exercises are perIormed in weight-
bearing postures to develop strength, endurance, and stabil-
ity across multiple joints. Typically, these exercises use
partial or Iull body weight as the source oI resistance.
Examples in the lower extremities include squats, lunges,
and step-ups or step-downs; and in the upper extremities
they include push-ups or press-ups in various positions and
pull-ups or chin-ups. These exercises can be progressed by
simply adding resistance with handheld weights, a weight-
ed belt or vest, or elastic resistance. Progressing Irom bilat-
eral to unilateral weight bearing (when Ieasible) also
increases the exercise load.
C R A P J E P 8 Pesislance Exercise For lnµaired Muscle Perfornance 210
Fl0uPE 8.51 C|osed-c|a|n ¦ra|n|nç. (/} |n ¦|e seu|-rec||n|nç µos|¦|on and
(3} s¦and|nç µos|¦|on us|nç ¦|e !o¦a| C,u s,s¦eu. (Cc0r:-·y cf ¯c:c| 0yr, Scr
0i-jc, C/.}
PerIormance oI bilateral and, later, unilateral squatting
exercises in a semireclining position allows the patient to
begin closed-chain training in a partially unloaded (partial
weight-bearing) position early in the rehabilitation pro-
gram. Later, the patient can progress to Iorward lunges
(where the Ioot slides Iorward on the glideboard) while in
a standing position.
N 0 ! L . !he !olal 6yn¹ syslen can also be sel uµ for lrunk
exercises and oµen-chain exercises for lhe uµµer or lower
8alancc 8oards
A balance board (wobble board) is used Ior proprioceptive
training in the upper or lower extremities. One example is
the BAPS (Biomechanical Ankle PlatIorm) system. This
system can be used in the standing position, the seated
position (with the Ioot placed on the board) Ior ankle exer-
cises, or in the quadriped position Ior upper extremity
activities. Progressively increasing the size oI the halI
spheres under the board or placing weights on the board
makes the balance activity more challenging.
Slìdc 8oards
The ProFitter
(Fig. 6.52) consists oI a moving platIorm
that slides side to side across an elliptical surIace against
adjustable resistance. Although it is most oIten used with
the patient standing Ior lower extremity rehabilitation, it
can also provide upper extremity closed-chain resisted
movements and trunk stability. Medial-lateral or anterior-
posterior movements are possible.
Mìnì-Jrampolìncs (Pchoundcrs}
Mini-trampolines enable the patient to begin gentle, bilat-
eral or unilateral bouncing activities on a resilient surIace
to decrease the impact on joints. A patient can jog, jump,
or hop in place. 'Mini-tramps¨ that have a waist-height
bar (attached to the Irame) to hold onto provide additional
Pccìprocal Excrcìsc Equìpmcnf
Similar to other types oI equipment that can be used Ior
closed-chain training, reciprocal exercise devices strength-
en multiple muscle groups across multiple joints. They
also are appropriate Ior low-intensity, high-repetition
resistance training to increase muscular endurance and
reciprocal coordination oI the upper or lower extremities
and improve cardipulmonary Iitness. They are oIten used
Ior warm-up or cool-down exercises prior to and aIter
more intense resistance training. Resistance is imparted by
an adjustable Iriction device or by hydraulic or pneumatic
Sfafìonary Excrcìsc Cyclcs
The stationary exercise cycle (upright or recumbent) is
used to increase lower extremity strength and endurance.
An upright cycle requires greater trunk control and bal-
ance than a recumbent cycle. A Iew exercise cycles
provide resistance to the upper extremities as well. Resis-
tance can be graded to challenge the patient progressively.
Distance, speed, or duration oI exercise can also be moni-
The exercise cycle provides resistance to muscles
during repetitive, nonimpact, and reciprocal movements
oI the extremities. Passive devices resist only concentric
muscle activity as the patient perIorms pushing or pulling
movements. Motor-driven exercise cycles can be adjusted
to provide eccentric as well as concentric resistance. The
placement oI the seat can also be adjusted to alter the arc
oI motion that occurs in the lower extremities.
Porfahlc Pcsìsfìvc Pccìprocal Excrcìsc unìfs
A number oI portable resistive exercisers are eIIective
alternatives to an exercise cycle Ior repetitive, reciprocal
exercise. One such product, the Chattanooga Group Exer-
(Fig. 6.53), can be used Ior lower extremity exercise
by placing the unit on the Iloor in Iront oI a chair or
wheelchair. This is particularly appropriate Ior a patient
who is unable to get on and oII an exercise cycle. In addi-
tion, it can be placed on a table Ior upper extremity exer-
cise. Resistance can be adjusted to meet the abilities oI
individual patients.
Fl0uPE 8.52 Prol|¦¦er µrov|des c|osed-c|a|n res|s¦ance ¦o |ower ez¦reu|¦,
uuscu|a¦ure |n µreµara¦|on ¦or ¦unc¦|ona| ac¦|v|¦|es.
Equìpmcnf for 0ynamìc Sfahìlìzafìon Jraìnìng
Swìss 8alls (Sfahìlìfy 8alls}
Heavy-duty vinyl balls, usually 20 to 30 inches in diame-
ter, are used Ior a variety oI trunk and extremity stabiliza-
tion exercises. A patient can also use elastic resistance or
Iree weights while on the ball to increase the diIIiculty
oI exercises. ReIer to Chapter 16 Ior descriptions oI a
number oI dynamic stabilization exercises using stability
The BodyBlade
(Fig. 6.55) is a dynamic, reactive Iorm
oI resistance equipment that uses the principle oI inertia as
the source oI resistance to produce dynamic stability.
While a patient drives the blade, rapidly, alternating con-
tractions oI agonist and antagonist muscle groups occur in
an attempt to control the instability in three planes oI
motion dictated by movements oI the blade. The greater
the amplitude or Ilex oI the blade, the greater the resist-
ance. This provides progressive resistance that the patient
Sfaìr-Sfcppìng Machìncs
The StairMaster
and the Climb Max 2000
are examples
oI a stepping machines that allow the patient to perIorm
reciprocal pushing movements against adjustable resistance
to make the weight-bearing activity more diIIicult. Step-
ping machines provide nonimpact, closed-chain strengthen-
ing as an alternative to walking or jogging on a treadmill.
A patient can also kneel next to the unit and place both
hands on the Ioot plates to use this equipment Ior upper
extremity closed-chain exercises.
Ellìpfìcal Jraìncrs and Cross-Counfry Skì Machìncs
Elliptical trainers and cross-country ski machines also pro-
vide nonimpact, reciprocal resistance to the lower extremi-
ties in an upright, weight-bearing position. Variable incline
adjustments oI these units Iurther supplement resistance
options. Both types oI equipment also incorporate sources
oI reciprocal resistance to the upper extremities into their
uppcr Exfrcmìfy Ergomcfcrs
Upper body ergometers (UBEs) provide resistance exclu-
sively Ior the upper extremities (Fig. 6.54). Typically, the
patient is seated, but the UBE can also be used with the
patient in a standing position to lessen the extent oI eleva-
tion oI the arms necessary with each revolution. This is
particularly helpIul Ior patients with impingement syn-
dromes oI the shoulder.
C R A P J E P 8 Pesislance Exercise For lnµaired Muscle Perfornance 221
Fl0uPE 8.58 Res|s¦ed rec|µroca| ezerc|se us|nç ¦|e C|a¦¦anooça Lzerc|ser.
(Cc0r:-·y cf C|c::crccjc 0rc0j, |rc., |ixcr, ¯N.}
Fl0uPE 8.54 Uµµer bod, Lzerc|ser (UbL} |s used ¦or uµµer ez¦reu|¦,
s¦renç¦| and endurance ¦ra|n|nç.
Initially, the oscillating blade is maintained in various
positions in space, particularly those positions in which
dynamic stability is required Ior Iunctional activities. The
patient can progress the diIIiculty oI the stabilization exer-
cises by moving the upper extremity through various
planes oI motion (Irom sagittal to Irontal and ultimately to
transverse) as the blade oscillates. The goal is to develop
proximal stability (a stable core) as a Ioundation oI con-
trolled mobility.
lsokìncfìc Jcsfìng and Jraìnìng Equìpmcnf
Isokinetic dynamometers (rate-limiting devices that control
the velocity oI motion) provide accommodating resistance
during dynamic exercises oI the extremities or trunk. The
equipment supplies resistance proportional to the Iorce
generated by the person using the machine. The preset rate
(degrees per second) cannot be exceeded no matter how
vigorously the person pushes against the Iorce arm. There-
Iore, the muscle contracts to its Iullest capacity at all points
in the ROM.
Fcafurcs of lsokìncfìc 0ynamomcfcrs
New product lines oI isokinetic equipment and improve-
ments in existing equipment have been developed over the
years. The Biodex isokinetic dynamometer (Fig. 6.56) is an
example oI a unit currently on the market. The speciIica-
tions oI the various manuIacturers` dynamometers diIIer
somewhat. Features include computerized testing capabili-
ties; passive and active modes that permit open-chain, con-
centric and eccentric testing and training; and velocity
settings Irom 0 per second up to 500 per second Ior the
concentric mode and up to 120 to 250 per second Ior
the eccentric mode. Isokinetic units can be used Ior con-
tinuous passive motion. Computer programming allows
limb movement within a speciIied range. Single-joint, uni-
planar movements are most common, but some multiplanar
movement patterns are possible. The Biodex dynamometer
has attachments Ior multijoint, closed-chain exercises. Rec-
iprocal training oI agonist and antagonist and concentric/
eccentric training oI the same muscle group are both
Fl0uPE 8.58 b|odez |so||ne¦|c d,nauoue¦er |s used ¦or ¦es¦|nç and ¦ra|n|nç.
(Cc0r:-·y cf 3icc-x |-cicc| Sy·:-r·, |rc., S|ir|-y, NY.}
Fl0uPE 8.55 0,nau|c s¦au|||za¦|on ezerc|ses o¦ ¦|e uµµer ez¦reu|¦, and
¦run| us|nç ¦|e bod,b|ade. (Cc0r:-·y cf 3ccy3|cc-/|yrcr·cr, |rc., |c· /rj-|-·,
C/, 1-800-773|/0|, cr 26288, www.¹ccy¹|cc-.ccr/.}
Advanfagcs and 0ìsadvanfagcs of lsokìncfìc Equìpmcnf
Isokinetic equipment can provide maximum resistance at
all points in the ROM as a muscle contracts.
Both high- and low-velocity training can be done saIely
and eIIectively.
The equipment accommodates Ior a painIul arc oI
As a patient Iatigues, exercise can still continue.
Isolated strengthening oI muscle groups is possible to
correct strength deIicits in speciIic muscle groups.
External stabilization keeps the patient and moving seg-
ment well aligned.
Concentric and eccentric contractions oI the same mus-
cle group can be perIormed repeatedly, or reciprocal
exercise oI opposite muscle groups can be perIormed,
allowing one muscle group to rest while its antagonist
contracts; the latter method minimizes muscle ischemia.
Computer-based visual or auditory cues provide Ieed-
back to the patient so submaximal to maximal work can
be carried out more consistently.
Equìpmcnf for lsomcfrìc Jraìnìng
To complete the total picture oI the importance oI equip-
ment Ior eIIective resistance training, isometric resistance
exercises must also be addressed. One oI the advantages oI
isometric training is that it is possible to perIorm a variety
oI exercises without equipment. For example, multiple-
angle isometrics can be carried out by simply having the
patient push against an immovable object, such as a door
Irame, a heavy table, a soIa, or a wall. OI course, manual
resistance is also an eIIective means oI strengthening mus-
cles isometrically, particularly early in a rehabilitation pro-
Many pieces oI equipment designed Ior dynamic
exercise can be adapted Ior isometric exercise. A weight-
pulley system that provides resistance greater than the
Iorce-generating capacity oI a muscle results in a static
muscle contraction. Most isokinetic devices can be set up
with the speed set at 0 /sec at multiple joint angles Ior iso-
metric resistance at multiple points in the ROM. II elastic
resistance or a pulley system is applied to the sound lower
extremity, as the patient stands and bears Iull weight on
the involved lower extremity, the muscles oI the involved
extremity must contract isometrically to hold the body in
a stable, upright position as the sound extremity moves
against the resistance.
The equipment is large and expensive.
Setup time and assistance Irom personnel are necessary
iI a patient is to exercise multiple muscle groups.
The equipment cannot be incorporated into a home exer-
cise program.
Most units allow only open-chain (non-weight-bearing)
movement patterns, which do not simulate most lower
extremity Iunctions and some upper extremity Iunctions.
Although Iunctional movements typically occur in com-
bined patterns and at many diIIerent velocities, most
exercises are perIormed in a single plane and at a con-
stant velocity.
Although the range oI concentric training velocities
(up to 500 /sec) is comparable to some lower extremity
limb speeds during Iunctional activities, even the upper
limits oI this range cannot begin to approximate the
rapid limb speeds that are necessary during many sports-
related motions, such as throwing. In addition, the eccen-
tric velocities available, at best, only begin to approach
medium-range speeds, Iar slower than the velocity oI
movement associated with quick changes oI direction
and deceleration. Both oI these limitations in the range
oI training velocities compromise carryover to Iunctional
C R A P J E P 8 Pesislance Exercise For lnµaired Muscle Perfornance 228
l h 0 E P E h 0 E h ! L E A P h l h 6 A C ! l v l ! l E S
Crìfìcal Jhìnkìng and 0ìscussìon
1. What physical Iindings Irom an examination and evalua-
tion oI a patient would lead you to determine that resist-
ance exercises were an appropriate intervention?
2. What are the beneIits and limitations oI isometric,
dynamic (constant or variable resistance), and isokinetic
3. What are the key changes that occur in muscle strength
and endurance throughout the liIe span?
