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Description of Active Assisted Range of Motion (AA/ROM) Intervention

Active-assisted ROM (AA/ROM) is a combination of the active contraction of the muscles affecting the joint–often the maximum movement arc that active range of motion (AROM) generates– and an outside force, passive range of motion (PROM) that then aides the joint into a greater range. However, the therapist can direct the per cent of total movement that the active contraction generates as well as the per cent of movement that the external assistance creates.  The amounts of each contribution will vary depending on the patient’s specific situation.1 AA/ROM is particularly important because it allows for combined assessment of joint range, control, muscle power, and the willingness of the patient to perform certain movements.2

Range of motion (ROM), which can be active or passive, is the measurement of a joint’s ability to go through its complete spectrum of movements. AROM is joint motion produced by musculotendinous contraction and relaxation, usually from a voluntary muscle.3,4 PROM reflects the available joint movement that an external passive force, such as a clinician’s hands, gravity, an assist device, or a machine (this is not an all-inclusive list), create. The amount of external force will affect the amount of PROM.3 The term "Torque ROM" or TROM, will include the designation of the amount of force the clinician applies and also usually the point on the limb at which the clinician applies the force (lever arm).5 With great frequency, AROM ≠ PROM. When unequal, PROM is the greater of the two measurements of the movement arc.

Indications for Intervention

ROM restrictions can significantly impact a patient’s ability to perform activities of daily living like eating, dressing, and grooming. They can interfere with both occupational and leisure activities.2 For patients with ROM impairments, ROM exercises are considered an essential component of a rehabilitation strategy.

The order of prescribing various ROM exercises depends on the patient’s specific condition. The therapist may begin with passive ROM exercises and then progress to active-assisted and then active exercises. A given tissue status may indicate that the therapist prescribes the opposite order of exercise with PROM contraindicated until a specific point in tissue healing. Ultimately, the approach taken will be the one with the lowest risk for further pain or tissue integrity.3,6,7 ROM exercises can be a form of proprioceptive neuromuscular facilitation in which the target muscle is actively lengthened by the contraction of its antagonist, and these exercises have been found to be more effective than static stretching for improving ROM.1

Evaluation to Determine Need for Intervention

Objectively evaluating AROM and PROM is essential for selecting appropriate treatments and for assessing the effectiveness of therapy.

Typically, a therapist will use a goniometer to measure either AROM or PROM. A short arm goniometer is recommended for the finger joints, a standard goniometer for wrist and possibly elbow joints, while a long arm goniometer is recommended for the shoulder joint and also the elbow joint.8 Electro-goniometers may also be used to measure the ROM of finger joints.9 A straight ruler will effectively measure finger tip to palm or the distance from thumb tip to a particular goal.

The therapist may choose to evaluate all cardinal movement joint planes or may prioritize or defer certain movement measurements. Comparison to the uninvolved side—if available—offers important information with regard to "normal movement" for a given patient.2 The following links to the exam chapter library provides generally accepted values for normal ROM. (Exams and Signs//AROM and PROM) When measuring ROM of any joint, the therapist must stabilize the proximal joints in a consistent manner.3

Therapists rarely measure AA/ROM. They use a judgement of the amount of AROM and PROM that will benefit a patient at a given point in rehabilitation. If the exercise has a specific end point goal, such as contact with the palm, they may use this end range point as an objective measure of the exercise’s effectiveness.

If the patient’s ROM measurements have changed since a previous appointment, the therapist notes what appears to be the cause for this change. With improvement, The clinician notes compliance with such program components as HEP, orthosis wear or activity modification. If the change involves regression, then the treatment note includes the possible causes pain, increased edema, stiffness, or other causal agents.8

Intervention Options

After identifying the specific AROM and/or PROM deficit(s), the clinician will design a personalized treatment program to increase ROM based on the time post injury or surgery and the state of tissue healing. This customized program will also take into consideration the patient’s specific movement deficits, functional abilities, and overall treatment goals.3 The therapist may choose from a variety of active-assisted ROM exercises and should select those that the patient is capable of completing independently without provoking significant pain.2 For each exercise, the therapist, the patient, gravity, an assistive device such as a dowel or a machine will assist the patient to a determined extent through the indicated ROM.

