Range of Motion Measurement PDF

Range of Motion Terminology 1 Range of Motion The term used to describe motion at a given joint or of a body part. 3 1  § Active Range of Motion (AROM) § Active Assistive Range of Motion (AAROM...

Range of Motion Terminology 1 Range of Motion The term used to describe motion at a given joint or of a body part. 3 1  § Active Range of Motion (AROM) § Active Assistive Range of Motion (AAROM) § Passive Range of Motion (PROM) § Gravity Resisted Range of Motion § Gravity Assisted Range of Motion § Gravity Eliminated/Minimized ROM 4 Active Range of Motion 5 2  Active-Assisted Range of Motion 6 Passive Range of Motion 7 3  Gravity and Its Effect on Range of Motion Gravity Gravity Resisted Range Gravity Assisted Range Eliminated/Minimized of Motion of Motion Range of Motion 8 § End Feel o The resistance felt by the therapist at the end of a passive movement 9 4  Capsular Pattern o A joint-specific pattern of motion restriction that is due to impairment or pathology o Associated with pathology in the joint and/or capsular fibrosis 10 Conclusion Important to know the different terms and types of motion that are assessed and used in patient intervention o Safety o Strength level o Correct assessment of patient impairments o Appropriate level of intervention 11 5  References Kisner C, Borstad J, Colby LA. Therapeutic Exercise: Foundations and Techniques. F.A. Davis Company; 2023. Norkin CC, White DJ. Measurement of Joint Motion: A Guide to Goniometry. F. A. Davis; 2016. 12 6  Range of Motion Procedures 1 Range of Motion Measurement in Physical Therapy § Joint motion is an integral part of human movement. § Full joint motion allows the individual to move efficiently and with minimal effort. § Full joint motion allows normal arthrokinematics. § Full joint motion allows optimal human function for postures, movements and performance. 2 1  Range of Motion Measurement in Physical Therapy § Physical therapists measure joint ROM: o To help determine causes of pain (body structure impairments) o To help identify potential causes of activity and participation limitations o To observe movement patterns that may contribute to inefficient mobility o To support the need for physical therapy intervention o To measure progress toward PT and patient goals 3 Factors Affecting ROM 4 2  Brief Checklist for ROM Procedure § Explain to the patient how and why ROM measurements are performed (use layperson’s terminology) § Position the patient for optimal measurement accuracy and reproducibility § Ensure proper stabilization of the proximal bone/joint segment and support of the moving segment to reduce error § 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 5 ROM Checklist: Explanation to the Patient § Explain; Use layperson’s terminology § Show the tool § Explain the patient position for the measurements 6 3  ROM Checklist: Patient Position § Position the patient for optimal measurement accuracy § Place the joint being measured in the starting position § Ensure position allows for optimal stabilization of the proximal segment § Ensure bony landmarks for goniometer placement are properly aligned and can be palpated § Ensure the joint can move through its full available motion and is not blocked § Ensure that your patient can achieve the correct testing position 7 ROM Checklist: Stabilization § Ensure proper stabilization of the proximal bone/joint segment § Ensure support of the moving segment § Isolate joint motion to be measured § Prevents substitutions § See individual ROM technique descriptions in the course material for specific stabilization and support information 8 4  ROM Checklist: ROM and End Feel § Ask the patient to move through the desired AROM. Measure AROM if desired. § Move the joint through PROM using proper stabilization and support § Gently push the part into the tissue resistance felt at the end of the motion to determine the "end feel". Soft- soft tissue approximation, ie muscle compressing muscle Hard- bony approximation Firm- firm tissue resistance from contractile structures, joint capsule, ligaments and surrounding connective tissue § Visually estimate the range of motion in degrees and establish the quality of the end- feel (soft, hard, firm) § PROM can be performed first or second; when first, it may help the patient understand the movement being performed. 