4. You have been asked to design a resistance exercise pro-
gram as part oI a total Iitness program Ior a group oI 7-
to 9-year-old soccer players (boys and girls). Indicate
the exercises you would include, the equipment you
need, and the guidelines Ior intensity, volume, Irequen-
cy, and rest.
5. Analyze Iive daily living tasks or recreational activities
that you currently perIorm or would like to be able to
perIorm eIIectively and eIIiciently. IdentiIy what aspects
oI muscle perIormance (strength, power, endurance) and
other parameters oI Iunction, such as mobility (Ilexibili-
ty), stability, balance, and coordinated movement, are
involved in each oI these tasks.
6. Develop an in-service instructional presentation that
deals with the appropriate and eIIective use oI elastic
resistance products.
7. You have been asked to help design a circuit weight
training sequence at a soon-to-open Iitness Iacility at the
outpatient treatment center where you work. Select
equipment to meet the needs oI beginning and advanced
individuals. Establish general guidelines Ior intensity,
repetitions and sets, order oI exercise, rest intervals, and
8. Analyze the plyometric training activities listed in Box
6.19 and determine in which muscle groups training-
induced gains in strength and power would occur and
what Iunctional tasks could each oI the activities
9. Design a resistance-training program as part oI a total
Iitness program Ior a group oI older adults who partici-
pate in activities at a community-based senior citizen
center. All participants are ambulatory and range in age
Irom 65 to 85 years. Each has received clearance Irom
his or her physician to participate in the program. What
types oI resistance equipment and levels oI resistance
would you recommend? IdentiIy special precautions you
would want to take.
Lahorafory Pracfìcc
1. PerIorm manual resistance exercise to all muscle groups
oI the upper and lower extremities in the Iollowing posi-
tions: supine, prone, side-lying, and sitting. What are the
major limitations to eIIective, Iull-range strengthening in
each oI these positions?
2. Apply manual resistance exercises to each oI the mus-
cles oI the wrist, Iingers, and thumb.
3. Practice upper extremity and lower extremity D
and D
PNF exercises on your laboratory partner`s right ana leIt
4. Determine a 1 RM and 10 RM Ior the Iollowing muscle
groups: shoulder Ilexors, shoulder abductors, shoulder
external rotators, elbow Ilexors and extensors, hip
abductors, hip Ilexors, knee Ilexors and extensors. Select
one upper and one lower extremity muscle group. Deter-
mine a 1 RM or 10 RM with Iree weights in two posi-
tions. Determine where in the ROM maximum
resistance is encountered. Then determine a 1 RM or
10 RM with a pulley system. Compare your results.
5. Set up and saIely apply exercises with elastic bands or
tubing to strengthen the major muscle groups oI the
upper and lower extremities. Include a dynamic open-
chain, a dynamic closed-chain, and an isometric exercise
Ior each muscle group.
6. Demonstrate a series oI simulated Iunctional activities
that could be used in the Iinal stages oI rehabilitation to
continue to improve muscle perIormance as a transition
into independent Iunctional activities Ior a mail carrier, a
nurse`s aide who works in a skilled nursing Iacility, a ski
instructor, a baseball player, and a daycare worker who
cares Ior a group oI active toddlers (each weighing
approximately 25 pounds).
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C R A P J E P 8 Pesislance Exercise For lnµaired Muscle Perfornance 220
Prlnclples ol ^eroblc
Fìfncss 282
Maxìmum 0xygcn Consumpfìon 282
Endurancc 282
Acrohìc Excrcìsc Jraìnìng (Condìfìonìng} 282
Adapfafìon 282
Myocardìal 0xygcn Consumpfìon 282
0ccondìfìonìng 288
Encrgy Sysfcms, Encrgy Expcndìfurc, and
Effìcìcncy 288
Funcfìonal lmplìcafìons 284
Encrgy Expcndìfurc 284
Effìcìcncy 284
Cardìovascular Pcsponsc fo Excrcìsc 285
Pcspìrafory Pcsponsc fo Excrcìsc 285
Pcsponscs Provìdìng Addìfìonal 0xygcn
fo Musclc 288
Fìfncss Jcsfìng of Rcalfhy Suh|ccfs 288
Sfrcss Jcsfìng for Convalcscìng lndìvìduals
and lndìvìduals af Pìsk 288
Mulfìsfagc Jcsfìng 287
lnfcnsìfy 287
0urafìon 280
Frcqucncy 280
Modc 280
Pcvcrsìhìlìfy Prìncìplc 240
Warm-up Pcrìod 240
Acrohìc Excrcìsc Pcrìod 240
Cool-0own Pcrìod 241
Applìcafìon 241
WlJR JPAlNlN0 241
Cardìovascular Changcs 241
Pcspìrafory Changcs 242
Mcfaholìc Changcs 242
0fhcr Sysfcm Changcs 248
lnpafìcnf Phasc (Phasc l} 248
0ufpafìcnf Phasc (Phasc ll} 248
0ufpafìcnf Program (Phasc lll} 244
Spccìal Consìdcrafìons 244
Adapfìvc Changcs 244
0EC0N0lJl0NE0 lN0lvl0uAL AN0 JRE PAJlENJ
Adapfafìons for 0ìsahìlìfìcs, Funcfìonal
Lìmìfafìons, and 0ccondìfìonìng 245
lmpaìrmcnfs, 0oals, and Plan of Carc 245
Chìldrcn 248
Young Adulfs 247
0ldcr Adulfs 248
C h A P ! L R
Karcn Ho|IgrcIc, 0HS, P1, 0CS
1crrI M. 0|cnn, Ph0, P1
There are numerous sources Irom which to obtain inIor-
mation on training Ior endurance in athletes and healthy
young people and Ior individuals with coronary heart dis-
ease. InIormation or emphasis on endurance training and
the improvement oI Iitness in the individual who has
other types oI chronic disease or disability is beginning to
emerge. Using the most recent research, the American Col-
lege oI Sports Medicine published basic guidelines Ior sev-
eral oI the more common chronic conditions.
This chapter
uses inIormation Irom well known sources to demonstrate
that the physical therapist can use aerobic-type activity
when working with either healthy individuals or patients
with a variety oI conditions. In addition, some Iundamental
inIormation about cardiovascular and respiratory parame-
ters in children and the elderly, as well as the young or
middle-aged adult, is presented so the physical therapist
can be prepared to treat individuals oI all ages.
Fitness is a general term used to describe the ability to
perIorm physical work. PerIorming physical work requires
cardiorespiratory Iunctioning, muscular strength and
endurance, and musculoskeletal Ilexibility. Optimum body
composition is also included when describing Iitness.
To become physically Iit, individuals must participate
regularly in some Iorm oI physical activity that uses large
muscle groups and challenges the cardiorespiratory system.
Individuals oI all ages can improve their general Iitness
status by participating in activities that include walking,
biking, running, swimming, stair climbing, cross-country
skiing, and/or training with weights.
Fitness levels can be described on a continuum Irom
poor to superior based on energy expenditure during a
bout oI physical work.
These ratings are oIten based
on direct or indirect measurement oI the body`s maximum
oxygen consumption (
2 max
). Oxygen consumption is
inIluenced by age, gender, heredity, inactivity, and disease.
Maxìmum 0xygcn Consumpfìon
Maximum oxygen consumption (
2 max
) is a measure oI
the body`s capacity to use oxygen.
It is usually meas-
ured when perIorming an exercise that uses many large
muscle groups such as swimming, walking, and running. It
is the maximum amount oI oxygen consumed per minute
when the individual has reached maximum eIIort. It is usu-
ally expressed relative to body weight, as milliliters oI oxy-
gen per kilogram oI body weight per minute (mL/kg per
minute). It is dependent on the transport oI oxygen, the
oxygen-binding capacity oI the blood, cardiac Iunction,
oxygen extraction capabilities, and muscular oxidative
Endurance (a measure oI Iitness) is the ability to work
Ior prolonged periods oI time and the ability to resist
It includes muscular endurance and cardio-
vascular endurance. Muscular endurance reIers to the
ability oI an isolated muscle group to perIorm repeated
contractions over a period oI time, whereas cardiovascu-
lar endurance reIers to the ability to perIorm large muscle
dynamic exercise, such as walking, swimming, and/or
biking Ior long periods oI time.
Acrohìc Excrcìsc Jraìnìng (Condìfìonìng}
Aerobic exercise training, or conditioning, is augmenta-
tion oI the energy utilization oI the muscle by means oI
an exercise program.
The improvement oI the muscle`s
ability to use energy is a direct result oI increased levels oI
oxidative enzymes in the muscles, increased mitochondrial
density and size, and an increased muscle Iiber capillary
Training is dependent on exercise oI suIIicient intensity,
duration, and Irequency.
Training produces cardiovascular and/or muscular adap-
tation and is reIlected in an individual`s endurance.
Training Ior a particular sport or event is dependent on
the speciIicity principle
; that is, the individual
improves in the exercise task used Ior training and may
not improve in other tasks. For example, swimming may
enhance one`s perIormance in swimming events but may
not improve one`s perIormance in treadmill running.
The cardiovascular system and the muscles used adapt to
the training stimulus over time.
SigniIicant changes
can be measured in as little as 10 to 12 weeks.
Adaptation results in increased eIIiciency oI the car-
diovascular system and the active muscles. Adaptation rep-
resents a variety oI neurological, physical, and biochemical
changes in the cardiovascular and muscular systems. Per-
Iormance improves in that the same amount oI work can be
perIormed aIter training but at a lower physiological cost.
Adaptation is dependent on the ability oI the organism
to change and the training stimulus threshold (the stimulus
that elicits a training response). The person with a low
level oI Iitness has more potential to improve than the one
who has a high level oI Iitness.
Training stimulus thresholds are variable. The higher
the initial level oI Iitness, the greater the intensity oI exer-
cise needed to elicit a signiIicant change.
Myocardìal 0xygcn Consumpfìon
Myocardial oxygen consumption (m
) is a measure oI
the oxygen consumed by the myocardial muscle.
The need or demand Ior oxygen is determined by the heart
rate (HR), systemic blood pressure, myocardial contractili-
ty, and aIterload. AIterload is determined by the leIt ven-
tricular wall tension and central aortic pressure. It is the
ventricular Iorce required to open the aortic valve at the
beginning oI systole. LeIt ventricular wall tension is prima-
rily determined by ventricular size and wall thickness.
The ability to supply the myocardium with oxygen
is dependent on the arterial oxygen content (blood sub-
strate), hemoglobin oxygen dissociation, and coronary
blood Ilow, which is determined by aortic diastolic pres-
sure, duration oI diastole, coronary artery resistance, and
collateral circulation. In a healthy individual, a balance
between myocardial oxygen supply and demand is main-
tained during maximum exercise. When the demand Ior
oxygen is greater than the supply, myocardial ischemia
Ior actin-myosin cross-bridge Iormation when contracting.
There are three major energy systems. The intensity and
duration oI activity determine when and to what extent
each metabolic system contributes.
Phosphagen, or ATP-PC, System
The ATP-PC system (adenosine triphosphatephosphocre-
atine) has the Iollowing characteristics.
Phosphocreatine and ATP are stored in the muscle cell.
Phosphocreatine is the chemical Iuel source.
No oxygen is required (anaerobic).
When muscle is rested, the supply oI ATP-PC is
The maximum capacity oI the system is small (0.7 mol
The maximum power oI the system is great (3.7 mol
The system provides energy Ior short, quick bursts oI
It is the major source oI energy during the Iirst 30 sec-
onds oI intense exercise.
Anaerobic Glycolytic System
The anaerobic glycolytic system has the Iollowing charac-
Glycogen (glucose) is the Iuel source (glycolysis).
No oxygen is required (anaerobic).
ATP is resynthesized in the muscle cell.
Lactic acid is produced (by-product oI anaerobic
The maximum capacity oI the system is intermediate
(1.2 mol ATP).
The maximum power oI the system is intermediate (1.6
mol ATP/min).
The systems provide energy Ior activity oI moderate
intensity and short duration.
It is the major source oI energy Irom the 30th to 90th
second oI exercise.
Aerobic System
The aerobic system has the Iollowing characteristics.
Glycogen, Iats, and proteins are Iuel sources and are uti-
lized relative to their availability and the intensity oI the
Oxygen is required (aerobic).
ATP is resynthesized in the mitochondria oI the muscle
cell. The ability to metabolize oxygen and other sub-
strates is related to the number and concentration oI the
mitochondria and cells.
The maximum capacity oI the system is great (90.0 mol
The maximum power oI the system is small (1.0 mol
The system predominates over the other energy systems
aIter the second minute oI exercise.
Recruitment of Motor Units
Recruitment oI motor units is dependent on the rate oI
work. Fibers are recruited selectively during exercise.
Because the myocardial muscle extracts 70° to 75°
oI the oxygen Irom the blood during rest, its main source
oI supply during exercise is through an increase in coro-
nary blood Ilow. The clinical relevance is described in
Box 7.1.
Deconditioning occurs with prolonged bed rest, and its
eIIects are Irequently seen in the patient who has had an
extended, acute illness or long-term chronic condition.
Decreases in maximum oxygen consumption, cardiac out-
put (stroke volume), and muscular strength occur rapidly.
These eIIects are also seen, although possibly to a lesser
degree, in the individual who has spent a period oI time
on bed rest without any accompanying disease process and
in the individual who is sedentary because oI liIestyle and
increasing age. Deconditioning eIIects associated with bed
rest are summarized in Box 7.2.
Encrgy Sysfcms, Encrgy
Expcndìfurc, and Effìcìcncy
Encrgy Sysfcms
Energy systems are metabolic systems involving a series oI
biochemical reactions resulting in the Iormation oI adeno-
sine triphosphate (ATP), carbon dioxide, and water.
