Therapeutic exercise ch. 3 ROM

General guidelines for CPM 3

3. The rate of motion is determined; usually 1 cycle/45 sec or 2 min is well tolerated.

Hip: Internal (Medial) and External (Lateral) Rotation

Hand Placement and Procedure With the Hip and Knee Extended ■ Grasp just proximal to the patient's knee with the top hand and just proximal to the ankle with the bottom hand. ■ Roll the thigh inward and outward. Hand Placement and Procedure for Rotation With the Hip and Knee Flexed ■ Flex the patient's hip and knee to 90°; support the knee with the top hand. ■ If the knee is unstable, cradle the thigh and support the proximal calf and knee with the bottom hand. ■ Rotate the femur by moving the leg like a pendulum. ■ This hand placement provides some support to the knee but should be used with caution if there is knee instability.

Cervical Spine Flexion (Forward Bending)

Stand at the end of the treatment table; securely grasp the patient's head by placing both hands (hands overlapped) under the occipital region, thumbs rest on zygomatic arch. Procedure ■ Lift the head as though it were nodding (chin toward larynx) to flex the head on the neck. ■ Once full nodding is complete, continue to flex the cervical spine and lift the head toward the sternum.

Functional patterns

motions used in ADLs

active insufficiency

the point at which a muscle cannot shorten any farther, occurs to the agonist.

shoulder flexion/extension PROM

**Patient supine 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. *patient safety=control of limb *flow w/ motion

evaluation

-Determine the ability of the patient to participate in ROM -PROM, A-AROM, or AROM can meet the immediate goals? -Determine the amount of motion that can be applied safely for the condition of the tissues and health of the individual. -Decide what patterns can best meet the goals.

examination

-Examine and evaluate the patient's impairments and level of function -determine any precautions and their prognosis -plan the intervention.

indications for PROM

-In the region where there is acute, inflamed tissue, passive motion is beneficial. -When a patient is not able to/not supposed to actively move a segment(s) of the body, as when comatose, paralyzed, or on complete bed rest, movement is provided by an external source. -indicated after surgical repair of contractile tissue when active motion would compromise the repaired muscle.

treatment planning

-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 -in the ROM, pain, or quality of movement -Document and communicate findings and intervention. -Re-evaluate and modify the intervention as necessary.

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. -additional exercise benefits= reciprocal patterning, endurance training, and strengthening by changing the parameters of the exercise and monitoring the heart rate and fatigue.

Overhead pulleys (self-assisted shoulder ROM/elbow flexion)

-The pulley has been demonstrated to utilize significantly more muscle activity than therapist-assisted ROM and continuous passive motion machines (described later in the chapter), so this form of assistance should be used only when muscle activity is desired. -The patient should be set up so the pulley is directly over the joint that is moving or so the line of pull is effectively moving the extremity and not just compressing the joint surfaces together. -The patient may be sitting, standing, or supine. PRECAUTION: Assistive pulley activities for the shoulder are easily misused by the patient, resulting in compression of the humerus against the acromion process. Elbow Flexion With the arm stabilized along the side of the trunk, the patient lifts the forearm and bends the elbow.

shoulder horizontal adduction/abduction PROM

-To reach full horizontal abduction, position the patient's shoulder at the edge of the table. Begin with the arm either adducted or abducted 90°. -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.

Skate board/powder board

-Use of a friction-free surface may encourage movement without the resistance of gravity or friction. -Any motion can be done, but most common are abduction/adduction of the hip while supine and horizontal abduction/adduction of the shoulder while sitting.

Wall climbing (self-assisted ROM)

-Wall climbing (or use of a device such as a finger ladder) can provide the patient with objective reinforcement and, therefore, motivation for performing shoulder ROM. -Wall markings may also be used to provide visual feedback for the height reached. -The arm may be moved into flexion or abduction -The patient steps closer to the wall as the arm is elevated.

