Active Vs Passive ROM (Cervical Spine)

Active VS Passive ROM (Cervical)

This is my first post relating to active vs passive ROM testing and treatments. I want to start in the cervical region.

One thing that I noticed going through school and then as a floater and now as a clinical instructor is how little therapists respect the great knowledge that you can gain by knowing the difference between active and passive ROM. Many, if not all, therapists check active/passive ROM of the shoulder. We mobes/PROM shoulders that have restrictions in both. If just active is limited but passive is full then we work on correcting the deficits in shoulder strength/control. Why don’t we take this into account throughout the rest of the body?

In school and in practice I see many people using the cervical ROM diagram. It allows us to easily list ROM, pain, stretching, radicular symptoms, etc. in one easy to find/use space. It works well and acts as a quick reference for busy times. The problem is: why is there only one of these on most initial evals? There should be one for active AND one for passive ROM. When one of these diagrams looks like the following:

pain diagram

Then we assume (as manual therapists) that there is a closing restriction on the right side. We then put them supine and check each individual segment for mobility and pain. I don’t want this to turn into a discussion of our palpation skills. That can be saved for another time. In short, they are not good. Have you seen a cadaver?

If AROM is limited in all planes or just one plane but passive ROM is full then we really need to start thinking motor control! If AROM and Passive ROM are both restricted then we do need to asses to see where that restriction is coming from. This passive restriction can have many components and that is where we use our heavily developed manual skills to address then retest and check for improvements. Most times, if there is a passive restriction to motion and you clear that up with manual therapy then there is usually a motor control deficit to follow when you re-test the AROM and PROM. Also, don’t just check that first day but rather continue to check the Active vs Passive ROM.

Passive ROM restrictions is a result of something. It doesn’t just happen (like hamstring tightness which is a very long future post). Often times, if you fix that passive restriction they may have full AROM right after as well. This doesn’t mean that there isn’t a motor control issue to address. This change in AROM can be a result of the neurological feedback that you get with manual therapy. It can help reset the system including the active restraints to motion. Re-test the PROM/AROM the next visit to make sure that the PROM remained. If it didn’t then suspect a motor control issue that is preventing motion on continual basis. Follow your manual therapy up with some motor control exercises and see what happens the next visit. If they are consistent with their HEP then there should be those lasting changes.

When I first started thinking of adding more motor control exercises (opposed to the usual row/shoulder/scapular therex) into my treatment plan I was skeptical that it would carry over from one treatment to the next. Once I saw the results I was excited. I always question how we can be better at treating patients and the thought processes behind certain treatments. If PROM is full and AROM of the cervical region is limited then how can I regain full/painless AROM?

I hear a lot of experts talk about the reasons why we aren’t great at treating patients and areas that we need to improve upon. In the SFMA course I took over the summer (the philosophy behind there treatments pretty much changed the way I treat) they had mentioned that diagnosis is the area that we struggle in the most and that we are passible with the interventions. I don’t disagree with that assessment. We struggle with the “real” diagnosis with many patients, that is, in regards to what are focus should be on. But, I also think we really struggle with our treatments. This includes doing too much, not enough, poor progression, targeting the wrong areas, etc.

The big area that we struggle in regards to treatments is wanting to strength train everyone. Motor control is a huge component of a lot of areas and compensations. This is a talk for maybe my next post and many, many posts after that. For now, let’s talk about just improving that cervical AROM. In some ways I don’t even care what is limiting AROM. AROM involves contractile movements as well as non-contractile structures. If PROM is free and clear then what is more of a concern to me is how I can access that motor control system or nervous system.

It isn’t about strengthening the muscles or stretching non-stop to restore motion but rather about the amount of inactivation that is occurring. The motor control system just isn’t working. Overtime, the patient, somehow, developed a poor movement pattern. This poor movement pattern is possibly a result of a poor nervous system activation. It is not strength! You can do all the muscular strengthening and upper trap stretching you want but if you can’t get the system to respond normally then there will not be lasting changes. The body is a system of nerves, nervous system firing and brain mapping that churns out a desired response.

Try going weight bearing first and then if they can’t complete the below exercises go to supine and work on first.

Pull a thera-band apart into shoulder horizontal abduction with both hands and then have the patient actively rotate their head to the left then right. Once finished with that have the patient relax the band back to a relaxed state. Repeat ten times. Then do the same with any other motion that is restricted.

Horizontalabductionpull

You should see an instant improvement in AROM. It will look cleaner, be less painful and the patient should also instantly see/feel the results. I am not saying that it will be pain-free but there should be a noticeable difference in pain levels as well as AROM. If they are still painful then try some sustained overpressure with movement (at some level of the cervical spine from posterior) while they complete the above exercise. This can provide a little neurological feedback to the system and help with the perception of pain.

There is no one definition of motor control or what happens/why we see altered movement patterns when there is pain present. Why/how the nervous system goes about its processes is poorly understood and needs a lot more research focused on this. Hodges and Tucker have a good article on this process in 2011 (see below). A possible mechanism could be through the nervous system. If we can activate a “core” muscular group such as the scapular stabilizers in the upper quarter then maybe this will feedforward. The goal of this exercise is to get the CNS firing first then performing the abnormal movement hoping that it restores the correct timing/coordination of muscles thereby reducing the perception of pain.

Remember this is just one way of improving that active ROM and should be combined with other techniques and ways to reduce the hyperactivity of the nervous systems in through the cervical region. I will only quickly mention the couple other ways that I use as well but save for another post.

