Test and Measurement - Benha University PDF

Benha University Faculty of Physical Therapy Basic science department COURSE OBJECTIVES 1- Range of Motion: At the end of this course the student will be able to express in writing and demonstrate on one of his colleagues the procedures of evaluation of the range of motion for any joint in...

Benha University Faculty of Physical Therapy Basic science department COURSE OBJECTIVES 1- Range of Motion: At the end of this course the student will be able to express in writing and demonstrate on one of his colleagues the procedures of evaluation of the range of motion for any joint in the body including the following criteria: 1. Place the subject in a suit able position that will allow him to perform the motion to be evaluated. 2. Choose a suitable mean of fixation of proximal part. 3. Apply the goniometer in the required pos. that will allow a precise evaluation. 4. Ensure that subject is performing accurate and all possible range of motion. 5. Record in writing the result of each motion test. 6. Compare the results with the ROM of the sound limb if possible or with the standard possible joint ROM. 2- Muscle Test: At the end of this course the student will be able to determine the muscle strength of human subject according to the following criteria: 1. Choose the best position in which he must place himself to evaluate each muscle or group of muscles. 2. Place the subject in a suitable position that will allow him to perform each task required from him to evaluate his muscle strength. 3. Establish the subject's passive range of motion. 4. Palpate the tendon or the muscle fibers being evaluated. 2 5. Support and stabilize the subject when necessary. 6. Obtain the maximal response from the subject and observe the contraction and the movement. 7. Identify possible substitution and try to avoid it. 8. Apply manual resistance in the suitable arm when necessary. 9. Write the quotation of the evaluated muscle strength and note any limitation of ROM. 10. Record in writing the results of each muscle or group of muscles test. 4- special tests for upper limb joints At the end of this course the student will be able to demonstrate on one of his colleagues the procedures of special tests for any joint in upper limb. 3 SECTION I THEROTICAL ASPECTSS OF MEASUREMENTS 4  Measurement of variables Measurement: is the assignment of numbers to objects, variables, or events according to rules. What is a Measurement Variable? A measurement variable is an unknown attribute that measures a particular entity and can take one or more values. It is commonly used for scientific research purposes. Unlike in mathematics, measurement variables can not only take quantitative values but can also take qualitative values in statistics. The four scales of measurement By understanding the scale of the measurement of their data, data scientists can determine the kind of statistical test to perform. 1. Nominal Scale: A nominal scale of measurement deals with variables that are non-numeric or where the numbers have no value. A nominal scale, as the name implies, is simply some placing of data into categories, without any order or structure. A physical example of a nominal scale is the terms we use for colours. The underlying spectrum is ordered but the names are nominal. In 5 research activities a YES/NO scale is nominal. It has no order and there is no distance between YES and NO. 2. Ordinal Scale: The ordinal type allows for rank order (1st, 2nd, 3rd, etc.) by which data can be sorted, but still does not allow for relative degree of difference between them. An ordinal scale of measurement looks at variables where the order matters, but the differences do not matter. When you think of 'ordinal,' think of the word 'order.' In the case of letter grades, we don't really know how much better an A is than a D. We know that A is better than B, which is better than C, and so on. But is A four times better than D? Is it two times better? In this case, the order is important but not the differences. 3. Interval Scale: Interval scales are numeric scales in which we know not only the order, but also the exact differences between the values. The classic example of an interval scale is Celsius temperature because the difference between each value is the same. For example, the difference between 60 and 50 degrees is a measurable 10 degrees, as is the difference between 80 and 70 degrees. Time is another good example of an interval scale in which the increments are known, consistent, and measurable. 4. Ratio Scale: The ratio scale of measurement includes properties from all four scales of measurement. The data is nominal and defined by an identity, can be classified in order, contains intervals and can be broken down into exact value. Weight, height, and distance are all examples of ratio variables. Data in the ratio scale can be added, subtracted, divided, and multiplied. Ratio scales also differ from interval scales in that the scale has a ‘true zero’. The number zero means that the data has no value point. An example of this is height or weight, as someone cannot be zero centimeters tall or weigh zero kilos – or be negative centimeters or negative kilos. Any good scientist knows that in every good data set there must be a way to look at the data objectively and subjectively. Without both types of data, it can be hard to have a full picture and understanding of what is being studied. 6 What Does Subjective Measurement Mean? Subjective measurement is how scientists measure what people say. It is very important that we listen to our patients and get feedback on their experience here. This can include using a survey to answer open ended questions, ranking an experience based on feelings, and more. Subjective data is important but can be challenging to comprehend without full context of an experience. What Does Objective Measurement Mean? Objective measurement is something that is measured consistently. For example, measuring how well someone can perform a set number of tasks in a controlled environment. There are no other factors that can alter the data gathered with this measurement. In the medical world, this could be repetition in tasks like a blood test or how many inches you can stretch. Objective data is not influenced by opinion or perspectives of others. Gathering objective data requires that each participant go through the same set of tasks. This will give you more reliable and consistent data. The objective measurement should be valid, reliable, and calibrated. What makes a good test? An employment test is considered "good" if the following can be said about it: The test measures what it claims to measure consistently or reliably. This means that if a person were to take the test again, the person would get a similar test score. The test measures what it claims to measure. For example, a test of mental ability does in fact measure mental ability, and not some other characteristic. The degree to which a test has these qualities is indicated by two technical properties: reliability and validity. 7 Test reliability Reliability refers to how dependably or consistently a test measures a characteristic. If a person takes the test again, will he or she get a similar test score, or a much different score? A test that yields similar scores for a person who repeats the test is said to measure a characteristic reliably. How do we account for an individual who does not get exactly the same test score every time he or she takes the test? Some possible reasons are the following: Test taker's temporary psychological or physical state. Test performance can be influenced by a person's psychological or physical state at the time of testing. For example, differing levels of anxiety, fatigue, or motivation may affect the applicant's test results. Environmental factors. Differences in the testing environment, such as room temperature, lighting, noise, or even the test administrator, can influence an individual's test performance. Test form. Many tests have more than one version or form. Items differ on each form, but each form is supposed to measure the same thing. Different forms of a test are known as parallel forms or alternate forms. These forms are designed to have similar measurement characteristics, but they contain different items. Because the forms are not exactly the same, a test taker might do better on one form than on another. Multiple raters. In certain tests, scoring is determined by a rater's judgments of the test taker's performance or responses. Differences in training, experience, and frame of reference among raters can produce different test scores for the test taker. Reliable assessment tools produce dependable, repeatable, and consistent information about people. In order to meaningfully interpret test scores and make useful employment or career- related decisions, you need reliable tools. 8 Types of Reliability Estimates Test-retest reliability indicates the repeatability of test scores with the passage of time. This estimate also reflects the stability of the characteristic or construct being measured by the test. Alternate or parallel form reliability indicates how consistent test scores are likely to be if a person takes two or more forms of a test. A high parallel form reliability coefficient indicates that the different forms of the test are very similar which means that it makes virtually no difference which version of the test a person takes. On the other hand, a low parallel form reliability coefficient suggests that the different forms are probably not comparable; they may be measuring different things and therefore cannot be used interchangeably. Inter-rater reliability indicates how consistent test scores are likely to be if the test is scored by two or more raters. It is possible to obtain higher levels of inter-rater reliabilities if raters are appropriately trained. Internal consistency reliability indicates the extent to which items on a test measure the same thing. A high internal consistency reliability coefficient for a test indicates that the items on the test are very similar to each other in content (homogeneous). It is important to note that the length of a test can affect internal consistency reliability. Test validity Validity is the most important issue in selecting a test. Validity refers to what characteristic the test measures and how well the test measures that characteristic. Validity also describes the degree to which you can make specific conclusions or predictions about people based on their test scores. In other words, it indicates the usefulness of the test. The following types of validity are popularly used, Face validity, Content validity, Predictive validity, Concurrent, Construct and Factorial validity. 