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Active Range of Motion

Information

Description of Intervention

Active Range of Motion is used to describe the use of one's own muscles to move the desired body parts under the patient's own volition.   After a hand injury or hand surgery, active range of motion (ROM) may be hindered for several weeks. While the patient’s hand, wrist or fingers are immobilized, therapists can begin with active, active assisted and passive ROM exercises to the uninvolved joints / body parts. When ROM is appropriate and ordered, it is vital that the patient initiates and continues with exercises every day.

Trauma to the thumb and fingers can affect pinch and grasp during functional tasks. Damage to the joints of the thumb and index finger will impede pinch and grip strength, as well as range of motion. In the multi-joint system of each digit, a change in one joint, such as the metacarpophalangeal (MCP) joint, can affect the functional ROM of the other joints, such as the proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints.1 Exercises which imitate daily activities will help to improve these functions over time.2 To ensure finger ROM for optimal outcomes, tendon gliding exercises are initiated as early as possible to maintain joint suppleness and tendon gliding and differentiation.   Active exercises help the body act as a pump to use muscle contraction and joint mobility to assist in decreasing edema.

Utilization of fingers in functional tasks and isolated ROM is key to function and edema reduction but need to be ordered by the surgeon when healing time of surrounding tissues is appropriate.  For example, patients who are carpenters or musicians, should avoid hand overuse, for a short time during the initial recovery. However, they should resume active motion, as soon as possible, in a gradual manner.3 To aid in this return to activity, relative motion, static progressive and dynamic splints may be helpful.  Many times, active ROM is ordered first to allow the patients to mobilize their fingers and/or thumb in their available ranges but can be progressed to active assisted (using non-involved hand to assist) or even passive ROM (using the non-involved hand to move the digits on the injured side).  Basic wrist, elbow and shoulder active ROM exercises can be initiated when appropriate as well.   Functional task performance and integration is an ideal way to recover ROM.

Timely immobilization followed by onset of active ROM is important with regard to healing of surrounding tissue. Patients under the age of 12, who have flexor tendon injuries, should keep their injured hand immobilized for 3-4 weeks, depending on their ability to follow the exercise recommendations.4 Additionally, patients with flexor tendon injuries may be encouraged to start passive ROM per protocol and progress to active as recommended by published protocols.  Patients with extensor tendon injuries may also be encouraged to begin short arc ROM as instructed in published protocols.

Respecting co-morbidities and connective tissue disorders is also crucial to an optimally functioning hand. Patients with rheumatoid arthritis (RA), as part of their multifaceted treatment program, should focus on relief of joint pain, reduction of inflammation and encouragement of joint mobility. These patients may need to pause exercise programs for times of extreme pain or surgical recovery. Medications will help them to resume exercises.3

Indications for Intervention

Variations in active ROM in the hand or digits can be post-traumatic, or post-surgical, after flexor or extensor tendon repair. Changes in joint function in the digits can also be caused by caput ulnae syndrome, in conjunction with RA.5

Diagnosis

  1. Ask for the patient’s medical history, including any recent injuries to the arm, hand or digits. If the patient has had a recent flexor tendon surgery, find out how many core sutures were used.4 This will help the therapist estimate the strength of the repair.
  2. With a goniometer, measure the dividual joint and total active motion (TAM) of the injured area. TAM is the sum of the degrees of motion from each joint level in the digit.6
  3. Measure the injured area, using the Littler Line Method and area under the Gaussian curve or assess active pulp to distal palmar crease measurements.7
  4. Examine the contralateral uninjured arm and hand to define the patient’s normal baseline.6
  5. Be sure to learn of any co-morbidities, ie: smoker, diabetes or osteopenia
  6. Look for signs of Complex Regional Pain Syndrome (CRPS) or Reflex Sympathetic Dystrophy (RSD)

Intervention Options

Post-surgical or post-traumatic treatment, to improve active ROM, could continue for approximately 2-4 months dependent on the diagnosis and patient participation. After flexor tendon surgery, if the patient has had two core sutures, it may be possible to introduce gentle active motion immediately. This decision should always be reviewed with the surgeon.  The timings of active motion and resisted motion depend on the tensile strength, and the response of each individual patient to surgery.4

Rather than exclusively using traditional ROM therapy exercises, it may be more beneficial to use activities that imitate activities of daily living, including locking and unlocking a door key, using scissors, tying a shoelace and writing. These functional activities may also improve the psychological motivation of the patient.2

For reduced active motion, due to extensor tendon injuries or sagittal band injuries, the relative motion splint can be effective. Patients should wear the splint at all times, for 2-3 months, for optimum recovery.5 Patients with RA can also use therapeutic splinting to help relieve pain and inflammation of the hand and wrist.3