Passive ROM (PROM)

-movement of a segment within the unrestricted ROM that is produced entirely by an external force; -there is little to no voluntary muscle contraction. -external force may be from: -gravity -a machine -another individual -another part of the individual's own body

Patient Preparation

1. Communicate with the patient. Describe the plan/method of intervention to meet the goals. 2. Free the region from restrictive clothing, linen, splints, and dressings. Drape the patient as necessary. 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 AROM

1. Demonstrate motion desired using PROM; then patient performs motion, your hands may guide/assist patient if needed. 2. Provide assistance only as needed for smooth motion. if weakness, assistance may be required only at beginning/end of ROM/when effect of gravity has the greatest moment arm (torque). 3. Motion is performed within available ROM.

application of PROM

1. During PROM, the force for movement is external; it is provided by a therapist or mechanical device. 2. No active resistance or assistance is given by the patient's muscles that cross the joint. 3. The motion is carried out within the free ROM, the range that is available without forced motion or pain.

General guidelines for CPM 1

1. The device may be applied to the involved extremity immediately after surgery while the patient is still under anesthesia or as soon as possible if bulky dressings prevent early motion.

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 and the patient's condition and response to the treatment.

General guidelines for CPM 2

2. The arc of motion for the joint is determined. A low arc of 20° to 30° is often used initially and progressed 10° to 15° per day as tolerated. The portion of the range used initially is based on the range available and patient tolerance. One study that looked at accelerating the range of knee flexion after total knee arthroplasty found that a greater range and earlier discharge were attained for that group of patients,39 although there was no difference between the groups at 4 weeks.

General guidelines for CPM 4

4. The length of time on the CPM machine varies for different protocols—anywhere from continuous for 24 hours to continuous for 1 hour three times a day.10,18,33 The longer periods of time per day reportedly result in a shorter hospital stay, fewer postoperative complications, and greater ROM at discharge,10 although no significant difference was found in a study comparing CPM for 5 hr/day with CPM for 20 hr/day.2 A study that compared short-duration CPM (3 to 5 hr/day) with long-duration CPM (10 to 12 hr/day) found that patient compliance and the most gained range occurred with a CPM duration of 4 to 8 hours.4

General guidelines for CPM 5

5. Physical therapy treatments are usually initiated during periods when the patient is not on CPM, including activeassistive and muscle-setting exercises. It is important that patients learn to use and develop motor control of the ROM as motion improves.

General guidelines for CPM 6

6. The duration minimum for CPM is usually less than 1 week or when a satisfactory range of motion is reached. Because CPM devices are portable, home use is possible in cases in which the therapist or physician deems that additional time would be beneficial. In these cases, the patient, a family member, or a caregiver is instructed in proper application.

General guidelines for CPM 7

7. CPM machines are designed to be adjustable, easily controlled, versatile, and portable. Some are battery operated (with rechargeable batteries) to allow the individual to wear the device for up to 8 hours while functioning with daily activities.

Muscle range of elongation

Antagonistic to line of pull of the muscle.

Wrist and Hand (Elongation of Extrinsic Muscles/Flexor and Extensor Digitorum Muscles)

General Technique Hand Placement and Procedure ■ First, move the distal interphalangeal joint and stabilize it; then move the proximal interphalangeal joint. ■ Hold both these joints at the end of their range; then move the metacarpophalangeal joint to the end of the available range. ■ Stabilize all the finger joints and begin to extend the wrist. When the patient feels discomfort in the forearm, the muscles are fully elongated.

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.

Forearm: Pronation and Supination PROM

Hand Placement and Procedure Perform pronation and supination with the elbow flexed as well as extended. When the elbow is extended, prevent the shoulder from rotating by stabilizing the elbow. ■ 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. Alternate Hand Placement Sandwich the patient's distal forearm between the palms of both hands.

Lumbar Spine Flexion

Hand Placement and Procedure ■ Bring both of the patient's knees to the chest by lifting under the knees (hip and knee flexion). ■ Flexion of the spine occurs as the hips are flexed full range and the pelvis starts to rotate posteriorly. ■ Greater range of flexion can be obtained by lifting under the patient's sacrum with the lower hand.

