Demonstration of Functional Approach in ROM Rehabilitation

This chapter explores the use of functional range of movement (ROM) rehabilitation within a clinical setting. The demonstration will focus on the ROM rehabilitation of the upper limb (shoulder and elbow) and trunk. The management approach described for these areas can be applied elsewhere in the body. The book is accompanied by a video demonstration of the ROM challengers, which can be viewed online at: www.therapeuticstretch.com.

General principles for functional stretching

There are several principles to consider during functional ROM challenges:

Use movements that resemble normal daily activities

Use external goals – provide instructions such as “Reach for my hand” or “Reach for the opposite wall”. Avoid internal prompts such “Bend your elbow” or instructions that are directed to particular muscles. If internal instructions become necessary, incorporate them into the overall task, e.g. “While reaching for my hand try to straighten your elbow”.

Amplify the four movement parameters within the task, in particular the ones most affected

Mix ranges and planes

Mix end- with full-range challenges

Mix dynamic and static tasks

Mix all of the above – this will enhance generalization within the task

Contents of THE demonstration

13.1. Demonstration of principles

13.1.1 Amplifying movement parameters during a dynamic task

13.1.2 Amplifying movement parameters during a static task

13.1.3 Alternating between dynamic and static tasks

13.1.4 Context and localization of amplification

13.1.5 Mixing ranges and planes

13.1.6 Overcoming compensatory movement patterns

13.1.7 Therapist’s stance and patient handling

13.2. Shoulder ROM challenges

13.2.1 ROM challenge during dynamic tasks

13.2.2 ROM challenges during static tasks

13.2.3 Guided challenge within a functional task

13.2.4 Assisted supine ROM challenges

13.3. Elbow ROM challenges

13.3.1 Assisted supine

13.4. Trunk ROM challenges

13.4.1 Standing challenges

13.4.2 Seated challenges

13.1 Demonstration of principles

13.1.1 Amplifying the movement parameters during a dynamic task

Fig. 13.1A–D: Challenging the force parameter in the task, such as reaching and retrieving. Resistance can be provided by use of heavier objects or varying degrees of resistance from the therapist (See further in this chapter).

Fig. 13.2A–D: Challenging the range parameter with the reaching–retrieving task. Here, the range parameter is challenged within the same plane (range-on-range), flexion–extension.

Fig. 13.3A,B: Challenging the range parameter of the same task but in a different plane, i.e. reaching and retrieving within abduction–adduction.

Notes on task parameters:

For the velocity parameters any of the above movements can be performed at slower or greater speeds.

The endurance parameter can be challenged by repetition of the same movement.

Task parameters can be mixed. For example, the force can be combined with the velocity challenges, for instance by using the heavier bottle at progressively greater speeds.

13.1.2 Amplifying movement parameters during a static task

Fig. 13.4A–D. Many functional activities contain static tasks. This is reflected in challenges where the patient is instructed to hold the same position. In the following example the patient is instructed to hold the bottle and maintain it in the same position.

Fig. 13.4A,B: Challenging the force parameter during a static task.

Fig. 13.4C: Here, the range parameter is challenged in different ranges, abduction and full flexion (in Fig. 13.4D).

Notes about task parameters during static activities:

Static endurance parameters can be challenged by maintaining the position for longer durations.

Static velocity is how rapidly a person can generate a peak force while maintaining their position. This can be achieved by adding an external perturbation (by the therapist) while the patient maintains their position (see Fig. 13.16B). This challenge is demonstrated in the accompanying video.

13.1.3 Alternating between dynamic and static tasks

Fig. 13.5A,B: Alternating between a dynamic task (Fig. 13.5A) and a static task (Fig. 13.5B). In the dynamic task the patient is instructed to touch the therapist’s hand. In the static task the patient is instructed to maintain the position and the therapist applies anterior–posterior perturbation in the same plane as the dynamic task. The alteration between dynamic and static task is often introduced at a progressively faster rate and can eventually be applied randomly.

Fig. 13.6A,B: Another example of alternating between dynamic (Fig. 13.6A) and static (Fig. 13.6B) challenges. The instruction in the dynamic task is “Place the bottle on my hands”, whereas in the static task the instruction is “Hold the bottle in the same position. Stop me from moving it”.

13.1.4 Context and localization of amplification

The contex principle suggests that tasks that typify arm movement can be used to challenge all the joints in the upper extremity (and the rest of the body). Some localization to specific areas/joints can be achived by positioning of the limb or changing the nature of the task. However, it should be noted that such localization of movement can be difficult to achieve clinically, in particular when ROM limitation in specific joints is compensated for by excessive movement in adjacent areas. This is further discussed in section 13.1.6 (overcoming compensatory movement patterns).

Fig. 13.7A,B: Localizing a dynamic challenge to the elbow. The therapist supports the patient’s elbow and instructs them to gently tap the rolled up paper against the therapist’s hand. This produces end-range flexion–extension cycles in the elbow with little dynamic activity from the shoulder (however, the shoulder is statically active).

Fig. 13.8A,B: Localizing the dynamic challenge to the shoulder (flexion–extension cycles, but also in the elbow). The patient is instructed to alternately tap the rolled up paper between the therapist’s hands.

13.1.5 Mixing ranges and planes

Normal functional movement is highly variable and often involves multiple planes. Generalization of training may occur more readily when end-ranges are mixed with the whole-range challenges, as well as performing the same task in different planes (this is better demonstrated in the accompanying video).

Patients who are unable to perform a movement in a particular range can be still challenged in that range (primary challenge) but with movements in another plane (secondary challenge). This principle of primary and secondary challenges is demonstrated in this section.

Fig. 13.9A–C: Imagine a clinical situation in which the patient is unable to elevate the arm in abduction above shoulder height. In this situation they are instructed to raise the arm to their end-range (primary challenge). While in that range they can be instructed to perform a movement challenge (secondary challenge). In this example, internal–external rotation (secondary challenge) is imposed on the abducted shoulder (primary challenge).

Fig. 13.10A–C: In this example, the primary challenge is external rotation with superimposed secondary abduction–adduction challenges.

Fig. 13.11A–D: In this example, the primary challenge is internal rotation. The patient is instructed to imagine that they are “washing their back”. This task produces secondary abduction–adduction cycles (superimposed on internal rotation).

Fig. 3.12A,B: Primary and secondary challenges exemplified in the elbow. Imagine a patient who has a flexion contracture in the elbow. They are encouraged to extend to their end-range (primary challenge). They are then instructed to perform a task such as “closing and opening a lid”, imposing a secondary pronation–supination challenge on the elbow.

13.1.6 Overcoming compensatory movement patterns

One common problem with ROM loss is compensatory movement patterns elsewhere, which may reduce the efficacy of rehabilitation. Often, these compensatory patterns can be overcome by small modifications of the task, while keeping the focus of attention towards external goals.