What is the recommended protocol for range of motion (ROM) exercises?

Range of Motion (ROM) Exercise Protocol

For optimal ROM improvement, perform flexibility exercises 2-3 days per week, holding static stretches for 10-30 seconds (or 30-60 seconds in older adults), with 3-4 repetitions per stretch and 30-60 seconds rest between stretches. 1

Frequency and Timing

• Minimum frequency: 2-3 days per week is effective for improving joint ROM 1
• Optimal frequency: Daily exercise produces the greatest gains in ROM 1
• Total stretching time per exercise: Target 60 seconds total per flexibility exercise 1
• Best timing: ROM exercises are most effective when muscles are warmed through light-to-moderate aerobic activity or external heat (moist heat packs, hot baths) 1

Stretch Duration and Intensity

Static Stretching Parameters

• Hold duration for most adults: 10-30 seconds per static stretch 1
• Hold duration for older adults: 30-60 seconds may confer greater benefit 1
• Intensity: Stretch to the point of feeling tightness or slight discomfort 1
• Repetitions: 2-4 repetitions of each flexibility exercise 1
• Rest intervals: 30-60 seconds rest between stretches 1

Evidence on Duration

Research demonstrates that 15-second holds produce significantly greater improvements in active ROM compared to 5-second holds, though passive ROM improvements are similar 2. This supports the guideline recommendation of 10-30 second holds as optimal 1.

Types of Stretching Techniques

Multiple stretching modalities are effective: 1

• Static flexibility (active or passive)
• Dynamic flexibility
• Ballistic flexibility
• Proprioceptive neuromuscular facilitation (PNF)

PNF Stretching Protocol

For PNF technique: 3-6 second contraction at 20-75% maximum voluntary contraction, followed by 10-30 second assisted stretch 1

Target Areas

• Include all major muscle-tendon units in the stretching routine 1
• Use both static and dynamic techniques to stretch all major muscle groups 1

Progression Strategy

• Methods for optimal progression are not well-established 1
• Add new stretches to the routine as tolerated 1
• Progress from static poses to dynamic movements 1
• Reduce reliance on balance support as function improves 1

Population-Specific Modifications

Stroke Survivors

• Passive and active-assisted ROM exercises should be provided for both upper and lower extremities 1
• Place upper limbs in various appropriate and safe positions within the patient's visual field 1
• Combine ROM exercises with physical activity and gait training for lower limbs 1
• A nurse-led ROM program performed twice daily, 6 days per week for 4 weeks produces significant improvements in joint angles, activity function, pain perception, and depressive symptoms 3

Older Adults

• Longer hold times (30-60 seconds) are specifically recommended for this population 1
• Chair- and bed-based exercises should be considered as starting points for frail patients 1
• Focus on improving functionality through exercises that simulate activities of daily living 1

Arthritis Patients

• Exercise affected joints using a pain-free range of motion 1
• Start with repeated short bouts of low-intensity exercise daily, progressively increasing duration 1
• Avoid vigorous, repetitive exercises using unstable joints and avoid overstretching 1
• Discontinue exercise if: unusual or persistent fatigue, increased weakness, decreased ROM, or joint swelling/pain lasting >1 hour after exercise 1

Integration with Other Exercise Components

ROM exercises should be part of a comprehensive program that includes: 1

• Aerobic training: 20-60 minutes, 3-7 days per week at moderate intensity
• Resistance training: 2-3 days per week, 8-12 repetitions for most adults
• Flexibility training: As outlined above, ideally performed before or after aerobic or strength training 1

Training Duration for Sustained Benefits

• Short-term interventions (≤4 weeks): Static stretching shows significant ROM improvements 4
• Longer interventions (>4 weeks): Both static stretching and foam rolling produce similar moderate ROM increases, though longer durations are needed for foam rolling to demonstrate effectiveness 4, 5
• Interventions >4 weeks produce significantly greater ROM gains than shorter protocols 5

Common Pitfalls to Avoid

• Avoid ballistic bouncing during stretches unless specifically trained in this technique 1
• Do not stretch cold muscles; always warm up first 1
• Avoid prolonged positioning at end ranges in patients with neurological conditions, as this may exacerbate symptoms 6
• Do not push through sharp pain; discomfort should be mild tightness only 1
• Avoid morning exercise in patients with rheumatoid arthritis if significant stiffness is present 1