Prac Viva Sem 2

1) Active ROM (AROM)

2) Active Assisted ROM (AAROM)

3) Passive ROM (PROM)

• Maintain physiological elasticity and contractility of the participating muscles

• Provide a stimulus for bone and joint tissue integrity

• Increase circulation and prevent thrombus (blood clot) formation

• Develop coordination and motor skills for functional activities

AROM = When a joints normal AROM is limited and / or the prevention of weakness and stiffness of uninjured body areas due to immobilisation e.g., shoulder in sling following shoulder surgery => encourage AROM exercise of non-operated joints (elbow, wrist, hand)

AAROM = When the patient's voluntary muscle contraction is not enough to complete the movement, or needs to be protected eg; pain, weakness, stifness, neurological conditions etc.

PROM = When AROM is severely limited by pain or stiffness or when AROM would be detrimental to the healing process

• Unhealed Fracture or new dislocation
• Inflammation or swelling
• Severe soft tissue damage

There is no general guide for the dosage of ROM exercises but rather differs depending on the patient. Use irritablity or fatigue as a guideline for the rep range and amount of sets. You don't want the patient in excess pain however a slight struggle or irritation should be present following the conclusion of a set

In order to improve Active ROM, we will need to prescribe AROM exercises. However, if the patient cannot achieve full AROM you may choose to begin with AAROM. For example the patient performs wrist ROM in all directions to the best of their ability, then using their unaffected side to achieve full ROM in movements where they cannot. Over time, this should progress to full AROM.

Another instruction you could give your patient to regain ROM is to encourage the functional use of their hand eg; dishes, washing, getting chnaged etc

1) Static Stretching

2) Dynamic Stretching

3) Ballistic Stretching

4) PNF Stretching

• To improve joint ROM and muscle flexibility

• Promote flexible scar during healing

• As part of a total fitness program to maintain/improve general health

• Relaxation and stress reduction

10-30 second hold, 2-4 reps > 2-3x week (with daily being the most effective). THIS IS BEST FOR THE HOME PROGRAM

comfortable passive stretch --> Isometric contraction 3-6 seconds --> Patient relaxes and physio actively stretches further for 10-30 seconds

REPEAT 3-5 times or until no further improvement

the protective mechanism activated by fast muscle stretch which causes immediate contraction to resist the stretch. The inverse of this is true aswell, that is, slow sustained stretch will produce relaxation through activation of golgi tendon organs (GTO’s) in a process known as AUTOGENIC INHIBITION.

• Isometric
• Open vs closed chain
• Plyometric
• Isotonic
– Body weight and gravity
– External loads

Minimum 2x a week at 70-85% of your RM.

This translates to 8-10 reps and 1-3 sets

For muscles that cross 2 or more joints, you must exclude any joint restriction when measuring muscle length. This is done by placing the muscle on ‘slack’, moving it through its full PROM. This can be done before or after assessment and is used to assess whether it is the JOINT impacting the stretch or the MUSCLE.
- The Muscle is the issue if ‘clearing the joint’ is successful
- The joint is the issue if ‘one of the muscles isn’t cleared successfully eg; poor ROM


EG: When measuring hamstring stretch (Hip Flexion and Knee Extension), you must:
- Clear the hip joint by taking it through PROM of Hip flexion (being stretched) with knee flexion (meaning hamstrings are on 'slack' as they are gently working)
- Clear knee joint by taking it through PROM of knee Extension with hip extension

TO CLEAR A JOINT - THE JOINT YOU WANT TO CLEAR PLACE ON STRETCH LEAVING THE OTHER MUSCLE IN ITS ACTION FOR THAT MUSCLE

1) Origin and Insertion: Femur & Hip (Rectus femoris - AIIS) whilst Insertion is Patella tendon

2) What Movement: Knee E and Hip Flexion (rectus femoris)

3) Clear Joints: Knee Flexion and Hip extension individually
- Hip extension and knee extension (to clear hip) and Knee FLEXION and hip Flexion (to clear knee)

