s is a handout collected from various books and websites.

(Rijwan Bhuiy
 This is a handout collected from various books and websites.

Rijwan Bhuiyan
BPT, CMT (MTFI-India)
McKenzie (MDT Part A & B)
Neurodynamics (NDS, Australia)
June 2012
Email: [email protected]

is is a handout collected from various books and websites. (Rijwan Bhuiya

 Contents
CHAPTER – 1: Introduction to therapeutic exercise
CHAPTER – 2: Introduction to movement
CHAPTER – 3: Classification of movement
CHAPTER – 4: Active and Passive Movement
CHAPTER – 5: Suspension Therapy
CHAPTER – 6: Fundamental & Derived Position
CHAPTER – 7: Manual Muscle Testing
CHAPTER – 8: Goniometry
CHAPTER – 9: Therapeutic massage
CHAPTER – 10: Motor learning
CHAPTER – 11: Therapeutic relaxation
CHAPTER – 12: Therapeutic gym

s is a handout collected from various books and websites. (Rijwan Bhuiy

 CHAPTER- 1
Introduction to
therapeutic exercise

s is a handout collected from various books and websites. (Rijwan Bhuiy

 CHAPTER: 1 INTRODUCTION TO THERAPEUTIC EXERCISE

DEFINITION OF THERAPEUTIC EXERCISE

Therapeutic exercise means, accelerating the patient's recovery from injury & diseases,
which have altered his normal way of life. (Gardiner, M. D, 1998, p. 26)
OR
Therapeutic exercise as the prescription of bodily movement, to correct impairment,
improves musculoskeletal function or maintains a state of well-being. It may vary from
highly selected activities restricted to specific muscles or parts of the body, to general and
vigorous activities that can return a convalescing patient to the peak of physical condition.
OR
Therapeutic exercise is a physical therapy intervention encompassing a broad range of
activities designed to restore or improve musculoskeletal, cardiopulmonary and/or
neurologic function.

The ultimate goal of any therapeutic exercise program is to achievement of symptom-free

movement & function. To apply an effective therapeutic exercise to a patient, a therapist
must have knowledge about basic Principles & Effects of exercise on the Musculoskeletal,
Neuromuscular, Cardiovascular & Respiratory systems. Also therapist must able to perform
a functional evaluation of the patient & must know the inter-relationship of anatomy &
kinesiology of the body, as well as have an understanding of the state of the injury, diseases
& surgical procedure & its potential rate of recover, complications, precautions &
contraindications. (Kisner, C., 1998, pp 3 -22)

AIMS OF THERAPEUTIC EXERCISE

 To promote activity, whenever or wherever it is possible to minimize the effects of

inactivity
 To regain normal joint range of motion.
 To increase the muscle power.
 To increase the strength & endurance.
 To encourage the patient activity.
 To accelerate the patient rehabilitation

N.B: Q: Define Therapeutic exercise. Write down the aims of Therapeutic exercise.

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 CHAPTER: 1 INTRODUCTION TO THERAPEUTIC EXERCISE

GOALS OF THERAPEUTIC EXERCISE

In the clinical decision making process, the therapist must determine the type of therapeutic
exercise that can be used to meet the predicted functional outcomes.

Therapeutic exercise seeks to accomplish the following goals:

 Enable ambulation
 Release contracted muscles, tendons, and fascia
 Maintain or improve Strength of muscles
 Mobilize joints
 Improve circulation
 Improve respiratory capacity
 Improve coordination
 Reduce rigidity
 Improve balance & stability
 Promote relaxation
 Improve muscle strength and, if possible, achieve and maintain maximal voluntary
contractile force (MVC)
 Improve exercise performance and functional capacity (endurance)
N.B: Q: Write down the goals of Therapeutic exercise

PRINCIPLES OF THERAPEUTIC EXERCISE

The principles of therapeutic exercise can be categorized in to two groups. That is ‘Basic
principles’ & ‘Mechanical principles’.

A. Basic principles:
 Determine the purpose of the exercises. Whether patient's condition needs to be
improved or whether improve the joint function or muscle strengthening.
 Determine the amount of stress the exercise place on the patient.
 Ensure that the type of stress imposed by the exercise should be relevant & that is
to be effective.
 The intensity & duration of stress imposed on the joint or muscles should increase
gradually to achieve increase in tolerance, endurance & strength.
 Last but not least, the exercise regimen should not make the patient exhausted &
tired.

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 CHAPTER: 1 INTRODUCTION TO THERAPEUTIC EXERCISE

B. Mechanical principles:
The mechanical principles that are utilized in exercise therapy for treating patient are given
below:
1. Force  Power
2. Position  Acceleration
 Gravity  Momentum
 Center of gravity (COG)  Inertia
 Line of gravity. (LOG)  Friction
 Base of support 4. Levers
 Equilibrium.  1st class lever
 Fixation & stabilization.  2nd class lever
3. Movement  3rd class lever
 Axes & planes 5. Pulleys
 Speed 6. Pendulums
 Velocity 7. Elasticity
 Work (Gardiner, M. D 1998, p. 1-20)
 Energy

TECHNIQUES OF THERAPEUTIC EXERCISE

The techniques which are used to treat the patients in exercise therapy are-

1. Positioning (Fundamental & Derived positioning)

2. Relaxation (General & Specific relaxation)
3. Movement
 Active movement
 Passive movement
 Resisted movement
 Manual mobilization techniques
4. Suspension therapy
5. Breathing exercise
6. PNF
7. Balance & co-ordination
8. Manual muscle testing
(Gardiner, M. D 1998, p. 26-27)

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 CHAPTER: 1 INTRODUCTION TO THERAPEUTIC EXERCISE

AREA OF APPLICATION OF THERAPEUTIC EXERCISE

Therapeutic exercise is a physical therapy intervention encompassing a broad range of

activities designed to restore or improve musculoskeletal, cardiopulmonary and/or
neurologic function. That’s why therapeutic exercises are used in different area of medical
science as well as different conditions. The areas & conditions where therapeutic exercises
are applied are given below:

1. In musculoskeletal area
 Any muscular pain
 Any joint pain
 Low back pain (LBP)
 Neck pain
 Thoracic pain
 Capsulitis in any joint (i.e. Frozen Shoulder)
 Bursitis in any joint
 Muscle injury (Strain)
 Ligament injury (Sprain)
2. In traumatology
 Fracture in the bone
 Dislocation in the joint
 Post operative Hip & Knee replacement
 Arthroscopy
 Spinal fixation
3. In Rheumatology
 Osteoarthritis
 Rheumatoid arthritis
 Septic arthritis
 Juvenile arthritis
 Osteoporosis
 Rheumatic fever
4. In Cardiopulmonary area
 Cardiac rehabilitation
 Post operative chest condition
 Cardiothoracic ICU

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 CHAPTER: 1 INTRODUCTION TO THERAPEUTIC EXERCISE

5. In Neurological area
 Stroke Rehabilitation
 Head injury
 Multiple sclerosis
 Peripheral nerve injury
 Motor neuron injury
 Spinal cord injury
 GBS
 Leprosy
6. In Pediatric area
 Developmental delay (Cerebral palsy)
 Congenital dislocation of hip (CDH)
 Knock knee problem
 Pase cavus
 Pase planus
 Telipase equinovarus
 TA tightness
 Spina bifida
 Hydrocephalus
 Congenital limb deficiency
7. In Sports
 Any joint, muscular & Ligament injury
 Faulty biomechanics
 Strength problems
 Muscle conditioning
 Co-ordination & Balance problem
 Sports Rehabilitation
8. In Gynecological area
 Pre & post Gynecological problems
 Gynecological Bowel, bladder problems
9. In Dermatology
 Burn
 Skin grafting
 Some skin diseases
10. In geriatric

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 CHAPTER: 1 INTRODUCTION TO THERAPEUTIC EXERCISE

VALUE OF THERAPEUTIC EXERCISE IN MUSCULOSKELETAL AREA

1. Management of pain (e.g. Decrease musculoskeletal pain)
2. Maintain joint mobility & flexibility
3. Maintain or increase joint Range of motion
4. Maintain or increase muscular strength & power
5. Maintain or increase endurance
6. Improve relaxation
7. Prevent further soft tissue injury by increasing muscle strength & flexibility
8. Prevent osteoporotic change by weight bearing therapeutic training
9. Correction of posture & thus improve quality of life
10. In sports correct biomechanics & improve performance by muscle conditioning

VALUE OF THERAPEUTIC EXERCISE IN NEUROLOGICAL AREA

1. Motor re-education
2. Normalization of muscle tone
3. Maintain or increase joint Range of motion (ROM)
4. Maintain or increase muscular strength & power
5. Maintain or increase muscle length
6. Improve co-ordination & balance
7. Improve sensory integration
8. Improve motor skills
9. Improve core stability
10. Prevent further injury e.g. Shoulder subluxation due to Stroke

VALUE OF THERAPEUTIC EXERCISE IN CARDIO PULMONARY AREA

1. Maintain or increase Cardiovascular fitness
2. Promote Cardiac Rehabilitation
3. Promote Thoracic rehabilitation
4. Maintain or increase lung Volume
5. Improve force expiratory rate
6. Reduce shortness of Breath (SOB) or Breathlessness
7. Remove excess secretion
8. Prevent lung collapse
9. Prevent the risk of further infection
10. Improve quality of life

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 CHAPTER: 1 INTRODUCTION TO THERAPEUTIC EXERCISE

Study question:
1. Define Therapeutic exercise. Write down the aims of Therapeutic exercise.
2. Write down the goals of Therapeutic exercise
3. Write down the principles of therapeutic exercise
4. What are techniques applied in Therapeutic exercise?
5. Write down the area of application of Therapeutic exercise
6. What are values of Therapeutic exercise in Musculoskeletal area?
7. What are the values of Therapeutic exercise in Neurological area?
8. What are the values of Therapeutic exercise in Cardio pulmonary area?
Advance question:
1. By knowing about Therapeutic exercise which goal can be fulfilled?
2. Under which basic principles a physiotherapist can apply his/her
knowledge about therapeutic exercise?
3. Suppose a Physiotherapist is appointed in a hospital. He/she has knowledge
about Therapeutic exercise. So in which areas he/she can apply this?
4. What can a physiotherapist do after getting knowledge about Therapeutic
exercise?
5. How can a physiotherapist manage disable, handicap condition by
therapeutic exercise?
6. Write down the disablement model according to Therapeutic exercise
Reference:

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 CHAPTER- 2

Introduction to
Movement

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 CHAPTER: 2 INTRODUCTION TO MOVEMENT

THE STUDY OF HUMAN MOVEMENT

Movement is a vital part of Human being. In our every day activity we can’t go forward
without movement. Basically we move our all body part in every day activities. The
movements that originate from our body are complex in nature.

Before studying about Human Movement, at first we have to face a question like, why should
we need to study it? Actually there are two fascinating factors which lead us to study about
Human movement. Firstly, the vast range of functional movement in our daily living
activities & Secondly, the complexity of our movements and the challenges that arise from
that complex movement.

To begin to understand how the systems of the body interact to produce finely controlled
and purposeful movement it is essential to know some introductory information about
Human Movement like how human movement is initiated, per-formed and controlled.

THE ASPECTS OF HUMAN MOVEMENT

Human movement can be viewed from a number of different standpoints:

1. Anatomical: Describing the structure of the body, the relationship between the
various parts and its potential for movement. Incorrect alignment or disruption of
anatomical structures will clearly affect movement.
2. Physiological: Concerned with the way in which the systems of the human body
function and the initiation and control of movement. In many cases incorrect
functioning or failure of integration between systems will lead to movement
abnormalities.
3. Mechanical: Involving the force, time and distance relationships in movement.
4. Psychological: Examining the sensations, perceptions and motivations that stimulate
movement and the neurological and chemical/ hormonal mechanisms which control
them.
5. Sociological: Considering the meanings given to various movements in different
human settings and the influence of social settings on the movements produced.
6. Environmental: Considering the influence of the environment on the way in which
movement occurs.
(Human movement, pp 1-4)

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 CHAPTER: 2 INTRODUCTION TO MOVEMENT

It is obvious that each of these aspects is interrelated and that between them they give a
framework and a direction for the study of movement.

[Figure: 1, there are a number of ways in which the study of human movement can be approached; each approach
is valid in its own right but, on its own, limited. For a holistic understanding of how the human body moves and
component parts work as they do, a multidimensional approach has to be taken.]

HUMAN LOCOMOTOR SYSTEM

Definition: Locomotion is the act or power of moving from place to place by means of one’s
own mechanisms or power. All four limbs are responsible for locomotion
(Luttgens, K & Hamilton, N, p519)
The human locomotor system (also known as the musculoskeletal system) is an organ
system that gives humans the ability to move using the muscular and skeletal systems. The
musculoskeletal system provides form, stability, and movement to the human body.
Components of Human Locomotor system:
1. The cells & Basic tissues
2. Connective tissues in Musculoskeletal system
3. Articulation
4. Skeletal muscle
5. Nervous tissue
6. The myotatic unit

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 CHAPTER: 2 INTRODUCTION TO MOVEMENT

MECHANICS OF HUMAN MOVEMENT

Every human movement is based on some basic mechanical principles. In the study of
therapeutic exercise it is necessary to understand the basic mechanical principles of human
movement. Here the mechanical principles of movement are described in details.

Axis
Definition: An axis is a line about which movement takes place.
Types:
There are three types of axis
 Sagital Axis
 Frontal Axis
 Vertical Axis

Sagital Axis:
Sagital axis lies parallel to the Sagital suture of the skull. The direction of this axis is
posterior to anterior direction. Movement about this axis is in frontal plane.

Frontal Axis:
Frontal Axis lies transverse to the suture of the skull. The direction of this axis is side to side
direction. Movement about this axis is in Sagital plane.

Vertical Axis:
This axis lies parallel to the line of gravity; the direction of this axis is up to down direction.
Movement about this axis is in transverse plane.

Plane
Definition: It is a surface which lies the right angle to the line in which movement takes
place.

Types:
There are three traditional planes corresponding to the three dimensions of space. Each
plane is perpendicular to each of the other two. The planes of the body are:
 Sagital or Anterior posterior or median plane
 Frontal or Lateral or Coronal plane
 Transverse or horizontal plane

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 CHAPTER: 2 INTRODUCTION TO MOVEMENT

Sagital or Anterior posterior or median plane:

It is a vertical plane passing through the body from front to back, dividing the body into
right & left haves.

Frontal or Lateral or Coronal plane:

It is a vertical plane passing through the body from side to side, dividing the body in to
anterior & posterior haves.

Transverse or horizontal plane:

It is a plane that passes through horizontally through the body, dividing the body into upper
& lower haves.

N.B: Q: Write down the 6 (six) aspects of Human movement.

Q: What is Human Locomotor system? Write down the component of Human
Locomotor system
Q: Define & classify Axis & Plane

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 CHAPTER: 2 INTRODUCTION TO MOVEMENT

Movements in the body according to Axis & Plane (Axis vs. Plane)
Movement in the Sagital plane about a frontal axis:
 Flexion
 Extension
 Planter flexion
 Dorsi flexion

Movement in the Frontal plane about a Sagital axis:

 Abduction
 Adduction
 Ulnar deviation
 Redial deviation
 Lateral flexion

Movement in the Horizontal plane about a Vertical axis:

 Medial rotation
 Lateral rotation
 Supination
 Pronation

N.B: Q: Write down the movement in the body according to Axis & Plane

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 CHAPTER: 2 INTRODUCTION TO MOVEMENT

Speed
Definition: The rate at which a body moves & takes no account of direction

Types:

1. Speed of relaxed passive movement: The speed at which passive movement is

performed. It is a slow & uniform movement so that relaxation can be maintained.

2. Speed of active movement:

 Natural speed: This is the speed at which normal exercise is done.
 Reduced speed: Exercise done more slowly require greater muscular effort &
more control.
 Increased speed: For increase muscular effort & increase joint range

Work:
Work is defined as the product of force & the distance through which the force acts. It is
measured as joules or erg.

Energy:
It is the capacity of a body for doing work.

Power:
Power is the rate of doing work. It is measured in joules per second. (J/s)

Acceleration:
Acceleration is the rate of change the velocity.

Momentum:
The momentum of a body is the quantity of motion it possesses, and it is represented by the
product of mass and velocity. The force responsible for the momentum will generate
movement slowly in a relatively heavy body and more rapidly in a lighter body (Gardiner.
MD, p 9)

Inertia:
Inertia is the resistance of a body to any change in its state of rest or motion.

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 CHAPTER: 2 INTRODUCTION TO MOVEMENT

MUSCULOSKELETAL BASIS FOR HUMAN MOVEMENT

In the human body, every movement is performed by interaction between muscular &
skeletal system. In order to be able to analyze movement it is essential to have a good
understanding of muscle function, anatomy and biomechanics. In this section we will
discuss about the muscular & skeletal action during performing movement.

There are three major types of muscle: skeletal (striated), cardiac and smooth muscle. The
latter is found in the walls of blood vessels and gut. Skeletal muscle is that which enables the
maintenance of posture and movement and will be considered in this section.

MUSCLE CONTRACTION

Basically muscle contraction means shortening the muscle. The word 'contraction' literally
means to 'draw together' or shorten.
But the nature of muscular contraction may cause some initial confusion. According to
‘sliding filament theory’ of muscle contraction - an active muscle will attempt to shorten. But
the length may be change or not. It is totally depends on the external resistance offered.

Actually a muscle contraction occurs whenever the muscle fibers generate tension in
themselves, a situation that may exist when the muscle is actually shortening, remaining the
same length, or lengthening

So it is important to realize the term 'contraction', is used to describe an active muscle &
relays on information about whether or not it changes length during activity.
(Luttgens, K & Hamilton, N, pp, 57-59) & (Lippert, L.S, p 42)
Types of muscle contraction:
 Static/Isometric
 Dynamic

Static/Isometric:
Isometric means 'Equal length'. An isometric contraction occurs when there is no external
movement, because the internal tension generated by the muscle is equal to the external
force.
Hislop and Perrine (1967) described isometric exercise as muscular contractions against a
load which is fixed or immovable or is simply too much to overcome.

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 CHAPTER: 2 INTRODUCTION TO MOVEMENT

To demonstrate this action, in the sitting position place your Rt. hand under your thigh &
place your Lt Hand on your Rt. biceps muscle. Now pull up with your Rt. hand or in other
words, attempt to flex your Rt. elbow. Note that there was no real motion at the elbow joint,
but you did feel the muscle contraction. This is an isometric contraction of your Rt. biceps
muscle. (Lippert, L.S, 2002, p 42)

Isometric contraction is likely to occur under two different conditions:

1. Muscles that are antagonistic to each other contract with equal strength, & in this way
they balance each other. Figure- A
For example: Flex the elbow in 90 degree, and then keep it in that position actively. In
this situation, the biceps is in isometric position, because it has to hold the elbow in 90
degree position against gravity by the both action of agonist & antagonist (Triceps).
Here the isometric position is maintained by the person himself.
2. Another one- here the isometric position is maintained by the external force. Figure-B
(Luttgens, K & Hamilton, N, pp, 57-59)

(Figure: A & B)
Dynamic:
Dynamic muscle contraction can be categorized in to two ways. That is:
1. Isotonic
2. Isokinetic

1. Isotonic: Isotonic means ‘equal tension’. Isotonic contraction is a contraction in which

the tension remains constant as the muscle shortens or lengthens.
(Luttgens, K & Hamilton, N, pp, 57-59)
Example: Hold a weight in your hand while flexing your elbow to bring the weight up
toward your shoulder. You will feel the biceps muscle contract, but this time there is joint
motion. This is an isotonic contraction occurs when a muscles contracts, the muscle length
changes, & the joint angle changes.

