Physical Therapy (PT)

Range of motion commonly becomes restricted after a stroke or prolonged bed rest. Restricted range of motion can cause pain, interfere with a person's ability to function, and increase the risk of skin being worn away (skin breakdown) and pressure sores. Range of motion typically decreases as people age, although this decrease does not usually prevent healthy older people from being able to care for themselves.

Increasing the Shoulder's Range of Motion

A therapist stabilizes the person's shoulder with one hand while slowly raising the person's elbow as high as possible with the other. Over several sessions, the elbow is gradually moved higher, increasing the joint's range of motion.

Before beginning therapy, the physical therapist often evaluates range of motion with an instrument called a goniometer, which measures the largest angle a joint can move through. The therapist also determines whether restricted motion results from tight muscles or from tight ligaments and tendons. If tight muscles are the cause, a joint may be stretched more vigorously. If tight ligaments or tendons are the cause, gentle stretching is attempted, but surgery is sometimes needed before progress can be made with range-of-motion exercises. Stretching is usually most effective and least painful when tissues are warmed up. Thus, therapists may apply heat first.

There are three types of range-of-motion exercises:

• Active exercise is for people who can exercise a muscle or joint without help. They must move their limbs themselves.

• Active-assistive exercise is for people who can move their muscles with a little help or who can move their joints but feel pain when they do. People move their limbs themselves, but a therapist helps them do so, by hand or with bands or other equipment.

• Passive exercise is for people who cannot actively participate in exercise. No effort is required from them. The therapist moves their limbs to prevent contractures (the permanent stiffening of muscles resulting from lack of movement), among other goals.

Active-assistive and passive range-of-motion exercises are done gently to avoid injury, although some discomfort may be unavoidable.

To increase range of motion, the therapist must move an affected joint beyond the point of pain, but the movement should not cause residual pain (pain that continues once the movement is stopped). Sustained moderate stretching is more effective than momentary forceful stretching.

Many forms of exercise increase muscle strength. All involve using progressively increased resistance. When a muscle is very weak, movement against gravity alone is sufficient. As muscle strength increases, resistance is gradually increased by using stretchy bands or weights. In this way, muscle size (mass) and strength are increased, and endurance improves.

These exercises can help people who have problems with coordination and balance, usually because of a stroke or brain damage. Coordination exercises aim to help people do specific tasks. The exercises involve repeating a meaningful movement that works more than one joint and muscle, such as picking up an object or touching a body part.

Balance exercises are initially done using parallel bars, with a therapist standing right behind the person. The person shifts weight between the right and left legs in a swaying motion. Once this exercise can be done safely, weight can be shifted forward and backward. When these exercises are mastered, the person can do them without parallel bars.

Walking (ambulation)—independently or with assistance—may be the main goal of rehabilitation. Before starting ambulation exercises, people must be able to balance while standing. To improve balance, people usually hold onto parallel bars and shift weight from side to side and from front to back. To keep them safe, the therapist stands in front of or behind them. Some people need to improve a joint's range of motion or muscle strength before they start ambulation exercises. Some people need an orthotic device such as a brace.

When people are ready for ambulation exercises, they may begin on parallel bars, then progress to walking with mechanical aids, such as a walker, crutches, or a cane. Some people need to wear an assistive belt, which the therapist uses to prevent them from falling.

As soon as people can walk safely on a level surface, they may be taught how to step over curbs or to climb stairs. When climbing up stairs, they are instructed to step up with the unaffected leg first. To climb down stairs, they are instructed to step down with the affected leg first. The phrase "good is up, bad is down" can help people remember. Family members and caregivers who help people walk should learn how to support them correctly.

Helping a Person Walk

If a person needs support while walking, family members or caregivers can place their arm under the person’s arm and gently grasp the forearm. Then they should lock their arm, pressing their upper arm firmly against the person’s upper arm. Thus, if the person starts to fall, support is provided at the person’s shoulder. The person may wear a special belt that caregivers can grasp from the back, if needed, to steady the person.

A combination of range-of-motion, muscle-strengthening, and ambulation exercises is used to counter the effects of prolonged bed rest or immobilization. General conditioning exercises help improve cardiovascular fitness (the ability of the heart, lungs, and blood vessels to deliver oxygen to working muscles), as well as maintain or improve flexibility and muscle strength.

For many people (particularly those who have had a hip fracture, an amputation, or a stroke), transfer training is a critical goal of rehabilitation. Being able to move safely and independently from bed to a chair, a wheelchair to a toilet, or a chair to a standing position is essential to remaining at home. People who cannot transfer without help usually require 24-hour assistance. Caregivers may help them transfer using special devices, such as a gait belt or harness.

The techniques used in transfer training depend on whether people

• Can bear weight on one or both legs

• Can balance well

• Are paralyzed on one side of the body

Assistive devices can sometimes help. For example, people who have difficulty standing from a seated position may benefit from a seat-lifting chair or a chair with a raised seat.

If people have been limited to strict bed rest for several weeks or have had a spinal cord injury, their blood pressure may decrease rapidly when they stand up (orthostatic hypotension), causing them to get dizzy. A tilt table may be used to help such people. This procedure may retrain blood vessels to narrow (constrict) and widen (dilate) appropriately in response to changes in posture, which helps to regulate blood pressure when changing positions. People lie face up on a padded table with a footboard and are held in place with a safety belt. The table is tilted very slowly, determined by how well people tolerate it, until they are nearly upright. The slow change in posture enables the blood vessels to regain the ability to constrict. How long the upright position is maintained depends on how well people tolerate it, but it should not exceed 45 minutes.

The tilt-table procedure is done once or twice a day. Its effectiveness varies depending on the type and degree of disability.