9 ROM Checklist Expanded: Goniometer § Palpate bony landmarks and properly align goniometer § Identify the three bony landmarks as targets: stationary goniometer arm, moving arm, axis/fulcrum § Fulcrum can move during ROM as joint axis is not stationary § Align the goniometer with the joint motion being measured § Adjust moving arm reading as needed 10 5  ROM Checklist Expanded: Test Results § Read the goniometer and record the range of motion § Take the extremity into 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, such as 0-180 degrees 11 ROM Procedure: Interpretation § Were patient symptoms reproduced or was it painful? Location? o AROM- contractile or passive tissues implicated o PROM- passive tissues implicated § Compare quantity to the AAOS (or AMA) standard in degrees for the movement being measured § Note the end feel obtained for the PROM movement when overpressure is applied o Is it as expected? o Soft, hard, firm o Not as expected: pathology? § Make note of quality of movement for PROM: was there clicking, crepitus, popping, smooth movement? 12 6  Conclusion § Accurate ROM measurements are supported by using correct and reproducible procedure § Physical therapists use range of motion measurements for a variety of reasons To help determine causes of pain (body structure impairments) To help 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 13 Normative Values for PROM: UE 14 7 Normative Values for PROM: Spine Reese, Nancy, B. et al. Joint Range of Motion and Muscle Length Testing. Available from: VitalSource Bookshelf, (3rd Edition). Elsevier Health Sciences (US), [Insert Year of Publication]. 15 Normative Values for PROM: Spine Reese, Nancy, B. et al. Joint Range of Motion and Muscle Length Testing. Available from: VitalSource Bookshelf, (3rd Edition). Elsevier Health Sciences (US), [Insert Year of Publication]. 16 8 Normative Values for PROM: LE Reese, Nancy, B. et al. Joint Range of Motion and Muscle Length Testing. Available from: VitalSource Bookshelf, (3rd Edition). Elsevier Health Sciences (US), [Insert Year of Publication]. 17 References § Reese NB, Bandy WD. Joint range of motion and muscle length testing. 3rd ed. Elsevier; 2017. § Appendix B: Normative range of motion of the extremities and spine in adults (AAOS values) 18 9  Introduction to Commonly Used Tools Measuring Range of Motion 1 What is range of motion (ROM)? 2 1  What tools are used to measure ROM? § Goniometer § Tape Measure § Inclinometer 3 What do I need to know about goniometers? § Stationary arm § Movement arm § Fulcrum 4 2  What is an inclinometer? 5 How can a tape measure be used for range of motion assessment? 6 3 7 References Kisner C, Borstad J, Colby LA. Therapeutic Exercise: Foundations and Techniques. F.A. Davis Company; 2023. Norkin CC, White DJ. Measurement of Joint Motion: A Guide to Goniometry. F. A. Davis; 2016. 8 4  Range of Motion Measurement Accuracy 1 Why Does Accuracy Matter? 2 1  How Do We Talk About ROM Accuracy? § Validity § Reliability 3 What is the Validity? 4 2  What is Reliability? 5 What can be done to get the highest reliability in ROM measurements? § Use consistent testing positions § Stabilize proximally § Palpate anatomic landmarks § Use the most appropriate tool 6 3  References Hanks J, Myers B. Validity, Reliability, and Efficiency of a Standard Goniometer, Medical Inclinometer, and Builder's Inclinometer. Int J Sports Phys Ther. 2023;18(4):989-996. Published 2023 Aug 1. doi:10.26603/001c.83944 Johnson M, Mulcahey MJ. Interrater reliability of spine range of motion measurement using a tape measure and goniometer. Journal of Chiropractic Medicine. 2021;20(3):138- 147. doi:10.1016/j.jcm.2021.09.003 Kato M, Echigo A, Ohta H, et al. The accuracy of goniometric measurements of proximal interphalangeal joints in fresh cadavers: comparison between methods of measurement, types of goniometers, and fingers. J Hand Ther. 2007;20(1):12-19. doi:10.1197/j.jht.2006.11.015 Kisner C, Borstad J, Colby LA. Therapeutic Exercise: Foundations and Techniques. F.A. Davis Company; 2023. Norkin CC, White DJ. Measurement of Joint Motion: A Guide to Goniometry. F. A. Davis; 2016. 