THERAPEUTIC EXERCISE

FOUNDATION AND TECHNIQUES

Part I

Applied Science of Exercise and Techniques

Applied Science of Exercise and Techniques

1. Range of Motion
2. Stretching for Impaired Mobility
3. Peripheral Joint
4. Mobilization
5. Resistance Exercise For Impaired
6. Muscle Performance
7. Principles of Aerobic Exercise
8. Exercise for Impaired Balance
9. Aquatic Exercise
Range of Motion
Part I
 Range of Motion
1. The full motion possible is called the range of motion (ROM).
2. Muscle range is related to the functional excursion of muscles
3. Functional excursion is the distance a muscle is
4. capable of shortening after it has been elongated to its maximum
5. In some cases the functional excursion, or range of a muscle, is directly influenced by the
joint it crosses.
6. For example, the range for the brachialis muscle is limited by the range available at the
elbow joint.
7. This is true of one-joint muscles (muscles with their proximal and distal attachments on the
bones on either side of one joint).
8. For two-joint or multi joint muscles (those muscles that cross over two or more joints), their
range goes beyond the limits of any one joint they cross
9. Example of a two joint muscle functioning at the elbow is the biceps brachii muscle. If it
contracts and moves the elbow into flexion and the forearm into supination while
simultaneously moving the shoulder into flexion, it shortens to a point known as active
insufficiency, where it can shorten no more.
10.The muscle is lengthened full range by extending the elbow, pronating the forearm, and
simultaneously extending the shoulder. When fully elongated it is in a position known as
passive insufficiency
Factors leading to decreased ROM

• Systemic joint disease

• Neurological disorder
• Muscular diseases
• Surgical or traumatic insults
• Inactivity or immobilization for any reason.

 To maintain normal ROM, the segments must be

moved through their available ranges periodically,
whether it is the available joint range or muscle range
 Range of Motion
Therapeutically, ROM activities are administered
• To maintain joint and soft tissue mobility
• To minimize loss of tissue flexibility and
contracture formation
 TYPES OF ROM EXERCISES
• Passive ROM
• Active ROM
• Active-Assistive ROM
 Passive ROM
• PROM is movement of a segment within the unrestricted ROM that is produced entirely by an external
force; there is little to or no voluntary muscle contraction.
Types external forces
1. Gravity
2. A machine
3. Another individual
4. Another part of the individual’s own body.
PROM and passive stretching are not synonymous
Indications for PROM
In acute, inflamed tissue, passive motion is beneficial; active motion would be detrimental to the healing
process. Inflammation after 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 of the body, as when
comatose, paralyzed, or on complete bed rest
Goals for PROM
5. Primary Goal is to decrease the complications of immobilization, such as
6. Cartilage
7. Degeneration
8. Adhesion
9. Contracture formation
10. Sluggish circulation
 Passive ROM
Specific Goals
1. Maintain joint and connective tissue mobility
2. Minimize the effects of the formation of contractures
3. Maintain mechanical elasticity of muscle
4. Assist circulation and vascular dynamics
5. Enhance synovial movement for cartilage nutrition and diffusion of materials in the joint
6. Decrease or inhibit pain
7. Assist with the healing process after injury or surgery
8. Help maintain the patient’s awareness
Other Uses for PROM
9. When a therapist is examining inert structures, PROM is
10.used to determine limitations of motion, to determine
11.joint stability, and to determine muscle and other soft tissue
12.elasticity.
13.When a therapist is teaching an active exercise program,
14.PROM is used to demonstrate the desired motion.
15.When a therapist is preparing a patient for stretching,
16.PROM is often used preceding the passive stretching
17.techniques.
 Active ROM (AROM)

