Arom Prom Aarom Practical Class Slides PDF

AROM PROM AAROM PRACTICAL Joint Mechanics & Vision Physical Motion Environment Tissue Health...

AROM PROM AAROM PRACTICAL Joint Mechanics & Vision Physical Motion Environment Tissue Health Psychological health and motivation Range of motion/Flexibility Pain Strength Sensation Balance Neuromotor Cardiorespiratory Postural Control control/coordination Health Assessing Joint Movement Passive Range Of Motion (pROM) Person stays completely relaxed, the joint is moved by an external force (e.g. another person, a mechanical device) Active Range Of Motion (aROM) Movement is performed entirely by the person with no external assistance Active Assisted Range Of Motion (aaROM) Person performs the movement themselves with assistance from an external force  Assessing Joint Movement pROM vs aROM ROM testing can help generate hypotheses regarding pathology e.g. - What can ROM testing tell us? ROM limitations? If knee extension is painful during aROM testing but not pROM testing Differences between sides? what does that tell us? Biomechanics of the movement (e.g. what moves first, additional/trick/compensatory movements, resistance/fluidity… Symptoms are more likely to be Fear/apprehension? coming from an active structure (e.g. muscle/tendon) than a passive structure Part of the range where symptoms occur (e.g. ligament/cartilage) Clicks? Pops? Note: “Limited” range is only important if it has a negative impact on QoL and/or function  End-feel is a subjective interpretation by Assessing Joint Movement the clinician of how the joint feels in an Overpressure end-range position Hard – usually bony contact (e.g. elbow extension If a patient is symptom-free towards the end of their range you can then apply Firm – usually ligament, muscle or tendon (gentle) overpressure tension (e.g. dorsiflexion) Soft – usually tissue approximation or Overpressure forces the joint into a swelling (e.g. knee flexion) maximal end-range position beyond what the patient is able to do actively Empty – no end-feel, suggests a ligament or tendon rupture This is often considered a “clearing test” An end-feel which is unexpected (e.g. knee for a joint, suggesting that the joint does flexion with a hard end-feel) can indicate not have any pathologies or limitations in pathology (e.g. loose body/impingement in that direction the joint) Assessing Joint Movement Hand positions Passive Range of Motion (pROM) One hand supporting the free lever Steady, firm hold, but be careful not to grip hard or pinch skin One hand as close to the joint as possible May not be possible if the joint is painful Ensure the joint is supported Assessing Joint Movement Passive Range of Motion (pROM) Therapist body position – Wide leg stance Upright torso Close to the plinth Use the big muscles at your legs and shoulders to steady the patient’s limb, not the smaller arm and wrist/hand muscles (especially important for lower limbs and patients who are bigger/heavier than you are) Assessing Joint Movement Passive Range of Motion (pROM) DF/PF Inv/Ever Handholds at calcaneus and talus or calcaneus Handholds at calcaneus and and distal tibia forefoot Assessing Joint Movement Passive Range of Motion Bilateral (better for (pROM) comparison between the two sides) Finger holds at radiocarpal/ulnocarpal joints and distal metacarpals Unilateral (more control)  Assessing Joint Movement Communication Passive Range of Motion (pROM) 1. Introduce yourself Remember, your patient has symptoms - Move slowly and carefully in a fluid manner, feel for 2. Explain what you are gradual increase in resistance leading up to the end of going to do and why, get range consent Make sure you’re testing only your intended 3. Demonstrate movement at the intended joint (watch for unwanted movements in other planes and/or at other joints) 4. Perform the technique & Watch your patient’s face for signs of pain/symptoms check-in with the patient Gentle handling, ensure the patient is relaxed (verbally, visually) Stop when symptoms are reproduced and note the 5. Feedback position  There are many reasons to Assessing Joint Movement choose different test positions…………. Passive Range of Motion (pROM) Shoulder Elbow Flexion/Extension Flexion/Extension Internal/External Rotation in neutral Internal/External rotation in abduction Wrist Abduction/Adduction Flexion/Extension Horizontal adduction/abduction Radial/Ulnar deviation Pronation/Supination Hip Knee Flexion/Extension Flexion/Extension Internal/External Rotation in neutral Internal/External Rotation in flexion Ankle Abduction/Adduction Plantar/dorsiflexion Inversion/eversion Adduction/Abduction Assessing Joint Movement Active/Active Assisted Range of Motion (aROM/aaROM) aROM allows us to observe how someone moves when aROM/aaROM tells us – asked to do something specific e.g. - Do they have full/sufficient “bend down and touch your toes” active ROM? Do they need assistance to use “lift your arms out to the sides and up” their full available range? (aaROM) These kinds of movements are often one of the first things Is there a difference in range we look at during