RANGE OF MOTION

ROM
Is 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.
Functional excursion (range of a muscle)
is the distance a muscle is capable of shortening after it has been elongated to its
maximum.
directly influenced by the joint it crosses.

Active Insufficiency
muscle shortens to a point where it can shorten no more
Passive Insufficiency
muscle elongates to a point where it can elongate no more

TYPES OF ROM EXERCISES

1. Passive ROM
o is movement of a segment within the unrestricted ROM that is produced
entirely by an external force; there is little to or no voluntary muscle
contraction.
External Forces- machine, another individual, another part of
individuals own body
Indications:
Passive motion is beneficial to acute inflamed tissues.
Active motion would be detrimental to the healing process.
Inflammation after injury or surgery usually lasts 2 to 6 days.
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, movement is provided by an external source.
Goals:
Main goal is to decrease the complications that would occur with
immobilization
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 patients awareness of movement
Other Uses:
Inert structures examination - determine limitations of motion, to
determine joint stability, and to determine muscle and other soft
tissue elasticity
PROM used for demonstration for active exercise program
PROM before passive stretching techniques
2. Active ROM

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 o is movement of a segment within the unrestricted ROM that is produced by
active contraction of the muscles crossing that joint
o there are physiological benefits that result from active muscle contraction and
motor learning from voluntary muscle control
Indications:
Px is able to move or contract body segment with or without
assistance
For aerobic conditioning programs
Body segment immobilized
Use AROM to regions above and below that segment to
maintain the areas normal a condition as possible and to
prepare for new activities (walking with crutches)
Goals:
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
3. Active-assistive ROM
o 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.
Indications:
Px has weak musculature and is unable to move a joint through the
desired range (usually against gravity)
o AAROM provides enough assistance to the muscles in a carefully
controlled manner so that muscle would function to its max level
and to progressively strengthened
If Px obtained ROM control
o progress to manual or mechanical resistance exercises to improve
muscle performance for a return to functional activities

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Stretching for Impaired mobility

Stretching exercises are thought to be an important element of fitness and conditioning

programs designed to promote wellness and reduce the risk of injury and reinjury.
Stretching is a general term used to describe any therapeutic maneuver designed to
increase the extensibility of soft tissues

TERMS:
MOBILITY
described based on two different but interrelated parameters.
often defined as the ability of structures or segments of the body to move or be
moved to allow the presence of range of motion for functional activities (functional
ROM)
ability of an individual to initiate, control, or sustain active movements of the body to
perform simple to complex motor skills (functional mobility)
HYPOMOBILITY (restricted motion)
caused by adaptive shortening of soft tissues can occur as the result of many
disorders or situations.
Factors:
o prolonged immobilization of a body segment
o sedentary lifestyle
o postural malalignment and muscle imbalances
o impaired muscle performance (weakness) associated with an array of
musculoskeletal or neuromuscular disorders
o tissue trauma resulting in inflammation and pain, and
o congenital or acquired deformities.
FLEXIBILITY
is the ability to move a single joint or series of joints smoothly and easily through an
unrestricted, pain-free ROM.
DYNAMIC FLEXIBILITY
o Referred to as active mobility or active ROM, is the degree to which an
active muscle contraction moves a body segment through the available
ROM of a joint.
PASSIVE FLEXIBILITY
o also referred to as passive mobility or passive ROM, is the degree to
which a joint can be passively moved through the available ROM
o dependent on the extensibility of muscles and connective tissues that
cross and surround a joint. Passive flexibility is a prerequisite for but does
not ensure dynamic flexibility.
SELECTIVE STRETCHING
is a process whereby the overall function of a patient may be improved by applying
stretching techniques selectively to some muscles and joints but allowing limitation
of motion to develop in other muscles or joints.
CONTRACTURE
Is defined as the adaptive shortening of the muscle-tendon unit and other soft
tissues that cross or surround a joint that results in significant resistance to passive
or active stretch and limitation of ROM, and it may compromise functional abilities.
Complete loss of motion; shortness,partial loss of motion

TYPES OF CONTRACTURE
1) Myostatic (myogenic) contracture
the musculotendinous unit has adaptively shortened and there is a significant loss
of ROM, there is no specific muscle pathology present

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 2) Pseudomyostatic Contracture
Impaired mobility and limited ROM may also be the result of hypertonicity
associated with a central nervous system lesion
3) Arthrogenic and Periarticular contracture
Arthrogenic contracture
o is the result of intra-articular pathology
o These changes may include adhesions, synovial proliferation, joint
effusion, irregularities in articular cartilage, or osteophyte formation.
Periarticular contracture
o develops when connective tissues that cross or attach to a joint or the
joint capsule lose mobility, thus restricting normal arthrokinematic motion.
4) Fibrotic Contracture and Irreversible Contracture
connective tissue of muscle and periarticular structures can cause adherence of
these tissues and subsequent development of a fibrotic contracture.
Although it is possible to stretch a fibrotic contracture and eventually increase
ROM, it is often difficult to reestablish optimal tissue length.