• AROM is movement of a segment within the

unrestricted ROM that is produced by active
contraction of the muscles crossing that joint.
Active-Assistive ROM (AAROM)
• AAROM is a type of AROM in which assistance is
provided manually or mechanically by an outside
force because the prime mover muscles need
assistance to complete the motion.
 (AROM)& (AAROM)
Indications for AROM& AAROM
• 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 carefully controlled manner so the
muscle can function at its maximum level and be progressively
strengthened. Once patients gain control of
their ROM, they are progressed to manual or mechanical
resistance exercises to improve muscle performance for a
return to functional activities (see Chapter 6).
 (AAROM)
1. AROM can be used for aerobic conditioning programs
2. When a segment of the body is immobilized for a period of time, AROM is used on the
regions above and below the immobilized segment to maintain the areas in as normal
a condition as possible and to prepare for new activities, such as walking with crutches.
Goals for AROM
3. If there is no inflammation or contraindication to active
4. motion, the same goals of PROM can be met with AROM.
5. In addition, there are physiological benefits that result from
6. active muscle contraction and motor learning from voluntary muscle control.
Specific goals
7. Maintain physiological elasticity and contractility of the participating muscles
8. Provide sensory feedback from the contracting muscles
9. Provide a stimulus for bone and joint tissue integrity
10.Increase circulation and prevent thrombus formation
11.Develop coordination and motor skills for functional activities
Limitations of ROM exercises

Limitations of Passive Motion

PROM does not:
1. Prevent muscle atrophy
2. Increase strength or endurance
3. Assist circulation to the extent that active, voluntary muscle
contraction does

Limitations of Active ROM

• Active ROM does not maintain or increase strength.
• It also does not develop skill or coordination
 Precautions and contraindications to
ROM exercises
1. ROM should not be done when motion is disruptive to the healing process
2. Carefully controlled motion within the limits of pain-free motion during early
phases of healing has been shown to benefit healing and early recovery.
3. Signs of too much or the wrong motion include increased pain and
inflammation.
4. ROM should not be done when patient response or the
5. condition is life-threatening.
6. PROM may be carefully initiated to major joints and
7. AROM to ankles and feet to minimize venous stasis and thrombus formation.
8. After myocardial infarction, coronary artery bypass surgery, or percutaneous
transluminal coronary angioplasty,AROM of upper extremities and limited
walking are usually tolerated under careful monitoring of symptoms.
 PRINCIPLES AND PROCEDURES
FOR APPLYING ROM TECHNIQUES
Examination, Evaluation, and Treatment Planning

1. Examine and evaluate the patient’s impairments and level of function

2. Determine the ability of the patient
3. Determine the amount of motion
4. Decide what patterns can best meet the goals
Anatomic planes of motion
Muscle range of elongation
Combined patterns
Functional patterns
5. Monitor the patient’s general condition and responses
6. Document and communicate findings and intervention
7. Re-evaluate and modify the intervention as necessary
Patient Preparation
1. Communicate with the patient. Describe the plan and
method of intervention to meet the goals.
2. Free the region from restrictive clothing, linen, splints,
and dressings. Drape the patient as necessary.
3. Position the patient in a comfortable position with proper
body alignment and stabilization but that also allows you
to move the segment through the available ROM.
4. Position yourself so proper body mechanics can be
used.
Application of Techniques
1.To control movement, grasp the extremity around the joints. If
the joints are painful, modify the grip, still providing support
necessary for control.
2. Support areas of poor structural integrity, such as a hyper
mobile joint, recent fracture site, or paralyzed limb segment.
3. Move the segment through its complete pain-free range to the
point of tissue resistance. Do not force beyond the available
range. If you force motion, it becomes a stretching technique.
4. Perform the motions smoothly and rhythmically, with 5 to 10
repetitions. The number of repetitions depends on the
objectives of the program and the patient’s condition and
response to the treatment.
Application of PROM
1.During PROM the force for movement is external, being
provided by a therapist or mechanical device. When
appropriate, a patient may provide the force 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. If the muscles
contract, it becomes an active exercise.
3. The motion is carried out within the free ROM, that is,
the range that is available without forced motion or pain.
Application of AROM
1. Demonstrate the motion desired using PROM; then ask
the patient to perform the motion. Have your hands in
position to assist or guide the patient if needed.
2. Provide assistance only as needed for smooth motion.
When there is weakness, assistance may be required
only at the beginning or the end of the ROM, or when
the effect of gravity has the greatest moment arm
(torque).
3. The motion is performed within the available ROM