A Guide to Goniometry: Chapter 2 - PDF

Competency in goniometry requires that the examiner learn the structure and function of each joint being measured. The examiner must also develop the necessary psychomotor skills for measuring range of motion and muscle length. This chapter contains exercises designed to assist the examiner in...

Competency in goniometry requires that the examiner learn the structure and function of each joint being measured. The examiner must also develop the necessary psychomotor skills for measuring range of motion and muscle length. This chapter contains exercises designed to assist the examiner in recognizing the end of the range of motion and identifying end-feels as well as exercises providing practice in reading the goniometer and other instruments employed in the measurement process. Positioning and stabilization are included in the chapter as initial parts of the 12-step examination sequence, which includes, among others, locating and palpating bony landmarks and methods of recording range of motion and muscle length. Positioning The **testing position** refers to the positions of the body recommended for obtaining both goniometric and muscle length measurements. Positioning is an important part of goniometry because it is used to place the joints in a zero starting position when measuring range of motion, and to lengthen a multi-joint muscle over all but the last joint crossed by the muscle when measuring muscle length. The last joint is moved to further stretch the muscle and determine the muscle length. In both goniometry and muscle length testing, positioning helps to stabilize the proximal joint segment. Positioning is important for the examiner, who should stand or sit close to the part of the individual's body being tested. If the examiner maintains a position close to the individual, it will improve the examiner's body mechanics and help prevent the examiner from incurring a back injury. Positioning is also important for the individual because choosing a comfortable and safe position relaxes the individual and may assist in reducing the amount of tension in soft tissue structures (capsule, ligaments, muscles) surrounding a joint. A testing position in which one or more of these soft tissues becomes taut results in a more limited range of motion (ROM) than a position in which the same structures become lax. However, when testing for muscle length, it is necessary to use an opposite position in which all of the tissues are stretched and taut. As can be seen in the following example, the use of different testing positions alters the ROM obtained for hip flexion. Example: Consider the effects of muscle length on ROM. A testing position in which the knee is flexed relaxes the hamstring muscles and allows for greater hip flexion ROM (Fig. 2.1A) than a testing position in which the knee is extended (Fig. 2.1B). When the knee is extended, hip flexion is prematurely limited by the tension in the hamstring muscles. Muscles such as the hamstrings that cross two or more joints are not of sufficient length to allow a full ROM to occur simultaneously at all joints that they cross (in this instance, the knee and the hip joints). The tension developed in the hamstring muscles that are stretched over two joints prevents a full ROM of the hip. Knee flexion relaxes the hamstrings at the knee so that the muscle length is reduced to allow full ROM at the hip. In contrast to positioning for relaxation of opposing muscles in ROM testing, muscle length testing requires the stretching of muscles. It is important for an examiner to use the same testing position and ideally conduct tests at the same time of day during successive measurements so that the relative amounts of tension in the soft tissue structures are the same as in previous measurements. A comparison of ROM measurements taken in the same position should yield similar results. When either different testing positions or different examiners are used for successive measurements of a joint ROM, more variability is added to the measurement, and less basis for comparison exists.1--7 It becomes difficult to determine whether any differences in successive measurements are the result of a true change in joint ROM or the result of a different position or examiner. Testing positions involve a variety of body positions such as supine, prone, sitting, and standing. When an examiner *2* **Procedures** C H A P T E R *Cynthia C. Norkin, PT, EdD* *D. Joyce White, PT, DSc* 20 PART I Introduction to Goniometry and Muscle Length Testing intends to test several joints and motions during one testing session, the goniometric examination should be planned to avoid moving the individual unnecessarily. For example, if the individual is prone, all possible measurements in this position should be taken before the individual is moved into another position. Table 2.1, which lists joint measurements by body position, has been designed to help the examiner plan a goniometric examination. The series of testing positions in this text are designed to follow the five guidelines discussed above. To summarize, the testing positions will do the following: 1\. Ensure that the individual being tested is in a comfortable, safe, and stable position. 2\. Place the joint being measured in a starting position of 0 degrees when testing for ROM. 3\. Permit complete and unobstructed motion of the joint when testing for ROM. 4\. Place the muscle in a lengthened position at all of the joints that the muscle crosses except for the one joint that will be measured for motion when testing for muscle length. 5\. Provide stabilization for the proximal joint segment. If a recommended testing position cannot be attained because of restrictions imposed by the environment or limitations of the individual, the examiner must use creativity to decide how to obtain a particular joint measurement. The alternative testing position that is created must serve the same five functions as the recommended testing position. In addition, the examiner must describe the position precisely in the individual's records so that the same position can be used for all subsequent measurements. **FIGURE 2.1** Positioning differs between ROM testing and muscle length testing. (A) Hip flexion ROM is tested with the knee flexed to relax the hamstring muscles, which will limit hip flexion ROM when the knee is extended. (B) To measure the muscle length of the hamstrings the knee must be extended and the hip flexed to ensure that the hamstring muscles are adequately lengthened. A B CHAPTER 2 Procedures 21 TABLE 2.1 Joint Measurements by Body Position Joint/Body Region Position *Prone Supine Sitting Standing* Shoulder Extension Flexion Abduction Medial rotation Lateral rotation Elbow Flexion Forearm Pronation Supination Wrist All motions Hand All motions Hip Extension Flexion Medial rotation Lateral rotation\* Abduction Lateral rotation Medial rotation\* Adduction Knee Flexion Ankle and foot Subtalar inversion Dorsiflexion Dorsiflexion Subtalar eversion Plantar flexion Plantar flexion Inversion Inversion Eversion Eversion Midtarsal inversion Midtarsal inversion Midtarsal eversion Midtarsal eversion Toes All motions All motions Cervical spine Rotation† Flexion Extension Lateral flexion Rotation Thoracolumbar spine Rotation Flexion Extension Lateral flexion Rotation† Temporomandibular joint All motions \* = alternative position. † = measured with inclinometer(s). 22 PART I Introduction to Goniometry and Muscle Length Testing **FIGURE 2.2** (A) The consequences of inadequate stabilization. The examiner has failed to stabilize the individual's pelvis and trunk; therefore, a lateral tilt of the pelvis and lateral flexion of the trunk accompany the motion of hip medial rotation. The range of medial rotation appears greater than it actually is because of the added motion from the pelvis and trunk. (B) The use of proper stabilization. The examiner uses her right hand to stabilize the pelvis (keeping the pelvis from rising off the table) during the passive range of motion (ROM). The individual assists in stabilizing the pelvis by placing her body weight on the left side. The individual keeps her trunk straight by placing both hands on the table. Stabilization The testing position for ROM helps to stabilize the individual's body and proximal joint segment so that a motion can be isolated to the joint being examined. Isolating the motion to one joint helps to ensure that a true measurement of the motion is obtained, rather than a measurement of combined motions that occur at a series of joints. Positional stabilization may be supplemented by manual stabilization provided by the examiner. Example: Measurement of medial rotation of the hip joint is performed with the individual in a sitting position (Fig. 2.2A). The pelvis (proximal segment) is partially stabilized by the