1. Range of motion
By:
Dr. Michael Banoub

2. Range of motion is a basic technique used for the examination of movement and for initiating movement into a program of therapeutic intervention.
Movement that is necessary to accomplish functional activities can be viewed, in its simplest form, as muscles or external forces moving bones in various patterns or ranges of motions.
When moving a segment through its ROM, all structures in the region are affected: muscles, joint surfaces, capsules, ligaments, fasciae, vessels, and nerves.

3. ROM activities are most easily described in terms of joint range and muscle range.
To describe joint range, terms such as flexion, extension, abduction, adduction, and rotation are used. Ranges of available joint motion are usually measured with a goniometer and recorded in degrees.
Muscle range is related to the functional excursion of muscles.
Functional excursion is the distance a muscle is capable of shortening after it has been elongated to its maximum.26 In some cases the functional excursion, or range of a muscle, is directly influenced by the joint it crosses. For example, the range for the brachialis muscle is limited by the range available at the elbow joint. This is true of one-joint muscles

4. An example of a two joint muscle functioning at the elbow is the biceps brachii muscle. If it contracts and moves the elbow into flexion and the forearm into supination while simultaneously moving the shoulder into flexion, it shortens to a point known as active insufficiency, where it can shorten no more.
The muscle is lengthened full range by extending the elbow, pronating the forearm, and simultaneously extending the shoulder. When fully elongated it is in a position known as passive insufficiency.
Two-joint or multijoint muscles normally function in the mid portion of their functional excursion, where ideal length-tension relations exist.

5. TYPES OF ROM EXERCISES
Passive ROM. Passive ROM (PROM) is movement of a segment within the unrestricted ROM that is produced entirely by an external force; The external force may be from gravity, a machine, another individual, or another part of the individual’s own body.

6. TYPES OF ROM EXERCISES
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.

7. TYPES OF ROM EXERCISES
Active-Assistive ROM. Active-assistive ROM (AAROM) 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.

8. INDICATIONS For Passive ROM
In the region where there is acute, inflamed tissue, passive motion is beneficial
When a patient is not able to or not supposed to actively move a segment or segments of the body, as when comatose, paralyzed, or on complete bed rest

9. GOALS For Passive ROM Maintain joint and connective tissue mobility
Minimize the effects of the formation of contractures
Maintain mechanical elasticity of muscle
Assist circulation and vascular dynamics

10. GOALS For Passive ROM
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

11. Other Uses for PROM
When a therapist is examining restricted structures, PROM is used to determine limitations of motion, to determine joint stability, and to determine muscle and other soft tissue elasticity.
When a therapist is teaching an active exercise program, PROM is used to demonstrate the desired motion.
When a therapist is preparing a patient for stretching

12. Limitations of Passive Motion
Prevent muscle atrophy
Increase strength or endurance
Assist circulation to the extent that active, voluntary muscle contraction does

13. PRECAUTIONS AND CONTRAINDICATIONS TO ROM EXERCISES
Both PROM and AROM are contraindicated under any circumstance when motion to a part 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

14. PRECAUTIONS AND CONTRAINDICATIONS TO ROM EXERCISES
PROM may be carefully initiated to major joints and AROM to ankles and feet to minimize venous stasis and thrombus formation.
After myocardial infarction, or coronary artery bypass surgery, AROM of upper extremities and limited walking are usually tolerated under careful monitoring of symptoms.

15. PRINCIPLES AND PROCEDURES FOR APPLYING ROM TECHNIQUES
Examination, Evaluation, and Treatment Plannig
1. Examine and evaluate the patient’s impairments and level of function, determine any precautions and prognosis, and plan the intervention.
2. Determine the ability of the patient to participate in the ROM activity and whether PROM, A-AROM, or AROM can meet the immediate goals.
3. Determine the amount of motion that can be safely applied for the condition of the tissues and health of the individual.

16. 4. Decide what patterns can best meet the goals
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, any change in the warmth and color of the segment, and any change in the ROM, pain, or quality of movement.
6. Re-evaluate and modify the intervention as necessary.

17. 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, 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.

18. 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, The number of repetitions depends on the objectives of the program and the patient’s condition and response to the treatment.

19. Techniques of ROM Exercises

20. 1- RELAXED PASSIVE MOVEMENT
Definition:
These are movements performed accurately, rhythmical and smoothly by the physiotherapist through available range of motion( according to anatomy of joints) . The joint is moved through the free range and within the limits of pain.

21. II- Forced passive movement
Definition An exercise performed on a subject by a partner who exerts an external force not only to produce a passive movement, but also to increase the range of movement of a joint. The partner presses the joint into its end-position (i.e. end of range), while the subject's muscles that normally carry out the movements are completely relaxed. There is a danger of overextension beyond the range of movement and damage to the joint if the exercise is not carried out carefully.

22. Continuous passive motion (CPM)
A continuous passive motion device maintains movement of a joint after limb sparing surgery. This device is usually called a CPM. Continuous movement limits stiffness and pain. It is very important to keep joints moving following surgery so that motion will not become limited. The CPM will move the involved leg through its full range of motion. It is only used in bed, but can be used while relaxing, eating, or sleeping.

23. Benefits of CPM
1-decreasing the complication of immobilization. 2-decreasing the post operative complication and pain. 3-improving the recovery rate and ROM. 4-improving the circulation through pumping action. 5-prevent adhesions and contracture. 6-prevent joint effusion and wound oedema.

24. Procedure of CPM
It is important that you understand the use of CPM. The therapist may adjust the device to fit you before surgery. You will begin to use the CPM right after surgery. Your therapist will give you instructions and monitor how you use the device. The CPM is set to allow 45 degrees of motion right after surgery. Generally, motion will be increased about 15 degrees a day. You will need to use the CPM for about 6 weeks after surgery.