1/31/15 4:22 PM Joint ROM the amount of movement that is
possible at a joint. It is the arc of motion through which a joint
passes when moving within a specific plane. Active range of motion
(AROM) when the joint is moved by the muscles that act on the
joint. Passive range of motion (PROM) when the joint is moved by an
outside force such as the therapist. In normal individuals, PROM is
slightly greater than AROM because of the slight elasticity of soft
tissue. The additional PROM that is available at the end of normal
AROM helps protect joint structures because it allows the joint to
give and absorb extrinsic forces. If PROM is significantly greater
than AROM for the same joint motion, it is likely that muscle
weakness is present. Decreased ROM can cause limited function and
interfere with performance in areas of occupation. The primary
concern of the OT is whether ROM is adequate for the client to
engage in meaningful occupations. Limitations in ROM may occur as a
result of injury to or disease in the joint itself or the
surrounding joint tissue structures, joint trauma, or joint
immobilization. Inflexibility at a joint may adversely affect both
speed and strength of movement. A client who constantly has to work
to overcome the resistance of an inflexible joint will probably
demonstrate decreased endurance and fatigue during activity. The
functional motion test, screening tests, and measurement of joint
ROM with a goniometer can all be used to assess ROM. Methods used
to screen limitations in ROM involve the observation of AROM and
PROM. To screen for AROM, the therapist asks the client to perform
all the active movements that occur at the joint. To screen for
PROM, the therapist moves the joint passively through all of its
motions. The purpose of this is to estimate ROM, detect
limitations, and observe the quality of movement, end-feel, and the
presence of pain. The therapist can then decide at which joints
precise ROM measurement in indicated. JOINT MEASUREMENT Body
function is a client factor that the occupational therapist must
consider when classifying the clients underlying abilities. Joint
measurement an assessment tool often used for physical disabilities
that cause limited joint motion. Such disabilities include: skin
contracture caused by adhesions or scar tissue; arthritis;
fractures; burns, and hand trauma; displacement of fibrocartilage
or the presence of other foreign bodies in the joint; bony
obstruction or destruction; and soft tissue contractures, such as
tendon, muscle, or ligament shortening. Limited ROM can also be
secondary to spasticity, muscle weakness, pain, and edema. ROM
measurements help the therapist: select intervention
goalsappropriate intervention modalitiespositioning techniquesand
other strategies to reduce limitations. Specific purposes for
measuring ROM are to: determine limitations that interfere with
function or may produce deformity determine additional range needed
to increase functional capacity or reduce deformity determine the
need for splints and assistive devices measure progress objectivity
record progression or regression. The use of formal joint
measurement will assist in determining the efficacy of intervention
modalities and may also serve as evidence in assisting the client
to see the outcome of the intervention through quantifiable data.
Normal ROM varies from one person to another. The OT can establish
norms for each individual by measuring the analogous uninvolved
part if possible. Otherwise, the therapist uses average ranges
listed in the literature as a guide. The therapist should check
records and interview the client to detect the presence of fused
joints and other limitations caused by old injuries. Joints should
not be forced when resistance is met on PROM. Pain may limit ROM,
and crepitation may be heard with movement in some conditions.