The cell uses the energy produced Irom the conversion oI
ATP to adenosine diphosphate (ADP) and phosphate (P) to
perIorm metabolic activities. Muscle cells use this energy
C R A P J E P 7 Princiµles of Aerobic Exercise 288
80X 7.1 Clìnìcal Pclcvancc-Excrfìonal Angìna
Pcisons wlo lavc coionaiy occlusion may nol picscnl will
any lypc of clcsl pain (angina) unlil llcy nccd lo cxcil
llcmsclvcs. 1lis is bccausc wlcn llc body woiks laidci
llc lcail ialc incicascs, diaslolic filling limc dccicascs, and
incicascd coionaiy blood flow is saciificcd by llc icduccd
limc foi filling llc coionaiy ailciics. Willoul an adcqualc
blood supply, llc undcilying caidiac lissuc no longci
icccivcs llc oxygcn nccdcd foi mclabolic aclivily, icsulling
in anginal pain.
80X 7.2 0ccondìfìonìng Effccfs Assocìafcd
Wìfh 8cd Pcsf
Musclc mass
Caidiovasculai funclion
1olal blood volumc
Plasma volumc
Ecail volumc
0illoslalic lolciancc
Fxcicisc lolciancc
Bonc mincial dcnsily
Slow-twitch Iibers (type I) are characterized by a slow
contractile response, are rich in myoglobin and mito-
chondria, have a high oxidative capacity and a low
anaerobic capacity, and are recruited Ior activities
demanding endurance. These Iibers are supplied by
small neurons with a low threshold oI activation and are
used preIerentially in low-intensity exercise.
Fast-twitch Iibers (type IIB) are characterized by a Iast
contractile response, have a low myoglobin content and
Iew mitochondria, have a high glycolytic capacity, and
are recruited Ior activities requiring power.
Fast-twitch Iibers (type IIA) have characteristics oI both
type I and type IIB Iibers and are recruited Ior both
anaerobic and aerobic activities.
Funcfìonal lmplìcafìons
Bursts oI intense activity (seconds) develop muscle
strength and stronger tendons and ligaments. ATP is sup-
plied by the phosphagen system.
Intense activity (1 to 2 minutes) repeated aIter 4 minutes
oI rest or mild exercise enhances anaerobic power. ATP
is supplied by the phosphagen and anaerobic glycolytic
Activity with large muscles, which is less than maxi-
mum intensity Ior 3 to 5 minutes repeated aIter rest
or mild exercise oI similar duration, may develop aer-
obic power and endurance capabilities. ATP is supplied
by the phosphagen, anaerobic glycolytic, and aerobic
Activity oI submaximum intensity lasting 20 to 30 min-
utes or more taxes a high percentage oI the aerobic sys-
tem and develops endurance.
Encrgy Expcndìfurc
Energy is expended by individuals engaging in physical
activity and is oIten expressed in kilocalories. Activities
can be categorized as light, moderate or heavy by deter-
mining the energy cost. The energy cost oI any activity is
aIIected by mechanical eIIiciency and body mass. Factors
that aIIect both walking and running are terrain, stride
length, and air resistance.
0uanfìfìcafìon of Encrgy Expcndìfurc
Energy expended is computed Irom the amount oI oxygen
consumed. Units used to quantiIy energy expenditure are
kilocalories and METs.
A kilocalorie is a measure expressing the energy value
oI Iood. It is the amount oI heat necessary to raise 1
kilogram (kg) oI water 1 C. A kilocalorie (kcal) can be
expressed in oxygen equivalents. Five kilocalories equal
approximately 1 liter oI oxygen consumed (5 kcal 1
liter O
A MET is deIined as the oxygen consumed (milliliters)
per kilogram oI body weight per minute (mL/kg). It is
equal to approximately 3.5 mL/kg per minute.
Classìfìcafìon of Acfìvìfìcs
Activities are classiIied as light, moderate, or heavy
according to the energy expended or the oxygen consumed
while accomplishing them.
Light work Ior the average male (65 kg) requires 2.0 to
4.9 kcal/min, or 6.1 to 15.2 mL O
/kg per minute, or 1.6
to 3.9 METs. Strolling 1.6 km/hr, or 1.0 mph, is consid-
ered light work.
Heavy work Ior the average male (65 kg) requires 7.5 to
9.9 kcal/min, or 23.0 to 30.6 mL O
/kg per minute, or
6.0 to 7.9 METs. Jogging 8.0 km/hr, or 5.0 mph, is con-
sidered heavy work.
Jogging 8.0 km/hr, or 5.0 mph, requires 25 to 28 mL
/kg per minute and is considered heavy work. The
energy expended is equivalent to 8 to 10 kcal/min, or 7
to 8 METs.
The energy expenditure necessary Ior most industrial
jobs requires more than three times the energy expendi-
ture at rest.
Energy expenditure oI certain physical activities can
vary, depending on Iactors such as skill, pace, and Iit-
ness level (Box 7.3).
EIIiciency is usually expressed as a percentage
(Box 7.4).
Work output equals Iorce times distance (W F D).
It can be expressed in power units or work per unit oI time
(P w/t). On a treadmill, work equals the weight oI the
subject times the vertical distance the subject is raised
walking up the incline oI the treadmill. On a bicycle
ergometer, work equals the distance (which is the circum-
Ierence oI the Ilywheel times the number oI revolutions)
times the bicycle resistance.
Work input equals energy expenditure and is expressed
as the net oxygen consumption per unit oI time. With aero-
bic exercise, the resting volume oI oxygen used per unit oI
time (VO
value) is subtracted Irom the oxygen consumed
during 1 minute oI the steady-state period.
80X 7.8 0aìly Encrgy Expcndìfurc
1lc avciagc individual cngagcd in noimal daily lasks
cxpcnds 1800 lo 2000 kcal pci day. Alllclcs cngagcd in
inlcnsc liaining can usc moic llan 10,000 kcal pci day.
Pala fiom Wilmoic, 1E, Coslill, PL. Plysiology of Spoil and Fxcicisc.
Euman Kinclics, Clampaign, lL, 1994.
80X 7.4 Effìcìcncy Exprcsscd as a Pcrccnfagc
Pciccnl cfficicncy 100
uscful woik oulpul
cncigy cxpcndcd oi woik inpul
Cardìac Effccfs
The Irequency oI sinoatrial node depolarization increas-
es, as does the heart rate.
There is a decrease in vagal stimuli as well as an
increase in SNS stimulation.
There is an increase in the Iorce development oI the car-
diac myoIibers. A direct inotropic response oI the SNS
increases myocardial contractility.
Pcrìphcral Effccfs
Net Reduction in Total Peripheral Resistance
Generalized vasoconstriction occurs that allows blood to
be shunted Irom the nonworking muscles, kidneys, liver,
spleen, and splanchnic area to the working muscles.
A locally mediated reduction in resistance in the work-
ing muscle arterial vascular bed, independent oI the
autonomic nervous system, is produced by metabolites
such as Mg
, Ca
, ADP, and PCO
The veins oI the working and nonworking muscles
remain constricted.
Increased Cardiac Output
The cardiac output increases because oI the:
Increase in myocardial contractility, with a resultant
increase in stroke volume
Increase in heart rate
Increase in the blood Ilow through the working muscle
Increase in the constriction oI the capacitance vessels on
the venous side oI the circulation in both the working
and nonworking muscles, raising the peripheral venous
Increase in Systolic Blood Pressure
The increase in systolic blood pressure is the result oI the
augmented cardiac output.
Pcspìrafory Pcsponsc fo Excrcìsc
Respiratory changes occur rapidly, even beIore the ini-
tiation oI exercise.
Gas exchange (O
, CO
) increas-
es across the alveolar-capillary membrane by the Iirst
or second breath. Increased muscle metabolism during
exercise results in more O
extracted Irom arterial blood
resulting in an increase in venous PCO
and H , an
increase in body temperature, increased epinephrine,
and increased stimulation oI receptors oI the joints and
muscles. Any oI these Iactors alone or in combination
may stimulate the respiratory system. Baroreceptor
reIlexes, protective reIlexes, pain, emotion, and volun-
tary control oI respiration may also contribute to the
increase in respiration.
Minute ventilation increases as respiratory Irequency and
tidal volume increase.
Alveolar ventilation, occurring with the diIIusion oI gases
across the capillary-alveolar membrane, increases 10- to
20-Iold during heavy exercise to supply the additional
oxygen needed and excrete the excess CO
Steady state is reached within 3 to 4 minutes aIter
exercise has started iI the load or resistance is kept
In the steady-state period, VO
remains at a constant
(steady) value.
Total net oxygen cost is multiplied by the total time
in minutes the exercise is perIormed. The higher the net
oxygen cost, the lower the eIIiciency in perIorming the
activity. EIIiciency oI large muscle activities is usually
20° to 25°.
The rapid increase in energy requirements during exercise
requires equally rapid circulatory adjustments to meet the
increased need Ior oxygen and nutrients to remove the
end-products oI metabolism such as carbon dioxide and
lactic acid and to dissipate excess heat. The shiIt in body
metabolism occurs through a coordinated activity oI
all the systems oI the body: neuromuscular, respiratory,
cardiovascular, metabolic, and hormonal (Box 7.5).
Oxygen transport and its utilization by the mitochon-
dria oI the contracting muscle are dependent on ade-
quate blood Ilow in conjunction with cellular respira-
Cardìovascular Pcsponsc fo Excrcìsc
Excrcìsc Prcssor Pcsponsc
Stimulation oI small myelinated and unmyelinated Iibers
in skeletal muscle involves a sympathetic nervous system
(SNS) response. The central pathways are not known.
The SNS response includes generalized peripheral vaso-
constriction in nonexercising muscles and increased
myocardial contractility, an increased heart rate, and
an increased systolic blood pressure. This results in
a marked increase and redistribution oI the cardiac
The degree oI the response equals the muscle mass
involved and the intensity oI the exercise.
C R A P J E P 7 Princiµles of Aerobic Exercise 285
80X 7.5 Facfors Affccfìng fhc Pcsponsc
fo Acufc Excrcìsc
Ambicnl lcmpcialuic, lumidily, and alliludc can affccl
llc plysiological icsponscs lo aculc cxcicisc. Piuinal
fluclualions as wcll as clangcs associalcd will a fcmalc
subjccl`s mcnsliual cyclc can affccl llcsc icsponscs as
wcll. 1lcicfoic, icscaiclcis conliol llcsc faclois as mucl
as possiblc wlcn cvalualing llc icsponsc lo cxcicisc.
Pcsponscs Provìdìng Addìfìonal
0xygcn fo Musclc
lncrcascd 8lood Flow
The increased blood Ilow to the working muscle previously
discussed provides additional oxygen.
lncrcascd 0xygcn Exfracfìon
There is also extraction oI more oxygen Irom each liter oI
blood. There are several changes that allow Ior this.
A decrease oI the local tissue PO
occurs because oI the
use oI more oxygen by the working muscle. As the par-
tial pressure oI oxygen decreases, the unloading oI oxy-
gen Irom hemoglobin is Iacilitated.
The production oI more CO
causes the tissue to become
acidotic (the hydrogen ion concentration increases) and
the temperature oI the tissue to increase. Both situations
increase the amount oI oxygen released Irom hemoglo-
bin at any given partial pressure.
The increase oI red blood cell 2,3-diphosphoglycerate
(DPG) produced by glycolysis during exercise also con-
tributes to the enhanced release oI oxygen.
0xygcn Consumpfìon
Factors determining how much oI the oxygen is consumed
Vascularity oI the muscles.
Fiber distribution.
Number oI mitochondria.
Oxidative mitochondrial enzymes present in the Iibers.
The oxidative capacity oI the muscle is reIlected in the
a VO
diIIerence, which is the diIIerence between the
oxygen content oI arterial and venous blood.
Testing Ior physical Iitness oI healthy individuals should
be distinct Irom graded exercise testing oI convalescing
patients, individuals with symptoms oI coronary heart dis-
ease, or individuals who are 35 years or older but asympto-
Regardless oI the type oI testing, the level oI
perIormance is based on the submaximum or maximum
oxygen uptake (
2 max
) or the symptom-limited oxygen
uptake. The capacity oI the individual to transport and uti-
lize oxygen is reIlected in the oxygen uptake. Readers are
reIerred to publications by the American College oI Sports
Ior additional inIormation.
Fìfncss Jcsfìng of Rcalfhy Suh|ccfs
Field tests Ior determining cardiovascular Iitness include
the time to run 1.5 miles or the distance run in 12 minutes.
These measures correlate well with
2 max
, but their use is
limited to young persons or middle-aged individuals who
have been careIully screened and have been jogging or
running Ior some time.
Multistage testing can provide a direct measurement
2 max
by analyzing samples oI expired air.
Testing is
usually completed in Iour to six treadmill stages, which
progressively increase in speed and or grade. Each stage is
3 to 6 minutes long. Electrocardiographic (ECG) monitor-
ing is perIormed during the testing. Maximum oxygen
uptake can be determined when the oxygen utilization
plateaus despite an increase in workload.
Sfrcss Jcsfìng for Convalcscìng
lndìvìduals and lndìvìduals af Pìsk
Individuals undergoing stress testing should have a physi-
cal examination, be monitored by the ECG, and be closely
observed at rest, during exercise, and during recovery
(Fig. 7.1).
Fl0uPE 7.1 P|aceuen¦ o¦ e|ec¦rodes ¦or ¦|e 12-|ead ezerc|se e|ec¦rocard|o-
çrau used ¦o de¦eru|ne |ear¦ ra¦e and r|,¦|u dur|nç ¦|e s¦ress ¦es¦.
Prìncìplcs of Sfrcss Jcsfìng
The principles oI stress testing include the Iollowing.
Changing the workload by increasing the speed and/or
grade oI the treadmill or the resistance on the bicycle
An initial workload that is low in terms oI the individ-
ual`s anticipated aerobic threshold.
Maintaining each workload Ior 1 minute or longer.
Terminating the test at the onset oI symptoms or a deIin-
able abnormality oI the ECG.
When available, measuring the individual`s maximum
oxygen consumption.
Jcrmìnafìon of Sfrcss Jcsfìng
Endpoints requiring termination oI the test period are
Progressive angina.
