CHAPTER 8

Active & Passive Exercises

(Movements)
2nd Year Physiotherapy — Visual Study Guide

📋 📌 This chapter covers: Types of exercises, Muscle contractions, Resistance training,

Exercise regimens (DeLorme, Oxford, DAPRE, MacQueen), Passive movements, CPM,
Mobilization, Stretching techniques
 SECTION 1: INTRODUCTION & CLASSIFICATION OF
EXERCISES

▶ What Are Therapeutic Exercises?

Exercises prescribed by physiotherapists for treating illness, injury, and disability. They help build
strength, flexibility, power, and endurance. A physiotherapist must know anatomy, kinesiology, and
physiology to prescribe these correctly.

◆ Classification of Exercises
Type Who Performs It? Examples
A. Active Exercises Patient performs Walking, lifting arms
independently using own
muscles
B. Active Assisted Patient + therapist/device Assisted arm raise with sling
helps
C. Passive Exercises Therapist/device — no CPM machine, manual ROM
muscle effort from patient
D. Resisted Exercises Patient works against Weights, therabands, pulleys
external resistance

▶ A. Active Exercises — Types of Muscle Contraction

◆ I. Isometric (Static) Exercise
• Definition: Muscle contracts but NO joint movement — muscle length stays same
• Example: Pushing against a wall, tightening quadriceps without bending the knee
• Uses: When joint movement is painful or restricted (post-surgery, fractures)

Isometric Exercise — Key Points

• Tension develops but muscle length does NOT change
• No joint movement occurs
• Blood pressure rises (due to valsalva effect) — caution in cardiac patients
• Good for early rehab when movement is not possible
• Multi-angle isometrics: done at multiple joint angles (0°, 30°, 60°, 90°) for full strength
• Precautions: Can raise BP; not ideal for cardiac patients
• Limitations: Strength gain is angle-specific; no functional carry-over; no endurance gain

◆ II. Isotonic (Dynamic) Exercise

• Definition: Muscle contracts WITH joint movement — muscle length changes
• Constant tension/load throughout the movement
• Two subtypes: Concentric and Eccentric

Feature Concentric Eccentric

Muscle length Shortens Lengthens
Force vs Resistance Muscle force > resistance Resistance > muscle force
Energy use Higher energy needed Lower energy, but more
DOMS
Example Lifting a dumbbell (bicep Lowering the dumbbell slowly
curls up)
DOMS risk Lower Higher (2 days after exercise)
Strength gain Good Greater strength gain
Metabolic demand Higher Lower
Motor unit recruitment More needed Less needed

🧠 🧠 MEMORY TIP: Concentric = COME together (muscle shortens). Eccentric = EXIT

lengthening (muscle gets longer). Think: Curl UP = concentric; Lower DOWN =
eccentric.

◆ III. Isokinetic Exercise

• Definition: Movement at a constant speed (velocity) — resistance varies with effort
• Requires special machines (e.g., Cybex, Biodex)
• Speed stays constant (usually 30–300°/sec); resistance automatically adjusts
• Benefits: Full-range strengthening, objective testing, safe
• Disadvantage: Needs expensive equipment

Feature Isometric Isotonic Isokinetic

Movement No Yes Yes
Speed Zero Variable Constant
Resistance Fixed Fixed Varies with effort
Equipment None needed Weights/bands Special machine
Best for Early rehab, General Assessment & rehab
immobilized joints strengthening

▶ Open vs Closed Kinematic Chain Exercises

OPEN Kinematic Chain (OKC) CLOSED Kinematic Chain (CKC)
 ─────────────────────────
Distal segment is FREE (not fixed) ─────────────────────────
Only one joint moves Distal segment is FIXED (on ground/surface)
Example: Leg extension machine Multiple joints move together
Example: Bicep curls Example: Squats
More stress on joint Example: Push-ups
More functional, safer for joints

▶ Isokinetic — Benefits Detailed

• Improves muscle tone, strength, coordination, and endurance
• Helps in neuromuscular coordination and re-learning movement patterns
• Consistent resistance at all points in ROM
• Allows objective measurement of limb strength

