Download Active Free ROM Exercises May be Limited by

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
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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.
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.
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3- Minimizes the effects of and the formation of contractures.
4- Enhances synovial movement.
5- Maintain mechanical elasticity of muscles.
6- Assist circulation and vascular dynamics.
7- 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
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 overstretch 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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Active Assisted Range of Motion Exercises
Definition:
Active assisted range of motion exercise (AAROM) is a type of active
(ROM) in which patient can voluntary produce movement but unable to complete
range of motion and assistance is provided by outside force to complete the range
of motion. The outside force may be therapist, family member, patient himself
(self assisted) or equipment (sling suspension unit, boards, and pulley circuits.
So active assisted range of motion 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 assisted ROM exercises are characterized by:
 Patient can voluntary activate the muscle and produce muscle contraction.
 Patient is unable to fully activate the muscle and complete the range of
motion.
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Assistance may be provided throughout the range or mostly just at ends,
depending upon the patient.
Motion can be performed against gravity or in a gravity-minimized
situation (omitting gravity or gravity eliminated).
Indications of AAROM Exercises
AAROM Exercises are Indicated When
 Patient is unable to complete ROM actively because of weakness due to
o trauma
o neurologic injury
o muscular or neuromuscular disease
o pain
 Pt is not allowed to fully activate muscle following surgery
(muscultendinous).
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When patient has weak musculature and is unable to move the joint through the
desired range of motion, AAROM exercises is used to provide enough
assistance to the muscles in a carefully controlled manner so that so that the
muscle can progressively be strengthened.
The amount of assistance should be progressively reduced as the muscle
strength increase.
Procedures for AROM Exercises
 Demonstrate motions using PROM.
 Choose the appropriate position to perform the exercise that enable or
modify the effect of gravity during the exercise (omitting or against
gravity).
 Assist only to complete range or make motion smooth and correct. The
assistance is given at the part of the range that the patient can not complete
 Motion is done within the available pain free ROM.
 The patient should be always encouraged to perform the motion through the
available range of motion by the clear and sharp order of the therapist.
Active Free Range of Motion Exercises
Definition:
Active free ROM 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 without external assistance or resistance behind that of the gravity.
Active Free ROM Exercises consists of simple everyday anatomical
movements and gymnastics exercises.
Active Free ROM exercises are characterized by:
 Mobility activities performed by active muscle contraction.
 Can be performed against gravity or in a gravity-minimized situation
(omitting gravity or gravity eliminated).
 Motions can be in cardinal planes, combined motions, or functional
activities.
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Indications of Active Free ROM Exercises
Active free ROM exercises may be used for
1- General mobility exercise.
2- Aerobic conditioning exercises.
3- When a segment of the body is immobilized for a period of time, active free
ROM exercise is used on the regions above and below the immobilized
segment to maintain the areas in as normal as possible and prepare for new
activities.
Active Free ROM Exercises May be Limited by
 Muscular strength
 Muscular or cardiovascular endurance
 Coordination and balance
Application of Active Free ROM Exercises
 Demonstrate motions using PROM then ask the patient to perform the
motion..
 Assist only to make motion smooth and correct
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Motion is done within the available pain free ROM.
Motion is done first omitting gravity then against gravity according to the
patient condition and the muscle strength.
Procedures
Active free ROM exercises have the same techniques and steps for application
as active assisted ROM exercises but the patient is able to perform the movement
through full range of motion without assistance of external force. So all the
procedures previously mentioned in the application of AAROM exercises can be
used for active free ROM exercises.
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Isometric Exercises
Definition
Isometric exercise also known as static exercise. It is exercise which involves
muscular contractions without movement of the involved parts of the body. So it
involves muscular contractions against a load which is fixed or immovable or is
simply too much to overcome.
Isometric comes from the Greek "iso-", equal + "metron", measure =
maintaining the same measure, dimension or length.
Isometric exercise is “exercise in which a muscle contracts and produces force
without an appreciable change in length of the muscle and without visible joint
motion.
Isotonic exercise: Exercise in which a contracting muscle shortens against a
constant load, as when lifting a weight.
Types of Isometric Exercises
1- Muscle setting exercises.
2- Stabilization exercises
3- Multiple angle isometrics
Muscle Setting Exercise
Definition: is low intensity isometric exercise performed against little to no
resistance.
As muscle setting is not performed against any appreciable resistance, it will not
improve muscle strength except in very weak muscles
Importance
1- Muscle setting can retard muscle atrophy in the stage of rehabilitation of a
muscle when immobilization is necessary.
2- It is used to promote muscle relaxation and circulation and to decrease
muscle pain and spasm after injury to soft tissues during the acute stage of
healing.