A signiIicant drop in systolic pressure in response to an
increasing workload.
Lightheadedness, conIusion, pallor, cyanosis, nausea, or
peripheral circulatory insuIIiciency.
Abnormal ECG responses including ST segment depres-
sion greater than 4 mm.
Excessive rise in blood pressure.
Subject wishes to stop.
Mulfìsfagc Jcsfìng
Each oI the Iour to six stages lasts approximately 1 to 6
minutes. DiIIerences in protocols involve the number oI
stages, magnitude oI the exercise (intensity), equipment
used (bicycle, treadmill), duration oI stages, endpoints,
position oI body, muscle groups exercised, and types oI
eIIort (Box 7.7).
Protocols have been developed Ior multistage testing.
The most popular treadmill protocol is the Bruce protocol.
Treadmill speed and grade are changed every 3 minutes.
Speed increases Irom 1.7 mph up to 5.0 mph, and the ini-
tial grade oI 10° increases up to 18° during the Iive
Just as testing Ior Iitness should be distinct Irom stress
testing Ior patients or individuals at high risk, training pro-
grams Ior healthy individuals are distinct Irom the exercise
prescription Ior individuals with cardiopulmonary disease.
EIIective endurance training Ior any population must
produce a conditioning or cardiovascular response. Elicita-
tion oI the cardiovascular response is dependent on three
critical elements oI exercise: intensity, duration, and
Determination oI the appropriate intensity oI exercise to
use is based on the overload principle and the speciIicity
0vcrload Prìncìplc
Overload is stress on an organism that is greater than that
regularly encountered during everyday liIe. To improve
cardiovascular and muscular endurance, an overload must
be applied to these systems. The exercise load (overload)
must be above the training stimulus threshold (the stimulus
that elicits a training or conditioning response) Ior adapta-
tion to occur.
Once adaptation to a given load has taken place, the
training intensity (exercise load) must be increased Ior the
Purposc of Sfrcss Jcsfìng
In addition to serving as a basis Ior determining exer-
cise levels or the exercise prescription, the stress test:
Helps establish a diagnosis oI overt or latent heart dis-
Evaluates cardiovascular Iunctional capacity as a means
oI clearing individuals Ior strenuous work or exercise
Determines the physical work capacity in kilogram-
meters per minute (kg-m/min) or the Iunctional capacity
in METs.
Evaluates responses to exercise training and/or preven-
tive programs.
Assists in the selection and evaluation oI appropriate
modes oI treatment Ior heart disease.
Increases individual motivation Ior entering and adhering
to exercise programs.
Is used clinically to evaluate patients with chest sensa-
tions or a history oI chest pain to establish the probabili-
ty that such patients have coronary disease. It can also
evaluate the Iunctional capacity oI patients with chronic
Prcparafìon for Sfrcss Jcsfng
All individuals who are taking a stress test should:
Have had a physical examination.
Be monitored by ECG and closely observed at rest, dur-
ing exercise, and during recovery.
Sign a consent Iorm.
P R L C A U ! l 0 N S . Precaulions lo be laken are sunna-
rized in 8ox 7.ß. !hey are aµµlicable for bolh slress leslinq
and lhe exercise µroqran.
C R A P J E P 7 Princiµles of Aerobic Exercise 287
80X 7.8 Prccaufìons for Sfrcss Jcsfìng
and Excrcìsc Program
Caidiopulmonaiy clangcs occui will slicss lcsling and
cxciciscs, moniloi and iccognizc llc following.
- Moniloi llc pulsc lo asscss abnoimal incicascs in lcail
- Blood picssuic incicascs will cxcicisc appioximalcly
7 lo 10 millimclcis (mm) of mcicuiy (Eg) pci MF1 of
plysical aclivily.
- Syslolic picssuic slould nol cxcccd 220 lo 240 mm
- Piaslolic picssuic slould nol cxcccd 120 mm Eg.
- Ralc and dcpll of icspiialion incicasc will cxcicisc.
- Rcspiialion slould nol bc laboicd.
- 1lc individual slould lavc no pciccplion of sloilncss
of bicall.
- 1lc incicasc in blood flow wlilc cxcicising, wlicl icgu-
lalcs coic lcmpcialuic and mccls llc dcmands of llc
woiking musclcs, icsulls in clangcs in llc skin of llc
clccks, nosc, and cailobcs. 1lcy bccomc pink, moisl, and
waim lo llc loucl.
individual to achieve Iurther improvement. Training stimu-
lus thresholds are variable, depending on the individual`s
level oI health, level oI activity, age, and gender. The high-
er the initial level oI Iitness, the greater the intensity oI
exercise needed to elicit a change.
A conditioning response occurs generally at 60° to
90° maximum heart rate (50° to 85°
2 max
) depend-
ing on the individual and the initial level oI Iitness.
Seventy percent maximum heart rate is a minimal-level
stimulus Ior eliciting a conditioning response in healthy
young individuals.
Sedentary or 'deconditioned¨ individuals respond to a
low exercise intensity, 40° to 50° oI
2 max
The exercise does not have to be exhaustive to achieve a
training response.
Determining the maximum heart rate and the exercise
heart rate Ior training programs provides the basis Ior
the initial intensity oI the exercise (Box 7.8).
When the individual is young and healthy, the maximum
heart rate can be determined directly Irom a maximum
perIormance multistage test, extrapolated Irom a heart
rate achieved on a predetermined submaximum test or,
less accurately, calculated as 220 minus age.
80X 7.7
Case Lzauµ| e o¦ an Lzer c| se S¦ r ess !es¦
Mi. Smill is a ¯¯-ycai-old scdcnlaiy man will a lisloiy of
clcsl pain will cxcilion. Ec las undcigonc a slicss lcsl lo
assisl in cvalualing lis angina. Ec is nol laking any mcdica-
lions al llc picscnl limc. Ec las bccn a smokci foi 20 ycais.
· Rcsling clccliocaidiogiam (FCC). noimal
· Rcsling lcail ialc. 7¯ bcals|min
· Agc-picdiclcd maximum lcail ialc. 16¯ bcals|min
· Rcsling blood picssuic. 128|86
· Rcsling icspiialion ialc. 20 bicalls|min
· 1icadmill. Biucc piolocol
Stagc Pcart ßatc 8Iood Prcssurc Commcnts
1 80
8¯ 128|88 No complainls
2 88
92 142|90 No complainls
2 98
102 1¯6|91 Complaining of lcg faliguc
4 114
122 161|90 Complaining of minimal clcsl pain
¯ 122
127 174|89 Complaining of scvcic clcsl pain,
lcsl lciminalcd
1lc slicss lcsl was lciminalcd bccausc of complainls of scvcic clcsl pain accompanicd by a diop in llc S1 scgmcnl of llc
FCC lo 4 mm. 1lc symplom-limilcd maximum lcail ialc was dclcimincd lo bc 127 bcals|min. Maximum oxygcn con-
sumplion was dclcimincd lo bc 22 mL|kg|min.
80X 7.8
Ve¦ |ods ¦ o 0e¦ er u| ne Vaz| uuu hear ¦ Ra¦ e and Lzer c| se hear ¦ Ra¦ e
Bctcrminc Maximum Hcart Ratc (HR)
· Fiom mullislagc lcsl (foi young and lcallly)
· ER aclicvcd in picdclcimincd submaximum lcsl
· 220 minus agc (lcss accuialc)
Bctcrminc Excrcisc Hcart Ratc
· Pciccnlagc of maximum lcail ialc (dcpcndcnl on lcvcl of
· Kaivoncn`s foimula (lcail ialc icscivc)
Fxcicisc lcail ialc ER
60-70% (ER
- ER
Muscle strength without a signiIicant increase in total
oxygen consumption.
Aerobic or endurance training without training the anaer-
obic systems.
Anaerobic training without training the aerobic systems.
Even when evaluating aerobic or endurance activities,
there appears to be little overlap. When training Ior
swimming events, the individual may not demonstrate
an improvement in
2 max
when running.
The optimal duration oI exercise Ior cardiovascular condi-
tioning is dependent on the total work perIormed, exercise
intensity and Irequency, and Iitness level. Generally speak-
ing, the greater the intensity oI the exercise, the shorter the
duration needed Ior adaptation; and the lower the intensity
oI exercise, the longer the duration needed.
A 20- to 30-minute session is generally optimal at
60° to 70° maximum heart rate. When the intensity is
below the heart rate threshold, a 45-minute continuous
exercise period may provide the appropriate overload. With
high-intensity exercise, 10- to 15-minute exercise periods
are adequate; three 5-minute daily periods are eIIective in
some deconditioned patients.
Like duration, there is no clear-cut inIormation provided
on the most eIIective Irequency oI exercise Ior adaptation
to occur. Frequency may be a less important Iactor than
intensity or duration in exercise training. Frequency varies,
dependent on the health and age oI the individual. Optimal
Irequency oI training is generally three to Iour times a
week. II training is at low intensity, greater Irequency may
be beneIicial. A Irequency oI two times a week does not
generally evoke cardiovascular changes, although older
individuals and convalescing patients may beneIit Irom a
program oI that Irequency.
Recommendations. The American Heart Association Sci-
entiIic Statement on physical activity and atherosclerotic
heart disease as reported by Thompson et al.
30 minutes oI moderate intensity aerobic exercise on most
iI not all days oI the week. The Centers Ior Disease Con-
trol (CDC) supports these recommendations,
whereas the
American College oI Sports Medicine, as described by
Pollock et al.,
recommends aerobic exercise 3 to 5 days/
week at 65° to 90° maximum heart rate Ior 20 to 60 con-
tinuous or intermittent minutes. They Iurther recommend
that iI the activity is lower intensity it should have a longer
duration and that multiple bouts oI exercise (no less than
10 minutes) may be accumulated throughout the day.
Many types oI activity provide the stimulus Ior improv-
ing cardiorespiratory Iitness. The important Iactor is that
The exercise heart rate is determined in one oI two
ways: (1) as a percentage oI the maximum heart rate (the
percentage used is dependent on the level oI Iitness oI
the individual); and (2) using the heart rate reserve
(Karvonen`s Iormula). Karvonen`s Iormula is based
on the heart rate reserve (HRR), which is the diIIerence
between the resting heart rate (HR
) and the maxi-
mum heart rate (HR
). The exercise heart rate is
determined as a percentage (usually 60° to 70°) oI
the heart rate reserve plus the resting heart rate (see
Box 7.8).
When using Karvonen`s Iormula, the exercise heart
rate is higher than when using the maximum heart rate
lndìvìduals af Pìsk
Maximum heart rate and exercise heart rate used Ior the
exercise prescription Ior individuals at risk Ior coronary
artery disease, individuals with coronary artery disease or
other chronic disease, and individuals who are elderly are
ideally identiIied based on their perIormance on the stress
test. The maximum heart rate cannot be determined in the
same manner as Ior the young and healthy.
Assuming that an individual has an average maximum
heart rate, using the Iormula 220 minus age produces
substantial errors in prescribing the exercise intensity Ior
these individuals.
Maximum heart rate, which may be symptom-limited, is
considered maximum. At no time should the exercise
heart rate exceed the symptom-limited heart rate
achieved on the exercise test.
Individuals with cardiopulmonary disease may start
exercise programs, depending on their diagnosis, as
low as 40° to 60° oI their maximum heart rate.
Exercising at a high intensity Ior a shorter period oI time
appears to elicit a greater improvement in
2 max
exercising at a moderate intensity Ior a longer period
oI time. However, as exercise approaches the maximum
limit, there is an increase in the relative risk oI cardiovas-
cular complications and the risk oI musculoskeletal
The higher the intensity and the longer the exercise
intervals, the Iaster the training eIIect.
Maximum oxygen consumption (
2 max
) is the best
measure oI exercise intensity. Aerobic capacity and heart
rate are linearly related; thereIore, the maximum heart
rate is a Iunction oI intensity.
Spccìfìcìfy Prìncìplc
The speciIicity principle as related to the speciIicity oI
training reIers to adaptations in metabolic and physiologi-
cal systems depending on the demand imposed. There is
no overlap when training Ior strengthpower activities and
training Ior endurance activities. Workload and workrest
periods are selected so training results in:
C R A P J E P 7 Princiµles of Aerobic Exercise 280
the exercise involves large muscle groups that are activat-
ed in a rhythmic, aerobic nature. However, the magnitude
oI the changes may be determined by the mode used.
For speciIic aerobic activities such as cycling and run-
ning, the overload must use the muscles required by the
activity and stress the cardiorespiratory system (speci-
Iicity principle). II endurance oI the upper extremities
is needed to perIorm activities on the job, the upper
extremity muscles must be targeted in the exercise pro-
gram. The muscles trained develop a greater oxidative
capacity with an increase in blood Ilow to the area. The
increase in blood Ilow is due to increased microcircula-
tion and more eIIective distribution oI the cardiac output.
Training beneIits are optimized when programs are
planned to meet the individual needs and capacities oI the
participants. The skill oI the individual, variations among
individuals in competitiveness and aggressiveness, and
variation in environmental conditions must be considered.
Pcvcrsìhìlìfy Prìncìplc
The beneIicial eIIects oI exercise training are transient and
Detraining occurs rapidly when a person stops exercising.
AIter only 2 weeks oI detraining, signiIicant reductions
in work capacity can be measured, and improvements can
be lost within several months. A similar phenomenon
occurs with individuals who are conIined to bed with ill-
ness or disability: the individual becomes severely decon-
ditioned, with loss oI the ability to carry out normal daily
activities as a result oI inactivity.
The Irequency or duration oI physical activity required
to maintain a certain level oI aerobic Iitness is less than
that required to improve it.
A careIully planned exercise program can result in hig-
her levels oI Iitness Ior the healthy individual, slow the
decrease in Iunctional capacity oI the elderly, and recondi-
tion those who have been ill or have chronic disease. There
are three components oI the exercise program: (1) a warm-
up period, (2) the aerobic exercise period, and (3) a cool-
down period.
