RANGE OF MOTION EXERCISE

 Define ROM exercise

 Knows deferent types of ROM exercise
 Identify indication, goals and limitation to ROM exercise
 Identify contra-indication and precaution to ROM exercise
 Clarify Principles and Procedures for Applying ROM Techniques
 Define self assisted ROM exercise and knows deferent equipment used to
assist in self assisted ROM exercise
 Define CPM unite
 Therapeutic
PROM exercise

AAROM ROM

AROM

Stretching Joint Resisited Specific

exercie mobilization exercise execise
Range of motion is a basic technique used for the examination of
movement and for initiating movement into a program of
therapeutic intervention.
Rane of motion is the full motion that occurs when bones move in
respect to each other at the connecting joints

Functional excursion is the distance a muscle is capable of

shortening after it has been elongated to its maximum.
• In some cases the functional excursion, or range of a muscle, is
directly influenced by the joint it crosses.

 To maintain normal ROM, the segments must be moved through

their available ranges periodically
Therapeutically, ROM activities are administered to:
1) maintain joint and soft tissue mobility
2) minimize loss of tissue flexibility and contracture
formation.

Types of ROM Exercises

1-passive range of motion
exercises(PROM)
2-active assisted rage of motion
exercise(AAROM)
3-active range of motion
exercises(AROM).
Passive ROM
Passive ROM (PROM) is movement of a segment within the
unrestricted ROM that is produced entirely by an external force.(no
muscle activity)
Active ROM.
Active ROM (AROM) is movement of a segment within the
unrestricted ROM that is produced by active contraction of the
muscles crossing that joint.
Active-Assistive ROM.
Active-assistive ROM (A-AROM) is a type of AROM in which
assistance is provided manually or mechanically by an outside force
because the prime mover muscles need assistance to complete the
motion.
Indications, Goals, and Limitations of ROM
Passive ROM
Indications for PROM

1- cute and inflamed tissues

2-when active movement is detrimental to the healing process.
3-When a patient is not able to or not supposed to actively
move a segment(s) of the body, as when comatose, paralyzed,
or on complete bed rest.
Goals for PROM

The primary goal for PROM is to decrease the complications that

would occur with immobilization, such as cartilage degeneration,
adhesion and contracture formation, and sluggish circulation.

■ Maintain joint and connective tissue mobility.

■ Minimize the effects of the formation of contractures.
■ Maintain mechanical elasticity of muscle.
■ Assist circulation and vascular dynamics.
■ Enhance synovial movement for cartilage nutrition and diffusion
of materials in the joint.
■ Decrease or inhibit pain.
■ Assist with the healing process after injury or surgery.
■ Help maintain the patient’s awareness of movement.

■ Examining limitation of ROM

■ To teach active program
■ As a preparation to stretching
Limitations of Passive Motion
• True passive, relaxed ROM may be difficult to obtain when
muscle is innervated and the patient is conscious.
• Passive motion does not:
■ Prevent muscle atrophy.
■ Increase strength or endurance.
■ Assist circulation to the extent that active,
voluntary muscle contraction does.
Active and Active-Assistive ROM
Indications for AROM
■ When a patient is able to contract the muscles actively and move
a segment with or without assistance, AROM is used.
■ When a patient has weak musculature and is unable to move a
joint through the desired range (usually against gravity), A-AROM
is used.
■ When a segment of the body is immobilized for a period of time,
AROM is used on the regions above and below the immobilized
segment.
■ AROM can be used for aerobic conditioning programs.
Goals for AROM
If there is no inflammation or contraindication to active motion, the
same goals of PROM can be met with AROM. In addition, there are
physiological benefits that result from active muscle contraction and
motor learning from voluntary muscle control.
Specific goals are to:
■ Maintain physiological elasticity and contractility of the
participating 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.

Limitations of Active ROM

For strong muscles, active ROM does not maintain or increase
strength. It also does not develop skill or coordination except in the
movement patterns used.
Precautions and Contraindications to ROM
Exercises
ROM should not be done when motion is disruptive to the healing
process.
■ Carefully controlled motion within the limits of pain-free motion
during early phases of healing has been shown to benefit healing
and early recovery.
■ Signs of too much or the wrong motion include increased pain
and inflammation. ROM should not be done when patient response
or the condition is life-threatening.
■ PROM may be carefully initiated to major joints and AROM
to ankles and feet to minimize venous stasis and thrombus
formation.
■ After myocardial infarction, coronary artery bypass surgery, or
percutaneous transluminal coronary angioplasty, AROM of upper
extremities and limited walking are usually tolerated under careful
monitoring of symptoms.
Principles and Procedures for Applying ROM
Techniques
Examination, Evaluation, and Treatment Planning
1. Examine and evaluate the patient’s impairments and level
of function, determine any precautions and their prognosis,
and plan the intervention.
2. Determine the ability of the patient to participate in the
ROM activity and whether PROM, A-ROM, or AROM can
meet the immediate goals.
3. Determine the amount of motion that can be applied
safely for the condition of the tissues and health of the
individual.
4. Decide what patterns can best meet the goals. ROM
techniques may be performed in the:
a. Anatomic planes of motion: frontal, sagittal,
transverse
b. Muscle range of elongation: antagonistic to the
line of pull of the muscle
c. Combined patterns: diagonal motions or
movements that incorporate several planes of
motion
d. Functional patterns: motions used in activities of
daily living (ADL)
5. Monitor the patient’s general condition and responses
during and after the examination and intervention; note
any change in vital signs, in the warmth and color of the
segment, and in the ROM, pain, or quality of movement.
6. Document and communicate findings and intervention.
7. Re-evaluate and modify the intervention as necessary.
Patient Preparation

1. Communicate with the patient. Describe the plan and

method of intervention to meet the goals.