Therefore, before beginning joint measurement procedures, the
therapist must explain what will be done and ask the client if he
or she is experiencing any joint pain and, if so, where is it
located and how severe it is. To not cause undue pain, the OT
further explains to the client the importance of indicating any
changes in pain throughout the procedure. PRINCIPLES &
PROCEDURES IN JOINT MEASUREMENT Before measuring ROM, the therapist
should be familiar with: average normal ROM ranges joint structure
and function normal end-feel recommended positioning for self and
the client bony landmarks related to each joint and joint axis The
therapist should be skilled in correct: Positioning and
stabilization for measurements Palpation Alignment and reading of
the goniometer Accurate recording of measurements For the most
reliable measurements, the same therapist should asses and reassess
the client at the same time of day with the same instrument and the
same measurement protocol. VISUAL OBSERVATION The joint to be
measured should be exposed, and the therapist should observe the
joint and adjacent areas. The therapist asks the client to move the
part through the available ROM, if muscle strength is adequate, and
observes the movement. The therapist should look for: compensatory
motions posture muscle contours skin color and condition and skin
creases and compare the joint with the non-injured part, if
possible. The therapist should then move the part through its range
to see and feel how the joint moves and to estimate ROM. PALPATION
Feeling the body landmarks and soft tissue around the joint is an
essential skill gained with practice and experience. The pads of
the index and middle fingers are used for palpation. The thumb is
sometimes used. The therapists fingernails should not make contact
with the clients skin. Pressure is applied gently but firmly enough
to detect underlying muscle, tendons, or bony structures. For joint
measurement, the therapist must palpate to locate bony landmarks
for placement of the goniometer. POSITIONING OF THERAPIST AND
SUPPORT OF LIMBS The therapists position varies, depending on the
joints being measured. When measuring finger or wrist joints, the
therapist may sit next to or opposite the client. If sitting next
to the client, the therapist should measure the wrist and finger
joints on that side and then move to the other side to measure the
joints on the clients opposite side. This procedure makes the
client more comfortable (eliminating the need to stretch across the
midline) and ensures more accurate placement of the goniometer.
When measuring the larger joints of the upper or lower extremity,
the therapist may stand next to the client on the side being
measured. The client may be seated or lying down. The therapist
needs to use good body mechanics in posture and in lifting and
moving heavy limbs. The therapist should use a broad base of
support and stand with the head upright while keeping the back
straight. The feet should be shoulder width apart, with the knees
slightly flexed. The therapists stance should be in line with the
direction of movement. The limb should be supported at the level of
its center of gravity, approximately where the upper and middle
thirds of the segment meet. The therapists hands should be in a
relaxed grasp that conforms to the contours of the part. The
therapist can provide additional support by resting the part on his
or her forearm. PRECAUTIONS AND CONTRAINDICATIONS In some
instances, measuring joint ROM is contraindicated or should be
undertaken with extreme caution. It is contraindicated if: there is
a joint dislocation or unhealed fracture immediately after surgery
on any soft tissue structures surrounding joints in the presence of
myositis ossificans or when ectopic ossification is a possibility.
Joint measurement must ALWAYS be done carefully. The following
situations call for extreme caution: The client has joint
inflammation or an infection. The client is taking either
medication for pain or muscle relaxants. The client has
osteoporosis, hypermobility, or subluxation of a joint. The client
has hemophilia. The client has a hematoma. The client ahs just
sustained an injury to soft tissue. The client has a newly united
fracture. The client has undergone prolonged immobilization. Bony
ankylosis is suspected. The client has carcinoma of the bone or any
fragile bone condition. END-FEEL PROM is normally limited by the
structure of the joint and surrounding soft tissues. Thus,
ligaments, the joint capsule, muscle and tendon tension, contact of
joint surfaces, and soft tissue approximation may limit the end of
a particular ROM. Each of these structures has a different end-feel
as the therapist moves the joint passively through its ROM.
End-feel is the normal resistance to further joint motion because
of stretching of soft tissue, stretching of ligaments and joint
capsule, approximation of soft tissue, and contact of bone on bone.