▶ Stabilization Exercises
• Low-intensity isometric contractions to stabilize joints
• Especially important in weight-bearing joints (spine, hip, knee)
• Done in various ranges — no movement produced
• Helpful in acute stage of disease or injury
 SECTION 2: ACTIVE EXERCISES IN DETAIL

▶ FREE Exercises (Active Free)

Exercises performed using body weight only — no external resistance, no assistance.
• Advantages:
– Improves motor control and coordination
– Increases circulation, ventilation, and lymphatic flow
– Prevents deformity and tightness
– Can be localized or generalized
– Induces relaxation of muscles
• Disadvantage: Cannot provide progressive resistance for strength building

Type Description Power of Muscle Required

Localized Free Exercise Works a specific muscle/joint Grade 3 (can work against
area gravity)
Generalized Free Exercise Whole body movements like Grade 2–3 (MRC scale)
walking, jogging, dancing

▶ ASSISTED Exercises (Active Assisted)

Patient uses own muscles but needs help to complete the movement due to weakness (muscle
power < Grade 3).

◆ Types of Assisted Exercise

• Manual Assisted: Done by therapist/relative using hands
• Mechanical Assisted: Done using slings, suspension therapy, pulleys, springs, hydrotherapy

◆ Auto-Assisted Exercise
• Patient uses their own stronger limb to assist the weaker limb
• Example: Using right (healthy) arm to lift the left (weak) arm
• Good for bilateral involvement — patient becomes independent

Principles of Active Assisted Exercise

• Assistance should be given in the middle range of motion
• Gradually reduce assistance as strength improves
• Command should guide patient clearly
• Speed should be low (allowing the patient to focus)
• Concentration of patient is important — they should focus on the activity
• Prevents muscle atrophy and maintains joint range
◆ Effects and Uses of Assisted Exercise
• Builds confidence — patient feels they can move
• Maintains and increases ROM in bed-ridden/pathological states
• Strengthens weak muscles, promotes elasticity of connective tissues
• Useful for early rehab after surgery or prolonged immobilization
• Prevents osteoporosis by pulling on bone through muscle tendons

▶ RESISTED Exercises
Patient works against an external resistance that is greater than normal to build strength and
endurance.

◆ Mechanical Equipment for Resisted Exercise

Equipment Description
Free weights (dumbbells) Most common — gravity is the resistance
Pulleys & weights Change direction of force
Therabands / Thera-tubing Elastic resistance — portable and cheap
Spring resistance Uses spring tension
Hydrotherapy Water provides resistance (buoyancy also
assists)
Gymnasium equipment Leg press, lat pull-down machines, etc.

◆ Types of Resisted Exercise

• Manual Resisted: Therapist/patient applies resistance by hand — very adaptable
• Mechanical Resisted: Uses devices like weights, bands, pulleys
• Dynamic resisted = concentric/eccentric contractions
• Static resisted = isometric contractions against resistance

▶ Plyometric Exercises
• Definition: Explosive exercises — eccentric (lengthening) immediately followed by concentric
(shortening)
• Trains the stretch-shortening cycle of muscle
• Examples: Jump squats, box jumps, hopping, sprinting
• Used in sports rehabilitation for athletes
• Develops power (force × velocity)
 SECTION 3: EFFECTS OF ACTIVE FREE EXERCISE ON
THE BODY

▶ Systemic Effects of Exercise

Body System Effect of Exercise
Muscles Increases strength, hypertrophy, endurance,
and coordination
Cardiovascular Increases heart rate, stroke volume, cardiac
output, VO2
Respiratory Increases depth and frequency of breathing,
better gas exchange
Lymphatic Promotes lymphatic return, reduces edema,
prevents DVT
Nervous System Improves neuromuscular coordination,
reduces fatigue time
Bones Prevents osteoporosis through mechanical
loading (Wolff's Law)
Skin Increases blood flow to skin, improves
nutrition
Mental health Increases confidence, reduces depression,
improves self-image

💡 💡 'Use it or lose it!' — Muscles not exercised regularly lose strength (atrophy).
Regular exercise prevents this and builds functional capacity.