9 1. Face Validity: Face Validity to the extent the test appears to measure what is to be measured. Face validity refers to whether a test appears to be valid or not i.e., from external appearance whether the items appear to measure the required aspect or not. If a test measures what the test author desires to measure, we say that the test has face validity. Thus, face validity refers not to what the test measures, but what the test ‘appears to measure’. This type of validity is not adequate as it operates at the facial level and hence may be used as a last resort. 2. Content Validity: Content Validity a process of matching the test items with the instructional objectives. Content validity is the most important criterion for the usefulness of a test, especially of an achievement test. It is also called as Rational Validity or Logical Validity or Curricular Validity or Internal Validity or Intrinsic Validity. Content validity refers to the extent to which a test contains items representing the behavior or action that we are going to measure. The items of the test should include every relevant characteristic of the whole content area and objectives in right proportion. 3. Predictive Validity: Predictive Validity the extent to which test predicts the future performance of students. Predictive validity is concerned with the predictive capacity of a test. It indicates the effectiveness of a test in forecasting or predicting future outcomes in a specific area. In order to find predictive validity, the tester correlates the test scores with teste’s subsequent performance, technically known as “Criterion”. Criterion is an independent, external, and direct measure of that which the test is designed to predict or measure. Hence, it is also known as “Criterion related Validity”. 10 4. Concurrent Validity: Concurrent Validity correlating the test scores with another set of criterion scores. Concurrent validity refers to the extent to which the test scores correspond to already established or accepted performance, known as criterion. To know the validity of a newly constructed test, it is correlated or compared with some available information. 5. Construct Validity: Construct Validity the extent to which the test may be said to measure a theoretical construct or psychological variable. It indicates the extent to which a test measures the abstract attributes or qualities which are not operationally defined. Finally, it is important to understand the differences between reliability and validity. Validity will tell you how good a test is for a particular situation; reliability will tell you how trustworthy a score on that test will be. You cannot draw valid conclusions from a test score unless you are sure that the test is reliable. Even when a test is reliable, it may not be valid. You should be careful that any test you select is both reliable and valid for your situation. 11 Section 2 RANGE OF MOTION 12  JOINT RANGE OF MOTION Joint range of motion (ROM) is the amount of movement that occurs at a joint to produce movement of a bone in space. To perform active range of motion (AROM), the patient contracts muscle to voluntarily move the body part through the ROM without assistance. To perform passive range of motion (PROM), the therapist or another external force moves the body part through the ROM. Purpose of joint range of motion evaluation: 1. To establish the existing range of motion available in a joint and to compare it to the normal range for that subject. The information will permit a therapist to establish a database for the patient. This information is used to develop goals and a treatment plan to increase or decrease the range of motion. 2. To aid in diagnosing and determining the patient's joint function. Goniometry reveals joint limitations in the arc of motion but does not identify the dysfunction. It does, however, provide information regarding limitations if joint disease is suspected. Hypermobility or hypomobility of joints affects a patient's function in activities of daily living. Hypermobility - laxity in the joint or structures-surrounding the joint allows motion to exceed the normal range. Hypomobility is joint tightness or a less than normal range of motion. An example of joint hypomobility interfering with a person's daily living activities would be an inability to perform stair climbing because of a 70-80 degree restriction in knee flexion. 3. To reassess the patient's status after treatment and compare it to that at the time of the initial evaluation. Goniometric measurements are used to evaluate the effectiveness of treatment programs. - If the range of motion is not increasing, the treatment program may need to be changed in order to obtain effective clinical results. 4. To develop the patient's interest in and motivation and enthusiasm for the treatment program. - Most patients are aware of changes in joint motion and usually are motivated by these improvement to participate in the treatment 13 Factors affecting range of motion: Age: Generally, the younger the subject, the greater his range of motion is. It has been found that there was a decline in range of motion in most patients between the age of 20 and 30 years, followed by a plateau until the age of 60 years, after which a decline again occurred. Sex: Many studies have been performed to determine the difference in range of motion between men and women. Overall, it has been found that women tend to have greater ranges than men but not all studies confirm that finding. Joint structure: Some persons, because of genetics or posture, normally have hyper-mobile or hypo-mobile joints. Body type can influence joint mobility, as can flexibility of the tendons and ligaments crossing the joint. Joints are structured so that motion is limited by the capsule, ligaments and tendons or by the bony configuration. Moreover, some motions are limited by soft tissue bulk of the segments. For instance, elbow flexion is usually limited by muscle bulk of the arm against the forearm. Soft tissues such as ligaments, tendons and capsules are dense; they may become tight or loose and affect the motion available at joints. Muscles: Muscles associated with the joints may become stretched or contracted; thereby affecting the joint motion. The shape of the joint surfaces is designed to allow motion in particular directions. These surfaces may be altered by such factors as posture, disease or trauma; to allow more or less motion than normal at a joint. Normally, each joint has a small amount of motion at the end of the range that is not under voluntary control. These accessory motions are not assessed during active range evaluation but are included under the term of passive measurements. Accessory motions help protect the joint structures by absorbing extrinsic forces. 14 Motion at a joint occurs as a result of movement of one joint surface in relation to another. Arthrokinematics (joint play) is the term used to refer to the movement of joint surfaces. The movements at the joint surfaces are described as slides (glides), spins, and rolls. These three usually occur in combination with each other and result in movement of the shafts of the bones. Osteokinematics refers to the movement of the shafts of the bones. These are usually described in terms of rotary movement about an axis of motion. Any movement should occur around an axis. There are 3 plane and 3 axis many functional movements occur in diagonal planes located between the cardinal planes. The planes and axes of the body plane Description of Axis Description of Most plane axis Common movement Frontal Divides body into Sagittal Runs Adduction / (coronal)(x) anterior and anterior/ abduction posterior posterior section Sagittal(y) Divides body into Frontal Runs Flexion, right and left medial/lateral extension sections Transverse(z) Divides body into Longitudinal Runs Internal horizontal upper and lower Vertical superior/ rotation, sections inferior external rotation 15 Assessment of joint range of motion: Active range of motion (AROM): The patient performs all active movements that normally occur at the affected joints and at the joints proximal and distal to the affected ones. The therapist observes as the patient performs each active movement one at a time; and if possible bilaterally and symmetrically. The active ROM provides information about the patient's willingness to move, co-ordination, level of consciousness, movements that cause or increase pain, muscle strength and ability to follow instructions and perform functional activities. Active range of motion may be decreased due to restricted joint mobility, muscle weakness, pain, and inability to follow instructions and / or unwillingness to move. Observation of active ROM should be followed by assessment of passive ROM. 16 Passive range of motion (PROM): Passive range of motion is assessed to determine the amount of movement possible at the joint. Passive ROM is usually slightly greater than active ROM due to the slight elastic stretch of tissues and in some instances due to the decreased bulk of the relaxed muscles. The therapist takes the body segments through a passive ROM to estimate each joint’s range of motion, determine the quality of the movement throughout the ROM and the end feel to determine whether a capsular on non-capsular pattern of movement is present and note the presence of pain. The therapist repeats the passive ROM and measures and records both using a goniometer. When performing goniometric measurements, the examiner should consider the "end feel" of each joint when determining passive range of motion. End feel therapist sensation of movement during PROM with pressure at end of range of motion Method to Assess End Feel Movement is isolated to the joint being assessed. With the patient relaxed, stabilize the proximal joint segment and move the distal joint segment to the end of its PROM for the test movement. Apply gentle overpressure at the end of the PROM and note the end feel. End feel may be normal or pathological Normal (physiological) end feel End Feel DESCRIPTION (physiological) Hard(Bony) A painless, abrupt, hard stop to movement when bone contacts bone; e.g. passive elbow extension, the olecranon process contacts the olecranon fossa Soft (Soft tissue When two body surfaces come together a soft compression of tissue is felt; apposition) e.g. in passive knee flexion, the soft tissue on the posterior aspects of the calf and thigh come together. Firm(Soft tissue A firm or springy sensation that has some give when muscle is stretched; for stretch) example, passive ankle dorsiflexion performed with the knee in extension is stopped due to tension in the gastrocnemius muscle. (Capsular A hard arrest to movement with some give when the joint capsule or stretch) ligaments are stretched. The feel is similar to stretching a piece of leather; for example, passive shoulder external rotation. 