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 CHAPTER: 2 INTRODUCTION TO MOVEMENT

Other examples of isotonic exercise are....

 lifting objects above the head - front shoulder (anterior deltoid) shortens
 lifting object up from lying position - chest muscle shortens
 lifting body up from squat position - quadriceps muscle shortens as legs extend
 doing a sit up
 throwing a ball
 swinging a bat
Isotonic muscle contraction can be classified in to two types:
a) Concentric or isotonic shortening:
In which the inner force is greater than
the external force applied. So the muscle
actively short. When a muscle performs
a contraction & its two attachments are
approximating to one another, the
contraction is known as an isotonic
shortening.
b) Eccentric or isotonic lengthening:
In which the external force generated is
greater than the internal force applied.
So the muscle actively lengthens. When
the attachment of a muscle move slowly
away from one another & the muscles
allows this movement to occur in a
controlled manner this muscles action is
called isotonic lengthening.
(Lippert, L.S, 2002 p 42) & (Hollis, M 1989, pp 2-3)
2. Isokinetic: Literally Isokinetic means
‘equal or same motion’. Through the use of
special equipment, it is possible to have
maximum muscle effort at the same speed
throughout the entire range of motion of
the related lever.
Example: Exercise in Cybax machine.
(Luttgens, K & Hamilton, N, pp, 57-59)

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 CHAPTER: 2 INTRODUCTION TO MOVEMENT

THE GROUP ACTION OF MUCLES

Muscles can’t work individually. To do any movement they need to work in together. Under
the smooth co-ordination among the muscle group, a movement is performed. This
combined action of muscles is called ‘Group action of muscles’ or ‘Role of muscles’.

Prime mover or Agonist:

Agonist means where the muscles are the major muscle involve in initiating, carrying out &
maintaining a particular movement.
Example: During knee extension quadriceps muscles are the agonist.

Antagonist:
Antagonist means where the muscle works wholly oppose the prime mover or agonist.
Antagonist relaxes reciprocally during the contraction of the agonist through the process of
reciprocal innervations.
Example: During knee extension hamstring is antagonist.

Fixator or Stabilizer:
The muscle which contract to position a bone to keep it a controlled steady base, from which
a prime mover can act. Thus the stabilizer acts to provide the fixed attachment of other
muscles.
Example: During knee extension Sartorius acts as Fixator.

Helper or Synergist:
Where a muscle team up with another muscle in the production of a movement neither
could perform alone.
Example: during extension of knee Sartorius muscles are synergist.

N.B:
Q: Define speed. Write down its types
Q: Define & Classify muscle contraction in details with examples
Q: Write down the two different conditions of isometric muscle contraction
Q: What are the group actions or Role of muscles?
Q: Write down the difference between: Dynamic & Static muscle contraction, Isotonic &
Isokinetic muscle contraction, Isotonic shortening & isotonic lengthening

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 CHAPTER: 2 INTRODUCTION TO MOVEMENT

Muscle contraction and movement matrix

Definitive and Types of contraction Movement without

descriptive Isometric Isotonic contraction
factors
Concentric Eccentric
Agonist muscle No appreciable Shortening Lengthening Dictated solely by gravity
length change   and/or external forces
Antagonist No appreciable Lengthening Shortening Dictated solely by-gravity
muscle length change   and/or external forces
Joint angle No appreciable In direction of In direction of Dictated solely by gravity
changes change force external force and/or external forces
(resistance)
Direction of Against Against With gravity Consistent with gravity
body part immovable object gravity and/or other and/or other external
or matched and/or other external force forces
external force external force (resistance)
(resistance) (resistance)
Motion Pressure (force) Causes Controls motion Either no motion or
applied, but no motion passive motion occurs as a
resulting motion result of gravity and/or
other external forces
Description Static Fixating Dynamic Dynamic Passive Relaxation
shortening lengthening
Positive work Negative work
Applied muscle Force = Force > Force < resistance No force, all resistance
force versus resistance resistance
resistance
Speed relative Equal to speed of Faster than Slower than the Consistent with inertia of
to gravity or applied the inertia of speed of gravity or applied external forces or
applied resistance the resistance applied inertial the speed of gravity
resistance forces
including
inertial forces
Acceleration/ Zero acceleration Acceleration Deceleration Either zero or acceleration
deceleration consistent with applied
external forces
Descriptive (=) (+) (-) (0)
symbol
(Floyd, R.T & Thompson, W.C, 2004, p 29)

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 CHAPTER: 2 INTRODUCTION TO MOVEMENT

JOINT RANGE OF MOTION (ROM)

RANGE
Range may be used in two senses. First, it may refer to the amount of movement which
occurs to the joint. Secondly, it may refer to the amount of shortening or lengthening of a
muscle as it acts to produce or control movement. (Hollis, M 1989, pp 5-6)

RANGE OF MOTION (ROM)

Definition:
The Range of motion is the maximum amount of displacement at any joint.
OR
This is the total quantity of movement when a joint is moved to its full extent
OR
The full motion possible is called ROM (Kisner, C, 1998, p)
OR
The amount of motion available at a synovial joint is called the joint Range of motion.
Normal ROM varies among individuals & is influenced by age, gender, body, habits &
whether motion is performed actively or passively (Huber, F.E & Wells, C.L, 2006, p 63)

Types of ROM:

Full ROM:
When a muscle is fully stretched & contracts to the limit of its normal capacity it is called full
ROM.

Outer ROM:
Contraction is from full stretched of the muscles to mid point of the full range.

Inner ROM:
Contraction is from the above mentioned mud pint to full contraction.

Middle ROM:
Contraction is any distance between the middle of the outer range & the middle of the inner
range. Middle ROM is that in which many muscles work most of the time when they are
producing movement. (Hollis, M 1989, pp 2-3)

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 CHAPTER: 2 INTRODUCTION TO MOVEMENT

Figure: In the movement from A-B the elbow

flexors are working in isotonic lengthening in outer
range (pulled by gravity). In the movement from D-
E the elbow extensors are working in isotonic
shortening in outer range (resisted by gravity);
from B-C the elbow extensors are working in
isotonic lengthening in outer range (pulled by
gravity). In the movement from D-E the elbow
extensors are working in isotonic shortening in
outer range (resisted by gravity); from E-F the
elbow flexors are working in isotonic lengthening in
outer range (pulled by gravity).

N.B: Q: What is Range of motion (ROM)? Write down the types of ROM with picture.

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 CHAPTER: 2 INTRODUCTION TO MOVEMENT

ROM depends on:

1. Shape of articular surface
2. The effects of the ligaments & muscles
3. Overlying skin & soft tissue over the joint
4. The balk of tissue in the adjacent joint

Why do we measure joint ROM?

1. Stabilize a record of active & passive ROM.
2. Find out the occurrence of pain
3. Guide the treatment
4. Evaluate the treatment
5. Analysis the treatment
6. Patient’s motivation

Methods of measuring joint ROM:

1. Goniometry
2. Tape measurement
3. Tracing
4. Flexible weir
5. Video
6. Computer
7. Photography

Normal ROM is affected by:

1. Injury
2. Age
3. Sex
4. Body type
5. Genetic make up
6. Level of activity

N.B:
Q: Why do we measure ROM?
Q: Write down some methods of measuring joint ROM
Q: Write down the factors that affects normal ROM

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 CHAPTER: 2 INTRODUCTION TO MOVEMENT

Common conditions that affects joint range of motion (ROM):

Adaptive muscles shortening:

1. Tight hamstring associated with posterior pelvic tilt.
2. Tight trunk extensors associated with increased lordosis & anterior pelvic tilt
3. Hip & knee flexion contractures with tight hip adductors flexors & hamstrings
Periarticular disease:
1. Adhesive capsulitis
2. Systemic lupus erythematosus
3. RA
Skin:
1. Burns
2. Scleroderma
(Huber, F.E & Wells, C.L, 2006, p 69)

Neuro muscular co-ordination of muscles

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 CHAPTER- 3

Classification of
Movement

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 CHAPTER: 3 CLASSIFICATION OF MOVEMENT

Our body is a series of long and short bones connected at junctions or joints. For movement,
the junctions must allow for free movement in the directions that their design allows.
Movement is produced by the internal forces generated by muscle contraction or by
external forces such as gravity and manual or mechanical forces. It occurs at joints and is
contained by ligaments.

DEFINITION OF MOVEMENT

Movement takes place at the joint, & it is brought about by either the patient's muscular
effort or by the application of an external force.

CLASSIFICATION OF MOVEMENT

A. Active movement
 Freely active movement
 Assisted active movement
 Resisted active movement
 Assisted-resisted movement
B. Passive movement
 Relaxed passive movement or passive physiological movement
 Accessory passive movement

ACTIVE MOVEMENT

Definition: The movement, which is performed or controlled by an internal force or by the

voluntary muscular contraction of person/patient

Type:
Active movement is divided into four types. They are:

1. Freely active movement:

This movement is controlled by voluntary action of muscles, without any external force.

2. Assisted active movement:

This movement is performed by the voluntary action of muscles with the help of
external force.

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 CHAPTER: 3 CLASSIFICATION OF MOVEMENT

3. Resisted active movement:

This movement is performed by the voluntary action of muscles against the application
of opposite force or any resistance (weight).
4. Assisted resisted active movement:
This movement is performed or controlled by the voluntary action of muscles with the
help of external force against the application of opposite force.

Freely active Assisted Resisted

PASSIVE MOVEMENT

Definition: This type of movement is performed by external force.

Type:
1. Relaxed passive movement or passive physiological movement:
This is a rhythmic passive movement with the help of external force. This movement is
performed within the unrestricted range by an external force.

Passive physiological movement is performed in three ways:

 Manual relaxed passive movement: This movement is performed by Physiotherapist.
 Auto relaxed passive movement: This movement is performed within the
unrestricted range by the patient themselves. E.g. this type of movement is performed
by the unaffected limb.
 Mechanical relaxed passive movement: Performed by any machine.
Characteristics of passive movement:
 It is a rhythmical passive movement
 Maintain or increase joint range of motion (ROM)
 Maintain or increase muscle strength
 Stimulate blood circulation
 It has 4 grades- I, II, III, IV

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 CHAPTER: 3 CLASSIFICATION OF MOVEMENT

2. Accessory passive movement:

Accessory movement are those movements of the joint which a person cant perform
actively, but which can be performed on that person by an external force, but he can
able to stop or restrict the movement (Maitiand 1986)
OR
Isolated translational movement are known as accessory movement & they cant
normally be produced through volitional effort. These translational movements are
used in manual therapy procedures known as joint mobilization (Huber, F.E & Wells,
C.L, p 63) TE new

Accessory movements are of two types:

a) The first type is seen in the MCP joint when rotate in grasping objects such as a hard
ball. The rotator movement is not possible unless resistance is encountered.
b) The second type of accessory movement can only be produced passively. They are
produced when the muscles acting on a joint are relaxed & are those which can't be
performed actively in the absence of resistance.

Name of accessory movement:

1. Anterior posterior (AP)
2. Posterior anterior (PA)
3. Medial glide
4. Lateral glide
5. Gaping
6. Compression AP & PA
7. Longitudinal caudal
8. Longitudinal cephalad

Compression Gaping

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 CHAPTER: 3 CLASSIFICATION OF MOVEMENT

MOVEMENT THAT OCCURRED IN THE BODY

SHOULDER JOINT

1. Flexion: A forward-upward movement in a plane at right angles to the plane of the

scapula (sagittal plane). If the movement exceeds 180 degrees, it is hyper flexion

2. Extension: Return movement from flexion (sagittal plane).

3. Hyperextension: A backward movement in a plane at right angles to the plane of the

scapula (sagittal plane).

4. Abduction: A sideward-upward movement in a plane parallel with the plane of the

scapula (frontal plane).

5. Adduction: Return movement from abduction (frontal plane)

6. Medial rotation: A rotation of the humerus around its mechanical axis so that when
the arm is in its nor-mal resting position, the anterior aspect turns medially (horizontal
plane). The full range of inward and outward rotation is best observed when the
forearm is held in 90 degrees of flexion and the humerus is held in 90 degrees of
abduction.

7. Lateral rotation: A rotation of the humerus around its mechanical axis so that when
the arm is in its nor-mal resting position, the anterior aspect turns laterally.

8. Horizontal flexion: A forward movement of the abducted humerus in a horizontal

plane (i.e., from a plane parallel to the plane of the scapula to a plane at right angles to
it). Sometimes identified as horizontal adduction in other textbooks.

9. Horizontal extension: A backward movement of the flexed humerus in a horizontal

plane (i.e., from a plane at right angles to the plane of the scapula to a plane parallel to
it). Sometimes called horizontal abduction in other texts.

10. Circumduction: A combination of flexion, abduction, extension, hyperextension, and

adduction per-formed sequentially in either direction so that the extended arm
describes a cone and the fingertips a circle

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 CHAPTER: 3 CLASSIFICATION OF MOVEMENT

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 CHAPTER: 3 CLASSIFICATION OF MOVEMENT

ELBOW JOINT

1. Flexion: From the anatomical position this is a forward-upward movement of the

forearm in the sagittal plane

2. Extension: Return movement from flexion. A few individuals are able to hyperextend
the elbow joint. This is probably because of a short olecranon process rather than loose
ligaments

PROXIMAL RADIOULNAR JOINT

1. Supination: Fore arm is in anatomical position

2. Pronation: Fore arm rotates as much as possible

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 CHAPTER: 3 CLASSIFICATION OF MOVEMENT

WRIST JOINT

1. Flexion: From the anatomical position, this is a forward-up ward movement in the
sagittal plane, whereby the palmar surface of the hand approaches the anterior surface
of the forearm.

2. Extension: Return movement from flexion.

3. Hyperextension: A movement in which the dorsal surface of the hand approaches the
posterior surface of the forearm—the exact opposite of flexion

4. Radial deviation: From the anatomical position this is a sideward movement in the
frontal plane, whereby the hand moves away from the body with the thumb side
leading. The movement corresponds to abduction of the humerus.

5. Ulnar deviation: From the anatomical position this is a sideward movement in the
frontal plane, whereby the hand moves inward to the body. The movement corresponds
to adduction of the humerus.

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 CHAPTER: 3 CLASSIFICATION OF MOVEMENT

MOVEMENT OF THUMB

1. Abduction: A forward movement of the thumb at right angles to the palm.

2. Adduction: Return movement from abduction.
3. Hyper adduction: A backward movement of the thumb at right angles to the hand.
4. Extension: A lateral movement of the thumb away from the index finger, on level with
the palm.
5. Flexion: Return movement from extension.
6. Hyper flexion: A medially directed movement of the thumb from a position of slight
abduction. The thumb slides across the front of the palm.
7. Circumduction: A movement in which the thumb as a whole describes a cone and the
tip of the thumb describes a circle. It consists of all the movements’ just described,
performed in sequence in either direction.
8. Opposition: This movement, which makes it possible to touch the tip of the thumb to
the tip of any of the four fingers, is essentially a combination of abduction and hyper
flexion and, according to some investigators, slight inward rotation.

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 CHAPTER: 3 CLASSIFICATION OF MOVEMENT

METACARPOPHALANGEAL JOINTS OF THE FOUR FINGERS

1. Flexion: The anterior surface of the finger approaches the palmar surface of the hand.

2. Extension: Return movement from flexion. Most individuals are able to achieve slight
hyper extension in these joints.

3. Abduction: For the fourth, fifth, and index fingers this is a lateral movement away
from the middle finger. This movement is limited and cannot be performed when the
fingers are fully flexed.

4. Adduction: Return movement from abduction.

PIP joint:
1. Flexion
2. Extension

DIP joint:
1. Flexion
2. Extension

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 CHAPTER: 3 CLASSIFICATION OF MOVEMENT

HIP JOINT

1. Flexion: A forward movement of the femur in the sagittal plane. If the knee is straight,
the movement is restricted by the tension of the hamstring muscles. In extreme flexion
the pelvis tilts backward to supplement the movement at the hip joint.

2. Extension: Return movement from flexion.

3. Hyperextension: A backward movement of the femur in the sagittal plane. This

movement is extremely limited. Except in dancers and acrobats, it is possible only when
the femur is rotated outward and is probably completely absent in many individuals.
The restricting factor is the iliofemoral ligament at the front of the joint. The advantage
of this restriction of movement is that it provides a stable joint for weight bearing
without the need for strong muscular contraction.

4. Abduction: A sideward movement of the femur in the frontal plane so that the thigh
moves away from the midline of the body. A greater range of movement is possible
when the femur is rotated outward. Abduction is limited by the adductor muscles and
the pubofemoral ligament.

5. Adduction: Return movement from abduction. Hyper adduction is possible only when
the other leg is moved out of the way. In extreme hyper adduction the teres femoris
becomes taut.

6. Medial rotation: A rotation of the femur around its longitudinal axis so that the knee
is turned inward. The range of inward and outward rotation is affected by the degree of
femoral torsion, (twisting of the femur on its long axis so that one end is inwardly
rotated with respect to the other). The range of outward rotation usually exceeds that of
inward rotation.

7. Lateral rotation: A rotation of the femur around its longitudinal axis so that the knee
is turned outward.

8. Circumduction: A combination of flexion, abduction, extension, and adduction

performed sequentially in either direction.

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 CHAPTER: 3 CLASSIFICATION OF MOVEMENT

KNEE JOINT

1. Flexion: Move the leg towards the thigh.

2. Extension: Return to the anatomical position.

3. Medial rotation: Rotate the leg towards the midline of the body. No movement in the
ankle

4. Lateral rotation: Rotate the leg in outward direction of the midline of the body. No
movement in ankle.

Flexion & Extension Medial & Lateral Rotation

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 CHAPTER: 3 CLASSIFICATION OF MOVEMENT

ANKLE JOINT

1. Planter flexion: A forward-downward movement of the foot in the sagittal plane, so

that the dorsal surface of the foot moves away from the anterior surface of the leg.

2. Dorsi flexion: A forward-upward movement of the foot in the sagittal plane, so that
the dorsal surface of the foot approaches the anterior surface of the leg.

3. Inversion and Adduction (Supination): A lifting of the medial border of the arch
combined with a medial bending of the front of the foot.

4. Eversion and Abduction (Pronation): A slight raising of the lateral border of the
foot combined with a slight lateral bending of the front of the foot.

Planter & Dorsi flexion Inversion & Eversion

MP joint:
1. Flexion
2. Extension
3. Abduction
4. Adduction
PIP joint:
1. Flexion
2. Extension
DIP joint:
1. Flexion
2. Extension

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 CHAPTER: 3 CLASSIFICATION OF MOVEMENT

CERVICAL SPINE

1. Flexion: Move the face downward so that chin touch the chest

2. Extension: Move the face upward

3. Side flexion: Move the ear towards the shoulder

4. Both side rotation: Turn the face towards the shoulder

Flexion Extension Side flexion Rotation

LUMBAR SPINE

1. Flexion: Move the forward

2. Extension: Return to the previous position

3. Hyperextension: Move the trunk backward

4. Both side flexion: Bent the trunk sideward

Flexion Hyperextension Side flexion

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 CHAPTER: 3 CLASSIFICATION OF MOVEMENT

Study question:
1. Define movement & classify it.
2. Define active movement. Write down the classification of active movement.
3. Define passive movement. Write down its classification.
4. Write down the Characteristics of passive movement.
5. Name of accessory movement.
6. How many types of active movement in shoulder joint? Write down their definition.
7. How many types of active movement in Elbow joint? Write down their definition.
8. How many types of active movement in wrist joint? Write down their definition.
9. How many types of active movement in Hip joint? Write down their definition.
10. How many types of active movement in knee joint? Write down their definition.
11. How many types of active movement in Ankle joint? Write down their definition.