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. Alternate Hand Placement One hand is placed on the posterior aspect of the patient's hand with the fingers and thumb cupping the metacarpals.

elbow flexion/extension PROM

Hand Placement and Procedure ■ Grasp the distal forearm and support the wrist with one hand. This hand also controls forearm supination and pronation. ■ With the other hand, support the elbow. ■ Flex and extend the elbow with the forearm supinated and also with the forearm pronated.

shoulder internal/external rotation PROM

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 like a spoke on a wheel.

Elongation of the Two-Joint Hamstring Muscle Group

Hand Placement and Procedure ■ Place the lower hand under the patient's heel and the upper hand across the anterior aspect of the patient's knee. ■ Keep the knee in extension as the hip is flexed. ■ If the knee requires support, cradle the patient's leg in your lower arm with your elbow flexed under the calf and your hand across the anterior aspect of the patient's knee. The other hand provides support or stabilization where needed.

Ankle: Dorsiflexion

Hand Placement and Procedure ■ Stabilize around the malleoli with the top hand. ■ Cup the patient's heel with the bottom hand and place the forearm along the bottom of the foot. ■ Pull the calcaneus distalward with the thumb and fingers while pushing upward with the forearm.

Joints of the Toes: Flexion and Extension and Abduction and Adduction (Metatarsophalangeal and Interphalangeal Joints)

Hand Placement and Procedure ■ Stabilize the bone proximal to the joint that is to be moved with one hand, and move the distal bone with the other hand. ■ The technique is the same as for ROM of the fingers. ■ Several joints of the toes can be moved simultaneously if care is taken not to stress any structure.

Transverse Tarsal Joint

Hand Placement and Procedure ■ Stabilize the patient's talus and calcaneus with one hand. ■ With the other hand, grasp around the navicular and cuboid. ■ Gently rotate the midfoot by lifting and lowering the arch.

Hip and Knee (flex/ext)

Hand Placement and Procedure ■ Support and lift the patient's leg with the palm and fingers of the top hand under the patient's knee and the lower hand under the heel. ■ As the knee flexes full range, swing the fingers to the side of the thigh.

Ankle: Plantarflexion

Hand Placement and Procedure ■ Support the heel with the bottom hand. ■ Place the top hand on the dorsum of the foot and push it into plantarflexion.

Hip: Abduction and Adduction

Hand Placement and Procedure ■ Support the patient's leg with the upper hand under the knee and the lower hand under the ankle. ■ For full range of adduction, the opposite leg needs to be in a partially abducted position. ■ Keep the patient's hip and knee in extension and neutral to rotation as abduction and adduction are performed.

Subtalar (Lower Ankle) Joint: Inversion and Eversion

Hand Placement and Procedure ■ Using the bottom hand, place the thumb medial and the fingers lateral to the joint on either side of the heel. ■ Turn the heel inward and outward.

Elongation of the Two-Joint Rectus Femoris Muscle

Hand Placement and Procedure ■ When supine, stabilize the lumbar spine by flexing the hip and knee of the opposite lower extremity and placing the foot on the treatment table (hook-lying). ■ When prone, stabilize the pelvis with the top hand (see Fig. 4.31). ■ Flex the patient's knee until tissue resistance is felt in the anterior thigh, which means the full available range is reached.

Lumbar spine Rotation

Position the patient in the hook-lying position with hips and knees flexed and feet resting on the table. Hand Placement and Procedure ■ Push both of the patient's knees laterally in one direction until the pelvis on the opposite side comes up off the treatment table. ■ Stabilize the patient's thorax with the top hand. ■ Repeat in the opposite direction.

Lumbar spine extension

Position the patient prone for full extension (hyperextension). Hand Placement and Procedure -With hands under the thighs, lift the thighs upward until the pelvis rotates anteriorly and the lumbar spine extends.

Scapula PROM (Elevation/depression protraction/retraction upward/downward rotation)

Position the patient prone with his or her arm at the side, or side-lying facing toward you with the patient's arm draped 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.

Cervical spine Lateral Flexion (Side Bending) and Rotation

Procedure -Maintain the cervical spine neutral to flexion and extension as you direct the head and neck into side bending (approximate the ear toward the shoulder) and rotation (rotate from side to side).

