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Chapter 20
Optimizing Abilities and Capacities: Range of Motion,
Strength, and Endurance
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Learning Objectives
• State the biomechanical and physiological mechanisms that
underlie therapeutic exercise and occupation.
• Apply the methods for decreasing edema, minimizing
contracture, and mobilization to prevent limitation of range of
motion.
• Apply biomechanical and physiological principles of the
biomechanical approach to the selection of occupations as a
means for treating range of motion, strength, and/or
endurance problems as needed for occupational performance.
• Design treatment goals and therapy for clients who have
problems with range of motion, strength, and/or endurance
to enhance occupational performance.
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Musculoskeletal System: Biomechanical
Aspects
• Kinematic analysis
– Describes the amount and direction of movement, speed,
and acceleration of body segments and joint angles
• Kinetics
– Addresses the forces that cause motion or maintain
stability
• Torque
– Tendency of a force to produce rotation about an axis
• Lever systems
– Effort is the force that causes movement and resistance is
the force that tends to keep the object moving.
• First-class lever
• Second-class lever
• Third-class lever
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Musculoskeletal System: Physiological
Aspects
• Strength
– Muscle hypertrophy
• Activity stresses the
muscle’s ability to produce
tension and force
– Result of neural change
• Development of more
effective neural patterns
and neuromotor
connections
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Biomechanical Approach to Treatment:
Maintaining or Preventing Limitation
in Range of Motion
• An individual’s actual ROM at any joint is determined by
the structures surrounding the segments that are
moving.
• Functional ROM is the range necessary to perform daily
activities.
• Occupational therapists are concerned with providing
treatment that helps clients maintain functional motion
or to help patients gain motion when there are
limitations that interfere with occupation.
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Factors That Limit Range of Motion
• Systemic, neurological, or muscular diseases impair
muscle performance.
• Joint diseases such as arthritis that create pain and
inflammation decrease motion, and surgical or traumatic
insults that produce edema and scarring.
• Simple inactivity or immobilization affects ROM.
• Changes may occur in the muscles, ligaments, joint
capsules, tendons, or joints.
• This leads to pain, inflammation, and edema.
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Intervention Methods: Decreasing
Edema
• Used to prevent ROM limitations secondary to edema
• Techniques include the following:
– Elevation
– Cryotherapy
– Compression
– Massage
– Electrical current
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Intervention Methods: Minimizing
Contractures
• Occupational therapists may use therapeutic positioning
and splinting.
• Therapeutic positioning is designed to help
– With edema resolution when limbs are elevated
– Preserve function by holding limbs at a proper
muscle length
– Patients avoid positions that result in tissue
shortening or contracture
• Splinting used to hold joints in a position with optimum
tissue length
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Intervention Methods: Movement
Through Full Range of Motion
• Methods for ranging
–
Teaching the patient to move the joints that are injured,
immobilized, or edematous
–
Passively move the joints if the patient is unable to
actively move the joint themselves
• Attention must be given to plane of motion, structures involved
with the movement of the joint, and joint biomechanics.
• AROM or AAROM is preferred to PROM for reduction of edema
because the contraction of the muscles helps pump the fluid
out of the extremity.
• AROM and PROM have no set protocol of frequency.
• Occupational therapists often structure activities to promote
AROM and PROM to prevent loss of motion.
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Increasing Range of Motion
• If limitations in ROM impair a patient’s ability to function
independently in occupations or are likely to lead to
deformity, treatment to increase ROM is indicated.
• Problems that can be changed
– Contractures of soft tissue
• Skin
• Muscles
• Tendons
• Ligaments
• Problems that cannot be changed
– Ankylosis or arthrodesis
– Long-standing contractures
– Severe joint destruction
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Increasing Range of Motion: Stretching
• Stretch is a process by which the target tissue is
lengthened by an external force, usually through manual
therapy or through the use of splinting, casting, or
external equipment.
• Change is only created when tissue is stretched
repeatedly or sustained over time.
• Factors that determine the effectiveness of stretching are
the duration, the intensity, the speed, and the frequency
of the stretch being applied.
• Gentle, controlled stretching that achieves small
increments of gain over time is thought to be more
effective than vigorous stretching aimed at large, rapid
gains.
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Intervention Methods for ROM: Active
Stretching
• The use of occupation for
stretching is empirically based on
the idea that a person involved in
an interesting and purposeful
activity will gain greater range.
• Because occupations can be
performed using a number of
muscle patterns, the therapist
must determine how the patient
completed the activity prior to
injury.
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Intervention Methods for ROM: Active
Stretching—(cont.)
• Occupations used as a means to increase ROM must
provide a gentle active stretch by use of slow, repetitive
isotonic contractions of the muscle opposite the
contracture or by use of a prolonged passive stretched
position of the contracted tissue.
• Exercises that increase the range of shortened tissue are
the proprioceptive neuromuscular facilitation (PNF)
techniques called contract relax and agonist contraction.
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Intervention Methods for ROM: Passive
Stretching
• Preparatory method for increasing ROM so patients are able to
engage in purposeful activity
• Techniques
– Manual stretch
– Use of orthotic devices
• Splints
• Casts
– Home program on specific joint stretches
– Pilates, yoga, or the ROM dance
– These tasks can be integrated into a patient’s daily
occupations.
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Biomechanical Approach to Treatment:
Strengthening
• If limitations in a patient’s strength prevent participation in
occupations or may lead to a deformity, treatment aimed
at increasing strength is warranted.
• If weakness prohibits patients from moving the limb or
maintaining a functional position, their lack of regular
active range of motion may lead to contracture.
• Occupation or exercise parameters that may be
manipulated to increase strength include the following:
– Type of contraction and speed
– Muscles involved
– Intensity of task
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Intervention Methods for
Strengthening: Occupations and
Exercise
• Therapists may find that various occupations provide
sufficient opportunities for muscle strengthening and are
more effective at maintaining the patient’s interest and
motivation than exercise alone.
• Exercise may be used as a warm-up to occupation, or
occupation may be introduced to enhance carryover of
the strength gained by exercise.
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Grading Muscle Strength Parameters
• When prescribing a strengthening program, therapists can
manipulate the exercise or occupational parameters.
• Amount of resistance imposed on the contracting muscle or
muscle groups during each repetition is increased.
– 40%–60% of one-repetition maximum (1 RM)
• Training volume: Changing the number of repetitions of an
activity, changing the number of sets required of that one
activity, or changing the number of activities done during a
treatment session.
• Rest period between activity should be 3–4 minutes for high
loads or repetitions; rest period of 1–2 minutes for low
intensity or low repetition activity.
• Patients starting a strengthening program should exercise
2–3 days a week, which can then increase to 3–5 days a
week as the strength progresses.
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Biomechanical Approach to Treatment:
Increasing Endurance
• Factors that influence muscle endurance
– With activities that call for maximum muscle
contraction, such as lifting heavy loads, more motor
units must contract simultaneously without the
opportunity to recover, resulting in quicker fatigue.
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Intervention Methods: Increasing
Endurance
• Provide patients with interestsustaining occupations that can be
graded along the dimension of time
or repetition.
• Work with patients to schedule their
everyday routines so that they
gradually increase the amount of
time they engage in occupations
throughout the day and/or gradually
increase the duration of
engagement in one particular
occupation.
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins