THERAPEUTIC EXERCISE
THEORY AND PRACTICE
First Edition 2005
Faculty of Physical Therapy
Cairo University
PART I
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Preface
Physical therapy as part of practice medicine involves
treating disease and injury with different modalities. The use of
therapeutic exercise in treatment is an important part of physical
therapy.
The ultimate goal of any therapeutic exercise program is
achievement of symptoms free movement and improvement of
function. The positive effect of therapeutic exercise include the
development, improvement, restoration, or maintenance of
normal range of motion, strength, endurance, mobility and
flexibility.
This book includes five chapters, which could provide a
theoretical bases and practical application of therapeutic exercise
which enables effective and safe administration of those
exercises.
Chapter one, introduce the student to the concept of
therapeutic exercises, its importance, classifications and the
different types of therapeutic exercises. Chapter two, views the
dofferent positions from which the exercises is started and how
to choose the appropriate position to the selected exercise.
Chapters three describe the exercises needed to increase
range of motion and includes traditional exercises as passive
exercises and active exercises
Chapter four deals with muscle performance exercises
with explanation of muscle performance and its components.
The chapter also demonstrate isometric exercises with its clinical
application The final chapter presents the principles and
guidelines for abdominal and back exercises with brief
presentation of the abdominal and back muscle anatomy.
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CONTENTS
Chapter1
Introduction To Therapeutic Exercises
9
Chapter 2
Positions For Starting Exercises
15
Chapter 3
Range of Motion Exercises
- Passive Range of Motion Exercises
25
29
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Continuous passive Motion
Active Range of Motion Exercises
Active Assisted Range of Motion Exercises
Active Free Range of Motion Exercises
Chapter 4
Muscle performance exercises
47
51
53
67
73
Isometric Exercises
76
Chapter 5
Abdominal and Back Exercises
*
*
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83
*
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Introduction to Therapeutic
Exercise
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THERAPEUTIC EXERCISE
Therapeutic exercise is an integral part of the practice of
physical therapy. One of the most difficult tasks for a physical
therapists is to design and apply an exercise program. Exercise
presents both benefits and risks. This balance can be easily
achieved towards the benefit side of the equation with the
optimal exercise prescription.
Definition
Therapeutic exercise is the systematic and planned
performance of body movements or exercises which aims to
improve and restore physical function.
Exercise is defined as “activity that is performed or practiced
in order to develop or improve a specific function or skill for the
sake of developing and maintaining physical fitness”
Importance Of The Therapeutic Exercise
1- The ultimate goal of a therapeutic exercise program is the
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achievement of an optimal level of symptoms free
movement during basic to complex physical activities.
To improve and restore physical function.
To enhance a patient’s functional capabilities and prevent
loss of function.
To prevent and decrease impairment and disability
To optimize overall health status, fitness and sense of
well-being
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Prerequisites For Designing Exercise Program
For the designing of successful and effective exercise
program the followings should be fulfilled:
1- The therapist must have knowledge of anatomy,
physiology, kinesiology and pathology and can integrate
and apply this knowledge to each condition.
2- The therapist must understand the different forms of
exercises and how these exercises affect body system.
3- The exercise program should be individualized to the
special needs of each patient.
Steps For Designing Exercise Program
1- Start with comprehensive examination of the patient.
2- Determine the problems and functional disabilities that
the patient has.
3- Set the aims and objectives of the treatment program.
4- Select the proper exercise program that can solve the
patient’s problems and improve functional capabilities.
5- Periodic e-evaluation and examination of the patients
should be carried out weekly or monthly depending on the
program.
6- According to the result of the re-evaluation, modifications
of the program should be made to attain the optimal
degree of improvement
7- The purpose and goal of the exercise program should be
very clearly identified to the patient.
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Classification of Therapeutic Exercises
Therapeutic exercises in general are classified into two main
categories from which many types are branched each for which
has its own effects and benefits
Therapeutic Exercises
Active Exercises
Passive Exercises
Relaxed
passive
Exercise
s
Forced
Passive
Exercises
Active
assisted
Exercises
Static
Exercises
Active
Free
Exercises
Active
resisted
Exercises
Passive exercise: is exercise in which movement is performed
entirely by an external force without any voluntary participation
of the patient, The external force may be from another
individual, a machine, or another part of the patient’s body.
Relaxed passive exercise: is exercise in which movement is
performed by an external force in the available pain free range of
motion in order to maintain range of motion.
Forced passive exercise: is exercise in which movement is
performed by an external force within the tolerance of pain in
order to increase limited range of motion.
Active exercise: is exercise in which movement is performed by
the voluntary effort of the patient.