▶ Prevents Deformity & Tightness

• Prevents contractures (shortening of muscles/soft tissue)
• Regular ROM exercises maintain length and flexibility
• Prevents joint stiffness and maintains joint nutrition through synovial fluid
 SECTION 4: RESISTANCE TRAINING — PRINCIPLES &
PRESCRIPTION

▶ Key Principles of Resistance Training

◆ 1. Overload Principle
• To gain strength, the muscle must work harder than normal
• Progressive increase in resistance, reps, or sets over time
• Body adapts → then overload again = continuous progression

◆ 2. Specificity (SAID Principle)

• Specific Adaptation to Imposed Demands
• Training effects are specific to the type of exercise, speed, and joint position
• Train the way you want to perform!
• Examples: Endurance training → improves endurance; Speed training → improves speed

◆ 3. Reversibility
• If training stops, strength gains are gradually lost (detraining)
• Strength loss begins within 1–2 weeks of cessation
• Endurance is lost faster than strength

◆ 4. Inter-individual Variability
• Different people respond differently to same training stimulus
• Factors: genetics, age, sex, initial fitness level
• Individualize programs accordingly

▶ Determinants of Resistance Training (How to Modify?)

Determinant How It Changes Training Clinical Note
Altering the Weight Increase/decrease load for Most common way to
overload or recovery progress
Altering the Leverage Move resistance Shorter lever = easier
closer/farther from pivot point
Altering the Speed Faster = more cardiovascular Use slow speed for weak
demand; Slower = more muscles
control
Natural Speed Natural movement speed Good for coordination
requires less effort training
 ▶ Exercise Prescription Parameters
• Mode — Type (manual, mechanical)
• Intensity — Amount of resistance (% of 1 RM)
• Volume — Total reps × sets in a session
• Frequency — Number of sessions per week
• Rest interval — Time between sets
• Speed of exercise — Slow for weak; faster as strength improves
• Periodization — Systematic variation in intensity and volume to prevent plateau

📌 📌 Follow Warm-up → Main Exercise → Cool Down protocol before and after every
resistance session to prevent injury.
 SECTION 5: REPETITION MAXIMUM & EXERCISE
REGIMENS

▶ What is 1 RM (Repetition Maximum)?

• 1 RM = Maximum weight a muscle can lift ONCE through full ROM
• Used as baseline to calculate training loads (%)
• 10 RM = max weight lifted 10 times before failure
• Used in DeLorme and other protocols to guide progressive resistance

▶ Training Zone Using RM

Goal % of 1 RM Reps Sets
Maximum Strength 85–100% 1–6 reps 3–5 sets
Hypertrophy (muscle 67–85% 6–12 reps 3–4 sets
size)
Endurance 50–67% 12–20+ reps 2–3 sets
Power (explosive) 30–70% 3–6 reps (fast) 3–5 sets

▶ Exercise Regimens — The 4 Famous Protocols

◆ 1. DeLorme Technique (Progressive Resistive Exercise — PRE)

• Most classic resistance training protocol in physiotherapy
• Uses 3 sets of 10 RM

Set Load Purpose

Set 1 1/2 of 10 RM (50%) Warm-up
Set 2 3/4 of 10 RM (75%) Intermediate
Set 3 Full 10 RM (100%) Actual training
• 10 RM is reassessed every week and adjusted
• Starts light → builds to heavy (ascending)

◆ 2. Oxford Technique
• Opposite of DeLorme — starts heavy, ends light (descending loads)
• Also uses 3 sets of 10 RM
 Set Load
Set 1 Full 10 RM (100%)
Set 2 3/4 of 10 RM (75%)
Set 3 1/2 of 10 RM (50%)
• Starts heavy to fatigue muscle at peak — then active recovery

◆ 3. MacQueen Technique
• Uses 4 sets, frequency: 4 sessions/week (Monday, Wednesday, Friday + one more)
• First week: 10 RM × 10 times × 3 sets
• Progresses weekly — every 1–2 weeks, weight increases by ~1 kg
• Suitable for general strength and hypertrophy

