2 P H Y S I O T H E R A P Y JUNE, 1975 Passive Movements i Perspective M . J. R U N N A L L S * A lth o u g h p a ssiv e m o v e m e n ts fo rm a n in te g ra l p a r t of p h y s io th e ra p y te c h n iq u e s, a n d h a v e b een u sed by p h y s io th e ra p is ts f o r as long as p h y s io th e ra p y h a s e xisted, th e a p p r o a c h to passive m o v e m e n ts has, the a u th o r feels, been s o m e w h a t h a p h a z a r d a n d in c o m p le te . B o th p h y s io ­ th e ra p is ts a n d p h y s io th e ra p y stu d e n ts a re p ro b a b ly a b it c o n fu se d , a n d th e a u th o r w ill th e r e f o r e e n d e a v o u r to c la rify th e v a rio u s types of p a ssiv e m o v e m e n ts w ith re fe re n c e to th e ir specific a p p lic a tio n as seem s la u d ib le to her. T h e c lassic d e fin itio n o f p assive m o v e m e n t re a d s as fo llo w s: “ M o v e m e n t w hich is p ro d u c e d by a n e x te rn a l fo rc e , d u rin g m u sc u la r in a c tiv ity o r w h e n th e la tte r is v o lu n ta rily re d u c e d as m u ch as p o ss ib le to p e rm it m o v e ­ m e n t.” (G a rd in e r 1973, p. 70).1 T h e ra n g e o f m o v e m e n t o f a jo in t d e lin e a te s th e a m o u n t o f m o v e m e n t o f a p a r tic u la r jo in t w hich ta k e s p la c e in a p a r tic u la r p la n e . T h e a m o u n t o f m o v e m e n t a v a ila b le is d e p e n d a n t u p o n age, h y p e r- o r h y p o - m o b ility o r a n y jo in t p a th o lo g y . T h e ra n g e o f m o v e m e n t m a y b e d ia g ra m a tic a lly re p re s e n te d (F ig . 1) as fo llo w s: I-----------------------------------1--------1--------1 A R a n g e o f m o v e m e n t U B L 2 A = B eg in n in g o f ra n g e B = A v e ra g e lim it o f ra n g e L , = L im it o f ra n g e o f h y p o m o b ile jo in t L 2 = L im it o f ra n g e of h y p e rm o b ile jo in t F ig. I P a ssiv e m o v e m e n ts m a y e x te n d th ro u g h o u t the ra n g e o f m o v e m e n t o r m a y be given in v a rio u s p a rts o f the ra n g e o f m o v e m e n t. A u se fu l m e th o d o f d e sc rib in g th e p a r t o f th e ra n g e b e ing used f o r tre a tm e n t h a s been p r o p a g a te d by G . D . M a itla n d . (M a itla n d , 1970 p . 22).2 T h e v a rio u s p a rts o f th e ra n g e b e in g d ia g ra m m a tic a lly re p re s e n te d as fo llo w s: I I I II IV -*1 R a n g e o f m ovem ent F ig . II G r a d e I: S m a ll a m p litu d e m o v e m e n t a t th e b e g in ­ n in g o f th e range. G r a d e I I : L a rg e a m p litu d e m o v e m e n t p e rfo rm e d w ith ­ in the ra n g e , b u t n o t re a c h in g th e lim it o f th e ra n g e . G r a d e I I I : L a rg e a m p litu d e m o v e m e n t p e rfo rm e d up to th e lim it o f th e ra n g e. G ra d e IV : S m a ll a m p litu d e p e rfo rm e d a t th e lim it of th e ra n g e . “ S e n i o r L e c tu r e r : H e a d D e p a r t m e n t o f P h y s i o th e r a p y , U n i v e r s i ty o f S te ll e n b o s c h a n d T y g e r b e r g H o s p i ta l , T ie rv le i. A r tic le r e c e iv e d M a r c h , 1975. \ If th e n o r m a l ra n g e o f jo in t m o v e m e n t is lim ited h p a th o lo g y , G ra d e s III a n d IV a re re stric te d to th e new lim it o f th e ra n g e , a n d G r a d e II m o v e m e n ts a re re stric te d to sm a lle r a m p litu d e s. (Fig. I l l ) (M a itla n d p. 23).3 ’ /U I III ^--------- > <---------------------------------^ ^------------ <----- ------^ II R a n g e o f m ovem ent IV L B P a t h o lo g ic a l A n a to m ic a l lim it lim it F ig. I l l C lassification o f passive m ovem ents. (1 ) P h y sio lo g ic a l passive m ovem ents: T h e t o ta l range o f p h y sio lo g ic a l p a ssiv e m o v e m e n ts is m o re o r less th e sa m e as th e c o m p a ra b le ra n g e o f active m ove­ m e n t, th e jo in t s u rfa c e re la tio n s h ip is h o w e v er ni a lw ay