1. THERAPEUTIC EXERCISES
Orthopaedic and Rheumatology skill for
Physiotherapy Students
Done by :
Assist Prof.
Mosab Amoudi 2011

2. Definition:
• Therapeutic Exercises is defined as science used
ultimately to restore the body function (ADL) as
normal as possible. This could be obtained through
development , improvement, restoration, or
maintenance of:
- Strength - Endurance - Relaxation
- Mobility & flexibility - Coordination
- Skills

3. Definitions of range of motion exercises
A- passive movement within the unrestricted ROM for a
segment which is produced entirely by an external
force ; there is no voluntary muscle contraction.
B- Active within the unrestricted ROM for a segment
which is produced by an active contraction of the muscles
crossing that joint.
C- Passive – Assistive. A type of active ROM in which
assistance is provided by an outside force , either
manually or mechanically, because the prime mover
muscles need assistance to complete the motion.

4. Goals of Therapeutic Exercises
• Improves range of motion
• Reduce Pain
• Restore joint flexibility
• Improve muscle mass, strength & endurance
• Reduction of limb edema
• Increase body function
• Improves balance control
• Increases cardiovascular strength and endurance
• Helps preventing further injury
• Gain self confidence.

5. Requirements
In order to effectively administer therapeutic exercise
to a patient & to ultimately achieve its target goal,
the therapist must know:
1. Basic principles & effects of treatment
2. The interrelationships of anatomy & kinesiology of
the body part.
3. The state of disability & potential rate of recovery,
complications, precautions & contraindications
4. The pathology of orthopedic, neurological,
cardiopulmonary & the other medical conditions.

6. 5. The accurate functional evaluation of the patient, that
identifies the patient’s of problems, the goals
treatment, the plan of treatment & the home care
program.
6. The basic evaluation procedures, including posture
evaluation, goniometric measurements, manual muscle
testing, orthopedic evaluation….. Etc.
7. The factors that affects the neuro muscular,
musculoskeletal & circulatory systems particularly
those lead to deformity and injury ( for example
absence of gravity and weight bearing)

7. Range of motion
Introduction : principles
- Movement of a body segment takes place as muscles
or external forces move bones. Bones move with
respect to each other of the connecting joint.
- The structure of the joints affects the amount of
motion that can occur between any tow bones. Also
the integrity and flexibility of the soft tissues plays
on important role in determining the amount of
motion.

8. - When moving a segment through its range of
motion, all structures in the region are affected:
muscle, joint surfaces, capsules, ligaments, vessels,
and nerves.
- To describe joint range, terms such as flexion,
extension, abduction, adduction, & rotation are used.
- ROM activities are most easily described in terms of
joint range & muscle range, 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

9. - In order to maintain normal range of motion, the segments
must be moved through their available ranges periodically,
whether it be the available joint range or muscle range
- It is recognized that many factors can lead to decreased
ROM , such as systemic joint, neurologic, or muscular
diseases, surgical or traumatic insult , or simply inactivity
or immobilization for any reason.

10. - Therapeutically, range of motion activities
are administered to maintain existing joint
& soft tissue mobility, which will
minimize the effects of contracture
formation.

11. Types of ROM Exercises
• Passive
• Active
• Active Assisted
_________________________________
• Manual
• Self Exercise‐
• Mechanical (CPM machine)
• Assistive tools (pulley, wand)

12. TYPES OF ROM EXERCISES
• Passive range-of-motion exercises
– PROM
• Active range-of-motion exercises
– AROM
• Active-Assistive range-of-motion exercises
– AAROM

13. PASSIVE ROM EXERCISES
Movement produced by an
external force within the
unrestricted range of motion of
a segment
Little to or no muscle
contraction elicited

14. Passive ROM exercises are
characterized by:
• No muscular activation by the patient
• Performed within the available ROM
• Applied by some external force
• No pain

15. 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.