body weight, but the individual is moving trunk and pelvis during hip rotation. Additional stabilization must be provided by the examiner and the individual (Fig. 2.2B). The examiner provides manual stabilization for the pelvis by exerting a downward pressure on the iliac crest of the side being tested. The individual shifts her body weight over the hip being tested to help keep the pelvis stabilized. For most measurements, the amount of manual stabilization applied by an examiner must be sufficient to keep the proximal joint segment fixed during movement of the distal joint segment. If both the distal and the proximal joint segments are allowed to move during joint testing, the end of the ROM is difficult to determine. Learning how to stabilize requires practice because the examiner must stabilize with one hand while simultaneously moving the distal joint segment with the other hand. In the case of some hip joint motions, a second person may be necessary to help either by stabilizing the proximal joint segment or by supporting the distal joint segment after the end of the ROM has been determined. This assistance provided by the second person helps to ensure that the goniometer can be accurately aligned. The techniques of stabilizing the proximal joint segment and of determining the end of a ROM (end-feel) are basic to joint range-of-motion measurement and should be mastered prior to learning how to use either the goniometer or the inclinometer. **Exercise 1** is designed to help the examiner learn how to stabilize and determine the end of the ROM and end-feel. CHAPTER 2 Procedures 23 Exercise 1 Determining the End of the Range of Motion and End-Feel This exercise is designed to help the examiner determine the end of the ROM and to differentiate among the three normal end-feels: soft, firm, and hard. **ELBOW FLEXION:** Soft End-Feel (Passive ROM) **Activities:** See Figure 5.13 in Chapter 5. 1\. Select an individual with whom to practice. 2\. Position the individual supine with the arm placed close to the side of the body. A towel roll is placed under the distal end of the humerus to allow space for full elbow extension. The forearm is placed in full supination with the palm of the hand facing the ceiling. 3\. With one hand, stabilize the distal end of the humerus (proximal joint segment) to prevent flexion of the shoulder. 4\. With the other hand, slowly move the forearm through the full passive range of elbow flexion until you feel resistance limiting the motion. 5\. Gently push against the resistance until no further flexion can be achieved. Carefully note the quality of the resistance. This soft end-feel is caused by compression of the muscle bulk of the anterior forearm with that of the anterior upper arm. 6\. Compare this soft end-feel with the soft end-feel found in knee flexion (see ROM Testing Procedures: Knee and Fig. 9.6 in Chapter 9). **ANKLE DORSIFLEXION:** Firm End-Feel (Passive ROM) **Activities:** See Figure 10.11 in Chapter 10. 1\. Select an individual with whom to practice. 2\. Place the individual in a sitting position so that the lower leg is over the edge of the supporting surface and the knee is flexed at least 30 degrees. 3\. With one hand, stabilize the distal end of the tibia and fibula to prevent knee extension and hip motions. 4\. With the other hand on the plantar surface of the metatarsals, slowly move the foot through the full passive range of ankle dorsiflexion until you feel resistance limiting the motion. 5\. Push against the resistance until no further dorsiflexion can be achieved. Carefully note the quality of the resistance. This firm end-feel is caused by tension in the Achilles tendon from the soleus muscle, the posterior portion of the deltoid ligament, the posterior talofibular ligament, the calcaneofibular ligament, the posterior joint capsule, and the wedging of the talus into the mortise formed by the tibia and fibula. 6\. Compare this firm end-feel with the firm end-feel found in metacarpophalangeal (MCP) extension of the fingers (see ROM Testing Procedures for Fingers MCP Extension and Fig. 7.12 in Chapter 7). **ELBOW EXTENSION:** Hard End-Feel (Passive ROM) **Activities:** Select an individual with whom to practice. 1\. Position the individual supine with the arm placed close to the side of the body. A small towel roll is placed under the distal end of the humerus to allow full elbow extension. The forearm is placed in full supination with the palm of the hand facing the ceiling. 2\. With one hand resting on the towel roll and holding the posterior, distal end of the humerus, stabilize the humerus (proximal joint segment) to prevent extension of the shoulder. 3\. With the other hand, slowly move the forearm through the full passive range of elbow extension until you feel resistance limiting the motion. 4\. Gently push against the resistance until no further extension can be attained. Carefully note the quality of the resistance. When the end-feel is hard, it has no give to it. This hard end-feel is caused by contact between the olecranon process of the ulna and the olecranon fossa of the humerus. 5\. Compare this hard end-feel with the hard end-feel usually found in radial deviation of the wrist (see ROM Testing Procedures for Radial Deviation and Fig. 6.18 in Chapter 6). 24 PART I Introduction to Goniometry and Muscle Length Testing **FIGURE 2.4** These metal goniometers are of different sizes but all have half-circle bodies. Metal goniometers with fullcircle bodies are also available. The smallest goniometer \(D) is specifically designed to lie on the dorsal or ventral surface of the fingers and toes while measuring joint motion. Goniometers A and B have a cut-out portion on the moving arm, whereas goniometers C and D have pointers on the moving arm to enable the reading of the scale on the bodies. Measurement Instruments A variety of instruments are available to measure joint motion and muscle length. These instruments range from tape measures to manual universal and digital goniometers,8--10 manual and digital inclinometers,9,11--13 cameras,14--18 electrogoniometers, 19 gyroscopes,20 motion analysis systems, and most recently goniometer and inclinometer applications (apps) for smartphones.13,21,22 An examiner may choose to use a particular instrument based on the purpose of the measurement (clinical versus research); the motion being measured; and the instrument's accuracy, availability, cost, ease of use, size, and record of reliability and validity. Universal Goniometer The **universal goniometer** is the instrument most commonly used to measure ROM in the clinical setting. Moore designated this type of goniometer as "universal" because of its versatility.23,24 It can be used to measure joint position and ROM at almost all joints of the body. The majority of measurement techniques presented in this book demonstrate the use of the universal goniometer. In the American Medical Association's sixth edition of the *Guides to the Evaluation* *of Permanent Impairment*,25 the universal goniometer is the instrument recommended for obtaining ROM for the upper and lower extremities. In the fifth edition of the *Guides*,26 the double inclinometer was the instrument recommended for measuring spinal ROM; however, the inclinometer was not included in the latest edition because there was insufficient evidence regarding its reliability/validity for measuring spinal motion. This change is one example of the need for more research to verify that the procedures and instruments used by physical therapists are thoroughly supported by evidence. **Goniometer Construction** Universal goniometers (UGs) may be constructed of plastic (Fig. 2.3) or metal (Fig. 2.4) and are produced in many sizes and shapes but adhere to the same basic design. Typically the **FIGURE 2.3** Plastic universal goniometers are available in different shapes and sizes. Some goniometers have fullcircle bodies (A, B, C, E), whereas others have half-circle bodies (D). The 14-inch goniometer (A) is used to measure large joints such as the hip, knee, and shoulder. The level on one arm helps the examiner ensure that the arms are either horizontal or vertical. Six- to 8-inch goniometers (B, C, D) are used to assess midsized joints such as the wrist and ankle. The small goniometer (E) has been cut in length from a 6-inch goniometer (C) to make it easier to measure the fingers and toes. CHAPTER 2 Procedures 25 design includes a body and two thin extensions called arms---a stationary arm and a moving arm. A relatively new innovation is a gravitational level that can be slipped on to one arm of the goniometer. The level helps to ensure that the goniometer arm is either vertical or horizontal. The *body* of a universal goniometer resembles a protractor and may form a half circle or a full circle (Fig. 2.5). The scales on a half-circle goniometer read from 0 to 