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Active assisted exercise: is exercise in which movement is
performed by the voluntary effort of the patient with assistance
of external force to complete the range of motion.
Active free exercise: is exercise in which movement is
performed by the voluntary effort of the patient through full
range of motion omitting gravity or against gravity.
Active resisted exercise: is active exercise in which the
movement is resisted by an external force.
Types of Therapeutic Exercises
The therapeutic exercises are also categorized according to
the aim and purpose of the exercises into many types
1- Range of motion exercises which aims to maintain and
increase range of motion as traditional ROM exercises
(passive- active and active assisted ROM exercises) and
other techniques of joint mobilization and soft tissue
stretching
2- Muscle performance exercises to increase muscle
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strength, power and endurance as resisted exercises,
endurance exercises
Postural exercises to improve posture and correct faulty
posture
Balance and coordination exercises to improve balance
and coordination
Relaxation exercises to induce relaxation
Area specific exercises as breathing exercises and
circulatory exercises
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Positions For Starting
Exercises
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POSITIONS FOR STARTING EXERCISES
There are fundamental positions which are usually described
along with their derivatives as the starting positions from which
exercises start.
Selection of the starting position
When selecting a starting position for an exercise, the
following points should be considered
1- The ability of the patient to assume the position.
2- The need to stabilize one segment of the body to permit
safe and efficient movement.
3- The use of gravity for assistance or resistance.
4- The presence of pain or discomfort ( the position should
be pain free to assure relaxation of the patient).
5- The use of a short lever arm versus a long lever arm.
Fig. (1): Lying (supine or backlying).
Characteristics
It is the easiest of the whole positions. The body is most
supported with a large base of support and low center of gravity.
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Description:
The body is erect with
- Eyes look up, ears at the same line ( head in neutral
position).
-
Shoulders at the same level.
Trunk is relaxed on bed.
-
Arms by the side of the body palms in contact with table.
Pelvis at the same level.
-
Lower limbs ( hips and knees) straight.
-
The feet free from the bed or in neutral position.
Positions derived from lying
Prone lying (Face lying) (Fig. 2)
- The body is face down rested on the forehead with chin
tucked in. also the head may be turned to one side for ease
of respiration.
-
Shoulders at the same level.
Trunk is relaxed on bed.
-
Arms by the side of the body palms facing up.
Pelvis at the same level.
Lower limbs ( hips and knees) straight.
The feet free from the bed or in planter flexion.
Fig. (2): Prone lying position.
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Side lying (Fig. 3)
- The body is lying on the side with the arms by the side and
the legs straight.
This position is difficult to assume as the base of support is
small and rounded, some modification is made to make this
position suitable for exercises performance.
-
The under arm is bent forward or placed under the head. The
upper arm is for balance and to prevent trunk rotation.
-
The under leg is bent forward ( flexed 45 degrees at hip and
knee) for balance and increase base of support. The upper
leg is extended.
Fig (3): Sid lying position.
Hook lying (Crook lying) (Fig. 4)
As supine lying position but hips and knees are flexed with
the feet rested on the table.
Fig (4): Crook lying position.
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Sitting
Characteristics
It is comfortable, natural and very stable position. The center
of gravity is low but near to the edge of the base of support
which is the area between both the legs of the seat and the feet.
Description:
The body is resting on a chair ( with back support) or stool
(without back support)
- Eyes look forward, ears at the same line ( head in neutral
-
position).
Shoulders at the same level.
-
Back is straight. The back is supported in case of sitting
on chair with back support. While when sitting on stool
the back is unsupported making the position less stable
and need effort of the subject to maintain back straight.
Arms by the side of the body.
-
Pelvis at the same level.
Thighs fully supported and together on the chair ( hips,
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knees, and ankles at right angle flexion).
The feet rested on the floor. In case of sitting on stool,
according to the height of the stool the feet may be rested
or not on the floor.
Positions derived from sitting
Long Sitting (Fig. 5)
As in supine position but the body is bent at the hips and the
trunk is raised from lying to an angle of 90 degree.
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-
Eyes look forward, ears at the same line ( head in neutral
position).
Shoulders at the same level.
-
Back is straight.
-
Arms by the side
Knees are extended
-
Ankles are relaxed.
Fig (5): Long sitting position.
Forward Lean Sitting (Fig. 6)
Trunk is inclined forwards and the head is supported on
pillows on a table at the front.
Fig (6): Forward Lean
Sitting Position.
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Kneeling
Characteristics
The position is unstable and difficult to maintain as the center of
gravity is high and the line of gravity falls close to the edge of
the base which the area of the legs only
Description:
The body is upright from the knees which are held at right angle
- Eyes look forward, ears at the same line ( head in neutral
position).