Interventions to Increase Mobility of Soft Tissues

1) Manual or Mechanical/Passive or Assisted Stretching
A sustained or intermittent external, end-range stretch force, applied with
overpressure and by manual contact or a mechanical device, elongates a
shortened muscletendon unit and periarticular connective tissues by moving a
restricted joint just past the available ROM.
o passive stretching- relaxed patient
o assisted stretching.- patient assists in moving the joint through a
greater range
2) Self-Stretching
Any stretching exercise that is carried out independently by a patient after
instruction and supervision by a therapist.
o Active stretching is another term sometimes used to denote self-
stretching procedures.
3) Neuromuscular facilitation and inhibition techniques
purported to relax tension in shortened muscles reflexively prior to or during
muscle elongation
o proprioceptive neuromuscular facilitation (PNF) - use of inhibition
techniques to assist with muscle elongation is associated with an
approach to exercise
4) Muscle energy techniques
Manipulative procedures that have evolved out of osteopathic medicine and
are designed to lengthen muscle and fascia and to mobilize joints.
They employ voluntary muscle contractions by the patient in a precisely
controlled direction and intensity against a counterforce applied by the
practitioner
These techniques are also called as postisometric isolation
5) Joint Mobilization/Manipulation
Are skilled manual therapy interventions specifically applied to joint structures
to modulate pain and treat joint impairments that limit ROM
6) Soft tissue mobilization/manipulation
designed to improve muscle extensibility and involve the application of
specific and progressive manual forces to effect change in the myofascial
structures that can bind soft tissues and impair mobility.
7) Neural tissue mobilization (neuromeningeal mobilization)

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 adhesions or scar tissue may form around the meninges and nerve roots or at
the site of injury at the plexus or peripheral nerves
Tension is applied

INDICATIONS and
CONTRAINDICATIONS

PROPERTIES OF SOFT TISSUERESPONSE TO IMMOBILIZATION AND STRETCH

Elasticity is the ability of soft tissue to return to its prestretch resting length directly
after a short-duration stretch force has been removed
Viscoelasticity is a time-dependent property of soft tissue that initially resists
deformation, such as a change in length, of the tissue when a stretch force is first
applied.
Plasticity is the tendency of soft tissue to assume a new and greater length after the
stretch force has been removed.
Mechanical Response of the Contractile Unit to Stretch and Immobilization
1) Response to stretch
During passive stretch both longitudinal and lateral force transduction occurs.
Tension rises sharply - lengthening occurs in the series elastic (connective
tissue) component
sarcomere give - abrupt lengthening of the sarcomeres due to mechanical
disruption (influenced by neural and biochemical changes) of the cross-
bridges as the filaments slide apart.
2) Response to immobilization and remobilization
Immobilization in a shortened position
o sarcomere absorption- reduction in the length of the muscle and its
fibers and in the number of sarcomeres in series within myofibrils
resulting from immobilization of muscle for several weeks
Immobilization in a lengthened position
o Sometimes a muscle is immobilized in a position of maximum
available length for a prolonged period of time.
o Myofibrillogenesis- muscle is held in a lengthened position for an
extended period of time, it adapts by increasing the number the
number of sarcomeres in a series

STRESS-STRAIN CURVE

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The stressstrain curve illustrates the mechanical strength of structures and is used to
interpret what is happening to connective tissue
under stress loads

Stress is force per unit area. Mechanical

stress is the internal reaction or resistance to
an external load
Strain: the amount of deformation or
lengthening that occurs when a load (stress)
or stretch force is applied.

TYPES OF STRESS

Tension: a force applied perpendicular to

the crosssectional area of the tissue in a
direction away fromthe tissue. A stretching
force is a tension stress.
Compression: a force applied perpendicular
to the crosssectional area of the tissue in a direction toward the tissue. Muscle
contraction and loading of a joint during weight bearing cause compression stresses
in joints.
Shear: a force applied parallel to the cross-sectional area of the tissue.
REGIONS OF THE STRESS-STRAIN CURVE

1) Toe region
considerable deformation without the use of much force is called the toe
region.
most functional activity normally occurs.
2) Elasticity range/linear phase
Strain is directly proportional to the ability of tissue to resist the force.
This occurs when tissue is taken to the end of its ROM, and gentle stretch is
applied
complete recovery from this deformation, and the tissue returns to its
original size and shape when the load is released if the stress is not
maintained for any length of time
3) Elastic Limit
point beyond which the tissue does not return to its original shape and size is
the elastic limit.
4) Plastic range
The range beyond the elastic limit extending to the point of rupture is the
plastic range
5) Ultimate strength
Greatest load a tissue can sustained
increased strain (deformation) without an increase in stress required.
region of necking is reached in which there is considerable weakening of the
tissue, and it rapidly fails.
6) Failure
Rupture of the integrity of the tissue
7) Structural stiffness
Slope of the linear portion of the curve (elastic range) is known as Youngs
modulus of elasticity and represents the stiffness of the tissue