End-feel is normal when full ROM is achieved and the motion is
limited by normal anatomic structures. Abnormal end-feel occurs
when ROM is increased or decreased or when ROM is normal but
structures other than normal anatomy stop the ROM. Practice and
sensitivity are required for the therapist to detect different
end-feels and to distinguish normal from abnormal. End-feel is
normally hard, soft, or firm. An example of hard end-feel is bone
contacting bone when the elbow is passively extended and the
olecranon process comes into contact with the olecranon fossa. Soft
end-feel can be detected on knee flexion when there is soft tissue
apposition of the posterior aspects of the thigh and calf. A firm
end-feel has a firm or springy sensation that has some give, as
when the ankle is dorsiflexed with the knee in extension and ROM is
limited by tension in the gastrocnemius muscle. In pathologic
states, end-feel is abnormal when PROM is increased or decreased or
when PROM is normal but movement is stopped by structures other
than normal anatomy. TWO-JOINT MUSCLES When the ROM of a joint that
is crossed by two-joint muscle is measured, the ROM of the joint
being measured may be affected by the position of the other joint
because of passive insufficiency. In other words, joint motion is
limited by length of the muscle. A two-joint muscle feels taut when
it is at its full length over both joints that it crosses and
before it reaches the limits of the normal ROM of both joints. For
example, when the wrist is in full extension, passive finger
extension is normally limited because of passive insufficiency of
the finger flexors that cross the wrist and finger joints. When
joints crossed by two-joint muscles are being measured, it is
necessary to place the joint not being measured in a neutral or
relaxed position to place the two-joint muscle on slack. For
example, when finger extension is being measured, the wrist should
be placed in neutral position to avoid full stretch of the finger
flexors over all of the joints that they cross. Similarly, when hip
flexion is being measured, the knee should also be flexed to place
the hamstrings in the slackened position. METHODS OF JOINT
MEASUREMENT THE 180-DEGREE SYSTEM In the 180-degree system of joint
measurement, 0 degree is the starting position for all joint
motions. For most motions, the anatomic position is the starting
position. The body of the measuring instrument, the goniometer, is
a half-circle protractor with an axis and two arms. It is
superimposed on the body in the plane at which the motion is to
occur. The axis of the instrument is aligned with the axis of the
joint. All joint motions begin at 0 degree and increase toward 180
degrees. The 180-degree system is used most often and is the one
used later in this chapter to describe procedures for joint
measurement. THE 360-DEGREE SYSTEM The 360-degree system of joint
measurement is used less frequently than the 180-degree system. The
goniometer is a full-circle, 360-degree protractor with two arms.
Movements occurring in the coronal and sagittal planes are related
to the full circle. When the body is in the anatomic position, the
circle is superimposed on it in the same plane in which the motion
is to occur, with the joint axis being the pivotal point. The
0-degree (360-degree) position will be overhead and the 180-degree
position will be toward the feet. For example, shoulder flexion and
abduction are movements that proceed toward 0 degree, and shoulder
adduction and extension proceed toward 360 degrees. The average
normal ROM for shoulder flexion is 170 degrees. Therefore, in the
360-degree system, the movement would start at 180 degrees and
progress toward 0 to 10 degrees. The ROM recorded would be 10
degrees. Shoulder extension that has a normal ROM of 60 degrees
would begin at 180 degrees and progress toward 360 to 240 degrees,
and 240 degrees would be the ROM recorded. The total ROM of
extension to flexion would be 240 to 10 degreesthat is, 230
degrees. Some motions cannot be related to the full circle. In
these instances, a 0-degree starting position is designated, and
the movements are measured as increases from 0 degree. These
motions occur in a horizontal plane around a vertical axis. They
are forearm pronation and supination, hip internal and external
rotation, wrist radial and ulnar deviation, and thumb palmar and
radial abduction (carpometacarpal flexion and extension).
GONIOMETERS Usually made of metal or plastic, goniometers come in
several sizes and types and are available from medical and
rehabilitation equipment companies. The word goniometer is derived
from the Greek gonia, which means angle, and metron, which means
measure. Thus, goniometer literally means to measure angles The
universal goniometer consists of a body, a stationary (proximal)
bar, and a movable (distal) bar. The stationary bar is attached to
the body of the goniometer. The body is a half-circle or a
full-circle protractor printed with a scale of degrees from 0 to
180 for the half-circle and 0 to 360 for the full-circle
goniometer. The movable bar is attached at the center, or axis, of
the protractor and acts as a dial. As the movable bar rotates
around the protractor, the dial points to the number of degrees on
the scale. Two scales of figures are printed on the half circle.