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3- Muscle setting maintain mobility between muscle fibers as they heal.
Indications of Isometric Exercises
1- During immobilization as joint movement is not possible due to
immobilization by casts, splints, braces, or various types of traction
apparatus.
2- After joint surgeries or injuries, when movement is too painful, or when
movement may interfere with the healing process.
3- When the muscle weakness is confined to a definite angle or part of the
range.
Aims of Isometric exercises
1- Prevent or minimize muscle atrophy when joint movement is not possible
2- Activate muscle and facilitate muscle contraction specially after surgeries
or when acute injury of the joint or the soft tissue surrounding it.
3- Develop posture or joint stability.
4- Improve muscle strength when use of dynamic resistance exercises could
harm the condition.
5- To develop static muscle strength at particular points of the range
consistent with specific task related needs.
Contraindications and precautions
1- Isometric exercise can increase blood pressure and heart rate to levels that
would be dangerous for anyone with undiagnosed cardiac problems.
2- Isometric exercise also increases intra abdominal pressure to dangerously
high levels.
3- Be wear to instruct the patient not to hold breathing during isometric
exercise to avoid valsalva maneuver.
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Points to remember
 Muscular strength is only at the specific angle at which the exercise is
performed. Hence, to make isometric exercise effective at increasing functional
strength it must be repeated at many different joint angles.
 Isometric exercise does not increase muscular endurance or functional capacity
in real world situation as dynamic exercise
 Isometric improvements have also been shown to be rate specific. Isometric
exercise is best effective at slower movements
 Isometric exercises on their own are not recommended for strength training.
They are only part of a complete exercise program.
 The great thing about isometric exercises is they can be performed just about
anywhere and at any time.
Clinical Application of Isometric Exercises
Principles of Application
 To achieve effect, it's necessary to maintain isometric contraction for 6 to10
seconds.
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The exercise should be repeated 5 to 10 times.
Any one isometric exercise will only increase muscle strength at one joint
angle. Strengthening the other joint positions requires repetition of further
corresponding exercises.
Allow a period of rest following each sets of contraction to avoid fatigue.
Quadriceps Setting (Fig. 1)
Patient position: supine lying. Involved lower limb straight and the other lower
limb may be flexed or straight.
Order: Keeping your knee straight, tighten your thigh muscle by pushing the back
of your knee down on the bed. Hold for a count of 5. Relax. Do 20 repetitions.
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Fig. (1): Quadriceps setting.
Terminal Knee Extension ( Short arc Quadriceps):
Patient Position: supine Lying on with a roll under the knee, so that it is
slightly bent.
Order: straighten your knee and hold for a count of 5. Relax. Do not lift your
leg off the roll. Do 20 repetitions.
Fig. (2): Short arc quadriceps.
Straight Leg Raising (Fig. 3)
Patient Position: supine Lying. The unexercised limb may be flexed for relaxation
of the back. The exercised limb is straight.
Order: slowly lift your leg up, making sure to lift the heel first. Lift only as high
as your other leg. Now slowly lower your leg back down. Do not hold. Do 20
repetitions.
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Fig. (3): Straight Leg Raising.
Gluteal Sets ( Fig. 4)
Patient Position: supine lying with the legs straight.
Order: Squeeze your buttocks together. Hold for 5 counts. Relax. Repeat.
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Fig. (4): Gleuteal Sets.
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RESISTANCE EXERCISE
Definition
Resistance exercise is active exercise in which muscle contraction is resisted
by an outside force. This outside force may be manual or mechanical.
Types of Resistive Exercise
Resistance Exercise
Isometric
Isotonic
Isokinetic
Isometric Resisted Exercise
Isometric resisted exercise is a static contraction of muscle against external
resistance without appreciable change in its length or joint motion.
Advantage
1- Isometric exercise is valuable when joint motion is uncomfortable or
contraindicated, during immobilization.
2- Isometric exercise is effective when weakness exist at a specific point in the
ROM.
3- Easy to understand.
Disadvantage
Isometric strength is specific to the joint angle (joint angle dependent).
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Isotonic Resisted Exercise
Isotonic resisted exercise is dynamic exercise that is carried out against
resistance as a muscle lengthens or shortens through the available range of motion.
CONCENTRIC CONTRACTION occurs when active muscle undergoes
shortening while overcoming external resistance.
ECCENTRIC CONTRACTION occurs when active muscle undergoes
lengthening while being overcome by an external resistance.
 Eccentric contraction performed against supramaximal resistance generates
greater force production than concentric contraction.
Mode of Resistance Application
Manual
Mechanical
Manual Resisted Exercise
Manual resistance exercise is active resisted exercise in which the resistance
force is applied by the therapist to either a dynamic or isometric contraction.