17 Abnormal (pathological) end feel End Feel DESCRIPTION (pathological) Hard An abrupt hard stop to movement, when bone contacts bone, or a bony grating sensation, when rough articular surfaces move past one another, for example, in a joint that contains loose bodies, degenerative joint disease, dislocation, or a fracture. Soft A boggy sensation that indicates the presence of synovitis or soft tissue edema Firm A springy sensation or a hard arrest to movement with some give, indicating muscular, capsular, or ligamentous shortening. Spring block A rebound is seen or felt and indicates the presence of an internal derangement; for example, the knee with a torn meniscus. spasm A hard sudden stop to passive movement that is often accompanied by pain, is indicative of an acute or subacute arthritis, the presence of a severe active lesion, or fracture. If pain is absent a spasm end feel may indicate a lesion of the central nervous system with resultant increased muscular tonus. empty If considerable pain is present, there is no sensation felt before the extreme of passive ROM as the patient requests the movement be stopped, this indicates pathology such as an extra-articular abscess, a neoplasm, acute bursitis, joint inflammation, or a fracture. Contraindications to ROM testing: Dislocation or unhealed fracture in the region Immediately following surgery On medication for pain or muscle relaxants (careful) Regions of osteoporosis or bone fragility, Immediately after an injury where disruption of tissue is present. Tools of ROM assessment The universal goniometer, tape measure, inclinometer, and the Cervical and Back Range of Motion Instrument (CROM & BROM) are the most common tools used to measure AROM. Universal Goniometer The universal goniometer is produced in a variety of forms and sizes. Most commonly, the universal goniometer is made of either metal or clear plastic and consists of a central protractor 18 portion on which are mounted two arms of varying lengths. The protractor portion of the goniometer may be either a full circle or a half circle, both of which are calibrated in degrees. Although the scales of some goniometers are marked in gradations of 2.5 or 5 degrees, for optimal accuracy the scale should be marked at 1-degree intervals. Many goniometers are marked with a line that runs from the 0-degree to the 180-degree mark on the protractor. This line represents the base line of the protractor and serves as a reference point for measurements. One of the two arms of the goniometer is an extension of the protractor (the stationary arm); the other arm is riveted to, and can move independently of, the protractor (the moving arm). The central rivet, which attaches the moving arm to the protractor, functions as the axis, or fulcrum, of the goniometer Inclinometer An inclinometer consists of a circular, fluid-filled disc with a bubble or weighted needle that indicates the number of degrees on the scale of a protractor. Most inclinometers are calibrated or referenced to gravity, analogous to the principle related to the level used by a carpenter. Because gravity does not change, using gravity as a reference point means that the starting position of the inclinometer can be identified and repeated consistently. Inclinometers are available in two types: mechanical and electronic. The least expensive of the two is the mechanical, with most inclinometers today consisting of a protractor and a weighted gravity-pendulum indicator that remains in the vertical position to indicate degrees on the protractor. Electronic inclinometers are more expensive, may have to be connected to computers with special programs and software, and frequently must be calibrated against some horizontal surface between measurements. Given that the mechanical inclinometer is easy to use, inexpensive, and fairly well represented in research in the literature, this textbook presents only information related to the mechanical inclinometer. 19 The inclinometer can be held against the patient during a variety of movements, or the device can be mounted on a frame. Examples of mounting the inclinometer onto a plastic frame include the cervical range of motion (CROM) device and the back range of motion (BROM) device. CROM The CROM device consists of a plastic frame that is placed over the patient’s head, aligned on the bridge of the nose and on the ears, and secured to the back of the head with straps made of Velcro. Cervical flexion and extension are measured by an inclinometer mounted on the side of the headpiece. An inclinometer mounted on the front of the headpiece is used to measure lateral flexion. Both inclinometers work by force of gravity. To measure cervical rotation, a compass inclinometer is attached to the top of the headpiece in the transverse plane and operated in conjunction with a magnetic yoke. The yoke consists of two padded bars, mounted on the shoulders, that contain magnetic poles. 20 BROM The BROM device consists of two plastic frames that are secured to the lumbar spine of the patient by two elastic straps. One frame consists of an L-shaped slide arm that is free to move within a notch of the fixed base unit during flexion and extension; ROM is read from a protractor scale. The second frame has two measurement devices attached to it. One attachment is a vertically mounted gravity-dependent inclinometer, which measures lateral flexion. The second attachment is a horizontally mounted compass to measure rotation. During measurement of trunk rotation, the device requires a magnetic yoke to be secured to the pelvis. Tape Measure One of the simplest tools for measuring ROM and muscle length is the tape measure (or ruler). Tape measures can be made of plastic or metal. They can possess a centimeter scale, an inch scale, or both. The tape measure is easy to use and is readily available in most clinics. One negative aspect related to use of the tape measure is that most systems used for rating ROM and muscle length impairment rely on measurement in degrees. It is better used for long and round measurement. 21 Electrogoniometer Electrogoniometers, which convert angular motion of the joint into an electric signal. The basic principle of this type of goniometer has been modified to produce a variety of styles of electrogoniometer that are currently in use. Some electrogoniometers are designed to measure motion at a single joint, such as the elbow or the hip, whereas others are designed to measure motion at a variety of joints. Designs range from fairly cumbersome devices to more compact, portable systems. Although many electrogoniometers are capable of measuring motion in several planes simultaneously, the cost of these devices and the skill required for application have resulted in electrogoniometers being used primarily in research applications The protractor used in a traditional goniometer is replaced by a potentiometer positioned over the center of rotation of the joint being monitored. When motion occurs at the joint, an electrical output from the potentiometer provides a continuous record of the angle present at the joint. The inter- rater and intra-rater reliability of the electro-goniometer is higher than the universal goniometer. 22 Photography and Video Recording Equipment Still photography has been used to measure joint ROM for decades and remains in use today. Although still photography has been reported to be more accurate than standard methods of goniometry in measuring ROM of the elbow joint and shoulder, measuring ROM with the use of still photography may require more time and effort than is practical in a normal clinical situation. More recently, photography has been incorporated into smartphone and computer applications for measuring joint range of motion and is thus likely to become more commonly used as a method of assessing range of motion. Video recording techniques also have been used to measure joint ROM. Although many motion analysis systems are commercially available, the examination of joint ROM using video recording equipment, such as motion analysis systems, remains generally confined to the research arena because of the prohibitive cost and decreased portability of such equipment. Techniques for Measuring Range of Motion Regardless of the instrument that is used, the individual who uses the measurement tool must become skilled in its use. Once a level of comfort in handling and reading a measurement device has been attained, the user must become skillful in using the instrument to measure joint ROM. Practice in using an instrument should continue until the user has established a high level of intrarater reliability. Many of the steps involved in measuring joint ROM and muscle length are the same, no matter which joint is being measured. These steps provide the basic framework for measurement. 23 Preparation for Measurement Before a patient’s ROM or muscle length is measured, the examiner should determine whether measurement of active or passive ROM is most appropriate. Both active ROM (AROM), which occurs when a patient moves a joint actively through its available ROM, and passive ROM (PROM), which occurs when the examiner moves the patient’s joint through the available ROM, may be used to examine the amount of motion available at a given joint. For example, a patient with supraspinatus tendinitis may be unwilling to abduct the shoulder more than 75 degrees because of pain, so AROM would be limited to 0 to 75 degrees. To ensure that the patient is not developing adhesive capsulitis of the shoulder, the examiner also may wish to measure the amount of passive shoulder abduction that is present. In some instances, the examiner has no choice but to measure PROM because the patient is unable or unwilling to perform AROM. Such cases include measuring ROM in infants, in young children, and in any patient who lacks the motor control to perform active movement at the joint in question. Instructing the Patient Patients should be provided with thorough instructions before any examination technique. Measurement of ROM and muscle length, particularly active motion, requires the full cooperation of the patient. As the patient’s understanding of the procedure increases, so does the likelihood that the patient will provide his or her best effort during the process. Positioning the Patient: Measuring Joint Range of Motion Proper positioning of the patient during measurement is critical to accurate measurement. The choice of a preferred patient position for measurement of motion at each joint is based on several criteria. For a position to be considered optimal, all criteria should be met. 24 Although this is not an exhaustive list, the major criteria used in selecting a preferred patient position for measurement of ROM are as follows: 1. The joint should be placed in the zero-starting position. The zero-starting position for almost all joints is the anatomical position of that joint. The only joint that is not placed in the anatomical position to start is the forearm, which is placed midway between full pronation and full supination (the neutral position of the forearm). When a joint is positioned in the zero-starting position, the joint is considered to be at 0 degrees ROM. 2. The joint should be positioned such that the proximal segment of the joint is stabilized most easily. This positioning allows maximal isolation of the intended motion. 3. The bony landmarks to be used to align the measurement tool should be palpable and in proper alignment. In some cases, this necessitates placing more proximal joints out of anatomical position. For example, when flexion of the wrist is measured, the shoulder is abducted to 90 degrees, the elbow flexed to 90 degrees, and the forearm pronated for placement of the bony landmarks for goniometric alignment in a linear relationship. 4. The joint to be measured should be free to move through its complete available ROM. Motion should not be blocked by external objects, such as the examining table, or by internal forces, such as muscle tightness. An example of the latter is positioning the patient in the prone position to measure knee flexion. Because tension in the rectus femoris muscle can limit knee flexion when the hip is extended (patient positioned prone), a better position for this measurement is with the patient supine. Such a position allows free flexion of the hip during knee flexion, thus eliminating potential restriction of knee flexion by rectus femoris tightness. 25 5. The patient must be able to assume the position. In some cases, this criterion cannot be met, and an alternative position must be used. In any instance in which an alternative position is used, the examiner should design the position so that it adheres as closely as possible to the previous four criteria. The amount of ROM measured may vary significantly, depending on the position in which the patient is placed during the measurement. For example, significantly higher amount of shoulder abduction was obtained when active or passive shoulder abduction was measured with the patient in the supine, compared with the sitting, position. Stabilization Accurate measurement of joint ROM and muscle length requires stabilization of the proximal bony segment of the joint being measured. Failure to provide adequate stabilization will prevent isolation of the intended motion and may allow the patient to substitute motion at another joint for the motion requested. For example, a patient who lacks forearm pronation may abduct and medially rotate the shoulder to substitute for the lack of forearm motion. If the examiner fails to stabilize the humerus in an adducted position during measurement of forearm pronation, the patient may perform the substitute motion, and the measurement of forearm pronation would then be inflated falsely. Palpating Bony Landmarks and Aligning the Measurement Device Accurate palpation of landmarks and precise alignment of the measurement device with those landmarks are critical to correct measurement of joint ROM. Bony landmarks are used for alignment of the measurement device whenever possible because bony structures are more stable and are less subject to change in position caused by factors such as edema or muscle atrophy. Aligning the Goniometer Three landmarks, as a minimum, are used to align the goniometer. Two landmarks are used to align the arms of the goniometer—one landmark for the stationary 26 arm and one for the moving arm. The stationary arm is generally aligned with the midline of the stationary segment of the joint, while the moving arm is aligned with the midline of the moving segment of the joint. The bony landmarks provided for alignment of the goniometer arms are generally target points on the bones of the stationary and moving joint segments. Although the arms of the goniometer may not actually cross these bony targets once the instrument is aligned, the examiner should sight the midline of each goniometer arm so that it points directly at the corresponding bony target. The third bony landmark provides a point for alignment of the fulcrum of the goniometer. The fulcrum of the goniometer is placed over a point that is near the axis of rotation of the joint. However, because the axis of rotation for most joints is not stationary but moves during motion of the joint, the goniometer’s fulcrum often will not remain aligned over its corresponding bony landmark throughout the ROM. Because the joint axis is not stationary, the landmark for alignment of the fulcrum of the goniometer is the least important of the three landmarks for goniometer alignment. To ensure accurate alignment, priority should be given to alignment of the stationary and moving arms of the goniometer. Once the examiner is satisfied that the goniometer is aligned correctly, a reading should be taken from the scale of the goniometer at the beginning of the ROM. Aligning the Inclinometer Only one bony landmark per measurement is needed for alignment of the standard inclinometer; therefore, the measurement device is not subject to error in estimating multiple anatomical landmarks for one measurement. An inclinometer with a two-point contact base is preferred because this type of base best maintains contact over convex surfaces of the body. Because of its ease of use, the inclinometer has gained favor for measurement of the spine. 27 The inclinometer has not been used as frequently as the goniometer to measure the extremities because of difficulties involved in stabilizing the instrument along the different anatomical contours of the body, especially on smaller joints. Additionally, any attempt to strap the inclinometer to the extremity introduces problems of soft-tissue variability, edema, and slippage. 28 MEASUREMENT OF RANGE OF MOTION OF UPPER LIMB 29  Measurement of range of motion R Procedures for measuring ROMANGE OF MOTION 1. Determine the type of measurement to be performed (AROM or PROM). 2. Explain the purpose of the procedure to the patient. 3. Position the patient in the preferred patient position for the measurement. 4. Stabilize the proximal joint segment. 5. Instruct the patient in the specific motion that will be measured while moving the patient’s distant joint segment passively through the ROM. Determine the end-feel at the end of the PROM. 6. Return the patient’s distal joint segment to the starting position. 7. Palpate bony landmarks for measurement device alignment. 8. Align the measurement device with the appropriate bony landmarks. 9. Read the scale of the measurement device and note the reading. 10. Have the patient move actively, or move the patient passively, through the available ROM. 11. Re-palpate the bony landmarks and readjust the alignment of the measurement device as necessary. 12. Read the scale of the measurement device and note the reading. 13. Record the patient’s ROM. The record should include, at a minimum, a. Patient’s name and identifying information b. Date measurement was taken c. Identification of person taking measurement d. Type of motion measured (AROM or PROM) and device used e. Any alteration from preferred patient position f. Readings taken from measurement device at beginning and end of ROM 30  GLENOHUMERAL JOINT The glenohumeral joint is classified as a ball-and socket joint that is formed by the articulation of the rounded humeral head with the anterolaterally facing glenoid fossa of the scapula. Because the glenoid fossa is shallow and provides only a small articular surface for the head of the humerus, the glenohumeral joint possesses some inherent instability. The relative instability of the glenohumeral joint allows large freedom of movement, permitting placement of the upper extremity in a wide variety of positions for function. The joint has three degrees of freedom of movement, allowing the motions of flexion/extension, abduction/adduction, and medial/lateral rotation. Motion at the glenohumeral joint is limited primarily by muscular and capsuloligamentous structures thus the normal end-feel for all motions of the normal shoulder joint complex is firm. Elevation (flexion or abduction) is limited by tension in the inferior glenohumeral ligament and the inferior joint capsule. Extension is limited by the superior and middle glenohumeral ligaments. Rotation is limited by ligamentous structures and by tension in muscles of the rotator cuff. Shoulder Flexion: Normal ROM = 160 to 190 degrees Patient position: Supine with shoulder in 0-degrees flexion, elbow fully extended, forearm in neutral rotation with palm facing trunk. 31 Starting position for measurement of shoulder flexion. Bony landmarks for goniometer alignment (lateral aspect of acromion process, lateral midline of thorax, lateral humeral epicondyle) indicated by red line and dots. Stabilization: Over anterosuperior aspect of ipsilateral shoulder, proximal to humeral head. Examiner action: After instructing patient in motion desired, flex patient’s shoulder through available ROM, avoiding extension of spine. Return limb to starting position. Performing passive movement provides an estimate of ROM and demonstrates to patient exact motion desired. End of shoulder flexion ROM, showing proper hand placement for stabilizing thorax and flexing shoulder. Bony landmarks for goniometer alignment (lateral midline of thorax, lateral humeral epicondyle) indicated by red line and dot. Goniometer alignment: Palpate the bony landmarks as shown in figures and align goniometer accordingly. Stationary arm: Lateral midline of thorax. Axis: Midpoint of lateral aspect of acromion process. Moving arm: Lateral midline of humerus toward lateral humeral epicondyle. Read scale of goniometer. Patient/Examiner action: Perform passive, or have patient perform active, shoulder flexion. 32 Confirmation of alignment: Re-palpate landmarks and confirm proper goniometric alignment at end of ROM, correcting alignment as necessary. Read scale of goniometer Shoulder Extension: Normal ROM = 60 to 70 degrees Patient position: Prone with shoulder in 0-degrees flexion, elbow fully extended, forearm in neutral rotation with palm facing trunk. Starting position for measurement of shoulder extension. Bony landmarks for goniometer alignment (lateral aspect of acromion process, lateral midline of thorax, lateral humeral epicondyle) indicated by red line and dots. Stabilization: Over posterosuperior aspect of ipsilateral shoulder, proximal to humeral head Examiner action: After instructing patient in motion desired, extend patient’s shoulder through available ROM, avoiding rotation of trunk. Return limb to starting position. Performing passive movement allows an estimate of ROM and demonstrates to patient exact motion desired. 33  End of shoulder extension ROM, showing proper hand placement for stabilizing thorax and extending shoulder. Bony landmarks for goniometer alignment (lateral aspect of acromion process, lateral midline of thorax, lateral humeral epicondyle) indicated by red line and dots Goniometer alignment: Palpate the bony landmarks as shown in figures and align goniometer accordingly. Stationary arm: Lateral midline of thorax. Axis: Midpoint of lateral aspect of acromion process. Moving arm: Lateral midline of humerus toward lateral humeral epicondyle. Read scale of goniometer. Patient/Examiner action: Perform passive, or have patient perform active, shoulder extension. Confirmation of alignment: Re-palpate landmarks and confirm proper goniometric alignment at end of ROM, correcting alignment as necessary. Read scale of goniometer. Note: To prevent artificial inflation of ROM measurements, no rotation of spine should be allowed during measurement of shoulder extension 34 Shoulder Abduction Normal ROM = 165 to 190 degrees Patient position: Supine with arm at side, upper extremity in anatomical position. Starting position for measurement of shoulder abduction with patient in the supine position. Bony landmarks for goniometer alignment (anterior aspect of acromion process, midline of sternum, medial humeral epicondyle) indicated by red line and dots. Stabilization: Over superior aspect of ipsilateral shoulder, proximal to humeral head. Examiner action: After instructing patient in motion desired, abduct patient’s shoulder through available ROM, avoiding lateral trunk flexion. Return limb to starting position. Performing passive movement provides an estimate of the ROM and demonstrates to patient exact motion desired. End of shoulder abduction ROM, showing proper hand placement for stabilizing thorax and abducting shoulder. Bony landmarks for goniometer alignment (midline of sternum, medial humeral epicondyle) indicated by red line and dot. Goniometer alignment: Palpate the landmark as shown in figures and align goniometer accordingly. 35 Stationary arm: Parallel to sternum. Axis: Anterior aspect of acromion process. Moving arm: Anterior midline of humerus toward medial humeral epicondyle. Read scale of goniometer. Patient/Examiner action: Perform passive, or have patient perform active, shoulder abduction. Confirmation of alignment: Re-palpate landmarks and confirm proper goniometric alignment at end of ROM, correcting alignment as necessary. Read scale of goniometer. Note: To prevent artificial inflation of ROM measurements, no lateral flexion of spine should be allowed during measurement of shoulder abduction. Shoulder Horizontal Abduction Patient position: Supine with shoulder abducted to 90 degrees, glenohumeral joint at edge of table, elbow fully extended, and forearm in neutral rotation. Starting position for measurement of shoulder horizontal abduction. Landmarks for goniometer alignment (superior aspect of acromion process, lateral epicondyle of humerus) indicated by red dots. 36 Stabilization: Over superior aspect of ipsilateral shoulder, proximal to humeral head Examiner action: After instructing patient in motion desired, horizontally abduct patient’s shoulder through available ROM. Return limb to starting position. Performing passive movement provides an estimate of ROM and demonstrates to patient exact motion desired End of shoulder horizontal abduction ROM, showing proper hand placement for stabilizing thorax and abducting shoulder in horizontal plane. Landmarks for goniometer alignment (superior aspect of acromion process, lateral epicondyle of humerus) indicated by red dots. Goniometer alignment: Palpate bony landmarks as shown in figures, and align goniometer accordingly. Stationary arm: Parallel to floor. Axis: Superior aspect of acromion process. Moving arm: Midline of humerus toward lateral humeral epicondyle. Read scale of goniometer. Patient/Examiner action: Perform passive, or have patient perform active, horizontal abduction of shoulder. Confirmation of alignment: Re-palpate landmarks and confirm proper goniometer alignment at end of ROM, correcting alignment as necessary. Read scale of goniometer 37 Shoulder Horizontal Adduction Patient position: Supine with shoulder abducted to 90 degrees, glenohumeral joint at edge of table, elbow fully extended, and forearm in neutral rotation Starting position for measurement of shoulder horizontal adduction. Landmarks for goniometer alignment (superior aspect of acromion process, lateral epicondyle of humerus) indicated by red dots. Stabilization: Over ipsilateral shoulder and proximal humerus. Examiner action: After instructing patient in motion desired, horizontally adduct patient’s shoulder through available ROM, making sure scapula does not lift off the table. Return limb to starting position. Performing passive movement provides an estimate of ROM and demonstrates to patient exact motion desired End of shoulder horizontal adduction ROM, showing proper hand placement for stabilizing thorax and adducting shoulder in horizontal plane. Landmarks for goniometer alignment (superior aspect of acromion process, lateral epicondyle of humerus) indicated by red dots. Stationary arm: Parallel to floor. Axis: Superior aspect of acromion process Moving arm: Midline of humerus toward lateral humeral epicondyle. Read scale of goniometer. Patient/Examiner action: Perform passive, or have patient perform active, horizontal adduction of shoulder, stopping at point of elevation of scapula off the table. 38 Confirmation of alignment: Re- palpate landmarks and confirm proper goniometer alignment at end of ROM, correcting alignment as necessary. Read scale of goniometer Shoulder Lateral Rotation: Normal ROM = 70 to 110 degrees Patient position: Supine with shoulder abducted to 90 degrees, elbow flexed to 90 degrees, forearm pronated, and folded towel under humerus. Starting position for measurement of shoulder lateral rotation. Landmarks for goniometer alignment (olecranon and styloid processes of ulna) indicated by red dots Stabilization: Place heel of hand over superior aspect of ipsilateral shoulder, proximal to humeral head; fingers over ipsilateral scapula. Examiner action: After instructing patient in motion desired, laterally rotate patient’s shoulder through available ROM, making sure the scapula does not lift off the table. Return limb to starting position. Performing passive movement provides an estimate of ROM and demonstrates to patient exact motion desired. 39  End of shoulder lateral rotation ROM, showing proper hand placement for stabilizing thorax and laterally rotating shoulder. Landmarks for goniometer alignment (olecranon and styloid processes of ulna) indicated by red dots. Stationary arm: Perpendicular to floor. Axis: Olecranon process of ulna. Moving arm: Ulnar border of forearm toward ulnar styloid process. Read scale of goniometer. Patient/Examiner action: Perform passive, or have patient perform active, lateral rotation of the shoulder, stopping at the point of elevation of the scapula off the table. Confirmation of alignment: Re palpate landmarks and confirm proper goniometer alignment at end of ROM, correcting alignment as necessary. Read scale of goniometer. Shoulder Medial Rotation Normal ROM = 70 to 100 degrees Patient position: Supine with shoulder abducted to 90 degrees, elbow flexed to 90 degrees, forearm pronated, and folded towel under humerus. 40  Starting position for measurement of shoulder medial rotation. Landmarks for goniometer alignment (olecranon and styloid processes of ulna) indicated by red dots. Stabilization: Place heel of hand over superior aspect of ipsilateral shoulder, proximal to humeral head, and fingers over ipsilateral scapula. Examiner action: After instructing patient in motion desired, medially rotate patient’s shoulder through available ROM, making sure the scapula does not lift off the table. Return limb to starting position. Performing passive movement provides an estimate of ROM and demonstrates to patient exact motion desired. End of shoulder medial rotation ROM, showing proper hand placement for stabilizing thorax and medially rotating shoulder. Landmarks for goniometer alignment (olecranon and styloid processes of ulna) indicated by red dots. Goniometer alignment: Palpate the bony landmarks and align goniometer accordingly. Stationary arm: Perpendicular to floor. Axis: Olecranon process of ulna. Moving arm: Ulnar border of forearm toward ulnar styloid process. Read scale of goniometer. Patient/Examiner action: Perform passive, or have patient perform active, medial rotation of the shoulder, stopping at the point of elevation of the scapula off the table. 