Range of Motion and Muscle Strength Assessment

Range of Motion (ROM)

• Normal ROM values:
  • Flexion: 45-50°
  • Extension: 45-50°
  • Lateral flexion: 40-45°
  • Rotation: 80-90°
• ROM assessment:
  • Active ROM: patient performs movement
  • Passive ROM: examiner performs movement
  • Compare ROM values to opposite side and normal values
• ROM limitations:
  • May indicate joint or muscle dysfunction
  • May be due to pain, stiffness, or muscle guarding

Muscle Strength

• Muscles to assess:
  • Neck flexors (scalene and suboccipital muscles)
  • Neck extensors (trapezius and rhomboids)
  • Rotators (sternocleidomastoid and scalene muscles)
• Muscle strength grading:
  • 0: no muscle contraction
  • 1: flicker or trace of muscle contraction
  • 2: active movement with gravity eliminated
  • 3: active movement against gravity
  • 4: active movement against resistance
  • 5: normal muscle strength
• Muscle strength testing:
  • Manual muscle testing (MMT) or handheld dynamometry
  • Compare strength values to opposite side and normal values

Ligamentous Instability

• Ligamentous instability signs:
  • Excessive movement or laxity
  • Pain or tenderness over ligamentous structures
  • Abnormal or asymmetric movement patterns
• Ligamentous instability tests:
  • Anterior shear test
  • Posterior shear test
  • Lateral shear test
  • Alar ligament test
  • Transverse ligament test
• Ligamentous instability grading:
  • Grade I: slight increase in movement
  • Grade II: moderate increase in movement
  • Grade III: significant increase in movement
  • Grade IV: grossly unstable or unstable in multiple directions

Range of Motion (ROM)

• Normal ROM values for flexion, extension, lateral flexion, and rotation are 45-50°, 45-50°, 40-45°, and 80-90°, respectively.
• Active ROM assessment involves the patient performing movement, while passive ROM assessment involves the examiner performing movement.
• ROM values should be compared to the opposite side and normal values to identify any limitations.

Muscle Strength

• The muscles to be assessed in the neck region include neck flexors (scalene and suboccipital muscles), neck extensors (trapezius and rhomboids), and rotators (sternocleidomastoid and scalene muscles).
• Muscle strength grading is a 6-point scale, ranging from 0 (no muscle contraction) to 5 (normal muscle strength).
• Manual muscle testing (MMT) or handheld dynamometry can be used to assess muscle strength, and values should be compared to the opposite side and normal values.

Ligamentous Instability

• Signs of ligamentous instability include excessive movement or laxity, pain or tenderness over ligamentous structures, and abnormal or asymmetric movement patterns.
• Various tests, such as anterior shear, posterior shear, lateral shear, alar ligament, and transverse ligament tests, can be used to assess ligamentous instability.
• Ligamentous instability can be graded on a 4-point scale, ranging from Grade I (slight increase in movement) to Grade IV (grossly unstable or unstable in multiple directions).

Thoracic Spine

• The thoracic spine is the second segment of the spine, located between the cervical and lumbar vertebral segments.
• It consists of 12 vertebrae, separated by intervertebral discs, and forms part of the thoracic cage.
• The thoracic spine lies in the upper back and provides attachment for the ribs.
• A natural, slight kyphotic curve exists in the thoracic spine.

Observations

From the Side

• Kyphosis (posterior convexity of the spine) can be observed, which may be senile kyphosis, Scheuermann's disease, gibbus, fracture, tuberculosis of the spine, or congenital abnormality.

From the Behind

• Listing of the trunk (due to muscle spasm) can be observed.
• Scoliosis (lateral curvature of the spine) can be observed, which may be postural (disappears with forward flexion of the spine) or structural (persists with forward flexion of the spine).
• The scapula can be observed, with the spina scapula at T3, the end of the scapula at T7-T9, and the medial border of the scapula and spinous processes 5 cm apart.

Palpation

• Skin temperature, soft tissues, tenderness, and the prominence of bones, vertebrae, and ribs can be palpated.
• The position of the sternum, ribs, clavicle, sternocostal and costochondral joints can be palpated in the supine position.
• The spinous process, costotransverse, and costovertebral joints can be palpated in the prone position.

Measurement of Scoliosis

• Inspection: one shoulder blade being more prominent than the other, or leaning to one side.
• Palpation: uneven shoulders, hips, waist, legs, or rib cage.
• Special tests: Adam's forward bend test.
• X-ray: Cobb angle, with 25-30 degrees being significant and 45-50 degrees being severe.

Measurement of Kyphosis

• Inspection, palpation, and X-ray: Cobb angle.

Flexion

• Starting position: tape is placed proximally on the spinous process of C7 and distal to S1.
• Ending position: following flexion of the vertebral using the same landmark.
• ROM: approximately 4 inches.
• Precaution: the pelvic and hip joints are stabilized.
• Factors limiting ROM: tension of spinal extensor muscles, contact of the last ribs with the abdomen, bone blockage, and tension of ligaments.

Extension

• ROM: 2 inches.
• Precaution: prevent hip extension and trunk rotation.
• Factors limiting ROM: tension of anterior abdominal muscles, contact of spinous processes, and tension of the longitudinal ligament of the spine.

Lateral Flexion

• Position: standing erect.
• Goniometer: axis at S1 spinous process, stationary arm vertical, moving arm at C7 spinous process.
• ROM: 20-40 degrees.
• Stabilization: the pelvis is stabilized.

Rotation

• Position: sitting without back support, feet flat on the floor.
• Goniometer: axis at the center of the superior aspect of the head, stationary arm aligned with the anterior superior iliac spines, moving arm aligned with the acromion processes.
• ROM: 45 degrees.
• Stabilization: the pelvis is stabilized.
• Precaution: prevent pelvic rotation, avoid trunk flexion, extension, and lateral flexion.
• Factors limiting ROM: tension of oblique abdominal muscle of opposite side being tested, tension of costovertebral ligament in the thoracic area, and interlocking of articular facets in the lumbar area.

Tests

• Bevor's sign
• Adam's forward bend test: the patient bends forward, starting at the waist, with the feet together, arms hanging, and knees in extension. The examiner looks along the horizontal plane of the spine for abnormalities of the spinal curve, such as increased or decreased lordosis/kyphosis, and asymmetry of the trunk. A positive test is indicated if asymmetry is observed (one side of the spine is higher than the other).