Advantage
1- The resistance can be varied with changes in strength production
throughout the range.
2- When joint motion is allowed, manual resisted exercise offer an easy
inexpensive method of strengthening muscle.
3- Specific or individual muscle could be strengthened.
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Disadvantage
1- The amount of resistance depend on the therapist condition.
2- The resistance can not be measures so the treatment results can not be
documented.
3- Effort and time consuming as the therapist can treat only one patient at a
time.
Mechanical Resistance Exercise
Mechanical resisted exercise is active resisted exercise in which the resistance
provided by equipments to either a isotonic or isometric muscle contraction.
- A variety of mechanical equipment are available ranging from simple to
complex, small to large, and expensive to inexpensive. The choice between them
depend on the patients need and ability, goal of the exercise and availability of
the apparatus.
1- Free weights
2- Weight machine
3- Exercise bicycle
4- Pulley system
Advantage
1- Objective quantitative documentation of the patient progress.
2- The level of resistance not limited by the therapist strength.
3- Add a variety to the exercise.
4- Safe time and effort of the therapist.
Disadvantage
1- The resistance can not be varied throughout the range of motion. Amount
of resistance is fixed all over the range.
2- Need space and may be expensive.
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Dose of Resisted Exercise
The exercise dosage can be increases
Exercise Dose
by:
Position
1- Changing the relationship to gravity
Lever arm
2- Increase lever arm (hand placement)
Repetitionٌٌ
3- Increase repetition of exercise
Duration
4- Increase duration of exercise
Amount
5- Increase amount of resistance (mildmoderate- maximum)
6- Decease speed
Speed
Be sure not to proceed to a more difficult exercise before the patient perform
the lower graduation first, otherwise overwork and fatigue occur
Isokinetic Resistive Exercise
Isokinetic exercise is a form of active exercise in which a muscle or group of
muscles contracts against a controlled accommodating resistance which is moving
at a constant angular velocity.
The isokinetic exercise are performed with a specialized apparatus that
provides variable resistance to a movement, so that no matter how much effort is
exerted, the movement takes place at a constant speed.
- The isokinetic device are computerized training and testing device that provide
maximum resistance through the entire ROM.
- The device provide multi-angle isometric resistance, resisted concentric and
eccentric exercise.
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Advantage
1- Ability to fully activate more muscle fiber for longer period because the
machine accommodate the resistance according to the changing ability
throughout the ROM.
2- Allow training at a variety of speeds
3- Provide objective documentation
4- The isokinetic device provides many strengthening protocols to chose from
according to the patient condition and the goal of exercise. For example
(isometric conditioning, isokinetic conditioning, eccentric & eccentric
conditioning and open & closed chain conditioning)
Disadvantage
1- The device is expensive
2- Require trained personnel for setting up the patient training program.
Precaution with Resisted Exercise
1- The use of valvasia maneuver should be avoided during resistive training
especially by a patient with cardiopulmonary disease, recent abdominal,
intervertebral disc, or eye surgery.
2- During resistive training especially with eccentric contraction and increase
exercise dose minor lesions of the muscle and inflammation occur resulting
in delayed onset muscle soreness. If this occur, start with warming up
period and decrease exercise dose.
Contraindication of Resisted Exercise
1- Acute inflammation of the musculoskeletal system
2- Pain
3- Infection.
4- Recent fracture or non-united fracture
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ABDOMINAL AND BACK EXERCISES
Function Of Abdominal And Back Muscles
1- The abdominal muscles and back muscles are key components of the muscular
network providing the strength to keep the body upright and for movement.
When these muscles are in poor condition, additional stress is applied to the
spine as it supports the body and back injury or back pain is more likely.
2- Abdominal muscles support the trunk, allow movement, and hold organs in
place by regulating internal abdominal pressure.
3- The abdominal muscles support the lower back. People with weak abdominal
muscles tend to suffer from back pain.
4- Back muscles help the vertebrae in providing support to the body.
Abdominal Muscles
Rectus abdominus: (Fig. 1)
Slung between the ribs and the pubic bone at the front of the pelvis. The main
action of the rectus abdominus is trunk flexion.
External oblique muscles: (Fig. 2)
These flank the rectus abdominus. The external oblique muscles allow the
trunk to twist (trunk rotation), but to the opposite side of whichever external
oblique is contracting. For example, the right external oblique contracts to turn the
body to the left.
Internal oblique muscles: (Fig. 2)
These flank the rectus abdominus, They operate in the opposite way to the
external oblique muscles. For example, twisting the trunk to the left requires the
left hand side internal oblique and the right hand side external oblique to contract
together.