Reference list:

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 CHAPTER- 4

Active & passive

Movement

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 CHAPTER: 4 ACTIVE & PASSIVE MOVEMENT

ACTIVE MOVEMENT

FREELY ACTIVE MOVEMENT/ ACTIVE MOVEMENT

Definition: Freely active movements are those which are performed by the patient's
muscular efforts without the assistance or resistance of any external force.

Types:
 Localized: Localized movement is designed primarily to produce some local &
specific effects. (To mobilize a particular joint or to strengthen particular muscle
groups.)
E.g. Flexion or extension exercises of UL
 General: In general exercise involves the use of many joints & muscles all over the
body & the effect in wide spread.
E.g. Running
(Principles of exercise therapy)

Indication of freely active movement:

1. Accomplish the same goals of passive movement with the added benefits that result
from muscle contraction.
2. Maintain physiologic elasticity & contractility of the participating muscles.
3. Provide sensory feedback from the contracting muscles.
4. Provide a stimulus for bone & joint tissue integrity.
5. Increase circulation & prevent thrombus formation.
6. Develop coordination & motor skills for functional activities.
[Therapeutic exercise foundation & technique]

Contraindication:
1. Any condition that disrupt the healing process.
2. Acute tear, fracture, surgery.
3. Some diseases condition as-Myocardial infarction (Ml), Coronary artery bypass
grafting (CABG), or Percutaneous transluminal coronary angioplasty (PTCA).
4. High blood pressure.
5. In unstable condition. (ICU patient).
(Therapeutic exercise foundation & technique)

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 CHAPTER: 4 ACTIVE & PASSIVE MOVEMENT

Techniques of application:
1. Select a starting position.
2. Teach the patient with care to ensure the maximum postural efficiency as a basis
for movement.
3. Give such type of instruction that will create an interest & co-operation among the
patient & therapist & lead the patient to understand the pattern & purpose of
movement.
4. The speed of exercise is done depends on the effects required. (Slow
movement during the learning period)
5. The duration of exercise depends on the patient's capacity.
(Principles of exercise therapy)

Factors affecting the effects of freely active movement:

 Nature of exercise.
 The extent of exercise.
 The intensity of exercise.
 Duration of exercise.

Effects of freely active movement:

A. Relaxation:
 Relaxation of hypertonic muscle ( Due swinging & pendular exercise)
 Reduce wasteful tension in muscle
 Achieve reciprocal relaxation of the opposing group
B. Joint mobility: When joint ROM is limited, rhythmical swinging exercise with over
pressure at the limit of free range may serve to increase joint ROM.
C. Muscle power/ tone: Muscle power & endurance is increased by creating tension in
them. This tension is greater when the exercise is performed.
D. Neuromuscular co-ordination: It is improved by the repetition of an exercise.
E. Confidence: The achievement of coordinated & efficient movement assures the patient
of his ability to maintain subjective control of his body, giving him confidence to
attempt other & new activities.
F. Circulatory & respiratory cooperation: Doing prolonged exercise it will increase the
body circulation.
(Principles of exercise therapy)

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 CHAPTER: 4 ACTIVE & PASSIVE MOVEMENT

ACTIVE ASSISTED MOVEMENT

Definition: This movement is performed by the voluntary action of muscles with the help
of external force.

Techniques of application:
1. Starting position: Stabilized the body part.
2. Pattern of movement: Taught the patient by passive movement or by active
movement in contra lateral side.
3. Support: The part of the body moved is supported throughout to reduce the load on the
weakened muscles by counterbalancing the effects of the force of gravity.
4. The antagonist muscles: Every effort must be made to reduce tension in the muscles
which are antagonistic to the movement. The starting position of the movement
should be chosen to ensure, that tension in these muscles is minimal. E.g.: A position in
which the knee is flexed, which is suitable for assisted dorsi flexion of the foot.
5. Traction: Preliminary stretching of the weak muscles to elicit the myotatic reflex
provides a powerful stimulus to contraction.
6. The assisting force: The assistive force performed by the therapist’s hands, which
should be placed in such a way that they rest on the surface of the patient's skin which
is in the direction of the movement. The ROM is as full as possible, but as the power of
muscles varies in different parts of their range, so more assistance will be necessary in
some parts than the others.
7. The character of movement: Movement should be smooth in response to patient's
voluntary muscle contraction.
8. Repetition: Repetition of movement should be maintained & it depends on the
injurious site, the cause
Principles of exercise therapy
Effects of active assisted exercise:
 The working muscle can cooperate in the production of movement, which they are
incapable of achieving without aid.
 The memory of the correct pattern of coordinated movement is unable for the
patient to achieve, without assistance.
 Assisted exercise is helpful for training coordination.
 Increase joint ROM.
 Establish confidence to the patient.
 When movement is compulsory in spite of pain in any joint than assisted exercise
are very useful. E.g.: in RA patient.
[Principles of exercise therapy]

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 CHAPTER: 4 ACTIVE & PASSIVE MOVEMENT

RESISTED MOVEMENT

Definition: This movement is performed by the voluntary action of muscles against the
application of opposite force or any resistance (weight).

Indication of resisted movement:

 Increase strength of muscles.
 Hypertrophy & recruitment of muscle fibers.
 Increase muscle endurance.
 Increase muscle power.
 Maintain normal length of muscle fibers & as well as prevent contracture.
(Therapeutic exercise foundation & techniques!
Precautions & Contraindications:
 Cardiovascular disease
 Unstable situation (high BP)
 Osteoporosis
 Acute inflammation
 Chronic pain
(Therapeutic exercise foundation & techniques)
Techniques of application of resisted movement:
 The starting position should be comfort & stable so that patient's can concentrate
the pattern of movement.
 The pattern of movement must be well known to the patient & it should be based
on a natural pattern of purposeful movement.
 Stabilization of the bone or bones of origin of the muscle to be resisted to be
improves their efficiency.
 Preliminary stretching of muscles to elicit the myotatic (stretch) reflex provides a
powerful stimulus to contraction.
 The character of movement should be smooth & controlled.
 Repetition should be maintained.
 The cooperation of the patient should be maintained.
(Principles of exercise therapy)

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 CHAPTER: 4 ACTIVE & PASSIVE MOVEMENT

Resistance may be provided by:

 The physiotherapist
 By the patient
 Resistance by weight
 Weight & pulley circuits
 Springs & other elastic structures
 Substances which are malleable
 By water

Effects & use of resisted exercise:

 Maintain or increase the muscle power.
 Increase the strength & hypertrophy the muscle.
 Increase power & endurance.
 Increase the blood flow.
(Principles of exercise therapy!

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 CHAPTER: 4 ACTIVE & PASSIVE MOVEMENT

Illustration of Resisted movement

[Resisted Shoulder flexion] [Resisted Shoulder extension]

[Resisted Shoulder abduction] [Resisted Shoulder adduction]

[Resisted Shoulder lateral rotation] [Resisted shoulder medial rotation]

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 CHAPTER: 4 ACTIVE & PASSIVE MOVEMENT

[Resisted Shoulder elevation] [Resisted Shoulder protraction]

[Resisted elbow flexion] [Resisted elbow extension]

[Resisted Fore arm supination] [Resisted Fore arm pronation]

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 CHAPTER: 4 ACTIVE & PASSIVE MOVEMENT

[Resisted Wrist flexion] [Resisted Wrist extension]

[Resisted MCP extension] [Resisted PIP flexion]

[Resisted MCP abduction] [Resisted thumb abduction]

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 CHAPTER: 4 ACTIVE & PASSIVE MOVEMENT

[Resisted Hip flexion] [Resisted Hip extension]

[Resisted Hip abduction] [Resisted Hip adduction]

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 CHAPTER: 4 ACTIVE & PASSIVE MOVEMENT

[Resisted Hip medial rotation] [Resisted Hip lateral rotation]

[Resisted Knee extension] [Resisted Knee flexion]

[Resisted Ankle Dorsi flexion] [Resisted Ankle planter flexion ]

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 CHAPTER: 4 ACTIVE & PASSIVE MOVEMENT

[Resisted Neck flexion] [Resisted Neck extension]

[Resisted Neck rotation] [Resisted Neck side flexion]

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 CHAPTER: 4 ACTIVE & PASSIVE MOVEMENT

PASSIVE MOVEMENT

RELAXED PASSIVE MOVEMENT/ PASSIVE PHYSIOLOGICAL MOVEMENT

Definition: This is a rhythmic passive movement with the help of external force. This
movement is performed within the unrestricted range by an external force.

Indications of passive physiological movement:

 When the patient is unable to perform active full ROM
 During unconsciousness
 Weak or De-nervated muscles
 Spinal cord injury
 Due to pain
 Neurological disease

Contraindications of passive physiological movement:

 Acute injury stage
 Early stage of fracture (#) healing
 Where pain may be beyond the patient's tolerance level
 Muscles or ligaments incomplete tear(May cause further damage)

Techniques of application of passive physiological movement:

 The part should be comfortable, supported, & located.
 The patient should be comfortable, warm, & supported.
 Hand hold should be as near to the joint as possible.
 The motion should be smooth & rhythmical.
 Speed & duration should be appropriate.
 Range should be maximum available without stretching or causing pain.
Human movement
Effects of passive physiological movement:
 Maintain ROM
 Prevent contracture
 Maintain integrity of soft tissue & muscle elasticity
 When active movement is impossible, because of muscular insufficiency, this
movement is help to preserve the memory of movement pattern by stimulating the
receptors of kinesthetic sense

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 CHAPTER: 4 ACTIVE & PASSIVE MOVEMENT

 Increase venous circulation

 Increase synovial fluid production
 Increase joint cartilage nutrition
 Increase kinesthetic awareness.
 Maintain functional movement pattern
 Reduce pain.

Illustration of Passive Physiological movement

[Passive Shoulder flexion] [Passive Shoulder extension]

[Passive Shoulder abduction] [Passive Shoulder medial & lateral rotation]

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 CHAPTER: 4 ACTIVE & PASSIVE MOVEMENT

[Passive Elbow flexion] [Passive Elbow extension with Shoulder extension]

[Passive Fore arm supination & pronation] [Passive Wrist movement]

[Passive Finger extension] [Passive Finger flexion]

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 CHAPTER: 4 ACTIVE & PASSIVE MOVEMENT

[Passive Hip flexion] [Passive Hip extension]

[Passive Hip abduction & adduction] [Passive Hip medial & lateral rotation]

[Passive Ankle dorsi flexion] [Passive Ankle planter flexion]

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 CHAPTER: 4 ACTIVE & PASSIVE MOVEMENT

[Passive Ankle inversion & eversion] [Passive finger flexion & extension]

[Passive Neck flexion] [Passive Neck rotation]

[Passive Lumbar flexion] [Passive lumbar rotation]

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 CHAPTER: 4 ACTIVE & PASSIVE MOVEMENT

Accessory movement:
Accessory movement are those movements of the joint which a person cant perform
actively, but which can be performed on that person by an external force, but he can able to
stop or restrict the movement (Maitiand 1986)
A full range of accessory movement is essential for normal active & passive joint
movements. A loss of an accessory movement produces a restriction in the normal range of
joint motion.
Indications of accessory movement:
Contraindications of accessory movement:
Techniques of application of accessory movement:
Effects & uses of accessory movement:
 Correction of bony block in the joint
 Loss the stiffness in any joint
 Restore the limited ROM
Clinical importance of accessory movement:
1. They play an essential role in the production of normal joint movement
2. Loss of accessory movement is associated with loss of normal joint movement
3. Normal or restricted accessory movements can be detected by appropriate clinical
testing
4. They are used to treat painful or stiff joints by a passive movement techniques
(Mobilization)

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 CHAPTER- 5

SUSPENSION
THERAPY

s is a handout collected from various books and websites. (Rijwan Bhuiy

 CHAPTER: 5 SUSPENSION THERAPY

SUSPENSION THERAPY

INTRODUCTION
Suspension therapy is a part of Therapeutic exercise. When patient want to move his/her
weak body part in ‘active-assisted’ way, without help of Therapist only then ‘Suspension
procedure’ helps them. Suspension therapy is very helpful for spinal cord injured patient.
The term ‘Suspension’ means hanging the body part by rope & sling.

Definition:
Suspension means a part of the body are suspended (Hanged) in ‘slings’ & elevated by the
‘ropes’, which is fixed to a ‘point’ above the body.
Basically suspension frees the body from the friction of the material upon which body
component may be resting. (TEFT)
Making the body suspended, need two things. They are ‘A fixed point’ & ‘A Suspension unit’

 A fixed point: The fixed point depends on the type of suspension therapy & the
body part.
 A Suspension unit: A suspension contains two things.
They are:
1. Sling
2. Adjustable rope

The fixed point

In the suspension bed three metal
meshes are used at the above, side &
head of the plinth. Fore example: 1m
or 2m wide × 2m long at above the
plinth. Perhaps 2m ×2m on the wall
at the side of the plinth, & at the head
of the plinth 1 m or 2m × 2m long &
2m high metal meshes are used for ‘a
fixed point’
(Hollis,M & Cook,P.F ,p 96)

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 CHAPTER: 5 SUSPENSION THERAPY

The Clip:
Clip may be small part but it has a vital role in suspension. Clip is used to attach the rope &
sling to the fixed point. There are two type of clip are used in suspension therapy. These are:
1. Dog clip
2. Karabiner clip
Picture of clip

Figure: The first one is ‘Dog clip’ & second one is ‘Karabiner clip’

The Suspension unit

The Sling:
There are different types of sling are used in Suspension Therapy. Each sling has its own
purpose. The slings are given below:

1. Single sling: It is a long sling with ‘D’ ring at each end. Single sling is 68cm long &
17cm wide. Single sling is used in different ways.

2. Double sling: This type of sling is used to support pelvis, thorax or thigh. The double
sling is 68cm long & 29cm wide.

3. Three ring sling: This type of sling is used to support the wrist & hand or ankle &
foot. Three ring slings are 71cm long & 3-4cm wide. It has three ‘D’ rings. Two ‘D’ rings
are attached at each end & one ‘D’ ring is free in the middle.

4. Head sling: A head sling is a short, split sling with its two halves stitched together at
an angle to create a central slit. This allows the head to rest supported at the back under
the lower & upper parts of the skull, or in the side lying position leaves the ear free.
Skilful tilting of the sling when it is applied in side lying will arrange it so that the front
ring lies at the level of the forehead & not over the eyes & nose, with the other half lying
below the occiput.

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 CHAPTER: 5 SUSPENSION THERAPY

Figure: A: Single sling, B: Double sling, C: Three ring sling, D: Head sling

Use of single sling

Use of three ring sling

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 CHAPTER: 5 SUSPENSION THERAPY

Use of double sling

Use of head sling

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 CHAPTER: 5 SUSPENSION THERAPY

The Suspension Rope/ Supporting rope:

The Suspension rope should be of 3-ply hemp so that they will not slip. The suspension rope
can be arranged in there ways.
1. Single rope: One ring is fixed at the one end of the rope, by which it is hung up. The
other end of the rope passes through one end of the wooden cleat & through a ring of
‘Dog clip’ & through the other end of wooden cleat.
2. Pulley rope: A ‘Dog clip’ attached to one end of the rope, then passes over the wheel of
a pulley. The rope then pass through the one end of ‘wooden cleat’, then passes through
the second ‘Dog clip’ & finally the other end of rope attached at the other end of
‘wooden cleat’. The two ‘dog clips’ are attached to the ring of sling. The pulley rope is
used for three dimensional movements of limb (Abduction or adduction with flexion or
extension, combined, oblique or rotator movement).
3. Double rope: In the double rope, one end fixed in a ring by which the rope is hung up
then goes through one end of wooden cleat then through the wheel of one pulley then
through another end of wooden cleat then through wheel of another pulley & finally
goes downwards & attached with wooden cleat. This type of rope is used to suspend
heavy part of body such as Pelvis, thorax.

[Single Rope] [Pulley Rope] [Double Rope]

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 CHAPTER: 5 SUSPENSION THERAPY

TYPE OF SUSPENSION THERAPY

Basically two types of suspension procedures are used in suspension

therapy. They are:

1. Vertical fixation:
The rope is fixed vertically over the center of gravity (COG) of
the moving segment (Body part). The part can then move like a
pendulum, describing an arc. Usually the movement is small
range, so this type of suspension is primarily used for support.
(Therapeutic exercise foundation & technique)

2. Axial fixation:
Here the point of attachment of all ropes, supporting the body
pat is above the axis of the joint to be moved. The part will move
on a flat plane parallel to the floor. This type of fixation always
used for maximum movement of the joint.
(Therapeutic exercise foundation & technique)

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 CHAPTER: 5 SUSPENSION THERAPY

Suspension procedure for upper extremity

Shoulder abduction & adduction:

 Position: Supine lying

 Type of Suspension: Axial Fixation
 Sling:
1. One single sling
2. One three ring sling
 Rope:
1. One single rope
 Procedure:
1. Fixed point is selected at the above of the axis of
shoulder abduction & adduction
2. Single sling is used for supporting the elbow joint
3. Three ring sling is used for supporting the wrist joint
4. A single rope start from fixed point & attached to the both single sling & three ring
sling

Elbow flexion & extension:

 Position: Sitting
 Type of Suspension: Both Vertical & Axial Fixation
 Sling:
1. One single sling
2. One three ring sling
 Rope:
1. Two single rope
 Procedure:
1. One Fixed point is selected at the above of the axis of
Elbow flexion & extension
2. Another fixed point is just above the mid point of arm
3. Single sling is used for supporting the arm
4. Three ring sling is used for supporting the wrist joint
5. One single rope is used to hang the arm & attached to the single sling
6. Another single rope is used to hang the wrist & attached to the three ring sling.