16. Indications & goals for ROM
• Passive ROM
1. When the patient is not able to or not to actively
move a segment or segment of the body, such as
comatose paralyzed, or on complete bed rest
2. When there is an inflammatory reaction and active
ROM is painful or sever inflamed injury
3. For assessment purposes
4.When teaching a patient movement
5. To prepare a patient for stretching

17. Goal for PROM
• To maintain joint & connective tissue mobility
• To minimize effects of the formation of contractures
• To maintain elasticity of muscle.
• To assist circulation
• improve synovial movement / nutrition of cartilage
• decrease pain
• maintain patient awareness
• Assist with healing process after injury or surgery

18. Other uses for PROM
- When the therapist is examination PROM / is used
• to determine limitation of motion
• to determine joint stability
• to determine muscle & other soft tissue elasticity
- When the therapist is teaching an active exercise program
PROM is used to demonstrate the desired motion
- When the therapist is preparation a patient for stretching,
PROM is often used preceding the passive stretching
techniques

19. ACTIVE ROM EXERCISES
Movement produced on a
segment upon active
contraction of the muscles
crossing the joint within the
unrestricted range of motion.
Assistance is provided by
an outside force (manual or
mechanical), as the prime
mover muscles is unable to
complete the motion.
ACTIVE-ASSISTIVE ROM
EXERCISES

20. Goal for AROM
The same goals of PROM can be met with AROM.
Specific goals are:
• Maintain elasticity and contractility of 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

21. Indications AROM
When a patient is able to actively
contract the muscles and move the
segment with or without assistance
Muscle weakness and inability to move
segment completely against gravity
Aerobic conditioning programs
During periods of immobilization,
AROM is used in joints above and below
the immobilized segment
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22. Limitations of ROM Exercises
• Limitations of passive & active motion
 Passive ROM exercise WILL NOT:
- prevent atrophy
- Increase strength or endurance
- Assist circulation to the extent that active, voluntary
muscle contraction improvement in circulation will
 Active ROM exercise WILL NOT:
– for strong muscles, it will not maintain or increase
strength
- it will not develop coordination extent in the movement
pattern used
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23. Contraindications of ROM exercise
A- Both active & passive ROM are contraindicated under any
circumstance where motion to a part will be disruptive to the healing
process, such as:
- Immediately following a tear to ligaments, tendons, or muscle
- In the region of unhealed fracture.
- Immediately following surgical procedures to tendons, ligament,
muscle, capsule, or skin
B- Active ROM is contraindicated when the cardiovascular
dysfunction of a patient is unstable & active exercise affect the
patient’s life. Such as immediately following a myocardial infarction
C- Should not be done if response will be life-threatening to the patient
E- Severe soft tissue trauma.

24. Active Assisted Range of Motion
Exercises
• Exercise in which movement is performed by the
voluntary effort of the patient with assistance of
external force to complete the range of motion.
• Patient can voluntary activate the muscle and
produce muscle contraction.
• Patient is unable to fully activate the muscle and
complete the range of motion.

25. • 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).

26. Indications of AAROM Exercises
• Patient is unable to complete ROM actively
because of weakness due to
– trauma
– muscular or neuromuscular disease
– pain
• Pt is not allowed to fully activate muscle
following surgery

27. PRINCIPLES OF ROM
TECHNIQUES
• Examination, evaluation, and treatment planning
1. Level of function , determine any precaution, &
prognosis, plan the intervention
2. Determine the ability of the patient to participate in the
ROM activity & whether PROM, A-AROM or AROM
3. determine the amount of motion that can be safely
4. decide what patterns can best meet the goals, ROM
techniques may be performed in the:
a. Anatomic planes of motion(transveres, frontal,
sagittal)

28. b. Muscle range of elongation: antagonistic to the line of
pull of muscle
c. Combined patterns: diagonal motion or movements that
incorporate several planes of motion
d. Functional pattern: motion used in activities of daily
living
5. Monitor the patient’s general condition & responses
during & after the examination & intervention
6. Document & communicate findings & intervention
7. Re-evaluate & modify the intervention as necessary

