PASSIVE RANGE OF MOTION EXERCISES PHTH 201 Definition: It is exercise in which movement is performed by an external force in the available pain free range of motion. The external force may be from the therapist, family member, or the patient or equipment. Passive ROM exercises are characterized by: 1. No muscular activation by the patient 2. Performed within the available ROM 3. Applied by some external force 4. No pain Importance of Passive ROM Exercises Passive ROM exercises are very important if you have to stay in bed or in a wheelchair. ROM exercises help keep joints and muscles as healthy as possible. Without these exercises, blood flow and flexibility (moving and bending) of the joints can decrease. Passive ROM exercises help keep joint areas flexible Indications when voluntary movements are impossible as when the subject is comatose, or when paralysis of the part. When Active movement may disrupt the healing process, as when there is acute inflammation of the joint or the surrounding tissue. When active movement is too painful to perform, as after surgery and injury for 2 to 6 days according to the condition. Aims of Passive ROM Exercise Passive exercises are largely preventive in nature and are used to: 1. Maintain range of motion. 2. Maintain joint and connective tissue mobility. 3. Minimizes the effects of and the formation of contractures. 4. Enhances synovial movement. 5. Maintain mechanical elasticity of muscles. 6. Assist circulation and vascular dynamics. 7. Help maintain the patient’s awareness of movement. Points to remember Passive ROM exercises will NOT: Build up muscles or make them stronger. Prevent muscle atrophy. Increase strength or endurance. Assist in circulation to the extent that active, voluntary muscle contraction will. Range of motion: Range of motion is the term that is used to describe the amount of movement that occur at each joint. Every joint in the body has a "normal" range of motion. Joints maintain their normal range of motion by being moved. It is therefore very important to move all your joints every day. Causes of decreased Range of Motion Prolonged immobilization or bed rest. Trauma to soft tissues, bones or other joint structures. Muscle weakness. Surgeries. Joint disease. Neuromuscular disease. Pain. Effect of Immobilization and Decreases Mobility Immobilization leads to decrease loading and stress on joints and soft tissues resulting in Joint stiffness and adhesion. Atrophy and weakness of the skeletal muscle. Decrease tensile strength of tendons and ligaments. Degeneration of articular surface. Adaptive shortening of the muscle and soft tissues. Osteoporotic changes of the bone Cycle of immobility Decreased loading Limitation of Decreased ability Adaptive shortening mobility to perform A.D.L and function Pain from disuse Weakness and adaptive Substitution shortening All these complications lead to decrease ability of to perform the activities of daily living Application of Passive Exercises Technical Principles Before performing passive exercises, some of the technical principles should be remembered 1. Place the patient in proper comfortable position with proper body alignment and stabilization to perform the exercise. 2. The therapist should be in a proper position and effective stance. 3. Free the region from restrictive closes, linen, splints, and dressings. 4. Drape and cover the patient as necessary. 5. Utilize the proper hand holds or grasps by the therapist. 6. Perform the exercise slowly, smoothly with rhythm within the available pain free range of motion without any force behind the range. 7. Do all ROM exercises smoothly and gently. Never force, jerk, or over-stretch a muscle. This can hurt the muscle or joint instead of helping. 8. Stop ROM exercises if the person feels pain. The exercises should never cause pain or go beyond the normal movement of that joint. 9. Repeat the exercise 5 to 10 repetitions according to the patient condition and response Active exercises Isometric Exercises (cont) i.e. – Eccentric cont. = max. tension – Isometric cont. = intermediate tension. – Isotonic cont. ( concentric) = minimum tension. i.e. to start a stregthening program: – Start by isotonic (concentric) harden by isometric then harden by eccentric . – If no contraction start by static then follow the same progression. Rules and Principles of Isometric Exs. 1. Strength will increase if an isometric contraction is sustained against resistance for at least 6 seconds. Isometric resistance exs. will not improve m. endurance as effectively as dynamic exs. 2. During isometric training it is suffiscient to use an exercise load ( resistance) up to 60-80% of th m. force-devloping capacity in order to gain strength. 3. Since there is no joint mov. , strength will devlop only at th position in which the ex. is performed. 4. To develop strength throughout the ROM, resistance must be applied when the jt. is in several positions. Rules and Principles of Isometric Exs.(cont.) 4.The length of a m. at the time of a contraction directly affects the amount of tension that can be produced at a specific point in the ROM.→ the amount of resistance will vary at different points in the range. 5. Resistance can be applied either manully or mechnically by having the pt. hold against a heavy load or push against an immovble object. Rules and Principles of Isometric Exs.(cont.) 6. Muscle setting exercises are also a form of isometric exs. but are not performed against apreciable resistance. a. Muscle setting exercises will be used to describe gentle static muscle contractions used to maintain mobility between muscle fibers and then decrease muscle spasm & pain. b. Quadriceps settings and gluteal settings are common examples. c. They are not performed against resistance and will not increase appreciably muscle strength. d. Settings may retard atrophy in the evry early stage of rehab. of muscle or joint when jt. Immobilization is necessary. Indications of Isometric contractions 1. Pain ( sever pain in joints e.g. arthritis); 2. Effusion of the knee.( static cont. of the knee). 3. Weakness of the m.( as 1st step in m. reeducation). 4. Immobilization in plaster cast or back splint. 5. Inflammation of the joint ( static contraction around the joint) to avoid weakness during theacute stage. Practical Points 1. Position: suitable & comfortable. 2. Time of contraction equal time of relaxation( not less than 6 sec.) 3. Repetition, teach the pt. on the sound limb, then on the affected limb to be repeated 10 min. every hour. 4. Manual or mechanical ( Velcro weights or elastised material as Theraband) could be used gradually , beginning with high repetitions and low resistance the reverse. 5. Instruct the pt. not to hold his breath. Contraindications to Isometric Exs. 1. Hypertension 2. Haert Disease Isometric Regimens Brief maximal isometric exercise (Hettinger & Muller): Single isometric cont. of the muscle to be strengthened against a fixed resistance. Hold for 5 -6 sec. , once a day, 5 – 6 days a week. Brief Repetitive Isometric Exs. (BRIME): Refinement of the previous study. 5 – 10 brief but max. isometric contactions are performed against max. isometric contactins are performed against resistance 5 days per week. Isometric Regimens in Rehabilitation & Conditioning • Early studies documented that isometric resistance exs. can be effective means of improving muscle strength. • Minimal effects in muscle endurance→ dynamic ( isotonic& isokinetic) exs. are more effective. • Multiple angle isometric exs. are necessary to improve strength throughout the ROM. – Resistance should be applied at least every 20° throughout the range. – 10 sets of 10 repetitions of 10 sec contraction every 10° in the ROM ( Davies).