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RANGE OF MOTION EXERCISES“Mobilization”
Mazyad Alotaibi
Introduction
To maintain normal ROM, it important to move the segments through their To maintain normal ROM, it important to move the segments through their
available joint range or muscle range periodically.available joint range or muscle range periodically.
Factors leads to decreased ROMFactors leads to decreased ROM::
1- systemic1- systemic
2- Joint2- Joint
3- neurologic3- neurologic
4- muscular4- muscular
5- surgical or traumatic insult5- surgical or traumatic insult
6- inactivity or immobilization 6- inactivity or immobilization
Types of ROM ExercisesTypes of ROM Exercises
PASSIVE MOVEMENTPASSIVE 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 relaxationGoals 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
5- Maintain the patient's awareness of movements by stimulating the kinaesthetic
receptors.
6- Decrease or inhibit pain
Limitations of PROM
Passive ROM will not:
1- Prevent muscle atrophy
2- Increase muscle strength and endurance
3- Assist circulation as active exercisesPrecautions 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 MovementPRINCIPLES OF RELAXED PASSIVE Movement
1-Relaxation:1-Relaxation:
A brief explanation of the procedure is given to the patient, who is asked 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 to relax as much as possible. The selection of a suitable starting
position ensures comfort and support. Describe the plane and method position ensures comfort and support. Describe the plane and method
to meet the goals. Free the region from restrictive clothing, linen, splint to meet the goals. Free the region from restrictive clothing, linen, splint
and dressing.and dressing.
2-Fixation: 2-Fixation:
Good fixation near the joint to be moved as close to the joint line as 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 possible to ensure that the movement is localized to that joint, and to
control movement. 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
- Mobilization cannot change the disease process of disorders (Rheumatoid
arthritis) but help in minimizing pain and increasing ROM.
Contraindications for Mobilization
• Avoid the following:– Inflammatory arthritis– Malignancy– Tuberculosis– Osteoporosis– Ligamentous rupture– Herniated disks with nerve compression– Bone disease
– Neurological involvement
– Bone fracture– Congenital bone
deformities– Vascular disorders
– Joint effusion
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
range of movement gained at each session, otherwise fibrous
deposits from the invertible exudation will form new adhesions.
Procedures Steps1. Evaluation and Assessment2. Determine grades and dosage3. Patient position4. Joint position5. Stabilization6. Treatment force7. Direction of movement8. Speed and rhythm9. Initiation of treatment10. 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.
6- Improve recovery rate and ROM following surgical procedures
ProcedureProcedure
- 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.