29. Patient Preparation
• Communicate with patient. Describe the plan &
method of intervention
• Remove all restrictive clothing, linen, splint, and
dressings; drape appropriately
• Place the patient in a comfortable position which
allow you to move the segment through the
available ROM
• Position yourself so that proper body mechanics
can be used

30. Application of Techniques
• Grasp the extremity around the joints providing support
needed for control
• Support areas of poor structural integrity such as hyper
mobile joint or a recent fracture site or where there is
paralysis
• Do the motion smoothly and rhythmically, with 5 to 10
repetitions. The number of repetition depends on the
objectives of the program & the patient’s conduction &
response to treatment.
• Move the segment throughout its pain-free range to
point of tissue resistance

31. Application of PROM
• Movement is being provided by an external force or
mechanical device.
• No active resistance or assistance is given by the
muscles that cross the joint.
• Motion is performed within the available or free ROM.
that is, the range that is available without forced motion
or pain

32. Application of AROM
• In active –Assistive or active ROM, Demonstrate to
the patient the motion desired motion using passive
ROM, then ask the patient perform the movement.
Have your hands in position to assist or guide the
patient if needed.
• Provide assistance only as needed for smooth .
Perform the motion within the available range

33. Upper Extremity ROM
Techniques
• Shoulder: flexion and
extension
– Hand placement and
procedure

34. • Shoulder Abduction
• Shoulder: extension
(hyperextension)
– Alternate positions

35. Upper Extremity ROM
Techniques (cont.)
• Shoulder: internal (medial)
and external (lateral)
rotation
• Shoulder: horizontal
abduction (extension) and
adduction (flexion)

36. • Scapula:
elevation/depression,
protraction/retraction,
and upward/downward
rotation

37. Mobility
• It is 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).
• It can also be defined as:
the ability of an individual to initiate, control, or
sustain active movements of the body to perform
simple to complex motor skills (functional
mobility).

38. • Mobility, as it relates to functional ROM, is
associated with joint integrity as well as the
flexibility (i.e., extensibility of soft tissues
that cross or surround joints—muscles,
tendons, fascia, joint capsules, ligaments,
nerves, blood vessels, skin), which are
necessary for unrestricted, pain-free
movements of the body during functional
tasks of daily living.

39. Flexibility
Flexibility is the ability to move a single joint or series of
joints smoothly and easily through an unrestricted, pain-
free ROM. M. length in conjunction with joint integrity
and extensibility of periarticular soft tissue determine
flexibility.
Flexibility related to the extensibility of musculotendinous
units that cross a joint
• What is Flexibility?
Flexibility is the amount of movement available at a joint.
For example, the amount of movement available at the
hip joint is determined by how far the leg can be moved
in each of the permitted motions (e.g. flexion - raising
the leg up in front).

40. Dynamic and Passive Flexibility
• Dynamic flexibility. This form of flexibility, also
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.
• It is dependent
on the degree to which a joint can be moved by a
muscle contraction and the amount of tissue
resistance met during the active movement

41. Passive flexibility
• This aspect of flexibility, also referred
to as passive mobility or passive ROM, is the
degree to which a joint can be passively
moved through the available ROM and is
dependent on:
• the extensibility of muscles
• and connective tissues that cross and
surround a joint.

42. Hypomobility
• Hypomobility refers to decreased mobility or
restricted motion. A wide range of pathological
processes can restrict movement and impair
mobility. There are many factors that may
contribute to hypomobility and stiffness of soft
tissues, the potential loss of ROM, and the
development of contractures.

