RANGE OF MOTION EXERCISES

“Passive ROM”
 Introduction
To maintain normal ROM, its 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)
7- In case of increased joint’s hypermobility or hematoma
 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
● Poor general health
● Patient’s inability to relax
 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
 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.
6- Improve recovery rate and ROM following surgical procedures
 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.