2. Free the region from restrictive clothing, linen, splints,

and dressings.

3. Position the patient in a comfortable position with

proper body alignment and stabilization but that also
allows you to move the segment through the available
ROM.

4. Position yourself so proper body mechanics can be used.

Application of Techniques
1. To control movement, grasp the extremity around the joints. If
the joints are painful, modify the grip, still providing support
necessary for control.
2. Support areas of poor structural integrity, such as a hypermobile
joint, recent fracture site, or paralyzed limb segment.
3. Move the segment through its complete pain-free range to the
point of tissue resistance. Do not force beyond the available range.
If you force motion, it becomes a stretching technique.
4. Perform the motions smoothly and rhythmically, with 5 to 10
repetitions. The number of repetitions depends on the objectives of
the program.
Application of PROM
1. During PROM the force for movement is external; it is provided
by a therapist or mechanical device. When appropriate, a patient
may provide the force and be taught to move the part with a normal
extremity.
2. No active resistance or assistance is given by the patient’s muscles
that cross the joint. If the muscles contract, it becomes an active
exercise.
3. The motion is carried out within the free ROM—that is, the range
that is available without forced motion or pain.
Application of AROM

1. Demonstrate the motion desired using PROM; then ask the

patient to perform the motion.
2. Have your hands in position to assist or guide the patient if
needed.
3. Provide assistance only as needed for smooth motion.
4. The motion is performed within the available ROM.
General concepts
• When making the transition from PROM to AROM, gravity has
a significant impact especially in individuals with weak
musculature.
• The term upper or top hand means the hand of the therapist that
is toward the patient’s head; bottom or lower hand refers to the
hand toward the patient’s foot.
PRACTICAL SECTION
Upper Extremity

Shoulder: Flexion and Extension

Hand Placement and Procedure

■ Grasp the patient’s arm under the elbow with your lower hand.
■ With the top hand, cross over and grasp the wrist and palm of the
patient’s hand.
■ Lift the arm through the available range and return.
NOTE: For normal motion, the scapula should be free to rotate
upward as the shoulder flexes. If motion of only the glenohumeral
joint is desired, the scapula is stabilized
Shoulder: Extension (Hyperextension)

To obtain extension past zero, position the patient’s shoulder at the

edge of the bed when supine or position the patient side-lying,
prone, or sitting.
Shoulder: Abduction and Adduction
Hand Placement and Procedure
Use the same hand placement as
with flexion, but move the arm
out to the side. The elbow may be
flexed.
NOTE: To reach full range of
abduction, there must be external
rotation of the humerus and
upward rotation of the scapula.
Shoulder: Internal (Medial) and External (Lateral) Rotation
If possible, the arm is abducted to 90°; the elbow is flexed to 90°;
and the forearm is held in neutral position. Rotation may also be
performed with the patient’s arm at the side of the thorax, but full
internal rotation is not possible in this position.
Hand Placement and Procedure

■ Grasp the hand and the wrist with your index finger between the
patient’s thumb and index finger.
■ Place your thumb and the rest of your fingers on either side of the
patient’s wrist, thereby stabilizing the wrist
.
■ With the other hand, stabilize the elbow.
■ Rotate the humerus by moving the forearm.
Shoulder: Horizontal Abduction and Adduction
To reach full horizontal abduction, position the patient’s shoulder at
the edge of the table. Begin with the arm either flexed or abducted
90°.
Hand Placement and Procedure

Hand placement is the same as with flexion, but turn your body and
face the patient’s head as you move the patient’s arm out to the side
and then across the body.
Scapula: Elevation/Depression, Protraction/ Retraction, and
Upward/Downward Rotation
Position the patient prone, with his or her arm at the side or
sidelying, facing toward you. Drape the patient’s arm over your
bottom arm.
Hand Placement and Procedure

■ Cup the top hand over the acromion process and place the other
hand around the inferior angle of the scapula.
■ For elevation, depression, protraction, and retraction, the clavicle
also moves as the scapular motions are directed at the acromion
process.
■ For rotation, direct the scapular motions at the inferior angle of the
scapula while simultaneously pushing the acromion in the opposite
direction to create a force couple turning effect.
Elbow: Flexion and Extension
Hand Placement and Procedure

Hand placement is the same as with shoulder

flexion except the motion occurs at the
elbow as it is flexed and extended.
NOTE:
 Control forearm supination and pronation
with your fingers around the distal forearm.
 Perform elbow flexion and extension with
the forearm pronated as well as supinated.
 The scapula should not tip forward when the
elbow extends, as it disguises the true range.
Elongation of Two-Joint Biceps Brachii Muscle
To extend the shoulder beyond zero, position the patient’s shoulder at
the edge of the table when supine or position the patient prone lying,
sitting, or standing.