7 4  Introduction to Palpation for ROM measurement 1 Palpation Basics What can we palpate? § Skin, bone, muscle, tendon, ligaments, swollen bursae, nerves, arteries What do we expect to feel? § Understand the anatomy § What characteristics does the target structure have § How much pressure will be required to palpate the target structure 2 1  Reliability of Measurement § Accurate palpation of landmarks is key to reliability of the measurement § To maximize reliability – use same instrument, positioning, procedure, and therapist if possible § Utilizing standardized landmark for axis, movement arm, and stationary arm of goniometer § Skilled palpation to locate landmarks is key 3 How to Palpate § More pressure not always better § Gradually sink into structure § Practice your palpation skills 4 2  Joint Integrity and Accessory Mobility 1 Objectives Understand osteokinematic versus Understand normal and abnormal end feels arthrokinematic joint motion Understand capsular patterns of resitricted joint Review the different types of joints and motion arthrokinematic motions Understand the concept of joint integrity Understand the concept of joint mobility Be able to apply the concept of end feel to joint testing 2 1  AROM Goniometric measurement PROM Osteokinematic Goniometric measurement Movement End feel Joint integrity Hypo/hyper/normal 0-6 scale Arthrokinematic End feel movement Pain 3 Osteokinematic Motion Review § Osteokinematic motion - grossly visible motion of the bones § Described relative to the 3 cardinal planes (sagittal, frontal, horizontal) 4 2  Arthrokinematic Motion Review § Movement of joint surfaces relative to one another § Allow osteokinematic motions to occur § Three fundamental arthrokinematic motions that allow osteokinematic motion: 1. Roll 2. Slide 3. Spin 5 Arthrokinematics Roll Slide Spin § Multiple points § Single point § Single point rotates contact multiple contacts multiple on a single point points points § Toy top rotating in § Tire moving on a § Tire skidding on ice one spot road 6 3  Arthrokinematics: Accessory Motions Distraction Compression § Separation of joint surfaces § Approximation of joint surfaces § Often used in combination with § Improves stability of a joint; joint mobilisations to increase occurs with muscle contraction stretch of the capsule 7 Arthrokinematics: Concave/Convex Guidelines 8 4  Arthrokinematics: Concave/Convex Guidelines For example, for GH abduction, the convex humeral head is rolling on the concave surface of the glenoid fossa, so the roll and slide are occurring in OPPPOSITE directions 9 Types of Joints Review § Ball and socket – a sphere on the head of one bone that fits into a rounded concavity in the other bone. Movement in all three cardinal planes. § Hinge –a spool-like surface and a concave surface. § Saddle – convex surface moving on a concave surface AND concave surface moving on a convex surface, moving in perpendicular planes. 10 5  Types of Joints Review § Pivot –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. § Condyloid - condylar articular surface which may articulate with one or two other surfaces. Motions include forward-backward and side- to-side motions 11 Classification of Synovial Joints Based on Mechanical Analogy 12 6  Joint Integrity § Joint integrity is assessed by considering several factors during the patient examination: § AROM § PROM § Joint mobility § Why do we test joint integrity? § Information on capsule and joint: quantity of motion present, quality of motion, symptom reproduction, and end feel § Help determine causes for impairments 13 Joint Mobility Testing § Why do we test joint mobility? § Full joint mobility is necessary for full ROM § To assess for joint-specific causes of pain § To help determine causes for impairments 14 7  Joint Mobility: Terminology § Accessory motion: the motion occurring at the joint surfaces § Component motion: the joint surface motions that are suspected to occur with osteokinematic motions § Passive Intervertebral Motion (PIVM): a specific mobility test for segmental spinal mobility 15 Joint Mobility: Terminology § Open-packed position of the joint: the anatomical position where the joint surfaces are in the least contact and ligaments/capsule are on the most slack , allowing for the greatest joint mobility § Closed-packed position: the anatomical position where the joint surfaces are in the most contact and/or ligaments/capsule are on the least amount of slack , allowing for the least joint mobility 16 8  Joint Mobility: Assessment § What is joint mobility testing? § While holding one side of the joint stable, moving the other bone at the joint surface § What data is being gathered? § Symptom provocation. To determine if joint anatomy is causing the patient's symptoms. § The quantity of motion. Within the joint, using gliding of the joint surfaces on one another and moving into the capsular resistance to determine how much joint motion is present. § The quality of motion. Norma lis 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. Exception- some joints have other tissues that limit motion. 17 Joint Mobility: Assessment § Move one joint surface through the full motion available, into tissue (joint capsule) resistance. § R1: the first resistance met from the joint capsule as § R2: 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. 