1. RANGE OF MOTION EXERCISES “Mobilization”
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Mazyad Alotaibi

2. 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

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

4. 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
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)

5. 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

6. 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

7. PRINCIPLES OF RELAXED PASSIVE Movement
1-Relaxation:
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 position ensures comfort and support. Describe the plane and method to meet the goals. Free the region from restrictive clothing, linen, splint and dressing.
2-Fixation:
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 control movement.

8. 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.

9. 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.

10. 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.

11. 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.

12. 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.

13. 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.

14. 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

15. 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.

16. 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

17. 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

18. 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

19. 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.

20. Techniques of
Joint Mobilization

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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.