Introduction to Goniometry & Manual Muscle Testing PDF

Introduction to Goniometry & Manual Muscle Testing Dr. Rebecca Pinkus, PT, DPT, NCS Slides with permissions from Dr. Keith Cole  Objectives Describe statistical concepts that impact the utilization of physical therapy tests & measures Describe...

Introduction to Goniometry & Manual Muscle Testing Dr. Rebecca Pinkus, PT, DPT, NCS Slides with permissions from Dr. Keith Cole  Objectives Describe statistical concepts that impact the utilization of physical therapy tests & measures Describe arthro and osteokinematics and their role in typical movement Define goniometry and discuss methods of measurement Discuss normal end feels, capsular patterns of limitation and muscle extensibility and implications of dysfunction Define manual muscle testing and discuss methods of measurement  Relevant Statistical Concepts Reliability (is the measurement highly reproducible?) – Intra-rater: – Improved when tester uses the same positions between data points (measurements) – 1SD ~3-4 degrees. – Inter-rater: – improved when all testers use consistent, well-defined testing positions; – poor when different testers used a variety of positions and measuring tools – SD ~5-6 degrees Validity – Does your measurement truly represent the movement of the joint? – Content Validity – essential that there is knowledge of landmarks to be able to accurately measure – Criterion-Rated Validity – comparison to a gold standard (radiograph) is strong – Construct Validity – the ability to use the information to infer disability (probably joint specific) Keypoint – results are rater and equipment dependent. Meaningful changes in ROM from an intervention should be ~2SD which is ~10 degrees.  Motion Arthrokinematics – the movement of joint surfaces – Includes translatory and rotational motion – Roll, Slide, Spin Osteokinematics – movement of the shaft of the bone – Takes place in three cardinal planes Review – Planes of Movement http://breakthroughgym.com/move-your-body-better/4614/ http://www.alimed.com/baseline-bubble-inclinometer.html GONIOMETRY https://www.fab-ent.com/evaluation/range-of-motion/baseline-plastic- goniometers/  Goniometric Data Utilized in conjunction with other information, provides a basis for: – Determining the presence or absence of impairments – Establishing a diagnosis – Developing prognosis, plan of care, and treatment goals – Evaluating progress – Modifying treatment interventions – Motivating the patient – Efficacy research – Fabricating orthoses and adaptive equipment  ROM Assessment Examiner must have knowledge of: – Standardized testing positions Stabilization required? Modifications may be necessary – Joint anatomy Expected end feel – Proper goniometer alignment Anatomical bony landmarks  Active ROM (AROM) Arc of motion during unassisted voluntary joint motion Provides info on: – Willingness to move – Coordination – Muscle strength – Joint ROM – Pain  Passive ROM (PROM) Arc of motion without assistance from the subject Provides info on: – Integrity of the articular surfaces – Extensibility of the joint capsule, ligaments, muscles, fascia and skin – Pain  Comparing AROM and PROM PROM usually > AROM – Stretch of tissues surrounding joint – Relaxed musculature PROM provides info about integrity of: – Articular surfaces, extensibility of joint capsule, ligaments, muscle, fascia, skin Pain w/PROM – Possibly related to inert (non-contractile) tissues – Ligaments, joint capsule, bursae, fascia, skin  End Feel Characteristic feel detected by the examiner at the end of PROM – dependent on joint being tested End Description Example Feel Soft Soft tissue Knee flexion approximation Firm Muscular stretch Hip flexion with knee straight Capsular stretch Ext of MCPs Ligamentous stretch Forearm supination Hard Bone contacting bone Elbow extension Empty No real end-feel pain prevents reaching end of range of motion.  Hypomobility Passive ROM is less than normal values for that joint, and given the patient’s age and gender Reasons: – Abnormal joint surfaces – Shortening of capsule, ligaments, muscles, fascia and skin – Inflammation – Space occupying lesion  Capsular Patterns of Restricted Motion “Pathological conditions involving the entire joint capsule cause a particular pattern of restriction involving all or most of the passive motions of the joint” » Cyriax (1982) – Not a fixed number of degrees, but proportion of degrees – There are typical patterns of restriction, but not always consistent – This also does not dictate prioritization of interventions  Hypermobility Increase in PROM that exceeds normal values for that joint, given the patient’s age and gender http://ftw.usatoday.com/2016/08/5-pictures-that-show-michael-phelps- ridiculous-flexibility  Causes of Hypermobility Laxity of soft tissue structures Abnormalities