Lakshmi NarayananTextbook of THERAPEUTIC EXERCISES masud.pdf · version 1

44 TEXTBOOK OF THERAPEUTIC EXERCISES • Stable arm: It is placed horizontally on the • Procedure: Therapist’s left hand is perfor- clavicle and is holding by the therapist’s left ming the medial and lateral rotation move- hand. ment of the shoulder joint with the gonio- meter and measuring the angle to see the • Procedure: Therapist’s right hand is perfor- passive range of motion and the active ROM ming the abduction movement of the is measured by patient himself performing shoulder joint with the goniometer and the movement. measuring the angle to see the passive range of motion and the active ROM is measured Elbow Joint by patient himself performing the move- Flexion ment. • Position of the patient: Supine lying. • Axis: Lateral epicondyle of the humerus. Medial and Lateral Rotation • Stable arm: Stable arm is placed over the • Position of the patient: Supine lying with lateral midline of the humerus. shoulder and elbow 90º position. • Movable arm: It is placed over the lateral • Axis: Olecranon process of the ulna is taken midline of the forearm. as the axis. • Movable arm: Movable arm is placed over the midline of the posterior aspect of forearm and is holding by the therapist’s left hand. • Stable arm: It is placed straight line to the movable arm, kept in the air without the patient’s body contact and is holding by the therapist’s right hand. Fig. 4.6: Measuring the elbow flexion movement with the goniometer Fig. 4.5: Measuring the shoulder medial and lateral Procedure rotation movement with the goniometer • Therapist’s left hand is holding the stable arm with the arm of the patient. • Therapist’s right hand is holding the movable arm with the forearm of the patient. • Procedure: Therapist’s right hand is perfor- ming the flexion movement of the elbow with the goniometer and measuring the angle to see the passive range of motion and the active ROM is measured by patient himself performing the movement.

GONIOMETRY 45 Radioulnar Joint Fig. 4.8: Measuring the radioulnar joint supination movement with the goniometer Pronation • Position of the patient: Long sitting and the forearm in midprone position. • Axis: Ulnar styloid process is taken as the axis and the movable arm and the stable arm is kept 90°. • Stable arm: Stable arm is placed perpen- dicular to the movable arm without any body contact. • Movable arm: It is placed over the anterior aspect of the wrist. • Axis: Ulnar styloid process is taken as the axis and the movable arm and stable arm is kept at 90°. • Stable arm: Stable arm is placed perpen- dicular to the movable arm without any body contact. • Movable arm: It is placed over the posterior aspect of the wrist. Fig. 4.7: Measuring the radioulnar joint pronation Procedure movement with the goniometer • Therapist’s left hand is holding the stable Procedure arm without the patient’s body contact. • Therapist’s right hand is holding the stable • Therapist’s right hand is holding the arm without the patient’s body contact. movable arm posterior aspect of wrist of the • Therapist’s left hand is holding the movable patient. • Procedure: Therapist’s right hand is perfor- arm in anterior aspect of wrist of the patient. ming the supination movement of the fore- • Procedure: Therapist’s left hand is perfor- arm with the goniometer and measuring the angle to see the passive range of motion ming the pronation movement of the fore- and the active ROM is measured by patient arm with the goniometer and measuring the himself performing the movement. angle to see the passive range of motion and the active ROM is measured by patient Wrist Joint himself performing the movement. Flexion • Position of the patient: Long sitting. The Supination • Position of the patient: Long sitting and the shoulder is abducted 90°, forearm is supinated and resting on the table and the forearm is midprone position. wrist is kept hanging in the couch end.

46 TEXTBOOK OF THERAPEUTIC EXERCISES the angle to see the passive range of motion and the active ROM is measured by patient himself performing the movement. Fig. 4.9: Measuring the wrist joint flexion and Ulnar Deviation extension movement with the goniometer • Position of the patient: Long sitting. The • Axis: Medial margin of the wrist is taken as shoulder is abducted 90°, forearm is pronated the axis. and resting on the table and the wrist is kept hanging in the couch end. • Stable arm: Stable arm is placed over the • Axis: Middle of the posterior aspect of the lateral midline of the forearm and is holding wrist is taken as the axis. by the therapist’s left hand. • Stable arm: Stable arm is placed over the midline of the posterior aspect of forearm • Movable arm: It is placed over the lateral and is holding by the therapist’s left hand. midline of the little finger and is holding by • Movable arm: It is placed over the midline the therapist’s right hand. of the posterior aspect of the middle finger and is holding by the therapist’s right hand. • Procedure: Therapist’s right hand is perfor- • Procedure: Therapist’s right hand is perfor- ming the flexion movement of the wrist with ming the ulnar deviation movement of the the goniometer and measuring the angle to wrist with the goniometer and measuring see the passive range of motion and the the angle to see the passive range of motion active ROM is measured by patient himself and the active ROM is measured by patient performing the movement. himself performing the movement. Extension Fig. 4.10: Measuring the wrist joint ulnar and radial • Position of the patient: Long sitting. The deviation movement with the goniometer shoulder is abducted 90°, forearm is pronated Radial Deviation and resting on the table and the wrist is • Position of the patient: Long sitting. The kept hanging in the couch end. • Axis: Medial margin of the wrist is taken as shoulder is abducted 90°, forearm is pronated the axis. and resting on the table and the wrist is • Stable arm: Stable arm is placed over the kept hanging in the couch end. lateral midline of the forearm and is holding by the therapist’s left hand. • Movable arm: It is placed over the lateral midline of the little finger and is holding by the therapist’s right hand. • Procedure: Therapist’s right hand is performing the extension movement of the wrist with the goniometer and measuring

GONIOMETRY 47 • Axis: Middle of the posterior aspect of the • Procedure: Therapist’s left hand is perfor- wrist is taken as the axis. ming the flexion movement of the MCP with the goniometer and measuring the angle to • Stable arm: Stable arm is placed over the see the passive range of motion and the midline of the posterior aspect of forearm active ROM is measured by patient himself and is holding by the therapist’s left hand. performing the movement. • Movable arm: It is placed over the midline Extension of the posterior aspect of the middle finger • Position of the patient: Long sitting. The and is holding by the therapist’s right hand. shoulder is abducted 90°, forearm is pronated • Procedure: Therapist’s right hand is perfor- and resting on the table and the wrist is ming the radial deviation movement of the kept hanging in the couch end. wrist with the goniometer and measuring the angle to see the passive range of motion and the active ROM is measured by patient himself performing the movement. MCP Fig. 4.12: Measuring the MCP joint extension Flexion movement with the goniometer • Position of the patient: Long sitting. The • Axis: Middle of the anterior aspect of the shoulder is abducted 90°, forearm is pronated joint line of the MCP is taken as the axis and resting on the table and the wrist is and the goniometer is placed in standing kept hanging in the couch end. manner. • Axis: Middleoftheposterioraspectofthejoint line of the MCP is taken as the axis and the • Stable arm: Stable arm is placed over the goniometer is placed in standing manner. midline of the anterior aspect of wrist and • Stable arm: Stable arm is placed over the forearm and is holding by the therapist’s midline of the posterior aspect of wrist and right hand. forearm and is holding by the therapist’s right hand. • Movable arm: It is placed over the midline • Movable arm: It is placed over the midline of the anterior aspect of the metacarpal and of the posterior aspect of the metacarpal and phalanx and is holding by the therapist’s left is holding by the therapist’s left hand. hand. Fig. 4.11: Measuring the MCP joint flexion move- • Procedure: Therapist’s left hand is perfor- ment with the goniometer ming the extension movement of the MCP with the goniometer and measuring the angle to see the passive range of motion and the active ROM is measured by patient himself performing the movement.

48 TEXTBOOK OF THERAPEUTIC EXERCISES Abduction and Adduction • Stable arm: Stable arm is placed over the • Position of the patient: Long sitting. The midline of the posterior aspect of meta- carpal, wrist and forearm and is holding by shoulder is abducted 90°, forearm is pronated the therapist’s right hand. and resting on the table and the wrist is kept hanging in the couch end. • Movable arm: It is placed over the midline • Axis: Middle of the posterior aspect of the of the posterior aspect of the phalanx and is joint line of the MCP is taken as the axis holding by the therapist’s left hand. and the goniometer is kept in lying position. • Stable arm: Stable arm is placed over the • Procedure: Therapist’s left hand is perfor- midline of the posterior aspect of wrist and ming the flexion and extension movement forearm and is holding by the therapist’s of the PIP with the goniometer and measu- left hand. ring the angle to see the passive range of • Movable arm: It is placed over the midline motion and the active ROM is measured by of the posterior aspect of the metacarpal and patient himself performing the movement. is holding by the therapist’s right hand. • Procedure: Therapist’s right hand is Hip Joint performing the abduction and adduction Flexion movement of the MCP with the goniometer • Position of the patient: Supine lying. and measuring the angle to see the passive • Axis: Greater trochanter of the femur is range of motion and the active ROM is measured by patient himself performing the taken as the axis. movement. • Stable arm: Stable arm is placed over the midline of the lateral aspect of lower trunk and is holding by the therapist’s left hand. • Movable arm: It is placed over the midline of the lateral aspect of the thigh and is holding by the therapist’s right hand. Fig. 4.13: Measuring the MCP joint abduction and adduction movement with the goniometer PIP Fig. 4.14: Measuring the hip joint flexion movement with the goniometer Flexion and Extension • Position of the patient: Long sitting. • Procedure: Therapist’s right hand is perfor- • Axis: Middle of the posterior aspect of the ming the flexion movement of the hip with the goniometer and measuring the angle to joint line of the PIP is taken as the axis and see the passive range of motion and the the goniometer is placed in standing posi- tion.

