PT 153: Therapeutic Exercise IIPT 153: Therapeutic Exercise II

Range-of-motion Range-of-motion ExercisesExercises

Aila Nica J. Bandong, PTRPInstructor

Department of Physical Therapy

UP- College of Allied Medical Professions

Learning ObjectivesLearning Objectives

At the end of the lecture, the students should be able to:

Differentiate the types of range-of-motion (ROM) exercises in terms of◦ Goals of treatment◦ Indications◦ Treatment variables◦ Limitations◦ Contraindications

Identify the appropriate type of ROM exercise to employ given a condition

Perform ROM exercises properly (lab)

Why use ROM exercises?Why use ROM exercises?

Basic technique for movement examination

Technique used for initiating or incorporating movement into a therapeutic intervention program◦Full ROM vs Functional ROM

TYPES OF ROM TYPES OF ROM EXERCISESEXERCISESPassive range-of-motion exercises

◦PROM

Active range-of-motion exercises◦AROM

Active-Assistive range-of-motion exercises◦AAROM

PASSIVE ROM PASSIVE ROM EXERCISESEXERCISESMovement produced by

an external force within the unrestricted range of motion of a segment◦Gravity◦Machine◦Therapist or another

person◦Another part of the

individual’s own body

Little to or no muscle contraction elicited

GGOO

AALLS S

Maintain joint and connective tissue mobility

Minimize the effects of the formation of contractures

Maintain mechanical elasticity of musclesAssist circulationEnhance synovial movement along jointsDecrease painAssist with healing process after injury or

surgeryMaintain patient’s awareness of

movement

! Minimize ill-effects of immobilization

IINNDDIICCAATTIIOONNS S

Acute or inflamed tissue where active motion may disrupt the normal healing process

Patients who are unable to move or are not allowed to move such as when comatose, paralyzed, or on complete bed rest

For assessment purposesWhen teaching a patient movementTo prepare a patient for stretching

LLIIMMIITTAATTIIOONNSS

Passive ROM exercise WILL NOT:

prevent atrophy

increase strength or endurance

assist in circulation to the extent that active, voluntary muscle contraction does

Evidence in PracticeEvidence in Practice

Clinical Question:

Is there evidence to suggest the effectiveness of continuous passive motion following total knee arthroplasty?

Evidence in PracticeEvidence in PracticeKey articles:Grella, RJ (2008) Continuous passive

motion following total knee arthroplasty: a useful adjunct to early mobilisation? A systematic review

Brosseau L, et al (2004) Efficacy of continuous passive motion following total knee arthroplasty: A meta analysis

Lenssen AF, et al (2003) Continuous passive motion following primary total knee arthroplasty: Short- and long-term effects on range of motion

Evidence in PracticeEvidence in PracticeResults/conclusion:Conflicting evidence on the

effectiveness of continuous passive motion following total knee arthroplasty

Potential benefits may need to be weighed against additional cost and inconvenience

There is need for further trials to ascertain the effects of using continuous passive motion post-total knee arthroplasty

Movement produced on a segment upon active contraction of the muscles crossing the joint within the unrestricted range of motion.

Assistance is provided byan outside force (manual or mechanical), as the prime mover muscles is unable to complete the motion.

ACTIVE ROM ACTIVE ROM EXERCISESEXERCISES

ACTIVE-ASSISTIVE ROM EXERCISES

Maintain elasticity and contractility of muscles

Provide sensory feedback from the contracting muscles

Provide a stimulus for bone and joint tissue integrity

Increase circulation and prevent thrombus formation

Develop coordination and motor skills for functional activities

GGOO

AALLS S

When a patient is able to actively contract the muscles and move the segment with or without assistance

Muscle weakness and inability to move segment completely against gravity

Aerobic conditioning programs

During periods of immobilization, AROM is used in joints above and below the immobilized segment

IINNDDIICCAATTIIOONNS S

Active ROM exercise WILL NOT:

maintain or increase strength of already strong muscles

develop skill or coordination except in the movement patterns used

LLIIMMIITTAATTIIOONNSS

PRECAUTIONS AND PRECAUTIONS AND CONTRAINDICATIONS OF CONTRAINDICATIONS OF ROM EXERCISESROM EXERCISES

Should not disrupt the healing process◦Excessive movement/wrong

performance of movement leads to increased pain and inflammation

Should not be done if response will be life-threatening to the patient

PRINCIPLES OF ROM PRINCIPLES OF ROM TECHNIQUESTECHNIQUESExamination, Evaluation, and