18 9  Joint Mobility: Assessment § Joint Hypermobility: excessive motion as compared to what is expected for a given joint or as compared bilaterally § Joint Hypomobility: limited joint motion as compared to what is expected for a given joint or as compared bilaterally § Typical Grading Scale Grade Description of Joint Mobility 0 Ankylosis or no detectable movement 1 Considerable limitation 2 Slight limitation 3 Normal 4 Slight increase in motion 5 Considerable increase 6 Unstable Olson, Kenneth. Manual Physical Therapy of the Spine. Available from: VitalSource Bookshelf, (3rd Edition). Elsevier Health Sciences (US) 19 Joint Integrity and Mobility: End-Feel § The feeling of resistance which is experienced by the physical therapist at the end of a passive movement, either of the body part or within the joint capsule. § The type of structure that limits joint physiologic ROM has a characteristic feel § Ligament § Muscle § Joint Capsule 20 10  Normal End-Feels § Soft – gradual increase in resistance as tissues are compressed between body parts § Firm – abrupt increase in resistance with varying amounts of creep (or give), depending on the barrier being stretched § Hard – abrupt and immediate stop as bone contacts another bone 21 Normal End-Feels Normal End-Feels End-Feel Structure Example Soft Soft tissue approximation Knee flexion (contact between soft tissue of posterior leg and thigh) Firm Muscular stretch Hip flexion with the knee straight (passive stretch hamstring) Capsular stretch Extension of MTP joints of fingers (tension in anterior capsule) Ligamentous stretch Forearm supination (tension in the palmar radioulnar ligament of the inferior radioulnar joint Hard Bone contacting bone Elbow extension (contact between olecranon of ulna and olecranon fossa of humerus) 22 11  Abnormal End-Feels § Same nomenclature: Soft, Firm and Hard § But at unexpected point in the ROM, or unexpected for a given joint § Often associated with pain § Empty End-Feel § abnormal end feel that cannot be categorized 23 Abnormal End-Feels Abnormal End-Feels End-Feel Examples Abnormal Occurs sooner or later in the ROM than is usual, Soft tissue edema Soft or in a joint that normally has a firm or hard end. Feels boggy, with fluid shift Abnormal Occurs sooner or later in the ROM that is usual, Increased muscular tonus, Firm or in a joint that normally has a soft or hard end capsular fibrosis or adhesion, feel abnormal muscular tightness, ligamentous shortening/adhesion Abnormal Occurs sooner or later in the ROM than is usual, Chondromalacia, Hard or in a joint that normally has a soft or firm end osteoarthritis, loose bodies in a A grating or bony block is felt joint, Myositis Ossificans, fracture Abnormal No real end feel because pain prevents reaching Acute joint inflammation, Empty end of ROM. No resistance if felt except for bursitis, abscess, fracture, protective muscle spasm psychogenic disorder 24 12  Capsular Pattern and Restricted Motion § Capsular Pattern - patterns of restricted motion § Joint specific patterns of restricted joint ROM § Due to intra-articular inflammation or anatomical changes involving the entire joint capsule § Measured by loss of one portion of motion relative to another § Varies from joint to joint 25 Capsular Pattern and Restricted Motion Joint effusion or synovial inflammation Relative capsular fibrosis § Entire joint capsule is distended, muscle § Decrease in extensibility of the entire spasms protect from further stretch capsule due to an increase in collagen or from internal changes to collagen tissue 26 13  Capsular Patterns of Extremity Joints Capsular Shoulder (GH joint) Maximum loss of External Rotation Moderate loss of Abduction Patterns of Minimum loss of IR Extremity (ER>Abd>IR) Joints Elbow complex Forearm Flexion>Extension Full and painless Equally restricted in pronation and supination Wrist Equal restriction in flexion and extension Flexion=Extension Hand Carpometacarpal Joint 1 Abduction and extension restriction Carpometacarpal Joint 2-5 Equally restricted in all directions Hip Max loss of IR, flexion, abduction Min loss extension Knee (Tibiofemoral joint) Flexion>Extension Ankle (talocrural joint) PF> Extension Subtalar Joint Restricted varus motion Midtarsal joint Restricted DF, PF, Abd and medial rotation Lower extremity digits MTP Joint 1 Extension>Flexion MTP Joint 2-5 Variable, tend toward flexion restriction IP Joints Tend toward extension restriction 27 Noncapsular Patterns of