GONIOMETRY 49 active ROM is measured by patient himself performing the movement. Extension Fig. 4.16: Measuring the hip joint abduction • Position of the patient: Prone lying. movement with the goniometer • Axis: Greater trochanter of the femur is • Procedure: Therapist’s right hand is per- taken as the axis. forming the abduction movement of the hip • Stable arm: Stable arm is placed over the with the goniometer and measuring the angle to see the passive range of motion midline of the lateral aspect of lower trunk and the active ROM is measured by patient and is holding by the therapist’s right hand. himself performing the movement. • Movable arm: It is placed over the midline of the lateral aspect of the thigh and is holding by the therapist’s left hand. • Procedure: Therapist’s left hand is perfor- ming the extension movement of the hip with the goniometer and measuring the angle to see the passive range of motion and the active ROM is measured by patient himself performing the movement. Medial and Lateral Rotation • Position of the patient: Sitting in the end of the couch and the legs are kept hanging. • Axis: Tip of the patella is taken as the axis. Fig. 4.15: Measuring the hip joint extension movement with the goniometer Abduction Fig. 4.17: Measuring the hip joint medial and lateral • Position of the patient: Supine lying. rotation movement with the goniometer • Axis: Two inches below the ASIS is taken as the axis. • Movable arm: It is placed over the midline of the anterior aspect of the thigh and is holding by the therapist’s right hand. • Stable arm: Stable arm is placed 90° to the movable arm and is holding by the therapist’s left hand.

50 TEXTBOOK OF THERAPEUTIC EXERCISES • Movable arm: It is placed over the midline Ankle Joint of the anterior aspect of the leg and is holding by the therapist’s right hand. Plantar and Dorsiflexion • Position of the patient: Sitting in the end of • Stable arm: Stable arm is placed straight line to the movable arm and is holding by the couch and the legs are kept hanging. the therapist’s left hand. • Axis: Tip of the medial malleolus is taken • Procedure: Therapist’s right hand is as the axis. performing the medial and lateral rotation • Stable arm: It is placed over the midline of movement of the hip with the goniometer and measuring the angle to see the passive the medial aspect of the leg and is holding range of motion and the active ROM is by the therapist’s left hand. measured by patient himself performing the • Movable arm: Movable arm is placed 90° to movement. the movable arm and is holding by the therapist’s right hand. Knee Joint • Procedure: Therapist’s right hand is perfor- Flexion ming the plantar and dorsiflexion movement • Position of the patient: Prone lying. of the hip with the goniometer and measur- • Axis: Lateral joint line is taken as the axis. ing the angle to see the passive range of • Movable arm: It is placed over the midline motion and the active ROM is measured by patient himself performing the movement. of the lateral aspect of the leg and is holding by the therapist’s right hand. • Stable arm: It is placed over the midline of the lateral aspect of the thigh and is holding by the therapist’s left hand. • Procedure: Therapist’s left hand is perfor- ming the flexion movement of the knee with the goniometer and measuring the angle to see the passive range of motion and the active ROM is measured by patient himself performing the movement. Fig. 4.18: Measuring the knee joint flexion move- Fig. 4.19: Measuring ankle joint plantar and ment with the goniometer dorsiflexion movement with the goniometer

GONIOMETRY 51 Subtalar Joint Inversion • Position of the patient: Long sitting and the legs are kept hanging. • Axis: Medial joint line of the head of the 1st metatarsal taken as the axis and the movable arm and the stable arm is kept 90°. • Stable arm: Stable arm is placed parallel to the medial aspect of the ankle and lower leg. • Movable arm: It is placed over dorsal aspect of the foot, perpendicular to the stable arm. Fig. 4.21: Measuring the subtalar joint eversion movement with the goniometer Fig. 4.20: Measuring the subtalar joint inversion • Axis: Lateral aspect of the head of the 5th movement with the goniometer metatarsal taken as the axis and the movable arm and the stable arm is kept 90°. Holding • Therapist’s right hand is holding the stable • Stable arm: Stable arm is placed parallel to the lateral aspect of the lower leg. arm. • Therapist’s left hand is holding the movable • Movable arm: It is placed over dorsal aspect of the foot perpendicular to the stable arm. with the dorsal aspect of the foot. • Procedure: Therapist’s left hand is perfor- Holding • Therapist’s right hand is holding the stable ming the inversion movement of the sub- talar joint with the goniometer and measu- arm. ring the angle to see the passive range of • Therapist’s left hand is holding the movable motion and the active ROM is measured by patient himself performing the movement. with the dorsal aspect of the foot. • Procedure: Therapist’s left hand is perfor- Eversion • Position of the patient: Long sitting and the ming the inversion movement of the subtalar joint with the goniometer and measuring legs are kept hanging. the angle to see the passive range of motion and the active ROM is measured by patient himself performing the movement.

552 TEXTBOOK OF THERAPEUTIC EXERCISES CHAPTER Starting and Derived Positions STARTING POSITION tal positions, depend on the patient convenient The position, which is adopted, by the patient or as well as therapist’s convenient, the positions an individual to perform the exercise or the are altered to perform an activity or movement. movement, to gain relaxation and stabilize the body is called as starting position. To perform a Uses movement or exercise, the person should adopt 1. To increase stability one stable position. “Every movement begins in 2. For relaxation posture and ends in posture”. It is applicable for 3. To perform a particular exercise the day-to-day activities too. For example, 4. For reducing the muscle work drinking bed coffee. In this example, the person 5. For localizing the activity. has to come out of the lying posture and attain sitting posture to drink the coffee or tea. So, the These derived positions may be useful for every activity, which we do in our day-to-day life our daily activities or to perform an exercise. also starts in one posture and ends in some This chapter elaborately explains about the other or same posture. There are five fundamen- position, which is helpful for an exercise and tal positions are found by which all the positions for the day-to-day activities with the relevant are derived. Whatever position we adopt for examples. The muscle work for a particular exercise or movement, it is the position, which derived position is not explained in this chapter altered from the five fundamental positions. instead of that the movements, which occur in 1. Standing that particular position, are mentioned. 2. Sitting 3. Lying STANDING (FIG. 5.1) 4. Kneeling Starting Position—Standing 5. Hanging. Introduction The whole body is supported or aligned by the DERIVED POSITIONS smaller base. So that this position is most These are the positions, which are derived from difficult to adopt for longer period. There will the starting position. From the five fundamen-

STARTING AND DERIVED POSITIONS 53 keep it in the adducted and slightly retracted position. • Normally arms are relaxed or sometimes muscle work is minimal or nil. • Spinal extensors work more to stabilize the spine in erect position. • The spinal flexor counteracts and balances the spinal extensors. • Hip extensors maintain the hip in neutral position and the flexors counteract on it for balancing the limb. • Hip lateral rotator keeps the hip in slightly rotated position. • Ankle plantar and dorsiflexors counteract and keeps in neutral position. • Toe flexors work more and make the ball of the toe grip with the floor. • Intrinsic muscles of the foot stabilize the foot. Fig. 5.1: Standing Derived Positions—Standing be a lot of coordinated muscle activity to Many of the derived positions can be derived maintain this posture. from the standing by altering the arm, trunk and the lower limb. These positions can be utilized for the different types of exercise regimen, relaxation and stability. Position By Altering Lower Limb • Foot is placed together and toes placed a. High standing b. Walk standing slightly apart. c. Stride standing • Knees are extended and aligned straight. d. Step standing • Hip is in neutral position and slight lateral e. Half-standing f. Toe standing rotated. g. Close standing • Spine is erect. h. Foot and onfoot standing • Shoulder adducted and slightly retracted. i. Cross standing. • Upper limb is hanging closely to the body. • Neck is aligned straight. High standing • Eyes look forward. • Standingonthestoolorinanyraisedplatform Muscle Works (Fig. 5.2). • Flexors and extensors of neck muscles • Movements as mentioned in the standing. Uses in exercise therapy counteract and align the neck in straight • To perform upper and lower limb exercises. position. • To perform hanging, swinging the arm and • Evertor of the mandible closes the mouth. • Retractors and adductors of the shoulder leg.

54 TEXTBOOK OF THERAPEUTIC EXERCISES Fig. 5.2: High standing Fig. 5.3: Walk standing Examples Fig. 5.4: Stride standing • To take some object from the height. Movements • Example fitting the fan in the ceiling. • Hip abduction Walk standing: One leg is placed forward and • Knee extension. the base is increased. So, stability will be more in this position (Fig. 5.3). Movements: • Hip—Flexion • Knee—Extension • Ankle—Mild plantar flexion. Uses in exercise therapy • Starting position for jogging. • To perform the hip, knee, ankle, and trunk muscles self-stretching. • Relaxation from the prolonged standing. Example • Balancing on rope or rod. Stride standing: Both the foot kept apart in the side ways. It gives more lateral stability (Fig. 5.4).

STARTING AND DERIVED POSITIONS 55 Uses in exercise therapy • To perform the trunk, hip, knee exercises. • Used for stability. • Helps to stretch the hip adductors. Examples • Sailors standing position. • Standing posture while traveling in the bus. Step standing: One foot is kept on the stool or on height. Hip and knee is flexed. This is also one of the stable postures (Fig. 5.5). Fig. 5.6: Half-standing • Spinal side flexors support the spine. • Supporting leg muscles work strongly. Fig. 5.5: Step standing Uses in exercise therapy • Leg swinging exercise. Movements • Stretching the knee, hip and muscles. • Hip flexion Examples • Knee flexion. • Pick-up some objects from the floor with Uses in exercise therapy • For stretching the knee ankle, hip and trunk the toes. • Position adopted to remove the thorn in the muscles. Examples sole of the foot. • Position adopted to tie the shoelace. Toe standing: Standing with the toes and toes • Position adopted to cutting the toenails. raise the body. This is also one of the unstable Half standing: Standing with the one leg. One position because the COG increases and the leg is flexed totally. It is the very difficult BOS decreases in this position (Fig. 5.7). position to maintain for long period (Fig. 5.6). Uses in exercise therapy Muscle works • Strengthening the plantar flexors and toe • Abductors of the opposite side, i.e. suppor- extensors. ting leg prevent the tilting. • Stretching the dorsiflexors. Example • Raising the body by the toes to see the invisible things in the crowd.