4) Measure (opposite of movement): Measure Knee flexion and Hip extension (Rectus femoris)
Patient Prone performing Knee flexion with hip in neutral or place towel under knee

The hamstrings are responsible for knee flexion and hip extension

Therefore to stretch that hamstrings we perform knee extension and hip flexion

To clear the knee: Knee extension with hip extension (cradle sidelined)
To clear the hip: Hip flexion with knee flexion

Iliopsoas crosses two joints (the hip and the spine) and the muscles perform hip flexion and lumbar spine extension

Therefore to stretch the hip flexors we need to test hip extension with spine flexion (or neutral spine) - THOMAS TEST

To clear the hip: Hip extension and spine extension (sidelined cradle leg)
To clear the spine: Hip flexion and spine flexion (bring knees to chest laying supine)

The gastroc performs knee flexion and plantarflexion

To stretch gastrocs we need to perform knee extension and dorisflexion

To clear the knee: Knee extension with plantarflexion
To clear the ankle: Dorsiflexion and knee flexion

Soleus is a one joint muscle, only crossing the ankle joint to produce plantarflexion

To measure Soleus we need to place gastrocs on slack (meaning slight action rather than stretch), this can be done by performing slight knee flexion then measuring plantarflexion. Either holding onto a bed with a bent knee and goniometer from lateral malleolus to up the tibia OR knee to wall measuring the distance of their knee to the wall.

The hip adductors cross one joint - the hip joint and function to adduct the leg.

Thus, to measure the muscle length of this muscle we need to place the hip in abduction, using a goniometer to measure from ASIS to ASIS

The biceps are a multi joint muscle crossing the elbow and the shoulder. Biceps brachii is responsible for elbow flexion and shoulder flexion

Therefore to stretch the biceps muscle and find its length we will put the muscle in elbow extension and shoulder extension (with the patient supine arm off the bed), using the goniometer to measure with the axis on lateral epicondyle, and the other arms towards the olecranon and distal radius

To clear the elbow joint: Elbow extension and shoulder flexion
To clear the Shoulder joint: Elbow flexion and shoulder extension

The triceps are multi joint muscle crossing the shoulder and elbow to produce shoulder extension and elbow extension

Therefore to stretch the triceps we need to produce shoulder flexion and elbow flexion - Ask patient to raise arm above their head with their elbow tucked in. Measure with axis on Lateral epicondyle and arms towards olecranon and radius

To clear the elbow joint: Elbow flexion with shoulder extension so the triceps are on slack,
To clear the shoulder joint: Elbow extension (so the triceps are on slack) with shoulder flexion

The pec is a one joint muscle that produces shoulder flexion and medial rotation. First we can do a general screen to assess pec tightness - This is done by asking the patient to place their hands behind their heads like their 'chilling'. The patient presents pec tightness or muscle length issue if their elbows are elevated off the bed. In this case you would measure olecranon to the bed with a tapemeasure

To measure the sternal head (lower portion): the patient will be supine and will extend the elbow and shoulder at about 135 degrees measurements are taken from olecranon process to plinth if the patient has poor stretch. For good stretch have the patient on the edge of the bed and measure olecranon to floor


To measure the clavicular head (upper portion): the patient will be supine and will extend the elbow directly 90 degrees out to the side. Measurements are taken from olecranon process to plinth if the patient has poor stretch. For good stretch have the patient on the edge of the bed and measure olecranon to floor

Pec minor is another one joint muscle that inserts onto the coracoid process of the clavicle to produce internal rotation and protraction of the scapula.

To measure the pec minor muscle length its quite simple, have the patient lie supine on the bed with their hands by their side and measure acromion process to plinth. You can also get a feel for tightness by lightly pressing down on their shoulders.

The long finger flexors (flexor digitorum) cross mutliple joints (including the elbow, wrist and fingers) to produce flexion.

