PT 153: Therapeutic Exercise II Range-of-motion Exercises Aila Nica J. Bandong, PTRP Instructor Department of Physical Therapy UP- College of Allied Medical Professions

Learning 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? 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 Exercises Passive range-of-motion exercises PROM Active range-of-motion exercises AROM Active-Assistive range-of-motion exercises AAROM

Passive ROM Exercises Movement 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

! Minimize ill-effects of immobilization G o a l s ! Minimize ill-effects of immobilization Maintain joint and connective tissue mobility Minimize the effects of the formation of contractures Maintain mechanical elasticity of muscles Assist circulation Enhance synovial movement along joints Decrease pain Assist with healing process after injury or surgery Maintain patient’s awareness of movement

I n d I c a t I o n 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 purposes When teaching a patient movement To prepare a patient for stretching

L I m I t a t I on s 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 Practice Clinical Question: Is there evidence to suggest the effectiveness of continuous passive motion following total knee arthroplasty?

Evidence in Practice Key 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 Practice Results/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

Active-Assistive ROM Exercises Active ROM Exercises Movement produced on a segment upon active contraction of the muscles crossing the joint within the unrestricted range of motion. Assistance is provided by an outside force (manual or mechanical), as the prime mover muscles is unable to complete the motion. Active-Assistive ROM Exercises

G o a l s 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

I n d I c a t I o n 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

L I m I t a t I on s Active ROM exercise WILL NOT: maintain or increase strength of already strong muscles develop skill or coordination except in the movement patterns used

Precautions and Contraindications of ROM 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 Techniques Examination, Evaluation, and Treatment Planning Patient preparation Application of techniques Application of PROM Application of AROM

Examination, Evaluation, and Treatment Planning Examine and evaluate the impairments and level of function. Determine any precautions and prognosis, and plan of intervention Determine the ability to participate in the ROM activity Note what type of ROM exercise to meet goals Decide on the patterns of movement Anatomic plane vs muscle range of elongation vs combined patterns vs functional patterns

Examination, Evaluation, and Treatment Planning Monitor the general condition and response during and after the examination and intervention Take vital signs, presence of pain, quality of movement, change in ROM Document and communicate findings and intervention Re-evaluate and modify the intervention as needed

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 Techniques Grasp the extremity around the joints providing support needed for control Support areas of poor structural integrity Move 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 ROM Movement is being provided by an external force No 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

Application of Active ROM 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

Exercise Prescription 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 required State the number of repetitions, sets, and the frequency (how often in a day) that the exercise is to be performed

Sample Case 1 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.

What does the case tell 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? 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 appropriate? AROM? AAROM? PROM? WHY?

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

References Brosseau, 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.