◆ 4. DAPRE Technique (Daily Adjustable Progressive Resistance Exercise)

• Most sophisticated protocol — adjusts load daily based on performance
• Uses 4 sets:
Set Load Reps
Set 1 50% of Working Weight 10 reps
(WW)
Set 2 75% of WW 6 reps
Set 3 100% of WW As many as possible (AMAP)
Set 4 Adjusted WW (based on Set AMAP
3 performance)

Reps in Set 3 Adjustment for Set 4 Next Session WW

0–2 reps Decrease by 2.5–5 lb Decrease by 2.5–5 lb
3–4 reps Decrease by 0–2.5 lb Keep the same
5–6 reps Keep the same Keep the same
7–10 reps Increase by 2.5–5 lb Increase by 2.5–5 lb
11+ reps Increase by 5–7.5 lb Increase by 5–10 lb

🧠 🧠 MEMORY: DAPRE = Daily Adjustable PRE. It adjusts every single day based on
what you did. Most clinical and responsive protocol.

▶ Exercise Regimen Comparison Chart

Protocol Sets Starting Load Progression Unique
 Feature
DeLorme 3 × 10 RM Light (50% Weekly Ascending loads
10RM)
Oxford 3 × 10 RM Heavy (100% Weekly Descending
10RM) loads
MacQueen 4 × 10 RM Medium Weekly +1kg 4 sessions/week
DAPRE 4 sets 50% WW Daily Auto-adjusts
every session
 SECTION 6: PASSIVE EXERCISES & PASSIVE
MOVEMENTS

Passive movements are done WITHOUT the patient's active muscle effort. The movement is
produced entirely by an external force (therapist, machine, gravity).

▶ Types of Passive Movements

Type Description Who Performs
Relaxed Passive Gentle movements within Physiotherapist
pain-free range by therapist
Passive Mobilization Techniques to restore joint Physiotherapist (manual)
mobility
Passive Stretching Prolonged stretch of tight soft Therapist or device
tissues
CPM (Continuous Passive Machine moves joint Machine (CPM device)
Motion) continuously
Manipulation High velocity thrust to joint Trained therapist/surgeon

▶ Principles of Passive Movement

• Patient must be fully relaxed — comfortable position
• Therapist supports the part being moved
• Movement within pain-free range (except for specific therapeutic stretching)
• Slow, smooth, rhythmic movements
• Follow the Concave-Convex Rule (see mobilization section)

▶ Relaxed Passive Movements — Goals

• Maintain ROM of joints and extensibility of soft tissues
• Prevent contractures and joint stiffness
• Maintain circulation and prevent DVT
• Reduce pain (gate control theory)
• Maintain sensation/proprioception in patients who cannot move
• Maintain memory of movement (psychological effect)
• Done twice daily is sufficient for maintaining range

▶ Continuous Passive Motion (CPM)

• A machine that moves the joint passively through a set range, continuously
• Used post-operatively (especially after knee replacement, shoulder surgery)
• Benefits: prevents adhesion formation, promotes cartilage nutrition, reduces pain
• Patient does NOT need to actively participate
• Passive movements classified into: Active force (therapist/patient) vs Passive force
(machine/external)

▶ Passive Manual Mobilization Techniques

◆ Concave-Convex Rule
Determines the direction of glide during joint mobilization:

Convex surface moving on Concave: Concave surface moving on Convex:

─────────────────────────── ────────────────────────────
─ Glide direction = SAME as bone movement
Glide direction = OPPOSITE to bone Example: Tibia (concave) moving on femur
movement (convex)
Example: Femoral head (convex) moving Glide = same direction
on acetabulum (concave)
Glide = opposite direction

◆ Accessory Movements
• Small movements within the joint that CANNOT be performed voluntarily
• Include: gliding, spinning, rolling
• Essential for full and pain-free physiological movement
• Can only be assessed and restored by therapist through manual techniques

