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.