As Physiotherapists, we often need to improve range of motion as one of our clinical goals for injury recovery.
But with so many different treatments that aim to improve range of motion, what’s your go-to option and does the research support it?
What are our options to improve range of motion?
In the toolbox of techniques to improve range of motion, we have:
- Joint mobilisations
- Muscle stretching
- Prolonged positioning
- Serial casting
- …and many more!
Let’s put serial casting aside for the moment – it’s a very specific and unique approach for spasticity and neurological conditions so it sits in a separate basket.
Here’s a synopsis of the most common Physiotherapist techniques to improve range of motion.
Each section includes the relevant research papers, reviews and findings with links for further reading or any Physio student trying to pad out their reference list 😉
This seems to be the favoured option for so many clinicians, and there seems to be a few reasons behind it.
On whether joint mobilisation can improve range of motion, the answer is “kinda”…
It’s been shown to have a benefit for short term improvements in range, particularly after ankle sprains (as one of the most researched topics due to availability of subjects).
The debate in that improvement is centred around the mechanism – is it actually improving tissue extensibility or is it just pain modulation?
Mobilisation has been shown to be more effective at improving range in acute ankle sprains, when pain is likely to be a limiting factor.
For chronic ankle injuries, it doesn’t improve range beyond a very short term change.
So that supports the pain-modulation argument, which I think makes sense.
The forces exerted on the ankle by our hands is tiny compared to the forces experienced during running, jumping, etc.
It would be naive of us to think that we can move a joint with less force than general activity and get a better result.
And before the Mulligan camp jump up and declare that it’s the method of mobilisation that makes the difference, it’s not.
Mulligan’s mobilisations have been shown to work in conditions where pain is the limiting factor, but not in conditions with other restrictions.
If any technique has been on a roller coaster ride of in-favour, out-of-favour, it’s stretching.
Stretching was the go-to for improving range – seems logical as we all feel more flexible after stretching and hey, ballerinas stretch lots and look at their flexibility!
Then came the research that found that static stretching will only temporarily improve range of motion and most likely due to a change in stretch perception rather than muscle changes.
It only got worse for static stretching when several research studies found no effect on injury prevention.
Other papers soon followed with notes of performance decline after static stretching.
So we focused on dynamic stretching – moving in and out of stretched positions.
It got a better reception – it might help with injury prevention for muscle injuries and it didn’t see the performance decline of static stretching.
But to improve range of motion? Nope, still no ongoing changes from dynamic stretching.
All this then raised the question of “do we bother stretching or should we actively discourage it?” – more on that in another post shortly.
We’ve also got PNF stretching and other active stretches.
Research tells us that it seems to show faster improvements in muscle length but less ongoing changes once stretching has stopped.
Essentially it’s helpful while you’re doing it but don’t expect any long term changes.
That’s not to say you shouldn’t bother – most forms of stretching produce worthwhile short term effects to improve range of motion.
As a side note, using a foam roller to improve flexibility doesn’t seem to have any merit.
It seems like an odd association but using strength training to change range actually makes sense based on what we know about physiology, assuming that the muscle is the most common cause of restricted range of motion.
Strength exercises can shift the length-tension curve based on the design of the exercise.
They can also change the muscle architecture, adding sarcomeres and lengthening muscle fibres.
For a great overview (and refresher) of muscle adaptation, sarcomeres, and all that jazz, see this post from NeuRA.
So can we strength train our way to longer muscles, and therefore more flexible joints?
Research says ‘yes’, with an ‘if’…
Eccentric exercise does a good job of lengthening muscle fascicles, particularly when they’re performed at long muscle lengths.
But not all eccentric exercise will do it, depending on the parameters involved.
And it won’t improve range of motion if the muscle isn’t the primary limiting factor.
So eccentric strength will work to improve range of motion if:
- muscle length is the limiting factor,
- you get the prescription of eccentric exercise spot on, and
- you continue to do the eccentric exercise (or eccentric activities) as long as you need the change to be in effect.
It’s by no means a bulletproof strategy but it can certainly be helpful in some/most cases.
This is a little bit of a hybrid strategy to improve range of motion.
It works through the same mechanisms as the above approach with eccentric exercises in lengthened positions.
But you achieve this by modifying existing, or readily accessible, daily activities.
It may be slightly less effective as the volume of exercise might be less than an exercise session.
But it overcomes the issue of the need for ongoing exercise – it’s easier to go for a hilly walk every 2nd day than it is to perform a 30 minute eccentric strength program on an ongoing basis.
So the trade off in short term effectiveness is matched (hopefully) by long term compliance.
The real-world application of this gets the best of both.
Start with an eccentric program to get rapid changes and then use activity modification to maintain the benefits over the long term.
Adjunct approaches to improve range of motion
There’s always more than one way to approach an improvement in range.
If the limitation is due to congenital joint changes, such as hip dysplasia, you can’t just push your way through.
You’ll need to find other methods of approaching it.
One such approach is to stop is stiffening up in the first place.
To do this, you could use supportive footwear or orthotics to reduce weight-bearing hip internal rotation during walking.
With less abnormal joint loading, there should be less inflammatory response in and around the hip.
Less inflammation should lead to less stiffness, which leads to better joint range.
In the case of hip dysplasia, it doesn’t mean you’ll regain full “normal” range.
But you’ll be able to improve range of motion to its full potential given the shape of the hip joint.
Another approach might involve anti-inflammatories to reduce inflammatory response.
This can be effective in a chronic joint synovitis when the chronic nature of the inflammation leads to reduces soft tissue compliance and extensibility.
For these cases, a short course of NSAIDs should be enough to improve range of motion within a week or two.
If it hasn’t changed by then, don’t bother continuing with the approach unless there are other non-range related benefits.
Physiotherapists have so many tools to improve range of motion that we can often resort to our favourite or fall back to the most reliable option.
But the effect of each approach is very context dependent and every case needs to be evaluated on its own merits.
Good outcome measures will be your best friend here – set a goal, make it measurable and be ready to pivot your approach if it’s not living up to expectation.