Cervical spine Extension (Backward Bending or Hyperextension)

Procedure -Tip the head backward.

Hip: Extension (Hyperextension)

Prone or side-lying must be used if the patient has near-normal or normal motion. Hand Placement and Procedure ■ If the patient is prone, lift the thigh with the bottom hand under the patient's knee; stabilize the pelvis with the top hand or arm. ■ If the patient is side-lying, bring the bottom hand under the thigh and place the hand on the anterior surface; stabilize the pelvis with the top hand. For full range of hip extension, do not flex the knee full range, as the two-joint rectus femoris would then restrict the range. Elongation of the Two-Joint Hamstring Muscle Group

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. Alternate Procedure Several joints can be moved simultaneously if proper stabilization is provided. Example: To move all the metacarpophalangeal joints of digits 2 through 5, stabilize the metacarpals with one hand and move all the proximal phalanges with the other hand.

Self-assisted ROM Thumb flexion with opposition and extension with reposition

The patient cups the uninvolved fingers around the radial border of the thenar eminence of the involved thumb and places the uninvolved thumb along the palmar surface of the involved thumb to extend it. To flex and oppose the thumb, the patient cups the normal hand around the dorsal surface of the involved hand and pushes the first metacarpal toward the little finger.

Elongation of Two-Joint Biceps Brachii Muscle PROM

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.

shoulder adduction/abduction PROM

Use the same hand placement as with flexion, but move the arm out to the side. The elbow may be flexed (90 degrees) for ease in completing the arc of motion. *Reverse T position

passive insufficiency

When a muscle cannot stretch anymore, occurs with the antagonist.

Elongation of Two-Joint Long Head of the Triceps Brachii Muscle PROM

When the 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.

Combined patterns

diagonal motions or movements that incorporate several planes of motion

Limitations of AROM

does not : -(for strong muscles) maintain or increase strength. -develop skill or coordination except in the movement patterns used.

limitations of PROM

does not: ■ Prevent muscle atrophy ■ Increase strength or endurance ■ Assist circulation to the extent that active, voluntary muscle contraction does

Active assisted 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.

Active ROM (AROM)

is movement of a segment within the unrestricted ROM that is produced by active contraction of the muscles crossing that joint.

Continuous passive motion (CPM)

refers to passive motion performed by a mechanical device that moves a joint slowly and continuously through a controlled ROM. The mechanical devices that exist for nearly every joint in the body

Range of Motion (ROM)

total motion possible in a joint, described by the terms related to body movements (i.e., ability to flex, extend, abduct, or adduct); measured in degrees *activities are administered to maintain joint and soft tissue mobility to minimize loss of tissue flexibility and contracture formation.

Self-assisted ROM Shoulder rotation

■ Beginning with the arm at the patient's side in slight abduction and with the elbow resting on a small pillow to elevate it or abducted 90° and elbow flexed 90°, the patient moves the forearm "like a spoke on a wheel" with the uninvolved extremity. It is important to emphasize rotating the humerus, not merely flexing and extending the elbow.

Self-assisted ROM Pronation and supination of the forearm

■ Beginning with the forearm resting across the body, the patient rotates the radius around the ulna. Emphasize to the patient not to twist the hand at the wrist joint.

Wand (T bar) exercise Variations and combinations of movements

■ For example, the patient begins with the wand behind the buttocks and then moves the wand up the back to achieve scapular winging, shoulder internal rotation, and elbow flexion.

goals for PROM

■ 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.

goals for AROM

■ 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.

Benefits of CPM

■ Preventing development of adhesions and contractures and thus joint stiffness ■ Providing a stimulating effect on the healing of tendons and ligaments ■ Enhancing the healing of incisions over the moving joint ■ Increasing synovial fluid lubrication of the joint and thus increasing the rate of intra-articular cartilage healing and regeneration ■ Preventing the degrading effects of immobilization ■ Providing a quicker return of ROM

Wand (T bar) exercise Shoulder hyperextension

■ Shoulder hyperextension. The patient may be standing or prone. He or she places the wand behind the buttocks, grasps the wand with hands a shoulder width apart, and then lifts the wand backward away from the trunk. The patient should avoid trunk motion.