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 CHAPTER: 5 SUSPENSION THERAPY

Suspension procedure for lower extremity

Hip abduction & adduction:

 Position: Supine lying

 Type of Suspension: Axial Fixation
 Sling:
1. One single sling
2. One three ring sling
 Rope:
1. One single rope
 Procedure:
1. Fixed point is selected at the above of the axis of
Hip abduction & adduction
2. Single sling is used for supporting the knee joint
3. Three ring sling is used for supporting the ankle joint
4. A single rope start from fixed point & attached to the both single sling & three ring
sling

Hip flexion & extension:

 Position: Side lying

 Type of Suspension: Axial Fixation
 Sling:
1. One single sling
2. One three ring sling
 Rope:
1. One single rope
 Procedure:
1. Fixed point is selected at the above of the axis of Hip flexion & extension
2. Single sling is used for supporting the knee joint
3. Three ring sling is used for supporting the ankle joint
4. A single rope start from fixed point & attached to the both single sling & three ring
sling

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 CHAPTER: 5 SUSPENSION THERAPY

Knee flexion extension:

 Position: Side lying

 Type of Suspension: Axial Fixation
 Sling:
1. One three ring sling
 Rope:
1. One single rope
 Procedure:
1. Fixed point is selected at the above of the axis of knee flexion & extension
2. Three ring sling is used for supporting the ankle joint
3. A single rope start from fixed point & attached to the three ring sling

BENEFITS OF SUSPENSION THERAPY

 Patient can actively use the particular muscle for particular movement
 For secure support relaxation can promoted
 As the part is suspended so little work is required for stabilizing muscles
 Reduce the friction resistance during the movement
 Patient can work independently after the instruction of the therapist.
(Therapeutic exercise foundation & technique)

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 CHAPTER: 5 SUSPENSION THERAPY

Study question:
1. Define suspension therapy. Write down the component of suspension therapy.
2. What is suspension unit?
3. Write down the measurement of fixed pint.
4. Write down the type of clip used in suspension therapy with picture
5. How many types of slings are used in suspension therapy? Describe them with
picture
6. Draw & level the use of single sling & three ring sling
7. What is suspension rope? Who many type of them? Draw & level of them
8. How many type of suspension therapy? Write down their benefits
9. Describe the types of suspension therapy with picture
10. Write down the procedure of suspension therapy in shoulder abduction &
adduction
11. Write down the procedure of suspension therapy in elbow flexion & extension
12. Write down the procedure of suspension therapy in hip abduction & adduction
13. Write down the procedure of suspension therapy in hip flexion & extension
14. Write down the procedure of suspension therapy in knee flexion & extension

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 CHAPTER- 6

FUNDAMENTAL &
DERIVED POSITION

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 CHAPTER: 6 FUNDAMENTAL & DERIVED POSITION

STARTING POSITION

Posture follows movement like a shadow. Every movement begins in posture & ends in
posture (Sherrington). The posture from which movement is initiated is known as starting
position and they may be either active or passive in character. Equilibrium & stability is
maintained in this position.
Starting position mainly two types:
1. Fundamental starting position
2. Derived position

FUNDAMENTAL POSITION
There are five basic fundamental starting positions. These are:
1. Standing (st)
2. Kneeling (Kn)
3. Sitting (Sitt)
4. Lying (ly)
5. Hanging (hg)
Standing (st)

This is the most difficult fundamental starting position to maintain

Joint position:
1. The heels are together & on the same line,
the toes slightly apart
2. The knees are together & straight
3. The hips are extended & laterally rotated
slightly
4. The pelvis is balanced on the femoral heads
5. The spine is stretched to its maximum
length
6. The vertex is thrust upwards, the are level
is same & the eyes look straight forwards
7. The shoulders are down & back
8. The arms hang loosely to the sides, palms
facing inwards towards the body

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 CHAPTER: 6 FUNDAMENTAL & DERIVED POSITION

Muscle work:
1. Ankle planter flexors: Balance the lower leg on the foot
2. Ankle dorsiflexors: Counter balance the action of the planter flexors & support the
medial longitudinal arch of the foot
3. Knee extensors: Work slightly
4. Hip extensors: Maintain hip extension & balance the pelvis on the femoral heads
5. The extensors of the lumber spine: Work to keep the trunk upright
6. Flexors of the lumber spine (abdominal muscle): Prevent over action of extensors,
also maintain the correct angle of pelvic tilt & support the abdominal viscera.
7. Prevertebral neck muscle: Control excessive extension of the neck & straighten the
cervical spine
8. Flexors & extensors of the A-0 joint: Reciprocally balance the head

Stability:
All the muscles group mentioned above stabilized the body in anterior & posterior direction.
In addition there must be a balanced contraction of the lateral muscles to maintain
equilibrium.

Effects & uses:

1. As the base of support (BOS) is small & gravity is high so it is effective starting
position for exercise for those who can maintain it correctly.
2. The muscle work is minimal when perfect balance is achieved, therefore practice in
attaining & holding in a satisfactory pattern of standing posture reduce fatigue & also
condition the postural reflex.
3. In this position the thorax is free & the abdominal viscera are welled supported.
4. Patient feels joy & efficiency during performing exercise in standing position.

Kneeling (kn):
Joint position:
1. Body is supported on the knees which may be together or slightly apart
2. The low leg rests on the floor with the feet planter flexed.
3. The hips are extended
4. The pelvis is balanced on the femoral heads
5. The spine is stretched to its maximum length
6. The vertex is thrust upwards, the are level is same & the eyes look straight forwards
7. The shoulders are down & back
8. The arms hang loosely to the sides, palms facing inwards towards the body

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 CHAPTER: 6 FUNDAMENTAL & DERIVED POSITION

Muscles work:
1. Flexors & extensors of knees: Balance the femur vertically on the knee.
2. Knee extensors: Work slightly.
3. Hip extensors: More strongly maintain the hip extension &
balance the pelvis on the femoral heads.
4. Spine extensors: Working to keep the trunk upright.
5. Flexors of lumbar spine: Prevent more strongly the action
of the extensors & maintain the correct angle of pelvic tilt.
6. Prevertribral neck muscle: Control the excessive extension
of neck & straighten the cervical spine.
7. Flexors & extensors of A-0 joint: Reciprocally balance the
head.

Stability: The body is stabilized on the both knees

Effects & uses: Use for controlling the hip joint & lower trunk in preparation for the
standing position.

Sitting (sitt)
Joint position:
1. Position is taken on a chair or stool
2. Hip & knee is flexed in right angle
3. Femurs are parallel & the feet rest on the floor
4. Pelvic is anteriorly tilted
5. Spine is straight & maintains appropriate curvature in each
region
6. The arms either hang loosely to the sides, or rest on the both
thigh

Muscle work:
1. No muscle work for holding the leg
2. Hip flexors: Maintain right angle flexion & prevent the tendency to slump
3. Extensors of spine: Keep the trunk upright
4. Prevertribral neck muscles: Control excessive extension of the neck & straighten
the cervical spine
5. Flexors & extensors of A-0 joint: Working reciprocally to balance the head.

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 CHAPTER: 6 FUNDAMENTAL & DERIVED POSITION

Effects & uses:

1. Comfortable, neutral, stable position
2. Commonly used for those who, lack the necessary strength & control to maintain
more difficult position.
3. For pelvic mobility
4. Effective for those who has contraindication in knee & ankle weight bearing

Lying (ly)
Joint position:
1. Same as the standing position but on the bed (Supine lying)
2. In this position the body is completely supported

Muscle work:
1. Minimal muscles are involve to maintain this posture
2. Head rotators: Work reciprocally to stabilize the head
3. Hip medial rotators: Keep the leg in neutral position

Effects & uses:

1. Most relax position
2. For treatment of spinal deformity
3. Effective for those who are suffering from respiratory & cardiac problem
4. Patient who has low muscle tone after stroke

Hanging (hg)
Joint position:
1. Body is supported by griping over the horizontal bar.
2. Fore arm: Pronated
3. Shoulder: Full flexion & apart
4. The trunk & legs: Hang straight
5. Knees: Together, Extension & maintain traction.
6. Ankle: Together & planter flexed

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 CHAPTER: 6 FUNDAMENTAL & DERIVED POSITION

Muscle work:
1. Fingers flexors: Work strongly to grip the bar.
2. Wrist Muscles round the wrist work as a synergists to prevent strain
of finger joints.
3. Elbow flexor: Reduce the strain of the joint
4. Shoulder abductors: Work strongly to lift the body to the arms.
5. Pre-vertebral neck muscles: Work reciprocally to maintain the
position of the head & neck.
6. The flexors of the lumber spine & the extensors of the hip: Work to
correct the tendency to arch the back as the result of the over action
of Latissimus dorsi, working on the sacrum.
7. Hip adductor: Keep the hip together
8. Knee extensors: Maintain knee extension
9. Ankle planter flexors: Work to point the toes to the floor

Effects & uses:

1. Useful for whom, who have well muscle strength & balance
2. Useful for limb traction
3. Useful for gymnast
4. Contraindicated for those who have respiratory & cardiac problems

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 CHAPTER: 6 FUNDAMENTAL & DERIVED POSITION

DERIVED POSITION

We know there are five basic fundamental starting positions, from where we start our
exercise. Sometimes we need to change or modify the fundamental position by altering the
arm, leg & trunk position for some exercise purpose. In this way a new starting position
comes out which is called derived position.

Purpose of derived position:

 To increase or decrease the size & stability of the base (BOS)
 To raise or low the center of gravity
 To ensure the maximum local or general relaxation
 To provide a convenient position from which a particular exercise is to be
performed
 To increase or decrease leverage

POSITION DERIVED FROM STANDING

By alteration of the arms

Wing standing ( wg.st)

Joint position
1. Hands rest on the iliac crest
2. Shoulder: Abducted
3. Elbow: Flexed
4. Wrist: Extended
5. Finger: Extended, Abducted finger face anteriorly &
thumb in posterior side
6. Another joint position is same as the standing position
Muscle work:
1. Shoulder abductor (Deltoid, Supra spinatus)
2. Elbow extensors work slightly to press hand on iliac
crest
Effects &uses:
1. As the shoulder is abducted so during some trunk exercise it is easy to the therapist
to grasp the trunk
2. Prevent the swinging of hand during trunk exercise

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 CHAPTER: 6 FUNDAMENTAL & DERIVED POSITION

Reach standing (rch.st)

Joint position
1. Shoulder: Forward flexed, Parallel right angles to the body
2. Elbow: Extended
3. Wrist & finger: Neutral position
Muscle work:
1. Shoulder: Flexors maintain position against gravity
2. Elbow extensors
3. Finger & wrist extensors work slightly
Effects & uses:
1. Assists balance during balance walking side ways
2. As the hand is forward so gravity & there is a natural tendency to overcompensate
for this by extension of lumbar spine

Yard standing (yd.st)

Joint position:
1. Shoulder: Abducted
2. Elbow: extended
3. Fore arm: pronated
4. Wrist: Neutral position
5. Finger: Neutral position
6. Other position is same as fundamental standing position
Muscle work:
1. Shoulder: Abductor, Extensors, Lateral rotators, Rotator of scapula work to
stabilized the arms
2. Elbow: Extensors keep the elbow straight
3. Wrist, Finger: Extensors to hold the limbs in a straight line
Effects & uses:
1. Facilitates body balance
2. Convenient for arm swing exercise

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 CHAPTER: 6 FUNDAMENTAL & DERIVED POSITION

Stretch standing (str.st)

Joint position:
1. Arm is fully elevated so that they are in line with the body, parallel to each other &
with palm facing.
2. Elbow: Extended
3. Wrist & finger: Neutral position
Muscle work:
1. Shoulder abductors, extensors & lateral rotators
2. Lateral rotators of scapula to hold the arms position
3. Elbow extensors: Keep straight
4. Wrist & fingers extensors

By alteration of leg

Close standing (cl.st.)

Joint position:
1. The hip joints are rotated internally so that the both are adjacent together
2. Rest of the joint position is same as fundamental standing position
Muscles work:
1. Leg muscles work more strongly than fundamental standing
position
Effects & uses:
1. For advance standing training

Toe standing (toe.st.)

Joint position:
1. The heel are closed together & raised from the floor
2. DIP: extended
3. Ankle: planter flexion
Muscles work:
1. Ankle planter flexors work strongly
Effects & uses:
2. More balance exercise
3. Useful for postural flat feet patient

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 CHAPTER: 6 FUNDAMENTAL & DERIVED POSITION

Stride standing (std.st.)

Joint position:
1. Both hip joints are abducted (Body weight equally distributed)
Muscles work:
1. Hip abductor: work strongly to prevent further sliding
Effects & uses:
1. More stable position when performing exercise in frontal plane
Walk standing (wlk.st.)
Joint position:
1. One leg is forward just two foot-length apart
2. Another leg is backward in the same line
Muscles work:
1. Extensors of hip & knee of rare leg work strongly to maintain this position
Effects & uses:
1. Useful for sagittal plane exercise
2. Useful for localized rotation of spine

Half standing (1/2 st.)

Joint position:
1. The whole weight of the body is supported on one leg
2. The other leg may be free or supported in variety in position
Muscles work:
1. Abductor of hip: maintain COG by slightly lateral tilting of pelvic
2. Opposite lumbar side flexors: Bring the trunk alignment
3. Supportive leg muscles work more strongly than fundamental position
Effects & uses:
1. Unsupported leg is free, so useful for some one leg exercise
2. For more balance exercise

[Stride standing, Walk standing, Step standing]

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 CHAPTER: 6 FUNDAMENTAL & DERIVED POSITION

By alteration of trunk

Lax stoop standing (lax.stp.st)

Joint position:
1. Hip & trunk flexion
2. Head & arms are relaxed so that they hang forward &
downward
Muscle work:
1. Ankle dorsiflexors stabilized the position & intrinsic foot
muscles grip the floor
Effects & uses:
1. For local relaxation of upper limb
2. For expiration

Stoop standing (stp.st.)

Joint position:
1. Hip joints are flexed
2. Head, trunk & arm remain in alignment & are inclined forward
Muscle work:
1. Ankle dorsiflexors stabilized the position & intrinsic
foot muscles grip the floor
2. Back muscles, extensors of shoulders & elbow
maintain the position against pull of gravity
3. Pre-vertebral neck muscles support the head
Effects & uses:
1. For strong work of back muscles

Fallout standing (fallout.st.)

Joint position:
1. One leg is placed directly forward to the distance of three foot lengths & knee is
bent
2. The back leg is remaining straight & the body is inclined forwards in line with it
Muscles work:
1. Forward leg: extensors & foot muscles work strongly
2. Back leg: extensors work to keep the trunk straight, dorsiflexors keep heel on
ground
3. Head & trunk muscles work as stoop standing

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 CHAPTER: 6 FUNDAMENTAL & DERIVED POSITION

Effects & uses:

1. Useful for treatment of spine curvature

POSITION DERIVED FROM KNEELING

Half kneeling (1/2 kn.)

Joint position:
1. One knee supports most of the weight, other leg bent forward right angle at hip,
knee, ankle
Muscle work:
1. Supported leg: abductors & lumbar spine flexors of
opposite side
2. Opposite leg: extensors of hip & knee
Effects & uses:
1. For trunk side bending & rotation exercise

Kneel sitting (kn. sitt.)

Joint position:
1. Knees & hip are flexed so that patient sit on heels
Effects & uses:
1. This position is comfortable for children
2. But uncomfortable for adult

Prone kneeling (pr. Kn.)

Joint position:
1. Trunk is horizontal & supported under the shoulders by the arms
2. Pelvis supported by the thighs
Muscles work:
1. Shoulder & hip joint muscles stabilize the supporting limb
2. Lumbar spine flexors prevent the hollowing the back
3. Extensors of head neck & preventable neck muscles

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 CHAPTER: 6 FUNDAMENTAL & DERIVED POSITION

Effects & uses:

 For trunk & head exercise

POSITION DERIVED FROM SITTING

Stride sitting (std. sitt.)

Joint position:
1. This is exactly similar to the fundamental position, except
that the legs are abducted so that the feet are up to two
foot-lengths apart.
Effects & uses:
1. This position increases the stability

Crook sitting (crk.sitt.)

Joint position:
1. The knees are bent so that the feet are together & flat on the floor
2. The knees are together or apart
Muscles work:
1. Hip flexors: work strongly to prevent the excessive flexion of
the lumbar region & to support the thighs
2. The flexors of the knees & the planter flexors of ankle to
maintain this position
3. The longitudinal & transverse back muscles work strongly to
maintain the upright position of the trunk
Effects & uses:
1. As the pelvis is posteriorly tilted & the lumbar spine is flexed so useful for upper
trunk localized exercise
2. Treatment for kypho-lordosis
3. Strong work for the extensors of thoracic spine

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 CHAPTER: 6 FUNDAMENTAL & DERIVED POSITION

Long sitting (lg.sitt.)

Joint position:
1. Both hips are flexing as right angle to the trunk
2. Both knees are extended & ankles are in neutral position
3. The legs are totally supported to the ground
Muscles work:
1. Hip flexors: keep the trunk right angle to the
lower limb
2. Knee extensors: keep the both leg straight
Effects & uses:
1. Useful for sitting balance practice

Cross sitting (X sitt.)

Joint position:
1. Both hip are flexed, strongly abducted & laterally rotated
2. Both knees are flexed & the both ankles cross each other so that the lateral part of
both knees touch the floor
Effects & uses:
1. To stretch the adductors of hip
2. Useful for children during sitting balance practice

Side sitting (s. sitt.)

Joint position:
1. In right side sitting the right leg position is same as cross sitting
2. Left leg: hip is flexed & medially rotated & knee is
flexed so that the medial aspect of the left leg touch the
floor
3. The pelvis is tilted in to the right side
4. The lumbar flexed left side to keep the balance
5. Total body weight on the right side
Effects & uses:
1. Useful for increase lateral mobility of the lumbar spine
2. Useful for weight transferring

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 CHAPTER: 6 FUNDAMENTAL & DERIVED POSITION

Stoop sitting (stp. sitt.)

Joint position:
1. Same as fundamental sitting position except the trunk is
lean forward by maintaining it curvature
Effects & uses:
1. Useful for arms & upper back exercise
2. Sometimes useful for giving back massage when prone
lying is impossible

Fallout sitting (fallout sitt.)

Joint position:
1. Same as fallout standing except the hip & thigh of the forward leg are supported
across a stool.
Effects & uses:
1. Here balance is easier than the fallout standing

POSITION DERIVED FRO LYING

Crook lying (crk.ly)

Joint position:
1. From lying hip & knee are bent so that the feet rest on the floor
Muscles work:
1. Adductor & medial rotators of hip work together to prevent the knees from falling
apart
Effects & uses:
1. Reduce tension of anterior aspect of knee & thigh, pelvis & lumbar spine
2. Useful for relaxation exercise
3. Appropriate for chest physiotherapy

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 CHAPTER: 6 FUNDAMENTAL & DERIVED POSITION

Bridging
Joint position:
1. From the crook lying elevate the trunk from the ground so that the trunk rests on
the shoulders & is brought in to line with the thighs
Muscles work:
1. Hip & lumbar extensors
Effects & uses:
1. Useful for re-education of muscles in pelvic floor
2. Useful for pelvic control of stroke patient

Half lying (1/2 ly.)

Joint position:
1. The trunk is supported in the oblique position by inclination of the long end of the
plinth, or by the arrangement of pillows
2. Both knees may be extended of flexed
Effects & uses:
1. Relaxed & comfortable in this position
2. Breathing is easier in this position so useful for
breathing exercise
3. Useful for word exercise

Prone lying (pr. Ly.)

Joint position:
1. Lying face downward, the body is fully supported anteriorly on the plinth
2. It may be active & passive
3. When this position is used as an exercise purpose at that time the head is kept
slightly raise
Muscles work (During active position):
1. The pre & post vertebral neck muscles work together to maintain the head position
2. The retractors & depressors of the scapula work to brace the upper back
3. The lateral rotators of the hips keep the heel together
Effects & uses:
1. Useful for patient who have a back pain
2. Some unloading lumbar extension
exercise
3. Contraindicated for cardiac patient

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 CHAPTER: 6 FUNDAMENTAL & DERIVED POSITION

Leg prone lying (L. pr. Ly.)

Joint position:
1. Same as prone lying except from the ASIS to the leg is supported on the plinth &
strap
2. The rest of the trunk is free in the space
3. A stool is placed under the trunk for safety
Muscles work:
1. The Prevertebral neck muscles, extensors of
hip & longitudinal & transverse back muscles
work strongly to maintain the position of the
trunk against gravity
2. The extensors of shoulder & elbow hold the arm to the side
Effects & uses:
1. Advance back muscle strengthening exercise
2. For sports man

Side lying (s. ly.)

Joint position:
1. From lying roll on side
2. Under arm support the head
3. Some times rotates the trunk more & keep the upper hip & knee flex
Effects & uses:
1. Useful for relaxation
2. Sometimes use for gravity elimination position of limb

Sit lying (sit. ly.)