56 TEXTBOOK OF THERAPEUTIC EXERCISES Fig. 5.7: Toe standing Movement Close standing: Both the foot is kept closer • Hip internally rotated. and parallel to each other. It is difficult to Uses in exercise therapy maintain this posture due to the tension created • To perform hip, trunk bending and in the leg muscles (Fig. 5.8). rotational exercises. • Arm swinging exercises. • Starting position for sit-up exercises. • To perform the upper and lower extremity exercises. Examples • Suriya namaskar position. • Erect standing posture in military. • Standing posture during national anthem. Lunge standing: The feet are placed right angle to each other. If the forward leg bends, the weight transmitted to the same leg (Fig. 5.9). Movements • Hip abduction and lateral rotation. • Knee flexion of the relaxing leg. Uses in exercise therapy • Weight transmitting exercises. • To perform balancing and coordination exercises. • Lower limb stretching exercises. Fig. 5.8: Close standing Fig. 5.9: Lunge standing

STARTING AND DERIVED POSITIONS 57 Example Fig. 5.11: Foot and onfoot standing • Relaxed standing positions after prolong Movements standing. • Hip flexed, adducted, and medially rotated. Cross leg standing: Legs are kept crossed. • Knee flexion. This is the unstable position due to the • Ankle plantar flexed. improper weight transmission. One leg is kept Uses in exercise therapy straight and weight bears, another leg is rotated • Weight transmission and coordination and kept cross to the supporting leg and the toes are placed on the floor (Fig. 5.10). exercises. Movements (non-weight bearing leg) Example • Hip laterally rotated and slightly abducted. • The posture adopted while walking on hot • Knee flexed and laterally rotated. • Ankle lightly plantar flexed. surface. Uses in exercise therapy • For relaxation. • Weight transmission and balancing exer- cises. Examples • Stylish and casual relaxed standing position. • Lord Krishna’s standing position. Fig. 5.10: Cross standing By Altering Arm a. Wing standing b. Bend standing c. Reach standing d. Stretch standing e. Yard standing f. Cross-arm standing g. Heave standing. Foot and onfoot standing: One foot is kept Wing standing: Both the hands are placed on on the dorsal surface of the other foot (Fig. 5.11). the pelvic region of the either side (Fig. 5.12).

58 TEXTBOOK OF THERAPEUTIC EXERCISES Fig. 5.12: Wing standing Fig. 5.13: Bend standing • Trunk bending exercises as well as neck Movements • Shoulder abducted and medially rotated. exercises. • Elbow flexed. Examples • Thumb abducted. • Policeman fixing the star in his shoulder. • Fingers adducted and flexed. • Removing dust from the shoulder. • Forearm pronated. Reach standing: The upper limbs are kept Uses in exercise therapy parallel and right angle to the body (Fig. 5.14). • To perform trunk bending exercises. • To perform neck exercises. Fig. 5.14: Reach standing • To perform lower limb strengthening and stretching exercises. Example • Relaxing position after prolonged walking or jogging. Bend standing: Elbow is flexed and hands placed on the same side of the shoulder (Fig. 5.13). Movements: • Shoulder abducted and laterally rotated. • Elbow flexed. • Forearm supinated. • Fingers flexed. Uses in exercise therapy • Shoulder rotation exercises.

STARTING AND DERIVED POSITIONS 59 Movements Example • Shoulder flexed and elevated. • Balancing while walking on the rope or rod. • Elbow extended. • Umpire’s wide signaling in cricket. • Forearm in midprone position. Stretch standing: Upper limb is totally eleva- • Wrist and fingers extended. ted up and placed parallel to the body line (Fig. Uses in exercise therapy 5.16). • To perform wrist exercise. • Grasping the horizontal bar with the hand Fig. 5.16: Stretch standing Movements can perform sit-up exercise. • Shoulder flexed and medially rotated. Examples • Elbow extended. • Position adopted to carry the child. • Wrist and finger extended. • Walking style in the dark place to avoid Uses in exercise therapy • To perform arm swinging exercises. dashing on the objects. • To perform trunk exercises. Yard standing: Upper limbs are kept in the Examples sides and perpendicular to the body with palm • Repairing the ceiling fan. facing up (Fig. 5.15). • Overhead activities. Movements Cross-arm standing: Elbowisflexedandhands • Shoulder abducted, laterally rotated and are placed on the opposite side shoulder (Fig. 5.17). extended. Movements • Elbow extended. • Shoulder adducted and medially rotated. • Forearm supinated. • Elbow flexed. • Wrist and fingers extended. • Forearm pronated. Uses in exercise therapy • Wrist and fingers flexion. • To perform trunk rotation and bending exercises. • To perform wrist, elbow, and finger exercises. • To perform arm swinging movements. Fig. 5.15: Yard standing

60 TEXTBOOK OF THERAPEUTIC EXERCISES Movements • Shoulder abducted, extended and laterally rotated. • Elbow flexed at 90°. • Wrist and finger extended. Uses in exercise therapy • Shoulder rotational movements. • To perform forearm supination and prona- tion. Examples • Carrying weight over the back by holding with the hand. • Symbol of surrender. Fig. 5.17: Cross-arm standing By Altering the Trunk Uses in exercise therapy a. Relaxed stoop standing. • To perform trunk bending and rotation b. Stoop standing. c. Fallout standing. exercises. Relax stoop standing: Hip and trunk are • To test the shoulder dislocation. flexed totally and the upper limb kept hanging Example (Fig. 5.19). • Waiters or slavery position. Movements Heave standing: Arm and forearm kept at • Hip flexed. right angle and shoulder kept 90° abducted (Fig. • Trunk flexed. 5.18). • Upper limb relaxed and kept hanging. Fig. 5.18: Heave standing Fig. 5.19: Relax stoop standing

STARTING AND DERIVED POSITIONS 61 Uses in exercise therapy Fig. 5.21: Fallout standing • Trunk bending and stretching movement Fallout standing: One leg kept forward with can be performed. knee bending, the other leg remains straight • Stretching the trunk and hip muscles. and the trunk inclined forward (Fig. 5.21). Examples Movements • Sweeping the floor. • Forward leg: Hip flexed and knee flexed. • Position adopted while tying the lace or • Backward leg: Hip extended, knee extended adjusting the shoes. and ankle dorsiflexed. Stoop standing: Trunk is inclined forward and Uses in exercise therapy upper limb placed parallel to the bodyline to • Stretching the hip flexors. this position (Fig. 5.20). • Strengthening exercises to the forward leg Movements • Trunk flexed. can be performed. • Hip flexed. Example • Shoulder adducted, extended and laterally • Pulling the loaded bullockcart. rotated. • Elbow is extended. • Finger and wrist extended. Uses in exercise therapy • Pendular movements of the shoulder. • Trunk bending and stretching exercises. Example • Rickshaw pulling position. Fig. 5.20: Stoop standing SITTING Starting Position—Sitting The position adopted while sitting on the stool or the chair is considered as the fundamental position of the sitting. The thighs and the legs are relaxed and the foot is resting on the floor. From the trunk to head the position is same as said in standing posture. The base of support is

62 TEXTBOOK OF THERAPEUTIC EXERCISES Fig. 5.22: Sitting Fig. 5.23: Cross sitting more, so the COG lies down. Due to the down- Movement ward movement of the COG the position gets Both the side hips are flexed, laterally rotated more stability than the standing and the muscle and knee flexed. work required is also less (Fig. 5.22). Uses in exercise therapy • Breathing exercise and reduce the respira- Muscle Works There is no muscle work in the lower limb tory distress because the stool supports thighs and legs, and • Hip adductor stretching the foot is resting on the floor. Remaining parts • Trunk and neck exercise. from the trunk to head the muscle work is same Example like the standing posture. • Some floor level activities like eating, cutting vegetables, etc. Derived Position—Sitting Side Sitting 1. Cross sitting This position is possible either one side of the 2. Side sitting hip. In right side sitting the right hip remains 3. Crook sitting like the cross sitting the left hip flexed, adducted 4. Long sitting medially rotated and knee flexed and kept in 5. Stoop sitting side. Weight is transmitted on right side (Fig. 6. Ride sitting 5.24). 7. Foot sitting (squatting). Uses in exercise therapy Cross Sitting • Progression from prone to sitting in mat Both the legs are crossed and the weight is transmitted through both the hips (Fig. 5.23). activity. • To perform trunk exercises.

