Active and active-assisted kinesiotherapy. Therapeutic exercises for mobility, muscle strength, and endurance. Principles of progression and dosage
Exercise the patient does with their own muscles, with help when they are too weak (active-assisted) and against resistance when they are strong enough. This page covers how to pick the right level from the muscle test, the methods (assisted, suspension, water, free and resisted exercise), the exercises for mobility, strength and endurance, and how each is dosed and stepped up.
- 14 min read
- 5 questions
- Checked 05 Nov 2026
Contents8 sections
At a glance
- In active kinesiotherapy the patient moves with their own muscles. It is the main way to rebuild strength, endurance, mobility and control, because only a working muscle adapts.
- The level follows the manual muscle test: grade 0 passive or electrical stimulation; 1 assisted; 2 active with gravity eliminated (suspension, water); 3 active against gravity; 4 and 5 resisted.
- Active-assisted exercise adds just enough help (hands, the other limb, pulleys, slings, buoyancy) for a weak muscle to complete the movement; the help is withdrawn as strength returns.
- Strength needs heavy load and few repetitions (about 8 to 12 at 60 to 80 per cent of the 1RM); endurance needs light load and many repetitions or long continuous work; mobility needs movement through the full available range, often and gently.
- Contraction types: isometric (no movement, usable in a cast), concentric (shortening), eccentric (lengthening, strong, good for tendons) and isokinetic (constant speed on a machine).
- Progress one step at a time: from assisted to free to resisted, short lever to long, slow to fast, stable to unstable, single movements to whole tasks. Pain or swelling that lasts into the next day means the dose was too high.
Active and active-assisted kinesiotherapy
Kinesiotherapy is divided by who makes the movement:
| Form | Who moves | When |
|---|---|---|
| Passive | the therapist, a device or gravity; the patient's muscles are relaxed | no voluntary contraction, or it is not allowed |
| Active-assisted | the patient, with help | the muscle works but cannot complete the movement alone |
| Active free | the patient, against gravity only | the muscle moves the limb against gravity |
| Active resisted | the patient, against added resistance | the muscle is strong enough to be overloaded further |
The rule of thumb: let the patient do as much as they can, and help only with what they cannot. Help that is not needed takes away the training stimulus; resistance that is too high makes the patient cheat with other muscles.
The book groups the forms and methods of active kinesiotherapy as follows; balance, gait and the neurological techniques have their own topics.
| Method | What it is |
|---|---|
| Therapeutic gymnastics | general conditioning exercises (whole-body fitness, almost no absolute contraindications); analytic exercises (single muscles and movements, chosen by the muscle test); breathing exercises; balance and coordination exercises; corrective exercises for spinal deformities |
| Suspension and pulley therapy | exercise with body segments hung in slings to cancel gravity |
| Underwater exercise | exercise in a pool, where buoyancy unloads the body |
| Exercise with devices | elastic bands, weights, pulleys, machines, cycle ergometers, isokinetic dynamometers |
| Sport and games | adapted sport elements for motivation and function |
| Gait training, terrain treatment, occupational therapy | covered with functional mobility |
| Neuromuscular re-education | PNF (Kabat), Bobath, Brunnstrom, Vojta; used mainly in stroke and paediatric neurology |
Choosing the level: the muscle test
The starting point is the manual muscle test (MMT, the MRC grades 0 to 5). Each grade says what the muscle can overcome, and so what kind of exercise will challenge it without defeating it.
| MMT grade | What the muscle can do | Exercise |
|---|---|---|
| 0 | no contraction | passive movement to keep joints and tissues supple; electrical stimulation; imagining the movement |
| 1 | a flicker, no movement | active-assisted; "trying" contractions (muscle setting), EMG biofeedback, electrical stimulation |
| 2 | full movement with gravity eliminated | active in a gravity-eliminated position: suspension slings, a smooth or powdered board, water; assisted against gravity |
| 3 | full movement against gravity | active free against gravity, then light resistance |
| 4 | against moderate resistance | resisted exercise, progressive |
| 5 | normal strength | functional, sport- and work-specific training, power and endurance |
Point at a name or a part to light it.
The manual muscle test grades a muscle by what it can overcome: nothing, its own weight with gravity taken away, gravity, then resistance. The grade says which exercise will challenge the muscle without defeating it, and the patient climbs the ladder one rung at a time: passive, assisted, gravity eliminated, against gravity, against resistance.
Simplified: one arm, the elbow's flexors, stands for every muscle tested; every grade is drawn with the patient lying on the back; the test's position changes with the grade. With gravity eliminated the forearm bends level, swinging in the slings or sliding across a table, never upward, so the arm in slings is drawn level; and lying on the back, the forearm works against gravity only until it stands upright; the plus and minus grades some examiners add are left out; the stimulator, biofeedback unit, slings and weights are drawn small and simple.