Restricted Motion § Restricted PROM that is not proportioned similarly to a capsular pattern § Caused by conditions involving structures other than the entire joint capsule § Internal joint derangement § Adhesion in part of a joint capsule § Ligamentous shortening § Muscle strain or muscle shortness 28 14  Noncapsular Patterns of Restricted Motion § Confirming noncapsular patterns require: § Patient history information § Observation § Palpation § A/PROM § End-feels § MMT § Joint mobility tests § Special tests 29 Possible Reasons for Altered Joint Mobility § Hypermobility § Hypomobility o Potential causes include Potential causes include § Connective tissue disorders § Fibrosis § Trauma § Adhesions/capsule restrictions § General hypermobility/laxity Possible factors § Osteoarthritis § Capsule inflammation/injury and poor healing § Sustained postures/immobility § Surgery § Idiopathic 30 15  Ramifications of Altered Joint Mobility § Hypermobility > Potential Ramifications § Hypomobility > Potential Ramifications o Altered arthrokinematics> abnormal joint Altered arthrokinematics> abnormal joint stress stress o Altered (excess) osteokinematic motion Altered (limited) osteokinematic motion § Abnormal tissue stress locally and Abnormal tissue stress locally and distally distally § Activity and participation restrictions Activity and participation restrictions § Direct § Indirect in kinetic chain 31 Conclusion § Joint integrity considers the functional status of the synovial or other joint that is being assessed. § It involves an analysis of AROM, PROM and specific joint mobility testing. § Joint mobility testing involves the therapist directly moving one joint surface on the other within the joint space. § Joints have specific end feels which are related to the joint anatomy § Joints have capsular patterns of motion limitation which are related to pathologic changes in within the joint. 32 16  References Fulk G, Chui K. O’Sullivan & Schmitz’s Physical Rehabilitation. 8th ed. F.A. Davis; 2024. Neumann, DA. Kinesiology of the Musculoskeletal System: Foundations for Rehabilitation, 3rd Edition Mosby; 2016. ISBN-13: 978-0323287531 Dutton, M. Dutton’s Orthopaedic Examination, Evaluation, and Intervention, 5th ed. McGraw Hill; 2020 S. Mattingly, James Cyriax, Textbook of Orthopaedic Medicine, Rheumatology, Volume 3, Issue 3, July 1956, Pages 112–113, https://doi.org/10.1093/rheumatology/III.3.112-b Freddy M. Kaltenborn, Olaf Evjenth. Manual Mobilization of the Joints: The Kaltenborn Method of Joint Examination and Treatment. 6th ed. Norli, 2002. Hertling D, Kessler RM. Management of Common Musculoskeletal Disorders: Physical Therapy Principles and Methods. Lippincott Williams & Wilkins; 2006 33 17 RISE: INTRODUCTION TO ROM Range of Motion and Associated Terminology Full joint range of motion (ROM) is essential for optimal human movement with less chance of injury. In joint ROM testing, movement is typically limited by joint structures such as the capsule or bone or by surrounding muscles. For accurate joint ROM testing, any muscles that cross two or multiple joints should not be lengthened across all the associated joints. This is discussed further in Unit 1.3. Be sure to understand the following definitions, adapted from your Reese & Bandy text:2 Kinematics:Human movement without consideration for the cause of the movement; subcategorized into arthrokinematics and osteokinematics Arthrokinematics: Movement of the joint surfaces in relation to one another; articulating bone ends roll, glide/slide, or spin on each other. Refer to Chapter 1 for more information on arthrokinematics Osteokinematics: Movement of the whole bone from rolling and sliding of the joint surfaces; type of motion measured by goniometry; typically occurs in three cardinal planes of movement with anatomical position as the reference point (see Chapter 1, Figures 1-1 to 1-4): AROM:Arc of motion that occurs when the patient moves a joint through its available ROM without assistance from the therapist ◦ May be limited by pain, weakness or lack of motor control/coordination (therefore must measure PROM also) PROM: Arc of motion that occurs when the therapist moves the patient’s joint through its available ROM without assistance from the patient ◦ Affected by integrity of joint surfaces and extensibility of surrounding soft tissues ◦ Typically greater than AROM ◦ Be sure to clearly document AROM vs. PROM to avoid confusion End Feel: Characteristic feel to the resistance encountered at the end of normal PROM ◦ Normal ‣ Hard – bony and abrupt resistance felt at