STARTING AND DERIVED POSITIONS 63 Fig. 5.24: Side sitting Fig. 5.26: Long sitting Example Long Sitting • All floor level activities like cutting vege- • Hip is flexed, knee is extended and resting tables and garland making. on the floor (Fig. 5.26). Uses in exercise therapy Crook Sitting • To perform hip rotational movements. Knee and hip are flexed in, and the feet are • To perform ankle and knee exercises. kept forward while sitting in the floor (Fig. 5.25). • To perform trunk exercises. Movements Example • Hip flexed, • Traditionally adopted position by the old age • Knee flexed, and • Ankle in neutral position. people for floor level activities. Uses in exercise therapy • To perform mat activities. Stoop Sitting • To perform breathing exercises. Sitting on the stool and the trunk is leaned • To perform neck and ankle exercises. forward (Fig. 5.27). Example Relaxed wall sitting while watching T.V. Fig. 5.25: Crook sitting Fig. 5.27: Stoop sitting

64 TEXTBOOK OF THERAPEUTIC EXERCISES Movement • Trunk flexion. Uses in exercise therapy • Used for back and neck massage • Back muscles relaxation • To perform breathing exercises. Example • Lazy sleeping position in the classroom. Stride Sitting Fig. 5.29: Foot sitting Both the hips are abducted and placed in either Movement sides of the stool. If the foot rests on the floor, • Hip and knees are flexed and weight is the position will be more stable (Fig. 5.28). Uses in exercise therapy transmitted through the feet. • To perform leg swinging exercises. Uses in exercise therapy • To perform neck and trunk exercises. • Starting position for sit-up exercises. • To perform upper limb exercises. • Starting position for running race. Example Example • Bike riding posture. • The position adopted while washing clothes • Horse riding posture. and cleaning vessels. • Indian style toileting. Fig. 5.28: Stride sitting LYING Foot Sitting (squatting) Starting Position—Lying Sitting on the feet (Fig. 5.29). Lying on the floor or on the plinth, in supine position with arm by the side of the body and legs are kept straight. It is the most stable posture than the any other fundamental starting position due to the lower placement of the COG and the broader base. This position can be adopted for prolonged period than any other starting position (Fig. 5.30). Muscle Works In this posture the muscle work is minimal. Maximum muscles are relaxed except some positions:

STARTING AND DERIVED POSITIONS 65 Fig. 5.30: Lying Uses in exercise therapy • Neck side flexors counter balanced to keep • Spinal extensor and neck extensor exercises the head in neutral position. can be performed. • Flexors of the lumbar spine counteract with • This position can be used for back massage. • Some of the upper and lower extremity the spinal extensors to maintain the lumbar lordosis. exercises can be performed. • Medial rotators of the hip keep the hip in Example neutral position. Toppled position of getting blessing from the elders. Uses It is very much useful position to perform many Half-lying of the upper limb, lower limb, trunk, neck Same like the supine lying and upper portion exercises like strengthening, stretching, is lifted and kept inclined. Some amount of spinal aerobic and anaerobic and breathing exercises. muscle work may be present in this posture (Fig. 5.32). Derived Position—Lying Fig. 5.32: Half-lying a. Prone lying Uses in exercise therapy b. Half-lying • To practice breathing exercise and postural c. Crook lying d. Side lying. drainage. Prone Lying • To perform Frenkle’s exercise. Anterior portion of the total body is turned • To perform upper limb, lower limb, and towards the couch or floor. This position is inconvenient for maintaining for longer period. trunk exercises. All the body parts are relaxed and if the head also Example gets relaxed, if it turned and kept apart. This • Relaxed position to adopt while reading book position is very much difficult for the respiratory distress and elderly patients (Fig. 5.31). or watching TV. Fig. 5.31: Prone lying Crook Lying Modifications are made in lower limb in the supine lying posture. The hip and knee are flexed, and the feet is kept forward (Fig. 5.33). Uses in exercise therapy • Abdominal muscle strengthening exercises can be performed. • Pelvic bridging exercises can be performed.

66 TEXTBOOK OF THERAPEUTIC EXERCISES Fig. 5.33: Crook lying Example • Relaxing position after yoga exercises. Side Lying Fig. 5.35: Kneeling Lying one side of the body. It is most incon- venient to maintain for longer period. The upper maintain for longer period. Even though the extremity which is placed under the body will be COG falls down and the larger BOS, it is incon- more painful and positioning the lower limb venient to adopt due to the weight transmitted also very much difficult. Upper extremity, which through the knee joint (Fig. 5.35). is below the body, is flexed and kept under the Muscle works head, and the lower limb which is up to be placed • The leg is relaxed except the plantar flexors forward to reduce the inconvenient (Fig. 5.34). Uses in exercise therapy of the ankle, which keeps the ankle in • Many of the upper limb and lower limb plantar flexion state. • Hip flexors, extensors counteracts with each exercises can be performed. other and keeps in vertical position and • Breathing exercises and postural drainage prevents the pelvic tilt. • Remaining muscle is as said in standing can be done. posture. Example Uses in exercise therapy • Daily-unknown activity while sleeping. • Many of the upper limb and trunk exercises can be performed. Fig. 5.34: Side lying • To perform the mat activities. • To perform coordination and balancing KNEELING exercises. This position is like the fundamental position Example of standing but the weight is transmitted • Christians prayer position. through the knee joint due to the right angle alignment of the knee to the body. The leg is Derived Position—Kneeling resting on the floor and the ankle is plantar 1. Half-kneeling flexed. It is the very much difficult position to

STARTING AND DERIVED POSITIONS 67 2. Kneel sitting Example 3. Prone kneeling • To practice some of yogic exercises. 4. Inclined prone kneeling. Kneel Sitting Half-kneeling Sitting on the heel by flexing the hip and knee It is like the kneeling position and weight is (Fig. 5.37). transmitted through one side knee. Another side hip is flexed 90°, the thigh and leg is kept right angle to each other and the foot is placed on the floor forward (Fig. 5.36). Fig. 5.36: Half-kneeling Fig. 5.37: Kneel sitting Uses in exercise therapy Movements • To perform trunk bending and stretching • Forward lower limb: Hip flexed 90°, knee exercises. flexed 90°. • To perform neck exercises. • Kneeling lower limb: Hip is in neutral • To perform the stretching and strengthen- position, knee flexed 90°. ing exercises for the knee and hip muscles. Uses in exercises therapy Example • To perform the balancing and coordination • Playing posture adopted by the child. • To perform some of the yogic exercises. exercises. • To perform trunk bending and neck Prone Kneeling It is otherwise called as quadruped position or exercises. animal position. Trunk is inclined forward and • To perform upper extremity strengthening is stabilized by the upper limb by placing on the floor, remaining are same like kneeling (Fig. and stretching exercises. 5.38). • To perform the mat activities. Movements • Trunk forward bending. • Shoulder flexed, elevated and medially rotated. • Elbow extended. • Wrist and finger extension.

68 TEXTBOOK OF THERAPEUTIC EXERCISES Uses in exercise therapy • To perform breathing exercises and postural drainage technique. Example • Muslim Namaz position. HANGING Total body is suspended by grasping a horizontal bar with the hand (Fig. 5.40). Fig. 5.38: Prone kneeling or quadruped position Uses in exercise therapy Fig. 5.40: Hanging • To perform mat activity. • To perform coordination exercises. • Cat and camel exercises. Example • Child crawling position. Inclined Prone Kneeling This is the modified variety of quadruped position. In this quadruped position the head also inclined forward and placed on the upper limb, which is flexed and kept on the floor (Fig. 5.39). Movements • Trunk forward bending. • Shoulder abducted, flexed and medially rotated. • Elbow flexed. Fig. 5.39: Inclined prone kneeling Movements • Shoulder flexed, adducted and medially rotated. • Elbow is extended. • Fingers flexed and grasping the rod. Muscle works • Adductor and medial rotators of the shoulder work strongly. • Flexors of elbow carry more weight and also strain.

STARTING AND DERIVED POSITIONS 69 • Finger flexors work strongly and grasping the bar. • Adductors of hip keep it in adducted posture. • Plantar flexors keep the ankle in plantar flexed position. • Trunk, knee and remaining muscles of the hip is free from the work and movement. Uses in exercise therapy • To perform total body swinging movements. • To perform upper limb strengthening and body-building exercises. • To perform stretching exercises. Examples • Mostly helpful in gymnastic activities. • Bar exercises. Derived Position: Hanging Fig. 5.41: Half-hanging Half-hanging for the upper extremity. Generally, it is helpful Same like hanging, but the body is hanging with for the body-builders and gymnastic peoples. one side upper limb support. It is also a difficult Example posture to maintain for longer period. Total • Normally, it is used in gymnastic activities. body weight is carried out by one side upper limb so that the shoulder, elbow and muscles are facing more strain. Uses in exercise therapy It is the most advanced strengthening program

670 TEXTBOOK OF THERAPEUTIC EXERCISES CHAPTER Relaxation DEFINITION • One pillow is placed under the head to If the muscles are free from tension or rest are prevent rotating either side. said to be relaxed. • One pillow under the knee, which prevents TYPES the hamstring tension, reduces the lordotic • Whole or total body curvature over the lumbar region, reduce • Mental the abdominal muscle and iliofemoral • Local. ligament tension. Whole or Total Body Relaxation (Fig. 6.1) • Both the arms are abducted and placed on Total body relaxation can be done by positioning the pillows inside. the person in some resting position, normally during the lying position only the postural tone • Ankle is positioned in neutral position by of the muscles will be less. So, the alternation placing sandbags. is made in the lying posture to attain the maxi- mum general body relaxation. All the derived Half-lying position from the lying is used for achieving the relaxation of an individual depends on the • This is similar like the supine lying and the situation. The person has to be positioned in head end is lifted up. This position is the firm mattresses or in the spring mattresses; convenient for the respiratory distress so that the mattresses used with mold depend patients and elderly patients because this on the body contours of the patient. position reduces the diaphragmatic tension by reducing the abdominal pressure. Supine Lying • The anterior portion of the body facing up • One pillow is placed under the head extended up to the thoracic region supports the upper or lying on the back. trunk. • One pillow is placed under the knee to reduce the hamstring, iliofemoral ligament and abdominal tension. • Ankle is positioned in neutral position by placing the sandbags.

