PASSIVCE RANGE OF MOTION

EXERCISES
 Introduction
To maintain normal ROM, it important to move the segments through their available joint range or muscle range periodically.

Factors leads to decreased ROM:

1- systemic

2- Joint

3- neurologic

4- muscular

5- surgical or traumatic insult

6- inactivity or immobilization
Types of ROM Exercises
 PASSIVE MOVEMENT

Movement within the unrestricted ROM produced by an external force, during which, there is little to or no voluntary muscular contraction. The external

force may be gravity, a machine, physical therapist, or another part of the individual’s own body.

CLASSIFICATION OF PASSIVE MOVEMENT

1- Relaxed manual Passive Movements, including accessory movements.

2- Forced Passive Movements including Joint Mobilization & Manipulation.

3- Mechanical Passive Movements including Continuous Passive Movements (CPM)

Indications:

1- In acute, inflamed tissues, where active movements is painful

2- In comatose, paralytic, or complete bed redden patient.

3- In muscle re-education as a first step

4- in relaxation
Goals of Passive movement

1- Maintain joint and connective tissue mobility

2- Maintain the physiological properties of the muscle (extensibility, elasticity, etc.)

and minimize the formation of contracture.

3- assist circulation and enhance synovial movement and diffusion of materials in

the joint

4- Maintain range of motion and prevent formation of adhesions

Limitations of PROM

Passive ROM will not:

1- Prevent muscle atrophy

2- Increase muscle strength and endurance

3- Assist circulation as active exercises

Precautions and Contraindications to PROM

1- Immediately after acute tears, fractures, and surgery.

2- Signs of too much effusion or swelling.

3- Sever sharp and acute joint pain

4- When motion disruptive to the healing process.

5- When bony block limits joint motions

6- acute infection around or in the joint ( arthritis)

 PRINCIPLES OF RELAXED PASSIVE Movement

1-Relaxation:

A brief explanation of the procedure is given to the patient, who is asked to relax as much as possible. The selection of a

suitable starting position ensures comfort and support. Describe the plane and method to meet the goals. Free the region

from restrictive clothing, linen, splint and dressing.

2-Fixation:

Good fixation near the joint to be moved as close to the joint line as possible to ensure that the movement is localized to that

joint, and to control movement.

3-Support:

Full and comfortable support to the moved part and to the areas of poor structural integrity such as a hypermobile joint or paralyzed limb segment, so

that the patient has confidence and will remain relaxed. The physiotherapist grasps the part firmly but comfortably in his hand, or it may be

supported by axial suspension in slings.

4-Traction:

Many joints allow the articular surfaces to be drawn apart by traction, which is always given in the long axis of a joint, the fixation of the bone

proximal to the joint providing an opposing force to a sustained pull on the distal bone. Traction is thought to facilitate the movement by

reducing inter- articular friction.

5-Range:

Move the segment through its complete pain –free range to point of tissue In normal joints slight over pressure can be given to ensure full

range, but in flail joint care is needed to avoid taking the movement beyond the normal anatomical limit.

6-Speed and Duration:

As it is essential that relaxation is maintained throughout the movement, the speed must be slowly, smoothly and rhythmically. The number of

repetitions depends on the objectives of the program and the patient's condition.
 Forced Passive Movements

Joint Mobilization & Manipulation

Joint Mobilization & Manipulation are passive, skilled manual therapy techniques applied to joints and related soft tissues at varying

speeds and amplitudes using physiologic or accessory motion to restore or maintain joint ROM and to treat pain.

According to the varying speeds and amplitudes, Joint Mobilization can be divided into:

1- Mobilization: is a passive low-velocity, high –amplitude motion performed by the therapist such that the patient can stop it. The

technique may be applied with

▲Passive oscillatory motion: 2-3/sec for 1-2 minutes, small amplitude, applied anywhere in the range of movement.

▲ Sustained stretch: distraction and gliding force 3-7 seconds, followed by partial release.
2- Manipulation: is a passive high-velocity, short –amplitude motion

using physiologic or accessory motion, which may be:

▲Manipulation under Anaesthesia: is a medical procedure used to

restore full ROM by breaking adhesions while the patient is

anesthetized.

▲ Thrust sudden motion: is high-velocity, short –amplitude motion

such that the patient cannot prevent it.

 Type of Movements

▲Physiological movement: are the traditional movements performed by the patient's voluntary muscle contraction, such

as flexion, abduction. The amount of movement can be measured in degrees using Goniometer.

▲Accessory movements: are movements within normal ROM of the joint and surrounding tissue but that cannot be
actively performed by the patient. They can be classified into:

●Component motion: are motions that accompany active motion but are not under voluntary control e.g. scapular upward
rotation during shoulder flexion.