s th e sam e. M uscles c o n tr a c t d u rin g acti m o v e m e n ts w ith re s u lta n t jo in t c o m p re ss io n ana g lid in g m o v e m e n ts. U n less c o m p re ss io n is specific­ a lly a p p lie d d u rin g p a ssiv e m o v e m e n ts the joint s u rfa c e a p p o s itio n m a y n o t be id e n tic a l. (2) A cccssory passive m ovem ents: T h e s e a re small m o v e m e n ts w h ic h a re n o t u n d e r m u sc le c o n tro l and a re b ro u g h t a b o u t in v a rio u s p a r ts o f th e ra n g e by the u se o f th e th u m b o r p re s s u re o f th e h a n d . It is im p o s sib le fo r th e p a tie n t to do th e s e m ovem ents v o lu n ta rily . (M a itla n d , 1970 p. 4).4 Accessory m o v e m e n ts h a v e been f u r th e r c a te g o riz e d in G ra y ’s A n a to m y as fo llo w s: “T h e m o v e m e n ts w h ich can be p e rfo rm e d a ctiv ely a t a n y jo in t d o n o t neces­ sa rily in c lu d e a ll the m o v e m e n ts w h ic h th e structure o f the jo in t w o u ld p e rm it. C e rta in m o v e m e n ts which c a n n o t be p e rfo rm e d v o lu n ta rily c a n nevertheless be p ro d u c e d w h e n re sista n c e is e n c o u n te re d to active m o v e m e n ts (a cc esso ry m o v e m e n ts, first ty p e), e.g. it is o n ly w h e n so m e solid o b je c t, su c h as a cricket b a ll, is g ra sp e d in th e h a n d , th a t fingers c a n be ro ta te d a t the m e ta c a rp o -p h a la n g e a l jo in ts. Other m o v e m e n ts c a n o n ly be p ro d u c e d p a ssiv e ly (acces­ so ry m o v e m e n ts , se c o n d ty p e) a n d th e ir w id e st range is o b ta in e d w h e n th e m u sc le s a c tin g o n th e joint a re fu lly re la x e d , e.g. w h e n th e a rm is partiall) a b d u c te d a t th e s h o u ld e r jo in t, th e h u m e ru s can bt d ra w n a w a y fro m th e g len o id c avity. S u c h m o v j m e n ts a re c o m m o n ly te rm e d “p a ssiv e m ovem ents* b u t as a ll th e m o v e m e n ts w h e th e r a c tiv e o r n o t cat be p e rfo rm e d p a ssiv e ly w h e n th e m uscles concernec a re re la x e d , th e term a c c e s so ry m o v e m e n ts will be used to d e sig n a te a ll m o v e m e n ts w h ich c a n n o t be p e rfo rm e d a ctiv ely in th e a b se n c e o f resistance.” (D a v ies, 1967 p. 492).5 M od alities o f passive m ovem ents. (1) R e la x e d — th e jo in ts a re m o v e d t h r o u g h o u t or th ro u g h p a r t o f th e ir ra n g e in e ith e r (i) a rhythmic o r (ii) a n o s c illa to ry m a n n e r. (2) F o rc e d — (i) A sm o o th s u s ta in e d stre tc h is m a in ta in e d a t the e n d o f th e ra n g e . F u r th e r m o r e , a single sus­ ta in e d s tre tc h m a y be fo rc e d p a s t th e end of th e ex istin g ra n g e ; th is m a y be r e g a rd e d as a m a n ip u la tio n . (ii) A sm a ll o s c illa to ry m o v e m e n t is m a in ta in e d at th e e n d o f th e ra n g e . (iii) A m a n ip u la tio n , a sm a ll, q u ic k m o v e m e n t with a c o n tro lle d a m o u n t o f fo rce , is p e rfo rm e d at th e end o f the a v a ila b le ra n g e . R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) jjiMlE 1975 F I S I O T E R A P I E 3 •jhe uses o f passive m ovem ents. fl) To m aintain and im prove the circu lation . T he v e n o u s c irc u la tio n is a id e d by p a ssiv e m o v e ­ m e n t e sp e c ia lly w hen th e veins a n d th e ly m p h a tic s are in fluenced by th e su rro u n d in g m uscles a nd fascia. (L effe la ar, 1971, p. 96).G F o r th e p u rp o se s of the m a in te n a n c e a n d th e im p ro v e m e n t o f c irc u la ­ tion, p assive p h y sio lo g ic a l m o v e m e n ts s h o u ld be a p ­ plied r h y th m ic a lly a t a g e n tle te m p o so as to e n a b le time fo r th e m e c h a n ic a l effects o f th e m o v em e n ts to be e sta b lish e d . (L effe la ar, 1971, p. 97).r T h e m ovem ents s h o u ld be d o n e ten tim e s in e ac h d ire c ­ tion a n d id e a lly th ree tim e s a day. (G u ttm a n 1973 p . 