41 Confirmation of alignment: Re palpate landmarks and confirm proper goniometer alignment at end of ROM, correcting alignment as necessary. Read scale of goniometer Measurement of range of motion R Elbow joint and forearm LIMITATIONS OF MOTION (elbow joint) Elbow flexion range of motion (ROM) is limited by soft tissue approximation between the structures of the anterior arm and the forearm, particularly during active flexion of the joint when contact between contracting flexors of the arm and forearm stops the motion. The range of elbow flexion tends to be greater when the joint is moved passively because there is less interference by the contracting muscle bulk. Elbow extension ROM is limited by contact of the olecranon process of the ulna with the olecranon fossa of the humerus. END-FEEL The normal end-feel for elbow flexion is soft because soft tissue approximation normally limits motion. The normal end-feel for elbow extension is hard, because the olecranon process of the ulna becomes wedged in the olecranon fossa of the humerus LIMITATIONS OF MOTION Forearm Joints Supination of the forearm is limited by tension in ligamentous structures (anterior radioulnar ligament and oblique cord). Limitation of forearm pronation occurs 42 as the result of contact between the bones of the forearm (radius crossing over ulna) and tension in the medial collateral ligament of the elbow and the dorsal radioulnar ligament of the distal radioulnar joint. END-FEEL The typical end-feel for forearm supination is firm as a result of ligamentous tension. Because bony contact limits pronation, the normal end-feel for that motion is hard. Elbow Flexion Normal ROM = 140 to 150 degrees Patient position: Supine with upper extremity in anatomical position, folded towel under humerus, proximal to humeral condyles. Starting position for measurement of elbow flexion. Bony landmarks for goniometer alignment (lateral aspect of acromion process, lateral humeral epicondyle, radial styloid process) indicated by red dots. Stabilization: Over posterior aspect of proximal humerus. Examiner action: After instructing patient in motion desired, flex patient’s elbow through available ROM. Return limb to starting position. Performing passive movement provides an estimate of ROM and demonstrates to patient exact motion desired. End of elbow flexion ROM, showing proper hand placement for stabilizing humerus and flexing elbow. Bony landmarks for goniometer alignment (lateral aspect of acromion process, lateral humeral epicondyle, radial styloid process) indicated by red dots. 43 Goniometer alignment: Palpate the bony landmarks and align goniometer accordingly. Stationary arm: Lateral midline of humerus toward acromion process. Axis: Lateral epicondyle of humerus. Moving arm: Lateral midline of radius toward radial styloid process. Read scale of goniometer. Patient/Examiner action: Perform passive, or have patient perform active, elbow flexion. Confirmation of alignment: Re palpate landmarks and confirm proper goniometric alignment at end of ROM, correcting alignment as necessary. Read scale of goniometer. Elbow Extension Normal ROM = 0 to 5 degrees Patient position: Supine with upper extremity in anatomical position , elbow extended as far as possible, folded towel under distal humerus, proximal to humeral condyles. Starting position for measurement of elbow extension. Bony landmarks for goniometer alignment (lateral aspect of acromion process, lateral humeral epicondyle, radial styloid process) indicated by red dots. Stabilization: None needed. 44 Examiner action: Determine whether elbow is extended as far as possible by (1) asking patient to straighten elbow as far as possible (if measuring active ROM) or (2) providing pressure across the elbow in the direction of extension (if measuring passive ROM). End of elbow extension ROM, showing proper hand placement for stabilizing humerus and extending elbow. Bony landmarks for goniometer alignment (lateral aspect of acromion process, lateral humeral epicondyle, radial styloid process) indicated by red dots. Goniometer alignment: Palpate the following bony landmarks and align goniometer accordingly. Stationary arm: Lateral midline of humerus toward acromion process. Axis: Lateral epicondyle of humerus. Moving arm: Lateral midline of radius toward radial styloid process. Read scale of goniometer. Forearm Supination Normal ROM = 80 to 100 degrees Patient position: Seated or standing with shoulder completely adducted, elbow flexed to 90 degrees, forearm in neutral rotation. 45  Starting position for measurement of forearm supination. Bony landmarks for goniometer alignment (anterior midline of humerus and ulnar styloid process) indicated by red line and dot Stabilization: Over lateral aspect of distal humerus, maintaining 0 degrees shoulder adduction. Examiner action: After instructing patient in motion desired, supinate patient’s forearm through available ROM, avoiding lateral rotation of shoulder or shoulder adduction past 0 degrees. Return limb to starting position. Performing passive movement provides an estimate of ROM and demonstrates to patient exact motion desired. End of forearm supination ROM, showing proper hand placement for stabilizing humerus against thorax and supinating forearm. Bony landmark for goniometer alignment (anterior midline of humerus) indicated by red line. Goniometer alignment: Palpate the bony landmarks and align goniometer accordingly Stationary arm: Parallel with anterior midline of humerus. Axis: On volar surface of wrist, in line with styloid process of ulna. 46 Moving arm: Volar surface of wrist, at level of ulnar styloid process. Read scale of goniometer. Patient/Examiner action: Perform passive supination or have patient perform active forearm supination. Confirmation of alignment: Re palpate landmarks and confirm proper goniometric alignment at end of ROM, correcting alignment as necessary Forearm Pronation Normal ROM = 70 to 80 degrees Patient position: Seated or standing with shoulder completely adducted, elbow flexed to 90 degrees, forearm in neutral rotation Starting position for measurement of forearm pronation. Bony landmarks for goniometer alignment (anterior midline of humerus and ulnar styloid process) indicated by red line and dot 47 Stabilization: Over lateral aspect of distal humerus, maintaining shoulder adduction Examiner action: After instructing patient in motion desired, pronate patient’s forearm through available ROM, avoiding shoulder abduction and medial rotation. Return limb to starting position. Performing passive movement provides an estimate of ROM and demonstrates to patient exact motion desired. End of forearm pronation ROM, showing proper hand placement for stabilizing humerus against thorax and pronating forearm. Bony landmark for goniometer alignment (anterior midline of humerus) indicated by red line. Axis: In line with, and just proximal to, styloid process of ulna. Moving arm: Dorsum of forearm, just proximal to ulnar styloid process. Read scale of goniometer. Patient/Examiner action: Perform passive forearm pronation or have patient perform active forearm pronation Confirmation of alignment: Re palpate landmarks and confirm proper goniometric alignment at end of ROM, correcting alignment as necessary. Read scale of goniometer Note: To prevent artificial inflation of ROM measurements, no abduction or medial rotation of shoulder should be allowed during measurement of forearm pronation. 48 49  Wrist joint ROM measurement LIMITATIONS OF MOTION: WRIST JOINT With the fingers free to move, limitation of wrist flexion and extension range of motion is produced by passive tension in the dorsal and palmar radiocarpal ligaments, respectively. In addition, the palmar ulnocarpal ligament also restricts wrist extension. Limitation of ulnar deviation occurs secondary to tension in the radial collateral ligament. Radial deviation of the wrist is terminated by bony impingement of the trapezium upon the radial styloid process. END-FEEL: WRIST JOINT The end-feel for passive flexion and extension of the wrist is firm as a result of ligamentous limitation of the motion if the fingers are mobile. However, if the fingers are not free to move and are flexed, the position of the fingers will limit wrist flexion secondary to passive tension in the extrinsic finger extensors. Conversely, extension of the fingers will limit wrist extension owing to passive tension in the extrinsic finger flexors. Wrist adduction is also limited by ligamentous structures and thus possesses a firm end-feel. Wrist abduction is limited by bony contact between the radial styloid process and the trapezium, which produces a bony end-feel at the limit of motion. Wrist Flexion Normal ROM = 70 degrees to 95 degrees Patient position: Seated, with shoulder abducted 90 degrees; elbow flexed 90 degrees; forearm pronated; arm and forearm supported on table; hand off table with wrist in neutral position. Starting position: for measurement of wrist flexion using lateral alignment technique. Bony landmarks for goniometer alignment (olecranon process of ulna, triquetrum, lateral midline of fifth metacarpal) indicated by red line and dots. 50 Stabilization: Over dorsal surface of forearm. Examiner action: After instructing patient in motion desired, flex patient’s wrist through available ROM. Return wrist to neutral position. Performing passive movement provides an estimate of ROM and demonstrates to patient exact motion desired. End of wrist flexion ROM, showing proper hand placement for stabilizing forearm and flexing wrist. Bony landmarks for goniometer alignment (olecranon process of ulna, triquetrum, lateral midline of fifth metacarpal) indicated by red line and dots. Goniometer alignment: Palpate the bony landmark and align goniometer accordingly Stationary arm: Lateral midline of ulna toward olecranon process. Axis: Triquetrum. Moving arm: Lateral midline of fifth metacarpal. Read scale of goniometer. Patient/Examiner action: Perform passive, or have patient perform active, wrist flexion. Confirmation of alignment: Re palpate landmarks and confirm proper goniometric alignment at end of ROM, correcting alignment as necessary. Read scale of goniometer. Note: Flexion of fingers should be avoided during measurement of wrist flexion to prevent limitation of motion by tension in extrinsic finger extensors. 