Hand Placement and Procedure

■ First, pronate the patient’s forearm by grasping the wrist and extend
the elbow while supporting it.
■ Then, extend (hyperextend) the shoulder to the point of tissue
resistance in the anterior arm region. At this point, full available
lengthening of the two-joint muscle is reached.
Elongation of Two-Joint Long Head of the Triceps Brachii Muscle
When near-normal range of the triceps brachii muscle is available,
the patient must be sitting or standing to reach the full ROM. With
marked limitation in muscle range, ROM can be performed in the
supine position.
Hand Placement and Procedure
■ First, fully flex the patient’s elbow with one
hand on the distal forearm.
■ Then, flex the shoulder by lifting up on the
humerus with the other hand under the elbow.
■ Full available range is reached when
discomfort is experienced in the posterior arm
region.
Forearm: Pronation and Supination

Hand Placement and Procedure

■ Grasp the patient’s wrist,

supporting the hand with the index
finger and placing the thumb and
the rest of the fingers on either side
of the distal forearm.
■ Stabilize the elbow with the
other hand.
■ The motion is a rolling of the
radius around the ulna at the distal
radius.
Wrist: Flexion (Palmar Flexion) and Extension (Dorsiflexion);
Radial (Abduction) and Ulnar (Adduction) Deviation
Hand Placement and Procedure

For all wrist motions, grasp the patient’s

hand just distal to the joint with one
hand and stabilize the forearm with your
other hand.
NOTE: The range of the extrinsic
muscles to the fingers affects the range
at the wrist if tension is placed on the
tendons as they cross into the fingers. To
obtain full range of the wrist joint, allow
the fingers to move freely as you move
the wrist.
Hand: Cupping and Flattening the Arch of the Hand at the
Carpometacarpal and Intermetacarpal Joints
Hand Placement and Procedure

■ Face the patient’s hand; place the

fingers of both of your hands in the
palms of the patient’s hand and
your thenar eminences on the
posterior aspect.
■ Roll the metacarpals palmarward
to increase the arch and dorsalward
to flatten it.
Joints of the Thumb and Fingers: Flexion and Extension and
Abduction and Adduction
The joints of the thumbs and fingers
include the metacarpophalangeal and
interphalangeal joints.
Hand Placement and Procedure
■ Depending on the position of the patient,
stabilize the forearm and hand on the bed or
table or against your body.
■ Move each joint of the patient’s hand
individually by stabilizing the proximal bone
with the index finger and thumb of one hand
and moving the distal bone with the index
finger and thumb of the other hand.
Elongation of Extrinsic Muscles of the Wrist and Hand: Flexor and
Extensor Digitorum Muscles
Self-Assisted ROM
Forms of Self-Assisted ROM
■ Manual
■ Equipment
■ Wand or T-bar
■ Finger ladder, wall climbing, ball rolling
■ Pulleys
■ Skate board/powder board
■ Reciprocal exercise devices
Guidelines for Teaching Self-Assisted ROM

■ Educate the patient on the value of the motion.

■ Teach the patient correct body alignment and stabilization.
■ Observe patient performance and correct any substitute or unsafe
motions.
■ If equipment is used, be sure all hazards are eliminated for
application to be safe.
■ Provide drawings and clear guidelines for number of repetitions and
frequency. Review the exercises at a follow-up session. Modify or
progress the exercise program based on the patient response and
treatment plan for meeting the outcome goals.
Manual self assistance
Arm and Forearm
Wrist and Hand
Wand (T-Bar) Exercises

Patient using a wand for self-assisted shoulder (A) flexion, (B)

horizontal abduction/adduction, and (C) rotation.
Wall Climbing
Overhead Pulleys
Skate Board/Powder Board
Reciprocal Exercise Unit

Several devices, such as a

bicycle, upper body or lower
body ergometer, or a reciprocal
exercise unit, can be set up to
provide some flexion and
extension to an involved
extremity using the strength of
the normal extremity.
Continuous Passive Motion
Continuous passive motion (CPM) refers to passive motion
performed by a mechanical device that moves a joint slowly and
continuously through a controlled ROM.
Benefits of CPM

■ Prevents development of adhesions and contractures and thus joint stiffness

■ Provides a stimulating effect on the healing of tendons and ligaments
■ Enhances healing of incisions over the moving joint
■ Increases synovial fluid lubrication of the joint and thus increases the rate of intra-
articular cartilage healing and regeneration
■ Prevents the degrading effects of immobilization
■ Provides a quicker return of ROM
■ Decreases postoperative pain
Write main goal of using ROM technique and
enumerates two contraindication and precautions
to ROM.
Kisner, C., Colby, L. A., & Borstad, J. (2017).
Therapeutic exercise: foundations and techniques. Fa
Davis.
THANK YOU