-
Shoulders at the same level.
Arms by the side of the body palms facing inward.
-
The back is straight.
Pelvis at the same level.
Lower limbs ( hips straight and knee right angle flexion).
Knees and legs are together and supported on the floor
The feet are planter flexed
Positions derived from kneeling
Kneel Sitting
The position is stable. From kneeling to sitting back on the heels.
Prone Kneeling (cat position) (Fig. 7)
Kneeling supported by the four limbs. The arms should be
straight and the hands in line below the shoulders. Right angle
should be maintained at the hips and knees. The ankles are
planter flexed.
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Fig (7): Prone Kneeling Position.
Standing
Characteristics
The base of support is very small and the center of gravity is
high.
Description:
The body is erect with
-
Eyes look forward, ears at the same line ( head in neutral
position).
Shoulders at the same level.
Arms by the side of the body palms facing inward.
The back is straight and stretched.
Pelvis at the same level.
Lower limbs ( hips and knees) straight.
The feet are together at the same level. The toes are
slightly apart (the angle between the feet not exceed 45
degree).
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Positions derived from standing
Stride Standing
It is the most commonly used position assumed by the
physical therapist during treatment of patients.
-
The same as standing but the feet are sideways pace apart
and the base is therefore wide side to side giving good
lateral stability.
Walk Standing
- The same as standing but the feet are a forward pace apart
and the base is therefore wide from front to back giving
good anteroposterior stability.
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Range of Motion Exercise
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RANGE OF MOTION EXERCISES
Range of motion:
Range of motion is the term that is used to describe the
amount of movement that occur at each joint. Every joint in the
body has a "normal" range of motion. Joints maintain their
normal range of motion by being moved. It is therefore very
important to move all your joints every day.
Causes of decreased Range of Motion
1- Prolonged immobilization or bed rest.
2- Trauma to soft tissues, bones or other joint structures.
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Muscle weakness.
Surgeries.
Joint disease.
Neuromuscular disease.
Pain.
Effect of Immobilization and Decreases Mobility
Immobilization leads to decrease loading and stress on joints
and soft tissues resulting in
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Joint stiffness and adhesion.
Atrophy and weakness of the skeletal muscle.
Decrease tensile strength of tendons and ligaments.
Degeneration of articular surface.
Adaptive shortening of the muscle and soft tissues.
Osteoporotic changes of the bone.
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All these complications lead to decrease ability of to perform
the activities of daily living
Range Of Motion Exercises
Active
Assisted
ROM
exercises
Passive
ROM
exercises
Active Free
ROM
exercises
Joint
Mobilization
Stretching
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Range of motion exercises:
Range of motion exercises are also called "ROM" exercises.
ROM exercises may be active or passive. Active ROM is
done when a person can do the exercises by himself. Activeassisted ROM exercises are done by the person and a helper.
Passive ROM exercises are done for a person by a helper. The
helper does the ROM exercises because the person cannot do
them by himself.
Importance of ROM Exercises
Range of motion (ROM) exercises are done to
1- Preserve and increase flexibility and mobility of the joints
on which they are performed.
2- Prevent or at least slow down the freezing or adhesion of
joints.
3- Reduce stiffness.
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PASSIVE RANGE OF MOTION EXERCISES
Definition:
It is exercise in which movement is performed by an
external force in the available pain free range of motion. The
external force may be from the therapist, family member, or the
patient or equipment.
Passive ROM exercises are characterized by:
 No muscular activation by the patient



Performed within the available ROM
Applied by some external force
No pain
Importance of Passive ROM Exercises
Passive ROM exercises are very important if you have to
stay in bed or in a wheelchair. ROM exercises help keep joints
and muscles as healthy as possible. Without these exercises,
blood flow and flexibility (moving and bending) of the joints can
decrease. Passive ROM exercises help keep joint areas flexible.
Indications
Passive exercises are indicated with the following conditions
1- when voluntary movements are impossible as when the
subject is comatose, or when paralysis of the part.
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2- When Active movement may disrupt the healing process,
as when there is acute inflammation of the joint or the
surrounding tissue.
3- When active movement is too painful to perform, as after
surgery and injury for 2 to 6 days according to the
condition.
Aims of Passive ROM Exercise
Passive exercises are largely preventive in nature and are
used to:
1- Maintain range of motion.
2- Maintain joint and connective tissue mobility.
3- Minimizes the effects of and the formation of
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contractures.
Enhances synovial movement.
Maintain mechanical elasticity of muscles.
Assist circulation and vascular dynamics.