◆ Manipulation of Joints
• High velocity, low amplitude thrust movements
• Performed under anesthesia (by surgeon) or in clinic (by trained physiotherapist)
• Used for chronic stiffness, hypomobility
• Grades (Maitland's grading):
Grade Range Used For
Grade I Small amplitude, at start of Acute pain, high irritability
range
Grade II Large amplitude, mid-range Pain
Grade III Large amplitude, at end of Stiffness + some pain
range
Grade IV Small amplitude, at end of Stiffness
range
Grade V Thrust beyond end-range Chronic stiffness
(manipulation)
◆ Principles of Passive Manual Mobilization
• Initial assessment of joint (ROM, end-feel, pain)
• Stabilize proximal segment, mobilize distal
• Follow Concave-Convex rule for direction
• Duration: 15–30 seconds per technique, repeated 3–5 times
• Patient must be relaxed; anesthesia used for high-grade manipulation
• Any gain must be maintained by regular exercises and functional integration
 SECTION 7: STRETCHING TECHNIQUES

Stretching = application of manual or mechanical force to elongate shortened soft tissues (muscles,
tendons, ligaments, fascia, capsules).

▶ Goals of Stretching
• Restore or increase range of motion
• Correct positional deformities (e.g., clubfoot)
• Reduce muscle spasm and tone
• Prepare muscle for exercise (warm-up) or recovery (cool-down)
• Prevent injury

▶ Types of Stretching
◆ 1. Passive Stretching
• Therapist applies force — patient is relaxed
• More effective than active stretching for very tight tissues
• Must be within pain tolerance

◆ 2. Active Stretching / Self-Stretching

• Patient stretches themselves independently
• Home exercise program — patient performs autonomously
• Patient contracts the opposite muscle to stretch the tight one

◆ 3. Static Stretching
• Most common stretching technique
• Muscle is slowly elongated to point of resistance/discomfort
• Held at that point for 15–60 seconds
• No bouncing — sustained gentle hold
• Duration per stretch: 15–30 seconds (ACSM recommendation)
• Most studies show 30-second holds are most effective

◆ 4. Static Progressive Stretching

• Stretches muscle to the end of range and holds, then progressively increases the stretch
• Each increment held for a short time
• Good for rigid, shortened tissues

◆ 5. Cyclic (Intermittent) Stretching

• Repeated short-duration stretches (5–10 sec) with rest between
• Muscle is stretched, released, then stretched again repeatedly
• Good for less tolerated patients

◆ 6. Ballistic Stretching
• High-speed, bouncing stretching using body momentum
• Risk of injury due to triggering stretch reflex
• NOT recommended for rehabilitation patients
• Only used in trained athletes

◆ 7. PNF Stretching (Proprioceptive Neuromuscular Facilitation)

• Most effective stretching technique for increasing ROM
• Uses neuromuscular mechanisms (Golgi Tendon Organs, muscle spindles)
• Involves: active contraction + relaxation + stretch sequence
• Hold-Relax technique: Isometric contraction of tight muscle → relax → therapist passively
stretches
• Contract-Relax technique: Isotonic contraction → relax → stretch
• Hold-Relax-Active-Contraction: Tight muscle contracts → relax → patient actively contracts
antagonist

🧠 🧠 PNF Works Because: Contracting a muscle maximally then relaxing it causes

autogenic inhibition (GTO fires, muscle relaxes more deeply). This allows greater ROM
than passive stretching alone.

▶ Duration of Stretching
• Stretch duration: 15, 30, 45, or 60 seconds — all show benefit
• Most research supports 30 seconds for optimal gains
• Total stretching time per muscle = 60–90 seconds (e.g., 3×30 sec or 2×45 sec)
• Frequency: 2–7 days/week recommended
• Warm tissue stretches more effectively (stretch after warm-up or hot pack)

▶ Parameters of Stretching Exercises (Critical Table)

Parameter Recommendation
Duration per stretch 15–60 seconds (30 sec most effective)
Repetitions 2–4 times per muscle group
Frequency 2–7 days per week
Total stretch time/muscle 60–90 seconds total
Intensity Mild to moderate discomfort — never pain
Position Warm muscles; comfortable, supported
 position

▶ Mechanical Stretching
• Devices like CPM, traction, orthotics, splints, weight cuffs used
• Low force, prolonged duration = most effective for permanent elongation
• Especially useful for contractures resistant to manual stretching

▶ Contraindications for Passive Stretching

DO NOT Stretch when:
• Recent fracture (bony block present)
• Acute inflammation or infection
• Haemophilia or bleeding disorders
• Loose body in joint
• Acute tendon repair/transfer
• Osteoporosis (risk of fracture)
• Early tendon repair
 SECTION 8: INTERVAL TRAINING & CIRCUIT TRAINING

▶ Interval Training
• Definition: Alternating periods of HIGH-intensity exercise with rest/low-intensity recovery
• Improves both cardiovascular and muscular endurance
• Example: Sprint 30 sec → Walk 30 sec → Sprint 30 sec → ...
• Allows higher total training volume than continuous exercise
• Includes: running, cycling, rowing, swimming

▶ Circuit Training
• A series of exercises (stations) targeting different muscle groups, performed one after another
• Primarily a resistance-based workout with some endurance component
• Patient moves through each station with minimal rest between
• Good for total body conditioning in rehabilitation
• Develops strength, endurance, and cardiovascular fitness together

▶ Negative Resisted Exercise (Eccentric Focus)

• Patient slowly lowers weight (eccentric phase) with a constant load
• Creates controlled mechanical stress on muscles/tendons
• Improves tendon healing (used in tendinopathies like Achilles tendinopathy)
• Dynamic variable resistance: resistance changes through the ROM
 SECTION 9: QUICK REVISION — IMPORTANT TERMS &
CONCEPTS

▶ Muscle Grading (MRC Scale)

Grade Description Exercise Type to Use
Grade 0 No contraction at all Passive exercises only
Grade 1 Flicker/trace of contraction Passive + electrical
stimulation
Grade 2 Movement with gravity Assisted exercise (horizontal)
eliminated
Grade 3 Movement against gravity Free active exercise
only
Grade 4 Movement against some Resisted exercise (light)
resistance
Grade 5 Normal strength Progressive resistance

▶ Key Terms at a Glance

Term Meaning
1 RM Max weight lifted ONCE through full ROM
10 RM Max weight lifted 10 times before failure
SAID Specific Adaptation to Imposed Demands
(Specificity principle)
DAPRE Daily Adjustable Progressive Resistive
Exercise
CPM Continuous Passive Motion (machine)
PNF Proprioceptive Neuromuscular Facilitation
(stretching)
OKC Open Kinematic Chain (distal segment free)
CKC Closed Kinematic Chain (distal segment
fixed)
DVT Deep Vein Thrombosis (prevented by
passive/active ex.)
DOMS Delayed Onset Muscle Soreness (occurs
after eccentric ex.)
GTO Golgi Tendon Organ (causes autogenic
inhibition in PNF)
ROM Range of Motion
WW Working Weight (used in DAPRE)

▶ Common Exam Questions — MCQ Hints

Most Likely Exam Topics
• Concentric vs Eccentric: Which causes more DOMS? → Eccentric
• Which is best for early rehab when joint can't move? → Isometric
• DeLorme starts with ___? → Light (50% 10RM) and goes heavy
• Oxford starts with ___? → Heavy (100% 10RM) and goes light
• DAPRE adjusts how often? → Daily (every session)
• PNF most effective for? → Increasing ROM
• CPM is used for? → Post-operative joint (passive machine movement)
• Concave on Convex: glide goes SAME direction
• Convex on Concave: glide goes OPPOSITE direction
• Static stretching hold time = 15–60 sec (optimally 30 sec)
• Ballistic stretching is NOT recommended in rehab (injury risk)
• Grade 3 muscle → needs FREE active exercise (can work against gravity)
• Grade 2 muscle → needs ASSISTED exercise (cannot work against gravity)

🌟 🌟 STUDY TIP: Make flashcards for each regimen (DeLorme, Oxford, DAPRE,
MacQueen) with their sets and progression. These are highly testable! Draw a flow chart
for Concentric → Eccentric differences.

Chapter 8 — Active & Passive Exercises | Physiotherapy Study Guide | Prepared for 2nd Year BPT Students