ROM PDF

JOINT RANGE OF MOTION Joint range of motion (ROM) is the amount of movement that occurs at a joint to produce movement of a bone in space. To perform active range of motion (AROM), the patient contracts muscle to voluntarily move the body part through the ROM without assistance. To perform passive r...

JOINT RANGE OF MOTION Joint range of motion (ROM) is the amount of movement that occurs at a joint to produce movement of a bone in space. To perform active range of motion (AROM), the patient contracts muscle to voluntarily move the body part through the ROM without assistance. To perform passive range of motion (PROM), the therapist or another external force moves the body part through the ROM. BEFORE WE ASSESS ROM, WE SHOULD KNOW JOINTS AND MOTION OCCURRED ON THEM. Joints is 2 articular surfaces connected together by fibrous, cartilage to allow movement. Table below represent types of joints according to function and structure TABLE. STRUCTURE AND FUNCTION OF JOINTS Joint Joint function Joint mobility examples structure Fibrous Synarthrotic Very little Sutures of skull movement Tibiofibular syndesmosis joint Gomphosis of teeth Cartilaginous Slightly Intervertebral joints Amphiarthrotic movable more Costochondral junctions of than fibrous ribcage one Pubic symphysis of pelvis Synovial Diarthrotic Freely movable Glenohumeral joint of shoulder Humeroulnar joint of elbow Tibiofemoral joint of knee An anatomical joint is formed when two bony articular surfaces, lined by hyaline cartilage, meet and movement is allowed to occur at the junction. The movements that occur at a joint are partly determined by the shape of the articular surfaces. 18 | P a g e Evaluation and measurements I Ass. Prof. Dr. Nesma A. Helmy Motion at a joint occurs as a result of movement of one joint surface in relation to another. Arthrokinematics (joint play) is the term used to refer to the movement of joint surfaces. The movements at the joint surfaces are described as slides (glides), spins, and rolls. These three usually occur in combination with each other and result in movement of the shafts of the bones. Osteokinematics refers to the movement of the shafts of the bones. These are usually described in terms of rotary movement about an axis of motion. Any movement should occur around an axis. There are 3 plane and 3 axis many functional movements occur in diagonal planes located between the cardinal planes. Table describes the planes and axes of the body plane Description of axis Description of Most plane axis Common movement Frontal Divides body into sagittal Runs Adduction / (coronal)(x) anterior and anterior/ abduction posterior posterior section Sagittal(y) Divides body into frontal Runs Flexion, right and left medial/lateral extension sections Transverse(z) Divides body into Longitudinal Runs Internal horizontal upper and lower vertical superior/ rotation, sections inferior external rotation 19 | P a g e Evaluation and measurements I Ass. Prof. Dr. Nesma A. Helmy  Fig. Planes of Motion 20 | P a g e Evaluation and measurements I Ass. Prof. Dr. Nesma A. Helmy Factors affecting range of motion: Age: Generally, the younger the subject, the greater his range of motion is. It has been found that there was a decline in range of motion in most patients between the age of 20 and 30 years, followed by a plateau until the age of 60 years, after which a decline again occurred. Sex: Many studies have been performed to determine the difference in range of motion between men and women. Overall, it has been found that women tend to have greater ranges than men but not all studies confirm that finding. Joint structure: Some persons, because of genetics or posture, normally have hyper-mobile or hypo-mobile joints. Body type can influence joint mobility, as can flexibility of the tendons and ligaments crossing the joint. Joints are structured so that motion is limited by the capsule, ligaments and tendons or by the bony configuration. Moreover, some motions are limited by soft tissue bulk of the segments. For instance, elbow flexion is usually limited by muscle bulk of the arm against the forearm. Soft tissues such as ligaments, tendons and capsules are dense; they may become tight or loose and affect the motion available at joints. Muscles: Muscles associated with the joints may become stretched or contracted; thereby affecting the joint motion. The shape of the joint surfaces is designed to allow motion in particular directions. These surfaces may be altered by such factors as posture, disease or trauma; to allow more or less motion than normal at a joint. Normally, each joint has a small amount of motion at the end of the range that is not under 21 | P a g e Evaluation and measurements I Ass. Prof. Dr. Nesma A. Helmy voluntary control. These accessory motions are not assessed during active range evaluation but are included under the term of passive measurements. Accessory motions help protect the joint structures by absorbing extrinsic forces. When performing goniometric measurements, the examiner should consider the "end feel" of each joint when determining passive range of motion. Assessment of joint range of motion: Active range of motion (AROM): The patient performs all active movements that normally occur at the affected joints and at the joints proximal and distal to the affected ones. The therapist observes as the patient performs each active movement one at a time; and if possible, bilaterally and symmetrically. The active ROM provides information about the patient's willingness to move, co-ordination, level of consciousness, movements that cause or increase pain, muscle strength and ability to follow instructions and perform functional activities. Active range of motion may be decreased due to restricted joint mobility, muscle weakness, pain, and inability to follow instructions and / or unwillingness to move. Observation of active ROM should be followed by assessment of passive ROM. Passive range of motion (PROM): Passive range of motion is assessed to determine the amount of movement possible at the joint. Passive ROM is usually slightly greater than active ROM due to the slight elastic stretch of tissues and in some instances due to the decreased bulk of the relaxed muscles. The therapist takes the body segments through a passive ROM to estimate each joint’s 22 | P a g e Evaluation and measurements I Ass. Prof. Dr. Nesma A. Helmy range of motion, determine the quality of the movement throughout the ROM and the end feel to determine whether a capsular on non-capsular pattern of movement is present and note the presence of pain. The therapist repeats the passive ROM and measures and records both using a goniometer. End feel therapist sensation of movement during PROM with pressure at end of range of motion Method to Assess End Feel Movement is isolated to the joint being assessed. With the patient relaxed, stabilize the proximal joint segment and move the distal joint segment to the end of its PROM for the test movement. Apply gentle overpressure at the end of the PROM and note the end feel. End feel may be normal or pathological Table shows normal (physiological) end feel End Feel DESCRIPTION (physiological) Hard(Bony) A painless, abrupt, hard stop to movement when bone contacts bone; e.g. passive elbow extension, the olecranon process contacts the olecranon fossa Soft (Soft When two body surfaces come together a soft compression of tissue tissue is felt; e.g. in passive knee flexion, the soft tissue on the apposition) posterior aspects of the calf and thigh come together. Firm(Soft A firm or springy sensation that has some give when muscle tissue is stretched; for example, passive ankle dorsiflexion performed stretch) with the knee in extension is stopped due to tension in the gastrocnemius muscle. (Capsular A hard arrest to movement with some give when the joint stretch) capsule or ligaments are stretched. The feel is similar to stretching a piece of leather; for example, passive shoulder external rotation. 23 | P a g e Evaluation and measurements I Ass. Prof. Dr. Nesma A. Helmy Table shows abnormal (pathological) end feel End Feel DESCRIPTION (pathological) Hard An abrupt hard stop to movement, when bone contacts bone, or a bony grating sensation, when rough articular surfaces move past one another, for example, in a joint that contains loose bodies, degenerative joint disease, dislocation, or a fracture. Soft A boggy sensation that indicates the presence of synovitis or soft tissue edema Firm A springy sensation or a hard arrest to movement with some give, indicating muscular, capsular, or ligamentous shortening. Spring A rebound is seen or felt and indicates the presence of an block internal derangement; for example, the knee with a torn meniscus. spasm A hard sudden stop to passive movement that is often accompanied by pain, is indicative of an acute or subacute arthritis, the presence of a severe active lesion, or fracture. If pain is absent a