Help maintain the patient’s awareness of movement.
Points to remember
Passive ROM exercises will NOT
 Build up muscles or make them stronger.
 Prevent muscle atrophy
 Increase strength or endurance
 Assist in circulation to the extent that active, voluntary
muscle contraction will
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Application of Passive Exercises
Technical Principles
Before performing passive exercises, some of the technical
principles should be remembered
1- Place the patient in proper comfortable position with
proper body alignment and stabilization to perform the
exercise.
2- The therapist should be in a proper position and effective
stance
3- Free the region from restrictive closes, linen, splints, and
dressings
4- Drape and cover the patient as necessary.
5- Utilize the proper hand holds or grasps by the therapist.
6- Perform the exercise slowly, smoothly with rhythm
within the available pain free range of motion without any
force behind the range.
7- Do all ROM exercises smoothly and gently. Never force,
jerk, or over-stretch a muscle. This can hurt the muscle or
joint instead of helping.
8- Stop ROM exercises if the person feels pain. The
exercises should never cause pain or go beyond the
normal movement of that joint.
9- Repeat the exercise 5 to 10 repetitions according to the
patient condition and response
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Procedures
Passive Exercises of the Upper limb
Shoulder Flexion and Extension (Fig. 1)
Patient Position: Supine lying
Therapist Position : Stride standing beside the involved part at
the level of the elbow. The therapist move his body weight over
his legs to follow the movement
Grasp:
* Distal hand grasps the patient’s arm just under the elbow
* Proximal hand, crossover and grasp the wrist and palm of the
patient’s hands
Motion: Lift the arm through the available range of motion of
flexion and return to extension.
Fig. (1): Shoulder
flexion and Extension
(A) initiating and (B)
Completing shoulder
flexion
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Alternate Position: if the patient can not assume supine lying
position the exercise could be performed from side lying. The
proximal hand stabilize the scapula and the distal hand and
forearm carry and support the weight of the patient’s upper limb.
This position enable the therapist to perform shoulder
hyperextension also (Fig. 2).
Fig. (2): Shoulder flexion, extension and hyperextension.
Shoulder Abduction and Adduction (Fig. 3)
Patient Position: Supine lying.
Therapist Position: Stride standing beside the involved part at
the level of the elbow. The therapist should step back to allow
the patient’s arm to move in full range of motion of abduction.
Grasps:
Proximal hand just under the elbow.
Distal hand grasps the patient’s wrist and the palm, or shake
hand with the patient’s hand.
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Motion: The therapist bring the arm horizontally away from the
body until 90 degree and then return with it again into adduction.
Fig. (3): Shoulder abduction and adduction.
Shoulder Internal and external Rotation (Fig. 4)
Patient Position: supine lying with the affected arm shoulder
flexed 90 degrees and elbow flexed 90 degrees, the forearm in
neutral position so the palm face the patient.
Therapist Position: Stride standing at the level of the elbow.
Grasp:
Proximal hand grasps patient’s wrist and hand with the index
between the patient’s thumb and index and thumb and the rest of
fingers on either sides of the patient’s wrist to stabilize it.
Distal hand grasps the elbow under grasp.
Motion: The therapist move the forearm towards the feet in
internal rotation then towards the head in external rotation.
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Fig. (4): Shoulder internal and external Rotation.
Shoulder Horizontal Abduction and Adduction (Fig. 5)
Patient Position: supine lying with the shoulder at the edge of
the table, shoulder in abduction 90 degree and elbow either
flexed or extended.
Therapist Position: Stride standing at the shoulder level facing
the patient.
Grasp: As in flexion and extension.
Motion: move the upper limb across the chest towards the other
shoulder then return.
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Fig. (5): Horizontal (A) abduction and (B) adduction
of the shoulder.
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Movements of the shoulder joint could be performed with
elbow flexed if the limb is completely paralyzed or the
patient is too obese and the weight of the limb is heavy for
the therapist.
Elbow Flexion and Extension (Fig. 6)
Patient Position: Supine lying with the forearm supinated.
Therapist Position: Stride standing at the level of the forearm.
Grasp:
Proximal hand grasp the wrist and hand of the patient.
Distal hand holding under the elbow..
Motion: the elbow is bend into flexion then extended with the
forearm in different position of supination, pronation and mid
position.
Fig. (6): Elbow flexion and extension.
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Pronation and Supination (Fig. 7)
Patient Position: Supine lying with elbow flexed 90 degrees.
Therapist position: Stride standing at the level of the elbow
Grasp:
Proximal hand grasping the patient’s wrist, supporting the hand
with the index finger and placing the thumb and the rest of the
fingers on either sides of the wrist. Other grasp is by shake hand
with the patient
Distal hand holding the elbow in position with under grasp.