RELAXATION 71 Prone Lying • Uppermost upper limb shoulder and elbow • Posterior portion of the body facing up or flexed and placed over the pillow which reduces the shoulder girdle and rotators of lying on the front portion of the body. the shoulder muscle tension. • This position will be difficult for the The whole body relaxation does not only respiratory distress and elderly patients to depend on the position or the support which maintain for longer period. we give to the patients also depends on the • One pillow is placed under the hips and the surrounding too. The patient may feel comfort lower abdomen to reduce the abdominal with the room temperature, the dress the pressure by which we reduce the diaphrag- patient wears, lighting and air-circulation. If matic tension. the climate is chill, the mild warm temperature • Small tension under the ankle is placed for has to be maintained for the soothing effect straight alignment. and during hot climate, chill whether should be maintained by the air-conditioner or air cooler. The tight clothing, corset, belt and the irritable materials should be removed which causes the inconvenient to achieving the relaxation, the fresh air circulation has to be made and there should be good lighting in the room which does not irritate the vision of the patient. Figs 6.1A to D: Relaxed positioning Mental Relaxation Mental relaxation plays the main role while Side Lying treating the patient and to render the good • The person lying on his one side of the body. service. The mental relaxation can be achieved • One pillow under head and neck, which with help of the above mentioned comfortable measures and also some other factors like supports and aligns with the body. The pillow psychological fear to the treatment, coloring of should not be too high. the room, peaceful mentality. The coloring of • Uppermost lower extremity hip and knee the room has to be perfectly done, the selection are flexed and placed on the pillow, which of the color place the main role in the alteration reduces the hip rotators and lower trunk of the mind. Normally, mild colors give the muscular tension. mental peaceness, so the dark colors should be avoided. Not only the coloring of the wall but also the curtains, the clothes that we use in the clinic set-up. The patient should have confident with the treatment, which he gets from the therapist. The therapist has to gain the confident of the patient by explaining about the condition, treatment procedure, and effect of the treatment and necessity of treatment. The psychological state of the patient much more important factor to treat an individual

72 TEXTBOOK OF THERAPEUTIC EXERCISES effectively. Health counseling may be effective body is called as local relaxation. It can be achie- and helps to gain the confidence of the patient. ved by massage, relaxed passive movement, The noisy surrounding should be avoided supporting the part and by applying the pain because the louder sound may cause the mental relieving modalities. Massage and relaxed alteration and may leads to frustration. The passive movement gives the soothing effects therapist’s manner should be courteous, to the patient, increases the blood circulation pleasant and his voice low-pitched and clear. and increases the venous drainage. If the The atmosphere of the room should be pleasant, patient has pain over part or segment of the sometimes low-pitched continuous “hum” can body, the pain relieving modalities like wax be used to smoothen the mind. bath, hot water fermentation, IFT, SWD, and ultrasound can be used. Whenever the patient Local Relaxation gets relieve from the pain, he feels relaxation. Relaxing the particular part or segment of the

PELVIC TILT 773 Pelvic Tilt CHAPTER DEFINITION increased said to be anterior pelvic tilt and if The pelvic motion along with the hip and the decreased called posterior pelvic tilts. vertebral column makes the normal sinusoidal curve in the Gait cycle, these pelvic motions AT > 30° > PT are called as “Pelvic tilt”. These pelvic tilts may occur due to some pathological problems also. Pelvic Inclinometer One arm of the pelvic inclinometer placed The pelvic may be inclined tilted in below over the pubic symphysis and another over the mentioned ways: PSIS. In normal pelvic tilt, it is 30° change in 1. Anterior pelvic tilt which said to be anterior or posterior pelvic 2. Posterior pelvic tilt tilt. 3. Lateral pelvic tilt 4. Pelvic drop Vertical Line 5. Pelvic rotation. The vertical line drawn from the ASIS to the pubic symphysis aligns in the same line, the ANTERIOR AND POSTERIOR alternation in which said to be anterior or PELVIC TILTS (TABLE 7.1) posterior pelvic tilt (Fig. 7.1). Anterior and posterior pelvic tilts occur in the sagittal plane and the coronal axis. Anterior Anterior Pelvic Tilt and posterior pelvic tilts can be measured by • ASIS moves anteroinferiorly and down the following ways: wards. Lumbosacral Angle • Pubic symphysis moves posteriorly and The angle made by the line parallel to the ground and the line along the base of the sacrum. moves closure to the femur. Normal lumbosacral angle should be 30°. If it is • ASIS aligned horizontal with the PSIS and vertical line with the symphysis pubis in normal aligned pelvic, it changes in the anterior tilt.

74 TEXTBOOK OF THERAPEUTIC EXERCISES • Sacral angle increases and the lumbar lordosis and thoracic kyphosis also increases. • Abdominal muscles and the hip extensors muscles are responsible for preventing the anterior pelvic tilt. • Contraction of the hip flexors and spinal extensor results in the anterior pelvic tilt. Posterior Pelvic Tilt • ASIS moves posteriorly. • Pubic symphysis moves away from the femur instead of femur moves from the pubic symphysis. • Spinal extensors and hip flexors are responsible for preventing the posterior pelvic tilt. Figs 7.2A to C: Anterior and posterior pelvic tilts Figs 7.1A to C: Measuring the pelvic tilt Fig. 7.3: Muscles responsible for pelvic tilt

PELVIC TILT 75 • Contracture of the hip extensors the spinal Dropping flexor results in the posterior pelvic tilt. • ASIS moves inferiorly and medically. • Spine goes for opposite side flexion. • Sacral angle decreases and the lumbar • Hip goes for adduction in the drop side. lordosis also decreases (Figs 7.2 and 7.3). • Pelvic drop occurs due to the opposite hip LATERAL PELVIC TILT AND DROP abductors weakness. This sign is called as • It occurs in the frontal plane and the AP axis. Trendelenburg’s sign. • Both the ASIS aligned in the horizontal line • Both the sides abductor paralysis leads to wadding type of gait otherwise called as in the normal pelvic. If any changes occur “Duck walking”. in these alignment said to be lateral tilt or • In the bilateral stance, if the weight is drop. transferred to the right side, dropping occurs • Possible during the unilateral as well as in the same side. During the right side bilateral stance. dropping the hip goes for adduction in the • In unilateral stance one hip is fixed and tilted side and abduction in the opposite side. another is freely moving and results in drop or hike. PELVIC ROTATION • Pelvic rotation occurs in the transverse Hiking In normal person the hip hiking occurs while plane and the vertical axis. clearing the foot from the ground. This is • Pelvic rotation occurs when the swinging needed from pressure relief during prolong sitting. Also it is helpful when the patient walks leg moves forward and backward on the with the long plaster cast or braces. This supported or stance leg. movement support to clear the foot from the Examples: ground during swing phase. • In normal walking the forward motion in • During hiking ASIS moves upwards and the right side leg results in the right side pelvic forward rotation, left side upper limb medially. swings forward and the stance or weight- • Spine goes for flexion in the same side. bearing hip goes for medial rotation. • Hip goes for abduction in the hiking side. • In case of backward motion of the right leg • Hiking occurs due to the contraction of the results in the backward rotation of the pelvic, right upper limb swings forward and quadratus lumborum and the spinal side the stance hip or weight-bearing hip goes flexors (Fig. 7.4). for a lateral rotation (Fig. 7.5). There should be a combination of the pelvic, hip and the spinal movements to maintain the proper gait and the proper sinusoidal curve. Figs 7.4A and B: Hip hiking and pelvic drop Figs 7.5A to C: Pelvic rotation

76 TEXTBOOK OF THERAPEUTIC EXERCISES Table 7.1 Pelvic tilt in short view Sr. no Pelvic Vertebral column Hip Arm 01 Anterior tilt - 02 Posterior tilt Hyperextension Flexion - 03 Lateral tilt (hike) Flexion Extension - 04 Drop Same side flexion Abduction at the same side - 05 Rotation (forward) Opposite side flexion Adduction at the same side Opposite side arm goes 06 Backward rotation Opposite side Medial rotation at opposite forward Opposite side side or weight bearing side Opposite side arm goes Lateral rotation at weight backwards. bearing side. So, during the normal walking itself there is strain in the weight transmission. If any anterior tilt, posterior tilt, lateral tilt, drop and pathological disturbance occurs there will be rotations present to propel the body forward. marked and visible tilts seen. These patholo- These tilts are altering the body segment during gical tilts or drops can be cured by the proper the normal walking and making convenient or treatment that is by the regular strengthening easier the walking pattern and reducing the or stretching program.

ACTIVE AND PASSIVE MOVEMENTS 877 CHAPTER Active and Passive Movements INTRODUCTION TYPES OF MOVEMENTS The exercise, which is needed for the treatment There are two types of movements. purpose, is called as therapeutic exercise. The 1. Active movement person performing the exercises in gym and jogging are to build the body and for healthy i. Assisted living. But the therapeutic exercises are the ii. Free exercises, which are performed to come out from iii. Assisted and resisted ones ailment or disease. These therapeutic iv. Resisted. exercises are totally different from the body- 2. Passive movement building exercises. The main goal of the thera- i. Relaxed passive movement peutic exercise is preparing or making the patient ii. Passive manual mobilization techniques independent or symptom-free movements. It iii. Mobilization brings back the diseased or injured patient to iv. Manipulation the normal state, and it plays the major role in v. Stretching. the rehabilitation of an individual. To perform the therapeutic exercise one should have ACTIVE MOVEMENTS thorough knowledge on anatomy, physiology, (ACTIVE—BY HIS /HER OWN) orthopedic, neurology, kinesiology, pathology, The movement, which is done by the patient cardiopulmonary and some of the physiotherapy himself, is said to be active movements. Active related medical fields. It is believed that the movements are the voluntary action of the perfect assessment of the disease is the 75 muscles. This may be classified into four percent of the treatment. The perfect assess- varieties. ment to be made before starting any sort of the 1. Assisted therapeutic maneuver. Stretching, streng- 2. Free thening, coordination exercises, mobilization 3. Assisted and resisted and manipulation, gait correction are the some 4. Resisted. of the therapeutic exercises used for treating the ailment of the patient.