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 Contractures and scar tissue have greater stiffness, probably because of a
greater degree of bonding between collagen fibers and their surrounding
matrix.
CONNECTIVE TISSUE RESPONSE TO LOAD
Creep
o When a load is applied for an extended period of time, the tissue elongates,
resulting in permanent deformation
o It is related to the viscosity of the tissue and is therefore time-dependent.
o The amount of deformation depends on the amount of force and the rate at
which the force is applied.
Stress-relaxation
o When a force (load) is applied to stretch a tissue and the length of the tissue
is kept constant, after the initial creep there is a decrease in the force
required to maintain that length, and the tension in the tissue decreases
Cyclic loading and connective tissue fatigue
o Repetitive loading of tissue increases heat production and may cause failure
below the yield point.
o The greater the applied load, the fewer number of cycles needed for failure.
o A minimum load is required for this failure.
Endurance limit
Below the minimum load an apparently infinite number of
cycles do not cause failure.

TYPES OF STRETCHING

1) Static stretching
commonly used method of stretching in which soft tissues are elongated just
past the point of tissue resistance and then held in the lengthened position
with a sustained stretch force over a period of time.
2) Static progressive stretching
is another term that describes how static stretch is applied for maximum
effectiveness. The shortened soft tissues are held in a comfortably
lengthened position until a degree of relaxation is felt by the patient or
therapist.
3) Cyclic (Intermittent) Stretching
A relatively short-duration stretch force that is repeatedly but gradually
applied, released, and then reapplied is described as a cyclic (intermittent)
stretch.
applied for multiple repetitions (stretch cycles) during a single treatment
session.
the end-range stretch force is applied at a slow velocity, in a controlled
manner, and at relatively low intensity
4) Ballistic Stretching
rapid, forceful intermittent stretchthat is, a high-speed and high-intensity
stretc
quick, bouncing movements that create momentum to carry the body
segment through the ROM to stretch shortened structures
5) Manual Stretching
a therapist or other trained practitioner or caregiver applies an external force
to move the involved body segment slightly beyond the point of tissue
resistance and available ROM.
therapist manually controls the site of stabilization as well as the direction,
speed, intensity, and duration of stretch.

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 6) Mechanical stretching
mechanical stretching devices provide either a constant load with variable
displacement or constant displacement with variable loads
Mechanical stretching devices apply a very low intensity stretch force (low
load) over a prolonged period of time to create relatively permanent
lengthening of soft tissues, presumably due to plastic deformation.
7) Self-stretching(flexibility exercises or active stretching)
is a type of stretching procedure a patient carries out independently after
careful instruction and supervised practice.
Self-stretching enables a patient to maintain or increase the ROM gained as
the result of direct intervention by a therapist.
8) PNF Stretching techniques (active stretching158 or facilitative stretching)
Integrate active muscle contractions into stretching maneuvers purportedly to
facilitate or inhibit muscle activation and to increase the likelihood that the
muscle to be lengthened remains as relaxed as possible as it is stretched.
TYPES OF PNF STRETCHING
Holdrelax (HR) or contractrelax (CR)
o Range limiting muscle is first lengthened to the point of limitation or to
the extent that is comfortable for the patient. The patient then
performs a prestretch, end-range, isometric contraction (for 5 to 10
seconds) followed by voluntary relaxation of the tight muscle.
Agonist contraction (AC)
o To perform the AC procedure the patient concentrically contracts
(shortens) the muscle opposite the range limiting muscle and then
holds the end-range position for at least several seconds.
Holdrelax with agonist contraction (HR-AC /slow reversal holdrelax
technique)
o To perform the HR-AC procedure, move the limb to the point that
tissue resistance is felt in the tight (range-limiting) muscle; then have
the patient perform a resisted, pre stretch isometric contraction of the
range-limiting muscle followed by relaxation of that muscle and an
immediate concentric contraction of the muscle opposite the tight
muscle.
DETERMINANTS OF STRETCHING EXERCISES
1) Alignment
Proper alignment or positioning of the patient and the specific muscles and
joints to be stretched is necessary for patient comfort and stability during
stretching.
2) Stabilization
To achieve an effective stretch of a specific muscle or muscle group and
associated periarticular structures, it is imperative to stabilize (fixate) either
the proximal or distal attachment site of the muscle-tendon unit being
elongated
3) Intensity of stretch
The intensity (magnitude) of a stretch force is determined by the load placed
on soft tissue to elongate it
4) Duration of stretch
to the period of time a stretch force is applied and shortened tissues are held
in a lengthened position
30 secs hold; 3 sets or 15 secs hold; 5 sets
5) Speed of stretch
Speed of initial application of stretch force
Should be applied and released gradually

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 To ensure optimal muscle relaxation and prevent injury to tissues, the speed
of stretch should be slow
6) Frequency of stretch
refers to the number of bouts (sessions) per day or per week a patient carries out
a stretching regimen
7) Mode of stretch
refers to the form of stretch or the manner in which stretching exercises are
carried out

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