1. Human Positions and Posture1 1

2. Human Positions and Posture
The position in which the parts of your body are hold upright against gravity while standing, sitting, or lying down is called posture.
Your posture constantly changes depending on the activity, but no matter what you are doing, you must keep holding and moving your body in a balanced and efficient way, that is called good posture
To gain good posture you must training your muscles, bones, and joints to stand, walk, sit, and lie with least strain and effort.

3. Proper Posture To achieve proper posture:
1- Keeps correct alignment of bones and joints to
help muscles used properly.
2- Decrease the abnormal wearing of joint surfaces
that could result in arthritis by proper alignment.

4. Proper Posture 3- Decreases the stress on the ligaments holding the
joints of the back.
4- Prevents the spine from becoming fixed in abnormal positions.
5- Prevents fatigue because muscles are being used more efficiently, allowing the body to use less energy.
6- Prevents strain or overuse problems.
7- Prevents backache and muscular pain.

5. Factors Affect Posture
There are some factors contribute to bad posture as:
OBESITY
PREGNANCY
muscle weakness.
use high-heeled shoes .

6. Factors Affect Posture
shortening of muscles.
decrease flexibility and ignorance of good posture.

7. Starting Positions Also called fundamental positions.
They are five positions.
1- Standing position.
2- Kneeling position.
3- Sitting position.
4- Lying position.
5- Hanging position.

8. 1- Standing
it is the most difficult position to maintain because the body is balanced and stabilized on a small base which needs coordination work of many muscle groups.

9. Correct Standing Position
1- The heels are on ground with angle not exceed 45°.
2- Keep your knee straight but not locked.
3- The hips are in extension and slightly rotated laterally.
4- The pelvic is balanced on the femoral head.
5- The spine is stretched to its maximum length and stomach flat.

10. Correct Standing Position
6- The head is hold up straight with chin in. do not tilt your head forward, backward, or sideways.
7- Keep your shoulder blades
back.
8- The arms are hanged loosely to the sides, palms facing sides of the body.
9- Your weight should be evenly distributed on both legs.

11. 2- KNEELING
The body is supported on the knees which may be together or slightly apart.
1- The lower leg rests on the floor with the feet planter flexed.
2- The feet may be in the mid position over the edge of the plinth.

12. 2- KNEELING
Effect: uncomfortable position for most people due to difficult balance.
Uses: as starting position for backward movements.

13. 3- SITTING the position is taken on chair or stool.
1- It is preferable to leave 2 or 3 inches of space between the back of your knees and the edge of the seat.

14. 3- SITTING
2- The height and width of seat must allow the thighs to be fully supported.
3- The hips and knees are flexed to right angle.
4- The knees are apart and feet rest on the floor.
5- Your weight should be evenly distributed on both buttocks.

15. 3- SITTING Effect: comfortable, natural, and very stable position.
Uses: for many non-weight bearing knee and foot exercises.

16. 4- LYING
This is the easiest position as the body can completely supported in the supine position and as stable as possible.

17. 4- LYING Effect: The alignment of the body is as in standing.
Breathing is impeded slightly by pressure on the posterior aspect of thorax and the pressure of the abdominal viscera on the under surface of the diaphragm is increased.
Uses: it is suitable for many exercises.

18. Derived Positions
Derived positions are positions used by modification of the arms, legs or trunk in each of fundamental position.
The aims of derived positions are:
1- To increase or decrease the base of support.
2- To rise or lower the center of gravity (COG).
3- To gain local or general relaxation.
4- To gain fixation and good control of specific area.
5- To increase or decrease the muscle work required to maintain the position.
6- To increase or decrease the leverage.

20. RANGE OF MOTION EXERCISES
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21. Introduction
To maintain normal ROM, it important to move the segments through their available joint range or muscle range periodically. Factors leads to decreased ROM: 1- systemic 2- Joint 3- neurologic 4- muscular 5- surgical or traumatic insult 6- inactivity or immobilization

22. Types of ROM Exercises Passive Exercises Active Exercises Resisted
Forced
Mechanical
Active
Exercises
Assisted
Free
Resisted

23. PASSIVE 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
Forced Passive Movements including Joint Mobilization & Manipulation.
Mechanical Passive Movements including Continuous Passive Movements (CPM)

24. Goals of Passive movement
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 relaxation
Goals 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

25. Precautions and Contraindications to PROM
Limitations of PROM Passive ROM will not: 1- Prevent muscle atrophy 2- Increase muscle strength and endurance 3- Assist circulation as active exercises
Precautions 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

26. 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.

27. 2- Manipulation: is a passive high-velocity, short –amplitude motion using physiologic or accessory motion.

28. 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.

29. 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.

30. 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

31. 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.

32. 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

33. 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

34. 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

35. Procedures Steps Evaluation and Assessment Determine grades and dosage
Patient position
Joint position
Stabilization
Treatment force
Direction of movement
Speed and rhythm
Initiation of treatment
Reassessment

36. 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
Grades I & II – often used before & after treatment with grades III & IV

37. 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 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

38. 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

39. 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

40. 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

41. Procedure
- The device may be applied to the involved extremity immediately after surgery.
- The arc of motion started using a low arc of degrees progressed 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.