spasm end feel may indicate a lesion of the central nervous system with resultant increased muscular tonus. empty If considerable pain is present, there is no sensation felt before the extreme of passive ROM as the patient requests the movement be stopped, this indicates pathology such as an extra-articular abscess, a neoplasm, acute bursitis, joint inflammation, or a fracture. Capsular Pattern versus Noncapsular Pattern If a lesion of the joint capsule or a total joint reaction is present, a characteristic pattern of restriction in the PROM will occur. Capsular Pattern Only joints that are controlled by muscles exhibit capsular patterns. When painful stimuli from the region of the joint provoke involuntary muscle spasm, a restriction in motion at the joint in the capsular proportions results. Each joint capsule resists stretching in selective ways; therefore, in time, certain aspects of the capsule become 24 | P a g e Evaluation and measurements I Ass. Prof. Dr. Nesma A. Helmy more contracted than others do. It manifests as a proportional limitation of joint motions that are characteristic to each joint Noncapsular Pattern exists when there is limitation of movement at a joint but not in the capsular pattern of restriction. It indicates the absence of a total joint reaction. Ligamentous sprains or adhesions, internal derangement, or extra-articular lesions may result in a noncapsular pattern at the joint. Contraindications to ROM testing: Dislocation or unhealed fracture in the region Immediately following surgery On medication for pain or muscle relaxants (careful) Regions of osteoporosis or bone fragility, Patients with hemophilia Immediately after an injury where disruption of tissue is present. Methods assess ROM The universal goniometer, tape measure, standard inclinometer, and the Cervical Range of Motion Instrument (CROM) are the tools used to measure spinal AROM as presented in this text. AROM measurements of the temporomandibular joints (TMJs) are performed using a ruler or calipers. These instruments and the measurement procedures employed when using these instruments to measure spinal and TMJ AROM Practical part of goniometer assessment of upper limb movement. Expose the Area Explain to the patient the need to expose the area to be assessed. Adequately expose the area and drape the patient as required. Explanation and Instruction Briefly explain the ROM assessment and measurement procedure to the patient. Explain and demonstrate the movement to be performed and/or passively move the patient’s uninvolved limb through the ROM. 25 | P a g e Evaluation and measurements I Ass. Prof. Dr. Nesma A. Helmy Assessment of the Normal ROM Initially assess and record the ROM of the uninvolved limb to determine the patient’s normal ROM and normal end feels, and to demonstrate the movement to the patient before performing the movement on the involved side. Substitute Movements. When assessing and measuring AROM and PROM, ensure that only the desired movement occurs at the joint being assessed. Position of patient comfortable well supported Position the patient so that the:  Joint to be assessed is in the anatomical position.  Proximal joint segment can be stabilized to allow only the desired motion.  Movement can occur through the full ROM unrestricted.  Goniometer can be properly placed to measure the ROM. Procedure for goniometric measurement  The patient is positioned in the recommended testing position.  Goniometer placement: The preferred placement of the goniometer is lateral to the joint, just of the surface of the limb, but it may also be placed over the joint using only light contact between the goniometer and the skin.  Axis: The axis of the goniometer is placed over the axis of movement of the joint. A specific bony prominence or anatomical landmark can be used to represent the axis of motion, even though this may not represent the exact location of the axis of movement throughout the entire ROM.  Stationary arm: The stationary arm of the goniometer normally lies parallel to the longitudinal axis of the fixed proximal joint 26 | P a g e Evaluation and measurements I Ass. Prof. Dr. Nesma A. Helmy  segment and/or points toward a distant bony prominence on the proximal segment.  