Joint position:
1. Supine lying position except the both knee is out from the plinth.
2. The whole trunk up the knee is supported on the plinth.
3. Both knees are flexed right angle at the edge of the bed
Effects & uses:
1. Knee extensor strengthening exercise

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 CHAPTER: 6 FUNDAMENTAL & DERIVED POSITION

Study question:
1. What is starting position? What are the types of starting position?
2. How many types of fundamental position?
3. What is the most difficult fundamental position? Write down its Joint position,
Muscle work, Stability, Effects & uses with picture.
4. Write down the Joint position, Muscles work, Effects & uses of five fundamental
positions.
5. What is derived position? What is the purpose of derived position?
6. Write down the positions derived from standing.
7. Write down the positions derived from sitting.
8. Write down the positions derived from lying.
9. Write down the positions derived from kneeling.
10. Write down the value of fundamental & derived positions.

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 CHAPTER- 7

MANUAL MUSCLE
TESTING

s is a handout collected from various books and websites. (Rijwan Bhuiy

 CHAPTER: 7 MANUAL MUSCLE TESTING

HISTORY OF MANUAL MUSCLE TESTING (MMT)

Wilhelmine Wright & Robert W. Lovett (M.D), Professor of orthopedic Surgery at Harvard
University Medical School, were the originators of the muscle testing system.
In Lovett's (1917) book, muscles were tested using a ‘resistance gravity system’ & graded on
a scale of 0 to 6.
Lowman described muscle testing procedures in the "Physiotherapy Review" in 1940. Legg
(M.D) & Janet Merrill (P.T) wrote a valuable small book on Poliomyelitis in 1932. This book,
which offered a comprehensive system of muscle testing, was used extensively in physical
therapy educational programs during the early 1940s. Here muscles were graded a scale of
0 to 5, & a ‘plus’ or ‘minus’ designation was added to all grades except 1 & zero.

The first comprehensive test on muscle testing was written by Lucille Daniels (M.A, P.T),
Marian Williams (Ph.D., P.T) & Catherine Worthingham (Ph.D., P.T) & was published in
1946. These three authors prepare a comprehensive hand book on the subject of manual
testing procedures that was concise & easy to use. It remains one of the most used texts in
the world over at the present time & is the predecessor of both the sixth & this seventh
edition of "Daniels & Worthingham's Muscle Testing."
[Hislop. H. J & Montgomery. J, 1995, 6 th ed, pp 9-10]

BASIC PRINCIPLES OF MANUAL MUSCLE TESTING (MMT)

Definition:
A manual muscle test is a test of the voluntary muscle strength of individual muscles in their
function as prime mover (Agonist).

The grading system

Rating muscle tests is a skill that takes a long time to learn and perform with reliability. It is
important to learn how much resistance a “normal” muscle can tolerate to know when a
muscle is not performing to its potential. All tests must be performed bilaterally and the
unaffected side should be tested first. This is crucial because the tester can then get an
accurate idea of how much resistance the unaffected side can tolerate and what would be
considered normal for the patient.

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 CHAPTER: 7 MANUAL MUSCLE TESTING

The scale below is comprised of both subjective and objective factors. The subjective is the
examiner knowing how much resistance to give and how much resistance the patient can
tolerate. The objective factors include: if the patient can complete the available range of
motion, move against gravity, and if he/she can hold this position. All of these factors make
accuracy in rating a muscle test difficult, but with practice intra-tester error can be kept at a
minimum.

Dr. Robert W. Lovett introduces a method of muscle testing using gravity resistance as an
objective measure for grading muscle strength. A description of muscle grading based on
the Lovett system & published in 1932 listed the following:

 Gone: no contraction felt

 Trace: muscle can be felt to tighten, but can’t produce movement
 Poor: produce movement with gravity eliminated, but can't function against gravity
 Fair: can raise part against gravity
 Good: can rise part against outside resistance as well as against gravity
 Normal: can overcome a greater amount of resistance than a good muscle.
[Muscle testing & functions]

Grading Scale: (Daniel & Worthingham 1995)

 Grade 5: Patient can hold the position against maximum resistance and through
complete range of motion.
 Grade 4: Patient can hold the position against strong to moderate resistance, has
full range of motion.
 Grade 3: Patient can tolerate no resistance but can perform the movement through
the full range of motion.
 Grade 2: Patient has all or partial range of motion in the gravity eliminated
position.
 Grade 1: The muscle/muscles can be palpated while the patient is performing the
action in the gravity eliminated position.
 Grade 0: No contractile activity can be felt in the gravity eliminated position.

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 CHAPTER: 7 MANUAL MUSCLE TESTING

OXFORD grade scale:

 Grade 5: Patient can hold the position against maximum resistance and through
complete range of motion.
 Grade 4: Patient can hold the position against strong to moderate resistance, has
full range of motion.
 Grade 3: Patient can tolerate no resistance but can perform the movement through
the full range of motion.
 Grade 2: Patient has all or partial range of motion in the gravity eliminated
position.
 Grade 1: The muscle/muscles can be palpated while the patient is performing the
action in the gravity eliminated position.
 Grade 0: No contractile activity can be felt in the gravity eliminated position.

Factors considering muscle strength:

Three factors are considered in the assessment of muscle strength:
1. Ability of the muscle to contract
2. Ability or inability of the muscle to move through range
3. Amount of resistance which can be give to the working muscle
(Human movement)
Requirements for muscle testing:
1. Knowledge of muscle & joint structure
2. Knowledge of nerve supply & function of particular muscle
3. Knowledge of test procedures & grading of muscle
4. The ability to observe, handle & palpate any muscle accurately & sensitively
5. The ability to recognize muscle substitution
(Human movement 2ND Ed)
Preparation for Manual muscle testing:
 The room should be worm light & quiet
 Should have firm examination table
 Give an explanation to the patient about the reason for the test
 Suitable state of undress
 Maintain comfortable well supported position so that, if possible the patient can see
the tested area
 The physiotherapist should previously read the medical notes & ask the patient
about the problems
 Observe posture &muscle wasting
(Human movement 2nd Ed)

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 CHAPTER: 7 MANUAL MUSCLE TESTING

Test position:
1. During testing grade 0 to 2 provide more support & move in horizontal plane
2. During testing grade 3 to 5 the positions are against gravity
Human movement

Technique of muscle testing:

 Adequate fixation should be maintained
 All joint should be tested through their available range either by active movement
when possible or by passive movement
 The resistance may be given through the range of movement by the physiotherapist
hand
 Resistance should be smooth adjustable & its line directly opposite to the line of
pull of muscle tendon
 Trick movement (Substitution movement) should be eliminated
 All possible tests should be carried out in one position before moving to the
patient another position
 The patient should be given an appreciation
 The, result should be memorized as the test proceeds & recorded during the rest
period for the patient
 The patient should not be fatigue
 On the completion of the test, the ‘muscle chart’ should be signed, dated, & filed
 Also regularity should be maintained
Human movement 2nd ed

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 CHAPTER: 7 MANUAL MUSCLE TESTING

MMT IN UPPER LIMB

SHOULDER FLEXION:
N.B: I in the absence of a deltoid the patient
may attempt to flex the shoulder with the
Muscles: biceps brachii, by first externally rotating
 Anterior Deltoid shoulder. To avoid this, the arm should be
kept in the mid position between internal &
 Corocobrachialis
external position rotation.

Grade 5 & Grade 4:

 Patient position: Short sitting, Elbow slightly flexed
& fore arm Pronated.
 Test:
 Give downward resistance at 90 degree flexion
position. Tell the patient "hold it; don't let me
push it down".
 If hold end position (90 degree) against maximum
resistance, it is G-5.
 If hold end position against strong to, moderate
resistance, it is G-4.

Grade 3:
 Patient position: Short sitting, Elbow slightly
flexed & fore arm Pronated.
 Test:
 Flex shoulder at 90 degree position. Ask patient
to hold their.
 If patient can hold that position, it is G-3. But can't
tolerate resistance.

Grade 2, Grade 1 & Grade 0:

 Patient position: Side lying with test side is up.
 Test:
 Instruct patient to flex shoulder at 90 degree position.
 If patient can complete ROM, it is G-2
 If there is contraction (Therapist can feel) but no movement, it is G-1.
 If there is no movement or contraction, it is G-0.

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 CHAPTER: 7 MANUAL MUSCLE TESTING

SHOULDER EXTENSION:

Muscles:
 Latissimus dorsi
 Teres major
 Posterior deltoid
G-5 & G-4
Grade 5 & Grade 4:
 Patient position: Prone with arms at sides & shoulder internally rotated.
 Test:
 Patient raises arm off the table. Give resistance & ask the patient to hold it &" don't
let me push it down".
 G-5: Complete available range against maximum resistance.
 G-4: Complete available range against moderate resistance.

Grade 3, Grade 2, Grade 1 & Grade 0:

 Patient position: Prone with arms at sides & shoulder internally rotated.
 Test:
 Patient raises arm off the table.
 G-3: Complete available range of motion with no manual resistance.
 G-2: Complete partial ROM or complete FROM in side lying with tested side up.
 G-l: Therapist palpate over the posterior shoulder just superior to the axilla for
posterior deltoid fiber. If contraction occurs then it is G-1.
 G-0: No contractile response in participating muscle.

[G- 3] [G-0]

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 CHAPTER: 7 MANUAL MUSCLE TESTING

SHOULDER ABDUCTION:

Muscle:
 Middle Deltoid
 Supraspinatus
Grade 5 to Grade 3:
 Patient position: Short sitting, with arm side
& Elbow slightly flexed.
 Test:
 Patient abducts his arm 90 degree. Apply
resistance downwards & ask patient to
hold it, not to go the therapist
G-5 & G-4
downwards.
 If hold in maximum resistance it is G-5, moderate resistance it is G-4.
 Only can abduct at 90 degree but can't tolerate any resistance it is G-3.

Grade 2 to Grade 0:
 Patient position: Supine lying with arm ;r. side, supported on the table. Fore arm
Pronated.
 Test:
 Patient attempts to abduct shoulder by sliding arm on table without rotating it.
 If complete FROM: it is G-2
 If palpable or visible contraction of Deltoid with no movement, it is G-l.
 If no movement or contraction it is G-0

[G-3] [G-2 to 0]

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 CHAPTER: 7 MANUAL MUSCLE TESTING

SHOULDER ADDUCTION:
Muscle:
 Pectoralis major

Grade 5 to Grade 4:
 Patient position: Supine, 90 degree shoulder
abduction, 90 degree elbow flexion,
 Test:
 Move arm across the chest, give resistance
ask patient to hold it. Don't let me pull it
back.
 If need maximum resistance it is G-5,
moderate resistance it is G- 4. G- 5 & G- 4

Grade 3:
 Patient position: Supine, Shoulder at 90 degree of abduction & Elbow 90 flexion.
 Test:
 Support patient's fore arm & ask to adduct the shoulder.
 If complete available range it is G-3.
Grade 2 to Grade 0:
 Patient position: Patient is seated with test arm supported on table (at level of axilla)
with arm in 90 degree of abduction & Elbow slightly flexed.
 Test:
 Patient tries to horizontally adduct his shoulder
 If patient horizontally adduct shoulder through available range of motion with the
weight of the arm supported by the examiner or the table. It is G-2.
 G-1: palpable contraction but no movement. G-0: no movement or contraction.

G-3 G- 2 to 0

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 CHAPTER: 7 MANUAL MUSCLE TESTING

SHOULDER EXTERNAL ROTATION:

Muscle:
 Infraspinatus
 Teres minor
Grade 5 to Grade 3:
 Patient position: Prone with head turn
towards tested side. Shoulder abducted 90
degree with arm fully supported on table, fore
arm hanging vertically over edge of the table.
 Test:
 Patient raises his fore arm & gives
resistance externally. Ask patient to hold G- 5 & G-4
it; don't let it push me down.
 If hold fore arm in two finger resistance, it is G-5. Need moderate resistance, G-4.
 G-3: If complete available ROM but; is unable to take any manual resistance.
Grade 2 to Grade 0:
 Patient position: Prone with head turn towards tested side, trunk is edge of the table.
The entire hangs downs loosely from the shoulder in neutral rotation, palm facing table.
 Test:
 Patient attempts to externally rotate the shoulder.
 If complete available range (palm race forward), it is G- 2.
 If contraction but no movement, G-1. No contraction G-0.

[G-3] [G- 2 to 0]

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 CHAPTER: 7 MANUAL MUSCLE TESTING

SHOULDER INTERNAL ROTATION:

Muscle:
 Subscapularis
Grade 5 to Grade 3:
 Patient position: Prone lying with head
turn towards tested side. Shoulder abducted
90 degree with arm fully supported on table,
fore arm hanging vertically over edge of the
table.
 Test:
 Moves towards internal rotation. Give
G-5 & G-4
resistance & ask to hold it, don't let me
push it down.
 If hold maximum resistance, G-5. Moderate resistance, G-4
 If complete available range with no resistance- G-3
Grade 2 to Grade 0:
 Patient position: Prone lying with head turn towards tested side, trunk is edge of the
table. The entire hangs downs loosely from the shoulder in neutral rotation, palm facing
table.
 Test:
 Patient infernally rotates arm with thumb leading so that the palm faces out away
from the table.
 G-2: Complete available range. G-l: Palpable contraction occurs but no movement.
 G-0: No movement or palpable contraction

[G- 3] [G-2 to 0]

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 CHAPTER: 7 MANUAL MUSCLE TESTING

ELBOW FLEXION:

Muscle:
 Biceps
 Brachialis
 Brachioradialis

Grade 5 to Grade 3:
 Patient position: Short sitting with arm sides.
 For Biceps brachii: Fore arm supination.
 For Brachialis: Fore arm pronation
 For Brachioradialis: Fore arm is mid position between supination & pronation.
 Test:
 Flex elbow against resistance
 G-5: Can hold in maximum resistance
 G-4: Hold in moderate resistance.
 G-3: Complete available range of motion with no manual resistance (Figure- next page)

G-5(Brachialis) G-5(Brachioradialis)

G-5(Biceps)

Grade 2 to Grade 0:
 Patient position: Short sitting with arm abducted to 90 degree & supported by
examiner. Fore arm is supinated (biceps), Pronated (For Brachialis), & in mid position
(For Brachioradialis).
 Test:
 Patient attempts to flex the elbow.
 G-2: Complete ROM against gravity.
 G -1: Palpable contractions-occurs but no movement.
 G 0: No contraction or movement occurs.

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 CHAPTER: 7 MANUAL MUSCLE TESTING

G-3 G-2 to 0

ELBOW EXTENSION:
Muscle:
 Triceps brachii.
Grade 5 to Grade 3:
 Patient position: prone lying. The arm 90 degree abduction & tore arm 90 degree
flexion, with hanging vertically over the side of the table.
 Test:
 Extend elbow against resistance & ask the patient to hold it, don't let me bend
 G-5: Can hold in maximum resistance
 G-4: Can hold in minimum resistance.
 G-3: Can extend available range with no manual resistance
Grade 2 to Grade 0:
 Patient position: Short sitting. The arm is 90 degree abducted, elbow flex 45 degree.
The entire limb is horizontal to the floor.
 Test:
 Patient attempts to extend the elbow
 G-2: Complete available range in the absence of gravity
 G-1: Contraction occurs but no movement
 G-0: No movement or no evidence of muscular activity

[G-5 & 4] [G- 3] [G- 2 to 0]

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 CHAPTER: 7 MANUAL MUSCLE TESTING

MMT IN LOWER LIMB

HIP FLEXION:
Muscle:
 Psoas major
 Iliacus
Grade 5 to Grade 3:
 Patient position: Short sitting, with thigh fully
supported on table & legs hanging over the edge.
Patient may use arm to provide trunk stability
by grasping table edge or with hands on table at
each side.
 Test:
 Patient flex hip & ask “lift your leg off the
table & don't let me push it down
 G-5: Thigh clear table against maximum
resistance G-5 & 4
 G-4: Hip flexion against moderate resistance
 G-3: Patient complete test range & holds the position without resistance
Grade 2 to Grade 0:
 Patient position: Side lying with tested limb upward
 Test:
 Patient flexes supported hip. Knee is permitted to flex to prevent hamstring tension.
Patient complete ROM with gravity eliminated.
 G-1: Palpable contraction but no visible movement. G-0: Normal or visible
contraction.

G-3 G-2 to 0

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 CHAPTER: 7 MANUAL MUSCLE TESTING

HIP EXTENSION:

Muscle:
 Gluteus maximus
G-5 & 4
 Hamstring

Grade 5 to Grade 3:
 Patient position: Prone position.
 Test:
 Patient extends the hip against
resistance. Ask him “lift your leg off
the table as high as you can
without bending your knee
 G-5: Holds test position against maximum resistance.
 G-4: Hold moderate resistance
 G-3: Complete range & hold the position without resistance

Grade 2 to Grade 0:
 Patient position: Side lying with tested leg up
 Test:
 Bring the leg back, don't bend the knee.
 G-2: Complete FROM. G-l: Palpable contraction but no movement
 G-O: No movement or palpable contraction

[G-3] [G- 2 to 0]

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 CHAPTER: 7 MANUAL MUSCLE TESTING

HIP ABDUCTION:

Muscle:
 Gluteus medius
 Gluteus minimus

Grade 5 to Grade 3:
 Patient position: Side lying with the G- 5 & 4
tested leg upward. Lowermost leg is
flexed for stability.
 Test:
 Lift the leg upward, against resistance
& ask the patient ‘hold it don't let me
push it down’
 G-5: Complete available range with maximum resistance
 G-4: Moderate resistance
 G-3: Compete available range of motion & hold that position without resistance
Grade 2 to Grade 0:
 Patient position: Supine position.
 Test:
 Abduct hip thorough available range
 G-2: Complete available range of motion, gravity eliminated.
 G-1: Palpable contraction but no ROM. G-0: No palpable contraction or ROM

[G-3] [G- 2 to 0]

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 CHAPTER: 7 MANUAL MUSCLE TESTING

HIP ADDUCTION:
Muscle:
 Adductors Magnus
 Adductor brevis
 Adductor longus G-5 & 4
 Pectineus
 Gracilis

Grade 5 to Grade 3:
 Patient position: Side lying with tested
limb upward.
 Test:
 Patient adducts hip until the lower
limb contracts the upper one. Ask
the patient ‘lift your bottom leg up to your top one. Hold it; don’t let me push it
down."
 G-5: Complete full range, hold end position against maximum resistance
 G-4: Complete full movement in moderate resistance
 G-3: Complete full movement, hold end position but takes no resistance
Grade 2 to Grade 0:
 Patient position: Supine position.
 Test:
 Adduct hip without rotation. G-2: Can adduct limb through full range.
 G-1: palpable contraction without limb movement. G-0: No limb movement &
contraction.

G-3

G-2 to 0

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 CHAPTER: 7 MANUAL MUSCLE TESTING

KNEE FLEXION:

Muscle:
 Hamstring muscle

G- 5 & 4
Grade 5 to Grade 3:
 Patient position: Prone lying
 Test:
 Ask the patient "bend your knee, hold
it, and don’t let me straighten it"
 G-5: Can hold in maximum resistance.
G-4: Can hold in moderate resistance.
 G-3: Hold end range position but
tolerates no resistance

Grade2 to Grade 0:
 Patient position: Side lying with tested side upward.
 Test:
 Flex the knee. G-2: Complete available ROM in side lying.
 G-1: palpable tendon become prominent but no movement.
 G-0: No movement or palpable contraction.

