15. Passive ROM

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

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.

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).

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.

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.

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.

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.

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.

Explain procedure; obtain informed consent.
Position patient for stability, comfort, modesty (draping) & unobstructed ROM.
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.
Provide support:
- Stabilize PROXIMAL segment, mobilize DISTAL segment.
- Use a lumbrical grip — firm, gentle, avoids bony prominences.
Execute smooth, slow, controlled motions through full unrestricted range, monitoring patient response (pain, guarding, tone).
Reposition limb comfortably at completion.
Document: joint, side, type (PROM/AAROM/AROM), range achieved, end-feel, pain, patient tolerance, and any abnormal findings.

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.

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.

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

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.

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.