On almost every home assessment there is a family member at the bed rail asking, "He cannot even get out of bed. Do we just have to wait until he is better before he moves?" The older man in bed often sighs and adds, "My arms and legs have no strength. However I try to move, I just cannot be bothered, so I may as well rest." Many people think that movement should only begin after recovery. This instinct sends recovery in the wrong direction. The longer movement is delayed, the faster the joints stiffen and the muscles waste.
Being unable to get out of bed does not mean lying completely still. Four types of bed exercise (joint movement, ankle pumps, bridging and isometric contractions) can still maintain joint range, promote venous return in the legs and slow muscle loss. The strength of the research evidence behind each exercise differs, though. The claim that they prevent contractures is still clinical consensus, and no rigorous RCT has confirmed it. Before starting, one basic idea needs to be clear. "Activity" for a bedbound person has two levels.
Two levels of bed exercise: the family helps, or the patient works alone
All of these are called bed exercise, but what different bedbound patients can actually do varies widely. The key is how much active strength remains. If the patient cannot exert any force, the carer has to do passive range of motion for the patient. As soon as a little strength returns, the patient should move on to active contraction as soon as possible, because force produced by the patient is the earliest and most valuable muscle stimulus. Separating these two levels first keeps the practice from being wasted.
One clinical figure is worth noting. Among critically ill patients who stayed in an intensive care unit for more than two weeks, as many as 39% had at least one joint contracture (a stiff joint that cannot be straightened) on leaving the ICU, and in 34% it was severe enough to interfere with daily life. Even when followed up after a median of 6.6 weeks, 34% of the contractures had not resolved (Clavet 2008). Once a joint contracture appears, a stiff joint is hard to stretch out even if strength training follows, so joint movement must begin early during bed rest. The Hong Kong government's elderly information website, run by the Elderly Commission and the Social Welfare Department, also lists joint movement as a basic physiotherapy care task that carers can do for older people at home.
Four types of bed exercise: joint movement, ankle pumps, bridging and isometric contraction
The four types of movement below cover three aims: keeping joint range, promoting venous return and holding on to muscle mass. Bedbound people can progress from passive assistance to active practice according to the strength they have left. Only the direction of each movement and the basic method are given here. The actual repetitions and progression are an individual prescription, and the therapist tailors them to the severity of each patient's condition.
Of the four, ankle pumps are the easiest to overlook. When family members look after a bedbound older person, daily feeding, face washing and dressing mostly focus on the hands and upper body, so the feet stay still all day. Yet it is the legs that matter most for deep vein thrombosis and calf muscle loss. Instead of treating ankle pumps as an extra exercise that takes time, they can be built into the daily care routine. Each time before turning the patient or changing a nappy, do a dozen or so ankle pumps first and move the body afterwards. This builds up enough repetitions over a day without much effort, and the carer does not feel burdened by having to find time to exercise as well.
Why bed exercises matter: preventing contractures, clots and muscle loss
When the body stops moving because of bed rest, joint range, circulation and muscle mass all decline together, and the four types of movement above each guard one of these three areas. The measured figures below show that bed exercise is not just a comfort with no effect. It is an immediate defence with a clear physiological mechanism.
Three problems that come with long bed rest
- Joint contracture: joints that do not move for a long time become stiff and shrink, and joint movement and isometric contractions are needed to keep the range
- Clot risk: long bed rest slows venous blood flow in the legs, and ankle pumps speed up venous return straight away
- Muscle loss: muscles waste quickly once the limbs are not used, and bridging and isometric contractions are needed to hold on to strength early
Measured clinical data
- On leaving the ICU, 39% of patients had at least one joint contracture, and in 34% it was severe enough to affect daily life (Clavet 2008)
- Ankle pumps raised popliteal vein blood velocity from 11 to 24 cm/s in lying, and from 3 to 18 cm/s in sitting (Stein 2009)
- After 7 days with the leg immobilised, myofibrillar protein synthesis fell 36% compared with the normal leg, and the fall reached 44% on days 2 to 7 (Kilroe 2020)
The speed of muscle loss explains why active exercises such as bridging and isometric contractions need to start early. A meta-analysis of resistance and active contraction exercise also confirmed that this kind of training effectively preserves quadriceps volume and prevents loss of thigh and calf strength (Guo 2025). To understand further how long bed rest slows recovery step by step after illness, deep vein thrombosis and pressure sores in bedbound people are the two common complications of bed rest, and they are covered in a separate article on preventing them.
Scientific evidence and clinical experience for bed exercises
The research evidence behind each bed exercise is not equally strong, and treating them all alike would harm credibility. Some movements are backed by measured data, and others are only routine clinical practice that carries low risk but has uncertain evidence. Being open about this avoids turning good intentions into a promise that they will certainly work.