Movable arm: The movable arm of the goniometer normally lies parallel to the longitudinal axis of the moving distal joint segment and/or points toward a distant bony prominence on the distal segment. If careful attention is paid to the correct positioning of both goniometer arms and the positions are maintained as the joint moves through the ROM, the goniometer axis will be aligned approximately with the axis of motion. The goniometer is first aligned to measure the defined zero position for the ROM at a joint To Measure AROM.  The patient moves actively through the full AROM and either move the movable arm of the goniometer along with the limb through the entire range of movement to the end of the AROM, or realign the goniometer at the end of the AROM To Measure PROM. One of the following two techniques is used to measure the PROM at a joint: 1. Have the patient actively move through the joint ROM and realign the goniometer at the end of the AROM. Have the patient relax and passively move the goniometer and the limb segment through the final few degrees of the PROM. 2. Passively move the movable arm of the goniometer and the limb segment through the entire range of movement to the end of the PROM.  The measurement is read and recorded.  Repeat measurement three times and record the average as the goniometric value for the joint’s ROM 27 | P a g e Evaluation and measurements I Ass. Prof. Dr. Nesma A. Helmy Goniometric measurement of Hip ROM Hip Flexion: Testing Position: Supine with hips and knees in neutral rotation Stabilization: Trunk stabilized by body position Goniometer Axis: Femoral Greater Trochanter Fixed (stationary) Arm: Parallel to midaxillary line of the trunk Distal (movable) Arm: Parallel to longitudinal axis of the femur in line with lateral femoral condyle Movement: Hip flexion with knee flexion allowed Expected ROM: 120°. Substitutions: Lumbar Spine flexion Hip Extension: Testing Position: Prone with hips & knees in neutral and feet extending off end of the table Stabilization: Pelvis is stabilized through straps or manual fixation Goniometer Axis, Fixed (stationary) Arm, Distal (movable) Arm: same as hip flexion Movement: Hip extension with knee extended. ASIS must remain on table. Expected ROM: 30°. Substitutions: Lumbar spine extension 36 | P a g e Evaluation and measurements I Ass. Prof. Dr. Nesma A. Helmy Hip Abduction: Testing Position: Supine with hips and knees in neutral Stabilization. The therapist stabilizes the ipsilateral pelvis. If additional stabilization of the trunk and pelvis is required, the contralateral lower extremity may be positioned in hip abduction with the knee flexed over the edge of the plinth and the foot supported on a stool Goniometer Axis: ASIS on measured side Fixed (stationary) Arm: Along a line between the two anterior superior iliac spines Distal (movable) Arm: Parallel to the long axis of the femur Movement: Abduction until motion is detected at the opposite anterior superior iliac spine Expected ROM: 45° Substitutions: Hip external rotation, knee flexion/internal rotation, or lateral pelvic tilt 37 | P a g e Evaluation and measurements I Ass. Prof. Dr. Nesma A. Helmy Hip Adduction: Testing Position: Supine with the opposite extremity abducted Stabilization. The therapist stabilizes the ipsilateral pelvis Goniometer Axis ASIS on measured side Fixed (stationary) Arm: Along a line between the two anterior superior iliac spines Distal (movable) Arm: Parallel to the long axis of the femur Movement: Adduction Expected ROM: 30° Substitutions: Hip internal rotation or lateral pelvic tilt Hip Internal and External Rotation: Testing Position: Sitting with the hip and knee flexed 90°. Opposite extremity abducted and resting on a foot stool Stabilization: prevent thigh abduction/adduction Goniometer Axis: mid-patella Fixed (stationary) Arm: Perpendicular to the floor Distal (movable) Arm: Parallel to long axis of the tibia Movement: internal and external ROM Expected ROM: 45° internal and external ROM Substitutions: thigh abduction/adduction 38 | P a g e Evaluation and measurements I Ass. Prof. Dr. Nesma A. Helmy Alternate Test Position for Hip Internal/External Rotation: Test Position: prone with knees flexed 90° Stabilization: strap or manual fixation of pelvis Diagnostic Findings: similar measurements with hips flexed or extended indicate structural limitations while different amounts of motion in each position may indicate soft tissue tightness of the hip flexors/extensors Goniometer measurements for knee ROM Knee Extension: Testing Position: Supine with hips and knees in neutral rotation Stabilization: Trunk and pelvis stabilized by body weight and position Goniometer Axis: Lateral Epicondyle of the femur