the end of PROM, no further motion can occur (e.g., elbow extension) ‣ Firm – slight “give”2 felt at the end of PROM due to joint capsule and surrounding non- contractile tissue limitations at end range (e.g., shoulder flexion) ‣ Soft – “mushy”2 resistance at the end of PROM due to soft tissue compression (e.g., elbow flexion) ◦ Abnormal: ‣ empty, muscle spasm, springy block (will be covered in later courses) Reliability: The overall consistency of a measurement, repeatability ◦ To maximize reliability, always use the same instrument, positioning, procedure, and therapist (if  possible) Validity: The accuracy of a measurement; measuring what is intended to be measured ◦ Affected by poor stabilization of segments, alignment of goniometer as joint axis always moves during measurement Osteokinematic Planes in more detail Sagittal ◦ Vertical plane dividing body into right and left sides ◦ "side view" ◦ Flexion and extension occur in this plane Frontal ◦ Vertical plane dividing body into front and back halves ◦ “front view” ◦ Also known as coronal plane ◦ Abduction, adduction, and spine lateral flexion occur in this plane Transverse ◦ Horizontal plane dividing body into upper and lower halves ◦ “view from top of the head” ◦ Medial and lateral rotation, pronation and supination occur in this plane Typical Movements Within the Planes ◦ Sagittal Plane: Flexion/Extension ◦ Frontal Plane: Abduction / Adduction, Lateral flexion of spine ◦ Transverse Plane: Rotation, Supination / Pronation ROM MEASUREMENT TOOLS Universal Goniometer ◦ Most widely used instrument for joint ROM measurements ◦ Device used in this course and AA2 ◦ Made of metal or clear plastic with large or small full circle or half circle central protractor calibrated in degrees ◦ Consists of fulcrum, stationary arm, and moving arm ◦ Arms can be used as rulers in in/cm for linear measurements as needed ◦ See van Rijn4 article on reliability and validity of goniometry-American Academy of Orthopedic Surgeons (AAOS) standards for joint ROM norms are used in this course (see Appendix B in your textbook) ◦ Take some time to familiarize yourself with the goniometers that you purchased (see Box 1-1 in Reese and Bandy textbook2) Inclinometer ◦ Several different types, mechanical and electronic versions, consists of protractor and weight gravity pendulum ◦ Uses gravity as a reference point-Can be mounted onto a plastic frame-CROM: Cervical range of motion device; placed over patient’s head and secured with Velcro; able to measure all cervical spine movements-BROM: back range of motion device; secured to the patient with two elastic straps;  able to measure all lumbar spine movements Electrogoniometer ◦ converts joint angular motion into an electrical signal; can measure multiple joint movements, but require skill to use; most often seen in research Therabite ◦ measures temporomandibular joint ROM Tape Measure ◦ simple tool to measure ROM and muscle length Radiography ◦ gold standard of joint ROM measurement; routine use not recommended due to health risks of repeated exposure to radiation and high costs of procedure Smart phones ◦ photography, video recording (becoming more common due to telehealth) - see the Dent et al.3 article Motion analysis systems ◦ typically used in research due to high cost and decreased portability of the equipment ROM Documentation Single Motion Recording Technique (see Figures 1-18 to 1-202) ◦ Separate documentation of individual joint ROM measurements, i.e., shoulder flexion, extension, abduction, adduction, etc. ◦ Recorded as a range from beginning to end of the motion Shoulder flexion: 0-180 degrees ◦ Shoulder external rotation: 0-80 degrees (lacks 10 degrees from AAOS standard of 90 degrees) ◦ Elbow flexion: 5-150 degrees (patient is unable to fully extend elbow for zero-degree starting point) ◦ Elbow extension: -5 degrees (patient is unable to reach elbow extension norm of zero degrees) Two Movements Recorded Together with Zero Degrees Between Motions to Denote Neutral Starting Point ◦ Also known as the arc of motion for a joint ◦ Examples: ‣ Shoulder internal to external rotation: 70-0-90 ‣ Elbow flexion and extension: 5-0-150 (patient is able to extend their elbow beyond the zero degree starting point and reaches full elbow flexion of 150 degrees) ◦ Be sure to establish the zero-degree starting point so you know the patient’s entire range for the motion tested. If documenting two movements together (arc of motion), such as elbow flexion and extension or shoulder internal and external rotation, place a zero between the measurements to