To measure, place the patients arm on a bed supinated with their hand off the bed and get them to produce elbow, wrist and finger extension, using your goniometer to measure at the wrist (ulnar styloid process)

To clear the elbow: Have the elbow extended with the fingers and wrist flexed
To clear the wrist: Have the wrist extended with the elbow and fingers flexed
To clear the fingers: Have the fingers extended with the elbow and wrist flexed

The long finger extensors cross multiple joints to produce elbow, wrist and finger extension

Thus to measure muscle length we place this muscle on stretch by having the patients arm extended and pronated with their hand off the end of the bed. We then ask the patient to flex their wrist and fingers (making a fist) off the bed towards the floor

To clear the elbow: Have the elbow flexed with the fingers and wrist extended
To clear the wrist: Have the wrist flexed with the fingers and elbow extended
To clear the fingers: Have the fingers flexed with the wrist and elbow extended

Lattisumus dorsi is a two joint muscle crossing the shoulder and spine to produce shoulder extension and spine extension

Thus to measure the muscle length we will have the patient produce shoulder flexion and spine flexion. Have the patient lie supine on the bed with their arm flexed as far behind their head as possible and hanging off the bed. If their ribs pull off the bed this indicates lat tightnesses. To measure either
a) tape measure from olecranon to floor and subtract that reading from a tape measure from bed to floor.
b) goniometer for shoulder flexion

To clear shoulder: Have the shoulder flexed with the spine extended (let them produce any arch)
To clear spine: Have the spine flexed with the arms extended or by their side (have the patient hunch over seated on the plinth)

Qualitative or observational balance is quick and easy and involves:

1. Static:
• Standing EO/EC, standing feet together EO/EC, single leg balance

2. Dynamic (internal pertubations):
• Head movements, reaching, turn around on spot

3. Dynamic (external pertubations):
• External push or tug from therapist

This test measures the maximum distances a person can reach forward with a clenched fist while standing in a fixed position. This test allows for 2 ‘practice’ trials and 3 ‘test’ trials. The patients score is the average of the three ‘test’ trials. Should be hinging at the hip with a clenched fist and shoes off

- The frail or elderly population will indicate a score <18.5cm which indicates high risk of fall

Measures the maximum distance a person can reach sideways while standing in a fixed position. Maximum reach position is to be maintained for three seconds. With a clenched fist and barefoot, the patient would hinge at the hips reaching to the side in a fixed position. 2x Practice test then Repeat 3x for test and average scores


Normal values = 20cm (pop of older women – age 73)

Measures functional lower extremity strength and ability to complete the transfer skill of STS. It requires a standard height chair and no use of hands for STS (hands on shoulders). Allow one practice ‘trial’ before test trial. The patient is to sit and stand 5x without the use of hands

A score of > 15 seconds indicates falls risk

Assesses mobility, balance, walking ability and falls risk in older adults. It is the time taken to stand up, walk 3 meteres, turn and walk back to the chair and sit down. Walking aid is allowed but must be recorded if used. One practice trial and one test trial.

A score >13.5 seconds indicates a risk of fall

In addition to the normal TUAG, we as phsyicians can call upon cognitive and other motor challeneges such as complete test while counting backwards by 3 from a randomly selected number or Complete test while holding a glass of water (both functional and muscle active)

Measures dynamic balance during an activity requiring weight-shift and movement while in Single leg (SL) stance. It requires the patient to place one foot onto a 7.5cm step and down again as fast as possible. Counter number completed within a 15 second timeframe.

Normative data:
18-35 years – 20+ steps
Healthy elderly population – 17 steps
Stroke population – 4 steps

Tests the ability to withstand an external perturbation (external force).
You will tell the patient instruction such as ‘ I am going to give you a brief tug from behind and I want you to resist the backward movement’.

Rate the result on a scale from 0-4. A normal score is between 0-1:
0 = Normal (no steps)
1 = Retropulsion but recovers unaided
2 = Absence of postural stability (would fall if not caught)
3 = Very Unstable, tends to lose balance spontaneously
4 = Unable to stand without assistance

Measures postural control under various sensory conditions. There are four stance conditions, each timed for 30 seconds:
- Feet together Eyes open
- Feet together Eyes closed
- Feet together on foam Eyes Open
- Feet together on foam Eyes closed