Motion: roll the forearm into supination and pronation.
Fig. (7): Supination and pronation.
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Wrist joint Flexion, Extension, Radial Deviation and Ulnar
Deviation (Fig. 8)
Patient Position: Supine lying with elbow flexed 90 degrees and
forearm in mid position.
Therapist Position: Stride standing facing the patient at the level
of the forearm.
Grasp:
Proximal hand stabilize the forearm just above the wrist joint.
Distal hand hold patient’s hand.
Motion: move the wrist in the four directions.
To get full range of wrist allow fingers to move freely as you
move the wrist.
Fig. (8): Passive exercises for wrist joint.
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Thumb and Fingers Passive Exercises( Fig. 9)
Patient Position: Supine with elbow flexed 90 degrees.
Therapist Position: Stride standing facing the patient.
Grasp:
There are many joints of the fingers (metacarpophalangeal and
proximal and distal interphalangeal joints, so as a role always
with one hand, stabilize proximal to the joint you want to move
and then with the other hand move the distal segment of the
joint.
Passive Exercises of the Lower Limb
Hip Flexion and Extension (Fig. 10)
Patient Position: supine lying position.
Therapist Position: Stride standing at the level of the patient’s
knee joint facing the patient.
Grasp:
Proximal hand under the patient’s knee to support and lift the
patient’s leg.
Distal hand under the heel.
Motion: the lower limb is taken into complete hip and knee
flexion and as you flex the knee the therapist’s hand should slide
to the side of the thigh to avoid limiting the range. At the end of
the range the therapist’s hand may slide over the knee to reach
full range. Then the therapist slides his hand under the knee to
carry the weight of the lower limb and bring the lower limb back
to extension of hip and knee.
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Fig. (9): Passive Exercises of
the thumb (A) and
Fig. (10): Flexion and
Extension of the hip.
the fingers (B).
Alternate Position: if the patient can not assume supine lying
position the exercise could be performed from side lying. The
proximal hand stabilize the pelvis and the distal hand and
forearm carry and support the weight of the patient’s lower limb.
This position also enable the therapist to perform hip
hyperextension also (Fig. 11).
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Fig. (11): Hip Flexion, Extension, and hyperextension
from side lying
Abduction and Adduction of the Hip (Fig. 12)
Patient Position: Supine lying with the affected lower limb in
neutral position and the other lower limb in slight abduction to
permit full adduction of the affected limb.
Therapist Position: Walk standing at the level of the patient’s
knee.
Grasp:
Proximal hand under the patient’s knee to support the leg .
Distal hand under the heel.
Motion: move the limb into abduction away from the patient and
towards you as you step back to allow full range. Then bring the
lower limb into full adduction until in contact with the
unaffected one.
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Fig. (12): Abduction and adduction of the hip.
Hip Internal and External Rotation with knee flexed (Fig. 13)
Patient Position: Supine lying With hip and knee flexed 90
degrees
Therapist Position: Stride standing at the level of the patient’s
knee.
Grasp:
Proximal hand over the patient’s knee to support the knee in
flexion.
Distal hand and forearm carrying the patient’s lower leg.
Motion: move the leg medial and lateral so the hip will rotate
into internal and external rotation
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Fig. (13): Hip Internal and External Rotation with knee flexed
Hip Internal and External Rotation with Extended knee
Patient Position: Supine lying
Therapist Position: Stride standing at the level of the patient’s
knee.
Grasp:
Proximal hand under the patient’s knee to support the knee.
Distal hand under the ankle.
Motion: roll the thigh inward and outward.
Ankle Dorsi and Planter Flexion (Fig. 14)
Patient Position: Supine lying
Therapist Position: Stride standing at the level of the patient’s
feet.
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Grasp:
Proximal hand just above ankle joint to stabilize the lower leg in
dorsi flexion and in planter flexion the hand over the dorsum of
the foot.
Distal hand and forearm carrying the patient’s foot.
Motion: move the foot up into dorsi flexion and pushing down
into planer flexion.
Fig. (14): Ankle Dorsi and Planter Flexion
Subtalar Inversion and Eversion (Fig. 15)
Patient Position: Supine lying
Therapist Position: Stride standing at the level of the patient’s
feet.
Grasp:
Proximal hand just above ankle joint to stabilize the lower leg.
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Distal hand and forearm carrying the patient’s foot. The thumb
medial and the fingers lateral to the joint on either side of the
heel.
Motion: turn the heel inward and outward.
Fig. (15): Subtalar inversion (A) and eversion (B).
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