[G-3] [G- 2 to 0]

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 CHAPTER: 7 MANUAL MUSCLE TESTING

KNEE EXTENSION:

Muscle:
 Quadriceps

Grade 5 to Grade 3:
 Patient position: Short sitting
 Test:
 Extend the knee. Ask patient "Straighten
your knee. Held it, don’t let me bend it."
 G-5: Hold end position against maximum
resistance
 G- 4: Hold end position in moderate G- 5 & 4
resistance
 G-3: Complete available range without resistance

Grade 2 to grade 0:
 Patient position: Side lying with tested leg upwards
 Test:
 Straighten the knee. G-2: Complete available-ROM.
 G-l: No motion but palpable muscle contraction.
 G-0: No movement & palpable contraction.

[G-3] [G-2 to 0]

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 CHAPTER: 7 MANUAL MUSCLE TESTING

MMT IN TRUNK MUSCLES

TRUNK EXTENSION:
Grade 5 to Grade 4: (Lumber spine)
 Patient position: Prone with clasped behind head.
 Test: Ask the patient "Raise your head, shoulder & chest off the table. Come up as high
as you can."The examiner distinguishes between Grade 5 & Grade 4 muscles by the
nature of the response. The grade-5 muscle holds like a lock, the Grade 4 muscle yield
slightly because of an elastic quality at the end pint. The patient with normal back
extensor muscles can quickly come to the end position & hold that position without
evidence of significant effort. The patient with Grade 4 back extensors can come to the
end position but may waver or display some signs of effort.

G- 5 & 4

Grade 5 to Grade 4: (Thoracic spine)

 Patient position: Prone with head & upper trunk extending off the table from about the
nipple line.
 Test:
 Ask the patient “Raise your head, shoulder & chest to table level"
 G-5: Patient is able to raise the upper trunk quickly from its forward flexed position
to the horizontal with ease & no sign of exertion.
 G-4: Patient is able to raise the trunk to the horizontal level but does it somewhat
laboriously.

G- 5 & 4

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 CHAPTER: 7 MANUAL MUSCLE TESTING

Grade 3 (thoracic & lumbar spine):

 Patient position: Prone with arm sides.
 Test:
 Patient extend spine, raising body from the table so that umbilicus clears the table.
 G-3: Patient completes the ROM. But
cont hold.
G-3
Grade 2 to Grade 0 (thoracic & lumbar):
Test:-
 These tests are identical to the Grade 3
test, except that the examiner must palpate
the lumbar & thoracic spine extensor
muscle masses adjacent to both sides of the
spine. The individual muscles can't be
isolated.
 G-2: Patient complete partial ROM. G-l: Contractile activity is detectable but re
movement.
 G-0: No contractile activity.

G-2 to 0

TRUNK FLEXION:
Muscle:
 Rectus abdominis
 External oblique
 Internal oblique
Grade 5:
 Patient position: Supine with hands clasped behind head
 Test:
 Patient flexes trunk through range of motion. A curl- up emphasized & trunk is
curled until scapulae clear table.
 G-5: Complete ROM, until inferior angle of scapula is off the table, as in a sit-up

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 CHAPTER: 7 MANUAL MUSCLE TESTING

G-5

Grade 4:
 Patient position: Supine with arms crossed
over chest. G-4
 Test: Same as grade 5
 G-4: Patient complete ROM, & rises
trunk until scapula are off the table.
 Resistance of the arms is reduced in the
cross-chest position.

Grade 3:
 Patient position: Supine with arms outstretched in full extension above piece of body.
 Test:
 Patient flexes trunk until inferior angles
G-3
of scapula are off the table. Position of
the outstretched arms "neutralizes"
resistance by bringing the weight of the
arms closer to the center of gravity.
 G-3: Patient complete ROM & flexes
trunk until inferior angles of scapula
are off the table.

Grade 2 to 0: G- 2 to 0

Patient position: Supine with arm side, knee

flexes.
Test:
Ask the patient to lift the head from the table.
If scapula doesn't clear the table G-2, only
contraction G-l, No contraction, it is G-0.

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 CHAPTER- 8

GONIOMETRY

s is a handout collected from various books and websites. (Rijwan Bhuiy

 CHAPTER: 8 GONIOMETRY

INTRODUCTION

A Goniometer is used in the medical field to measure a joint's range of motion. It can be
helpful in determining, if a patient is lacking in mobility due to an injury, or how well he/she
is recovering after sustaining an injury.
In 1912, the physicist, Max von Laue, used a Goniometer to aid in the investigation of the
atomic structure of crystals. It is used in different purpose. In physical therapy, the
Goniometer is used to measure range of motion in patients. Therapists can determine what
it is before therapy begins, and how it progresses with therapy.

GONIOMETRY

DEFINITION:
The term goniometry is derived from two Greek words, ‘gonia’, meaning angle and
‘metron’, meaning measure.

So goniometry refers to the measurement of angles. Specifically it can say that the
measurement of angles created at human joints by the bones of the body.
Goniometry may be used to determine both a particular joint position & the total amount of
motion available at a joint. Goniometry is an important part of a comprehensive evaluation
of joints & surrounding soft tissue. (Norkin, C.C & White, D.J, 1998, p 3)

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 CHAPTER: 8 GONIOMETRY

Importance of Goniometry:
1. Determine the presence or absence of dysfunction
2. Establishing a diagnosis
3. Develop treatment goal
4. Evaluating progress or lack of progress towards rehabilitative goal
5. Modify treatment
6. Motivating the subject
7. Researching the effectiveness of specific therapeutic techniques or regimens
8. Fabricating orthosis & adaptive equipment
(Norkin, C.C & White, D.J, 1998, p 3)

Competency in Goniometry:
To use goniometry successfully therapists acquires the following knowledge & develop the
following skills.
1. Recommended the testing position
2. Alternative position
3. Stabilization required
4. Joint structure & function
5. Normal end-feel
6. Anatomical bony landmark
7. Instrument alignment

Importance of End-feel in Goniometry:

The felling which is experienced by an examiner as a barrier to further motion at the end of
a passive ROM is called the end-feel.

The amount of passive ROM is determined by the orientation of particular joint. Some joint
are structured so that the joint capsule limit the end of the ROM in a particular direction. In
other joint ligaments limit the ROM. Other normal limitations to motion include passive
muscle tension, soft tissue approximation & contact of joint surface.

So in every joint in the body have a normal characteristic end-feel which is specific for that
joint. Due to abnormality in the joint we will find another end-feel which is called abnormal
end-feel. Abnormal end-feel indicates the limitation of ROM of that particular joint.
So during measurement of joint ROM it is necessary to understand & feel the end-feel of a
joint to detect accurate Joint range.

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 CHAPTER: 8 GONIOMETRY

Importance of positioning in Goniometry:

Positioning is one of the most important components of goniometry. Joint ROM vary
according to the different position of the body. In resting position the ROM of one joint can
be vary in loading position.

Fore example: The ROM of hip flexion with knee straight is limited than the ROM of hip
flexion with knee flex position.

That’s why, during the measurement of joint ROM, every joint has a particular
‘Recommended testing’ positions, from which ROM are measured.

HOW TO USE A GONIOMETER

Step 1:
Place the Goniometer over the fulcrum of the joint. This will vary depending on which joint
you are measuring. Place the stationary arm of the Goniometer along the stationary line of
the body (again, this will vary depending on which joint you are measuring), and the
movable arm on the moving part of the body.

Step 2:
Ask your patient to move the joint in the desired direction. Have the patient move to her
fullest extent of motion, following the movement with the movable arm of the Goniometer.
Make sure the stationary arm stays straight.

Step 3:
Stabilize the stationary portion of the body. This is the part of the body that is proximal
(closer to the midline of the body) to the joint you are testing. It is important that the patient
does not move his body while moving the joint; this step isolates the joint movement for a
more accurate measurement.

Step 4:
Look at the reading on the Goniometer before removing it from the patient's body. Ensure
that you take an accurate reading of the degree of motion on the Goniometer, and that you
consistently use the same stationary and movable landmarks on the body when measuring,
to ensure consistency. Be sure to record the range of motion for the joint.

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 CHAPTER: 8 GONIOMETRY

TECHNIQUE OF MEASUREMENT

1. The procedure & its purpose should be clearly explained to the patient.
2. The relevant part of the body should be undress
3. At the beginning of the examination the position of the part should be stable & the
standard position of zero.
4. If pain is present, the starting position may have to be modified & the test given in
the most comfortable position possible & with gentle handling
5. When possible, the motion should be compared with the opposite limb or side
6. The movement can be active or passive. If possible both are used. Any difference
between these movements should be recorded
7. The movement should be carried out slowly. Both limbs may be used to aid
movement, improve stability or to prevent trick movement
8. Place the Goniometer in correct position
9. Patient should complete the range before measuring commences
10. The Goniometer should be place along the lateral side of the limb in the appropriate
position & should not press on the limb in any way
11. Several reading needs to be taken. The average of these reading should be recorded
12. Joint range & the range of pain should be clearly recorded. The result should be
signed, dated & filed
13. Re-test should be done at regular intervals so that progress can be detected
(Galley,P.M & Farster,A.L, 1987, p 142-143) Human movement old
Different types of goniometry

Plastic Goniometers:
 12 ½" Goniometer: Scale reads 0° to
180° and 0° to 360° in 1° increments
 8" Goniometer: Scale reads 0° to 180°
in opposite directions in 1° increments
 6" Goniometer: Scale reads 0° to 180°
in opposite directions in 1° increments
 6 ¾ " Goniometer: Scale reads 0° to
180° in 5° increments. I deal for small
joints

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 CHAPTER: 8 GONIOMETRY

Stainless Steel Goniometers:

1. 360° Goniometer: Features one 360° and two 180° scales that read in opposite
directions. 14" long. Scales marked in 1° increments. Locking arm. Knurled knob adjusts
Goniometer arm tension.
2. 180° Goniometer: Has two 180° scales that read in opposite directions. 14" long. Scales
marked in 10 increments. Non-
locking friction arm.
3. 8" Goniometer: Has two 180° scales
in opposite directions marked in
1°increments. Turn the knurled knob
to vary amount of tension on the
arms or to fully lock them.
4. 180° "Robinson" Pocket Goniometer:
Scale is marked in 5° increments.
Ideal for measuring small joints of
the hand. 7" long.

Stainless Steel Goniometer Set:

Padded carrying case with compartments holds Goniometers firmly in place. Set includes
the following 6 pieces:
 180° "Robinson" pocket Goniometer
 180° Goniometer
 360° Goniometer
 5½" finger Goniometer
 8" Aluminum X-ray Goniometer
 8" Stainless-Steel Goniometer

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 CHAPTER: 8 GONIOMETRY

ROM OF ALL JOINTS IN THE BODY

Shoulder joint:

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Shoulder joint:

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 CHAPTER: 8 GONIOMETRY

Elbow & Fore arm:

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 CHAPTER: 8 GONIOMETRY

Wrist joint:

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 CHAPTER: 8 GONIOMETRY

Hip joint:

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 CHAPTER: 8 GONIOMETRY

Hip joint:

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 CHAPTER: 8 GONIOMETRY

Knee joint:

Ankle joint:

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 CHAPTER: 8 GONIOMETRY

Lumbar spine:

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 CHAPTER: 8 GONIOMETRY

GONIOMETRY IN UPPER LIMB

SHOULDER

FLEXION:

1. Recommended testing position: Supine lying position. Both arm straight & placed
side of the trunk
2. Goniometer alignment:
 The fulcrum of the Goniometer is placed over the acromion process.
 The stationary and moving arms are aligned with the midline of the humerus and
lateral epicondyle.
3. Procedure:

A. The subject is shown at the beginning of the ROM of glenohumeral flexion. The body of
the full-circle metal Goniometer is
aligned with the subject's acromion
process. The two arms of the
Goniometer are aligned along the
lateral midline of the thorax and the
lateral midline of the humerus and
extend over the lateral epicondyle of
the humerus.

B. The alignment of the Goniometer at the end of the ROM of glenohumeral flexion. The
examiner's right hand supports
the subject's extremity and
maintains the goniometer's
distal arm in correct alignment
over the lateral epicondyle. The
examiner's left hand aligns the
goniometer's proximal arm with
the lateral midline of the thorax.

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 CHAPTER: 8 GONIOMETRY

EXTENSION:
1. Recommended testing position: Prone lying position. Both arms are on the side of
the trunk with elbow slightly flexed
2. Placement of Goniometer:
 The fulcrum is placed over the acromion process.
 The stationary and moving arms are aligned with the lateral midline of the humerus
and the lateral epicondyle.
3. Procedure:

A. The subject is at the beginning of the ROM of

extension with her head turned away from the
joint being tested. The body of the Goniometer
is aligned with the acromion process, and the
arms are aligned along the lateral midline of
the thorax and the lateral midline of the
humerus and extend over the lateral
epicondyle.

B. This photograph shows the Goniometer

alignment at the end of the ROM in extension.
The examiner's left hand supports the subject's
extremity and holds the distal arm of the
Goniometer in correct alignment over the
lateral epicondyle of the humerus. The
Goniometer body is held over the subject's
acromion process, while the proximal arm is
aligned along the lateral midline of the thorax.

ABDUCTION:
1. Recommended testing position: Supine lying or in standing
2. Alignment of Goniometer:
 The fulcrum is placed at the acromion process.
 The stationary and moving arms are aligned with the anterior midline of the
humerus.

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 CHAPTER: 8 GONIOMETRY

3. Procedure:
A. The supine starting position for measuring ROM of shoulder abduction; the body of the
Goniometer is aligned over the anterior aspect of the acromion process. The arms of the
Goniometer are aligned along the anterior midline of the humerus and parallel to the
sternum.

[A & B]
B. At the end of the ROM in shoulder abduction, the proximal arm of the Goniometer is
aligned parallel to the sternum. The distal arm of the Goniometer is held in position
along the medial midline of the humerus by the examiner. Note that the humerus is
laterally rotated.

MEDIAL ROTATION:
1. Recommended testing position: Supine lying with 90° shoulder abduction,
forearm pronation & 90° elbow flexion
2. Alignment of Goniometer:
 The fulcrum should be centered over the olecranon
process.
 The moving arm is aligned with the ulnar styloid
and the stationary arm should be perpendicular to
the floor.
3. Procedure:
A. The examiner places the body of the Goniometer over
the olecranon process and aligns the distal arm with
the ulnar styloid process in the testing positions for
both medial and lateral rotation at the glenohumeral
joint. The proximal arm of the Goniometer should be
freely movable so that gravity causes it to hang
perpendicular to the floor.

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 CHAPTER: 8 GONIOMETRY

B. The examiner supports the subject's left

forearm and maintains the distal arm of
the Goniometer over the ulnar styloid
process at the end of the ROM of medial
rotation. The examiner's right hand holds
the body of the Goniometer over the
olecranon process. The freely moving
proximal arm of the Goniometer hangs
perpendicular to the floor.

LATERAL ROTATION:
1. Recommended testing position: Supine lying
with 90° shoulder abduction, forearm pronation & 90°
elbow flexion
2. Alignment of Goniometer:
 Fulcrum should be on the olecranon process.
 The moving arm should be aligned with the ulnar
styloid and the stationary arm should be
perpendicular to the floor.
3. Procedure:
A. The Goniometer alignment for ROM in lateral rotation
is the same as the alignment for medial rotation. The
examiner, however, has to change hand positions so
that the left hand rather than the right hand holds the
body of the Goniometer.

B. The alignment of the Goniometer at the

end of the ROM in lateral rotation may
require the examiner to sit on a chair
or stool to read the Goniometer at eye
level.

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 CHAPTER: 8 GONIOMETRY

ELBOW & FORE ARM

ELBOW FLEXION:
1. Recommended testing position: Supine, arm should be in the anatomical position.
It will be easier to align the Goniometer if the arm of the patient is resting on the edge of
the table.
2. Alignment of Goniometer:
 The fulcrum should be aligned with the lateral epicondyle of the humerus.
 The stationary arm is positioned along the midline of the humerus, the moving arm
is aligned with the radial styloid process.
3. Procedure:

A. In the starting position for measuring the ROM of elbow flexion, the examiner positions
the proximal arm of the half-circle metal Goniometer along the lateral midline of the
subject's left humerus The distal arm
of the Goniometer is positioned along
the lateral midline of the forearm and
aligned with the radial styloid process.
A towel placed under the distal
humerus and elbow ensures that the
supporting surface does not prevent
the full ROM of elbow extension. As
can be seen in this photograph, the
subject's elbow is in about 10 degrees
of hyperextension.

B. The examiner left hand holds the

distal arm of the Goniometer
aligned over the subject's left radial
styloid process at the end of elbow
flexion. With her right hand, the
examiner holds the proximal arm
in alignment along the lateral
midline of the subject's humerus.

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 CHAPTER: 8 GONIOMETRY

FORE ARM PRONATION

1. Recommended testing position: Sitting or standing with tested shoulder in neutral
position & elbow is flexed in 90°. Fore arm is mid way between supination & pronation
2. Placement of Goniometer:
 The fulcrum is placed just behind the ulnar styloid process.
 The moving arm and stationary arm are parallel with the anterior midline of the
humerus.
3. Procedure:

A. In the starting position for pronation, the Goniometer is placed lateral to the distal
radioulnar joint. The arms of the Goniometer are aligned parallel to the anterior midline
of the humerus.

B. At the end of pronation, the proximal arm of the Goniometer is aligned parallel to the
anterior midline of the humerus, while the distal arm lies across the dorsum of the
forearm just proximal to the radial and ulnar styloid process. The fulcrum of the
Goniometer is aligned so that it is proximal and lateral to the ulnar styloid process.

FOREARM SUPINATION
1. Recommended testing position: Sitting or standing with tested shoulder in neutral
position & elbow is flexed in 90°. Fore arm is mid way between supination & pronation
2. Placement of Goniometer:
 The Goniometer is placed on the medial aspect of the forearm with the fulcrum at
the radioulnar joint.

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 CHAPTER: 8 GONIOMETRY

3. Procedure:
A. In the starting position for measuring the ROM in supination, the examiner places the
Goniometer body on the medial aspect of the forearm at the level of the distal
radioulnar joint and aligns the arms of the instrument parallel to the anterior mid-line
of the humerus. Above, the examiner's right hand supports the subject's forearm and
helps to keep the elbow at 90 degrees of flexion.

B. At the end of the ROM of supination, the distal arm of the Goniometer rests on the
medial aspect of the forearm at the level of the distal radioulnar joint. The position of
the examiner’s right hand is incorrect because it was altered for this photograph. The
examiner's right hand should be grasping the subject's radius rather than the subject's
hand.
WRIST & HAND

WRIST FLEXION:
1. Recommended testing position: Sitting position with fore arm kept on the table in
Pronated position where the wrist joint is out of the table. Just like the picture
2. Placement of Goniometer: Goniometer is kept on the ulnar side in straight position
3. Procedure:
A. In the starting position for palmar flexion,
the body of the Goniometer is placed at the
level of the triquetrum. The proximal
Goniometer arm is aligned along the ulna
in line with the olecranon process and the
ulnar styloid process. The distal arm is
aligned along the fifth metacarpal.

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 CHAPTER: 8 GONIOMETRY

B. At the end of the ROM in palmar flexion, the Goniometer body lies over the lateral
aspect of the carpal bones just distal to the ulnar
styloid process. The distal Goniometer arm is
aligned with the subject's fifth metacarpal. The
examiner maintains the wrist in palmar flexion
by using her left hand to exert pressure on the
middle of the dorsum of the subject's hand1.
The examiner avoids exerting pressure directly
on the fifth metacarpal because such pressure
will distort the Goniometer alignment.