- Ankle pumps promote venous return: popliteal vein velocity in lying rose from 11 to 24 cm/s, with an immediate measured effect (Stein 2009)
- Early active movement improves function: ICU patients regained independent function at discharge 59% vs 35% (Schweickert 2009)
- Early mobilisation reduces ICU-acquired weakness: early mobilisation group 2% vs usual care group 16% (Zhou 2022 EMAS)
- Resistance and active contraction prevent disuse atrophy: preserving quadriceps volume and strength (Guo 2025)
- Whether passive range of motion alone can prevent contractures: only 2 RCTs with 122 people, and ankle range improved by only about 4 degrees
- GRADE evidence level very low, and the Cochrane conclusion was that it is unclear whether passive movement is effective (Prabhu 2013)
- Still recommended clinically: low risk, and it has other benefits such as maintaining range and comfort
- But it should not be promised as a guarantee of preventing contractures. It is a good-faith measure, not a guarantee
Setting the two kinds of evidence side by side makes the direction of practice clear. The most worthwhile effort goes into ankle pumps and the various active contraction exercises, because they have measured data behind them and are easy to carry out. Passive range of motion should still continue, but expectations must be realistic. Its role is to maintain tissue flexibility and comfort, not to guarantee that no contracture will appear. Research also shows that when active movement begins early in bed and at the bedside during a hospital stay, a clearly higher proportion of patients regain self-care after discharge (Schweickert 2009; Zhou 2022). This is why the focus of rehabilitation should be on active effort as far as possible rather than relying only on others to move the patient.
Safety rules for bed exercises at home: repetitions, force and when not to exercise
Besides correct technique, problems at home more often come from judging force and choosing the time. The government elderly information website sets out several clear practical rules for home exercise for bedbound people. Following them closely keeps the risk of injury during assisted movement to a minimum.
- Practise 1 to 2 times a day, about 10 to 20 repetitions of each movement, with gentle, slow movements through the full range
- Stop when there is a slight stretch or mild resistance, and never pull hard, to avoid hurting the patient or causing a fracture
- Exercise only at least 30 minutes after a meal, and when the patient's blood pressure, pulse and breathing are stable
- As soon as the patient regains a little strength, the patient should do the exercise alone, and the carer only helps to complete the remaining range
- Do not move a joint or muscle that has acute inflammation, infection, a fracture that has not healed, or recent joint surgery
While exercising, pay attention to these points.
- Force: stop at mild resistance—When doing passive range of motion for a patient, carers easily go to one of two extremes. One is being afraid of hurting the patient and only touching lightly, so the movement never reaches the end and the effort is wasted. The other is hurrying and pulling hard, which hurts the older person. The correct way is to push the joint slowly to the point where resistance just begins to be felt, stop there, hold for a few seconds and then release slowly.
- Range: never beyond the normal joint range—People who are bedbound long term or on long-term medication usually have osteoporosis. Forcing a joint beyond its normal range can easily cause a fracture. The patient should feel no pain during practice, and each time the joint should be moved forward only a little. Do not rush to the end in one go.
- Warning signs: stop at unusual noises or discomfort—Stop at once if the joint makes an abnormal noise, the patient looks pained or has a changed colour, or breathing or pulse changes, and note down what happened. If the same movement keeps causing pain, pause the practice and have the physiotherapist assess it in detail before deciding what to do.
When a physiotherapist should step in, and carer support in Hong Kong
A physiotherapist home assessment is suitable when the family cannot tell whether to move the limbs for the patient or let the patient do it, is unsure about the force and range to use, or when a bedbound patient's progress has stalled and nothing seems to move things forward. In the home physiotherapy service provided by Nova Health, on the first visit the registered physiotherapist assesses the active muscle strength the patient still has, guides the carer in telling passive from active practice, and demonstrates the right force and range in person. The therapist also makes ankle pumps a fixed step before each turn (10 to 20 on each side). The most common oversight in caring for a bedbound patient is moving only the hands and forgetting the feet, and forgetting how important the calf muscle pump is for venous return. Building joint movement into the daily turning and chest-clearing routine means the practice gets done along the way without extra time being set aside. Practising getting out of bed is in fact the first hurdle in the move from bed to standing within the five stages of progressive rehabilitation after hospital. The joint range and active strength kept during bed rest through bed exercises are the foundation for retraining daily movements and returning to real life later.
Living spaces in Hong Kong are generally small, and the single bed or hospital bed an older person sleeps in often has one side against the wall, so the carer can only stand on the side nearer the corridor to apply force. In this situation, for passive range of motion, first work on the arm and leg nearer the corridor, then help the person to turn and work on the other side. This completes the exercise along the way and also keeps up regular turning to prevent pressure sores. For more teaching material on care skills or immediate support, the community resources below can be used.
Carer support resources in Hong Kong: the government elderly information website run by the Elderly Commission and the Social Welfare Department (elderly.gov.hk) has free teaching material in its Carers' Corner, titled 〈長者肌肉痙攣及攣縮的護理（物理治療篇）〉 (care of muscle spasm and contracture in older people, physiotherapy section, in Chinese). The Social Welfare Department also runs a 24-hour Carers Hotline on 182 183, where registered social workers provide community care information, immediate consultation and service referral.