4 sources
- Medical Research Council. Aids to the Examination of the Peripheral Nervous System. Her Majesty's Stationery Office, 1976.
- Aleksiev AR. Physical Medicine and Rehabilitation, lecture 4 handnotes. Medical University of Sofia, 2026. Manual muscle testing.
- Aleksiev A. Physical Medicine and Rehabilitation for English-speaking MD students. Medical University of Sofia, 2002. Manual muscle testing; Suspense and pulley therapy.
- Kisner C, Colby LA, Borstad J. Therapeutic Exercise, foundations and techniques, 8th edition. FA Davis, 2022.
Methods of active-assisted exercise
The help can come from many sources; the choice depends on the joint, the setting and how the help can be measured and reduced.
| Source of help | Example |
|---|---|
| The therapist's hands | guiding the arm through shoulder flexion, helping only through the weak part of the range |
| The patient's other limb | clasped hands lifting the weak arm; a stick (wand) pushed by the good arm |
| Pulleys | an overhead pulley: pulling down with the good arm raises the weak one |
| Gravity | pendulum (Codman) swings of a relaxed arm, leaning forward, early after shoulder surgery |
| Slings and suspension | the limb hung in slings so it moves without its weight |
| Buoyancy | the limb floats up in water |
| Devices | motor-assisted bicycles, robotic gait trainers, arm robots that assist as needed |
Suspension and pulley therapy
Hanging a limb or the whole body in slings from a frame overhead (the suspension cage, in the book "Roshe's cage") removes the effect of gravity, so a muscle of grade 2 can move the limb through its whole range. The book says suspension is needed whenever strength is below grade 3.
The position of the hook decides the task. With the hook directly above the joint, the limb swings in a horizontal plane with no help or resistance from gravity. Moving the hook changes the arc, so the swing either helps or resists the movement. Adding springs, elastic cords or a pulley with weights gives graded assistance or resistance. Modern sling systems also use the slings as an unstable base for trunk and pelvic control. The slides suggest short sessions, about 5 minutes, repeated several times a day: a weak muscle tires quickly and learns best from frequent short practice.
Underwater exercise
In water, Archimedes' principle does the work. The water pushes up with a force equal to the weight of water displaced, so the immersed body weighs much less. Standing still, the water carries roughly two thirds of body weight when it reaches the chest and about half at the waist; walking adds load back. A painful joint or a weak muscle can move in water when it cannot on land, which is why the book uses water "to start active kinesiotherapy as soon as possible".
| Property of water | Effect | Use |
|---|---|---|
| Buoyancy | unloads joints and spine; helps upward movements, resists downward ones | buoyancy-assisted, -supported or -resisted exercise; early walking after injury |
| Resistance (drag) | rises steeply with speed; acts in every direction | strengthening with speed or paddles; the faster, the harder |
| Hydrostatic pressure | squeezes limbs evenly, helping venous return and reducing swelling | oedema, proprioceptive input |
| Warmth (about 31 to 34 °C, warmer for very painful conditions) | relaxes muscle, eases pain | arthritis, back pain, spasticity |
Sessions are usually 20 to 45 minutes, 2 to 3 times a week. Contraindications follow from the water and the warmth: open wounds and skin infection, infectious diarrhoea or incontinence, uncontrolled epilepsy, severe or unstable heart or lung disease (immersion pushes blood into the chest and loads the heart), a tracheostomy, and fear of water.
Exercises for mobility
Mobility exercises keep or restore the range of motion (ROM) of joints and the length of soft tissues. A joint that is not moved through its range loses it, as capsule and muscle shorten.
- Active range-of-motion exercise: the patient moves each joint slowly through its full available, pain-free range in every direction. Done actively, it also keeps muscles working, circulation moving and the brain's map of the movement alive.
- Active-assisted ROM: when weakness or pain stop the patient short of the end of range, help completes it.
- Active stretching and self-stretching: the patient holds the end of range, or uses their own muscles to push into it. Stretching and its dosage are covered in passive kinesiotherapy, and using a muscle's own contraction to relax it in post-isometric relaxation.
Dosage: slow, rhythmic movements, about 5 to 10 repetitions of each movement, 1 to 2 sets, several times a day. Little and often works better than one long session, because stiffness returns in hours. After immobilisation, range comes back first, then strength through that range.
Exercises for muscle strength
Strength grows only when the muscle is overloaded: asked for more force than it is used to. How the overload is applied gives the exercise its type.