the objective part of an assessment or symptoms between active and passive movements? Lumbopelvic rhythm and scapulohumeral rhythm are movement patterns which physios often look at - Zawadka et al (2018); Laird, Keating & Kent (2019) “An organized pattern characterised by coordination of the lumbar spine and hip connected to the pelvis, especially LUMBOPELVIC RHYTHM during flexion and extension in the sagittal plane” Zawadka et al (2018) Iliopsoas Lumbar flexion Glutes Pelvic anterior rotation (hip flexion)  Lumbopelvic rhythm is different in different people, under different circumstances, and with different muscle balances, strength, endurance, flexibility etc – LUMBOPELVIC RHYTHM e.g. impact of low hamstring flexibility on lumbopelvic rhythm Zawadka et al (2018); Laird, Keating & Kent (2019) LUMBOPELVIC RHYTHM There have been “normal” definitions of lumbopelvic rhythm, followed by recent attempts to identify subgroups Laird, Keating & Kent (2019)  Look for – LUMBOPELVIC RHYTHM Thoracic vs lumbar flexion Lumbar flexion vs hip flexion (lumbopelvic rythym) Scapular protraction vs spine/hip flexion Symmetry/rotation/side-flexion Knee flexion (trick/compensation movement) Note: The pattern you see may or may not be important, there are many ‘normal’ ways to move Spine flexion & extension For now – get used to observing and noticing  SCAPULOHUMERAL RHYTHM Scapula moves and positions itself in different ways, and needs to coordinate with arm/shoulder movements Armfield et al (2003) SCAPULOHUMERAL RHYTHM Scapula movement angles the glenoid during movement to: Maintain joint congruency Increase overall shoulder ROM Initial movement occurs only at the GHJ ~25-30֯ abduction ~60֯ flexion Armfield et al (2003) S/C, A/C and ST joint move simultaneously SCAPULOHUMERAL RHYTHM After ~25-30֯ abduction/~60֯ flexion: Scapula and humerus move together in a reported ratio of ~1:1 ratio (overall ratio ~2:1) Note: These are reported averages, there is a high degree of variability between people Scapula abduction and upward rotation  https://lh4.googleusercontent.com/bPs nMNDoB9y4aegkL1- FvjvYeVNk6r2RPw3M5TrwaU_V9oDY PDpt4qXRRlDaN3PWafdSmw0Vygz7 SCAPULOHUMERAL 1vy- iR1_lwTvh7EMR2eWqyk71aLzzGa_LX j1F1INUE1bTXqc_95Knb0mHz31 RHYTHM Asymmetrical scapula movement Note: This may not be important, no one is perfectly symmetrical For now – get used to observing and noticing Assessing Joint Movement Communication Active/Active Assisted Range of Motion (aROM/aaROM) 1. Introduce yourself Demonstration 2. Explain what you are going to do and why, get Clear explanation/instructions consent Manual guidance 3. Demonstrate For active-assisted – add manual support as needed following the same principles as 4. Perform the technique & pROM check-in with the patient (verbally, visually) Role-play this… more people make mistakes with instructions than with manual techniques 5. Feedback  There are many reasons to Assessing Joint Movement choose different test positions…………. Active Range of Motion (aROM) Shoulder Elbow Flexion/Extension Flexion/Extension Internal/External Rotation in neutral Internal/External rotation in abduction Wrist Abduction/Adduction Flexion/Extension Horizontal adduction/abduction Radial/Ulnar deviation Pronation/Supination Hip Knee Flexion/Extension Flexion/Extension Internal/External Rotation in neutral Internal/External Rotation in flexion Ankle Abduction/Adduction Plantar/dorsiflexion Inversion/eversion Adduction/Abduction Assessing ROM Spine (aROM +/- OP) Be careful with overpressure - Watch your patient for signs of discomfort This module won’t cover passive ROM techniques for Explain what you’re doing and what they the spine should expect to feel Patients may experience pins and needles For now, we’ll focus on or numbness due to tension on nerves aROM and overpressure Patients may experience autonomic symptoms (e.g. sweating, dizziness) with thoracic flexion OP  Assessing ROM Cervical Spine (aROM +/- OP) Flexion/Extension Broad hand position on Sideflexion side of the head (careful Rotation over the ear) Watch patient’s face Forearm steadying during rotation OP, look scapula for nystagmus  Thoracic Assessing ROM Flexion/Extension Spine (aROM +/- OP) Sideflexion Rotation Sitting with arms crossed helps to localize movement to the TxSp Hand position at shoulders or over spine (pros and cons to each)  Isolating active lumber rotation Lumbar Assessing ROM Flexion/Extension isn’t possible. You can assess Spine (aROM +/- OP) thoracolumbar rotation in Sideflexion standing using the same principles as for thoracic rotation “Slide your hand down and lean to the side as far as you can” Apply OP at different places along the spine depending on what region you are assessing Assessing ROM In practice Usually check active range initially, starting on the unaffected side If active range is limited or symptomatic on the affected side, then check passive range If symptoms or range are different on active and passive testing, consider what the reasons for this could be – pain, apprehension/fear, involved structure(s), swelling  NEXT TIME – MEASURING RANGE OF MOTION