Passive kinesiotherapy. Passive exercises, positioning, mobilization, and stretching. Indications, contraindications, and application techniques

01What passive kinesiotherapy is, and what it cannot do

In kinesiotherapy, movement is the medicine. When the patient makes the movement with their own muscles it is active; when the muscles stay relaxed and the movement comes from outside, it is passive. In between is active-assisted movement, where the patient helps as much as they can (see active kinesiotherapy).

Think of a door hinge left unused in a damp house: it stiffens and rusts. Moving it keeps it free, but moving it does not make the person opening it stronger. That is passive movement exactly.

Muscles in this school are split into two kinds, an idea the professor's book takes from Janda. Postural (static) muscles, rich in slow type I fibres, tend to tighten and shorten under strain, and are treated by relaxation and stretching. Phasic (dynamic) muscles, richer in fast type II fibres, tend to weaken and lengthen, and are treated by strengthening. The upper trapezius, pectorals, hamstrings, iliopsoas and calf are typical tight muscles; the gluteals, abdominals and lower scapular stabilisers typical weak ones. This is a clinical model rather than a law, but it explains why passive stretching is aimed at some muscles and not others.

02Passive exercises

A passive range-of-motion exercise moves a joint through its available range while the patient stays relaxed. It is done by a therapist, by a machine, by gravity (a pendulum), or by the patient with their other hand (self-assisted, which is passive for the moved limb).

1. 1

   Position

   The patient lies or sits comfortably and relaxed, the limb uncovered, the therapist with a stable stance.
2. 2

   Grip and stabilise

   Hold close to the joint. Fix the bone above the joint so the movement happens only where it is meant to.
3. 3

   Move

   Slowly and smoothly through the whole available range in each of the joint's planes (flexion and extension, abduction and adduction, rotations), stopping at the first firm resistance or pain.
4. 4

   Repeat

   Usually 5 to 10 slow repetitions of each movement, at least once or twice a day; more often in early paralysis.
5. 5

   Check

   Watch the face for pain, feel the end of the range, note swelling and skin; record the range with goniometry.

Rules that follow from the patient having no muscle protection:

• Never force past the end of the range; a relaxed or anaesthetised joint can be torn.
• Move each joint separately, and two-joint muscles over both joints (the hamstrings: hip flexion with the knee straight).
• In a paralysed shoulder, support the whole arm, let the shoulder blade move, turn the humerus outwards before lifting the arm above shoulder height, and never pull on the hand. Overhead pulleys and pulling on a flaccid arm cause the painful hemiplegic shoulder.
• In spasticity, slow movement relaxes; fast movement provokes the stretch reflex and resistance.
• Combine with breathing, and with active help as soon as the patient has any.

Continuous passive motion (CPM) does the same by machine, over hours a day; see Mechanotherapy below.

03Positioning

Positioning means placing the body and its parts in chosen positions, and changing them on a schedule, so that lying or sitting itself becomes treatment. It works because tissues adapt to what they are given: skin dies where pressure stops its blood flow, muscles shorten if kept short, fluid pools where it is low, and lungs collapse where they are not ventilated.

Positioning is planned for the whole day and taught to the nurses and family. Splints and orthoses are positioning that stays in place: a resting hand splint, an ankle-foot orthosis against foot drop. In a frail patient, too much lying is itself the problem, so positioning is paired with getting up and sitting out as early as possible.

04Mobilization

Joint mobilization is a skilled passive movement of a joint to restore its motion. It comes in two kinds:

• Physiological movements: the large movements a person can make actively (bending the knee), done passively by the therapist, often slowly at the end of the range to gain a few degrees.
• Accessory movements, or joint play: small glides, rolls and separations of the joint surfaces that happen during normal motion but cannot be made on purpose. A stiff joint often loses its joint play first. The therapist fixes one bone and glides the other in a precise direction.

The direction of a glide follows the convex-concave rule. If the moving bone has the convex surface (the head of the humerus), it glides in the opposite direction to the movement: to gain shoulder abduction the head is glided down. If the moving bone is concave (the tibia on the femur), it glides in the same direction as the movement.

Mobilization is graded by how far into the range and how forcefully it goes, from small gentle movements that ease pain to firm movements into the stiffness that stretch the capsule. The grades and the related manual techniques, including manipulation, are in manual therapy and post-isometric relaxation.