43. Factors That Contribute to Restricted Motion
• Prolonged immobilization
Casts and splints
Skeletal traction
• Pain
• Joint inflammation an effusion
• Muscle, tendon, or fascial
disorders
Skin disorders
Bony block
Vascular disorders
or asymmetrical postures
Paralysis, tonal abnormalities,
and muscle imbalances

44. Contracture
• Restricted motion can range from mild muscle
shortening
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.

45. Types of Contracture
• Myostatic Contracture
In a myostatic (myogenic) contracture, although the
musculotendinous unit .there is no specific muscle
pathology
Pseudomyostatic Contracture
Impaired mobility and limited ROM may also be the result
of hypertonicity (i.e., spasticity or rigidity) associated
with a central nervous system lesion such as a CVA,
spinal cord injury, or traumatic brain injury.

46. • Arthrogenic and Periarticular Contractures
An arthrogenic contracture is the result of intra-articular
pathology. These changes may include adhesions,
synovial proliferation, joint effusion, irregularities in
articular cartilage, or osteophyte formation.
• Fibrotic Contracture and Irreversible Contracture
Fibrous changes in the connective tissue of muscle and
periarticular structures can cause adherence of these
tissues and subsequent development of a fibrotic
contracture.
(UNKOWN CASE)

47. Indications for Use of Stretching
• ROM is limited because soft tissues have lost their
extensibility as the result of adhesions, contractures, and
scar tissue formation, causing functional limitations or
disabilities.
• Restricted motion may lead to structural deformities
• There is muscle weakness
• May be used as part of a total fitness program designed to
prevent musculoskeletal injuries.
• May be used prior to and after vigorous exercise
potentially to minimize postexercise muscle soreness.

48. Contraindications to Stretching
• A bony block limits joint motion.
• There was a recent fracture, and bony union is incomplete.
• acute inflammatory or infectious process (heat and
swelling) or soft tissue healing
• acute pain, A hematoma ,trauma , Hypermobility
• Shortened soft tissues enable a patient with paralysis or
severe muscle weakness to perform specific functional
skills

49. Changes in Collagen Affecting Stress–
Strain Response
• Effects of Immobilization
• There is weakening of the tissue because of collagen
turnover and weak bonding between the new,
nonstressed fibers. There is also adhesion formation
because of greater cross-linking between
disorganized collagen fibers and because of
decreased effectiveness of the ground substance
maintaining space and lubrication between the fibers.
The rate of return to normal tensile strength is slow.

50. Effects of Inactivity (Decrease of
Normal Activity)
• There is a decrease in the size and amount of
collagen fibers, resulting in weakening of the tissue.
There is a proportional increase in the predominance
of elastin fibers, resulting in increased compliance.
Recovery takes about 5 months of regular cyclic
loading. Physical activity has a beneficial effect on
the strength of connective tissue.

51. Effects of Age
• There is a decrease in the maximum tensile
strength and the elastic modulus, and the
rate of adaptation t stress is slower. There
is an increased tendency for overuse
syndromes, fatigue failures, and tears with
stretching.

52. Effects of Corticosteroids
• There is a long-lasting deleterious effect on
the mechanical properties of collagen with a
decrease in tensile strength. There is
fibrocyte death next to the injection site
with delay in reappearance up to 15 weeks.

53. Effects of Injury
• Excessive tensile loading can lead to
rupture of ligaments and tendons at
musculotendinous junctions. Healing
follows a predictable pattern with bridging
of the rupture site with newly synthesized
type III collagen.

54. Determinants of Stretching Interventions
• Alignment: positioning a limb or the body such that
the stretch force is directed to the appropriate muscle group
• Stabilization: fixation of one site of attachment of the
muscle as the stretch force is applied to the other bony
attachment
• Intensity of stretch: magnitude of the stretch force applied
• Duration of stretch: length of time the stretch force is
applied during a stretch cycle

55. • Speed of stretch: speed of initial application of the
stretch force(should be slow & should be applied and
released gradually)
• Frequency of stretch: number of stretching sessions per
day or per week
• Mode of stretch: form or manner in which the stretch
force is applied (static, ballistic, cyclic); degree of
patient participation (passive, assisted, active); or the
source of the stretch force (manual, mechanical, self)