Contraction types
| Contraction | What happens | Strengths | Cautions |
|---|---|---|---|
| Isometric (static) | tension without movement; the length stays the same | possible in a cast or when movement hurts; simple | strength gains mostly at the trained angle; raises blood pressure |
| Concentric | the muscle shortens as it lifts | everyday lifting | |
| Eccentric | the muscle lengthens under load, as when lowering | the greatest force for the least energy; strengthens tendons | more muscle soreness after unaccustomed work |
| Isokinetic | movement at a constant speed set by a machine; resistance matches the force applied | safe maximal loading through the whole range; measures strength | needs a dynamometer; not functional |
The book describes isotonic contraction as constant tension; in real movement tension changes as the lever changes, so "dynamic" or "concentric and eccentric" is the more exact term now.
Point at a name or a part to light it.
A working muscle pulls; what happens to its length depends on the load. If the pull just holds the load, nothing moves and the muscle keeps its length: isometric. If it lifts the load, the muscle shortens: concentric. If the load wins and the muscle lets it down under control, the muscle lengthens while it still pulls: eccentric, as when lowering a cup or walking downstairs.
Simplified: one arm drawn three times, seen as if through the skin; biceps stands for the elbow's flexors; brachialis, which works with it, is left out; the speed of the movement is not drawn; how hard the muscle pulls changes with it; the radius and ulna are drawn as one bone.
5 sources
- Aleksiev A. Physical Medicine and Rehabilitation for English-speaking MD students. Medical University of Sofia, 2002. Kinesitherapy, muscle contraction.
- Kisner C, Colby LA, Borstad J. Therapeutic Exercise, foundations and techniques, 7th edition. FA Davis, 2017. Chapter 6, Resistance exercise for impaired muscle performance.
- Alfredson H, Pietilä T, Jonsson P, Lorentzon R. Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. American Journal of Sports Medicine, 1998;26(3):360–366.
- Standring S (ed). Gray's Anatomy, the anatomical basis of clinical practice, 42nd edition. Elsevier, 2020. Arm.
- Lieber RL. Skeletal Muscle Structure, Function and Plasticity, 3rd edition. Lippincott Williams and Wilkins, 2010.
Exercises are also open or closed chain. In an open kinetic chain exercise the far end of the limb moves freely (sitting knee extension): it isolates one muscle. In a closed kinetic chain exercise the foot or hand is fixed and the body moves over it (a squat, a step-up): muscles around several joints work together, as in standing and walking, with more joint compression and stability.
Methods
- 1
Isometric exercise
Brief maximal or near-maximal contractions, held for about 6 to 10 seconds, repeated about 5 to 10 times, at several joint angles because the gain is angle-specific. Muscle setting (tightening the quadriceps with the knee straight) is the simplest form, used in bed or in a cast. - 2
Free active exercise
Moving the limb against gravity alone, with the lever and starting position chosen to make it easier or harder. - 3
Progressive resistance exercise
Resistance from the therapist's hands, body weight, free weights, elastic bands of graded stiffness, pulleys, machines or water, raised as the muscle adapts. DeLorme's method, developed with wounded soldiers in the 1940s (and set out as 3 sets in 1948): find the 10-repetition maximum (10RM), then do 3 sets of 10 at 50, 75 and 100 per cent of it. The Oxford method reverses the order to allow for fatigue. - 4
Eccentric training
Lowering a load slowly. In chronic Achilles tendinopathy the classic programme (Alfredson's) is slow heel drops off a step, 3 sets of 15 with the knee straight and 3 with it bent, twice a day, for 12 weeks, some pain being allowed. - 5
Functional strengthening
Sit-to-stand, step-ups, lifting and carrying: strength trained in the tasks the patient needs, the final aim of analytic work.
Dosage by goal
| Goal | Load | Repetitions | Sets and rest |
|---|---|---|---|
| Strength | about 60 to 80 per cent of 1RM | about 8 to 12 | 1 to 3 sets, 2 to 3 minutes rest; 2 to 3 sessions a week for each muscle group |
| Starting out, older or deconditioned | about 40 to 50 per cent of 1RM | 10 to 15 | 1 set, building to 2 to 3 |
| Muscular endurance | under about half of 1RM | 15 to 25 or more | short rests |
| Power (speed of force) | light to moderate loads | fast lifting, few repetitions | for older people at risk of falls, after a strength base |
The 1RM is rarely tested directly in patients; it is estimated from the most repetitions done with a lighter load, or the load is set by effort ("the last two repetitions are hard but done with good form"). With elastic bands, the colour sets the stiffness and the stretch sets the force.
Exercises for endurance
Endurance is the ability to keep going. There are two kinds, and they are trained differently.
- Local muscular endurance: one muscle group repeating a task, such as climbing stairs or holding a posture. It is trained with light loads and many repetitions, which builds capillaries and mitochondria in that muscle.