535).8 P r e c a u tio n s . (a) I f these m o v e m e n ts a re d o n e to o v ig o ro u sly a n d to o d e e p in to th e ra n g e , e sp e c ia lly as re g a rd s h ip flex io n a n d e x te n sio n p e rta in in g to tr e a t ­ m e n t o f p a ra p le g ic s , p a r a - a r tic u la r ossification w ill be fa c ilita te d . (G u ttm a n , 1973, p. 535).” (b) D o rsiflexion o f th e a n k le m u s t be p e rfo rm e d to its fu ll ra n g e w ith th e k n e e in ex te n sio n to be effective in th e p re v e n tio n of d e e p vein th ro m b o s is . (2) To im prove join t nutrition. Jt is th e o riz e d th a t p a ssiv e m o v e m e n ts w hich im ­ prove th e c irc u la tio n w ill in d ire c tly a lso im p ro v e th e jo in t n u tr itio n b y m e a n s o f im p ro v e d b lo o d su p p ly to th e jo in t. It is p ro b a b le th a t th e o v e rp re ss u re and tra c tio n u sed in effecting p assive m o v e m e n ts e x h ib it a su c tio n p u m p a c tio n on th e vessels w h ich su p p ly the joint. (3) To induce relaxation . G e ntle p a ssiv e p h y sio lo g ic a l m o v e m e n t e n c o u ra g e s the lo ca l re la x a tio n o f “p ro te c tiv e ” m u sc le spasm . It is h o w e v er im p o r ta n t to re m e m b e r t h a t tre a tin g the p ro te c tiv e m u sc le sp a sm is n o t tru ly th e answ er. T h e u n d e rly in g p a th o lo g y w h ic h cau ses th e m uscle to go in to sp a sm sh o u ld be tre a te d . F o r e x am p le, protective m u sc le sp a sm o f th e tra p e z iu s is a p ­ p ro a ch e d fa r m o re sc ientifically by tre a tin g the v e rte b ra l c o m p o n e n t w ith p a ssiv e in te rv e rte b ra l accessory m o v e m e n ts a t th e a p p r o p ria te level. (4) To prevent contractures and adh esion s and to m ain­ tain joint range. T he a d a p tiv e s h o rte n in g o f jo in t stru c tu re s a n d especially th e tw o -jo in t m u sc le s. (B a sm a s jia n , 1967, p. 128)1" a re o f p a rtic u la r im p o rta n c e . A s re g a rd s the stru c tu re s s u r ro u n d in g the jo in ts, p h y sio lo g ic a l passive m o v e m e n ts fro m th e fu ll c lo s e -p a c k p o sitio n to the fu ll lo o se -p a c k p o sitio n a re o f p r im a r y f u n c ­ tional im p o rta n c e (T w o m ey , 1974, p. 172)11 a nd should be given w ith th e n e c e ssa ry tr a c tio n a nd o v erpressure. T w o -jo in t m uscles re q u ire tw o fu lly m a in ta in e d stre tc h e s p e r day. Precautions: T he sta rtin g p o s itio n is o f c a rd in a l im p o rta n c e fo r efficiency o f te c h n iq u e . F o r e x a m p le , in th e case of a flaccid p a ra ly s is th e c o n tr a la te r a l h ip sh o u ld be positioned in fu ll flex io n a n d th e ip s ila te ra l k nee should be h e ld in flexion fo r ip s ila te ra l h ip e x ­ tension effecting fu ll stre tc h o n th e re c tu s fe m o ris. W ith re fe re n c e to sp a stic p a ra ly sis th e p o s itio n of the h ead a n d n e ck a re a b so lu te s fo r effective tr e a t­ m ent. T h e la b y rin th a n d to n ic n e ck reflexes in ­ fluence the m u sc le to n e w h ic h u n d e r n o c irc u m ­ stances m u s t be a llo w e d to increase. (5) To im prove joint range. W hen c a p s u la r in v o lv e m e n t p re v e n ts th e fu ll ra n g e of m o v em e n t th e re a re v a rio u s w ays in w h ic h th e range m ay be im p ro v e d . A m a n ip u la tio n , a sm all ra n g e fo rc e d p assive m o v e m e n t, m ay be p e rfo rm e d o r a n o s c illa to ry fu ll stre tc h sm a ll ra n g e m o v e m e n t m a y be m a in ta in e d a t th e e n d o f the ra n g e (G ra d e IV m o v e m e n t). T h is o s c illa to ry m o v e m e n t c o u ld be e ith e r a p a ssiv e p h y sio lo g ic a l o r p a ssiv e a c c e sso ry m o v em e n t. (M a itla n d , 1973, p. 65).12 W h en jo in t ra n g e is lim