51 Wrist Extension Normal ROM = 60 degrees to 85 degrees Patient position: Seated, with shoulder abducted 90 degrees; elbow flexed 90 degrees; forearm pronated; arm and forearm supported on table; hand off table with wrist in neutral position Starting position: for measurement of wrist extension using lateral alignment technique. Bony landmarks for goniometer alignment (olecranon process of ulna, triquetrum, lateral midline of fifth metacarpal) indicated by red line and dots Patient position: Seated, with shoulder abducted 90 degrees; elbow flexed 90 degrees; forearm pronated; arm and forearm supported on table; hand off table with wrist in neutral position. Stabilization: Over dorsal surface of forearm Examiner action: After instructing patient in motion desired, extend patient’s wrist through available ROM. Return wrist to neutral position. Performing passive movement provides an estimate of ROM and demonstrates to patient exact motion desired. End of wrist extension ROM, showing proper hand placement for stabilizing forearm and extending wrist. Bony landmarks for goniometer alignment (olecranon process of ulna, triquetrum, lateral midline of fifth metacarpal) indicated by red line and dots. Goniometer alignment: Palpate the following bony landmarks and align goniometer accordingly Stationary arm: Lateral midline of ulna toward olecranon process. Axis: Triquetrum. Moving arm: Lateral midline of fifth metacarpal Patient/Examiner action: Perform passive, or have patient perform active, wrist extension. 52 Confirmation of alignment: Re palpate landmarks and confirm proper goniometric alignment at end of ROM, correcting alignment as necessary. Read scale of goniometer. Note: Extension of fingers should be avoided during measurement of wrist extension to prevent limitation of motion by tension in extrinsic finger flexors. Wrist Adduction: Ulnar Deviation Normal ROM = 30 degrees to 40 degrees Patient position: Seated, with shoulder abducted 90 degrees; elbow flexed 90 degrees; forearm pronated; upper extremity (UE) supported on table; wrist and hand in neutral position. Starting position for measurement of wrist adduction. Bony landmarks for goniometer alignment (lateral epicondyle of humerus, capitate, dorsal midline of third metacarpal) indicated by red line and dots. Stabilization: Over dorsal surface of distal forearm. Examiner action: After instructing patient in motion desired, adduct patient’s wrist through available ROM. Return wrist to neutral position. Performing passive movement provides an estimate of ROM and demonstrates to patient exact motion desired. 53  End of wrist adduction ROM, showing proper hand placement for stabilizing forearm and adducting wrist. Bony landmarks for goniometer alignment (lateral epicondyle of humerus, capitate, dorsal midline of third metacarpal) indicated by red line and dots. Goniometer alignment: Palpate the following bony landmarks and align goniometer accordingly. Stationary arm: Dorsal midline of forearm toward lateral epicondyle of humerus. Axis: Capitate. Moving arm: Dorsal midline of third metacarpal. Read scale of goniometer. Patient/Examiner action: Perform passive, or have patient perform active, wrist adduction. Confirmation of alignment: Re palpate landmarks and confirm proper goniometric alignment at end of ROM, correcting alignment as necessary. Read scale of goniometer Wrist Abduction: Radial Deviation Normal ROM = 20 degrees to 25 degrees 54 Patient position: Seated, with shoulder abducted 90 degrees; elbow flexed 90 degrees; forearm pronated; UE supported on table; wrist and hand in neutral position. Starting position for measurement of wrist abduction. Landmarks for goniometer alignment (lateral epicondyle of humerus, capitate, dorsal midline of third metacarpal) indicated by red line and dots. Stabilization: Over dorsal surface of distal forearm. Examiner action: After instructing patient in motion desired, abduct patient’s wrist through available ROM. Return wrist to neutral position. Performing passive movement provides an estimate of the ROM and demonstrates to patient exact motion desired. End of wrist abduction ROM, showing proper hand placement for stabilizing forearm and adducting wrist. Landmarks for goniometer alignment (lateral epicondyle of humerus, capitate, dorsal midline of third metacarpal) indicated by red line and dots. Goniometer alignment: Palpate the following bony landmarks and align goniometer accordingly. Stationary arm: Dorsal midline of forearm toward lateral epicondyle of humerus. Axis: Capitate. Moving arm: Dorsal midline of third metacarpal. Read scale of goniometer. Patient/Examiner action: Perform passive, or have patient perform active, wrist abduction. Confirmation of alignment: Re palpate landmarks and confirm proper goniometric alignment at end of ROM, correcting alignment as necessary. Read scale of goniometer. 55 Section 3 MANUAL MUSCLE TESTING 56  Muscle testing Muscle testing is an integral part of physical examination. It provides information, not obtained by other procedures, that is useful in differential diagnosis, prognosis and treatment of neuromuscular and musculoskeletal disorders. Many neuromuscular conditions are characterized by muscle weakness. Some show definite patterns of muscle involvement; others show spotty weakness without any apparent pattern. In some cases, weakness is symmetrical, in others, asymmetrical. The site or level of peripheral lesion may be determined because the muscles distal to the site of the lesion will show weakness or paralysis. Careful testing and accurate recording of test results will reveal the characteristic findings and aid in diagnosis. Musculoskeletal conditions frequently show patterns of muscle imbalance. Some patterns are associated with handedness, some with habitually poor posture. Muscle imbalance may also result from occupational or recreational activities in which there is persistent use of certain muscles without adequate exercise of opposing muscles. Imbalance that affects body alignment is an important factor in many painful postural conditions. The technique of manual muscle testing is basically the same for cases of faulty posture as for neuromuscular conditions. Examination to determine muscle length and strength is essential before prescribing therapeutic exercises because most of these exercises are designed either to stretch short muscles or to strengthen weak muscles. Muscle length testing is used to determine whether the muscle length is limited or excessive, i.e., whether the muscle is too short to permit normal range of motion, or stretched and allowing too much range of motion. When stretching is indicated, tight muscles should be stretched in a manner that is not injurious to the part or to the body as a whole. 57 Muscle strength testing is used to determine the capability of muscles or muscle groups to function in movement and their ability to provide stability and support. Many factors are involved in the problems of muscle weakness. Weakness may be due to nerve involvement, disuse atrophy, stretch weakness, pain, or fatigue. Essential terminology of muscle strength ▪ Muscle Strength: the maximal amount of tension voluntary exerted by the one or group of muscles in one maximal effort (maximum or high external weight –low repetition) ▪ Muscular endurance: the ability of muscle to repeat contraction against resistance (low weight-high repetition). ▪ Muscle power: the product of muscle force and contraction velocity ▪ Range of muscle work: The full range in which a muscle work refers to the muscle changing from a position of full stretch and contracting to a position of maximal shortening. The full range is divided into parts, outer, inner, and middle ranges. Outer range: Is from a position where the muscle is on full stretch to a position halfway through the full range of motion. Inner range: Is from a position halfway through the full range to a position where the muscle is fully shortened. Middle range: Is the portion of the full range between the mid-points of the outer and inner ranges ▪ Active insufficiency: The active insufficiency of a muscle that crosses two or more joints, occurs when the muscle produces simultaneous movement at all of the joints it crosses and reaches such a shortened position that it no longer has the ability to develop effective tension. When a muscle is placed in a shortened position of active insufficiency it is described as putting the muscle on slack. ▪ Passive insufficiency occurs when the muscle fails to extend far enough. This happens since a full stretch at multiple joints cannot occur. This position is the longest possible length of a muscle. 58 There are several types of Muscle contraction: 1-isotonic muscle contraction: the ability of muscle to exert constant tension against resistance and change in muscle length. It consists of A) Concentric muscle contraction: the ability of muscle to contract against load direction with shortening in muscle fibers B) Eccentric muscle contraction: the ability of muscle to contract with the same direction of the load and produce lengthening in muscle fibers. 2-isometric muscle contraction: the ability of muscle to contract with constant (no change) in muscle length 3-isokinetic muscle strength: the ability of muscle to contract with constant angular velocity of movement. It consists of a) Concentric muscle contraction: the ability of muscle to contract against load direction with shortening in muscle fibers b) Eccentric muscle contraction: the ability of muscle to contract with the same direction of the load and produce lengthening in muscle fibers. Functional muscle strength: the ability of muscle to play a role in producing the movement and categorized to 1-agonist: the prime mover: the muscle can produce major contribution of movement at the joint. e.g.: middle fiber of deltoid is prime mover for shoulder abduction. 