Images
Active Exercises Thumb
  • Rest the little finger side of your hand on the table so that your thumb faces up. Move thumb straight out away from fingers, as if you were signaling the number 5. Then slide thumb across palm, signaling a number 4. Continue to move your thumb back and forth between these two positions. The therapist tells the patient how many seconds to hold each position, how many times to relax and repeat the exercise, and how many sessions to do each day.
    Rest the little finger side of your hand on the table so that your thumb faces up. Move thumb straight out away from fingers, as if you were signaling the number 5. Then slide thumb across palm, signaling a number 4. Continue to move your thumb back and forth between these two positions. The therapist tells the patient how many seconds to hold each position, how many times to relax and repeat the exercise, and how many sessions to do each day.
  • With the little finger side of your hand resting on the table, move thumb next to your index finger. Then move thumb out to the side away from your hand, forming an "L" shape. Continue to move your thumb back and forth between these two positions.
    With the little finger side of your hand resting on the table, move thumb next to your index finger. Then move thumb out to the side away from your hand, forming an "L" shape. Continue to move your thumb back and forth between these two positions.
  • Touch the tip of your thumb to the nail of your index finger, making an "O" shape. Repeat for each finger.
    Touch the tip of your thumb to the nail of your index finger, making an "O" shape. Repeat for each finger.
Thumb Blocking Exercises
  • Hold below bottom joint using other hand. Bend thumb. Then straighten fully.
    Hold below bottom joint using other hand. Bend thumb. Then straighten fully.
  • Hold second joint (MP joint) straight. Bend tip (IP joint) of thumb. Then straighten fully
    Hold second joint (MP joint) straight. Bend tip (IP joint) of thumb. Then straighten fully
Finger Active Range of Motion & Tendon Gliding Exercises
  • Do active tendon gliding exercises, beginning with fingers straight & ending with full fist. Do each 10x, holding position 2 seconds. You may use other hand to stretch your involved fingers. Stretch in each position for 10 seconds each, 5 reps of each.
    Do active tendon gliding exercises, beginning with fingers straight & ending with full fist. Do each 10x, holding position 2 seconds. You may use other hand to stretch your involved fingers. Stretch in each position for 10 seconds each, 5 reps of each.
Wrist Active Range of Motion Exercises
  • With your fingers straight, bend your wrist down.
    With your fingers straight, bend your wrist down.
  • Make a fist. Bend your wrist down.
    Make a fist. Bend your wrist down.
  • With your fingers straight, lift your wrist up.
    With your fingers straight, lift your wrist up.
  • Make a fist. Lift your wrist up.
    Make a fist. Lift your wrist up.
  • With your fingers curled in, move your wrist toward your thumb.
    With your fingers curled in, move your wrist toward your thumb.
  • With your fingers curled in, move your wrist toward your little finger.
    With your fingers curled in, move your wrist toward your little finger.
Forearm Active Range of Motion Exercises
  • With elbow bent at your side, turn your forearm so the stick points to the ceiling.
    With elbow bent at your side, turn your forearm so the stick points to the ceiling.
  • With elbow bent at your side, turn your palm down toward the floor.
    With elbow bent at your side, turn your palm down toward the floor.
  • With elbow bent at your side, turn your palm up toward the ceiling.
    With elbow bent at your side, turn your palm up toward the ceiling.
Elbow Active Range of Motion Exercises
  • Straighten your elbow as far as possible.
    Straighten your elbow as far as possible.
  • Bend your elbow toward your shoulder.
    Bend your elbow toward your shoulder.
Shoulder Active Range of Motion Exercises
  • Beginning shoulder active abduction exercise
    Beginning shoulder active abduction exercise
  • Continued shoulder active abduction exercise
    Continued shoulder active abduction exercise
  • Full shoulder active abduction exercise
    Full shoulder active abduction exercise
  • Beginning shoulder active extension exercise
    Beginning shoulder active extension exercise
  • Completing shoulder active extension exercise
    Completing shoulder active extension exercise
  • Shoulder active internal rotation exercise
    Shoulder active internal rotation exercise
  • Shoulder active external rotation exercise
    Shoulder active external rotation exercise
Diagnoses Where This Intervention May be Relevant
Comments and Pearls
  • Because the Littler line method highlights the mid-ranges of digital motion, this method may be a very effective way to evaluate functional assessment of the digits.7
  • Patients with RA may seek counseling, in addition to hand therapy, to aid in motivation for dealing with joint changes, to continue with activities they enjoy.3
  • Whenever the patient injuries the distal upper extremity, the patient should be started on shoulder exercises like pendulum exercises as soon as possible to avoid secondary shoulder capsulitis.
References
  1. Hume MC, Gellman H, McKellop H, et al. Functional range of motion of the joints of the hand. J Hand Surg 1989 etc. PMID: 2324451
  2. Guzelkucuk U, Duman I, Taskaynatan MA, et al. Comparison of therapeutic activities with therapeutic exercises in the rehabilitation of young adult patients with hand injuries. J Hand Surg 2007;32(9):1429-35. PMID: 17996780
  3. Salter M, Cheshire L. Hand Therapy: Principles and Practice. Oxford: Reed Educational and Professional Publishing Ltd, 2000.
  4. Wietlisbach C. Cooper’s Fundamentals of Hand Therapy. Missouri: Elsevier, 2020.
  5. 5. Merritt WH. Relative motion splint: active motion after extensor tendon injury and repair. J Hand Surg 2014;39(6): 1187-94. PMID: 24862114
  6. Culp R, Jacoby S. Musculoskeletal Examination of the Elbow, Wrist and Hand: Making the Complex Simple. New Jersey: SLACK Incorporated, 2012.
  7. Catalano LW III, Browne RH, Carter PR, et al. The Littler line method and the area under a Gaussian curve: a new method of assessing digital range of motion. J Hand Surg 2001;26A:23-30. PMID: 11172364
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