Fixed (stationary) Arm: Parallel to the long axis of the femur & pointing at the greater trochanter 39 | P a g e Evaluation and measurements I Ass. Prof. Dr. Nesma A. Helmy Distal (movable) Arm: Parallel to the long axis of the fibula and pointing at the lateral malleolus Movement: Knee extension Expected ROM: 0°. Hyperextension may be present up to 10-15° Knee Flexion: Testing Position: Supine reclined with hip and knee in neutral rotation Stabilization: Trunk and pelvis stabilized by body weight and position Goniometer Axis: Lateral epicondyle of the femur Fixed (stationary) Arm: Parallel to the long axis of the femur & pointing at the greater trochanter Distal (movable) Arm: Parallel to the long axis of the fibula and pointing at the lateral malleolus Movement: The hip and knee are flexed as the heel moves toward the buttock Expected ROM: from 0° to (120-135°) Alternate Position: Prone lying with the femur stabilized. Knee flexion motion may be decreased as the rectus femoris is now stretched over two joints. Prevent substitute motion of hip abduction and/or hip flexion. 40 | P a g e Evaluation and measurements I Ass. Prof. Dr. Nesma A. Helmy  Goniometer measurements of ankle and foot motions Talocrural Dorsiflexion: Testing Position: supine with ankle off edge of table and knee extended or put towel under knee to flex it Stabilization: Manual stabilization of tibia against the supporting surface Goniometer Axis: Lateral calcaneus at bisection of fibula and 5th metatarsal Fixed (stationary) Arm: Parallel to the long axis of the fibula and pointing towards the fibular head Distal (movable) Arm: Parallel to the long axis of the 5th metatarsal Movement: The ankle is actively dorsiflexed Expected ROM: 10° with knee extended; increased to 20° with the knee flexed Substitutions: Therapist must monitor for subtalar pronation. Watching for calcaneal eversion can monitor this. Alternate Test: The above procedure should be repeated with the knee flexed 90° to isolate soleus flexibility. A 10° increase in ROM to 20° should be expected 41 | P a g e Evaluation and measurements I Ass. Prof. Dr. Nesma A. Helmy Talocrural Plantar flexion: Testing Position: Prone or supine with the knee in slight flexion Stabilization: Therapist stabilizes the lower leg Goniometer Axis: Lateral calcaneus at bisection of fibula and 5th metatarsal Fixed (stationary) Arm: Parallel to the long axis of the fibula and pointing towards the fibular head Distal (movable) Arm: Parallel to the long axis of the 5th metatarsal Movement: The ankle is actively plantar flexed Expected ROM: 40-50 degrees. Subtalar Inversion/Eversion: Testing Position: Standing with bilateral stance Stabilization: No stabilization necessary Goniometer Axis: Just proximal to the Achilles insertion on the calcaneus Fixed (stationary) Arm: Parallel to the distal bisection of the lower leg Distal (movable) Arm: Parallel to the bisection of the calcaneus Movement: Patient can perform trunk and/or tibial rotation to maximally invert and evert the calcaneus Expected ROM: Approximately 10-20° of calcaneal eversion (pronation) and 20- 30° of calcaneal inversion (supination) from the subtalar neutral position Alternate Position: Prone lying or unilateral stance positions. Maximal motion and greatest test-retest reliability has been demonstrated in the bilateral stance position 42 | P a g e Evaluation and measurements I Ass. Prof. Dr. Nesma A. Helmy Metatarsophalangeal and Interphalangeal Flexion/Extension: Testing Position: Ankle in resting position of mild plantar flexion and the STJ is in neutral. Stabilization: Careful stabilization of metatarsals without metatarsal compression Goniometer Axis: Over the dorsum of the measured joint. If measuring the 1st or 5th the axis can be placed over the medial or lateral aspect of the joints, respectively. Proximal Axis: Parallel to the longitudinal axis of the metatarsal of the digit being measured Distal Axis: Parallel to the longitudinal axis of the metatarsal of the digit being measured Movement: Active flexion and/or extension of the distal digit being measured Expected ROM: MTP flexion 60-70°, extension 45°- IP flexion 60°; extension 20° Substitutions: The long toe flexors and extensors will affect ROM according to the positioning of the more proximal joints that they cross. 43 | P a g e Evaluation and measurements I Ass. Prof. Dr. Nesma A. Helmy EXTENSION ABDUCTION ADDUCTION 44 | P a g e Evaluation and measurements I Ass. Prof. Dr. Nesma A. Helmy