78 TEXTBOOK OF THERAPEUTIC EXERCISES Assisted Exercise up to his ability. In passive movement, there If the strength or the coordination of the muscle will not be a muscle work but in assisted is insufficient to perform an activity, the exercise the muscle will be acting throughout external force is utilized to compensate the lack. the movement. The muscle has the strength or endurance but Mechanical assisted exercises: The assisted is not sufficient to perform an activity or control exercise is done with the help of the mechanical an action. devices are called mechanical assisted exercises. Suspension therapy, pulleys and springs are the Assisted → Manual → Active some of the examples for the mechanical exercise → Passive assistance. The same can also be used for the resisted exercises. → Mechanical Types of Assisted Exercises Principles Range: The assistance given is changeable The assisted exercises can be performed depends on the range. Normally, in the manually and mechanically again the manual beginning and end range, the muscles strength assisted exercise having the two divisions, i.e. will be less while comparative with the middle active and passive. range. So, that the assistance provided should be more in the beginning and end range than Active assistance: The patient himself can assist the middle range. with his opposite extremity to perform the Command: Some command is needed to assisted exercise. activate the patient and perform the effective movement the command gives perfect guideline For example, to the patient to practice an activity. a. The opposite leg is used by the patient to Concentration: Concentration of the patient is the must in the assisted exercises otherwise increase the flexion movement of the knee the movements will be passive in character. in long sitting or prone lying. Therapist has to make the patient to concen- b. Upper limbs are used to move the lower trate on the treatment well for effective limb or opposite side upper limb. performing the assisted exercises. This type of active assisted exercise is very Speed: Speed determine the assisted exercises much helpful for the home programming more, if the speed is increased it shows the exercise. The main advantage is the patient, passive character and also the patient cannot he himself only knows the pain limit and cop up the movement. availability range of movement. So, that he can Repetition: The movement has to be repeated, perform the exercise conveniently within the so that the joint range and the muscle power pain limit. can be improved. Passive assistance: It is classified into: Uses 1. Manual assisted exercise • Increase the ROM of the joint. 2. Mechanical assisted exercise. • Increase the strength, power and the Manual assisted exercise: The passive assistance endurance of the muscles. may be given by the therapist or by any of the medical professionals or sometime by the patient’s relatives and friends. This type of assisted exercise is maximum passive in nature. The patient has to try to perform the movement

ACTIVE AND PASSIVE MOVEMENTS 79 • It breaks the adhesion formation around the Characteristics of the Free Exercises joint. There are two types of characteristics of the free exercises namely subjective and objective. • It reduces the spasm of the muscles. Subjective: It means performing the movements • It stretches the tightened soft tissue. within the perfect anatomical range and • It reminds the coordinated movement of the pattern. Patient has to concentrate on the perfection of the movement, which he performs. joint or a muscle. Objective: There will be some goal to achieve • Increase the blood circulation and venous in the exercise program, but not spoiling the perfect pattern and anatomical range move- return to the joint and muscle. ment. Example: Bending and touching the great toe Free Exercise with the middle finger. Here the goal is set to touch the toe. These are the exercises, which are performed by the patient himself without any assistance Uses and resistance by the external force except the gravity. There will not be any of the manual or • Increases the joint range. mechanical assistance or resistance given in • Increases the muscle strength, power and this type of exercise. It is much more useful for the home program schedule. The patient endurance. can perform without depending on anybody. But • Increases the neuromuscular coordination. the same has the more disadvantage also. There • Increases the circulation and venous drain- is the possibility to perform the improper or irrelevant movements and accessory move- age. ments, which results in the wrong or the insuffi- • Increases the relaxation of the muscle by cient neuromuscular activation. So, that there the swinging movements and the pendular should be proper supervision or proper guidance movements. to the patient to perform the free exercises. • Repeated active movement breaks the There are two types of free exercises. adhesion formation and elongates the 1. Localized shortened soft tissues. 2. General body. • Regulating the cardiorespiratory function, and the active exercise increases the Localized: The localized free exercises are respiratory and venous return so that the planned and formed to perform to improve one tOo2 supply to muscles and blood circulation particular joint range or to increase the the muscle increases. strength power and endurance of the one group or particular muscles. Resisted Exercises The activities, which are performed by opposing Examples: the mechanical or manual resistance is called • Exercise to knee joint. as resisted exercises. • Free exercises to shoulder flexor. Types of Resisted Exercises General body: These types of free exercises are Resisted exercises are of two types namely, formed to increase the joint range in multi- 1. Manual joints or to increase the strength of many group 2. Mechanical or the total body muscles. Examples: Jogging relaxed walking.

80 TEXTBOOK OF THERAPEUTIC EXERCISES Manual resisted exercises Example: The resistance offered by the In the manual resisted exercise, the resistance application of the resistance over the elbow can be given by therapists, some other medical region for the shoulder flexion is less while professionals and relatives or friends. The comparing with application of the resistance resistance also can be applied by the patient over the wrist region. himself with his opposite extremity, otherwise By increasing the weight: While performing the it may be taught to the patient’s attenders like resisted exercise with the particular amount his relatives or friends. This will be helpful for of weight for a particular period of time the the home exercises. These exercises can be muscle group able to achieve the full range of operated by the following individuals: contraction. If the muscle power increases, the 1. The therapist person feels the insufficient with the same 2. Patient himself weight. So, in that circumstance proportionally 3. Any other medical professionals weight has to be added to increase the 4. Relatives and friends. resistance to the movement. Mechanical resisted exercise By altering the speed: The muscle can contract If the mechanical devices are used to oppose most efficiently when it moves with natural the active movement of a person is called as speed. The increasing and decreasing the speed mechanical resisted exercise. may alter the effect of resistance. The speed of the contraction increases the effect of the Mechanical resisted exercises can be resistance in the concentric muscle work. performed by the followings: Reducing the speed increases the power of 1. Weights contraction in the eccentric contraction. These 2. Springs varieties in speed are as under: 3. Pulleys • Natural speed 4. Water • Reduced speed • Increased speed. Examples: Weights, springs, pulleys and water are needed for the resisted exercise. Natural Speed If the movement is performed in the natural The resisted exercise increases the muscle speed requires the less effort of the muscle and strength and the muscle bulk earlier than any also it may vary with the individuals. Generally, other exercise program. These resisted all the exercise performed to the natural speed exercises can be stated when the muscle power is the beneficial and effective. is 2., i.e. from gravity eliminated position. Reduced Speed We can increase the resistance by altering If the speed is decreased the greater muscle the below mentioned factors. work is required to perform the full ROM. • By altering the leverage During the reduced speed exercise, the gravity • By increasing the weight exerts more resistance on the muscles. • By altering the speed • By changing the duration. Increased Speed By altering the leverage: The resistance of an The increased speed exercise needs the greater object felt by the muscle differs and depends muscular effort. In the more speed exercise the on the position of the fulcrum. If the application of the resistance is near from the fulcrum, the resistance will be less. It is the reverse if the application of the resistance is far away from the fulcrum.

ACTIVE AND PASSIVE MOVEMENTS 81 full ROM may be sometimes neglected. It may Type II ( Phasic, fast twitch)—Anaerobic lead to trick movement or inaccurate move- muscle fiber ment. Type I (Tonic, slow twitch)—Aerobic mus- Generally, relaxed passive movement has cular fiber. to practice in the slow speed, i.e. decreased speed and the active movements have to be The strenuous exercise increases the body performed in the natural speed. heat and the resisted exercise too. It stimulates the vasodilator center and dilates the blood By changing the duration: The repeated vessels. As a result the muscles are getting good contraction of the muscle leads fatigue. The blood supply and nutrition. The body-builders fatiguability reduces the efficiency of muscle are mostly performing the resisted exercise to contraction and increases the effect of the build the muscle bulk. resistance. Progressive Resisted Exercise Uses of Resisted Exercises While performing the resisted exercise with the weights, it is very much difficult to find out 1. Resisted exercises increase the strength of how much weight has to be used and how many the muscle earlier. The weak muscle can repetitions to be done by the injured patients be strengthened much earlier than the any after recovering. At the same time, if the more other exercise regimen. This can be started weight is lifted more time, the muscle gets from the muscle power 2 onwards. Strength fatigue or sometime possibility for microtears. of the muscle is directly proportional to the To come out of this situation De Lorme and tension created inside the muscle. The Watkins are formed one exercise regimen in resisted exercise can create the more 1945 to improve the muscle strength, power amount of intramuscular tension. and endurance. As per this regimen the weight Strength α Tension is gradually increased and also he explained 2. Increases the endurance of the muscle. about how many repetition to be practiced. One 3. Powerful muscle contraction increases the should know about repetition maximum (RM) blood flow of the muscle fiber and it gets before entering into the exercise regimen. nutrition and the Oin2.creases 4. Resisted exercise the muscular Repetition Maximum power. Power is related to the strength of The maximum amount of the weight a person the muscle and the speed. can lift throughout the range of motion exactly Power = Force × Distance / Time 10 times. Some authors recommended the lifts The force creating the particular motion or between 6-15 considering as the repetition the movement of the body lever for the maximum. particular duration is meant as power. The force or tension created inside the The exercise regimens may vary depends muscle is high in restricted exercise. Some on the condition or the disease and from one theories are explained about the power, which patient to another. At present 3 types of is the high intensity of muscle activity. High progressive resisted exercise regimens are intensity exercise carried out over a short available. period of time called as anaerobic power, lower 1. DeLorme and Watkins intensity exercise carried out for a longer period 2. MacQueen of time is called as aerobic exercise. 3. Zinovieff (Oxford technique).