Self-assisted ROM Elbow flexion and extension

■ The patient bends the elbow until the hand is near the shoulder and then moves the hand down toward the side of the leg.

Self-assisted ROM Shoulder flexion and extension

■ The patient lifts the involved extremity over the head and returns it to the side

Self-assisted ROM Wrist flexion and extension and radial and ulnar deviation

■ The patient moves the wrist in all directions, applying no pressure against the fingers.

Self-assisted ROM Combined hip abduction with external rotation

■ The patient sits on the floor or on a bed with the back supported, the involved hip and knee flexed, and the foot resting on the surface. The knee is moved outward (toward the table/bed) and back inward, with assistance from the upper extremities.

Self-assisted ROM Ankle and Toes

■ The patient sits with the involved extremity crossed over the uninvolved one so the distal leg rests on the normal knee. The uninvolved hand moves the involved ankle into dorsiflexion, plantarflexion, inversion, and eversion and toe flexion and extension

Self-assisted ROM Finger flexion and extension

■ The patient uses the uninvolved thumb to extend the involved fingers and cups the normal fingers over the dorsum of the involved fingers to flex them

Wand (T bar) exercise Shoulder internal and external rotation

■ The patient's arms are at the sides, and the elbows are flexed 90°. Rotation of the arms is accomplished by moving the wand from side to side across the trunk while maintaining the elbows at the side (Fig. 3.33C). The rotation should occur in the humerus; do not allow elbow flexion and extension. To prevent substitute motions as well as provide a slight distraction force to the glenohumeral joint, a small towel roll may be placed in the axilla with instruction to the patient to "keep the roll in place." ■ Alternate position. The patient's shoulders are abducted 90°, and the elbows are flexed 90°. For external rotation, the wand is moved toward the patient's head; for internal rotation, the wand is moved toward the waistline.

Wand (T bar) exercise Elbow flexion and extension

■ The patient's forearms may be pronated or supinated; the hands grasp the wand a shoulder -width apart. Instruct the patient to flex and extend the elbows.

Wand (T bar) exercise Shoulder flexion and return

■ The wand is grasped with the hands a shoulder width apart. The wand is lifted forward and upward through the available range, with the elbows kept in extension if possible (Fig. 3.33A). Scapulohumeral motion should be smooth; do not allow substitute motions such as scapular elevation or trunk movement.

Wand (T bar) exercise Shoulder horizontal abduction and adduction

■ The wand is lifted to 90° shoulder flexion. Keeping the elbows extended, the patient pushes and pulls the wand back and forth across the chest through the available range (Fig. 3.33B). Do not allow trunk rotation.

indications for AROM

■ When a patient is able to contract the muscles actively and move a segment with or without assistance ■ When a patient has weak musculature and is unable to move a joint through the desired range (usually against gravity), A-AROM is used to provide enough assistance to the muscles in a carefully controlled manner so the muscle can function at its maximum level and be progressively strengthened. ■ When a segment of the body is immobilized for a period of time, it is used on the regions above and below the immobilized segment to maintain the areas in as normal a condition as possible and to prepare for new activities such as walking with crutches. ■ used for aerobic conditioning programs and is used to relieve stress from sustained postures

Self-assisted ROM Hip and knee flexion

■ With the patient supine, instruct the patient to initiate the motion by lifting the involved knee by slipping his or her normal foot under the knee or with a strap or belt under the involved knee. The patient can then grasp the knee with one or both hands to bring the knee up toward the chest to complete the range. With the patient sitting, he or she may lift the thigh with the hands and flex the knee to the end of its available range.

other uses for PROM

■ examining inert structures, is used to determine limitations of motion, joint stability, muscle flexibility, and other soft tissue elasticity. ■ teaching an active exercise program, PROM is used to demonstrate the desired motion. ■ preparing a patient for stretching, PROM is often used preceding the passive stretching techniques.

Self-assisted ROM Shoulder horizontal abduction and adduction

■Beginning with the arm abducted 90°, the patient pulls the extremity across the chest and returns it to the side.