180 degrees and from 180 to 0 degrees. The scales on a full-circle instrument may read either from 0 to 180 degrees and from 180 to 0 degrees, or from 0 to 360 degrees and from 360 to 0 degrees. Sometimes full-circle instruments have both 180-degree and 360-degree scales. Therefore, the examiner must pay close attention to avoid reading the wrong scale. The examiner should also check the increments on the scales, which may vary from 1 to 10 degrees, but 1- and 5-degree increments are the most common. The *arms* of a universal goniometer are designated as moving or stationary according to how they are attached to the body of the goniometer (Fig. 2.6). The *stationary arm* is a structural part of the body of the goniometer and cannot be moved independently from the body. The *moving arm* is attached to the center of the body of most plastic goniometers by a rivet that permits the arm to move freely on the body. The moving arm may have one or more of the following features: a pointed end, a black or white line extending the length of the arm, or a cut-out portion (window). Goniometers that are used to measure ROM on radiographs have an opaque white line extending the length of the arms and opaque markings on the body. These features help the examiner to read the scales. The length of the arms varies among instruments from approximately 1 to 14 inches. These variations in length represent an attempt on the part of the manufacturers to adapt the size of the instrument to the size of the joints. At least one manufacturer9 has a goniometer with arms that can expand from 8 to 28 inches in length. Half-circle body Full-circle body **FIGURE 2.5** The body of the goniometer may be either a half circle (*top*) or a full circle (*bottom*). The scales on the body of the goniometer are usually in increments of 1 (*bottom*) or 5 degrees (*top*). **FIGURE 2.6** The body of this universal goniometer forms a half circle. The stationary arm (colored blue for emphasis) is an integral part of the body of the goniometer. The moving arm (colored gray for emphasis) is attached to the body by a rivet so that it can be moved independently from the body. In this example, a cut-out portion, sometimes referred to as a "window," is found in the center and at the end of the moving arm. The windows permit the examiner to read the scale on the body of the goniometer. 26 PART I Introduction to Goniometry and Muscle Length Testing Example: A universal goniometer with 14-inch arms is appropriate for measuring motion at the knee joint because the arms are long enough to permit alignment with the greater trochanter of the femur and the lateral malleolus of the tibia (Fig. 2.7A). A goniometer with short arms would be difficult to use because the arms do not extend a sufficient distance along the femur and tibia to permit good alignment with the bony landmarks (see Fig. 2.7B). A goniometer with long arms would be awkward for measuring the MCP joints of the hand. Goniometers that are designed to measure the joints of the hand usually have arms that measure 4 to 6 inches in length and are well adapted to the small size of the fingers and thumb. **FIGURE 2.7** Selecting the right-sized goniometer makes it easier to measure joint motion. \(A) The examiner is using a full-circle instrument with long arms to measure knee flexion ROM. The arms of the goniometer extend along the distal and proximal segments of the joint to within a few inches of the bony landmarks (black dots) that are used to align the arms. The proximity of the ends of the arms to the landmarks makes alignment easy and helps ensure that the arms are aligned accurately. (B) The small half-circle metal goniometer is a poor choice for measuring knee flexion ROM because the landmarks are so far from the ends of the goniometer's arms that accurate alignment is difficult. CHAPTER 2 Procedures 27 **Alignment** **Goniometer alignment** refers to the alignment of the arms of the goniometer with the proximal and distal segments of the individual's joints. The examiner must learn and use the bony **anatomical landmarks** to more accurately visualize the joint segments. These landmarks, which have been identified for all joint measurements, should be exposed completely so that they may be easily located and palpated (Fig. 2.8). The careful visualization, palpation, and alignment of the arms of the goniometer with the landmarks improve the accuracy and consistency of the measurements. Customarily, the stationary arm is aligned parallel to the longitudinal axis of the proximal segment of the joint and the moving arm is aligned parallel to the longitudinal axis of the distal segment of the joint (Fig. 2.9). In some situations, because of limitations imposed by either the goniometer or the individual, it may be necessary to reverse the alignment of the two arms so that the moving arm is aligned with the distal part and the stationary arm is aligned with the distal part (Fig. 2.10). However, the angle measured by the goniometer will be the same regardless of which arms are aligned with the proximal or distal segments of the joint. Therefore, we use the term **proximal arm** to refer to the arm of the goniometer that is aligned with the proximal segment of the joint and the term **distal arm** to refer to the arm aligned with the distal segment **FIGURE 2.8** The examiner is using a washable ink pen to mark the location of the left acromion process. Note that the individual's clothing has been removed so that the bony landmark can be easily visualized. The examiner often uses the index and middle fingers to palpate the bony landmarks. **FIGURE 2.9** When using a full-circle goniometer to measure ROM of elbow flexion, the stationary arm is usually aligned parallel to the longitudinal axis of the proximal part (humerus) and the moving arm is aligned parallel to the longitudinal axis of the distal part (forearm). However, if the arms of the goniometer are reversed, the same angle will be measured. 28 PART I Introduction to Goniometry and Muscle Length Testing **FIGURE 2.10** (A) When the examiner uses a half-circle goniometer to measure left elbow flexion, aligning the moving arm with the forearm causes the pointer to move beyond the goniometer body, which makes it impossible to read the scale. (B) Reversing the arms of the instrument so that the stationary arm is aligned parallel to the distal part and the moving arm is aligned parallel to the proximal part causes the pointer to remain on the body of the goniometer, enabling the examiner to read the scale along the pointer. CHAPTER 2 Procedures 29 of the joint (Fig. 2.11). The anatomical landmarks provide reference points that help to ensure that the alignment of the arms is correct. The **fulcrum** of the goniometer is usually placed over the approximate location of the axis of motion of the joint being measured. However, because the axis of motion changes during movement, the location of the fulcrum must be adjusted accordingly. Moore23,24 suggested that careful alignment of the proximal and distal arms ensures that the fulcrum of the goniometer is located at the approximate axis of motion. Therefore, alignment of the arms of the goniometer with the proximal and distal joint segments should be emphasized more than placement of the fulcrum over the approximate axis of motion. Errors in measuring joint position and motion with a goniometer can occur if the examiner is not careful. When aligning the arms and reading the scale of the goniometer, the examiner must be at eye level with the goniometer to avoid parallax. This situation occurs if the examiner is higher or lower than the goniometer; as a consequence, the alignment and scales are distorted. Often a goniometer will have several scales, one reading from 0 to 180 degrees and another reading from 180 to 0 degrees. Examiners must determine which scale is correct for the measurement. If a visual estimate is made before the measurement is taken, gross errors caused by reading the wrong scale will be obvious. Another source of error is misinterpretation of the intervals on the scale. For example, the smallest interval of a particular goniometer may be 5 degrees, but an examiner may believe the interval represents 1 degree. In this case, the examiner would incorrectly read 91 degrees instead of 95 degrees. **Cost** The cost of universal goniometers varies according to construction material (stainless steel or plastic), size, and special features for measuring particular joints. Universal goniometers range in cost from about \$5.00 for a plastic goniometer with 6-inch arms to about \$75.00 for a stainless steel goniometer with 14-inch arms. Goniometers specifically designed for measuring the finger joints cost anywhere from \$20.00 to \$100.00. Generally, universal goniometers are the least expensive and most cost--effective option for measuring joint motion and muscle length. After the examiner has read this section on universal goniometer construction and alignment, **Exercises 2 and 3** should be completed. **FIGURE 2.11** The term "proximal arm" indicates the arm of the goniometer that is aligned with the proximal segment of the joint being examined. The term "distal arm" is used to indicate the arm of the goniometer that is aligned with the distal segment of the joint. During the measurement of elbow flexion, the proximal arm is aligned with the humerus, and the distal arm is aligned with the forearm. 