WRIST EXTENSION:
1. Recommended testing position: Sitting position with fore arm kept on the table in
Pronated position where the wrist joint is out of the table. Just like the picture
2. Placement of Goniometer: Goniometer is kept on the ulnar side in straight position
3. Procedure:

A. Starting position and Goniometer alignment for wrist extension are the same as for
measuring wrist flexion.

B. At the end of the ROM of wrist extension, the examiner's left hand maintains the
alignment of the distal Goniometer arm with the fifth metacarpal while holding the
wrist in extension. The examiner avoids exerting pressure on the fifth metacarpal.

RADIAL DEVIATION:
1. Recommended testing position: Sitting position with fore arm kept on the table
where the wrist joint is out of the table. Just like the picture
2. Placement of Goniometer: On the carpal bone

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3. Procedure:
A. The starting positions for measuring radial and ulnar deviation are the same. The
examiner centers the Goniometer body on the dorsal aspect of the wrist, close to the
capitate. The examiner aligns the proximal Goniometer arm with the dorsal midline of
the subject's forearm and the distal arm with the third meta-carpal. The examiner's left
hand supports the weight of the subject's hand under the metacarpals and holds the
proximal Goniometer arm in correct alignment. The examiner keeps the subject's hand
in the same plane as the forearm and avoids wrist flexion and extension.

B. At the end of the radial deviation ROM, the examiner supports the subject's hand at the
level of metacarpals so that the wrist is maintained in a neutral position relative to
flexion and extension. The examiner's right hand maintains the goniometer's proximal
arm in alignment with the dorsal midline of the subject's forearm using the left lateral
epicondyle as a reference.

ULNAR DEVIATION:

1. Recommended testing position: Sitting position with fore arm kept on the table
where the wrist joint is out of the table. Just like the picture
2. Placement of Goniometer:
3. Procedure:

A. The starting position for measuring ulnar deviation is the same as that for measuring
radial deviation.

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B. At the end of the ulnar deviation ROM, the examiner's right hand maintains the
proximal Goniometer arm in alignment with the dorsal midline of the forearm and the
lateral epicondyle of the humerus. The examiner's left hand keeps the distal Goniometer
arm aligned with the subject's third metacarpal.

MCP FLEXION:

A. In the starting position for MCP flexion, the body of the plastic half-circle Goniometer is
positioned over the dorsal aspect of the subject's second MCP joint. The proximal arm of
the Goniometer is held on the dorsal midline of the subject's second metacarpal by the
examiner's right hand. The distal Goniometer arm is aligned on the dorsal midline of the
subject's second proximal phalanx. The examiner's left thumb supports the subject's
proximal phalanx and helps to maintain the second MCP joint in a neutral position
relative to abduction and adduction.

B. At the end of MCP flexion, the examiner's right hand holds the proximal Goniometer
arm in alignment and stabilizes the subject's second metacarpal. Note that the fulcrum
of the Goniometer lies somewhat distal and superior to the MCP joint.

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MCP EXTENSION:
A. A full-circle plastic Goniometer is being used to measure the extension ROM at the
subject's second MCP joint. The proximal arm of the instrument is slightly longer than
necessary for optimal alignment. If a Goniometer of the right size is not available, the
examiner can cut the arm of a plastic model to suitable length.

B. At the end of MCP extension, the body of the Goniometer is aligned over the dorsal
aspect of the subject's second MCP joint. The examiner's right hand maintains the
subject's wrist in a neutral position and holds the proximal arm of the Goniometer
aligned over the subject's second metacarpal. It is easy to see that the subject's ROM in
extension is smaller than her ROM in flexion.

MCP ABDUCTION:
A. In the starting position for MCP abduction, the proximal arm of the Goniometer is
aligned along the dorsal midline of the subject's second metacarpal. The distal
Goniometer arm is aligned over the dorsal mid-line of the subject's second proximal
phalanx.

B. At the end of MCP abduction, the examiner holds the Goniometer arms in correct
alignment.

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GONIOMETRY IN LOWER LIMB

HIP JOINT
HIP FLEXION:
1. Recommended testing position: The patient should be lying supine in the
anatomical position.
2. Placement of Goniometer:
 The fulcrum is aligned with the greater trochanter of the femur.
 The stationary arm is positioned along the lateral midline of the abdomen, using the
pelvis for reference, the moving arm along the lateral midline of the femur.
3. Procedure:

A. At the beginning of the ROM, the proximal arm of the Goniometer is aligned along the
lateral midline of the subject's pelvis. The fulcrum is centered over the greater
trochanter, and the distal arm is aligned with the lateral midline of the femur using the
femoral epicondyle for reference.

B. At the end of the hip flexion ROM, the examiner's left hand holds the distal Goniometer
arm in alignment and maintains the hip in flexion. The examiner's right hand holds the
proximal Goniometer arm aligned with the lateral midline of the subject's pelvis.

HP EXTENSION:
1. Recommended testing position: Patient is lying prone with legs together and arms
at sides.
2. Placement of Goniometer: Goniometer positioning is the same as for hip flexion.

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3. Procedure:

A. In the prone starting position for measuring hip extension ROM, the proximal
Goniometer arm is aligned with the lateral midline of the subject's pelvis. Using the
lateral femoral epicondyle as a landmark, the examiner aligns the distal arm along the
lateral midline of the thigh. She aligns the fulcrum over the greater trochanter.

B. At the end of the hip extension ROM, the examiner's right hand holds the proximal
Goniometer arm in correct alignment. The examiner's left hand supports the subject's
femur and keeps the distal Goniometer arm in correct alignment.

HIP ABDUCTION:
1. Recommended testing position: Patient is supine in anatomical position.
2. Placement of Goniometer:
 Fulcrum is placed in line with the anterior superior iliac spine.
 The moving arm of the Goniometer is aligned with the midline of the patella, the
stationary arm with the ASIS of the opposite side.
3. Procedure:

A. In the starting position for measuring hip abduction ROM, the proximal Goniometer arm
is aligned with the subject's anterior superior iliac spines. The distal arm is aligned with
the midline of the patella. Although the Goniometer is at 90 degrees, this is the 0-degree
starting position. Therefore, the examiner must transpose her reading from 90 degrees
to 0 degrees. For example, an actual reading of 90-120 degrees on the Goniometer is
recorded as 0-30 degrees.

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B. At the end of the hip abduction ROM, the distal Goniometer arm is aligned with the
midline of the patella, and the proximal arm is aligned with the anterior superior iliac
spines.

HIP ADDUCTION:
1. Recommended testing position: Patient is supine the leg not being measured is
abducted to allow full adduction of the opposite leg.
2. Placement of Goniometer: The Goniometer positioning is the same as for
abduction, fulcrum at the ASIS, moving arm aligned with the midline of the patella, and
the stationary arm with the ASIS of the opposite side. Also, remember to adjust due to
the Goniometer starting at a reading of 90 degrees.
3. Procedure:

A. In the starting position for measuring left hip

adduction, the subject's right lower extremity has
been abducted to allow adequate space for
adduction of the left lower extremity. The proximal
Goniometer arm is aligned with the subject's
anterior superior iliac spines, and the distal arm is
aligned along the anterior midline of the femur. This
alignment places the Goniometer at 90 degrees.
Therefore, when the examiner records the
measurement, she will transpose the reading so that
90 degrees is equivalent to 0 degrees. For example,
an actual reading of 90 - 60 degrees is recorded as
0-30 degrees.

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B. At the end of the hip adduction ROM, the examiner's right hand holds the Goniometer
body over the subject's anterior superior iliac spine. The
examiner is able to prevent hip rotation by maintaining a
firm grasp at the subject's knee.

HIP MEDIAL ROTATION:

1. Recommended testing position: The patient will be

sitting off of the edge of the table, knees against the table,
with their legs dangling down off the table.
2. Placement of Goniometer:
 The fulcrum is aligned with the patella and both arms
of the Goniometer with the midline of the tibia.
 Ending Position: The fulcrum and moving arm remain in the same position as
above. The stationary arm should now be hanging freely but should be
perpendicular to the floor.
3. Procedure:
A. In the starting position for measuring hip rotation, the fulcrum of the Goniometer is
placed over the patella. Both arms of the instrument are together.

B. At the end of hip medial rotation, the proximal Goniometer arm hangs freely so that it is
perpendicular to the floor. The distal Goniometer arm is aligned along the crest of the
tibia.

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 CHAPTER: 8 GONIOMETRY

HIP LATERAL ROTATION:

1. Recommended testing position: Patient is sitting on the edge of the table as was
done for internal rotation.
2. Placement of Goniometer: Goniometer positioning is the same as for medial
rotation. The fulcrum is aligned with the patella, and both arms with the midline of the
tibia.
3. Procedure:
A. In the starting position for measuring lateral hip rotation, Goniometer alignment is the
same as that for measuring medial hip rotation.

B. At the end of the ROM of hip lateral rotation, the examiner uses her left hand to support
the subject's leg and to maintain alignment of the distal Goniometer arm. When the
examiner holds the Goniometer body, the freely moving proximal arm hangs so that it is
perpendicular to the floor.

KNEE JOINT

KNEE FLEXION:
1. Recommended testing position: Patient should be supine with both legs flat on the
table.
2. Placement of Goniometer:
 The fulcrum is aligned with the lateral epicondyle of the femur.
 The stationary arm is in line with the greater trochanter and midline of the femur,
the moving arm with the lateral malleolus and midline of the fibula.

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 CHAPTER: 8 GONIOMETRY

3. Procedure:
A. In the alternative starting position for measuring knee flexion ROM, the subject is prone.
A towel is placed under the thigh, and the foot is off the supporting surface to allow the
knee to extend fully.

B. At the end of the knee flexion ROM, the examiner's right hand aligns the proximal
Goniometer arm with the lateral midline of the subject's thigh, using the greater
trochanter as a reference point. The examiner uses her left hand to maintain knee
flexion and to keep the distal Goniometer arm aligned along the lateral midline of the
lower leg.

KNEE EXTENSION:

1. Recommended testing position: The patient should be lying prone with both legs
flat on the table.
2. Placement of Goniometer: The Goniometer positioning for knee extension is the
same as it is for knee flexion.
3. Procedure:

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ANKLE JOINT
ANKLE DORSI FLEXION:
1. Recommended testing position: Patient is sitting with legs off the table.
2. Placement of Goniometer:
 The fulcrum is aligned with the lateral malleolus.
 The stationary arm is in line with the midline of the lower leg; use the head of the
fibula for reference. The moving arm is parallel to the fifth metatarsal.
3. Procedure:

A. In the starting position for measuring dorsi flexion ROM, the examiner aligns the
proximal arm of the Goniometer with the lateral midline of the lower leg, using the head
of the fibula as a reference point. The examiner aligns the distal Goniometer arm
parallel to the fifth metatarsal. The ankle is positioned so that the Goniometer is at 90
degrees. However, this Goniometer reading is transposed and recorded as 0 degrees.
The examiner sits on a stool or kneels in order to align and read the Goniometer at eye
level.

B. At the end of dorsi flexion, the examiner's right hand aligns the proximal Goniometer
arm, while the examiner's left hand maintains dorsi flexion and alignment of the distal
Goniometer arm.

ANKLE PLANTER FLEXION:

1. Recommended testing position: Patient is sitting with legs off table.
2. Placement of Goniometer: Goniometer alignment is the same as for dorsi flexion.

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3. Procedure:
A. The starting position and Goniometer alignment for measuring plantar flexion ROM are
the same as those for measuring dorsi flexion ROM.

B. At the end of plantar flexion, the examiner uses her right hand to maintain plantar
flexion and to align the distal Goniometer arm. The examiner grasps the dorsum and
sides of the foot to avoid exerting pressure on the toes.

ANKLE INVERSION:
1. Recommended testing position: Patient sitting with legs off the table, or patient
can be supine on the table with the foot resting on the table.
2. Placement of Goniometer: The fulcrum is positioned between the two malleoli.
The stationary arm with the midline of the tibia and the moving arm with the second
metatarsal.
3. Procedure:

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ANKLE EVERSION:

1. Recommended testing position: Patient sitting with legs off the table, or patient
can be supine on the table with the foot resting on the table.
2. Placement of Goniometer: The fulcrum is positioned between the two malleoli.
The stationary arm with the midline of the tibia and the moving arm with the second
metatarsal.
3. Procedure:

A. In the starting position for measuring eversion ROM, Goniometer alignment is the same
as for measuring inversion ROM.

B. At the end of the eversion ROM, the examiner's left hand maintains eversion and keeps
the distal Goniometer arm aligned with the subject's second metatarsal. The examiner's
right hand maintains the alignment of the proximal Goniometer arm with the anterior
midline of the tibia. Because eversion includes pronation, abduction, and dorsi flexion,
the subject's foot is moved in these three directions.

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 CHAPTER: 8 GONIOMETRY

GONIOMETRY IN SPINE

CERVICAL REGION

CERVICAL FLEXION:

1. Recommended testing position: Sitting on chair

2. Procedure:
A. In the starting position for measuring cervical flexion ROM, the examiner aligns the
proximal Goniometer arm so that it is perpendicular to the floor. The Goniometer body
is centered over the subject's external auditory meatus. The exainer aligns the distal
arm with the base of the nares. The Goniometer will read 90 degrees in the zero starting
position. This Goniometer reading should be transposed and recorded as 0 degrees.

B. At the end of the ROM, the examiner's left hand aligns the proximal Goniometer arm.
The examiner uses her right hand to maintain alignment of the distal arm with the base
of the nares. In this photograph, the Goniometer reads 130 degrees at the end of the
ROM. The cervical flexion ROM should be recorded as 0 to 40 degrees because the
Goniometer reads 90 degrees in the zero starting position. Alternatively, the examiner
can align the distal arm parallel to the tongue depressor that the subject is holding
between her teeth.

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CERVICAL EXTENSION:
1. Recommended testing position: Sitting position
2. Procedure:
A. In the starting position for measuring cervical extension ROM, Goniometer alignment is
the same as for measuring cervical flexion ROM.

B. At the end of cervical extension, the examiner maintains the perpendicular alignment of
the proximal Goniometer arm with her left hand. With her right hand she aligns the
distal arm with the base of the nares. The tongue depressor between the subject's teeth
also can be used to align the distal arm.

CERVICAL SIDE FLEXION:

1. Recommended testing position:
2. Procedure:
A. In the starting position for measuring lateral flexion ROM, the examiner centers the
body of the Goniometer over the subject's seventh cervical vertebra. The freely movable
proximal Goniometer arm hangs so that it is perpendicular to the floor.
B. At the end of the lateral flexion ROM, the examiner maintains alignment of the proximal
Goniometer arm with her right hand. In practice, the examiner would have one hand on
the subject's head to maintain lateral flexion; for this photograph, the examiner is using
only one hand so that the Goniometer alignment is visible.

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 CHAPTER: 8 GONIOMETRY

LUMBAR REGION
LUMBAR FLEXION:
1. Recommended testing position:
2. Procedure:
A. In the starting position for measuring thoracic and lumbar flexion ROM, the examiner
positions one end of the tape measure at the subject's seventh cervical vertebra and the
other end over the first sacral vertebra.

B. At the end of the ROM, the examiner is maintaining the cervical end of the tape measure
over the spinous process of the subject's seventh cervical vertebra. The sacral end of the
tape measure is allowed to unwind and accommodate the spinal movement. The metal
tape measure case (not visible in the photo) is in the examiner's right hand.

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 CHAPTER: 8 GONIOMETRY

LUMBAR EXTENSION:
1. Recommended testing position:
2. Procedure:
A. The positioning of the tape measure for measuring thoracic and lumbar extension ROM
is the same as that for measuring thoracic and lumbar flexion ROM. In this photograph,
the tape measure case is in the examiner's left hand. When the subject moves into
extension, the tape slides into the case.

B. At the end of thoracic and lumbar extension ROM, the distance between the two
reference points is less than that in the starting position. The difference between the
measurement taken in the starting position and that at the end of the ROM constitutes
the total ROM. The starting measurement, the end measurement, and the difference
between these measurements are recorded in either inches or centimeters.

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LUMBAR SIDE FLEXION:

1. Recommended testing position:
2. Procedure:
A. In the starting position for measuring thoracic and lumbar lateral flexion, the examiner
centers the fulcrum of the Goniometer over the spinous process of the subject's first
sacral vertebra; the freely movable proximal Goniometer arm hangs so that it is
perpendicular to the floor. The examiner aligns the distal Goniometer arm with the
spinous process of the subject's seventh cervical vertebra.

B. At the end of thoracic and lumbar lateral flexion, the examiner keeps the distal
Goniometer arm aligned with the subject's seventh cervical vertebra. The examiner
makes no attempt to align the distal arm with the subject's vertebral column. As can be
seen in the photograph, the lower thoracic and upper lumbar spine become convex to
the left during right lateral flexion.

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 CHAPTER- 9

THERAPEUTIC
MASSAGE

s is a handout collected from various books and websites. (Rijwan Bhuiy

 CHAPTER: 9 THERAPEUTIC MASSAGE

INTRODUCTION

Massage is the practice of soft tissue manipulation with physical, functional, and in some
cases psychological purposes and goals. The word comes from the French massage "friction
of kneading” or from Arabic ‘massa’ meaning "to touch, feel or handle" or from Latin massa
meaning "mass, dough".

Massage involves acting on and manipulating the body with pressure – structured,
unstructured, stationary, or moving – tension, motion, or vibration, done manually or with
mechanical aids. Target tissues may include muscles, tendons, ligaments, skin, joints, or
other connective tissue, as well as lymphatic vessels, or organs of the gastrointestinal
system. Massage can be applied with the hands, fingers, elbows, forearm, and feet.

In professional settings massage involves the client being treated while lying on a massage
table, sitting in a massage chair, or lying on a mat on the floor. The massage subject may be
fully or partly unclothed. Parts of the body may be covered with towels or sheets.

HISTORY

Professional therapeutic massage is an age-old healing art, which can alleviate physical,
mental and emotional ailments. The practice dates to the Chinese in 3000 BC. Other
references in the bible refer to anointing the body with oil. In 460 BC, Hypocrites prescribed
it as a beneficial treatment for his patients.

In one form or another, it developed in all the nations of the old World. Hippocrates, who is
considered a father of medicine, said that all physicians should have experience of the
techniques of rubbing, it is recognized that rubbing can bind a joint that is too loose and
loosen a joint that is too rigid. Furthermore, rubbing can make the flesh and cause parts to
waste, it is these latter beliefs that are so important for those concerned with figure
improvement. In 1813, the Royal Central Institute was established in Stockholm, Sweden,
and here the known massage movements were studied scientifically and systematized. This
was the most important single development in the field in modern times and it is because of
this that remedial massage is often called "Swedish".

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 CHAPTER: 9 THERAPEUTIC MASSAGE

Ancient and medieval times:

Writings on massage have been found in many ancient civilizations including Rome, Greece,
India, Japan, China, Egypt and Mesopotamia. A biblical reference from 493 BC documents
daily massage with olive oil and myrrh as a part of the beauty regimen of the wives of
Xerxes. Hippocrates wrote in 460 BC that "The physician must be experienced in many
things, but assuredly in rubbing".

The ancient Chinese book called Huangdi Neijing by the Yellow Emperor recommended
"massage of skin and flesh". The technique of massage abortion, involving the application of
pressure to the pregnant abdomen, has been practiced in Southeast Asia for centuries. In
Romania some illnesses were treated by a massage in which the client was trodden on by a
tame bear.