05Stretching

Stretching lengthens soft tissue that has become too short: muscle, tendon, fascia, joint capsule, skin and scar. Soft tissue behaves like warm toffee more than like a rubber band: a short stretch springs back, but a gentle stretch held for a while lets it slowly give (creep), and repeated over weeks the tissue adapts.

What lengthens is not only the tissue. In the first weeks most of the gain comes from the nervous system tolerating the stretch better: the same pull hurts less, so the person lets the joint go further.

a static stretch held to mild tightness; 30 to 60 in older people

10–30secondsa static stretch held to mild tightness; 30 to 60 in older people

of each stretch, about 60 seconds in all

2–4repetitionsof each stretch, about 60 seconds in all

daily is better

2–3days a week at leastdaily is better

Rules for stretching:

• Warm the tissue first (gentle active movement or heat), since warm collagen gives more easily.
• Stretch to mild discomfort, never into pain; pain means the tissue is being torn or the muscle is guarding.
• Fix the bone at one end so the pull goes into the intended tissue.
• Stretch a hypomobile joint, not a hypermobile one next to it (stretching the back of a stiff hip, not a loose lumbar spine).
• After stretching, use the new range actively, or it is lost.

06Other passive methods: mechanotherapy, traction and massage

Mechanotherapy and continuous passive motion

Mechanotherapy is passive movement made by a machine. The old Zander apparatus of the spa era moved single joints; the modern form is the continuous passive motion (CPM) device, which slowly flexes and extends the knee, hip, shoulder or ankle through a set range for hours. The professor's slides give sessions of 10 to 60 minutes, once or twice a day, slow speed, the range increased gradually within what is pain-free.

Its weaknesses follow from it being a machine: it only moves one joint in one simple pattern, trains no movement skill, builds no strength, and cannot adapt to the tissue as a therapist's hands can. After knee replacement, trials show it adds only about 2 degrees of flexion, too little to matter, so it is not used routinely. Active exercise with a machine (an exercise bike, an isokinetic device) is different: the patient does the work.

Traction

Traction is a controlled pull along a body segment, used mostly for the neck and lower back, by hand, by weights, by a motorised table, on a sloping bed, or under water. The professor prefers the word traction to "extension", since extension is a movement. Pulls can be longitudinal, at an angle (kyphotic, lordotic, sideways), rotational, or a combination.

The slides make an important point: the pulls used in therapy widen the disc space little, if at all, and not in a lasting way. The main effect is a reflex relaxation of shortened, tense postural muscles, with less pain. Before mechanical traction a short manual traction test shows which direction relieves the pain; a direction that gives relief is easier to find with one disc herniation than with several. Contraindications follow from the pull: instability, fracture, tumour, infection, severe osteoporosis, and a progressive neurological deficit or cauda equina syndrome, which need surgical assessment, not traction. Evidence for traction in low back pain and radiculopathy shows little benefit over sham; it is used, if at all, within a package of exercise.

Massage

Massage is mechanical treatment of the soft tissues with the hands (or water jets, air pressure or devices). The classical techniques, in their usual order:

The professor's school uses relaxing massage for tight postural muscles and stimulating (irritating) massage for weak phasic ones, and adds reflex massages (connective tissue, segmental, periosteal) that work through the skin zones linked to an organ's spinal segment. Manual lymph drainage, very light rhythmic stroking toward working lymph nodes, is part of decongestive therapy for lymphoedema.

Massage reduces pain and muscle tension in the short term and patients value it; for chronic low back pain the benefit is small and short-lived, so it is used with exercise, not instead of it.

07Indications

The indications follow from what passive treatment can do:

• The patient cannot move: paralysis (stroke, spinal cord injury, peripheral nerve injury, Guillain-Barré syndrome), muscle strength grade 0 to 1, coma, sedation in intensive care.
• The patient should not move actively: complete bed rest, a repair that must not be loaded by muscle pull, severe pain that active movement would worsen.
• To keep range while waiting for active movement: the immobilised neighbours of a fracture, burns over joints, after surgery.
• To regain lost range: a stiff joint after immobilisation, a capsule contracture (frozen shoulder), shortened muscles.
• Positioning: every bedridden or immobile patient.
• To prepare for active exercise: relaxing, warming and freeing the tissues first.

08Contraindications and safety

The single rule: do not move a structure that movement would damage. The contraindications are grouped by why.

Massage adds its own: skin infection, open wounds, burns and fresh scars in the area, varicose veins and thrombophlebitis, fever and acute illness, and a tumour in the treated area. Traction adds instability, fracture, tumour, infection and progressive neurological loss.