Interventions for Limited PROM PDF

Interventions for Limited PROM J.J. MOWDER-TINNEY PT, PHD, NCS Learning Objectives Identify the common causes/mechanisms for limited PROM Describe the functional impact of limitations in PROM Describe the hypothesis driven examination specific to the impairment of limited PROM Identify when and how...

Interventions for Limited PROM J.J. MOWDER-TINNEY PT, PHD, NCS Learning Objectives Identify the common causes/mechanisms for limited PROM Describe the functional impact of limitations in PROM Describe the hypothesis driven examination specific to the impairment of limited PROM Identify when and how to intervene related to limited PROM Imagine you have a 50 ° elbow flexion contracture. What would you have difficulties with? Imagine…. Pushing up from the chair in sit to stand. Using a rolling walker Reaching for your drink Pulling a suitcase Reaching down to put on your sock Is having “normal” ROM ever detrimental? Mechanism of Decreased ROM Inertia of limb Increased stiffness is demonstrated when it is not moved recently Neural factors Stretch reflex opposition influences muscle stiffness Spasticity influences muscle stiffness contributing to contracture Spastic hypertonia and hyperreflexia due to lowered threshold of alpha motor neuron activation results in a muscle contraction that has higher-than-normal amplitude Non-neural Factors Limited by tightness in contractile (Viscoeleastic properties of muscle, connective tissue) or noncontractile tissue (ligament, joint capsule, tendons) Immobilization Heterotrophic Ossification Formation of bone What drives you to hypothesize there may be a limitation in PROM? Start with Observation – What do you see? Then HYPOTHESIZE the WHY they look that way! What is the PROM required for the functional movement you are observing. Easy to RULE out PROM FIRST! Always go back to your normal (or functional) ranges available for the specific joint you are looking at. Make sure to know PROM of DF with knee flexed (soleus – sit to stand) and with knee extended (gastric – terminal stance) Preparatory Interventions for ROM Limitations Stretching Contract OR Hold Relax When able combine closed chain stretching with functional activity Contracture prevention: Position in a prolonged stretch to maintain full PROM for patients at risk for contracture Passively: bouts of 30 sec over 15 min session Inconclusive evidence on effectiveness in patients with established contracture Splinting or Serial Casting Splinting Static versus dynamic splints Wear schedule – provide prolonged stretch over hours Serial Casting Used to treat established contracture Decision Making for Serial Casting Complete Assessment: PROM/AROM/Tone Are there PROM Limitations? ↑ Spasticity Only Serial casting not recommended ↑ Spasticity and contracture Contracture only Begin serial casting Preparatory Options Joint Mobilization Used for mechanical joint dysfunction due to hypomobile capsule Can break up connective tissue build up in chronic shortening Instrumented Assisted Soft Tissue Mobilization (IASTM) Heat Modalities Referral for Surgical Release (last option) Does increasing Ankle DF PROM automatically improve the ability to sit to stand symmetrically? In Summary Limitations in PROM is very common in the type of patients we are discussing this quarter Functional impact is BIG and commonly overlooked Prevention is key and “aggressive” intervention is necessary when PROM loss has happened Gaining PROM in isolation is not enough – ALWAYS finish with the task specific activity