Each starts at 0 degree and progresses toward 180 degrees, but in
opposite directions. Because the starting position in the
180-degree system is always 0 degree and increases toward 180
degrees, the outer row of figures is read if the bony segments
being measured are end to end, as in elbow flexion. The inner row
of figures is read if the bony segments being measured are
alongside one another, as in shoulder flexion. Review the different
types of goniometers on page 502 in Figure 21-1. One important
feature of the goniometer is the fulcrum. The nut or rivet that
acts as the fulcrum must move freely yet be tight enough to remain
where it was set when the goniometer is removed after measurement
of the joint. For easy, accurate readings, some goniometers have a
locking nut that is tightened just before the goniometer is
removed. RECORDING MEASUREMENTS When using the 180-degree system,
the evaluator should record the number of degrees at the starting
position and the number of degrees at the final position after the
joint has passed through the maximally possible arc of motion.
Normal ROM always starts at 0 degree and increases toward 180
degrees. When it is not possible to start the motion at 0 degree
because of limitation of motion, ROM is recorded by writing the
number of degrees at the starting position followed by the number
of degrees at the final position. For example, elbow ROM
limitations can be noted as follows: Normal: 0 to 140 degrees
Extension limitation: 15 to 140 degrees Flexion limitation: 0 to
110 degrees Flexion and extension limitation: 15 to 110 degrees
Abnormal hyperextension of the elbow may be recorded by indicating
the number of degrees of hyperextension below the 0-degree starting
position with a minus sign, followed by the 0-degree position and
then the number of degrees at the final position. This may be noted
as follows: Normal: 0 to 140 degrees Abnormal hyperextension: -20
to 0 to 140 degrees There are alternative methods of recording ROM.
The evaluator is advised to learn and adopt the particular method
required by the health care facility. A sample form for recording
ROM measurements is shown in Figure 21-2 (p. 504). Average normal
ROM for each joint motion is listed on the form and in Table 21-1
(p. 505). When measurements are being recorded, every space on the
form should be filled in. If the joint was not test, NT should be
entered in the space. It should be noted that scapula movement
accompanies movements of the shoulder (glenohumeral) joint, as
outlined. The range of glenohumeral joint motion is highly
dependent on scapula mobility, which gives the shoulder its
flexibility and wide ranges of motion. Although it is not possible
to measure scapula movement with the goniometer, the evaluator
should assess scapula mobility by observation of active motion or
passive movement before proceeding with shoulder joint
measurements. Scapular ROM is noted as full or restricted. If
scapular motion is restricted, as when the musculature is in a
state of spasticity or contracture, and the shoulder joint is moved
into extreme ranges of motion (for example, above 90 degrees of
flexion or abduction), glenohumeral joint damage can result. When
joint measurements may be performed in more than one position
(e.g., as in shoulder internal and external rotation), the
evaluating OT should note on the record the position in which the
measurement was taken. The therapist should also note any pain or
discomfort experienced by the client, the appearance of protective
muscle spasm, whether AROM or PROM was measured, and any deviations
from recommended testing procedures or positions. RESULTS OF
ASSESSMENT AS THE BASIS FOR PLANNING INTERVENTION After joint
measurement, the therapist should analyze the results in relation
to the clients life role requirements. The therapists first concern
should be to correct ROM that is below functional limits. Many
ordinary ADLs do not require full ROM. Functional ROM refers to the
amount of joint range necessary to perform essential ADLs and IADLs
without the use of special equipment. The first concern of
intervention is to attempt to increase to functional levels any ROM
that is limiting performance of self-care and home maintenance
tasks. For example, severe limitation of elbow flexion affects
eating and oral hygiene. Therefore, it is important to increase
elbow flexion to nearly full ROM for function. Likewise, severe
limitation of forearm pronation affects eating, washing the body,
telephoning, caring for children, and dressing. Because sitting
comfortably requires hip ROM of at least 0 to 100 degrees, a first
goal might be to increase flexion to 100 degrees if it is limited.
