RANGE OF MOTION EXERCISES
“Mobilization”
Mazyad Alotaibi
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
Types of ROM Exercises
Active
Exercises
Passive
Exercises
Relaxed
Forced
Mechanical
Assisted
Free
Resisted
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)
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
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
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.
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.
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.
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.
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.
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.
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.
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
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.
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
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
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
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.
Procedures Steps
1. Evaluation and Assessment
2. Determine grades and dosage
3. Patient position
4. Joint position
5. Stabilization
6. Treatment force
7. Direction of movement
8. Speed and rhythm
9. Initiation of treatment
10. Reassessment
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
– Manage pain and spasm
• Grades I & II – often used before & after treatment with grades III
& IV
• 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 to gain motion within the joint
• 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
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
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
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
Procedure
- The device may be applied to the involved extremity immediately
after surgery.
- The arc of motion started using a low arc of 20-30 degrees
progressed 10-15 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.