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Phth+224+Lecture+ (1) ROM PDF
Phth+224+Lecture+ (1) ROM PDF
Semester - Lecture 1
Joint Range of Motion
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Factors affecting range of motion:
* Reliability:
Although experienced therapists are reliable in taking goniometric
measurements, there is still some concern about the clinical reliability of
goniometry. It was stated that “Although the inferences that can be made
from measuring joint motion are limited (validity), the measurement itself
is invaluable as a basic indicator of patient’s status”. When measuring,
the therapist must try to rule out as many of the factors that decrease
reliability as possible. Some of the factors which improve reliability
include removal of tight and restrictive clothing, duplications of positions
used and measuring at the same time of the day.
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. Some motions are
limited by soft tissue bulk of the segments and not by a limitation
associated with the joint itself. For instance, elbow flexion is usually
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limited by the 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 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.
When performing goniometric measurements, the examiner should
consider the "end feel" of each joint when determining passive range of
motion. The “end feel” is the sensation transmitted to the therapist’s
hands at the extreme end of the passive ROM and indicates the structures
that limit the joint movement. A normal end feel exists when there is full
ROM at the joint and the normal anatomy of the joint stops movement.
An abnormal end feel exists when there is either a decreased or increased
joint ROM or when there is a normal ROM but structures other than the
normal anatomy stop joint movement. The end feel may be normal
(physiologic) or abnormal (pathologic).
Types of Motion:
1. Active range of motion:
Testing the active ROM provides limited information regarding
joint motion. Assuming that the subject has complete passive ROM, an
inability to actively move the segment completely through the motion
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must be attributed to muscle weakness. Active range grossly evaluates
coordination of movement and functional ability.
2. Passive range of motion:
It is the amount of motion possible when the examiner moves a
body part with no assistance from the subject. It is usually greater than
active ROM because the integrity of the soft tissue structures does not
dictate the limits of movement. A passive ROM test gives the examiner
information about the Integrity of the joint but provides no information
about the capabilities of the contractile tissues.
Instruments:
The instruments used for measuring joint range of motion are
called goniometers or arthrometers. The tools, although varying in size,
shape and appearance; all possess the capabilities to provide specific
information regarding joint motion. The widely used universal
goniometer is durable, washable and can be applied to almost all joints.
The goniometer is basically a protractor with two long arms. One arm is
considered movable and the other is stationary and both are attached to
the body of the protractor tension knob.
Movement Terminology:
* Angular Movement: It refers to movement that produces an increase or
decrease in the angle between the adjacent bones. It includes: flexion,
extension, abduction and adduction.
* Rotation Movements: They generally occur around a longitudinal
vertical axis. They include: internal (medial, inward) rotation, external
(lateral, outward) rotation, neck or trunk rotation, scapular rotation,
circumduction, thumb opposition, horizontal abduction and adduction and
tilting (anterior and posterior tilt of the scapula and pelvis).
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Contraindications and precautions:
Both active and passive ROM assessment techniques are
contraindicated in:
* Region of a dislocation or unhealed fracture.
* Immediately following surgical procedures to tendons, ligaments,
muscle, joint capsule or skin.
* Presence of myositis ossificans.
The therapist must take extra care when performing active or
passive ROM assessment where motion to the part might aggravate the
condition, such as in:
- Patients under medications for pain or muscle relaxants.
- Patients with hemophilia.
- Presence of an infection or inflammatory process in a joint.
- Region of marked osteoporosis.
- Region of hematoma (notably at the elbow, hip or knee).
- Hyper-mobile or subluxed joint.
- Painful conditions, where the assessment technique might reinforce the
severity of symptoms.
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be decreased due to restricted joint mobility, muscle weakness, pain,
inability to follow instructions and/or unwillingness to move. Observation
of active ROM should be followed by assessment of passive ROM.
2. Passive range of motion:
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 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 the range of
motion using a goniometer.
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stretching a piece of leather. For example, it occurs in passive shoulder
external rotation.
Dominance:
Most researchers have found that there is essentially no difference
for corresponding joints between the left and right sides of the body.
Comparative goniometry is done when a joint is involved unilaterally,
while the contra-lateral limb can then be used as the standard for normal
range of motion for that subject.
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Basic elements of ROM testing:
* The simple double-armed goniometer is the most desirable for general
clinical use, especially for the large joints. There are small goniometers
which used for small joints, such as the finger joints.
* In an attempt to make joint measurement as accurate as possible, bony
prominences are used as reference points. The stationary arm of the
goniometer is lined up with two prominences and the nail head or axis of
the goniometer is placed in the area of the axis of apparent motion of the
joint itself.
* As a general rule, the goniometer is always applied to the lateral side of
the joint, except for in measuring forearm supination.
* The instrument should be held loosely away from, or in light contact
with the patient's body. When trying to maintain the position of the
goniometer against the moving part, the instrument position may prohibit
the patient from executing his full ROM.
* No force should be exerted on the body during placing the instrument
otherwise the accuracy of placement may be affected. For example: A
slight pressure on the volar surface of the wrist might give 5° to 10°
above true supination.
* When the limb moves anteriorly to produce flexion, the protractor is
directed anteriorly in the antero-posterior plane. Conversely, when the
limb moves posteriorly to produce extension, the protractor is inverted
and directed posteriorly in the same plane. In other words, the protractor
is always placed in the direction of the movement to be measured, except
in pronation and supination.
* Measurement of each arc of motion should begin at 0° and progress
towards 180°. Most joints, when are in the anatomical position, are at 0°
of motion.
* As joint motion occurs, the amount of joint motion is positively
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recorded in degrees. When the anatomical position cannot be attained, the
degree of disability is recorded by a lack of motion equal to its
magnitude.
* Measuring the unaffected side often will give the expected normal
range for this particular individual.
* The mid-position is the starting position for certain measurements, as in
pronation and supination, shoulder rotation, wrist flexion and extension
and ankle plantar and dorsiflexion.
* An understanding of both the anatomical position and the preferred
starting position is necessary in the proper orientation of the therapist to
the problems of joint measuring.
* Placing the patient in good body alignment simulates the anatomical
position as closely as possible. Deviation from the initial alignment
should be prevented as possible during the execution of the movement to
be measured. Such deviation or substitution of motion may affect results
significantly
* Before starting measurement, the patient should be told clearly what to
do. If necessary, the movement is demonstrated to the patient to execute
as pure an anatomical motion as possible with no substitution or
compensatory movements.
* For ease in measuring and to isolate best the desired motion, the joints
are measured from specific starting positions rather than in the true erect
anatomical position.
* Having aligned the body, instruct the patient to swing the moving part
rhythmically through the arc of motion to be measured and localize the
approximate axis of rotation by inspection. If this cannot be done
volitionally, move the part passively.
* By finding the maximum degree of motion in both directions, the ROM
can be calculated. For example, flexion plus extension equals full ROM
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and pronation plus supination equals full ROM.
* The elbow and knee are considered to be at 0° extension, since motion
progresses normally in only one direction from the anatomical position.
The ROM is found by subtracting the lack of extension of the joint from
the flexion obtained. For example, if flexion is 100° and extension is 20°,
so ROM equals 80°.
* In joints moving in two directions from zero position, the maximum
motion in both directions is added to obtain the full ROM. For example in
shoulder, wrist and radio-ulnar joints; flexion and extension equals ROM.
If the return to the zero anatomical position is not possible, the two
figures are subtracted.
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