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Physical therapy aims to improve joint and muscle function (eg, range of motion) and thus improve the patient's ability to stand, balance, walk, and climb stairs. For example, physical therapy is usually used to train lower-extremity amputees.
Limited range of motion impairs function and tends to cause pain (for normal values, see Table 1: Rehabilitation: Normal Values for Range of Motion of Joints* ). Range-of-motion exercises stretches stiff joints. Stretching is usually most effective and least painful when tissue temperature is raised to about 43° C (see Rehabilitation: Heat).
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Table 1
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Normal Values for Range
of Motion of Joints*
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Joint
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Motion
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Range (°)
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Hip
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Flexion
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0–125
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Extension
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115–0
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Hyperextension†
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0–15
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Abduction
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0–45
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Adduction
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45–0
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Lateral rotation
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0–45
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Medial rotation
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0–45
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Knee
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Flexion
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0–130
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Extension
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120–0
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Ankle
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Plantar flexion
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0–50
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Dorsiflexion
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0–20
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Foot
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Inversion
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0–35
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Eversion
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0–25
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Metatarsophalangeal joints
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Flexion
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0–30
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Extension
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0–80
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Interphalangeal joints of toes
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Flexion
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0–50
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Extension
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50–0
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Shoulder
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Flexion to 90°
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0–90
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Extension
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0–50
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Abduction to 90°
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0–90
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Adduction
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90–0
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Lateral rotation
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0–90
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Medial rotation
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0–90
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Elbow
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Flexion
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0–160
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Extension
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145–0
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Pronation
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0–90
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Supination
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0–90
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Wrist
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Flexion
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0–90
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Extension
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0–70
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Abduction
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0–25
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Adduction
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0–65
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Metacarpophalangeal joints
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Abduction
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0–25
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Adduction
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20–0
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Flexion
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0–90
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Extension
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0–30
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Interphalangeal proximal joints of fingers
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Flexion
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0–120
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Extension
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120–0
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Interphalangeal distal joints of fingers
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Flexion
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0–80
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Extension
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80–0
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Metacarpophalangeal joint of thumb
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Abduction
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0–50
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Adduction
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40–0
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Flexion
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0–70
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Extension
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60–0
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Interphalangeal joint of thumb
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Flexion
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0–90
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Extension
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90–0
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*Ranges are for people of all ages. Age-specific ranges have not been established; however, values are typically lower in fully functional elderly people than in younger people.
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†Extension beyond midline.
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Active range-of-motion exercise is used when patients can exercise without assistance; patients must move their limbs themselves. Active assistive range-of-motion exercise is used when muscles are weak or when joint movement causes discomfort; patients must move their limbs, but a therapist helps them do so. Passive range-of-motion exercise is used when patients cannot actively participate in exercise; no effort is required from patients.
Many exercises aim to improve muscle strength (for grading muscle strength, see Table 2: Rehabilitation: Grades of Muscle Strength). Muscle strength may be increased with progressive resistive exercise. When a muscle is very weak, gravity alone is sufficient resistance. When muscle strength becomes fair, additional manual or mechanical resistance (eg, weights, spring tension) is needed.
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Table 2
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Grades of Muscle Strength
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Grade
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Description
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5 or N
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Full range of motion against gravity and full resistance for the patient's size, age, and sex
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N−
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Slight weakness
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G+
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Moderate weakness
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4 or G
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Movement against gravity and moderate resistance at least 10 times without fatigue
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F+
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Movement against gravity several times or mild resistance one time
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3 or F
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Full range against gravity
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F−
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Movement against gravity and complete range of motion one time
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P+
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Full range of motion with gravity eliminated but some resistance applied
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2 or P
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Full range of motion with gravity eliminated
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P−
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Incomplete range of motion with gravity eliminated
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1 or T
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Evidence of contraction (visible or palpable) but no joint movement
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0
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No palpable or visible contraction and no joint movement
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N = normal; G = good; F = fair; P = poor; T = trace.
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General conditioning exercises combine various exercises to treat the effects of debilitation, prolonged bed rest, or immobilization. The goals are to reestablish hemodynamic balance, increase cardiorespiratory capacity, and maintain range of motion and muscle strength.
Proprioceptive neuromuscular facilitation helps promote neuromuscular activity in patients who have upper motor neuron damage with spasticity. For example, applying strong resistance to the left elbow flexor (biceps) of patients with right hemiplegia causes the hemiplegic biceps to contract, flexing the right elbow.
Coordination exercises improve motor skills by repeating a movement that works more than one joint and muscle simultaneously.
Before proceeding to ambulation exercises, patients must be able to balance in a standing position. Balancing exercise is usually done using parallel bars with a therapist standing in front of or directly behind the patient. While holding the bars, patients shift weight from side to side and from forward to backward. Once patients can balance safely, they can proceed to ambulation exercises.
Ambulation is often the main goal of rehabilitation. If individual muscles are weak or spastic, an orthosis (eg, a brace) may be used (see Rehabilitation: Therapeutic and Assistive Devices). Ambulation exercises are commonly started using parallel bars; as patients progress, they use a walker, crutches, or cane and then walk without devices. Some patients wear an assistive belt used by the therapist to help prevent falls. Anyone assisting patients with ambulation should know how to correctly support them (seesee Fig. 1: Rehabilitation: Supporting a patient during ambulation. ).
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Fig. 1
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Supporting a patient during ambulation.
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Aides should place one arm under that of the patient, gently grasp the patient's forearm, and lock their arm firmly under the patient's axilla. Thus, if the patient starts to fall, the aide can provide support at the patient's shoulder. If a patient is wearing a waist belt, the aide uses his free hand to grasp the belt.
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Transfer training is particularly important after a hip fracture, amputation, or stroke. Transferring safely is critical to remaining at home. Patients who cannot transfer independently from bed to chair, chair to commode, or chair to a standing position usually require attendants 24 h/day. Adjusting the heights of commodes and chairs may help; sometimes assistive devices are useful.
Last full review/revision November 2005
Content last modified November 2005
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