Treatment Planning

Patient preparation

Application of techniques◦Application of PROM◦Application of AROM

Examination, Evaluation, and Examination, Evaluation, and Treatment PlanningTreatment PlanningExamine and evaluate the

impairments and level of function.◦Determine any precautions and prognosis,

and plan of interventionDetermine the ability to participate in

the ROM activity◦Note what type of ROM exercise to meet

goalsDecide on the patterns of movemento Anatomic plane vs muscle range of

elongation vs combined patterns vs functional patterns

Monitor the general condition and response during and after the examination and intervention◦Take vital signs, presence of pain,

quality of movement, change in ROMDocument and communicate

findings and interventionRe-evaluate and modify the

intervention as needed

Examination, Evaluation, and Examination, Evaluation, and Treatment PlanningTreatment Planning

Patient Preparation Patient Preparation Communicate with the patient that

plan of intervention and the method to be used

Remove all restrictive clothing, linen, splint, and dressings; drape appropriately

Position the patient comfortably maintaining proper alignment and stabilization while allowing movement along the available ROM

Maintain proper biomechanics (therapist)

Application of TechniquesApplication of TechniquesGrasp the extremity around the joints

providing support needed for controlSupport areas of poor structural

integrityMove the segment throughout its

pain-free range to point of tissue resistance

Perform the movements smoothly and rhythmically 5 to 10 reps◦Depends on the objectives of the

program and patient’s general condition and response to the exercise

Application of Passive Application of Passive ROMROMMovement is being provided by

an external forceNo active resistance or

assistance is provided by the muscles that cross the joint.

Motion is performed within the available or free ROM◦There should be no pain or forced

motion elicited

Demonstrate the desired motion through PROM

Ask the patient to perform the movement independently◦Be ready to provide assistance or

guidance when necessary To complete movement smoothly In the presence of weakness (may provide at

the beginning or end of ROM, or when torque is greatest)

Perform the motion within the available range

Application of Active ROMApplication of Active ROM

Identify the appropriate ROM exercise for the case with due consideration to the ff:◦baseline function of the patient◦available resources

Note the joint segments that are involved, therefore, require mobilization

Identify joint motions requiredState the number of repetitions, sets,

and the frequency (how often in a day) that the exercise is to be performed

EXERCISE EXERCISE PRESCRIPTIONPRESCRIPTION

You are a physical therapist working in an aged care facility. A 67-year old female diagnosed with cerebrovascular accident was referred to you for management. She presents with weakness of both the right upper and lower extremity muscles. Result of which, she has difficulty moving her involved extremities to full range. One of your goals is to maintain joint flexibility. You deem that a regular ROM exercise may be beneficial.

SAMPLE CASE 1SAMPLE CASE 1

What does the case tell What does the case tell you?you?Patient has inability to move both

upper and lower extremities to full range due to weakness of muscles

There’s a need for an ROM exercise that will maintain joint flexibility

What does evidence say?What does evidence say?Tseng et al, in 2007, reported that a

simple range-of-motion exercise can generate positive effects in physical function of older people with stroke.

* randomized controlled trial* statistically significant improvements in joint angles, activity function, and perception of pain and depressive symptoms

What ROM ex is What ROM ex is appropriate?appropriate?AROM?AAROM?PROM?

WHY?

Exercise prescriptionExercise prescription

AAROM exercise of the right upper and lower extremities, all planes x 10 repetitions x 1 set, 3 times daily

ReferencesReferencesBrosseau, L., Milne, S., Wells, G., Tugwell, P., Robinson, V.,

Casimiro, L., Pelland, L., Noel, M.J., Davis, J., and Drouin, H. (2004) Efficacy of continuous passive motion following total knee arthroplasty: a metaanalysis. The Journal of Rheumatology. 31(11): 2251-2264.

Encabo, M. (2004). Lecture notes on PT 153: Therapeutic exercises II, range of motion exercise and stretching. UP-College of Allied Medical Professions

Grella, R. J. (2008) Continuous passive motion following total knee arthroplasty: a useful adjunct to early mobilisation? Physical Therapy Reviews. 3(4): 269-279.

Kisner, C., Colby, L. (2007). Therapeutic exercise: Foundations and techniques (4th ed). Philadelphia: F. A. Davis Company.

Lenssen, A. F., Koke, A., de Bie, R. A., and Geesink, R. (2003). Continuous passive motion following primary total knee arthroplasty: short- and long-term effects on range of motion. Physical Therapy Reviews. 8(3):113-121.

Rothstein, J., Roy, S., and Wolf, S. (2005). The rehabilitation specialist’s handbook (3rd ed). Philadelphia: F. A. Davis Company.

Tseng, C. N., Chen, C. C., Wu, S. C. & Lin, L. C. (2007). Effects of a range of motion exercise programme. Journal of Advanced Nursing. 57(2): 181-191.