ite d by m uscle s h o rte n in g a p assive p h y sio lo g ic a l m o v e m e n t is m a in ta in e d a t th e end o f th e a v a ila b le ra n g e . Precaution: F o r b o th G r a d e IV m o v e m e n ts a n d m a n ip u la tio n an a c c u ra te a n d fu ll su b je ctiv e a n d o b je c tiv e e x a m in a ­ tio n is an a b s o lu te p re -re q u is ite fo r tre a tm e n t. (6) T o m aintain the m em ory pattern o f m ovem en t and to provide norm al sensori-m otor experience. W h e n p a ra ly s is e n su e s p assive p h y sio lo g ic a l m o v e ­ m e n ts a re p e rfo rm e d to m a in ta in th e m e m o ry p a t ­ te rn o f m o v e m e n t. T h e k in a e sth e tic re c e p to rs a re th u s c o n s ta n tly s tim u la te d by these m o v em e n ts. P a ss iv e p h y sio lo g ic a l m o v e m e n ts a re f u r t h e r given to c h ild re n w ith a d is tu rb a n c e o f m o v e m e n t so th a t th e y can o b ta in a n a p p re c ia tio n o f th e n o rm a l s e n s o ri-m o to r e x p e rie n c e . (7) T o relieve pain. T h e use o f passive m o v e m e n t in the tre a tm e n t of p a in as d istin c t fro m tre a tin g stiffness is b eco m in g in c re a s in g ly m o re im p o rta n t. P a in is re liev e d by o s c illa to ry re la x e d p assive m o v e m e n ts, G ra d e s I a n d I I w ith th e jo in t in th e n e u tra l p o s itio n a n d p a ssiv e p h y sio lo g ic a l m o v e m e n ts G ra d e s II a n d III o n c e 50% o f th e a v a ila b le a ctiv e ra n g e h a s b e en a c h ie v e d . ( M a itla n d , 1973, p. 67).13 O n e of th e p o ss ib le th e o rie s f o r th e re lie f o f pain is the “ G a te C o n tr o l T h e o r y ” p ro p a g a te d by M e lz a c k a n d W all, 1965, p. 971.11 O f c o u rse , c h an g e s in fluid b a la n c e , th e b lo o d su p p ly , th e p u re m e c h a n ic a l effects of p a ssiv e m o v e m e n ts a n d th e “ te n d e r lo v in g c a re ” e le m e n t o f p a ssiv e m o v e m e n ts a re a ll p o ss ib ly r e a so n s fo r th e r e lie f o f p a in effected by p assive m o v em e n ts. P recaution: P a in m ay e asily be e x a c e rb a te d by tre a tm e n t by p assive m o v e m e n t e v en if th e m o v e m e n ts a re p e r ­ fo rm e d in th e p a in fre e ra n g e . T h e G a te C o n tro l T h e o r y (M e lz a c k a n d W all, 1965, p. 9 71)15 is the p o ss ib le e x p la n a tio n fo r this p h e n o m e n o n . In c o n c lu sio n , it c a n be seen th a t p a ssiv e m o v e ­ m e n ts c a n n o t b e given in d is c rim in a te ly . T h e p h y s io ­ th e r a p is t m u st b e a r in m in d th e aim o f h e r tr e a t ­ m e n t a n d th e n a p p ly th e n e c e ssa ry m o d ific atio n s of th e v a rio u s p a ssiv e m o v e m e n ts te c h n iq u e s to a cc o m p lish h e r specific aim . O P S O M M IN G : P a ssie w e bew egings is in gedeel en h u lle g e b ru ik e om die b lo e d v o o rs ie n in g te b e h o u en v e rb e te r, om gew rigs- v o e d in g te v e rb e te r, om o n ts p a n n in g te v e ro o rs a a k , om k o n tr a k tu r e en v a sk lew in g s te v o o rk o m , om gew rigs- o m v a n g te b e h o u en v e rb e te r, o m die g e h e u e -p a tro o n van b e w eg in g te b e h o u , om die n o rm a le se n so ri- m o to rie s e o n d e rv in d in g te v o o rsie n e n om p y n te verlig, is b e sp ree k . A C K N O W L E D G E M E N T S : M r. G . D . M a itla n d , A .U .A ., F .C .S .P ., M .A .P .A ., P a rt- tim e L e c tu re r in P h y s io th e ra p y , S o u th A u s tra lia n I n s ti­ tu te o f T e c h n o lo g y , A d e la id e a n d M iss S. Irw in- C a rru th e rs , N a t. D ip l. P h y sio . (P ta .), T e a c h in g D ip . P h y sio . (P ta .), L e c tu re r in P h y s io th e ra p y , U n iv e rs ity of S te lle n b o sc h , fo r th e ir e n c o u ra g e m e n t a n d help. (C ontinued o n page 5) R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )