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Physical Therapy (PT)

by Alex Moroz, MD, FACP

Physical therapy aims to improve joint and muscle function (eg, range of motion, strength) and thus improve the patient’s ability to stand, balance, walk, and climb stairs. For example, physical therapy is usually used to train lower-extremity amputees. On the other hand, occupational therapy (see Occupational Therapy (OT)) focuses on self-care activities and improvement of fine motor coordination of muscles and joints, particularly in the upper extremities.

Range of motion

Limited range of motion impairs function and tends to cause pain and to predispose patients to pressure ulcers. Range of motion should be evaluated with a goniometer before therapy and regularly thereafter (for normal values, Normal Values for Range of Motion of Joints*).

Range-of-motion exercises stretch stiff joints. Stretching is usually most effective and least painful when tissue temperature is raised to about 43° C (see Heat). There are several types:

  • Active: This type is used when patients can exercise without assistance; patients must move their limbs themselves.

  • Active assistive: This type is used when muscles are weak or when joint movement causes discomfort; patients must move their limbs, but a therapist helps them do so.

  • Passive: This type is used when patients cannot actively participate in exercise; no effort is required from them.

Normal Values for Range of Motion of Joints*

Joint

Motion

Range (°)

Hip

Flexion

0–125

Extension

115–0

Hyperextension

0–15

Abduction

0–45

Adduction

45–0

Lateral rotation

0–45

Medial rotation

0–45

Knee

Flexion

0–130

Extension

120–0

Ankle

Plantar flexion

0–50

Dorsiflexion

0–20

Foot

Inversion

0–35

Eversion

0–25

Metatarsophalangeal joints

Flexion

0–30

Extension

0–80

Interphalangeal joints of toes

Flexion

0–50

Extension

50–0

Shoulder

Flexion to 90°

0–90

Extension

0–50

Abduction to 90°

0–90

Adduction

90–0

Lateral rotation

0–90

Medial rotation

0–90

Elbow

Flexion

0–160

Extension

145–0

Pronation

0–90

Supination

0–90

Wrist

Flexion

0–90

Extension

0–70

Abduction

0–25

Adduction

0–65

Metacarpophalangeal joints

Abduction

0–25

Adduction

20–0

Flexion

0–90

Extension

0–30

Interphalangeal proximal joints of fingers

Flexion

0–120

Extension

120–0

Interphalangeal distal joints of fingers

Flexion

0–80

Extension

80–0

Metacarpophalangeal joint of thumb

Abduction

0–50

Adduction

40–0

Flexion

0–70

Extension

60–0

Interphalangeal joint of thumb

Flexion

0–90

Extension

90–0

*Ranges are for people of all ages. Age-specific ranges have not been established; however, values are typically lower in fully functional elderly people than in younger people.

Extension beyond midline.

Strength and conditioning

Many exercises aim to improve muscle strength (for grading muscle strength, Grades of Muscle Strength). Muscle strength may be increased with progressive resistive exercise. When a muscle is very weak, gravity alone is sufficient resistance. When muscle strength becomes fair, additional manual or mechanical resistance (eg, weights, spring tension) is added.

General conditioning exercises combine various exercises to treat the effects of debilitation, prolonged bed rest, or immobilization. The goals are to reestablish hemodynamic balance, increase cardiorespiratory capacity and endurance, and maintain range of motion and muscle strength.

For the elderly, the purpose of these exercises is both to strengthen muscles enough to function normally and possibly to regain normal strength for age.

Grades of Muscle Strength

Grade

Description

5 or N

Full range of motion against gravity and full resistance for the patient’s size, age, and sex

N

Slight weakness

G+

Moderate weakness

4 or G

Movement against gravity and moderate resistance at least 10 times without fatigue

F+

Movement against gravity several times or mild resistance one time

3 or F

Full range against gravity

F

Movement against gravity and complete range of motion one time

P+

Full range of motion with gravity eliminated but some resistance applied

2 or P

Full range of motion with gravity eliminated

P

Incomplete range of motion with gravity eliminated

1 or T

Evidence of contraction (visible or palpable) but no joint movement

0

No palpable or visible contraction and no joint movement

N = normal; G = good; F = fair; P = poor; T = trace.

Proprioceptive neuromuscular facilitation

This technique helps promote neuromuscular activity in patients who have upper motor neuron damage with spasticity; it enables them to feel muscle contraction and helps maintain the affected joint’s range of motion. For example, applying strong resistance to the left elbow flexor (biceps) of patients with right hemiplegia causes the hemiplegic biceps to contract, flexing the right elbow.

Coordination exercises

These task-oriented exercises improve motor skills by repeating a movement that works more than one joint and muscle simultaneously (eg, picking up an object, touching a body part).

Ambulation exercises

Before proceeding to ambulation exercises, patients must be able to balance in a standing position. Balancing exercise is usually done using parallel bars with a therapist standing in front of or directly behind a patient. While holding the bars, patients shift weight from side to side and from forward to backward. Once patients can balance safely, they can proceed to ambulation exercises.

Supporting a patient during ambulation.

Aides should place one arm under that of the patient, gently grasp the patient’s forearm, and lock their arm firmly under the patient’s axilla. Thus, if the patient starts to fall, aides can provide support at the patient’s shoulder. If a patient is wearing a waist belt, aides use their free hand to grasp the belt.

Ambulation is often a major goal of rehabilitation. If individual muscles are weak or spastic, an orthosis (eg, a brace) may be used (see Therapeutic and Assistive Devices). Ambulation exercises are commonly started using parallel bars; as patients progress, they use a walker, crutches, or cane and then walk without devices. Some patients wear an assistive belt used by the therapist to help prevent falls. Anyone assisting patients with ambulation should know how to correctly support them (see Figure: Supporting a patient during ambulation.).

As soon as patients can walk safely on level surfaces, they can start training to climb stairs or to step over curbs if either skill is needed. Patients who use walkers must learn special techniques for climbing stairs and stepping over curbs. When climbing stairs, ascent starts with the better leg, and descent starts with the affected leg (ie, good leads up; bad leads down). Before patients are discharged, the social worker or physical therapist should arrange to have secure handrails installed along all stairs in the patients’ home.

Transfer training

Patients who cannot transfer independently from bed to chair, chair to commode, or chair to a standing position usually require attendants 24 h/day. Adjusting the heights of commodes and chairs may help. Sometimes assistive devices are useful; eg, people who have difficulty standing from a seated position may benefit from a chair with a raised seat or a self-lifting chair.

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