15. Passive ROM

Objectives

• Define the different types of Range of Motion (ROM)
• Recognize indications and contraindications for Passive ROM (PROM)
• Correctly demonstrate PROM:
  • Safe hand placement
  • Appropriate patient and therapist positioning
  • Proper body mechanics

Core Definitions & Concepts

• Range of Motion (ROM): Movement of a joint and its associated muscles through the available arc.
  • Interventions are aimed at preventing muscle shortening, joint limitations, capsular tightness, ligament/tendon restrictions, and to provide sensory stimulation.
• Normal ROM: Every joint has a characteristic "normal" range (beginning ➔ end of movement).
  • Example documentation: “Right Hip Flexion – PROM (10^\circ\text{ to }100^\circ).”
  • Adequate soft-tissue extensibility is essential for the joint to reach full range (e.g., hamstring length limits Straight-Leg-Raise test).
• PROM (Passive ROM): Movement created entirely by an external force within an unrestricted range.
  • External force can be manual (therapist, caregiver) or mechanical (e.g., CPM machine).
  • No active muscle contraction → no stretch beyond current range.
  • Primarily used to assess or maintain, not to gain ROM.
• AAROM (Active-Assistive ROM): Patient initiates motion; assistance (manual or mechanical) completes it.
• AROM (Active ROM): Patient moves independently through full range without outside help.
• Stretching vs ROM Exercise:
  • ROM exercise (active, passive, or AAROM) stays within available range.
  • Stretching purposely pushes beyond available ROM to increase flexibility.

Factors Influencing ROM

• Joint‐related factors:
  • Bony architecture & integrity of articular surfaces
  • Capsular & ligamentous tightness
  • Internal derangement (e.g., loose bodies, meniscal tears)
• Muscle-related factors:
  • Insufficient muscle length
  • To lengthen a muscle, move the joint(s) in the direction opposite to the muscle’s action.
  • Single-joint vs multi-joint muscles have different lengthening patterns.
• Soft-tissue influences: tendon compliance, vascular or neural tension, scar formation, general connective-tissue density.
• Other limitations: pain, fear/lack of trust, contraindicated condition (post-op restrictions), or systemic factors (e.g., cardiopulmonary stress).

Purpose & Expected Benefits of PROM

• Maintain currently available ROM and minimize negative sequelae of immobility:
  • Help preserve muscle elasticity & avoid adaptive shortening.
  • Reduce risk of joint-capsule, ligament, or tendon adhesions.
  • Facilitate synovial fluid movement → cartilaginous nutrition (“nourish the joint”).
• Sensory effects:
  • Kinesthesia: awareness of movement.
  • Proprioception: awareness of position in space.
  • PROM can enhance both through gentle, repetitive motion.
• Comfort & positioning:
  • Allows pain-free movement during acute phases or when active movement is contraindicated.
  • Pre-positions limbs for easier transfers and caregiver tasks.
• Circulatory considerations:
  • Provides only minimal perfusion benefits when compared with active contraction but can help reduce risk of venous stasis.

Indications (pp. 278)

Assessment

• Determine joint mobility & end-feel.
• Evaluate stability & integrity of non-contractile tissues.
• Identify pain patterns (physiologic vs pathologic).

Intervention

• When AROM would damage healing tissues or provoke pain.
• Patient cannot produce movement (paralysis, paresis, ↓ consciousness, severe weakness, abnormal tone, pain).
• Early post-surgical protection phase.
• Prevention of venous stasis or contracture formation in immobilized patients.

Quick Reference: Type ➔ Typical Uses

• PROM: paralysis, pain, excessive cardiopulmonary stress with activity, lack of safe motor control.
• AAROM: paresis, weakness, abnormal tone, cardiopulmonary compromise.
• AROM: patient able to move correctly without undue stress on any system.

Precautions & Contraindications (p. 278)

• PROM may temporarily increase pain or facilitate abnormal tone.
• Evaluate SINSS:
  • Severity, Irritability, Nature, Stage, Stability of condition.
• Contraindicated when:
  • Patient refuses consent.
  • Motion would disrupt healing tissues (early tendon repair, fracture fixation, graft sites).
  • Strong, protective muscle guarding that patient cannot voluntarily relax, especially if coupled with pain.

PROM: What It Will NOT Do

• Prevent muscle atrophy.
• Reduce adipose tissue.
• Increase strength or endurance.
• Increase ROM beyond existing limits (no long-term gains if used alone).
• Maintain ROM indefinitely without adjuncts like positioning, splinting, or functional activity.
• Provide significant circulatory improvement compared with active exercise.

Procedure / Technique (pp. 283-284)

1. Explain procedure; obtain informed consent.
2. Position patient for stability, comfort, modesty (draping) & unobstructed ROM.
3. Therapist positioning:
   • Stand close to extremity; adjust bed/table height to avoid excessive bending/reaching.
   • Adopt a wide Base of Support (BOS) so weight shifts parallel limb motion.
4. Provide support:
   • Stabilize PROXIMAL segment, mobilize DISTAL segment.
   • Use a lumbrical grip — firm, gentle, avoids bony prominences.
5. Execute smooth, slow, controlled motions through full unrestricted range, monitoring patient response (pain, guarding, tone).
6. Reposition limb comfortably at completion.
7. Document: joint, side, type (PROM/AAROM/AROM), range achieved, end-feel, pain, patient tolerance, and any abnormal findings.

Body Mechanics & Environmental Awareness

• Minimize patient repositioning; treat all joints on the same side before moving around bed.
• Employ large muscle groups; shift weight rather than reaching across the patient.
• Monitor equipment/tubes; maintain clear pathways.
• Keep bed/table at ergonomically sound height.

Manual Contact Guidelines

• Contact should feel “secure” – firm yet gentle.
• Avoid excessive pressure on bony landmarks.
• Combine appropriate draping for warmth & modesty.
• Stabilize where necessary to obtain desired isolated movement.
• In laboratory settings, practice slowly: normal joints first, then pathologic variations.

Infection Control / Professional Etiquette

• Always wash hands before and after patient contact.
• Maintain a respectful, communicative approach: “¿Preguntas? Gracias!” (inviting questions, showing gratitude).

Example Applications & Clinical Pearls

• Hamstrings & SLR: Tight hamstrings limit hip flexion during straight-leg-raise; PROM helps maintain but will not lengthen unless stretching protocols added.
• Hip PROM documentation: (10^\circ – 100^\circ) shows loss of full flexion (typically \approx 120^\circ in healthy adults).
• PROM as adjunct: Combine with positioning (e.g., splints) to preserve range overnight or post-surgery.
• Early CPM: Continuous Passive Motion devices often used post-knee arthroplasty within surgeon-specified parameters to nourish cartilage and reduce adhesions.

Connections to Broader Practice

• Ethical duty to respect patient autonomy: never proceed without consent.
• Foundational principle: “First, do no harm.” PROM chosen when active motion jeopardizes healing.
• Practical implication: Frequent, gentle PROM sessions can prevent costly contractures, decreasing caregiver burden and improving quality of life.