Warm-up Pcrìod
Physiologically, a time lag exists between the onset oI
activity and the bodily adjustments needed to meet the
physical requirements oI the body. The purpose oI the
warm-up period is to enhance the numerous adjustments
that must take place beIore physical activity.
Physìologìcal Pcsponscs
During this period there is:
An increase in muscle temperature. The higher tempera-
ture increases the eIIiciency oI muscular contraction by
reducing muscle viscosity and increasing the rate oI
nerve conduction.
An increased need Ior oxygen to meet the energy
demands Ior the muscle. Extraction Irom hemoglobin is
greater at higher muscle temperatures, Iacilitating the
oxidative processes at work.
Dilatation oI the previously constricted capillaries with
increases in the circulation, augmenting oxygen delivery
to the active muscles and minimizing the oxygen deIicit
and the Iormation oI lactic acid.
Adaptation in sensitivity oI the neural respiratory center
to various exercise stimulants.
An increase in venous return. This occurs as blood Ilow
is shiIted centrally Irom the periphery.
The warm-up also prevents or decreases:
The susceptibility oI the musculoskeletal system to
The occurrence oI ischemic electrocardiographic (ECG)
changes and arrhythmias.
The warm-up should be gradual and suIIicient to increase
muscle and core temperature without causing Iatigue or
reducing energy stores. Characteristics oI the period
A 10-minute period oI total body movement exercises,
such as calisthenics, and walking slowly.
Attaining a heart rate that is within 20 beats/min oI the
target heart rate.
Acrohìc Excrcìsc Pcrìod
The aerobic exercise period is the conditioning part oI the
exercise program. Attention to the determinants oI intensi-
ty, Irequency, duration, and mode oI the program, as previ-
ously discussed, has an impact on the eIIectiveness oI the
program. The main consideration when choosing a speciIic
method oI training is that the intensity be great enough to
stimulate an increase in stroke volume and cardiac output
and to enhance local circulation and aerobic metabolism in
the appropriate muscle groups. The exercise period must
be within the person`s tolerance, above the threshold level
Ior adaptation to occur, and below the level oI exercise that
evokes clinical symptoms.
In aerobic exercise, submaximum, rhythmic, repetitive,
dynamic exercise oI large muscle groups is emphasized.
There are Iour methods oI training that challenge the
aerobic system: continuous, interval (work relieI), circuit,
and circuit interval.
Confìnuous Jraìnìng
A submaximum energy requirement, sustained through-
out the training period, is imposed.
Once the steady state is achieved, the muscle obtains
energy by means oI aerobic metabolism. Stress is placed
primarily on the slow-twitch Iibers.
duction oI lactic acid prior to the availability oI oxygen
supplying the ATP.
Cool-0own Pcrìod
A cool-down period is necessary Iollowing the exercise
The purpose oI the cool-down period is to:
Prevent pooling oI the blood in the extremities by con-
tinuing to use the muscles to maintain venous return.
Prevent Iainting by increasing the return oI blood to the
heart and brain as cardiac output and venous return
Enhance the recovery period with the oxidation oI meta-
bolic waste and replacement oI the energy stores.
Prevent myocardial ischemia, arrhythmias, or other car-
diovascular complications.
Characteristics oI the cool-down period are similar to those
oI the warm-up period.
Total-body exercises such as calisthenics and static
stretching are appropriate.
The period should last 5 to 10 minutes.
Application oI aerobic training is summarized in Box 7.9.
Changes in the cardiovascular and respiratory systems as
well as changes in muscle metabolism occur Iollowing
endurance training. These changes are reIlected both at
rest and with exercise. It is important to note that all oI the
Iollowing training eIIects cannot result Irom one training
Cardìovascular Changcs
Changcs af Pcsf
A reduction in the resting pulse rate occurs in some indi-
viduals because oI a decrease in sympathetic drive, with
decreasing levels oI norepinephrine and epinephrine; a
decrease in atrial rate secondary to biochemical changes
in the muscles and levels oI acetylcholine, norepineph-
rine, and epinephrine in the atria; and an apparent
increase in parasympathetic (vagal) tone secondary to
decreased sympathetic tone
A decrease in blood pressure occurs in some individuals
with a decrease in peripheral vascular resistance. The
largest decrease is in systolic blood pressure and is most
apparent in hypertensive individuals.
The activity can be prolonged Ior 20 to 60 minutes with-
out exhausting the oxygen transport system.
The work rate is increased progressively as training
improvements are achieved. Overload can be accom-
plished by increasing the exercise duration.
In the healthy individual, continuous training is the most
eIIective way to improve endurance.
lnfcrval Jraìnìng
With this type oI training, the work or exercise is Iollowed
by a properly prescribed relieI or rest interval. Interval
training is perceived to be less demanding than continuous
training. In the healthy individual, interval training tends
to improve strength and power more than endurance.
The relieI interval is either a rest relieI (passive recov-
ery) or a work relieI (active recovery); and its duration
ranges Irom a Iew seconds to several minutes. Work
recovery involves continuing the exercise but at a
reduced level Irom the work period. During the relieI
period, a portion oI the muscular stores oI ATP and the
oxygen associated with myoglobin that were depleted
during the work period are replenished by the aerobic
system; an increase in
2 max
The longer the work interval, the more the aerobic sys-
tem is stressed. With a short work interval, the duration
oI the rest interval is critical iI the aerobic system is to
be stressed (a work/recovery ratio oI 1:1 to 1:5 is appro-
priate). A rest interval equal to one and a halI times the
work interval allows the succeeding exercise interval to
begin beIore recovery is complete and stresses the aero-
bic system. With a longer work interval, the duration oI
the rest is not as important.
A signiIicant amount oI high-intensity work can be
achieved with interval or intermittent work iI there is
appropriate spacing oI the workrelieI intervals. The
total amount oI work that can be completed with inter-
mittent work is greater than the amount oI work that can
be completed with continuous training.
Cìrcuìf Jraìnìng
Circuit training employs a series oI exercise activities. At
the end oI the last activity, the individual starts Irom the
beginning and again moves through the series. The series
oI activities is repeated several times.
Several exercise modes can be used involving large and
small muscle groups and a mix oI static or dynamic
Use oI circuit training can improve strength and
endurance by stressing both the aerobic and anaerobic
Cìrcuìf-lnfcrval Jraìnìng
Combining circuit and interval training is eIIective
because oI the interaction oI aerobic and anaerobic pro-
duction oI ATP.
In addition to the aerobic and anaerobic systems being
stressed by the various activities, with the relieI interval
there is a delay in the need Ior glycolysis and the pro-
C R A P J E P 7 Princiµles of Aerobic Exercise 241
An increase in blood volume and hemoglobin may occur.
This Iacilitates the oxygen delivery capacity oI the sys-
Changcs 0urìng Excrcìsc
A reduction in the pulse rate occurs in some individuals
because oI the mechanisms listed earlier in this section.
Increased stroke volume may occur because oI an
increase in myocardial contractility and an increase in
ventricular volume.
Increased cardiac output may occur as a result oI the
increased stroke volume that occurs with maximum exer-
cise but not with submaximum exercise. The magnitude
oI the change is directly related to the increase in stroke
volume and the magnitude oI the reduced heart rate.
Increased extraction oI oxygen by the working muscle
occurs in some individuals because oI enzymatic and
biochemical changes in the muscle, as well as increased
maximum oxygen uptake (
2 max
). Greater
2 max
results in a greater work capacity. The increased cardiac
output increases the delivery oI oxygen to the working
muscles. The increased ability oI the muscle to extract
oxygen Irom the blood increases the utilization oI the
available oxygen.
Decreased blood Ilow per kilogram oI the working mus-
cle may occur even though increasing amounts oI blood
are shunted to the exercising muscle. The increase in
extraction oI oxygen Irom the blood compensates Ior
this change.
Decreased myocardial oxygen consumption (pulse rate
times systolic blood pressure) Ior any given intensity oI
exercise may occur as a result oI a decreased pulse rate
with or without a modest decrease in blood pressure. The
product can be decreased signiIicantly in the healthy sub-
ject without any loss oI eIIiciency at a speciIic workload.
Pcspìrafory Changcs
Changcs af Pcsf
Larger lung volumes develop because oI improved pul-
monary Iunction, with no change in tidal volume.
Larger diIIusion capacities develop because oI larger
lung volumes and greater alveolar-capillary surIace area.
Changcs 0urìng Excrcìsc
Larger diIIusion capacities occur Ior the same reasons as
those listed previously; the maximum capacity oI venti-
lation is unchanged.
A smaller amount oI air is ventilated at the same oxygen
consumption occurs; maximum diIIusion capacity is
The maximal minute ventilation is increased.
Ventilatory eIIiciency is increased.
Mcfaholìc Changcs
Changcs af Pcsf
Muscle hypertrophy and increased capillary density
The number and size oI mitochondria are increased,
increasing the capacity to generate ATP aerobically.
The muscle myoglobin concentration increases, increas-
ing the rate oI oxygen transport and possibly the rate oI
oxygen diIIusion to the mitochondria.
Changcs 0urìng Excrcìsc
A decreased rate oI depletion oI muscle glycogen at
submaximum work levels may occur. Another term
Ior this phenomenon is glycogen sparing. It is due to
an increased capacity to mobilize and oxidize Iat and
increased Iat-mobilizing and Iat-metabolizing enzymes.
Lower blood lactate levels at submaximum work may
occur. The mechanism Ior this is unclear; it does not
appear to be related to decreased hypoxia oI the muscles.
Less reliance on phosphocreatine (PC) and ATP in skele-
tal muscle and an increased capability to oxidize carbo-
hydrate may result because oI an increased oxidative
potential oI the mitochondria and an increased glycogen
storage in the muscle.
N 0 ! L . lll heallh nay influence nelabolic adaµlalions lo
80X 7.0 0cncral 0uìdclìncs for an Acrohìc
Jraìnìng Program
- Fslablisl llc laigcl lcail ialc and maximum lcail ialc.
- Waim up giadually foi ¯ lo 10 minulcs. lncludc sliclcl-
ing and icpclilivc molions al slow spccds, giadually
incicasing llc cffoil.
- lncicasc llc pacc of llc aclivily so llc laigcl lcail ialc
can bc mainlaincd foi 20 lo 20 minulcs. Fxamplcs
includc fasl walking, iunning, bicycling, swimming,
cioss-counliy skiing, and aciobic dancing.
- Cool down foi ¯ lo 10 minulcs will slow, lolal body
icpclilivc molions and sliclcling aclivilics.
- 1lc aciobic aclivily slould bc undcilakcn llicc lo fivc
limcs pci wcck.
- 1o avoid injuiics fiom slicss, usc appiopiialc cquipmcnl,
sucl as coiiccl foolwcai, foi piopci biomcclanical sup-
poil. Avoid iunning, jogging, oi aciobic dancing on laid
suifaccs sucl as asplall and conciclc.
- 1o avoid ovciusc syndiomcs in sliucluics of llc muscu-
loskclclal syslcm, piopci waim-up and sliclcling of
musclcs lo bc uscd slould bc pcifoimcd. Piogicssion of
aclivilics slould bc willin llc lolciancc of llc individ-
ual. 0vciusc commonly occuis wlcn llcic is an incicasc
in limc oi cffoil willoul adcqualc icsl (iccovciy) limc
bclwccn scssions. lncicasc llc icpclilions oi llc limc by
no moic llan 10% pci wcck. lf pain bcgins wlilc cxci-
cising oi lasls longci llan 4 louis aflci cxcicising, lccd
llc waining and icducc llc slicss.
- lndividualizc llc piogiam of cxcicisc. All pcoplc aic nol
al llc samc filncss lcvcl and llcicfoic cannol pcifoim
llc samc cxciciscs. Any onc cxcicisc las llc polcnlial lo
bc dcliimcnlal if allcmplcd by somconc nol ablc lo cxc-
culc il piopcily. Puiing iccovciy following an injuiy oi
suigciy cloosc an cxcicisc llal docs nol slicss llc vul-
nciablc lissuc. Bcgin al a safc lcvcl foi llc individual
and piogicss as llc individual mccls llc dcsiicd goals.
0ufpafìcnf Phasc (Phasc ll}
The outpatient phase oI the program is initiated either
upon discharge Irom the hospital or, depending on the
severity oI the diagnosis, 6 to 8 weeks later. This delay
allows time Ior the myocardium to heal as well as time
to monitor the patient`s response to a new medical regi-
men. Participants are monitored via telemetry to determine
heart rate and rhythm responses; blood pressure is recor-
ded at rest and during exercise; and ventilation responses
are noted. These programs usually last 6 to 8 weeks
(Box 7.10).
The purpose oI the program is to:
Increase the person`s exercise capacity in a saIe, pro-
gressive manner so adaptive cardiovascular and mus-
cular changes occur. The early part oI the program is
reIerred to by some as 'low-level¨ exercise training.
Enhance cardiac Iunctions and reduce the cardiac cost
oI work. This may help eliminate or delay symptoms
such as angina and ST-segment changes in the patient
with coronary heart disease.
Produce Iavorable metabolic changes.
Determine the eIIect oI medications on increasing levels
oI activity.
Relieve anxiety and depression.
Progress the patient to an independent exercise program.
A symptom-limited exercise stress test is perIormed 6 to
12 weeks aIter hospital discharge (or as early as 2 to 4
weeks Iollowing discharge).
The exercise program is predominantly aerobic. Gen-
erally, Ior patients with Iunctional capacities greater than 5
METs, the exercise prescription is based on the results oI
the symptom-limited test.
0fhcr Sysfcm Changcs
Changes in other systems that occur with training include:
Decrease in body Iat
Decrease in blood cholesterol and triglyceride levels
Increased heat acclimatization
Increase in the breaking strength oI bones and ligaments
and the tensile strength oI tendons
AEP08lC C0N0lJl0NlN0 PP00PAM
Employing the principles oI aerobic conditioning in physi-
cal therapy has been most dominant in program planning
Ior the individual Iollowing a myocardial inIarction (MI)
or Iollowing coronary artery bypass surgery.
During the past 20 to 25 years, there have been major
changes in the medical management oI these patients. The
changes have included shortened hospital stays, more
aggressive progression oI activity Ior the patient Iollowing
MI or cardiac surgery, and earlier initiation oI an exercise
program based on a low-level stress test prior to discharge
Irom the hospital. An aerobic conditioning program, in
addition to risk Iactor modiIication, is a dominant part oI
cardiac rehabilitation.
lnpafìcnf Phasc (Phasc l}
The inpatient phase oI the program occurs in the hospital
Iollowing stabilization oI the patient`s cardiovascular status
aIter MI or coronary bypass surgery. Because the length oI
hospital care has decreased over the past Iew years, this
time may be limited to 3 to 5 days. When hospital stays
were longer, this phase oIten lasted 7 to 14 days and was
reIerred to as phase 1 oI the cardiac rehabilitation program.
The purpose oI the early portion oI cardiac rehabilitation
is to:
Initiate risk Iactor education and address Iuture modiIi-
cation oI certain behaviors, such as eating habits and
Initiate selI-care activities and progress Irom sitting to
standing to minimize deconditioning (1 to 3 days
Provide an orthostatic challenge to the cardiovascular
system (3 to 5 days postevent). This is usually accom-
plished by supervised ambulation. Ambulation is usually
monitored electrocardiographically, as well as manually
monitoring the heart rate, ventilation rate, and blood
Prepare patients and Iamily Ior continued rehabilitation
and Ior liIe at home aIter a cardiac event.
C R A P J E P 7 Princiµles of Aerobic Exercise 248
80X 7.10 Casc Examplc of a Cardìac
Pchahìlìfafìon Pcfcrral
Mi. Smill is icfciicd and undcigocs fuillci cvalualion lo
dclciminc llc causc of lis clcsl pain. Ec is diagnoscd will
singlc vcsscl coionaiy ailciy discasc. Ec is icfciicd lo cai-
diac iclabililalion.
- Mcdicalions. Nilioglycciin as nccdcd lo iclicvc angina.
Mi. Smill will allcnd caidiac iclabililalion llicc limcs
pci wcck foi 8 lo 12 wccks lo impiovc lis filncss lcvcl
and allcnd smoking ccssalion classcs. Ec will mccl will
a mcdical diclilian lo discuss mcal planning lo lowci lis
inlakc of fal and clolcslciol
- Fxcicisc picsciiplion. Mi. Smill will cxcicisc al an
inlcnsily lowci llan lis anginal llicslold. 1lis inlcnsily
will bc inilially cslablislcd al 60% lo 6¯% of lis maxi-
mum lcail ialc oi ¯0% of lis
2 max
. Ec will cxcicisc
llicc limcs pci wcck foi 20 lo 40 minulcs, dcpcnding
on lis lolciancc.
Intensity. The initial level oI activity or training intensity
may be as low as 40° to 60° oI the maximum heart rate
or 40° to 70° oI the Iunctional capacity deIined in METs.
The starting intensity is dictated by the severity oI the
diagnosis in concert with the individual`s age and prior Iit-
ness level. The intensity is progressed as the individual
responds to the training program.
Duration. The duration oI the exercise session may be
limited to 10 to 15 minutes at the start, progressing to 30
to 60 minutes as the patient`s status improves. Each session
usually includes 8- to 10-minute warm-up and cool-down
Frequency. Participants oIten attend sessions oIIered three
times per week.
Mode. The mode oI exercise is usually continuous, using
large muscle groups, such as stationary biking or walking.
These activities allow ECG monitoring via telemetry.
Method. Circuit-interval exercise is a common method
used with the patient during phase II. The patient can exer-
cise on each modality at a deIined workload, compared
with exercising continuously on a bicycle or treadmill.
As a result, the patient can:
PerIorm more physical work.
Exercise at a higher intensityIitness may improve
within a shorter period oI time.
Maintain lactic acid and the oxygen deIicit at minimum
Exercise at a lower rate oI perceived exertion.
Weight training. Low-level weight training may be initiat-
ed during the outpatient program, provided the individual
has undergone a symptom-limited stress test. Resistive
exercises should not produce ischemic symptoms associ-
ated with an increase in heart rate and systolic blood pres-
sure. ThereIore, heart rate and blood pressure should be
monitored periodically throughout the exercise session.
Starting weight may be calculated using 40° oI a one rep-
etition maximum (1-RM) eIIort.
Progression. Progression oI the workload occurs when
there have been three consecutive sessions (every-other-
day sessions) during which the peak heart rate is below the
target heart rate.
0ufpafìcnf Program (Phasc lll}
The outpatient phase oI cardiac rehabilitation includes a
supervised exercise conditioning program, which is oIten
continued in a hospital or community setting. Heart rate
and rhythm are no longer monitored via telemetry. Partici-
pants are reminded to monitor their own pulse rate, and a
supervisory person is available to monitor blood pressure.
The purpose oI the program is to continue to improve
or maintain Iitness levels achieved during the phase II
Recreational activities. Activities to maintain levels gained
during phase II may include:
Swimming, which incorporates both arms and legs.
However, there is a decreased awareness oI ischemic
symptoms while swimming, especially when the skill
level is poor.
Outdoor hiking, which is excellent iI on level terrain.
Activities at 8 ME1s.
Jogging approximately 5 miles per hour
Cycling approximately 12 miles per hour
Vigorous down-hill skiing.
Spccìal Consìdcrafìons
There are special considerations related to types oI exercise
and patient needs that must be recognized when developing
conditioning programs Ior patients with coronary disease.
Arm exercises elicit diIIerent responses than leg exercises.
Mechanical eIIiciency based on the ratio between output
oI external work and caloric expenditure is lower than
with leg exercises.
Oxygen uptake at a given external workload is signiIi-
cantly higher Ior arm exercises than Ior leg exercises.
Myocardial eIIiciency is lower with leg exercises than
with arm exercises.
Myocardial oxygen consumption (heart rate systolic
blood pressure) is higher with arm exercises than with
leg exercises.
P R L C A U ! l 0 N . Palienls wilh coronary disease
conµlele 86% less work wilh arn exercises lhan wilh
leq exercises before synµlons occur.
Adapfìvc Changcs
Adaptive changes Iollowing training oI individuals with
cardiac disease include:
Increased myocardial aerobic work capacity.
Increased maximum aerobic or Iunctional capacity
by predominantly widening the arteriovenous oxygen
(a VO
) diIIerence.
Increased stroke volume Iollowing high-intensity train-
ing 6 to 12 months into the training program.
Decreased myocardial demand Ior oxygen.
Increased myocardial supply by the decreased heart rate
and prolongation oI diastole.
Increased tolerance to a given physical workload beIore
angina occurs.
SigniIicantly lower heart rate at each submaximum
workload and thereIore a greater heart rate reserve.
When muscles are used that are not directly involved in
the activity, the reduction in heart rate is not as great.
Improved psychological orientation and, over time, an
impact on depression scores, scores Ior hysteria,
hypochondriasis, and psychoasthenia on the Minnesota
Multiphasic Personality Inventory.
maximum oxygen uptake, circulating blood volume,
plasma volume and red blood cells, and lean body mass
A reversal oI the negative nitrogen and protein balance
An increase in levels oI mitochondrial enzymes and
energy stores
Less use oI the anaerobic systems during activity
Adapfafìons for 0ìsahìlìfìcs, Funcfìonal
Lìmìfafìons, and 0ccondìfìonìng
Individuals who have a physical disability or Iunctional
limitation should not be excluded Irom a conditioning
program that can increase their Iitness level. This includes
individuals in wheelchairs or persons who have problems
ambulating, such as those with paraplegia, hemiplegia, or
amputation, and those with an orthopedic problem, such
as arthrodesis.
Adaptations must be made when testing the physically
disabled using a wheelchair treadmill or more Irequently
using the upper extremity ergometer.
Exercise protocols may emphasize upper extremities and
manipulation oI the wheelchair.
It is important to remember that energy expenditure is
increased when the gait is altered, and wheelchair use is
less eIIicient than walking without impairment.
lmpaìrmcnfs, 0oals, and Plan of Carc
The goals oI an aerobic exercise program are dependent on
the initial level oI Iitness oI the individual and on his or her
speciIic clinical needs. The general goals are to decrease
the deconditioning eIIects oI disease and chronic illness
and to improve the individual`s cardiovascular and muscu-
lar Iitness.
Common lmpaìrmcnfs
Increased susceptibility to thromboembolic episodes,
pneumonia, atelectasis, and the likelihood oI Iractures
Tachycardia, dizziness, and orthostatic hypotension
when moving Irom sitting to standing
A decrease in general muscle strength, with diIIiculty
and shortness oI breath in climbing stairs
A decrease in work capacity that limits distances walked
and activities tolerated
Increased heart rate and blood pressure responses
(ratepressure product) to various activities
A decrease in the maximum ratepressure product toler-
ated with angina or other ischemic symptoms appearing
at low levels oI exercise
Prevention oI thromboembolic episodes, pneumonia,
atelectasis, and Iractures
Decrease in the magnitude oI the orthostatic hypotensive
Ability to climb stairs saIely and without shortness oI
N 0 ! L : Cardiovascular conµlicalions are µrevenled andjor
reduced if lhe µroqran includes aµµroµriale seleclion of
µalienls, conlinuous evalualion of each µalienl, nedical
suµervision of lhe exercise lhrouqhoul lhe lraininq µeriod,
reqular connunicalion wilh lhe µhysician, sµecific inslruc-
lions lo µalienls aboul adverse synµlons, class size linila-
lions lo 80 or fewer µalienls, and nainlenance of accurale
records relaled lo conµliance lo lhe µroqran.
Deconditioned individuals, including those with chronic
illness and the elderly may have major limitations in pul-
monary and cardiovascular reserve that severely curtail
their daily activities.
Deconditioning. Implications oI the changes due to decon-
ditioning brought on by inactivity resulting Irom any ill-
ness or chronic disease are important to remember.
There is decreased work capacity, which is a result
oI decreased maximum oxygen uptake and decreased
ability to use oxygen and perIorm work. There is also
decreased cardiac output, which is the major limiting
There is decreased circulating blood volume that can be
as much as 700 to 800 mL. For some individuals, this
results in tachycardia along with orthostatic hypotension,
dizziness, and episodes oI syncope when initially
attempting to stand.
There is a decrease in plasma and red blood cells, which
increases the likelihood oI liIe-threatening embothrom-
bolic episodes and prolongation oI the convalescent
There is a decrease in lean body mass, which results in
decreased muscle size and decreased muscle strength
and ability to perIorm activities requiring large muscle
groups. For example, the individual may have diIIiculty
walking with crutches or climbing stairs.
There is increased excretion oI urinary calcium, which
results Irom a decrease in the weight-bearing stimulus
critical in maintaining bone integrity, in bone loss or
osteoporosis, and in an increased likelihood oI Iractures
upon Ialling because oI osteoporosis.
Reversal of deconditioning. Through an exercise program,
the negative cardiovascular, neuromuscular, and metabolic
Iunctions can be reversed. This results in:
A decrease in the resting heart rate, the heart rate with
any given exercise load, and urinary excretion oI calcium
An increase in stroke volume at rest, stroke volume with
exercise, cardiac output with exercise, total heart vol-
ume, lung volume (ventilatory volume), vital capacity,
C R A P J E P 7 Princiµles of Aerobic Exercise 245
Tolerance Ior walking longer measured distances and
completing activities without Iatigue or symptoms
Decrease in the heart rate and blood pressure (ratepres-
sure product) at a given level oI activity
An increase in the maximum ratepressure product toler-
ated without ischemic symptoms
Improved pulmonary, cardiovascular, and metabolic
response to various levels oI exercise
Improved ability to complete selected activities with
appropriate heart rate and blood responses to exercise
Guidelines Ior establishing a saIe program oI intervention
Ior the deconditioned individual and the convalescent
patient with chronic illness are summarized in Boxes
7.11 and 7.12.
DiIIerences in endurance and physical work capacity
among children, young adults, and middle-aged or elderly
individuals are evident. Some comparisons are made
between maximum oxygen uptake and the Iactors inIluenc-
ing it and among blood pressure, respiratory rate, vital
capacity, and maximum voluntary ventilation in the diIIer-
ent age categories. It is important when developing aerobic
conditioning programs that these age-related diIIerences
are taken into consideration.
Between the ages oI 5 and 15 there is a threeIold increase
in body weight, lung volume, heart volume, and maximum
oxygen uptake.
Rcarf Pafc
Resting heart rate is on the average above 125 (126 in
girls, 135 in boys) at inIancy.
Resting heart rate drops to adult levels at puberty.
Maximum heart rate is age-related (220 minus age).
Sfrokc volumc
Stroke volume is closely related to size.
Children 5 to 16 years oI age have a stroke volume oI 30
to 40 mL.
Cardìac 0ufpuf
Cardiac output is related to size.
Cardiac output increases with increasing stroke vol-
The increase in cardiac output Ior a given increase in
oxygen consumption is a constant throughout liIe: It is
the same in the child as in the adult.
Arfcrìovcnous 0xygcn 0ìffcrcncc
Children tolerate a larger a VO
diIIerence than
The larger a VO
diIIerence makes up Ior the smaller
stroke volume.
80X 7.11 0uìdclìncs for lnìfìafìng an
Acrohìc Excrcìsc Program for fhc
0ccondìfìoncd lndìvìdual and fhc
Pafìcnf wìfh Chronìc lllncss
- Pclciminc llc cxcicisc lcail ialc icsponsc llal can bc
safcly icaclcd using llc Kaivoncn foimula as a guidc,
accounling foi mcdical condilions, mcdicalions, and llc
individual`s pciccivcd cxcilion.