30 PART I Introduction to Goniometry and Muscle Length Testing Exercise 2 The Universal Goniometer The following activities are designed to help the examiner become familiar with the universal goniometer. **EQUIPMENT:** Full-circle and half-circle universal goniometers made of plastic and metal. **Activities:** 1\. Select a goniometer. 2\. Identify the type of goniometer selected (full-circle or half-circle) by noting the shape of the body. 3\. Differentiate between the moving and the stationary arms of the goniometer. (Remember that the stationary arm is an integral part of the body of the goniometer.) 4\. Observe the moving arm to see whether it has a cut-out portion or pointer. 5\. Find the line in the middle of the moving arm and follow it to a number on the scale. 6\. Study the body of the goniometer and answer the following questions: a\. Is the scale located on one or both sides? b\. Is it possible to read the scale through the body of the goniometer? c\. What intervals are used? d\. Does the body contain one, two, or more scales? 7\. Hold the goniometer in both hands. Position the arms so that they form a continuous straight line. When the arms are in this position, find the scale that reads 0 degrees. 8\. Keep the stationary arm fixed in place and shift the moving arm while watching the numbers on the scale, either at the tip of the moving arm or in the cut-out portion. Shift the moving arm from 0 to 45, 90, 150, and 180 degrees. 9\. Keep the stationary arm fixed and shift the moving arm from 0 degrees through an estimated 45-degree arc of motion. Compare the visual estimate with the actual arc of motion by reading the scale on the goniometer. Try to estimate other arcs of motion and compare the estimates with the actual arc of motion. 10\. Keep the moving arm fixed in place and move the stationary arm through different arcs of motion. 11\. Repeat Steps 2 to 10 using different plastic and metal goniometers. Exercise 3 Goniometer Alignment for Elbow Flexion The following activities are designed to help the examiner learn how to align and read the universal goniometer. **EQUIPMENT:** Full-circle and half-circle universal goniometers of plastic and metal in various sizes and a skin-marking pen or pencil. **Activities:** See Figures 5.9 to 5.15 in Chapter 5. 1\. Select a goniometer and an individual with whom to practice. 2\. Position the individual supine. The individual's left arm should be positioned so that it is close to the side of the body with the forearm in supination (palm of hand faces the ceiling). A towel roll placed under the distal humerus helps to ensure that the elbow is fully extended. (See Fig. 5.14 in Chapter 5.) 3\. Locate and mark each of the following landmarks: acromion process, lateral epicondyle of the humerus, radial head, and radial styloid process. (See Figs. 5.9 to 5.12 in Chapter 5.) 4\. Align the proximal arm of the goniometer along the longitudinal axis of the humerus, using the acromion process and the lateral epicondyle as reference landmarks. To avoid parallax, make sure that you are positioned so that the goniometer is at eye level during the alignment process. 5\. Align the distal arm of the goniometer along the longitudinal axis of the radius, using the radial head and the radial styloid process as reference landmarks. (See Fig. 5.14 in Chapter 5.) CHAPTER 2 Procedures 31 Gravity-Dependent Goniometers (Inclinometers) Although not as common as the universal goniometer, several other types of manual and digital goniometers may be found in the clinical setting. **Gravity-dependent goniometers** or **inclinometers** use gravity's effect on pointers and fluid levels to measure joint position and motion (Fig. 2.12). The **pendulum** **goniometer** consists of a 360-degree protractor with a weighted pointer hanging from the center of the protractor. This device was first described by Fox and Van Breemen27 in 1934\. The **fluid (bubble) goniometer,** which was developed by Schenkar28 in 1956, has a fluid-filled circular chamber containing an air bubble. It is similar to a carpenter's level but being circular has a 360-degree scale motion. Some inclinometers are either attached to or held on the distal segment of the joint being measured. The angle between the long axis of the distal segment and the line of gravity is noted. Inclinometers may be easier to use in certain situations than universal goniometers because they do not have to be aligned with two bony landmarks and centered over the axis of motion, but they do have to be put over particular landmarks for consistency. Misplacement over anatomical landmarks can give inaccurate readings. In addition, it is critical **FIGURE 2.12** Each of these gravitydependent goniometers uses a weighted pointer (A, B, D) or bubble (C) to indicate the position of the goniometer relative to the vertical pull of gravity. All of these inclinometers have a rotating dial so that the scale can be zeroed with the pointer or bubble in the starting position. 6\. The fulcrum should be close to the lateral epicondyle. Check to make sure that the body of the goniometer is not being deflected by the supporting surface. 7\. Recheck the alignment of the arms and readjust the alignment as necessary. 8\. Read the scale on the goniometer. 9\. Remove the goniometer from the individual's arm and place it nearby so it is handy for measuring the next joint position. 10\. Move the individual's forearm into various positions in the flexion ROM, including the end of the flexion ROM. At each joint position, align and read the goniometer. Remember that you must support the individual's forearm while aligning the goniometer. (See Fig. 5.15.) 11\. Repeat Steps 3 to 10 on the individual's right upper extremity. 12\. Repeat Steps 4 to 10 using goniometers of different sizes and shapes. 13\. Answer the following questions: a\. Did the length of the goniometer arms affect the accuracy of the alignment? Explain. b\. What length goniometer arms would you recommend as being the most appropriate for this measurement? Why? c\. Did the type of goniometer used (full-circle or half-circle) affect either joint alignment or the reading of the scale? Explain. d\. Did the side of the body that you were testing make a difference in your ability to align the goniometer? Why? 32 PART I Introduction to Goniometry and Muscle Length Testing **FIGURE 2.13** (A) The cervical range of motion (CROM) device has three inclinometers mounted on a plastic frame that fits over the head. One inclinometer is mounted on the side of the head to measure lateral motion of the head. A second inclinometer is located in front of the head in order to measure flexion and extension. A compass inclinometer mounted on top of the head is used in conjunction with a magnetic yoke placed around the individual's shoulder to measure rotation. (B) The back range of motion (BROM) device also has a compass inclinometer mounted horizontally that is used in conjunction with a magnetic yoke fastened around the pelvis to measure rotation. that the proximal segment of the joint being measured be positioned vertically or horizontally to obtain accurate measurements; otherwise, adjustments must be made in determining the measurement.29 Inclinometers are also difficult to use on small joints and where there is soft tissue deformity or edema. Some inclinometers are specifically used for measuring spinal motion. The cervical range of motion (CROM) device and back range of motion (BROM) device manufactured by Performance Attainment30 are examples of inclinometers that are mounted on plastic frames. The CROM device (Fig. 2.13A) has three inclinometers fastened on a plastic frame that fits over the head. The inclinometer located on the frame on the lateral side of the head is used to measure lateral cervical flexion. The inclinometer on the front of the plastic frame is used to measure cervical flexion and extension. A compass inclinometer attached to the top of the headpiece is used to measure cervical rotation. The compass inclinometer reacts to the earth's magnetic field to measure motions in the horizontal plane and is used in conjunction with a magnetic yoke placed around the individual's shoulders. The BROM device (Fig. 2.13B) has similar arrangements for its inclinometers, with a compass inclinometer