of joint surfaces Trauma to a joint Heredity conditions – Ehlers-Danlos syndrome – Marfan syndrome https://www.washingtonpost.com/news/early-lead/wp/ 2013/01/07/rgiii-injury-a-guide-to-the-qbs-knee-and-the- shanahan-criticism/ – Down syndrome Generalized hypotonia  Hypermobility Beighton Hypermobility Score The ability to.. Points Passive oppose thumb to forearm 1-2 Passively extend 5th MCP > 90 1-2 Hyperextend elbow > 10 1-2 Hyperextend knee more than 10 1-2 Place palms on floor during trunk 1 flexion (knees straight) Total score 0-9  Documenting 0-180o notation system Neutral = anatomical position = 0o In some cases, starting point will be beyond the ‘0’ point Ex – the tibiofemoral joint goes into hyperextension – 6o to 0o to 140o – 6o - 0o - 140o  Goniometric Procedures  Observe Posture/Starting position  First, perform on the CONTRALATERAL side  Observe AROM  Palpate landmarks for goniometery  Measure AROM using an appropriate device (re-palpating if need be!)  Measure PROM using an appropriate device (re-palpating if need be!)  Assess end feel  Document objective measure, end feel, any subjective report  Now perform all steps on the affected side  Contextualize! (Normal, Hypermobile, Hypomobile)  Recording Goniometric Measures Any subjective information (pain, discomfort) should be recorded Protective muscle spasm, crepitus, capsular or non-capsular pattern of restriction should be noted e.g. AROM elbow (humeroulnar) = 0 to 140° (R) – 20° to 0° to 140° (hyperextension, neutral, flexion)  Clinical Pearls Know the expected ROM and end feel at the joint to be tested PRIOR to testing Make sure you are able to read the goniometer without adjustment – Ex: the goniometer is often applied backwards or upside down prior to measurement Try to do your measurements efficiently – Involved joint may be symptomatic – Testing position may be uncomfortable – Abnormal joint motion can create compensatory actions  http://reliefkinesiology.com/about-kinesiology/how-it- MANUAL MUSCLE TESTING can-help/  Muscle Testing Approaches to muscle strength testing – Isotonic (isos = equal, constant; tonos = muscle tension)- constant tension, changing muscle length – Isokinetic resistance through ROM against constant velocity – Isometric (metric = measure)- constant joint angle and muscle length  Muscle Testing Muscle strength screening (MSK systems review) – Provides quick overview of muscle strength – Used to identify areas of strength deficits – Testing of muscle groups (vs. individual muscles) Standardized methods of strength assessment – e.g. manual muscle testing (MMT) Resisted movement testing – Used to differentiate b/t contractile & non-contractile sources of pain (Cyriax)  Muscle Testing STEP 1: Patient instructions – Standardized, clear, explicit STEP 2: Patient positioning – Distal segment placed in desired position Gravity-resisted “Gravity-eliminated” (gravity minimized/lessened) – Position proximal segment for optimal stabilization – Motion should not be restricted – Observe movement through full ROM – Be sure you manage your own body mechanics for proper stabilization & application of resistance  Muscle Testing STEP 3: Application of Resistance – “Break” test Patient holds against maximal resistance for 4-5 seconds – Apply force perpendicular to distal end of segment Consider lever arm length Apply resistance to distal end of bone to which muscle being tested is attached Avoid crossing 2 joints whenever possible  Grading Muscle Strength (0-5 scale) Grade Descriptio Definition n 5 Normal Movement through complete ROM against gravity & able to hold against maximal resistance 4 Good Movement through complete ROM against gravity & able to hold against moderate resistance 3 Fair Movement through complete ROM against gravity 2 Poor Movement through complete ROM in gravity-minimized position 1 Trace Slight palpable muscle contraction, no motion 0 Zero No evidence of muscle contraction (by observation or palpation)  Grading Muscle Strength (+ and -) Grade Descriptio Definition n 3+ Fair plus Movement through complete ROM against gravity and able to hold against minimal resistance 3 Fair Movement through complete ROM against gravity 3- Fair Movement through complete ROM in gravity-minimized position & through >= minus ½ ROM against gravity 2+ Poor plus Movement through complete ROM in gravity-minimized position & through < ½ ROM against gravity 2 Poor Movement through complete ROM in gravity-minimized position 2- Poor Movement through partial test range in gravity-minimized position  Manual Muscle Test 2+ Alternative Moves without gravity with Minimal or greater resistance  ALWAYS, SIEMPRE, TOUJOURS, IMMER, SEMPRE, 总是 , 항상 Always consider: – Proximal Stabilization and Proximal landmarks – Center of rotation – Distal mobility and distal landmarks Practice!!!