- lnilialc a piogiam of aclivilics foi llc palicnl llal docs
nol clicil a caidiovasculai icsponsc ovci llc cxcicisc
lcail ialc (c.g., walking, icpclilivc aclivilics, casy calis-
- Piovidc palicnls will clcaily wiillcn insliuclions aboul
any aclivily llcy pcifoim on llcii own.
- lnilialc an cducalional piogiam llal piovidcs llc palicnl
will infoimalion aboul cffoil symploms and cxcicisc
piccaulions, moniloiing llc lcail ialc, and modificalions
wlcn indicalcd.
80X 7.12 0uìdclìncs for Progrcssìon of an
Acrohìc Jraìnìng Program
- Pclciminc llc maximum lcail ialc oi symplom-limilcd
lcail ialc by mullislagc lcsling will FCC moniloiing.
- Pccidc on llc llicslold slimulus (pciccnlagc of maxi-
mum oi symplom-limilcd lcail ialc) llal clicils a con-
dilioning icsponsc foi llc individual lcslcd and llal can
bc uscd as llc cxcicisc lcail ialc.
- Pclciminc llc inlcnsily, duialion, and ficqucncy of cxci-
cisc llal icsulls in allaining llc cxcicisc lcail ialc and a
condilioning icsponsc.
- Pclciminc llc modc of cxcicisc lo bc uscd bascd on llc
individual`s plysical capabililics and inlcicsl.
- lnilialc an cxcicisc piogiam will llc palicnl and piovidc
clcaily wiillcn insliuclions icgaiding llc dclails of llc
- Fducalc llc palicnl aboul.
- Fffoil symploms and llc nccd lo ccasc oi modify cxci-
cisc wlcn llcsc symploms appcai and lo communicalc
will llc plysical llciapisl and|oi plysician aboul
llcsc pioblcms.
- Moniloiing lcail ialc al icsl as wcll as duiing and
following cxcicisc.
- 1lc impoilancc of cxcicising willin llc guidclincs
piovidcd by llc plysical llciapisl.
- 1lc impoilancc of consislcnl long-lcim follow-up
aboul llc cxcicisc piogiam so il can bc piogicsscd
willin safc limils.
- 1lc impoilancc of modifying iisk faclois iclalcd lo
caidiac pioblcms.
Sfrokc volumc
The adult values Ior stroke volume are 60 to 80 mL (75
mL in a sitting, sedentary young man).
With maximum exercise, stroke volume is 100 mL in
that same sedentary young man.
Cardìac 0ufpuf for fhc Scdcnfary Young Man af Pcsf
Cardiac output at rest is 75 beats per minute 75 mL,
or 5.6 liters per minute.
With maximum exercise, cardiac output is 190 beats per
minute 100 mL, or 19 liters per minute.
Arfcrìovcnous 0xygcn 0ìffcrcncc (a v0
Approximately 25° to 30° oI the oxygen is extracted
Irom blood as it runs through the muscles or other tis-
sues at rest.
In a normal, sedentary young man, it increases threeIold
(5.2 to 15.8 mL/dL blood) with exercise.
Maxìmum 0xygcn upfakc
The diIIerence in
2 max
between males and Iemales is
greatest in the adult.
DiIIerences in
2 max
between the sexes is minimal
2 max
is expressed relative to lean body weight.
In the sedentary young man, maximum oxygen uptake
equals 3000 mL/min (oxygen uptake at rest equals 300
8lood Prcssurc
Systolic blood pressure is 120 mm Hg (average). At peak
eIIort during exercise, values may range Irom as low as
190 mm Hg to as high as 240 mm Hg.
Diastolic blood pressure is 80 mm Hg (average). Dias-
tolic pressure does not change markedly with exercise.
Respiratory rate is 12 to 15 breaths per minute.
Vital capacity is 4800 mL in a man 20 to 30 years oI age.
Maximum voluntary ventilation varies considerably Irom
laboratory to laboratory and is dependent on age and the
surIace area oI the body.
Musclc Mass and Sfrcngfh
Muscle mass increases with training as a result oI hyper-
trophy. This hypertrophy can be the result oI an
increased number oI myoIibrils, increased actin and
myosin, sarcoplasm, and/or connective tissue.
Limited evidence suggests that the number oI muscle
Iibers may increase, reIerred to as hyperplasia.
As the nervous system matures, increased recruitment oI
motor units or decreased autogenic inhibition by Golgi
tendon organs appears also to dictate strength gains.
Anacrohìc Ahìlìfy
Anaerobic training increases the activity oI several con-
trolling enzymes in the glycolytic pathway and enhances
stored quantities oI ATP and phosphocreatine.
Maxìmum 0xygcn upfakc (
2 max
The VO
2 max
increases with age up to 20 years (expressed
as liters per minute).
BeIore puberty, girls and boys show no signiIicant diIIer-
ence in maximum aerobic capacity.
Cardiac output in children is the same as in the adult Ior
any given oxygen consumption.
Endurance times increase with age until 17 to 18 years.
8lood Prcssurc
Systolic blood pressure increases Irom 40 mm Hg at birth
to 80 mm Hg at age 1 month to 100 mm Hg several years
beIore puberty. Adult levels are observed at puberty.
Diastolic blood pressure increases Irom 55 to 70 mm Hg
Irom 4 to 14 years oI age, with little change during ado-
Respiratory rate decreases Irom 30 breaths per minute at
inIancy to 16 breaths per minute at 17 to 18 years oI age.
Vital capacity and maximum voluntary ventilation are
correlated with height, although the greater increase in
boys than girls at puberty may be due to an increase in
lung tissue.
Musclc Mass and Sfrcngfh
Muscle mass increases through adolescence, primarily
owing to muscle Iiber hypertrophy and the development
oI sarcomeres. Sarcomeres are added at the musculo-
tendinous junction to compensate Ior the required
increase in length.
Girls develop peak muscle mass between 16 and 20
years, whereas boys develop peak muscle mass between
18 and 25 years.
Strength gains are associated with increased muscle
mass in conjunction with neural maturation.
Anacrohìc Ahìlìfy
Children generally demonstrate a limited anaerobic
capacity. This may be due to a limited amount oI phos-
phoIructokinase, a controlling enzyme in the glycolytic
Children produce less lactic acid when perIorming
anaerobically. This may be due to a limited glycolytic
Young Adulfs
There are more data on the physiological parameters oI Iit-
ness Ior the young and middle-aged adult than Ior children
or the elderly.
Rcarf Pafc
Resting heart rate reaches 60 to 65 beats per minute at
17 to 18 years oI age (75 beats per minute in a sitting,
sedentary young man).
Maximum heart rate is age-related (190 beats per minute
in the same sedentary young man).
C R A P J E P 7 Princiµles of Aerobic Exercise 247
Anaerobic training increases the muscle`s ability to
buIIer the hydrogen ions released when lactic acid is
produced. Increased buIIering allows the muscle to
work anaerobically Ior longer periods oI time.
0ldcr Adulfs
With increasing interest in the aged, data are appearing
in the literature about this age group and their response to
Rcarf Pafc
Resting heart rate is not inIluenced by age.
Maximum heart rate is age-related and decreases with
age (in very general terms, 220 minus age). The average
maximum heart rate Ior men 20 to 29 years oI age is 190
beats/min. For men 60 to 69 years oI age, it is 164
The amount that the heart rate increases in response to
static and maximum dynamic exercise (hand grip)
decreases in the elderly.
Sfrokc volumc
Stroke volume decreases in the aged and results in
decreased cardiac output.
Cardìac 0ufpuf
Cardiac output decreases on an average oI 7.0 to 3.4 liters
per minute Irom age 19 to 86 years.
a vo
Arteriovenous oxygen diIIerence decreases as a result
oI decreased lean body mass and low oxygen-carrying
Maxìmum 0xygcn upfakc
According to cardiorespiratory Iitness classiIication, iI
men 60 to 69 years oI age oI average Iitness level are
compared with men 20 to 29 years oI age oI the same
Iitness level, the maximum oxygen uptake Ior the older
man is lower.
· 20 to 29 years: 31 to 37 mL/kg per minute
· 60 to 69 years: 18 to 23 mL/kg per minute
Aerobic capacity decreases about 10° per decade when
evaluating sedentary men. Maximum oxygen consump-
tion decreases on an average Irom 47.7 mL/kg per
minute at age 25 years to 25.5 mL/kg per minute at
age 75 years. This decrease is not directly the result
oI age; athletes who continue exercising have signiIi-
cantly less decrease in
2 max
when evaluated over a
10-year period.
8lood Prcssurc
Blood pressure increases because oI increased peripheral
vascular resistance.
Systolic blood pressure oI the aged is 150 mm Hg
Diastolic blood pressure is 90 mm Hg (average).
II the deIinition oI high blood pressure (stage II hyper-
tension) is 160/100, then 22° oI men and 34° oI
women 65 to 74 years oI age are hypertensive
Using 150/95 mm Hg as a cutoII, 25° oI individuals are
hypertensive at age 50 years and 70° between the ages
oI 85 and 95 years.
Respiratory rate increases with age.
Vital capacity decreases with age. There is a 25°
decrease in the vital capacity oI the 50- to 60-year-old
man compared with the 20- to 30-year-old man with the
same surIace area.
Maximum voluntary ventilation decreases with age.
Musclc Mass and Sfrcngfh
Generally, the strength decline with age is associated
with a decrease in muscle mass and physical activity.
The decrease in muscle mass is primarily due to a
decrease in protein synthesis, in concert with a decline in
the number oI Iast-twitch muscle Iibers.
Aging may also aIIect strength by slowing the nervous
system`s response time. This may alter the ability to
recruit motor units eIIectively.
Continued training as one ages appears to reduce the
eIIects oI aging on the muscular system.
l h 0 E P E h 0 E h ! L E A P h l h 6 A C ! l v l ! l E S
Crìfìcal Jhìnkìng and 0ìscussìon
1. A 16-year-old cross-country runner is reIerred to the
clinic where you are employed with the diagnosis oI a
right ankle sprain. You examine and evaluate him and
develop a treatment plan Ior the ankle. You must also
address his desire to return to competition when able.
· Discuss the energy systems utilized with distance
· Discuss the notion oI sport speciIicity.
· What aerobic exercises could the patient do to maintain
his aerobic condition while his ankle heals but not
stress the ankle?
2. You are an invited speaker at a senior citizen center Ior a
lunchtime discussion oI liIetime Iitness and establishing
an appropriate exercise program Ior individuals in this
age category.
· Discuss the deIinition oI Iitness.
· Discuss the concept oI the exercise prescription.
· Describe the necessary precautions when dealing with
the older population (both the older athlete and the
untrained individual).
3. Explain the concepts oI energy expenditure, oxygen con-
sumption, and eIIiciency with regard to ambulating with
an assistive device with each oI these diagnoses:
5. You have been invited to speak to a group oI elementary
and preschool teachers about the importance oI aerobic
exercise Ior children. Explain the basic physiological
diIIerences between children and adults at rest with
regard to heart rate, respiratory rate and metabolism, and
their response to exercise.
rheumatoid arthritis, post-tibial Iracture, and post-
total-hip replacement.
4. Design an exercise program Ior the local Iire Iighters.
Utilize the concepts oI the aerobic energy systems,
anaerobic energy system, and strength training.
C R A P J E P 7 Princiµles of Aerobic Exercise 240
R L l L R L N C L S
1. American College oI Sports Medicine: Exercise Management Ior Per-
sons with Chronic Diseases and Disabilities, ed 2. Human Kinetics,
Champaign, IL, 2003.
2. American College oI Sports Medicine: ASCM`s Guidelines Ior Exer-
cise Testing and Prescription, ed 7. Lippincott Williams, & Wilkins,
Philadelphia, 2005.
3. American College oI Sports Medicine: Resource Manual Ior Guidelines
Ior Exercise Testing and Prescription, ed 5. Lippincott Williams &
Wilkins, Philadelphia, 2005.
4. Brannon, FJ, Foley, MW, Starr, JA, Saul, LM: Cardiopulmonary Reha-
bilitation: Basic Theory and Application, ed 3. FA Davis, Philadelphia,
5. Center Ior Disease Control and Prevention. Physical Activity Ior Every-
one: Recommendations |website|. Available at:
htm. Accessed March 2006.
6. Hillegass, S, Sadowsky, H: Essentials oI Cardiopulmonary Physical
Therapy, ed 2. WB Saunders, Philadelphia, 2001.
7. Irwin, S, Teckline, JS: Cardiopulmonary Physical Therapy, ed 4. CV
Mosby, St. Louis, 2004.
8. McArdle, WD, Katch, FI, Katch VL: Essentials oI Exercise Physiolo-
gy, ed 3. Lippincott Williams & Wilkins, Philadelphia, 2005.
9. McArdle, WD, Katch, FI, Katch, VL: Exercise Physiology: Energy,
Nutrition, and Human PerIormance, ed 5. Lippincott Williams &
Wilkins, Philadelphia, 2001.
10. Pollock M, Gaesser G, Butcher J, et al. The recommended quantity
and quality oI exercise Ior developing and maintaining cardiorespira-
tory and muscular Iitness, and Ilexibility in healthy adults. Med Sci
Sports Exerc 30(6):975991, 1998.
11. Powers, SK, Howley, ET: Exercise Physiology: Theory and Applica-
tion, ed 4. McGraw-Hill, Boston, 2001.