Modern times:

 Marathon runners receiving massages at the 2004 ING Taipei International Marathon
 China: In modern times, massage in China has developed by absorbing western ideas
into the traditional framework. It is widely practiced and taught in hospital and medical
schools and is an essential part of primary healthcare.
 United States: Massage started to become popular in the United States in the middle
part of the 1800s, and was introduced by two New York physicians based on Per Henrik
Ling's techniques developed in Sweden.
During the 1930s and 1940s massage's influence decreased as a result of medical
advancements of the time, while in the 1970s massage's influence grew once again with
a notable rise among athletes. Massage was used up until the 1960s and 1970s by
nurses to help ease patients’ pain and help them sleep.
Because it is illegal to advertise or offer sexual services in much of the United States,
such services are sometimes advertised as "massage," hence the rise of the term
"massage therapy" in an attempt to provide a distinction between sexual and non-
sexual services.
 United Kingdom: Massage is popular in the United Kingdom today and gaining in
popularity. There are many private practitioners working from their own premises as
well as those who operate from commercial venues.
 Massage in sports, business and organizations: The 1996 Summer Olympics in
Atlanta was the first time that massage was offered as a core medical service. Massage
has been employed by businesses and organizations such as the U.S. Department of
Justice, Boeing and Reebok.

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 CHAPTER: 9 THERAPEUTIC MASSAGE

DEFINITION OF MASSAGE

Definition: Therapeutic massage involves the manipulation of the soft tissue structures of
the body to prevent and alleviate pain, discomfort, muscle spasm, and stress; and, to
promote health and wellness.
Or
AMTA (American massage therapy association) defines Massage as, "a manual soft tissue
manipulation that includes holding, causing movement, and/or applying pressure to the
body."

MASSAGE THERAPY:
Massage therapy is “a profession in which the practitioner applies manual techniques, and
may apply adjunctive therapies, with the intention of positively affecting the health and
well-being of the client." (AMTA)

MASSAGE EQUIPMENT

There are some equipments are needed for massage therapy. These equipments are given
below:
 Massage table
 Massage chair
 Massage mat
 Body support
 Draping materials
 Lubricants
 Additional equipment(Music)

PREPARATION FOR MASSAGE

Uncomfortable massage is usually born of failure of coordinated performance by the

therapist. Minor adjustment of foot position & trunk position will change the relationship of
the therapist to the support & the subject; & the totality of hand contact & the angle of
contact will be altered by the posture of the trunk & arms. So the therapist must make
certain preparation before beginning massage.

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SELF/THERAPIST’S PREPARATION:
 General Preparation:
 Attention to personal appearance & hygiene
 Wear protective clothing which allows freedom of movement
 Keep short hair
 Remove wristwatch & ring
 Keep short clean nail
 Wash hand before & after treatment
 Fill ROM of all forearm & Hands joints
 Hand exercise:
 Touch the finger tips of one hand with the finger tips of the other and press so that
your thumbs and little fingers are separated widely
 Push the fist of one hand between two adjacent fingers of the other hand so that
they are separated into wider abduction. Keep your fingers in the same plane.
Repeat for each space (Figure-1)
 Place your hands together as in prayer and with your thumbs resting on your chest
push your wrists downwards to extend them without separating the heels of your
hands
 Reverse your hands, placing the backs together and push your elbows downwards
thus flexing your wrists
 Place your hands in the prayer position and, keeping them together, turn them
down and up. Try to touch your abdomen and chest alternately at each rotation
(Figure- 2)

[Figure- 1] [Figure-2]

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 CHAPTER: 9 THERAPEUTIC MASSAGE

 Relaxation:
Relaxation of therapist’s hands is very important so that therapist always use his/her
hands in full contact with the model/patient. Relaxed hand contact is one in which the
hand conforms to the contour of the part. The natural rest position of the human hand is
with the fingers and thumb a little apart and very slightly flexed at each joint and it can
easily be adjusted to allow contact with any size of body part
ENVIRONMENTAL PREPARATION:
 Treatment room is well heated
 Well ventilation system
 Maintain privacy in the room
 Appropriate lighting of the room
 Adjustable treatment couch
 Treatment couch is covered by large & small washable blankets & sheets
 Standard size of pillows & pillows covers
 Keep different kinds of lubricant equipments
PREPARATION OF PATIENT:
 Patient should be suitably undressed
 In supine lying need one or two head pillows & a pillow under the knees
 In prone lying need two head pillows crossing one another so that the nose rest
below the crossing, a pillow under the abdomen & a pillow under the ankle joints
for semi flexion of both knee
 Use sheet to cover body to keep body warm

TYPES OF MASSAGE/MANIPULATION
There are different types of massage. The types are used in Physiotherapy profession is
given below:
1. Effleurage 4. Friction
2. Stroking  Circular friction
3. Petrissage  Transverse friction
 Kneading 5. Tapotement or percussive
 Picking up  Clapping
 Wringing  Hacking
 Rolling  Vibration
 Shaking  Beating
 Pounding
 Taping

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EFFLEURAGE

Definition:
Effleurage means in which the intention is primarily to assist venous & lymphatic drainage
& in which the direction of the work is from distal to proximal.

Principles:
1. It is unidirectional
2. It starts from distally & ends at proximal area, (e.g.: Finger tip to Axilla; Toes to
Groin; Buttock to Axilla.)
3. Pressure of technique should be such as to push fluid onwards in the superficial
vessels.
Procedure:
1. At first therapist stand in the walk standing position (Figure-3).
2. Next therapist fit the part (which will treat), making 'C' curve the whole hand by
one or two hands
3. In case of using both hands may fit as together on opposite aspects of a part or may
follow one another. (Figure-4& 5)
4. For single hand, one hand is for manipulation & other is for supporting the part.
(Figure-6)
5. At the end of the every line of effleurage there should be a small increase in depth &
a slight pause.
6. Next therapist lifted off his hand & return to the distal part & start the next line of
work

[Figure-3] [Figure-4]

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 CHAPTER: 9 THERAPEUTIC MASSAGE

[Figure- 5] [Figure -6]

Indication:
1. To relieve congestion
2. To reduce Edema
3. Traumatic periostitis
4. Peripheral congestion of the breast

STROKING

Definition:
Stroking means in which the intention is primarily to obtain a sensory reaction either
sedative or stimulative & in which direction is not important but is often from proximal to
distal.

Principles:
1. It is unidirectional
2. Start from proximal & end at distal area
3. Pressure & speed depends on effects
4. Slow stroke for 'Sedative' effects
5. Faster stroke for 'Stimulating' effects

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 CHAPTER: 9 THERAPEUTIC MASSAGE

Procedure:
1. At first therapist stand in 'Walk standing' position
2. Hand position is obliquely
3. Next start with firm contact & finish with a smooth lift off of therapist hands
4. Starts in slow motion & then go faster
5. At the beginning time 5 seconds for one stroke, (slow stroke)
6. Then try faster & every 5 seconds done 4 stroke
7. Pressure can be achieved at the slower rate
8. The whole area under treatment should be covered by a sequence of stroke
9. Stroke may be performed using:
a) One hand: For narrow area.
b) Two hands simultaneously: For broad area
10. A technique called 'thousand hands': In which one hand performs a short stroke,
the second hand does the same overlapping the first, & the hand pass over one
another to gain contact as the manipulation process down the length of the part
under treatment.
Indication:
1. Evacuation of pus & granular sequestration
2. Sedative effects
3. Sensory stimulation

PETRISSAGE MANIPULATION

Definition:
Petrissage manipulations are those in which the soft tissues [mainly muscles) are
compressed either against underlying bone or against themselves
They are divided into:
1. Kneading manipulation: When the tissues are compressed against the underlying
structures
2. Picking up manipulation: When the tissues are compressed then lifted and
squeezed
3. Wringing manipulation: The tissues are lifted and squeezed by alternating hand
pressure
4. Rolling manipulation: When the tissues are lifted and rolled between the fingers
and thumbs as in skin rolling or muscle rolling
5. Shaking manipulation: When the tissues are lifted and shaken from side to side

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 CHAPTER: 9 THERAPEUTIC MASSAGE

KNEADING

Definition:
Kneading is a circular manipulation performed so that the skin & subcutaneous tissues are
moved in a circular manner on the underlying structures. It is a part of 'Petrissage'
manipulation, when the tissues are compressed against the underlying structures.

Principles:
1. Circular manipulation
2. Performed with
 The palmar aspect of the whole hand
 With the palm only
 With all the fingers
 With the pads
 Tips of the thumb
 With the fingers

Procedure:
1. In performing all kneading manipulations use walk standing so that the body
weight can move easily from one foot to the other
2. On flat areas, (e.g. the back) the pressure with the right hand is from 8 o'clock to 11
o'clock with that hand circling clockwise. The left hand circles counter clockwise
and exerts pressure from 4 o'clock to 1 o'clock (Figure- 7)
3. On the limbs, the pressure is exerted from 6 o'clock to 9 o'clock with the right hand
and from 6 o'clock to 3 o'clock with the left hand (Figure- 8)
4. On the non-pressure phase of the circle the hand maintains contact but glides on to
the next area of skin a small enough distance to allow the next circle to cover at
least half the previous area.
5. The right hand moving clockwise will slide downwards from 4 o'clock, while the left
hand will glide downwards from 8 o'clock

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 CHAPTER: 9 THERAPEUTIC MASSAGE

[Figure- 7, for flat area] [Figure- 8, for round area]

Kneading may be performed with:

 The whole hand - whole hand kneading (Fig- 9)

 The palm only - palmar kneading (Fig- 10)
 The fingers only:
 flat finger kneading (Fig- 11)
 finger pad kneading (Fig- 12)
 finger tip kneading (Fig- 13)
 The thumb:
 thumb pad kneading (Fig. 14)
 thumb tip kneading (Fig. 15 )
 Both hands when one is superimposed on the other superimposed (rein forced)
kneading (Fig- 16)
 Elbow kneading (Fig. 17)
 Heel of hand kneading. (Fig-18)

Indication:
1. Assist the maintenance of power & range in muscles near the site of injury or
during immobilization.
2. It is a good preventive of the painful muscular cramps suffered by some athletes.
3. Effective for diminishing the sensitivity of painful amputation stumps.

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[Figure- 9, Whole hand kneading] [Figure- 10, Palmar kneading]

[Figure- 11] [Figure-12] [Figure-13]

[Fig- 14, thumb pad kneading] [Fig-15, finger tip kneading]

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 CHAPTER: 9 THERAPEUTIC MASSAGE

[Fig-16] [Fig-17] [Fig-18]

SHAKING
All long muscle bellies may be shaken and the manipulation may be performed on the larger
muscles such as biceps, triceps, and the quadriceps and also on the small muscles of the
thenar and hypothenar eminences.
 For longer muscles the length of your thumb should be placed on one side of the
muscle belly and all your fingers placed on the other side of the muscle belly. Your palm
should be off-contact (Fig.). Your hand is then rapidly shaken from side to side as you
traverse the length of the muscle belly avoiding contact with the underlying bone. Stand
in walk standing so that your weight is transferred as you work from proximal to distal
on the muscle belly. The muscle will be 'thrown' rapidly from side to side and feels very
invigorated.
 For very small muscles, the tip of your thumb should be placed on one side, and an
appropriate number of finger tips placed on the other side of the muscle belly, and the
shaking movement described above is performed.

VIBRATIONS
Definition: Vibrations are often wrongly called shakings. The difference is that a vibration
involves a movement in which the tissues are pressed and released using an up and down
motion. In shaking, the movement on the model is sideways and involves rapid radial and
ulnar deviation of your wrists.
Vibrations may be fine or very coarse and demonstrate best on a partly filled rubber hot
water bottle or on the abdomen though the more common use is on the chest. Vibration may
be performed with the whole hand, or the finger tips. Practice with your hand stationary or
side it backwards & forwards on the area. They are best practiced by placing the whole hand
on a partly filled hot water bottle with the arm outstretched, and oscillating the whole hand
into rapid and minute wrist flexion and extension. The movement is sustained from the
shoulder and can be observed to occur spontaneously in some people if the arms are
outstretched.

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THE DEEP FRICTION MASSAGE/MANIPULATION (DFM)

Definition:
Frictions are small range, deep manipulations performed on specific anatomical structures
with the tips of the fingers or thumbs. No other part of the practitioner's hand must rest on
the part. There are two types of frictions:
 Circular
 Transverse
Circular frictions

1. Circular frictions are performed with the finger tips.

2. The structure to be treated should be identified by careful palpation and the finger
tip placed so that they cover the area. The rest of the hand is kept off-contact.
3. Pressure is applied and a small, stationary manipulation is performed, in a circular
manner and at gradually increasing depth for three or four circles.
4. The pressure is released and the manipulation 15 repeated. One hand may
reinforce the other on deeper structures.
5. The manipulation can be used over ligaments and myofascial junctions Fig. 2.27).

Transverse frictions (DTFM)

Transverse frictions were advocated by Dr J. Cvriax in 1941 for treatment of tendon,

ligament, myofascial junctions and muscles. The manipulation is a unidirectional movement
performed with:
 Either the thumb tip or the finger tip of the index finger sometimes reinforced by
placing the tip of the middle finger on top of the index finger nail
 Or by the middle finger reinforced by placing the index finger on top of the middle
finger nail (more useful when the hand is curved round a limb]
 Or by two finger tips when a long structure is affected (such as a tendon)
 Or by the opposed fingers and thumb on structures which can be grasped e.g.
tendocalcaneous
Phases:
There are two phases of transverse friction massage. They are:
1. Active phase
2. Relaxed phase (Passive)

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 CHAPTER: 9 THERAPEUTIC MASSAGE

Procedure:
1. Identify the structure to be treated and place your fingers across the longitudinal
axis of the structure, i.e. across the length of the collagen fibres .
2. Now perform the friction by moving your digit and the model's skin as one, keeping
your digit, hand and forearm in a line parallel to the movement to be performed.
3. Do not flex and extend only your digit or wrist.
4. Try to use a movement from your upper arm, trunk or feet so that you achieve
greater power with less fatigue.
5. Start to move your fingers forwards and backwards across the structure under
treatment with sufficient sweep.
6. The movement must not take place between your fingers and the model's skin, but
between the affected structure and the overlying tissues.
7. The model's skin must be dry to ensure your ringers do not slip.
8. Maintain the friction for five to ten minutes but the area should be examined at
intervals to check that bruising is not occurring or the skin blistering.
9. Keep tendons taut by putting them on the stretch, but keep muscles relaxed by
positioning the model so that the part and the attachments of the muscle are
approximated during treatment.
Indication:
1. For ligament lesion
2. Tendon lesion
3. Muscular lesion
4. Capsular contracture
5. Subdeltoid bursitis
DTFM in knee

[DTFM in EPL] [DTFM in ankle] [DTFM in elbow]

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 CHAPTER: 9 THERAPEUTIC MASSAGE

EFFECTS OF THERAPEUTIC MASSAGE/MANIPULATION

On circulatory system:
The following are some of the beneficial results that can receive from massage
treatments:
 The squeezing, compressive & pushing elements of massage carried out with
centripetal pressure are widely considered to bring out drainage of venous blood &
lymph
 Red blood cells increase, as well as the amount of hemoglobin in the bloodstream.
Blood circulation is increased by the dilation of capillaries. Lymph flow is increased.
Lymph, which is a key player in the body's immune system, is the bodily fluid that
transports white blood cells.
 Bring peripheral blood to the heart
 Massage produce the blood flow thus accelerate healing
 It removes chemical substance which produce pain & thus reduce pain
 Improve lymphatic drainage
 Assist in removal of deposits of tissue
On the Nervous system (NS):
 Massage inhibit 'Hoffman reflex' (H-reflex)  Reduce spinal motor neuron
excitability of SCI patient Produce a viable option to other accepted treatment
technique.
 Stroking produce stimulation on pain afferent fiber activate pain gate thus reducing
pain.
 Massage also produce sedative effects on the CNS.
 Improve muscle tone Induce muscle tone
 Soothe and relax nerves
 Relieve Stress
 Release emotional tension
 Relieve pain in certain conditions
On Musculoskeletal system:
 After friction massage  break down of scar tissue fiber arrange in direction of
stress  thus improve muscle or soft tissue strength.
 In case of DOAMS massage improve blood flow  Remove lactic acid  decrease
fatigueness.
 Muscles gain elasticity and lose tenseness.

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 CHAPTER: 9 THERAPEUTIC MASSAGE

On respiratory system:
 Vibration, Shaking with the use of Gravity remove the distal sputum to the trachea
& thus clear secration.
 Massages accelerate ventilation & perfusion & thus proper oxygenation of blood.
 Help breathing Stimulate breathing Assist the flow of nutrients & oxygen to tissues

On intigumentary system:
 Massage constant passage of hand over the skin  remove dead surface cells 
sweat gland, hair follicles & sebaceous gland function better.
 Friction massage on scar tissue  convert one type of collage fiber into another
type of collage fiber  arrange the fiber in line of stress  recover scar tissue.
 Nourish the skin (with the right oils) Promote nourishment, repair and renewal of
body cells

BENEFITS OF MASSAGE
1. Pain relief: Relief from pain due to musculoskeletal injuries and other causes is cited as
a major benefit of massage. Pressure point massage may be more beneficial massage in
relieving back pain.
2. State anxiety: Massage has been shown to reduce state anxiety, a transient measure of
anxiety in a given situation.
3. Blood pressure and heart rate: Massage has been shown to reduce blood pressure
and heart rate as temporary effects.
4. Attention: After massage, EEG patterns indicate enhanced performance and alertness
on mathematical computations, with the effects perhaps being mediated by decreased
stress hormones.
5. Diseases: Massage, involving stretching, has been shown to help with spastic Cerebral
palsy Massage has been used in an effort to improve symptoms, disease progression,
and quality of life in HIV patients, however, this treatment is not scientifically
supported.
6. Other: Massage also stimulates the immune system by increasing peripheral blood
lymphocytes (PBLs). However, this immune system effect is only observed in
aromatherapy massage, which includes sweet almond oil, lavender oil, cypress oil, and
sweet marjoram oil. It is unclear whether this effect persists over the long term.

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 CHAPTER: 9 THERAPEUTIC MASSAGE

Overall Indication of massage:

1. For relaxation
2. For muscular lesions
3. Lesion of tendons, with & without a sheath
4. Ligamentous lesions
5. Capsular contractre
6. Subdeltoid bursitis
7. For sensory stimulation
8. For facial palsy patient
9. Massage for scar, burn & plastic surgery
10. Treatment for hematoma
11. Massage for oedema
12. For chest thrapy

Contraindication of massage:
1. Skin disease (acute infection)
2. In the presence of malignant tumours
3. Early bruising
4. Open wound
5. Tuberculosis (TB)
6. Inflammation due to bacterial action
7. Traumatic arthritis
8. Ossification of soft structures
9. Infective arthritis
10. Perineuritis

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 CHAPTER- 10

MOTOR LEARNING

s is a handout collected from various books and websites. (Rijwan Bhuiy

 CHAPTER- 11

THERAPEUTIC
RELAXATION

s is a handout collected from various books and websites. (Rijwan Bhuiy

 CHAPTER- 12

THERAPEUTIC
GYMNASIUM

s is a handout collected from various books and websites. (Rijwan Bhuiy

 Rijwan Bhuiyan completed his bachelor degree in
Physiotherapy in 2009. He then completed his MPhil
and MPH and, started career as a researcher along with
clinical practice. Therapeutic exercise hand book was
his early work for undergrad students, which is now in
compiled form.

Email: [email protected]
Cell: +88 01786279327
Linked In: www.linkedin.com/in/rijwanbhuiyan

s is a handout collected from various books and websites. (Rijwan Bhuiy