PE1 unit 2

• Range of Motion is used to describe the motion at a joint or body part.

Types of Range of Motion

• Active Range of Motion (AROM) involves the patient moving a joint themselves.
• Active Assistive Range of Motion (AAROM) involves the patient moving a joint with some assistance.
• Passive Range of Motion (PROM) involves someone else moving the patient's joint.
• Gravity Resisted Range of Motion is movement performed against the force of gravity.
• Gravity Assisted Range of Motion is movement aided by gravity.
• Gravity Eliminated/Minimized ROM is movement performed in a way that reduces the effect of gravity.

Gravity's Effect on Range of Motion

• Gravity can resist, assist, or be minimized/eliminated during range of motion exercises.

End Feel

• End feel is the resistance felt at the end of passive movement.

Capsular Pattern

• A capsular pattern is a joint-specific pattern of motion restriction that is due to impairment or pathology.
• Capsular patterns can be associated with pathology in the joint and/or capsular fibrosis.

Why knowing the Terms and Motion of ROM are important

• Safety is paramount
• Knowing strength level
• Assists with correct assessment of patient impairments
• Helps determine appropriate level of intervention

Physical Therapists measure joint range of motion to:

• Determine causes of pain (body structure impairments).
• Identify potential causes of activity and participation limitations.
• Observe movement patterns contributing to inefficient mobility.
• Support the need for physical therapy intervention.
• Measure progress toward PT and patient goals.

Factors Affecting ROM:

• Ligament and joint capsule laxity
• Range of motion
• Extension/flexibility of the skin and subcutaneous tissue
• Build/body composition
• Age
• Gender
• Culture, occupation and recreation

Brief Checklist for ROM Procedure:

• Explain the procedure to the patient. Use terminology they understand.
• Position the patient for accuracy and reproducibility of measurements.
• Stabilize the proximal bone/joint segment and support the moving segment.
• Estimate ROM measurement and determine end-feel for PROM.
• Palpate bony landmarks and properly align goniometer.
• Read the goniometer and record the range of motion.

ROM Checklist: Explanation to the Patient

• Use layperson's terminology.
• Show the tool to be used.
• Explain patient position for measurement.

ROM Checklist: Patient Position

• The patient should be positioned for optimal measurement accuracy.
• The joint being measured should be in the starting position.
• Ensure that the position allows for proper stabilization of the proximal segment.
• Ensure that bony landmarks can be palpated and are properly aligned for goniometer placement.
• The joint should be able to move through its full available motion and not be blocked.
• Ensure the correct testing position can be achieved by the patient.

ROM Checklist: Stabilization

• Ensure proper stabilization of the proximal bone/joint segment.
• Make sure the moving segment has support.
• Isolate the motion being measured.
• Prevent substitutions.

ROM Checklist: ROM and End Feel

• Patient moves through the desired AROM; measure AROM if desired.
• Therapist moves the joint through PROM with proper stabilization and support.
• Tissue resistance felt at the end of the motion determines the "end feel."
• Soft: soft tissue approximation, like muscle compressing muscle.
• Hard: bony approximation.
• Firm: tissue resistance from contractile structures, joint capsule, and ligaments.
• Visually estimate the range of motion in degrees and the end-feel quality.
• PROM can be performed first or second to help patient understand the movement.

ROM Checklist Expanded: Goniometer

• Palpate bony landmarks and properly align the goniometer.
• Identify the goniometer arm, moving arm, and axis/fulcrum targets.
• The goniometer fulcrum can move during ROM if the joint axis is not stationary.
• Align the goniometer with the joint motion being measured.
• Adjust moving arm reading as needed.

ROM Checklist Expanded: Test Results

• Read the goniometer and record the range of motion.
• Move the extremity in the opposite direction of the tested motion to establish a zero-degree starting position.
• Document the patient's PROM with a beginning and ending point. Example- 0 -180 degrees.

ROM Procedure: Interpretation

• Note if patient symptoms were reproduced or if it was painful, and where.
• AROM implicates contractile or passive tissues; PROM implicates passive tissues.
• Compare the range of motion quantity to AAOS (or AMA) standards.
• Note the end feel of the PROM movement.
• Is it as expected?- soft, hard, firm.
• Not as expected?- pathology
• Note movement quality during PROM: clicking, crepitus, popping, or smooth movement?

Why accurate measurements are important

• Accurate ROM measurements are supported by using correct and reproducible procedure
• To determine causes of pain
• To identify potential causes of activity and participation limitations
• To observe movement patterns that may contribute to inefficient mobility
• To support the need for intervention to payors and to the patient
• To measure progress toward PT and patient goals

Joint motion:

• An integral part of human movement
• Allows efficient movement with minimal effort
• Allows normal arthrokinematics
• Allows optimal human function

What is required to achieve the highest reliability in ROM measurements?

