Prom v AROM for finger fractures and dislocation
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[00:00:00] If you're working in the hand therapy world and you get confused about when is it safe to do active range of motion versus passive range of motion based on the injury that you're receiving, well, my name is Hoang I'm an occupational therapist and certified hand therapist and I help other therapists develop their clinical skills in the area of hand therapy.
Now, I had a student of mine inside the mentorship program ask me this very question and it's very common, like, It's, it's easy to get confused when is it safe to do active, passive, and what the hell is active assisted range of motion anyway? So I go into this detailed explanation based on the nature of the injury.
Take a listen to this video. Hey Liz, thanks for the question. I think it's a great question. Um, all right, so let's talk about the difference. you know, passive range of motion versus active range of motion and not always sure when to initiate passive range of motion, which is correct because you're not always, [00:01:00] um, initiating passive range of motion for sometimes it's active first and then passive, sometimes it's passive and then active, right?
So passive range of motion just means the patient's not doing it. You are manually. moving it by yourself. And of course, passive range of motion is based also on degrees, right? So if someone's joint is really loose when you do passive range of motion, it's not very aggressive because it's by its nature, they're loose already when it is more stiff and rigid than you might be doing more critical, aggressive range of motion.
So specifically you have a patient four weeks post surgical middle finger, distal failings, dislocation and fracture. We're talking about middle finger, distal failings, no weight bearing. I love it when they're like [00:02:00] no weight bearing, who the hell's weight bearing on their finger. Anyway, um, um, weight bearing as tolerated.
And to start active and passive range of motion in your head, I'm association passive range of motion, which stretch, which I know is not the case, but do you have a way to break down the different range of motion and when it's appropriate based on healing times? Absolutely. So, um, range of motion is based on is based on, um, how do you call it?
the frameworks, right? So let's say I have a bone issue, a muscle tendon issue and a ligament issue, right? So in terms of a bone [00:03:00] issue, if you have a fracture, right, if you have a fracture, once that fracture is stable, stable, unstable, right? So most of the time a fracture, if it's unstable, is going to be immobilized, isn't it?
Once it's immobilized and it becomes more stable, then you can move it, then it becomes stable. So if you have a fracture and it's stable, AKA, it could be a surgery or something like that, or just by the nature of the fracture, wasn't that bad? It's stable. You are allowed to move it. So then it becomes, well, how can you move it?
Right. How can you move it? So here when it's stable, you would essentially start with an active range of motion. And then as it becomes more stable, as it becomes more [00:04:00] stable, you can do passive range of motion, right? So the key timeline when it comes to fractures is bone healing. So the nature of the injury.
The nature of the, the, the tissue, right? Going back to that fast track framework, the nature of the tissue is bones heal within four weeks. There's a certain amount of clinical healing around four weeks, four to six weeks. And so by four weeks, if they're more stable, you might be able to start gentle passive range of motion.
gentle passive range of motion, right? And by six weeks, you can do more aggressive passive range of motion and all the whole time you can do active, right? So if you start doing active and they get better and better, then you can, you want to get more range of motion. So then you're going to go passive range of motion so that you're moving and stretching all the tissues you're stretching and, um, the [00:05:00] tendons and the muscles, you're stretching the ligaments, you're moving the.
skin and fascia. And so then you get more, you get more past the range of motion. So when you get more past the range of motion, then you're able to do actually more active range of motion, can't you? Right? So in your case, this is a fracture plus ligament dislocation. So two problems, right? So now we have to take into account, let's go into ligaments.
So ligaments hold bone and bone together. So if you're the ligaments hold bone and bone together and something happened to it, it's torn, it's sprained, it's strained. Do you want to passively move it? Probably not. You have to, you have to let it stiffen, let it harden. And then you start to do active range of motion.
And then you can move into passive range of motion as you have more stability, right? So [00:06:00] if you always go back to the nature of the tissue, ligaments hold bone and bone together and provide stability. So if it's unstable, do you want to push on it some more and make it more unstable? No, you actually want to let it stiffen up.
Right and then let it get more stable and then you can start to move it So safe way to move its acts of range of motion and then as it becomes more stable Then you can do more passive range of motion, right? So if you have a two part problem Right, you have a two part problem your bone and ligament Now you have to determine, is the bone stable enough for me to move it?
Now, if we have to stabilize it for the bone, then by, by default, the, the ligaments have to be stabilized as well, right? So if you're four weeks out, Right. Four to six weeks of your four, like ligaments, ligaments sometimes need more time, right? But that is dependent on [00:07:00] location in the, in the fingers.