mounted horizontally to measure rotation in conjunction with a magnetic yoke fastened around the pelvis. Although both universal and gravity-dependent goniometers may be available within a clinical setting, they should not be used interchangeably.31--34 For example, an examiner should not use a universal goniometer on Tuesday and an inclinometer on Wednesday to measure the same individual's knee ROM. The two instruments may provide slightly different results, making comparisons for judging changes in ROM inappropriate. Given the adaptability and widespread use of the universal goniometer in the clinical setting, this book focuses primarily on teaching the measurement of the extremity joints using the universal goniometer. However, sections of the book that focus on the spine and temporomandibular joints use inclinometers and tape measures as well as the universal goniometer. **Cost** Generally, inclinometers are more expensive than universal goniometers.9 The price of a bubble inclinometer ranges between \$60.00 and \$180.00, whereas the price of the Acumar Single Digital inclinometer is about \$300.00.9 Specialized inclinometers such as the CROM and the BROM cost about \$380.00 to \$400.00.10 After the examiner has read the preceding information about inclinometers, **Exercises 4 and 5** should be completed. A B CHAPTER 2 Procedures 33 Exercise 5 Inclinometer Alignment for Cervical Rotation The following activities are designed to help the examiner learn how to align and read the bubble inclinometer. **Activities:** Refer to Figures 11.42 and 11.43 in Chapter 11. 1\. Select an inclinometer and an individual with whom to practice. 2\. Position the individual in a supine position with arms at the side and head in a neutral position. 3\. Stand or sit at the end of the table so that you are looking at the top of the individual's head. 4\. Use your hands to roll the individual's head to the right and to the left, making sure that the end of the range of motion has been reached. 5\. Ask the individual to repeat the motions until the motions are being performed correctly. 6\. Reposition the individual's head in a neutral position. 7\. Place the inclinometer on the individual's forehead, holding it firmly in contact with the skin while you zero the inclinometer. 8\. Ask the individual to move her head to the right. 9\. Hold the inclinometer firmly on the forehead throughout the motion, being careful not to tip it up or down. 10\. Read the correct scale at the end of the ROM. 11\. Record your findings. 12\. Reposition the head in neutral and zero the inclinometer. 13\. Repeat the activity by asking the individual to move her head to the left. 14\. Hold the inclinometer firmly on the on the forehead throughout the motion. 15\. Record your findings. a\. Did you experience more or less difficulty holding the inclinometer to the right or the left? b\. What things did you like about the inclinometer and what things did you dislike? Exercise 4 Inclinometers The following activities are designed to help the examiner become familiar with inclinometers. **EQUIPMENT:** Bubble inclinometer and pendulum inclinometer. **Activities** 1\. What does the face of the bubble inclinometer look like? The pendulum inclinometer? What do you see in the moveable clear plastic circle of the bubble inclinometer? What do you see in the face of the pendulum inclinometer? How are the two instruments alike and how are they different? 2\. Stand the bubble inclinometer up vertically on its two legs. Note that there are inner and outer scales on the plastic circle. Does the pendulum inclinometer have the same arrangement? a\. Are the increments the same on each instrument? The scales go from 0 to 350 on the bubble inclinometer and from 0 to 50 on the pendulum inclinometer. b\. What happens to the inside scale on the bubble inclinometer if you set the outside scale to zero? c\. On the bubble inclinometer, in which direction does the outside scale go---clockwise or counterclockwise? d\. If you tilt the bubble inclinometer to the right, which scale should you use to take a measurement? If you tilt the pendulum inclinometer to the right, what happens? To the left? 3\. If both the inside and outside scales on the bubble inclinometer are on zero, what does the scale directly across from the zero read? What does the scale directly across from zero read on the pendulum inclinometer? 4\. Did you find it difficult to keep the liquid at zero in the bubble inclinometer? Did you have any difficulty maintaining a zero position on the pendulum inclinometer? 5\. What happens to the liquid in the bubble inclinometer if you tilt it forward? Backward? 6\. Which instrument appears to be the easiest to handle and read? Why? 34 PART I Introduction to Goniometry and Muscle Length Testing Electrogoniometers **Electrogoniometers,** introduced by Karpovich and Karpovich35 in 1959, are used primarily in research to obtain dynamic joint measurements. Most devices have two arms, similar to those of the universal goniometer, which are attached to the proximal and distal segments of the joint being measured.34--39 A potentiometer is connected to the two arms. Changes in joint position cause the resistance in the potentiometer to vary. The resulting change in voltage can be used to indicate the amount of joint motion. Some electrogoniometers resemble pendulum goniometers. 40,41 Changes in joint position cause a change in contact between the pendulum and the small resistors. Contact with the resistors produces a change in the electrical current, which is used to indicate the amount of joint motion. Potentiometers measuring angular displacement have also been integrated with strain gauges and isokinetic dynamometers. Flexible electrogoniometers with two plastic end-blocks connected by a flexible strain gauge have been designed to measure angular displacement between the end-blocks in one or two planes of motion,33,42 but cannot measure rotation. Torsiometers (single axis) are designed to measure rotations in one plane such as supination and pronation of the forearm. However, Shiratsu and Coury, in a study of torsiometers, found that the reliability and accuracy of the torsiometer sensors varied between sensors and movements. The authors concluded that electrogoniometers were more reliable and accurate than torsiometers.43 A systematic review of measurement tools (standard goniometers, fluid- and gravity-based inclinometers, photographs, and motion analysis systems) used to quantify knee joint motion found that for dynamic measurements, electrogoniometers and 3D motion analysis systems were the most reliable and had low measurement error. For quantifying static joint position, handheld goniometers and inclinometers followed sequential MRI and 2D motion analysis systems in having the least measurement error.44 Perriman and colleagues45 found that the flexible electrogoniometer demonstrated excellent accuracy and testretest reliability when used to measure thoracic kyphosis. **Cost** Electrogoniometers are more expensive than most goniometers and inclinometers but less expensive than most motion analysis systems such as the magnetic motion capture system Flock of Birds, which costs about \$40,000.00, and computer-assisted video motion analysis systems that cost about \$150,000.00 to \$200,000.00. Burnfield and Norkin46 suggest that in comparison to motion analysis systems, electrogoniometers are an affordable means of measuring joint motion during walking. Radiography For many years, radiographs produced by x-ray imaging were the gold standard used to verify joint position measurements made with goniometers and inclinometers. However, this method had the major drawback of exposing the individual to radiation. Another problem was the length of time involved in developing the film. Digital radiography, which is a form of x-ray imaging using x-ray digital sensors instead of traditional photographic film, uses less radiation and gives instant images. This new technology is an important development and it is likely that in the future digital radiography may be used as the new gold standard. Photography The use of a goniometer to measure joint angles directly on photographs is another method of measuring joint motion and muscle length. This type of ROM measurement has received some reports of good to excellent reliability.14,18 Photography has been used in the past to measure joint ROM, but it was considered to be a more time-consuming and expensive process than traditional goniometry. The ease of printing and transmitting photographs with small digital cameras and phones has made digital photography less expensive and time consuming than developing film, but according to Bennett and associates,15 digital imaging is still relatively time consuming and a digital camera, computer, and angle measurement software are expensive and may