- General (cardiorespiratory) endurance: the whole body working for long periods, limited by heart, lungs and muscle oxidative capacity. It is trained with large-muscle rhythmic activity: walking, Nordic walking, cycling, swimming, ergometers, stepping.
| Method | How | Who |
|---|---|---|
| Continuous | steady moderate effort, 20 to 60 minutes | most patients, once they can sustain it |
| Interval | short bouts of harder work alternating with easy recovery | deconditioned patients, who can do more total work this way; heart failure and COPD |
| High-intensity interval | for example 4 bouts of 4 minutes at 85 to 95 per cent of peak heart rate with 3 minutes of active recovery | stable cardiac patients under supervision, fit people |
| Circuit training | stations of strength and aerobic exercise in sequence | general conditioning, groups |
How intensity and weekly volume are set (heart rate reserve, Borg scale, METs, the WHO targets) is covered in kinesiotherapy principles; programmes for heart and lung patients are in cardiopulmonary rehabilitation.
Principles of progression and dosage
The general rules of overload, progression and specificity apply to every active exercise. In practice, an exercise is made harder by changing one of these at a time:
| Make it harder by | Easier | Harder |
|---|---|---|
| Assistance | full assistance | none |
| Gravity | gravity eliminated | against gravity, then resistance |
| Lever | short (bent elbow, hand near the body) | long (straight arm, weight far from the joint) |
| Resistance | light band, low weight | stiffer band, heavier weight |
| Repetitions and sets | few | more, then a heavier load and fewer repetitions |
| Speed | slow and controlled | faster, then explosive |
| Base and posture | lying, sitting, stable surface | standing, one leg, unstable surface |
| Complexity | one joint, one plane | several joints, diagonal patterns, whole tasks, dual tasks |
| Rest | long | short |
Practical rules:
- The two-for-two rule. When the patient can do two more repetitions than the target in the last set, in two sessions running, the load goes up by a small step (about 2 to 10 per cent) and repetitions return to the target.
- Quality before quantity. A repetition with a trick movement does not count; if form breaks, the load is too high.
- Breathe. Breathe out with the effort, never hold the breath during a lift.
- Watch the response. Warmth and tiredness are expected. A common rule of thumb, from arthritis care: pain that settles within about 2 hours and is no worse the next morning is acceptable; pain that lingers, swelling or lost range mean the next dose is smaller.
- Respect healing. After surgery or fracture, the surgeon's protocol sets when resistance and loading may start.
Indications and contraindications
Active exercise is indicated wherever muscles, joints or fitness have to be built back or kept: weakness and atrophy after immobilisation, injury, surgery or nerve damage; stiffness and contractures; deconditioning after illness; osteoarthritis and back pain, where exercise is a core treatment; chronic heart, lung and metabolic disease; ageing, frailty and fall prevention; and before surgery (prehabilitation).
The general reasons not to exercise at all (unstable heart disease, acute illness, fever, untreated clots) are in kinesiotherapy principles. Those particular to active and resisted exercise:
| Situation | Problem | What is done |
|---|---|---|
| Acute inflammation of a joint or muscle, a fresh muscle tear | load worsens damage and swelling | rest the part, gentle isometric or assisted movement only |
| Unhealed fracture, fresh tendon or ligament repair | resistance can break the repair | protocol: isometric and assisted first, resistance later |
| Hypertension, aneurysm, recent eye surgery, heart disease | straining and maximal isometric holds raise blood pressure | no breath-holding, moderate loads, short holds |
| Neuromuscular disease (post-polio, Guillain–Barré recovery, motor neurone disease, myopathies) | an exhausted denervated muscle can lose strength (overwork weakness) | submaximal loads, rest, stop before fatigue |
| Severe osteoporosis | loaded spinal flexion can fracture a vertebra | extension and weight-bearing exercise, no heavy flexion |
| Inability to follow instructions, severe pain, marked spasticity | the movement cannot be done correctly | passive or assisted methods, treat the cause |
| Haemophilia, anticoagulation | muscle and joint bleeds | graded, supervised loading |
Check yourselfAnswer, then say how sure you were: a lucky guess still counts as a weak point.
1After a peroneal nerve injury, a man's ankle dorsiflexors move the foot through its full range only when he lies on his side, with gravity taken out. What exercise fits his muscle grade?
2A woman's knee is in a cast for 6 weeks after a tibial plateau fracture. Which exercise keeps her quadriceps working without moving the knee?
3A man with poorly controlled hypertension is starting resisted exercise. Which instruction matters most?
4A patient does 3 sets of 10 knee extensions with 5 kg. In the last two sessions she completed 12 repetitions in her last set without pain. What is the next step?
5Which sign after a session shows the active exercise dose was too high?