Mackenzie extension (clean up PROM/AROM)

Instrument assisted soft tissue massage to the cervical region (neurological feedback not scar tissue!)

Nerve tensioning/slides/glides/release via David Butler

I intend on going through the rest of my cervical treatment interventions to decrease pain and increase ROM as well as increasing function in following posts. I believe that it is very important to know why you perform the interventions as opposed to just assigning interventions because “you have always done it like that”. My interventions and treatment strategies have changed a lot over time and it is because I am trying to constantly look for ways to improve my outcomes and question the norm.

TJ Slowik PT DPT

Hodges, P.W., Tucker (2011). Moving differently in pain: A new theory to explain the adaptation to pain.

Hodges, P.W (2011). Pain and Motor Control: From laboratory to rehabilitation.

Changing Conventional Thought

Changing conventional thought

My first real post on here was originally going to be reserved for pain or maybe motor control and inhibition/compensation seen in runners/athletes of all types since I have seen a few more of those patients recently. But, now I just want to talk about being a physical therapist for a moment.

Over the previous 6 months my treatment principles have undergone a major transformation. You tend to realize the things that you don’t know or don’t have a good answer for when you have a student. Wanting to educate the student and really increase their level of understanding comes first from your understanding what is going on. This extends to the treatment of the patient. The why questions pop up a lot and I hate not having a good answer for them or at least a possible reason. I always had a lot of questions and attempted to answer them for myself but something about being partially responsible for a future physical therapist really motivates me.

This week a new student started with me. Today we talked a lot about pain and the the difference between motor control and strength/core stability. Going through the explanations of everything made me really think back to this whole changing a young therapists mindset and how much different it is to think along these lines vs what you are taught in school. I just graduated about a year and a half ago and for the most part the information being taught hasn’t changed much. ROM/MMT/flexibility and biomechanical changes in joint positioning. These were the things that were heavily stressed to be important. What wasn’t stressed was how meaningless all these are. Humor me for a second.

ROM: Yes, A/PROM is very important but it is amazing at how little so many therapists take into account active vs passive ROM in the spine. Just because lumbar flexion is limited in standing doesn’t mean that the hamstrings are tight or there is a joint that is out of place. You have to check passive as well in an unloaded position. What is worse is the cervical region. Limitation in ROM sitting does NOT mean that there is a closing/opening restriction. You have to check PROM in NWB. Most times this motion is actually perfectly fine and it is not something you need to start closing down or manipulating telling the patient that they have something out of place. All this does is raise their pain avoidance levels.

MMT: Please don’t rate someone a 4/5 via MMT of hip extension if they can’t complete AROM of hip extension without hamstring compensation. That 4/5 in glutes quickly turns into a 4/5 in hamstring strength and less than a 3/5 in glutes. Also, strength, most times means nothing if they can’t use it properly.

Flexibility: Tight hamstrings? The cause of Pain? Really? Come on. Just ask yourself this question. Why does something get tight? It a protective reflex from the CNS. You have the find the cause/movement dysfunction that is causing this massive compensation.

Manipulation changes joint mechanics: Where have you ever read that palpation skills are good? Have you ever seen a cadaver? If you manipulate something that isn’t out of place do you make it out of place? So how is it that manipulating something returns it back into place? Most research shows that it is impossible to target a specific joint without getting residual movement in surrounding areas so how can you really say that you are only manipulating the SI/C6/L4 etc.? Yes, manipulate and mobe but know why you are doing it so that you don’t scare the patient into believing that they will fall apart if they rotate slightly.

I know that I took the above to the extremes and there are always exceptions but for the majority the above is very much true.

This got completely off track quickly.

I faced the above reality when I stopped thinking about conventional PT treatments (cough, any doctor TV show, cough) and began to look at the body like we should. This includes less about strength/ROM and more about movement patterns and inhibition. Less about core stability and more about what pain is and what it isn’t. It is difficult to reboot much of what you have learned and takes time to really get back into a comfortable treatment approach incorporating all the new information you learned especially with major changes being made.

With a new student, I realized that I am still learning how to incorporate these new philosophies into my evaluation and treatment processes. It isn’t engrained into my thinking patterns yet but, like motor control/inhibition, practice will help write that new book.

Signed…the always honest TJ

Introduction…about the author

Hi, I am a currently a Physical Therapist in Pittsburgh and I created this blog to share some of my experiences in our profession with others. I graduated from University of Pittsburgh in 2013 and have spent considerable time improving my skills by learning some of the more  popular concepts of treatment. I am not a singular therapist…meaning one that is solely invested in only one type of treatment such as Mackenzie/Mulligan/biomechanical/Pain/movement impairment syndrome based…but rather a young therapist attempting to take all those skills/concepts and combine them into a singular treatment plan. If I had to specify my approach to treating my patients it would include something like:

Pain education/science -> Mackenzie -> Manual therapy -> movement based/motor control/SFMA exercise regimen

I question many of our basic concepts and am always eager to learn. I am not perfect and I do not have all the answers! I will rant and rave occasionally about random topics (I get emotional in regards to our profession and some terrible treatment plans that I have seen out there). I will consistently bring most of my posts back around to the concepts of pain and the central nervous system as well as motor control vs strength.

I want to learn a lot from myself with this blog and I hope that I am able to help others along the way. Let this journey begin!

TJ Slowik PT DPT