be difficult to access. Another problem identified by Dunleavy, Cooney, and Gormley16 is the perspective error that occurs when the photographed angle is rotated away from the camera's perpendicular view. Obviously, an examiner cannot operate a camera correctly if he or she is moving the individual's extremity throughout a ROM, and an examiner cannot determine an end-feel or palpate bony landmarks while using a camera. Smartphones Smartphones, such as the iPhone and phones with Android operating systems,13,21,22 loaded with appropriate software applications (TiltMeter) can easily be turned into inclinometers by using their built-in tilt-sensitive systems. This capability increases the likelihood that they may be used in clinical settings in the future. In addition, some applications such as Dr. Goniometer enable a moveable angle to be superimposed over a digital photograph of body parts taken with a smartphone. However, there is an insufficient body of evidence regarding the reliability and validity of smartphone applications to support their use in the clinical setting at this time.13,22 A study by Anderson and associates21 that compared the universal goniometer and the TiltMeter inclinometer's measurements of shoulder motion concluded that the two instruments were not interchangeable. The instruments were acceptable for clinical use only when the same examiner made the measurements using the same instruments. Kolber and Hanely13 compared lumbar spine measurements made by a bubble inclinometer and an iPhone app. These authors found both instruments had good intra- and interrater reliability as well as concurrent validity when strict measurement procedures were followed. However, like Anderson and associates,21 the authors cautioned clinicians about using these instruments interchangeably. Visual Estimation Although some examiners make visual estimates of joint position and motion rather than use a measuring instrument, we do not recommend this practice. The use of visual estimates in situations in which the individual has excessive soft tissue covering anatomical landmarks has been suggested,47 but most authorities report more accurate and reliable measurements CHAPTER 2 Procedures 35 with a goniometer than with visual estimates.48--52 Even when produced by a skilled examiner, visual estimates yield only subjective information in contrast to the objective information gotten from goniometric measurements. Visual estimates made prior to goniometric measurements may help to reduce errors attributable to incorrect reading of the goniometer. If the goniometric measurement is not made in the same quadrant as the estimate, the examiner is alerted to the possibility that the wrong scale is being read. However, there is a possibility that knowledge of the estimate may influence the results of the goniometric measurement. Recording Goniometric measurements are recorded in numerical tables, in pictorial charts, or within the written text of an evaluation. Regardless of which method is used, recordings should provide enough information to permit an accurate interpretation of the measurement. The following items are recommended to be included in the recording: Individual's name, age, and gender Examiner's name or initials Date and time of measurement Type of goniometer/inclinometer used Side of the body, joint, and motion being measured (for example, left knee flexion) For ROM, include the number of degrees at the beginning and end of the motion. For muscle length, include only the degrees at the end of the motion. Type of motion being measured (passive or active) Any subjective information, such as discomfort or pain, that is reported by the individual during the testing Any objective information obtained by the examiner during testing, such as a protective muscle spasm, crepitus, or capsular or noncapsular patterns of restriction A complete description of any deviation from the recommended testing positions If an individual has normal pain-free ROM during active or passive motion, the ROM may be recorded as normal (N) or within normal limits (WNL). To determine whether the ROM is normal, the examiner should compare the ROM of the joint being tested with the tables that report normal values by age and gender and methods of measurement presented in the Research Findings sections in Chapters 4 through 13. A selection of normal ROM values for adults is usually presented at the beginning of testing procedures for each motion. The ROM of the joint being tested may be compared with the same joint of the individual's contralateral extremity, provided that the contralateral extremity is neither impaired nor used selectively in athletic or occupational activities. Recordings of ROM values should include both the starting and the ending joint positions to completely define the ROM. A recording that includes only the total ROM, such as 50 degrees of flexion, gives no information as to where a motion begins and ends. Likewise, a recording that lists --20 degrees (minus 20 degrees) of flexion is open to misinterpretation because the lack of flexion could occur at either the end or the beginning of the ROM. A motion such as flexion that begins at 0 degrees and ends at 50 degrees of flexion is recorded as 0--50 degrees of flexion (Fig. 2.14A). A motion that begins with the joint flexed at 20 degrees and ends at 70 degrees of flexion is recorded as 20--70 degrees of flexion (Fig. 2.14B). The total ROM is the same (50 degrees) in both instances, but the arcs of motion are different. 0°--50° 20°--70° **FIGURE 2.14** (A) Recording of ROM should include the beginning of the range as well as the end. In this illustration, the motion begins at 0 degrees and ends at 50 degrees so that the total ROM is 50 degrees. (B) In this illustration, the motion begins at 20 degrees of flexion and ends at 70 degrees, so that the total ROM is 50 degrees. For both individuals, the total ROM is the same, 50 degrees, even though the arcs of motion are different. A B 36 PART I Introduction to Goniometry and Muscle Length Testing 20°--0°--140° **FIGURE 2.15** This individual has 20 degrees of hyperextension at his elbow. In this case, motion begins at 20 degrees of hyperextension and proceeds through the 0-degree position to 140 degrees of flexion. **Examiner** **Date** **Hip** Name **Left Right** Flexion Extension Abduction Adduction Medial rotation Lateral rotation Comments: Age Gender **FIGURE 2.16** This numerical table records the results of ROM measurements of an individual's left and right hips. The examiner has recorded her initials and the date of testing at the top of each column of ROM measurements. Note that the right hip was tested once, on March 18, 2016; and the left hip was tested twice, once on March 18, 2016, and again on April 1, 2016. Because both the starting and the ending joint positions have been recorded, the measurement can be interpreted correctly. If we assume that the normal ROM for this movement is 0 to 140 degrees, the individual who has a flexion ROM of 0 to 50 degrees lacks motion at the end of the flexion ROM. The individual with a flexion ROM of 20 to 70 degrees lacks motion both at the beginning and at the end of the flexion ROM. The term **hypomobile** may be applied to both of these joints because both joints have a less-than-normal ROM. Sometimes the opposite situation exists, in which a joint has a greater-than-normal range of motion and is **hypermobile.** If an elbow joint is hypermobile, the starting position for measuring elbow flexion may be in hyperextension rather than at 0 degrees. If the elbow was hyperextended 20 degrees in the starting position, the beginning of the flexion ROM would be recorded as 20 degrees of hyperextension (Fig. 2.15). To clarify that the 20 degrees represents hyperextension rather than limited flexion, a "0" representing the zero starting position, which is now within the ROM, is included. A ROM that begins at 20 degrees of hyperextension and ends at 140 degrees of flexion is recorded as 20--0--140 degrees of flexion. A ROM that does not start with 0 degrees or ends prematurely indicates hypomobility. The addition of zero, representing the usual starting position within the ROM, indicates hypermobility. Numerical Tables Numerical tables typically list joint motions in a column down the center of the form (Fig. 2.16). Space to the left of the central column is reserved for measurements taken on the left side of the individual's body; space to the right is reserved for measurements taken on the right side of the body. The examiner's initials and the date of testing are noted at the top of the measurement columns. The instrument used is listed in the comment section along with any observations, such as the individual's pain or discomfort during the examination. Subsequent measurements are recorded on the same form and identified by