• Use consistent Testing Positions
• Stabilize Proximally
• Palpate Anatomic Landmarks
• Use Most Appropriate Tool

Introduction to Commonly Used Tools:

• Goniometer
• Tape Measure
• Inclinometer

Goniometer:

• Stationary Arm
• Movement Arm
• Fulcrum

Palpation Basics

• Palpate skin, bone, muscle, tendon, ligaments, swollen bursae, nerves, and arteries
• Understand the anatomy
• Recognize characteristics of target structure.
• Determine application of appropriate pressure

Reliability of measurements

• Accurate palpation of ligaments is key to the reliability of a measurement
• To Maximize reliability, use the same instrument, positioning, procedure and therapist
• Utilize standardized landmark for axis, movement arm, and stationary arm of the goniometer
• Skilled palpitation to locate landmarks is key

Correct Methods of Palpation

• More pressure is not always better
• Gradually Sink into structure
• Practice palpation skills

Objectives of Joint Integrity and Accessory Mobility

• Understand osteokinematic versus arthrokinematic joint motion
• Review the different types of joints and arthrokinematic motions.
• Understand the concept of joint integrity and mobility
• Understand normal and abnormal end feels
• Understand capsular patterns of restricted joint motion
• Be able to apply the concept of end feel to joint testing

Osteokinematic Motion

• Grossly visible motion of the bones
• Described relative to 3 cardinal planes: sagittal, frontal, and horizontal

Arthrokinematic Motion

• Movement of joint surfaces relative to one another
• Allows osteokinematic motions to occur
• Three fundamental arthrokinematic motions that allow osteokinematic motion: roll, slide, spin

Arthrokinematics: Accessory Motions

• Distraction involves the separation of joint surfaces which is often used to increase stretch of the capsule.
• Compression involves the approximation of joint surfaces which improves stability of a joint and occurs with muscle contraction.

Types of Joints

• Ball and socket joints have movement in all three cardinal planes.
• Hinge joints have a spool-like surface and a concave surface.
• Saddle joints have convex surface moving on a concave surface AND concave surface moving on a convex surface, moving in perpendicular planes
• Pivot joint- pivot-like process turning within a ring or a ring on a pivot
• Gliding - flat joint surfaces that slide over each other. Movement does not occur around an axis
• Codnyloid - condylar articular surface which may articulate with one or two other surfaces. Motions include forward-backward and side-to-side motions.

Joint Integrity

• Joint integrity is assessed by considering several factors during the patient examination: AROM, PROM, Joint mobility.
• Information from assessments of joint integrity provide insight related to- capsule and joint: quantity of motion present, quality of motion, symptom reproduction, and end feel

Joint Mobility Testing

• Joint mobility testing assesses Joint-specific causes of pain, by helping determine causes for impairments
• Full joint mobility is necessary for full a ROM

Joint Mobility: Terminology

• Accessory motion includes: the motion occurring at the joint surfaces and component motion; the joint surface motions that are suspected to occur with osteokinematic motions
• Open-packed position of the joint is the anatomical position where the ligaments/capsule are on the the least slack, allowing for the greatest joint mobility
• Closed-packed position is the anatomical position where the the ligaments/capsule are on the least amount of slack, allowing for the least joint mobilit

Joint Mobility: Assessment: What is

• Involves holding one side of the joint stable, moving the other bone at the joint surface

Joint Mobility: Assessment: Gathering Data

• Symptom provocation to determine if join anatomy are causing the patient's symptoms.
• Gathering the quantity of motion, by using gliding of the joint surfaces on one another.
• And moving into the capsular resistance determines how much joint motion is present.
• The quality of motion. Normal is smooth movement, abnormal might be crepitus, clicking grinding, popping.
• The End feel. The expected to be firm resistance and with mild give due to creep of the joint capsule tissue.

Move one joint surface:

• through the full motion available, into tissue (joint capsule) resistance
• R1 is the first resistance met from the joint capsule
• R2 is pushing into the first resistance (R1), a second level of resistance will be felt as tissue elasticity is taken up. No further joint motion will occur after R2. This is where the end feel is assessed

Assess grade amount to Joint Motion

• Joint Hypermobility: excessive motion as compared to what is expected for a give joint or compared bilaterally
• Joint Hypomobility: limited joint motion as compared to what is expected for a give joint or compared bilaterally

Joint Integrity and Mobility-End Feel:

• The feeling of resistance which is experienced by the physical therapist either in the body part or within the joint capsule

Normal End Feel

• Soft is gradual incline in resistences as tissues are compressed b/t body parts
• Firm is abrupt incline in resistences with small amounts of seep
• Hard is abrupt and immediate and immediate stop as a bone connects to another bone.

Normal End Feel Characteristics and Examples

• Soft; soft tissue approximation. Ex: contact between posterior leg and thigh
• Firm; muscular stretch. Ex: passive stretch hamstring
• Firm; capsular stretch Ex: tension in anterior capsule in fingers
• Firm; ligamentiouse stretch. Ex; tension in palmer in the inferior radioulnar joint.

Abnormal End-Feels

• Same nomenclature applies: ie Soft, Firm and Hard
• But is an unexpected point in ROM, or unexpected in the joint
• Often associated with pain
• Empty end-feel

Capsular Patterns of Extremity Joints

• Shoulder (GH joint): Maximum loss of External Rotation and minimum loss of internal rotation.
• Elbow complex is flexion and extension
• Forearm is full and painless
• Wrist is is equally restricted in pronation and supination

Noncapsular Patterns of Restricted motion

• Restricted PROM that is not proportional similarly to a capsular pattern
• Caused by conditions involving features other than the entire joint capsule
• Possible causes:
• Trauma
• Ligament Shortening
• Muscle strain or muscle shortness

Possible Reasons for Altered Joint Mobility:

• Hypermobility: connective tissue disorders/laxity or trauma
• Hypomobility: Osteoarthritis, surgery, Idiopathic,Capsule inflammation/injury and poor healing

Ramifications of Altered Joint Mobility

• Hypermobility can potentialy cause: abnormal Joint stress and excessive osteokinematic motion
• Hypomobility results in: altered arthrokinematics and stress around the joint