indicate the neutral position if applicable. Factors Affecting ROM ROM Procedures Brief Checklist 1. Explain to the patient how and why ROM measurements are performed (use layperson’s terminology) 2. Position the patient for optimal measurement accuracy 3. Ensure proper stabilization of the proximal bone/joint segment and support of the moving segment 4. Estimate PROM measurement and determine end-feel 5. Palpate bony landmarks and properly align goniometer 6. Read the goniometer and record the range of motion Expanded Explanation of the Checklist 1. Explain to the patient how and why ROM measurements are performed (use layperson’s terminology) A. Show the patient the goniometer (or other measurement tool) B. Explain the patient position for the measurements (use “on your back” instead of “supine”) C. Keep this brief to avoid confusion, no need to explain the entire procedure from start to finish at this point in the evaluation (you can explain as you go) D. Example: “Ms. Haynes, I need to measure how much you can move your knee. This information will tell me how much progress you are making since your surgery and help me estimate how soon you will be able to be discharged from treatment. I am going to use this instrument, called a goniometer, to measure your movement. I will need you to lie on this table on your back so that I can perform the measurement.”2 2. Position the patient for optimal measurement accuracy A. Place the joint being measured in zero degree starting position (may be 90 degrees depending on the movement, e.g., shoulder internal rotation) B. Ensure position allows for optimal stabilization of the proximal segment (e.g., humerus for elbow flexion) C. Ensure bony landmarks for goniometer placement are properly aligned and can be palpated D. Ensure the joint can move through its full available motion and is not blocked by internal (muscle tightness) or external (exam table) forces E. Ensure that your patient can achieve the correct testing position; be prepared to modify but maintain alignment as much as possible. Document any difference in position for replication at  future appointments or by different examiners if needed. 3. Ensure proper stabilization of the proximal bone/joint segment and support of the moving segment A. Isolates joint motion to be measured B. Prevents substitutions (e.g., lack of pronation may result in patient substituting with shoulder internal rotation and abduction; thus, therapist must stabilize humerus against the body to prevent substitutions during pronation ROM) C. Lack of proper stabilization affects reliability of ROM measurement D. See individual ROM techniques for specific stabilization and support information 4. Estimate PROM measurement and determine end-feel A. Move the joint through PROM using proper stabilization and support (see #3 above) B. Visually estimate the range of motion in degrees and establishes the quality of the end-feel (see individual ROM technique descriptions for expected end-feel) C. State the AAOS standard (normal measurement in degrees) for the movement being measured (see Appendix B in Reese and Bandy textbook) D. PROM helps patient understand the movement being performed and examiner to determine if any ROM limitations exist due to pain, tightness, or other causes. E. Estimating the ROM helps novice therapist learn to properly read the goniometer 5. Palpate bony landmarks and properly align goniometer A. Bony landmarks are used because their location does not change with movement B. Identify three bony landmarks (at minimum) as targets for the fulcrum, stationary arm, and moving arm of goniometer C. Fulcrum can move during ROM as joint axis is not stationary so ensure proper alignment of stationary and moving arms D. Pre-set goniometer to estimated PROM from previous step, align with the joint motion being measured, and adjust moving arm reading as needed 6. Read the goniometer and record the range of motion A. Once in the proper position, read the position of the moving arm on the goniometer scale to report the PROM of the movement being tested (be sure to read the correct scale) B. Take the extremity into the opposite direction of the tested motion to establish a zero-degree starting position C. Document the patient’s ROM with a beginning and ending point, such as 0-180 degrees D. If the patient does not have a zero-degree starting point, document their available range (e.g., unable to fully extend elbow, so elbow flexion measurement starts at 3 degrees and reaches 150 degrees with range reported as 3-150 degrees of elbow flexion).