82 TEXTBOOK OF THERAPEUTIC EXERCISES De Lorme and Watkins exercise has to be practiced and remaining 10 times with 1/2 10 RM. days, i.e. Tuesday, Thursday, Saturday given 10 times with 3/4 10 RM. rest. 10 times with 10 RM. Progression MacQueen 10 times with 10 RM i. 30 times weekly 4 sessions 10 times with 10 RM ii. Every week 10 RM progression. 10 times with 10 RM a. For example 10 times with 10 RM Consider 10RM—1 kg Progression First week. i. 40 times 3 sessions weekly. ii. Every 1-2 weeks progression 10 RM 1/2 of 10 RM—1/2 kg. 3/4 of 10 RM—3/4 kg a. For example Full of 10 RM—1 kg Consider 10 RM = 1 kg Exercise regimen is First week 10 times with 1/2 kg 10 times with 1 kg 10 times with 3/4 kg 10 times with 1 kg 10 times with 1 kg 10 times with 1 kg Second week 10 times with 1 kg Progression 10 RM Second week = 10 RM + 10 RM Progression 10 RM = 1 kg +1 kg Second week 10 RM = 10 RM + 10 RM = 2 kg = 1 kg + 1 kg Exercise Regimen is Second week 10 RM = 2 kg 10 times with 1 kg Third week – progression 10 RM from the 10 times with 11/2 kg second week weight. 10 times with 2 kg Third week program: 10 RM added in the b. One kg weight is lifted 40 times with 3 second week weight. breaks per each session. In this regimen no b. In this exercise regimen, the weight is change of weight between each and every increased, i.e. first with 1/2 kg followed by breaks. Same weight is used throughout 3/4 kg and 1 kg. one session. c. Each and every session the patient has to 10 times with 1 kg → break → 10 times lift the above said three types of weights 10 with 1 kg → break → 10 times with 1 kg → times each. So, that daily 30 times lifting break → 10 times with 1 kg. been done. d. In each and every session 30 times the c. The exercise has to be carried out 3 sessions exercise should be done with 2 breaks by weekly. Example: Monday, Thursday, the patient. Sunday (i.e. two days) once has to be i.e. 10 times 1/2 10 RM (1/2 kg) → Break → practiced and remaining four days rest. 10 times with 3/4 10 RM (3/4 kg) → Break→ 10 times 10 RM (1 kg) Zinovieff (Oxford technique) e. Weekly 4 sessions the exercise has to be 10 times with 10 RM practiced. Forexample,Monday,Wednesday, 10 times with 10 RM minus 1 lb Friday, Sunday (i.e. every alternative day’s) 10 times with 10 RM minus 2 lb 10 times with 10 RM minus 3 lb 10 times with 10 RM minus 4 lb

ACTIVE AND PASSIVE MOVEMENTS 83 10 times with 10 RM minus 5 lb break → 10 lifts with 12 lb→ break→ 10 lifts 10 times with 10 RM minus 6 lb with 11 lb. 10 times with 10 RM minus 7 lb c. Every week 5 sessions of exercises are 10 times with 10 RM minus 8 lb carried out. Example, Monday to Friday the 10 times with 10 RM minus 9 lb exercises will be performed and remaining Progression two days given rest before starting next 100 times 5 sessions weekly week exercise regimen. 10 RM progression daily. a. For example PASSIVE MOVEMENT Consider 10 RM = 20 lb The movement, which is performed with the help of the external force whenever the muscles 10 times with 20 lb fail to perform the movement by its own. 10 times with 19 lb 10 times with 18 lb Types of Passive Movements 10 times with 17 lb 1. Relaxed passive movement 10 times with 16 lb 2. Passive manual mobilization 10 times with 15 lb 10 times with 14 lb • Mobilization of the joints 10 times with 13 lb • Manipulation of the joints and soft tissues 10 times with 12 lb • Stretching of the soft tissues. 10 times with 11 lb Second day Specific Classification of Passive Movements Progression 10 RM daily Passive movements are classified into the Second day 10 RM = 10 RM + 10 RM following two types: = 20 lb + 20 lb i. Manual passive movements = 40 lb ii. Mechanical passive movemetns 10 times lift with 40 lb 10 times lift with 39 lb Manual Passive Movements 10 times lift with 38 lb The passive movements performed by the 10 times lift with 37 lb therapists or any other medical professionals 10 times lift with 36 lb are called as manual passive movements. Some 10 times lift with 35 lb time it shall be performed by the patient’s 10 times lift with 34 lb attenders like his relatives and friends. 10 times lift with 33 lb 10 times lift with 32 lb Mechanical Passive Movemetns 10 times lift with 31 lb The passive movements which are performed Third day progression 10 RM from the by the mechanical devices are called as mecha- second day weight. nical passive movements. Depends on the type b. Each and every 10 lifts break has to be given of passive movement the device may vary. the 1 lb also reduced for each 10 lifts. Finally, Example the patient will be performing 100 lifts per • Continuous passive mobilizer (CPM)—Used section. 10 lifts with 20 lb→ break→ 10 lifts with 19 for relax passive movement and joint lb→ break → 10 lifts with 18 lb → break → mobilization, joint stretches, etc. 10 lifts 17 lb → break →10 lifts with 16 lb→ • Springs, weights, pulleys, splints, plaster break→ 10 lifts with 15 lb→ break → 10 lifts cast—stretching and mobilization. with 14 lb → break → 10 lifts with 13 lb →

984 TEXTBOOK OF THERAPEUTIC EXERCISES CHAPTER Relaxed Passive Movement DEFINITION the proximal joints have to be fixed or This is the smooth, rhythmical and accurate stabilized. anatomical movement performed by the therapist within the pain-limited range. Traction The long axis traction given to increase the PRINCIPLES space between the articular surfaces. It reduces Relaxation the intra-articular friction as well as breaks the Patient has to be positioned in relaxed manner adhesion formation in the joint. Free passive before starting the treatment procedure. movement can be performed due to the less During the relaxed state there will not be any friction effect done by the long axis traction. muscle work and the total body part will be fully relaxed and also the patient can cooperate Range for the treatment. If the patient feels incon- The movement performed within the pain- venient by the position, he cannot cooperate limited range. In that joints care must be taken for the treatment. So, the position of the patient to avoid the movement exceeding the is strictly noticed before giving the treatment anatomical movement in the stiff joint the and also the position should not be changed movement has to be done bit forcefully to break during a treatment process. The therapist’s the adhesions as well as to maintain the muscle position also plays an important role to treat property. the patient. The therapist has to adopt the walk standing position while treating the patient. Speed and Duration Speed should be rhythmical, smooth and same Fixation speed should be maintained throughout the The proximal joints to the joint to be moved movement. There should not be jerky move- should be fixed. Otherwise trick movement may ment, the movements performed number of occur. To prevent it and localize the movement times may vary depends on the condition we treat.

RELAXED PASSIVE MOVEMENT 85 Sequence • Increases the venous and lymphatic drainage The sequence to be decided before treating the • Breaks the adhesion formations in the joints patients, while treating the flaccid conditions • Prevents the DVT the movement should be proximal to distal, in • Induces the relaxation. spastic as well as to increase the venous and lymphatic drainage the movement has to be PROCEDURE OF RELAXED performed from distal to proximal. PASSIVE MOVEMENT (FIG. 9.1) The therapist has to adopt the walk stand INDICATIONS position and should face the patient’s face. So, • The patients who cannot perform active that he can observe the patient’s reaction while performing movement. movements. • The patients who cannot perform full range Right side is taken as an example and explai- ned in detail about to the passive movements of movements. to be performed for each and every joint and • For the prolonged bed-ridden patients action. mainly to prevent DVT, maintain the Upper Limb muscle property and increase the venous Shoulder Joint drainage as well as lymphatic drainage. Flexion • To break adhesion formation through that Position of the patient: Supine lying. joint range can be increased. • Unconscious patients. • For relaxation. • Edematous limb. CONTRAINDICATIONS • Recent fractures • Recent dislocations • DVT • Malignant tumor • Psoriatic arthritis • Recently injuries and inflammation • Precaution must be taken for the flial joints • Hemarthrosis • Early burns • Immediately after any joint surgery or repair • Hemophilic joints • Patients with external appliances • Patients with POP plaster cast. EFFECTS AND USES Fig. 9.1: Relaxed passive movement of flexion of • Maintains the muscle properties shoulder • Increases the ROM

86 TEXTBOOK OF THERAPEUTIC EXERCISES Position of the therapist: Standing beside the Procedure: It is not possible to apply the long patient and facing the patient’s face. axial traction. Therapist’s right hand is Holding: performing the extension movement of the • Left hand of the therapist restricts the wrist shoulder. Abduction (Figs 9.3 and 9.4) and carpometacarpal movement of the Position of the patient: Supine lying: patient. Position of the therapist: Standing beside the • Therapist’s right hand should grasp the patient and facing the patient’s face. lower part of the arm of the patient. Procedure: Mild long axial traction is given and Fig. 9.3: Relaxed passive movement of abduction the movement is performed. The traction of shoulder (starting stage) should be maintained throughout the move- ment, beginning stage traction is applied by the right hand and above 90º the traction is maintained by the left hand of the therapist. Perform the movement up to the available range. Extension (Fig. 9.2) Position of the patient: Side lying. Position of the therapist: Standing back to the patient and facing the shoulder joint. Holding: • Forearm and elbow is placed over the right side forearm of the therapist by flexing the elbow of the patient and wrist movement is restricted by the therapist’s hand. • Left hand of the therapist stabilizes the shoulder joint of the patient. Fig. 9.2: Relaxed passive movement of extension of Fig. 9.4: Relaxed passive movement of abduction shoulder of shoulder (end stage)