12. Thompson P, Buchner D, Pina I, et al. Exercise and Physical Activity
in the Prevention and Treatment oI Atherosclerotic Cardiovascular Dis-
ease: AHA ScientiIic Statement. Circulation 107(24):31093116,
lxerclse lor lmpalred Balance
8alancc: Kcy Jcrms and 0cfìnìfìons 251
8alancc Confrol 252
Scnsory Sysfcms and 8alancc Confrol 258
Mofor Sfrafcgìcs for 8alancc Confrol 254
8alancc Confrol undcr varyìng Condìfìons 258
Scnsory lnpuf lmpaìrmcnfs 258
Scnsorìmofor lnfcgrafìon 250
8ìomcchanìcal and Mofor 0ufpuf 0cfìcìfs 250
0cfìcìfs wìfh Agìng 250
0cfìcìfs from Mcdìcafìons 280
Examìnafìon and Evaluafìon of lmpaìrcd
8alancc 280
8alancc Jraìnìng 281
Rcalfh and Envìronmcnfal Facfors 285
Evìdcncc-8ascd 8alancc Excrcìsc Programs 285
Jaì Chì for 8alancc Jraìnìng 288
Loss oI balance and Ialling are problems that aIIect indi-
viduals with a wide range oI diagnoses. Physical therapists
commonly evaluate balance and use balance training/exer-
cises as either primary or secondary interventions Ior
patients undergoing many types oI rehabilitation programs.
Because oI the importance oI balance assessment and treat-
ment in clinical practice, The Guiae to Phvsical Therapist
Practice (2001)
has designated an entire preIerred practice
pattern (pattern 5A) to primary prevention/risk reduction
Ior loss oI balance and Ialling. The purpose oI this chapter
is to present an overview oI key background terms and
concepts related to balance, how balance control is normal-
ly achieved in humans Ior a variety oI conditions, possible
causes oI balance impairments, and evidence-based assess-
ments and interventions Ior enhancing all aspects oI an
individual`s balance control.
8alancc: Kcy Jcrms and 0cfìnìfìons
Balance, or postural stability, is a generic term used to
describe the dynamic process by which the body`s position
is maintained in equilibrium. Equilibrium means that the
body is either at rest (static equilibrium) or in steady-state
motion (dynamic equilibrium). Balance is greatest when
the body`s center oI mass (COM) or center oI gravity
(COG) is maintained over its base oI support (BOS).
Center of mass. The COM is a point that corresponds to
the center oI the total body mass and is the point where the
body is in perIect equilibrium. It is determined by Iinding
the weighted average oI the COM oI each body segment.
Center of gravity. The COG reIers to the vertical projec-
tion oI the center oI mass to the ground. In the anatomical
position, the COG oI most adult humans is located slightly
anterior to the second sacral vertebra
or approximately
55° oI a person`s height.
Momentum. Momentum is the product oI mass times
velocity. Linear momentum relates to the velocity oI the
body along a straight path, Ior example in the sagittal or
transverse planes. Angular momentum relates to the rota-
tional velocity oI the body.
Base of support. The BOS is deIined as the perimeter oI
the contact area between the body and its support surIace;
Ioot placement alters the BOS and changes a person`s pos-
tural stability.
A wide stance, such as is seen with many
elderly individuals, increases stability, whereas a narrow
BOS, such as tandem stance or walking, reduces it. So
long as a person maintains the COG within the limits oI
the BOS, reIerred to as the limits of stabilitv, he or she
does not Iall.
Limits of stability. 'Limits oI stability¨ reIers to the sway
boundaries in which an individual can maintain equilibri-
um without changing his or her BOS (Fig. 8.1).
C h A P ! L R
Annc 0. K|oos, P1, Ph0, NCS
0cborah 0Ivcns HcIss, P1, Ph0, 0P1, 0CS
boundaries are constantly changing depending on the task,
the individual`s biomechanics, and aspects oI the environ-
For example, the limits oI stability Ior a person
during quiet stance is the area encompassed by the outer
edges oI the Ieet in contact with the ground. Any devia-
tions in the body`s COM position relative to this boundary
are corrected intermittently, producing a random swaying
motion. For normal adults, the anteroposterior sway limit
is approximately 12 Irom the most posterior to most ante-
rior position.
Lateral stability varies with Ioot spacing
and height; adults standing with 4 inches between the Ieet
can sway approximately 16 Irom side to side.
a person sitting without trunk support has much greater
limits oI stability than when standing because the height oI
the COM above the BOS is less and the BOS is much larg-
er (i.e., perimeter oI the buttocks in contact with a surIace).
Cround reaction force and center of pressure. In accor-
dance with Newton`s law oI reaction, the contact between
our bodies and the ground due to gravity (action Iorces) is
always accompanied by a reaction Irom it, the so-called
ground reaction Iorce.
The center oI pressure (COP) is the location oI the
vertical projection oI the ground reaction Iorce.
It is
equal and opposite to the weighted average oI all the
downward Iorces acting on the area in contact with the
ground. II one Ioot is on the ground, the net COP lies with-
in that Ioot. When both Ieet are on the ground, the net COP
lies somewhere between the two Ieet, depending on how
much weight is taken by each Ioot. When both Ieet are in
contact, the COP under each Ioot can be measured sepa-
rately. To maintain stability, a person produces muscular
Iorces to continually control the position oI the COG,
which in turn changes the location oI the COP. Thus the
COP is a reIlection oI the body`s neuromuscular responses
to imbalances oI the COG.
A Iorce plate is traditionally
used to measure ground reaction Iorces |in newtons (N)|
and COP movements |in meters (m)|.
8alancc Confrol
Balance is a complex motor control task involving the
detection and integration oI sensory inIormation to assess
the position and motion oI the body in space and the exe-
cution oI appropriate musculoskeletal responses to control
body position within the context oI the environment and
task. Thus, balance control requires the interaction oI the
nervous and musculoskeletal systems and contextual
eIIects (Fig. 8.2).
Standing Walking Sitting
Fl0uPE 8.1 boundar|es o¦ ¦|e ||u|¦s o¦ s¦au|||¦, w|||e
s¦and|nç, wa|||nç, and s|¦¦|nç.
Range of motion
Sensation Muscle
Fl0uPE 8.2 ln¦erac¦|ons o¦ ¦|e uuscu|os|e|e¦a| and nerv-
ous s,s¦eus and con¦ez¦ua| e¦¦ec¦s ¦or ua|ance con¦ro|.
stress), and skin mechanoreceptors (sensitive to vibration,
light touch, deep pressure, skin stretch) are the dominant
inputs Ior maintaining balance when the support surIace is
Iirm, Ilat, and Iixed. However, when standing on a surIace
that is moving (e.g., on a boat) or on a surIace that is not
horizontal (e.g., on a ramp), inputs about body position
with respect to the surIace are not appropriate Ior main-
taining balance; thereIore, a person must rely on other
sensory inputs Ior stability in these conditions.
InIormation Irom joint receptors does not contribute
greatly to conscious joint position sense. It has been
demonstrated that local anesthetization oI joint tissues
and total joint replacement does not impair joint position
Muscle spindle receptors appear to be most-
ly responsible Ior providing joint position sense, whereas
the primary role oI joint receptors is to assist the gamma
motor system in regulating muscle tone and stiIIness to
provide anticipatory postural adjustments and to counteract
unexpected postural disturbances.
vcsfìhular Sysfcm
The vestibular system provides inIormation about the posi-
tion and movement oI the head with respect to gravity and
inertial Iorces. Receptors in the semicircular canals (SCCs)
detect angular acceleration oI the head, whereas the recep-
tors in the otoliths (utricle and saccule) detect linear accel-
eration and head position with respect to gravity. The
SCCs are particularly sensitive to Iast head movements,
such as during walking or during episodes oI imbalance
(slips, trips, stumbles), whereas the otoliths respond to
slow head movements, such as during postural sway.
By itselI, the vestibular system can give no inIorma-
tion about the position oI the body. For example, it cannot
distinguish a simple head nod (head movement on a stable
trunk) Irom a Iorward bend (head movement in conjunc-
tion with a moving trunk).
Consequently, additional
inIormation, particularly Irom mechanoreceptors in the
neck, must be provided Ior the central nervous system
(CNS) to have a true picture oI the orientation oI the head
relative to the body.
The vestibular system uses motor
pathways originating Irom the vestibular nuclei Ior postural
control and coordination oI eye and head movements. The
vestibulospinal reIlex brings about postural changes to
compensate Ior tilts and movements oI the body through
vestibulospinal tract projections to antigravity muscles at
all levels oI the spinal cord. The vestibulo-ocular reIlex sta-
bilizes vision during head and body movements through
projections Irom the vestibular nuclei to the nuclei that
innervate extraocular muscles.
Scnsory 0rganìzafìon for 8alancc Confrol
Vestibular, visual, and somatosensory inputs are normally
combined seamlessly to produce our sense oI orientation
and movement.
Incoming sensory inIormation is integrat-
ed and processed in the cerebellum, basal ganglia, and sup-
plementary motor area.
Somatosensory inIormation has
the Iastest processing time Ior rapid responses, Iollowed by
visual and vestibular inputs.
When sensory inputs Irom
one system are inaccurate owing to environmental condi-
The nervous svstem provides the (1) sensory processing
Ior perception oI body orientation in space provided
mainly by the visual, vestibular, and somatosensory sys-
tems; (2) sensorimotor integration essential Ior linking
sensation to motor responses and Ior adaptive and antici-
patory (i.e., centrally programmed postural adjustments
that preceed voluntary movements) aspects oI postural
control; and (3) motor strategies Ior planning, program-
ming, and executing balance responses.
Musculoskeletal contributions include postural align-
ment, musculoskeletal Ilexibility such as joint range
oI motion (ROM), joint integrity, muscle perIormance
(i.e., muscle strength, power, and endurance), and sen-
sation (touch, pressure, vibration, proprioception, and
Contextual effects that interact with the two systems are
the environment whether it is closed (predictable with no
distractions) or open (unpredictable and with distrac-
tions), the support surIace (i.e., Iirm versus slippery,
stable versus unstable, type oI shoes), the amount oI
lighting, eIIects oI gravity and inertial Iorces on the
body, and task characteristics (i.e., well learned versus
new, predictable versus unpredictable, single versus
multiple tasks).
Even iI all elements oI the neurological and muscu-
loskeletal systems are operating eIIectively, a person may
Iall iI contextual eIIects Iorce the balance control demands
to be so high that the person`s internal mechanisms are
Scnsory Sysfcms and 8alancc Confrol
Perception oI one`s body position and movement in space
require a combination oI inIormation Irom peripheral
receptors in multiple sensory systems including the visual,
somatosensory (proprioceptive, joint, and cutaneous recep-
tors), and vestibular systems.
vìsual Sysfcm
The visual system provides inIormation regarding (1) the
position oI the head relative to the environment; (2) the
orientation oI the head to maintain level gaze; and (3) the
direction and speed oI head movements because as your
head moves, surrounding objects move in the opposite
direction. Visual stimuli can be used to improve a person`s
stability when proprioceptive or vestibular inputs are unre-
liable by Iixating the gaze on an object. Conversely, visual
inputs sometimes provide inaccurate inIormation Ior bal-
ance control, such as when a person is stationary and a
large object such as a nearby bus starts moving, causing
the person to have an illusion oI movement.
Somafoscnsory Sysfcm
The somatosensory system provides inIormation about the
position and motion oI the body and body parts relative to
each other and the support surIace. InIormation Irom mus-
cle proprioceptors including muscle spindles and Golgi
tendon organs (sensitive to muscle length and tension),
joint receptors (sensitive to joint position, movement, and
C R A P J E P 8 Exercise for lnµaired 8alance 258
tions or injuries that decrease the inIormation-processing
rate, the CNS must suppress the inaccurate input and select
and combine the appropriate sensory inputs Irom the other
two systems. This adaptive process is called sensorv
organi:ation. Most individuals can compensate well iI one
oI the three systems is impaired; thereIore, this concept is
the basis Ior many treatment programs.
Jypcs of 8alancc Confrol
Functional tasks require diIIerent types oI balance control,
including (1) static balance control to maintain a stable
antigravity position while at rest such as when standing and
sitting; (2) avnamic balance control to stabilize the body
when the support surIace is moving or when the body is
moving on a stable surIace such as sit-to-stand transIers or
walking; and (3) automatic postural reactions to maintain
balance in response to unexpected external perturbations,
such as standing on a bus that suddenly accelerates Iorward.
Feeaforwara, or open loop motor control, is utilized
Ior movements that occur too Iast to rely on sensory Ieed-
back (e.g., reactive responses) or Ior anticipatory aspects oI
postural control. Anticipatorv control involves activation oI
postural muscles in advance oI perIorming skilled move-
ments, such as activation oI posterior leg and back extensor
muscles prior to a person pulling on a handle when stand-
or planning how to navigate to avoid obstacles in the
environment. Closea loop control is utilized Ior precision
movements that require sensory Ieedback (e.g., maintain-
ing balance while sitting on a ball or standing on a balance
Mofor Sfrafcgìcs for 8alancc Confrol
To maintain balance, the body must continually adjust its
position in space to keep the COM oI an individual over
the BOS or to bring the COM back to that position aIter a
perturbation. Horak and Nashner
described three primary
movement strategies used by healthy adults to recover bal-
ance in response to sudden perturbations oI the supporting
surIace (i.e., brieI anterior or posterior platIorm displace-
ments) called ankle, hip, and stepping strategies (Fig. 8.3).
Factors that determine which strategy most eIIectively
addresses a balance disturbance are identiIied in Box 8.1.
Results oI research examining the patterns oI muscle activ-
ity underlying these movement strategies suggest that pre-
programmed muscle synergies comprise the Iundamental
movement unit used to restore balance.
A synergy is
a Iunctional coupling oI groups oI muscles so they must
act together as a unit; this organization greatly simpliIies
the control demands oI the CNS.
The CNS uses three movement systems to regain
balance aIter the body is perturbed: reIlex, automatic, and
voluntary systems. Table 8.1 summarizes the key character-
istics oI reIlexes, automatic postural responses, and volun-
tary movements.
'Stretch¨ reflexes mediated by the spinal
cord comprise the Iirst response to external perturbations.
They have the shortest latencies ( 70 ms), are independ-
80X 8.1 Facfors lnflucncìng Sclccfìon
of 8alancc Sfrafcgìcs
- Spccd and inlcn