2-antagonist: the muscle opposite the action of the agonist and should be relaxed when the agonist contract.e.g.: triceps (elbow extensor) is antagonist to biceps (elbow flexor). 3-synergist: the muscle contract along with agonist to produce a desired movement. Neutralizing or counter acting synergists: Muscles contracted to prevent unwanted movements produced by the prime mover. For ex. When the long finger flexors contract to produce finger flexion the wrist extensors contract to prevent wrist flexion from occurring. 59 Conjoint synergists: Two or more muscles that work together to produce the desired movement. The muscles contracting alone would be unable to produce the movement. For ex.: Wrist extension is produced by contraction of extensor carpiradialis longus and brevis and extensor carpiulnaris. If the extensor carpiradialis longus or brevis contract alone the wrist extends and radially deviates, if the extensor carpiulnaris contracts alone the wrist extends and ulnar deviates. When the muscles contract as a group the deviation actions cancel out and the common action of wrist results (extension). Stabilizing or Fixating Synergists: Muscle that prevents movement or control the movement the movement at joints proximal to the moving joint to provide a fixed or stable base from which the distal moving segment can effectively work. For ex.: If the elbow flexors contract to lift an object off a table anterior to the body, the muscles of the scapula and glenohumeral joint must contract to either allow slow controlled movement or no movement to occur at the scapula and glenohumeral joint to provide the elbow flexors with a fixed origin from which to pull. If the scapular muscles did not contract the object could not be lifted as the elbow flexors would act to pull the shoulder girdle downward toward the table top. Manual muscle testing Manual muscle testing is a procedure for the evaluation of the function and strength of individual muscles and muscles group based on effective performance of a movement in relation to the forces of gravity and manual resistance through the available ROM. The purpose of muscle test: * Is to provide information that may be of assistance to a number of health professionals in differential diagnosis, treatment planning and prognosis, but it has limitations in the treatment of neurological disorders where there is an alteration in muscle tone if reflex activity is altered or if there is a loss of cortical control due to lesions of the central nervous system. * To assess muscle strength, the therapist must have a sound knowledge of anatomy (including joint motions, muscle origin and insertion, and muscle function) and surface anatomy (to know where a muscle or its tendon is best palpated). 60 * The therapist must be a keen observer and be experienced in muscle testing to detect minimal muscle contraction, movement, and/or muscle wasting and substitutions or trick movements. * A consistent method of manually testing muscle strength is essential to assess accurately a patient's present status, progress, and the effectiveness, of the treatment program. Factors Affecting Strength: The therapist must consider these factors when assessing a patient's strength. 1. Age: A decrease in strength occurs with increasing age due to deterioration in muscle mass. Muscle fibers decrease in size and number, there is an increase in connective tissue and fat, and the respiratory capacity of the muscle decreases. 2. Sex: Males are generally stronger than females. 3. Type of muscle contraction: More tension can be developed during an eccentric contraction than during an isometric contraction. The concentric contraction has the smallest tension capability. 4. Muscle size: The larger the cross-sectional area of a muscle, the greater the strength of the muscle. When testing a muscle that is small, the therapist would expect less tension to be developed than if testing a large, thick muscle. 5. Speed of muscle contraction: When a muscle contracts concentricity the force of contraction decreases as the speed of contraction increases. The patient is instructed to perform each muscle test movement at a moderate pace. 6. Previous training effect: Strength performance depends up on the ability of the nervous system to activate the muscle mass. Strength may increase as one becomes familiar with and learns the test situation. The therapist must instruct the patient well and give the patient an opportunity to move through or be passively moved through the test movement at least once before strength is assessed. 7. Joint position: The tension developed within a muscle depends up on the initial length of the muscle. Regardless of the type of muscle contraction, a muscle contracts with more force when it is stretched that when it is shortened. The greatest amount of tension is developed when the muscle 61 is stretched to the greatest length possible within the body, that is if the muscle is in full outer range. 8. Fatigue: As the patient fatigues, muscle strength decreases. The therapist determines the strength of muscle using as few repetitions as possible to avoid fatigue. The patient's level of motivation, level of pain, body type, occupation, and dominance are other factors that may affect strength. Individual versus group muscle test: Muscles with a common action or actions may be tested as a group or a muscle may be tested individually. For example, flexor carpiulnaris and flexor carpiradialis may be tested together as a group in the action of wrist flexion. Flexor carpiulnaris may be tested more specifically in the action of wrist flexion with ulnar deviation. Muscle testing assessment procedure: 1. Explanation and instruction: The therapist demonstrates and/or briefly explains the movement to be performed and/or passively moves the patient's limb through the test movement. 2. Assessment of normal muscle strength: Initially assess and record the strength of the uninvolved limb to determine the patients normal strength, and to demonstrate the movement before assessing the strength of the involved side considering the factors that affect strength (age, sex, dominance and occupation). 3. Patient position: The patient is positioned to isolate the muscle or muscle group to be tested in either gravity elimination or against gravity position. Ensure that the patient is comfortable and well supported. The muscle or muscle group being tested is placed in full outer range, with only slight tension. 4. Stabilization: Stabilize the site of attachment of the origin of the muscle so that the muscle has a fixed point from which to pull. Prevent substitutions and trick movements by making use of the following methods: 62  A. The patient's normal muscles: a) As the patient holds the edge of the plinth when hip flexion is tested. b) The patient uses the scapular muscles when glenohumeral flexion is performed. B. The patient's body weight: Used to help fix the shoulder or pelvic girdles. C. The patient position: For example, when assessing hip abduction muscle strength in side lying, the patient holds the non-test leg in hip and knee flexion in order to tilt the pelvis posteriorly and fix the pelvis and lumbar spine. D. External forces: a. External pressure applied directly by the therapist. b. Devices such as belt and sandbags. 5. Substitution and trick movements: When muscles are weak or paralyzed, other muscles may take over or gravity may be used to perform the movements normally carried out by the weak muscles. Screen test: A screen test is a method used to streamline the muscle strength assessment, avoid unnecessary testing, and avoid fatiguing and/or discouraging the patient. The therapist may screen the patient through the information gained from: 1. The previous assessment of the patient's active range of motion. 2. Reading the patient's chart or previous muscle test result and/or. 3. Observing the patient perform functional activities, for example: shaking the patients hand may indicate the strength of grasp, i.e. the finger flexors. - Alternatively, the patient may be screened by: 4. Beginning all muscle testing at a particular grade, this is usually a grade of 3. The patient is instructed to actively move the body part through full range of motion against gravity based upon the results of the initial test the muscle test is either stopped or proceeds. 63 Conventional Methods: Manual grading of muscle strength is based on three factors: 1. Evidence of contraction: No palpable or observable muscle contraction (grade 0) or a palpable or observable muscle contraction and no joint motion (grade 1). 2. Gravity as a resistance: The ability to move the part through the full available range of motion gravity eliminated (grade 2) or against gravity (grade 3) the most objective part of test. 3. Amount of manual resistance: The ability to move the part through the full available range of motion against gravity and against moderate manual resistance (grade 4) or maximal manual resistance (grade 5). Adding (+) or (-) to the whole grades to denote variation in the range of motion. - Movement through less than half of the available range of motion is denoted by a (+) (outer range) and - Movement through greater than half of the available range of motion by (-) (inner range). 64  CONVENTIONAL GRADING Numerals Letters Description Against gravity test: The patient is able to move through: The full available ROM against 5 N (normal) gravity and against maximal resistance. The full available ROM against gravity and against 4 G (good) moderate resistance. Greater than one half the available ROM against gravity 4 G- and against moderate resistance. Less than one half the available ROM against gravity and 3+ F+ against moderate resistance. 3 F (Fair) The full available ROM against gravity. 3- F- Greater than one half the available ROM against gravity. 2+ P+ Less than one half the available ROM against gravity. Gravity eliminated test: The patient is able to actively move through: 2 P (Poor) The full available ROM gravity eliminated. Greater than one half the available 2- P- ROM gravity eliminated. 1+ T+ Less than one half the available ROM gravity eliminated. None of the available ROM gravity eliminated and there is 1 T (Trace)