They're usually tend to be more stable because the ligaments. are just tight all the way around. So usually around four weeks, you can start to do active range of motion. And then if they're able to tolerate, you can start to do passive range of motion as well. Right? So the doctor is saying you can start both, but what do you, what do you feel like you're able to start with?
Well, if I don't know this person, I'm going to start with some active range of motion. Cause I want to see how they move and how they respond. Once I see, Hey, They're moving. Okay. They're responding. Okay. I'm going to start to add more passive range of motion into it so that they can get more active. And then when they get more active, then I can get more passive.
So it's, um, you know, it's this, this, you know, round robin thing, right? Now, I also have to always take into account tendon issues, right? [00:08:00] So let's say, for example,
I only have a tendon problem. I only have a tendon problem. Which one, which one is it? Is it a flexor problem or an extensor problem, right? Herein lies the difference because the tendons Due to its location plays a role in whether you can do passive or active first, right? So in the flexor tendons, they're over here, they're big and they're long.
And when we are able to put them into a. safe position so it's not so tight. And once it's healed, you know, we're allowed to, once they suture it together, we're allowed to do passive range of motion because we need the glide. So in the flexor tendon issue, we do number one, passive range of motion first, and then two active.
As it heals, [00:09:00] as the sutures heal, as they're scarring, we're able to do more active. And the reason why is because when you can do, when you do more passive, it loosens up the joint. So there's less drag and stress on the repaired tendon, right? So if you, you think about it, this is, The one structure, oh, sorry, the flexor, this is the one structure that you do passive and then active.
Right? Now, if you look at extensor tendon, also based on its location, right? Based on its location, we're just talking about extensor tendons to someone, right? The only way to make it slack is to be in extension. So it's on slack, right? And because of the direction of pull, when you go and you go into a fist, it's going to stretch it.
So if the tendon, the nature of the tendon [00:10:00] needs to be repaired, right? Sutured together because there's no blood supply, right? No blood supply. It relies on the sutures. It relies on the scarring, right? So if I go and I suture it and I stretch it out too far, too fast, I can have issues, right? So, with an extensor tendon, you have to, at the very beginning, either have no motion, Depending on where it is, then you can start.
Once you hit a time period, that's why you have to now know some of the details of timeline, then you can start into an active range of motion. And then as it heals and it gets stronger, then you can move into passive range of motion, right? Um, so you have to essentially know, know the, you have to know the, um, the structures.
[00:11:00] You have to know, you have to know the structures. So it goes down to knowing your anatomy, right? Doesn't it go down to knowing your anatomy, right? Fast track framework. Is it a bone issue? Is it a ligament issue? Muscle tendon? Is it a nerve? Is it skin and fascia? After you know that, you know, you, um, you have to know, The nature of the injury
and, you know, and potentially, um, surgery, right? You have to know the nature of the injury, nature of the surgery from that, you really need to know the date of the injury or the date of the surgery so that you can work into protocols. So you can work into timelines. They, you know, based on X, Y, and Z, I'm allowed to move here, here, here.
Right. [00:12:00] So for the most part, can we clump most of it up? Sure. But you can have a broad overall picture and then dial into the details based on your injury and based on location. Because yes, we can talk about extensor tendons a certain way, but they're different at different parts of the fingers, right? If you're talking about a terminal tendon, dude, terminal tendons, what do you understand about the nature of that, of that structure?
Well, it's very thin, very small, very weak, right? So if you start stretching the hell out of it and it's not really, uh, if it was disrupted somehow, you might discover that you're going to get a lag, right? So you gotta watch out for that just in case, right? The dislocation just means like it's going to be really stiff.
So you're going to have a joint issue and you're going to have to do [00:13:00] passive range of motion. Do some joint distraction, joint distraction, right? Do some passive, you know, I like to do passive rotations to loosen up the ligaments, whatever. And then you can also do passive. But when you do passive, you have to also make sure active.
That it goes up, right? And it goes down. Um, and then active assisted is really like, you know, passive is completely, you do it by yourself, right? Active is you, they do it by themselves. Active assisted is, okay, I'm gonna, you know, you're gonna bend down and I'm going to help you. So go into a, you know, block that finger, you know, bend that little knuckle.
They're going to bend, bend, and then you're going to go and you're going to stretch it further. Bend it, bend it. You're going to go and stretch it further. That's a little bit more active assisted range of motion because they do some work. You do some work. All right. Uh, and that's essentially how I tell my patients.
It's literally the same [00:14:00] way. So I hope this video helps to guide your thinking and, um, breaks down passive, active and active assisted for you. Hey, listen, I hope you enjoyed that video. If you have any follow up questions, leave me a comment below. And if you're interested in any of the programs I have, the links are below as well.