●Joint play: motions that occurs between the joint surfaces as well as the joint capsule, which allows the bones to move.
This movements occurs passively but cannot occur actively by the patient .e.g. distraction, gliding, spinning of the
joint.
 1- MOBILIZATION OF JOINTS

Definition:

▲Mobilization is manual therapy designed to restore joint movement. These are usually small repetitive rhythmical

oscillatory, localised accessory, or physiological movements performed by the physiotherapist in various

amplitudes within the available range, and under the patient’s control. These can be done very gently or quite

strongly, and are graded according to the part of the available range in which they are performed.
 Effects of Joint Mobilization
• Neurophysiological effects :
– Stimulates mechanoreceptors to  pain
– Affect muscle spasm & muscle guarding
– Increase in awareness of position & motion because of afferent nerve
impulses

• Nutritional effects :
– Distraction or small gliding movements – cause synovial fluid
movement
– Movement can improve nutrient exchange due to joint swelling &
immobilization

• Mechanical effects :
– Improve mobility of hypomobile joints (adhesions & thickened CT from
immobilization – loosens)
– Maintains extensibility & tensile strength of articular tissues
Indications for Joint Mobilization

1- Pain and muscle spasm to stimulate neurophysiological and mechanical

effects

2- Joint hypomobility to elongate hypomobile capsular and ligamentous

connective tissues.

3- Progressive limitation of ROM to maintain available motion.

4- Functional immobility to prevent the degenerating effects of immobility.

5- Positional fault as a result of traumatic injury, immobility or muscle

weakness.

Limitations of Joint Mobilization

- The outcome of the results will be determined by the skill of the therapist and
patient condition
 Contraindications for Mobilization

• Avoid the following:

– Inflammatory arthritis – Neurological
involvement
– Malignancy
– Bone fracture
– Tuberculosis
– Congenital bone
– Osteoporosis
deformities
– Ligamentous rupture – Vascular disorders
– Herniated disks with nerve compression
– Joint effusion
– Bone disease
Precautions of Joint Mobilization

●Malignancy

●Bone disease detected on X-ray

● unhealed fracture

● Elderly individuals with weakened connective tissue.

● Osteoarthritis

●Total joint replacement

 Patient Response
• May cause soreness
• Perform joint mobilizations on alternate days to
allow soreness to decrease & tissue healing to
occur
• Patient should perform ROM techniques
• Patient’s joint & ROM should be reassessed
after treatment, & again before the next
treatment
• Pain is always the guide
 II- MANIPULATION OF JOINTS BY PHYSIOTHERAPIST
Definition

These are accurately localised, single, quick movements of small amplitude and high

velocity completed before the patient can stop it.

MANIPULATION OF JOINT BY SURGEON /PHYSICIAN

Definition: Manipulations performed by a surgeon or physician are

usually given under a general or local anaesthetic which eliminates
pain and protective spasm, and allows the use of greater force.

Even well-established adhesions can be broken down; but when

these are numerous, it is usual to regain full range progressively, by
a series of manipulations, to avoid excessive trauma and marked
exudation. Maximum effort on the part of the patient and the
physiotherapist must be exerted after manipulation to maintain the
range of movement gained at each session, otherwise fibrous
 Procedures Steps
1. Evaluation and Assessment
2. Determine grades and dosage
3. Patient position
4. Joint position
5. Stabilization
6. Treatment force
7. Direction of movement
8. Speed and rhythm
9. Initiation of treatment
10. Reassessment
 Maitland Joint Mobilization Grading Scale
• Grading based on amplitude of movement & where within
available ROM the force is applied.

• Grade I
– Small amplitude rhythmic oscillating movement at the
beginning of range of movement
– Manage pain and spasm
• Grade II
– Large amplitude rhythmic oscillating movement within
midrange of movement
– Manage pain and spasm

• Grades I & II – often used before & after treatment with grades III
& IV
• Grade III
– Large amplitude rhythmic oscillating movement up to
point of limitation (PL) in range of movement
– Used to gain motion within the joint
– Stretches capsule & CT structures
• Grade IV
– Small amplitude rhythmic oscillating movement at very
end range of movement
– Used to gain motion within the joint
• Used when resistance limits movement in absence
of pain

• Grade V – (thrust technique) - Manipulation

– Small amplitude, quick thrust at end of range
– Accompanied by popping sound (manipulation)
– Velocity vs. force
– Requires training
 Indications for Mobilization
• Grades I and II - primarily used for pain
– Pain must be treated prior to stiffness
– Painful conditions can be treated daily
– Small amplitude oscillations stimulate
mechanoreceptors - limit pain perception
• Grades III and IV - primarily used to
increase motion
– Stiff or hypomobile joints should be treated 3-4
times per week – alternate with active motion
exercises
 Joint Traction Techniques

• Technique involving pulling one articulating surface

away from another – creating separation
• Performed perpendicular to treatment plane
• Used to decrease pain or reduce joint hypomobility
 Continuous Passive Motion( CPM)

Definition: Is slowly and continuously passive motion performed by mechanical device through a controlled Rom without

patient effort.

Benefits of CPM:

1- Lessening the negative effects of joint immobilization.

2- Prevent adhesions and contracture formation.

3- Stimulate the healing process of tendons and ligament.

4- increase synovial fluid lubrication of the joint.

5- Decrease post operative pain.

 Procedure

- The device may be applied to the involved extremity immediately after surgery.

- The arc of motion started using a low arc of 20-30 degrees progressed 10-15 degrees per day as tolerated.

- The rate of motion is determined by the patient tolerant.

- The total time on CPM machine varies for different protocol. Longer periods reported a shorter hospital stay.

- During the off period, physical therapy treatment ca be applied.