the examiner's initials and the date at the top of the appropriate measurement column. The first set of measurements may be recorded in a column on either side of the central column, with subsequent measurements in the next CHAPTER 2 Procedures 37 column toward the edges of the form (see Fig. 2.16). Alternately, the first set of measurements may be recorded in the left column, with subsequent measurements in the next column toward the right. Either format makes it easy to compare a series of measurements to identify problem motions and then to track rehabilitative response over time. Pictorial Charts Pictorial charts may be used in isolation or combined with numerical tables to record ROM measurements. Pictorial charts usually include a diagram of the normal starting and ending positions of the motion (Fig. 2.17). Sagittal--Frontal--Transverse-- Rotation (SFTR) Method of Recording Although not commonly used in the United States, another recording method is the **sagittal--frontal--transverse--** **rotation (SFTR) method of recording**, developed by Gerhardt and Russe.53,54 In the SFTR method, three numbers are used to describe all motions in a given plane. The first and last numbers indicate the ends of the ROM in that plane. The middle number indicates the starting position, which would be 0 in normal motion. The SFTR may be included in a written text or formatted into a table. In the sagittal plane, represented by S, the first number indicates the end of the extension ROM, the middle number indicates the starting position, and the last number indicates the end of the opposite ROM in the same plane, that is, flexion. For example, if an individual has 50 degrees of shoulder extension and 170 degrees of shoulder flexion, these motions would be recorded: Shoulder S: 50--0--170 degrees. See Table 2.2 for information about recording motion in the other planes using this measurement system. Limb position during measurement is noted if it varies from anatomical position. The notation (F90) would indicate that a measurement was taken with the limb positioned in 90 degrees of flexion. For example, if an individual has 45 degrees of lateral rotation and 35 degrees of medial rotation measured with the hip in 90 degrees of flexion, these ROM values would be recorded as: Hip R: (F90) 45--0--35 degrees. Hypomobility is noted by the lack of 0 as the middle number or by less-than-normal values for the first and last numbers, which indicate the ends of the ROM. For example, if elbow flexion ROM was limited and could move only between 20 and 90 degrees of flexion, it would be recorded: Elbow S: 0--20--90 degrees. A fixed-joint limitation such as ankylosis is indicated by the use of only two numbers. The zero starting position is included to clarify in which motion the fixed position occurs. Therefore, a recording of Elbow S: 0--40 degrees would indicate that the elbow is fixed in 40 degrees of flexion. 4/1/16 3/18/16 3/18/16 **FIGURE 2.17** This pictorial chart records the results of flexion ROM measurements of an individual's left hip. For measurements taken on March 18, 2016, note the 0 to 73 degrees of left hip flexion; for measurements taken on April 1, 2016, note the 0 to 98 degrees of left hip flexion. Blue shading has been added to highlight the improvement in ROM values. (Adapted with permission from Range of Motion Test, New York University Medical Center, Rusk Institute of Rehabilitation Medicine.) 38 PART I Introduction to Goniometry and Muscle Length Testing American Medical Association Guides to Evaluation of Permanent Impairment Method The sixth edition of the American Medical Association's (AMA's) *Guides to the Evaluation of Permanent Impairment*25 also uses the 0--180 degree system for recording ROM. The neutral starting position is recorded as 0 degrees with motions progressing toward 180 degrees. However, the recording system differs from the recording system used in this text. In the AMA book, extension that exceeds the neutral starting position even when normally found in the body is referred to as hyperextension and is expressed with the plus (+) symbol. The minus (−) symbol is used to indicate an extension limitation in which the neutral starting position cannot be attained. It should be noted that the American Academy of Orthopaedic Surgeons51 does not use the minus (−) symbol to indicate an extension limitation or hypomobility. Likewise, we have avoided the use of plus (+) and minus (−) symbols in this text as we believe that these symbols can be interpreted in different ways and can create confusion. Ratings of permanent impairment for all major body systems are provided in the AMA book, including three chapters on evaluation of the musculoskeletal system: upper extremities, lower extremities, and spine and pelvis. Restricted active motion, ankylosis, amputation, sensory loss, vascular changes, loss of strength, pain, joint crepitation, joint swelling, joint instability, and deformity are measured and converted to percentage of impairment for the body part. The total percentage of impairment for the body part is converted to the percentage of impairment for the extremity and, finally, to a percentage of impairment for the entire body. Often these permanent impairment ratings are used, along with other information, to determine the patient's level of disability and the amount of monetary compensation to be expected from the employer or the insurer. Physicians and therapists working with patients with permanent impairments who are seeking compensation for their disabilities should refer to the AMA's book for more detail. Procedures Precautions to Range of Motion and Muscle Length Prior to conducting a goniometric evaluation, the examiner should review the individual's medical record and gather information during the interview process to determine whether any precautions to ROM and muscle length testing are present. Some precautions include suspected or confirmed: joint dislocation, joint subluxation, unstable bone fracture,55 rupture of tendon or ligament, infectious or acute inflammatory process, and severe osteoporosis.56 The examiner also should consider whether the ROM would disrupt the healing process and increase tissue damage following an acute injury or recent surgery. Measurement procedures may need to be modified or postponed if they increase an individual's pain or elicit an increase in muscle spasms.57 Of course, ROM measurements are not possible if the joint to be tested is immobilized in a cast or external fixation device. Once these concerns have been addressed, the goniometric examination of ROM or muscle length can begin. Preparation for Testing This section includes exercises designed to prepare the examiner for carrying out goniometric testing procedures using the universal goniometer. Initially, examiners practice the testing procedures on classmates. Once examiners feel confident with the procedure, they proceed to the final exercise and perform an examination of elbow flexion ROM. The examiners follow the steps in the exercise while referencing Chapter 5 (The Elbow and Forearm). Prior to beginning the measurement of joint ROM or muscle length the following information needs to be considered: Determine whether there are contraindications or precautions to ROM or muscle length testing Determine which joints and motions need to be tested Organize the testing sequence by body position TABLE 2.2 Sagittal--Frontal--Transverse--Rotation Recording Method Plane of Motion First Number Middle Number Last Number Sagittal Extension Dorsiflexion Start (0) Start (0) Flexion Plantarflexion Frontal Abduction Spinal lateral flexion Left Start (0) Start (0) Adduction Spinal lateral flexion Right Transverse Horizontal abduction Start (0) Horizontal adduction Rotation Lateral rotation Forearm supination Ankle eversion Spinal rotation Left Start (0) Start (0) Start (0) Start (0) Medial rotation Forearm pronation Ankle inversion Spinal rotation Right CHAPTER 2 Procedures 39 Gather the necessary equipment, such as goniometers or inclinometers, towel rolls, and recording forms Prepare an explanation of the procedure for the individual Explanation of Procedure The listed steps and the example that follow provide the examiner with a suggested format for explaining the ROM testing procedure to an individual. **Steps** 1\. Introduce yourself and explain purpose of the visit. 2\. Explain and demonstrate how the goniometer/inclinometer works and let the individual inspect the instrument. 3\. Explain and demonstrate anatomical landmarks and why they need to be exposed. 4\. Explain and demonstrate testing position and why positioning is important. 5\. Explain and demonstrate the examiner's and the individual's roles. 