56. Types of Stretching
• Static stretching (5 seconds to 5 minutes)
per repetition
• Cyclic/intermittent stretching
• Ballistic stretching
• Proprioceptive neuromuscular
facilitation stretching procedures
(PNF stretching)
• Manual stretching
• Mechanical stretching
• Self-stretching
• Passive stretching
• Active stretching

57. • 1- static stretching: When we extend the work of a particular
muscle, until they reach the maximum muscle length was then
steadfast in that situation
For ten seconds if we want to calm or stability on a
prolongation for 30 seconds if we want to develop and increase
the dynamic range.
• 2- dynamic stretching: Are the types of prolongation which
is positive about the performance of the prolongation of the
movement such as walking, for example, dynamic,
prolongation does not help much in the development of
flexible joints and muscles.

58. • 3- proprioceptive neuromuscular facilitation (PNF)
PNF, or proprioceptive neuromuscular facilitation, is a
type of stretching used to increase flexibility quickly.
The PNF technique allows for greater muscle relaxation
following each contraction and increases the soldiers
ability to stretch through a greater range of motion.
4- Ballistic stretching: involves movements such as
bouncing or bobbing to attain a greater range of
motion and stretch.

59. • techniques. It was originally reserved for
therapeutic use in stroke patients, but has in
recent years gained popularity with athletes.
• Common PNF varieties include:
1- Hold-Relax The hold-relax is the most
common type of PNF stretch.
The muscle is held in a passive stretch for
about 20 seconds. Then that same muscle is
contracted.

60. The muscle is contracted in a stationary
position and is not moved.
This contraction is held for 10 to 15 seconds
before the muscle is relaxed for no longer
than 3 seconds. After this, the passive stretch
is done again for 20 seconds. The contraction
allows the muscle to be stretched further than
before.

61. • 2- Contract-Relax
The contract-relax technique is very similar to the hold-
relax technique. A passive stretch is held for 20 seconds.
The muscle is then contracted. The difference between
the contract-relax and and the hold-relax is that in the
contract-relax technique, the muscle is contracted
concentrically. This means the muscle is moved so it
temporarily shortened. The contraction is released for a
couple of seconds and then the passive stretch is
repeated for another 20 seconds.

62. • Contract-Relax with Antagonist Contract
• The contract-relax with antagonist contract method appears
to be the most effective type of PNF stretch. In this stretch,
the muscle is stretched for 20 seconds. It is then contracted
concentrically, such as in the contract-relax. After holding
the contraction for 10 seconds, the muscle opposite to the
contracted muscle is contracted statically for 10 seconds as
well. After a quick three second relax, the passive stretch is
repeated.

63. Benefits of stretching
There are many benefits to be gained from a regular
stretching programme:
• Increased flexibility and range of motion
• Injury prevention
• Preventing DOMS (Delayed Onset Muscle Soreness)
• Improved posture
• Improvements in sports performance
• Stress relief

64. 1- What are type of stretching? (3)
1) Clinician Guided
2) Joint Mobilization
3) Auto Stretching
2- What is mobility related to?
joint integrity and flexibility
3- What is hypomobility?
Adaptive Shortening of soft tissue

65. 4-What are factors leading to hypomobility?
1) Prolonged immobilization
2) Sedentary Lifestyle
3) Postural Mal alignment
4) Muscle Imbalance
5) Impaired Muscle Performance
6) Tissue Trauma
7) Congenital deformities
5- What is dynamic flexibility?
Amount of motion you have control over

66. 6- Passive Flexibity
Static, End Range type of motion
7- What is passive flexibility dependent on?
the extensibility of the muscle and connective tissue that
croos or surround the joint
8- What is dynamic flexibility dependent on?
the muscle contraction and the amount of tissue
resistance met.

67. 9- What is a contracture?
Adaptive shortening of the muscle tendon unit and
other soft tissues that surround a joint
10- What does a contracture lead to?
Significant resistance to stretching and limited ROM
11- What are the 4 types of contractures?
1) Myostatic
2) Pseudomyostatic
3) Arthrogenic and Periarticular
4) Fibrotic and irreversable

68. 12- What is a myostatic contracture?
Musculotendinous unit adaptively shortened
13- What is a common problem with Myostatic
Contracture?
Significant loss of ROM
14-Myostatic Contracture is a result of a reduced number
of ?
Sarcomere units
15- How can Myostatic Contracture be healed?
With stretching exercises in a short amount of time

69. 16-What is Pseudomyostatic Contractures a result of?
1) hypertonicity or spasticity
2) CNS Lesions
17-Who usually suffers from Pseudomyostatic
Contractures? Neuro Pt
18-Why do pseudomyostatic Contractures give resistance
to passive stretch?
Muscle appears to be in a constant state of contraction

70. 19- How do you treat a pseudomyostatic contracture?
inhibition procedures
20- What is an Arthrogenic and Periarticular Contracture a
result of? (2)
1) intra-articualr pathology
2) connective tissues that cross a joint capsule becomes
stiff
21-What do Arthogenic Contractures inhibit?
Normal arthrokinematic Motion

71. 22- How are fibrotic Contractures caused?
Fibrous changes in connective tissue
23- What are the treatments for Fibrotic Contractures?
1) Stretching 2) surgical intervention
24- What are interventions for soft tissue mobility? (5)
1) Manual or mechanical stretching
2) Self Stretching
3) Neuromuscular Inhibition
4) Joint Mobilization
5) Neural Tissue Glide

72. 25- What is over stretching?
stretch well beyond the normal length of muscle ROM
26-What can over stretching result in?
stretch well beyond the normal length of muscle ROM
27- What can over stretching result in? (3)
1) Hypermobility
2) joint instability
3) strength of the muscle are insufficient

73. 28- What are the responses to Soft tissue to
immobilization and stretch? (3)
1) Elastic Change
2) viscoelastic Change
3) Plastic Change
29- What are the types of muscular connective tissue? (3)
1) Endomysium
2) Perimysium
3) Epimysium
30- What type of forces occur during a passive
stretch? Longitudinal and lateral

74. 31- What are connective tissue composed of?
1) collagen fibers
2) Elastin Fibers
3) Reticulin Fibers
4) Ground Substance
32-What are collagen fibers responsible for?
1) strength
2) Stiffness
3) Resisting tensile deformation
33- What do elastin fiber provide? extensibility

75. 34- What type of intensity should be applied to a
stretch? Low
35- What is a static progressive stretch?
a stretch that is held in a comfortably lengthened
position until relaxed and then progressively
lengthened further
36- What is a cyclic stretch?
- Short duration
-repeatedly but gradually applied
-released then reapplied

76. 37- What are the 3 way to inhibit the nueromuscular system
1) Hold-Relax and Contract-relax
2) Agonist Contraction
3) Hold relax with agonist contraction
38- what are the steps to Hold-Relax and Contract-Relax
Stretching?
1) Muscle is lengthened to point of limitation
2) Pt. Performs a pre-stretch, end range and isometric
contration fro 5-10 sec
3) voluntary relaxation of tight muscle
4) limb passively moved into new range

77. 39- What are the steps to an agonist contraction?
1) Concentrically contract the muscle opposite the
limited muscle
2) Hold the end range position for several sec
40-What are the steps for hold-relax with agonis
contraction?
1) Move the limb to the point of resistance
2) Pt perform a resisted, pre-stretch isometric
contraction of the range limited muscle
3) relaxation of that muscle
4) immediate concentric contraction of the oppoiste
muscle

78. BEST WISHES
Dr. Mosab Amoudi
2011/2012