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Fig. (1): Rectus abdominus muscle
Fig. (2): External oblique and internal oblique muscles
Back Muscles (Fig 3)
There are several back muscles which are function as trunk flexors.
Erector spinae: iliocostalis thoracis and lumborum, longissimus thoracis,
spinalis thoracis, semispinalis thoracis and multifidus
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Fig. (3): Trunk Extensors
Benefits of strong abdominal and back muscles
1- Help to maintain good posture.
2- Reduce the likelihood of back pain episodes.
3- Provide protection against injury by responding efficiently to stresses
4- Help to avoid back surgery in some cases.
5- Facilitate healing after a back injury or spine surgery
Technical Principles
1- Avoid performing exercises immediately after meals. don't eat for around two
to three hours before starting your exercise.
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2- The key focus point for this exercise is the speed you perform the movement.
Avoid momentum and bouncing off the floor, keep the action smooth and
slow.
3- The movement should be slow. the slower the motion, the harder the exercise.
4- Hold at the end of the motion momentary to assure stabilizing action of the
muscles ( don’t return quickly).
5- Stabilize the lower limbs to avoid substitution using the lower extremities.
6- Perform 8 - 12 reps in a slow controlled manner, rest for 20 seconds and repeat
again. Increase repetition as the muscle strength increased.
7- Never push through back pain. Stop immediately at even the slightest twinge in
the lower back.
Abdominal exercises
Pelvic Tilt: (fig. 4)
Patient position: crock lying position with feet parallel and arms to the side.
Action: the patient is asked to tighten lower abdominal muscles (isometric
contraction), pulling the lower back toward the floor, without using buttocks or leg
muscles; hold for 5 seconds.
If the patient not understand, The therapist may put the hand under the lumber
region and ask the patient to press on his hand
Fig.(4): Pelvic tilt.
Curl-Ups (trunk flexion) (Figs. 5-8)
This exercise emphasis on the rectus abdominus muscle
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Patient Position: crock lying position with feet parallel and arms to the side (Fig.
5).
Therapist Position: Standing at the level of the patient’s feet to stabilize the feet
and knees.
Action: the subject is asked to
1- perform the drawing in maneuver and the lift the head
2- lift the head
3- progress by lifting the shoulders until the scapulae and thorax clear off the bed
to an approximately 30 -45 degrees. Do not rise all the way up to sitting
position, as this is done with the leg muscles and not the abdominals.
Fig. (5): Curl Up with arms beside the body.
For further progression ( to make the exercise more difficult) change the
position of the arm position as following
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The arms are forward (Fig. 6)
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The arms are folded across the chest (Fig. 7)
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The arms are behind the head (Fig. 8)
Fig. (6): Curl Up with arms forward.
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Fig. (7): Curl Up with arms across the chest.
Fig. (8): Curl Up with arms behind the head.
Diagonal Curl-Ups (trunk Rotation) (Figs. 9-11)
This exercise strength the oblique muscle.
The same patient position and progression but the patient is asked to turn and
reach one hand toward the opposite knee while curling up. And then repeat turning
to the other side.
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Fig. (9): Diagonal Curl-Ups with arms forward.
Fig. (10): Diagonal Curl-Ups with arms across the chest.
Fig. (11): Diagonal Curl-Ups with arms behind the head.
Double Knee to Chest (Fig. 12)
This exercise emphasis the lower rectus abdominus and oblique muscles.
Patient Position: Supine lying with arms beside the body.
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Action: ask the patient to do pelvis tilt then bring both knees to the chest remain
for 5 seconds and return. For progression decrease the angle of hip and knee
flexion.
Fig. (12): Double knee to chest.
Bilateral Straight Leg Raising
Patient Position: Supine lying .
Action: with the knees straight the patient flex both hips
This exercise should be performed with caution under the inspection of the
therapist as it may harm the spine if the patient has back problem ( increase
intradisc pressure).
Back Exercises (Trunk Extension)
Aching the back
Patient position: supine lying arms at the side
Action: the patient arch the back by pressing against the bed by the back of the
neck and the sacrum.
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Fig. (13): Arching the back.
Second Step
Patient Position: prone lying arms beside the body (Fig. 14)
Therapist position: stride standing at the level of the patient’s lower limb to
stabilize the lower limbs.
Action: the patient is asked to tuck chin in and lift the head and thorax
Fig. (14): Back Exercises with arms beside the body.
For further progression ( to make the exercise more difficult) change the
position of the arm position as following
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The arms are folded behind the back (Fig. 15)
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The arms are behind the head (Fig. 16)
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The arms reaching overhead (Fig. 17)
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Fig. (15): Back Exercises with arms behind the back.
Fig. (16): Back Exercises with arms behind the head
Fig. (17): Back Exercises with arms reaching overhead.
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