Of course, if additional ROM can be gained, the therapist should
plan the progression of intervention to increase ROM to the normal
range. Some limitations in ROM may be permanent. The role of the
therapist in such cases is to work out methods to compensate for
the loss of ROM. Possibilities include assistive devices, such as a
long-handled comb, brush, shoehorn, and device to apply stockings,
or adapted methods of performing a particular skill. In many
conditions, such as burns and arthritis, loss of ROM can be
anticipated. The goal of intervention is to prevent joint
limitation with splints, positioning, exercise, activity, and
application of the principles of joint protection. Limited ROM, its
causes, and the prognosis for increasing ROM will suggest
intervention approaches. Such methods include stretching exercise,
resistive activity and exercise, strengthening of antagonistic
muscle groups, activities that require active motion of the
affected joints through the full available ROM, splints, and
positioning. To increase ROM, the physician may perform surgery or
manipulate the part while the client is under anesthesia. The PT or
certified hand therapist may use joint mobilization techniques such
as manual stretching with heat and massage. PROCEDURE FOR MEASURING
PASSIVE RANGE OF MOTION Average normal ROM for each joint motion is
listed in Table 21-1, in Figure 21-2, and before each of the
following procedures used for measurement. Keep in mind that these
are averages; ROM may vary considerably among individuals. Normal
ROM is affected by age, gender, and other factors, such as
lifestyle and occupation. In the illustrations, the goniometer is
shown in such a way that the reader can most easily see its
positioning. However, the OT may not always be in the best position
for the particular measurement. For the purposes of clear
illustration, the therapist is necessarily shown off to one side
and may have one hand, rather than two, on the instrument. Many of
the motions require that the therapist actually be in front of the
client or that the therapists hands obscure the goniometer. How the
therapist holds the goniometer and supports the part being measured
is determined by factors such as the position of the client, amount
of muscle weakness, presence or absence of joint pain, and whether
AROM or PROM is being measured. Both the therapist and the client
should be positioned for the greatest comfort, correct placement of
the instrument, and adequate stabilization of the part being tested
to ensure the desired motion in the correct plane. GENERAL
PROCEDURE180-DEGREE METHOD OF MEASUREMENT 1. The client should be
comfortable and relaxed in the appropriate position (described
later) for the joint measurement. 2. Uncover the joint to be
measured. 3. Explain and demonstrate to the client what you are
going to do, why, and how you expect him or her to cooperate. 4. If
there is unilateral involvement, assess PROM on the analogous limb
to establish normal ROM for the client. 5. Establish and palpate
bony landmarks for the measurement. 6. Stabilize joints proximal to
the joint being measured. 7. Move the part passively through ROM to
assess joint mobility and end-feel. 8. Return the part to the
starting position. 9. To measure the starting position, place the
goniometer just over the surface of and lateral to the joint. Place
the axis of the goniometer over the axis of the joint by using the
designated bony prominence or anatomic landmark. Place the
stationary bar on or parallel to the longitudinal axis of the
proximal or stationary bone and the movable bar on or parallel to
the longitudinal axis of the distal or moving bone. To prevent the
indicator on the movable bar from going off the protractor dial,
always face the curved side away from the direction of motion,
unless the goniometer can be read after movement in either
direction. 10. Record the number of degrees at the starting
position and remove (or back off) the goniometer. Do not attempt to
hold the goniometer in place while moving the joint through ROM.
11. To measure PROM, hold the part securely above and below the
joint being measured and gently move the joint through ROM. Do not
force the joint. Watch for signs of pain and discomfort. (Note:
PROM may also be measured by asking the client to move actively
through ROM and hold the position. The therapist then moves the
joint through the final few degrees of PROM.) 12. Reposition the
goniometer and record the number of degrees at the final position.
13. Remove the goniometer and gently place the part in the resting
position. 14. Record the reading at the final position and any
notations on the evaluation form. DIRECTIONS FOR JOINT
MEASUREMENT180-DEGREE SYSTEM SPINE Found on pp. 506-510 UPPER
EXTREMITY Found on pp. 510-522 LOWER EXTREMITY Found on pp.
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