RELAXED PASSIVE MOVEMENT 87 Holding: Procedure: Therapist’s both hand is performing • Patient’s elbow is flexed (90º). the abduction movement of the shoulder. In • Patient’s wrist is grasped by the left hand the final range to gain the maximum abduction range, the lateral rotation of the shoulder is of the therapist. done. • Dorsal aspect of the elbow and the lower Medial and lateral rotation Position of the patient: Supine lying. part of the arm is grasped by the therapist’s Position of the therapist: Standing beside the right hand (Figs 9.5 and 9.6). patient and facing the patient’s shoulder. Holding: Fig. 9.5: Relaxed passive movement of medial • Patient’s shoulder is abducted for 90º and rotation of shoulder the elbow also flexed for 90º. • Therapist’s left hand grasping the lower end of the humerus of the patient. • Therapist’s right hand grasping the wrist and the hand of the patient. Procedure: The long axial traction is applied and the medial and lateral rotation movement of the shoulder is performed by the therapist. Elbow Joint Flexion and extension (Fig. 9.7) Position of the patient: Supine lying: Position of the therapist: Standing beside the patient and facing the patient’s elbow. Fig. 9.6: Relaxed passive movement of lateral Fig. 9.7: Relaxed passive movement of flexion and rotation of shoulder extension of elbow

88 TEXTBOOK OF THERAPEUTIC EXERCISES Fig. 9.8: Relaxed passive movement of supination Fig 9.9: Relaxed passive movement of flexion, and pronation of forearm extension, ulnar and radial deviation of the wrist Holding: Procedure: It is impossible to apply traction in • Therapist has to fix the arm of the patient this technique. Therapist’s right hand is performing the supination and pronation with the couch by his left hand. movement in the available range. • Therapist’s right hand grasps the wrist and Wrist Joint hand of the patient. Flexion and extension (Fig. 9.9) Procedure: Therapist’s right hand is performing Position of the patient: Supine lying. the elbow flexion and extension. Position of the therapist: Standing beside the patient and facing him. Forearm Joint Holding: Supination and pronation (Fig. 9.8) • Lower part of the forearm is holding by the Position of the patient: Supine lying. Position of the therapist: Standing beside the therapist’s left hand. patient and facing him. • Right hand of the therapist grasping the Holding: • Wrist and hand is grasped by the therapist’s MCP and PIP joints. Procedure: right hand. With mild long axial traction the flexion and • Arm is fixed with the couch by the extension movements are performed by the therapist’s right hand in available range. therapist’s left hand.

RELAXED PASSIVE MOVEMENT 89 Ulnar and radial deviations Holding: Position of the patient: Supine lying. • Therapist’s right hand grasping the palm of Position of the therapist: Standing beside the patient and facing him. the patient. Holding: • Left hand holding the thumb of the patient. • Lower part of the forearm is holding by the Procedure : With mild long axis traction all the thumb movements can be performed with the therapist’s left hand. therapist’s left hand (flexion, extension, • Right hand of the therapist grasping the abduction, adduction, opposition). MCP and PIP joints. Metacarpophalangeal Joint (Fig. 9.11) Procedure: Flexion, extension, abduction, adduction With mild long axial traction the ulnar and Position of the patient: Supine lying. radial deviation movements are performed by Position of the therapist: Standing beside the the therapist’s right hand in available range. patient and facing him. Holding: Thumb Joint (Carpometacarpal joint) • Therapist’s right hand grasping the palm of Flexion, extension, abduction, adduction, opposition (Fig. 9.10) the patient by leaving the MCP joint. Position of the patient: Supine lying. • Left hand of the therapist holding the finger Position of the therapist: Standing beside the patient and facing him. of the patient in extension. Procedure: With mild long axis traction flexion and extension of the metacarpophalangeal Fig. 9.10: Relaxed passive movement of flexion, Fig. 9.11: Relaxed passive movement of flexion, extension, abduction, adduction and opposition extension, abduction and adduction of MCP joint movement of the thumb

90 TEXTBOOK OF THERAPEUTIC EXERCISES Fig. 9.12: Relaxed passive movement of flexion Fig. 9.13: Relaxed passive movement and extension of interphalangeal joint of flexion of hip movement is performed by the left hand of the Holding: therapist (Flexion, extension, abduction, • Therapist’s right palm grasping the calca- adduction). neum of the patient. Interphalangeal Joint (Fig. 9.12) • Therapist’s left hand grasping the posterior Flexion and extension Position of the patient: Supine lying. part of knee and the thumb is kept lateral Position of the therapist: Standing beside the side of the knee. patient and facing him. Procedure: It is impossible to apply long axial Holding: traction. Knee and hip flexion movements • Left hand fingers of the therapist stabilize performed together to achieve full range of hip flexion by reducing the hamstring and rectus- proximal part of the joint. femoris tension. While performing movement • Distal part of the joint is grasping by the the therapist’s left hand from the posterior part of the knee gradually moved and comes to right hand fingers. anterior side of the knee. Vice versa while Procedure: With mild traction flexion and coming to neutral. extension movements are performed in Extension (Fig. 9.14) available range by the therapist’s right hand. Position of the patient: Side lying. Position of the therapist: Standing back to the Lower Limb patient and facing him. Hip joint (Fig. 9.13) Holding: Flexion • Patient’s knee is flexed 90º. Position of the patient: Supine lying. • Patient’s leg is placed on the therapist’s Position of the therapist: Standing beside the forearm of the right hand and the palm is patient and facing him. grasping the knee joint. • Therapist’s left hand stabilize the pelvic of the patient.

RELAXED PASSIVE MOVEMENT 91 Fig. 9.14: Relaxed passive movement of hip extension Fig. 9.16: Relaxed passive movement of hip medial Procedure: Therapist’s right hand is performing and lateral rotation the extension movement of the hip. Medial and lateral rotation (Fig. 9.16) Fig. 9.15: Relaxed passive movement of hip Position of the patient: Supine lying. abduction and adduction Position of the therapist: Standing beside the patient and facing the hip joint of the patient. Abduction and Adduction (Fig. 9.15) Holding: Position of the patient: Supine lying. • Patient’s knee and hip are kept in 90º flexed Position of the therapist: Standing beside the patient and facing him. position. Holding: • Left hand of the therapist grasping the lower • Right hand of the therapist grasping the part of femur. lower part of leg. • Right hand grasps the lower part of the leg • Therapist’s left hand grasps the posterior of the patient. part of the knee joint. Procedure: Movement is performed without any Procedure: Without traction the abduction and traction by the therapist’s right hand within adduction movement is performed within the the available range. available range by the therapist’s both hands. Knee Joint Knee flexion and extension can be performed as said in flexion of hip. Patellofemoral Joint As said in the mobilization chapter. Ankle Joint Plantar and Dorsiflexion (Fig. 9.17) Position of the patient: Supine lying. Position of the therapist: Standing beside the patient and facing the ankle joint of the patient.

92 TEXTBOOK OF THERAPEUTIC EXERCISES Fig. 9.17: Relaxed passive movement of ankle Fig. 9.18: Relaxed passive movement of midtarsal plantar and dorsiflexion inversion and eversion Holding Metatarsophalangeal Joint (Fig. 9.19) • Patient’s knee joint is flexed. Position of the patient: Supine lying. • Leg is supported by the therapist’s left side forearm and the same side hand grasps the lower part of the leg. • Right palm of the therapist grasping the calcaneum of the patient and the forearm is placed over the ball of the metatarsals. Procedure: The therapist’s right hand and the forearm perform the plantarflexion and Dorsiflexion movement. Knee joint is flexed for reducing tension in the gastrocnemius muscle. Midtarsal Joint Fig. 9.19: Relaxed passive movement of Inversion and eversion (Fig. 9.18) metatarsophalangeal flexion and extension Position of the patient: Supine lying. Position of the therapist: Standing beside the Position of the therapist: Standing beside the patient and facing the foot of the patient. patient and facing the foot of the patient. Holding: Holding: • Left hand of the therapist grasps the meta- • Therapist’s left hand grasps the lower part tarsals. • Right hand of the therapist grasps the proxi- of the leg. mal phalanx. • Right palm of the therapist grasping the Procedure: Right hand of the therapist perfor- ming all the movement (flexion, extension, calcaneum of the patient the forearm is abduction and adduction) for all toes together placed over the ball of the metatarsals. in same time with recommended traction. Procedure: Therapist’s right hand is performing the inversion and eversion movement.

RELAXED PASSIVE MOVEMENT 93 Fig. 9.21: Relaxed passive movement of lumbar flexion Fig. 9.20: Relaxed passive movement of neck Holding: Therapist is grasping the occipital region with both the hands with thumb abduction. Procedure: With mild traction flexion, exten- sion, side flexion and rotational movements are performed by therapist’s both hands. Interphalangeal Joint Lumbar Flexion (Fig. 9.21) Position of the patient: Supine lying. Position of the patient: Crook lying. Position of the therapist: Standing beside the Position of the therapist: Standing besides the patient and facing the interphalangeal joint of patient. the patient. Holding: Holding: • Left hand of the therapist grasping the sole • Left hand of the therapist grasps the of the patient. proximal articular segment. • Right hand of the therapist is placed on the • Right hand grasps the distal articular thigh. segment. Procedure: Heel is lifted up until the knee Procedure: Therapist’s right hand is performing touches the chest of the patient. To attain the flexion and extension movement of the maximum flexion range right hand placed interphalangeal joint. under the sacrum and lifted up. Neck (Fig. 9.20) Lumbar Extension (Fig. 9.22) Position of the patient: Supine lying. Position of the patient: Prone lying. Position of the therapist: Standing back to the Position of the therapist: Standing besides the patient’s head. patient.