Regardless of the exercises prescribed, the overall goal is always to help the patient regain normal active ROM of the affected joint(s).10 The therapist should regularly monitor the patient’s progress throughout the treatment program, paying close attention to changes in pain levels, swelling, proprioception, and overall movement patterns, in addition to active ROM. As the patient improves, the intensity, frequency, and duration of the prescribed exercises should gradually increase according to the patient’s progress. As recovery continues, resistance can be gradually introduced, and the amount of assistance provided can decrease. The timing of resisted motion depends on injured tissue tensile strength and the response of each individual patient to treatment.

Therapists may prescribe orthotic devices to increase active ROM.3 Custom designed and fabricated orthoses can provide unique AA/ROM to various upper limb joints.

Diagnoses Where This Intervention May be Relevant

AA/ROM exercise may well apply to any diagnosis that results in a loss of ROM. The majority of diagnoses presenting to any upper limb specialist will commonly involve ROM loss. Limitations in ROM of the upper extremity joints can result from a variety of reasons, such as acute or overuse injury, arthritis, muscle weakness, neurologic conditions, inflammation, or surgery.2,3

Comments and Pearls
  • Pain will always guide the amount of ROM of any type of exercise, and this applies to AA/ROM as well.6
  • Active ROM tends to decrease as individuals grow older age due to age-related changes and decreased physical activity levels.2
  1. Stanziano DC, Roos BA, Perry AC, Lai S, Signorile JF. The effects of an active-   assisted stretching program on functional performance in elderly persons: a pilot     study. Clin Interv Aging 2009;4:115-120. PMID: 19503774
  2. Aizawa J, Masuda T, Hyodo K, Jinno T, Yagishita K, et al. Ranges of active joint motion for the shoulder, elbow, and wrist in healthy adults. Disabil Rehabil 2013;35(16):1342-1349. PMID: 23826904
  3. Wietlisbach C. Cooper’s Fundamentals of Hand Therapy: Clinical Reasoning and Treatment Guidelines for Common Diagnoses of the Upper Extremity. Third ed. St. Louis, MO: Elsevier; 2020.
  4. Aziz A, Hasim HM, Ali HD. Comparison of Outcome of Passive Joint Mobilization Techniques with Active Assisted Pulley Exercises in Patients with Frozen Shoulder in Improving Range of Motion. International Journal of Science and Research 2013;4(4):255–259.
  5. Brand PW, Hollister AM. Methods of Clinical Measurement in the Hand; In Clinical Mechanics of the Hand 3rd Ed. St Louis, Mosby 1999: 326-332.
  6. Murphy AM, Haykal S, Lalonde DH, et al. . Contemporary approaches to postoperative   pain management. Plast Reconstr Surg. 2019;144:1080e–1094e.
  7. Salter M, Cheshire L. Hand Therapy: Principles and Practice. Oxford, UK: Reed Educational and Professional Publishing Ltd, 2000.
  8. Culp R, Jacoby S. Musculoskeletal Examination of the Elbow, Wrist and Hand: Making the Complex Simple. New Jersey: SLACK Incorporated, 2012.
  9. Pham T, Pathirana PN, Trinh H, Fay P.  A Non-Contact Measurement System for the Range of Motion of the Hand. Sensors (Basel) 2015; 15(8):18315-18333. PMID: 26225976
  10. Guzelkucuk U, Duman I, Taskaynatan MA, Dincer K. Comparison of therapeutic activities with therapeutic exercises in the rehabilitation of young adult patients with hand injuries. J Hand Surg Am 2007;32(9):1429-1435.PMID: 17996780
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