6\. Confirm the individual's understanding and willingness to participate. During the explanation and testing procedure, common layperson terms rather than medical terms are used so that the individual can understand the procedure. The examiner should try to establish a good rapport and enlist the individual's participation in the evaluation process. After reading the example, the examiner should practice **Exercise 6**. Example: Explanation of Goniometric Testing Procedure for Measuring Elbow Flexion ROM 1\. Introduce Self and Explain Purpose *Introduction:* My name is \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_. I am a (occupational title). *Explanation:* I understand that you have been having some difficulty moving your elbow. I am going to measure the amount of motion that you have at your elbow joint to see if it differs from what is normally expected. I will use this information to plan a treatment program and assess its effectiveness. *Demonstration:* The examiner flexes and extends his or her own elbow so that the individual is able to observe a joint motion. 2\. Explain and Demonstrate Goniometer *Explanation:* The instrument that I will use to take the measurements is called a goniometer. It is similar to a protractor, but it has two extensions called arms. It is placed on the outside of your body, next to your elbow. *Demonstration:* The examiner presents the goniometer and encourages the individual to ask questions. The examiner shows the individual how the goniometer is used by holding it next to his or her own elbow. 3\. Explain and Demonstrate Anatomical Landmarks *Explanation:* To obtain accurate measurements, I need to identify some anatomical landmarks to help me to align the arms of the goniometer. To find these landmarks I may have to ask you to remove certain articles of clothing, such as your shirt. Also, to locate some of the landmarks, I may have to press my fingers against your skin. *Demonstration:* The examiner shows the individual an easily identified anatomical landmark such as the radial styloid process. 4\. Explain and Demonstrate Recommended Testing Positions *Explanation:* Certain testing positions have been established to make joint measurements easier and more accurate. If you need some help in getting into a particular position, I will be happy to assist you. Please let me know if you need assistance. *Demonstration:* The sitting or supine positions. 5A. Explain and Demonstrate Examiner's and Individual's Roles During Active Motion *Explanation:* I will ask you to move your arm in exactly the same way that I move your arm. *Demonstration:* The examiner takes the individual's arm through a passive ROM and then asks the individual to perform the same motion. 5B. Explain and Demonstrate Examiner's and Individual's Roles During Passive Motion *Explanation:* I will move your arm and take a measurement. You should relax and let me do all of the work. These measurements should not cause discomfort so please let me know if you have any pain and I will stop moving your arm. *Demonstration:* The examiner moves the individual's arm gently and slowly through the range of elbow flexion. 6\. Confirm Individual's Understanding and Willingness to Participate. *Explanation:* Do you have any questions? Are you ready to begin? Testing Procedure The testing procedure is initiated after the explanation has been given and the examiner is assured that the individual understands the nature of the testing process. The testing procedure consists of the following 12-step sequence of activities. **Steps** 1\. Position the individual in the recommended testing position and as close to the side of the bed or plinth as possible. 2\. Stabilize the proximal joint segment. 3\. Move the distal joint segment to the zero starting position. If the joint cannot be moved to the zero starting position, it should be moved as close as possible to the zero starting position. Slowly move the distal joint segment to the end of the passive ROM and determine the end-feel. Ask the individual whether there was any discomfort during the motion. 4\. Make a visual estimate of the ROM. 5\. Return the distal joint segment to the starting position. 6\. Palpate the bony anatomical landmarks. 7\. Align the goniometer. 8\. Read and record the starting position. Remove the goniometer. 9\. Stabilize the proximal joint segment. 40 PART I Introduction to Goniometry and Muscle Length Testing 10\. Move the distal segment through the full ROM. 11\. Replace and realign the goniometer. Palpate the anatomical landmarks again. 12\. Read and record the ROM. **Exercise 6**, which is based on the 12-step sequence, affords the examiner an opportunity to use the testing procedure for an evaluation of the elbow joint. This exercise should be practiced until the examiner is able to perform the activities sequentially without reference to the exercise. Once these exercises have been completed, the examiner should be well prepared for conducting goniometric exercises on patients. Exercise 6 Explanation of Goniometric Testing Procedure **EQUIPMENT:** A universal goniometer. **Activities:** Practice the following six steps with an individual. 1\. Introduce yourself and explain the purpose of goniometric testing. Demonstrate a joint ROM on yourself. 2\. Show the goniometer to the individual and demonstrate how it is used to measure a joint ROM. Let the individual inspect the instrument if he would like to do so. 3\. Explain why bony landmarks must be located and palpated. Demonstrate how you would locate a bony landmark on yourself, and explain why clothing may have to be removed. 4\. Explain and demonstrate why changes in position may be required. 5\. Explain the individual's role in the procedure. Explain and demonstrate your role in the procedure. 6\. Obtain confirmation of the individual's understanding of your explanation. Exercise 7 Testing Procedure for Goniometric Measurement of Elbow Flexion ROM **EQUIPMENT:** A universal goniometer, skin-marking pencil, recording form, and pencil. **Activities:** See Figures 5.9 to 5.15 in Chapter 5. 1\. Place the individual in a supine position, with the arm to be tested positioned close to the side of the body. Place a towel roll under the distal end of the humerus to allow full elbow extension. Position the forearm in full supination, with the palm of the hand facing the ceiling. 2\. Stabilize the distal end of the humerus to prevent flexion of the shoulder. 3\. Move the forearm to the zero starting position and determine whether there is any motion (extension) beyond zero. Move to the end of the passive range of flexion. Evaluate the end-feel. Usually the end-feel is soft because of compression of the muscle bulk on the anterior forearm in conjunction with that on the anterior humerus. Ask the individual whether there was any discomfort during the motion. (Refer to Fig. 5.13 in Chapter 5.) 4\. Make a visual estimate of the beginning and end of the ROM. 5\. Return the forearm to the starting position. 6\. Palpate the bony anatomical landmarks (acromion process, lateral epicondyle of the humerus, radial head, and radial styloid process) and mark with a skin pencil. (Refer to Figs. 5.9 to 5.12 in Chapter 5.) 7\. Align the arms and the fulcrum of the goniometer. Align the proximal arm with the lateral midline of the humerus, using the acromion process and lateral epicondyle for reference. Align the distal arm along the lateral midline of the radius, using the radial head and the radial styloid process for reference. The fulcrum should be close to the lateral epicondyle of the humerus. 8\. Read the goniometer and record the starting position. (Refer to Fig. 5.14 in Chapter 5.) Remove the goniometer. 9\. Stabilize the proximal joint segment (humerus). 10\. Perform the passive ROM, making sure that you complete the available range. 11\. When the end of the ROM has been attained, replace and realign the goniometer. Palpate the anatomical landmarks again, if necessary. (Refer to Fig. 5.15.) 12\. Read the goniometer and record your reading. Compare your reading with your visual estimate to make sure that you are reading the correct scale on the goniometer. R E F E R E N C E S 1\. Sabari, JS, et al: Goniometric assessment of shoulder range of motion: Comparison of testing in supine and sitting positions. Arch Phys Med Rehabil 79:64, 1998. 2\. Marshall, MM, Morzall, JR, and Shealy, JE: The effects of complex wrist and forearm posture on wrist range of motion. Hum Factors 41:205, 1999. 3\. Werner, SL, and Plancher, KD: Biomechanics of wrist injuries in sports. Clin Sports Med 17:407, 1998. 4\. Simoneau, GG, et al: Infl uence of hip position and gender on active hip internal and external rotation. J Orthop Sports Phys Ther 28:158, 1998. 5\. Kebaetze, M, McClure, D, and Pratt, NA: Thoracic position effect on shoulder range of motion, strength, and three-dimensional scapular kinematics. Arch Phys Med Rehabil 80(8):945, 1999. 6\. 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