Range Of Motion Assessment

Physiotherapy aims at correcting movements. But how do we correct them if we don't know the measurement of these movements?
Movements occur in a particular range that is measured in degrees with the help of GONIOMETER.
So in this presentation, we are going to discuss about goniometry!

1. GONIOMETRY PRESENTED BY : MALEEHA AMJED

2. About The Topic

3. What is Goniometry? The term goniometry is derived from two Greek words : Gonia-metron Therefore, goniometry refers to the measurement of angles , in particular the measurement of angles created at human joints by the bones. ANGLE MEASURE

4. PARTS OF MOTOR EXAMINATION Nutrition Of Muscle Muscle Tone Reflexes Range Of Motion and TCD’s Manual Muscle Testing

5. Why Is It Performed ? Determining the presence of joint impairment Developing treatment goals. Evaluating progress or lack of progress. Modifying treatment. Motivating the subject. Research

6. PLANES AND AXIS Osteo -kinematic motions are described to be taking place in 3 cardinal planes and axis

7. Synovial joint Most evolved & hence most mobile type of joints The ends of bony components are free to move in relation to one another Bony components are indirectly connected to one another by means of a joint capsule that encloses the joint

8. Joint Ranges Active ROM Passive ROM Active motion is the unassisted voluntary movement of a joint. (Quality of ROM) Passive motion is attained by the examiner without the patient’s assistance. (Quantity of ROM ) ** Normally, PROM is slightly greater than AROM because joints have a small amount of motion at the end range that is not under voluntary control.

9. The barrier Concept

10. physiologic motion is limited by a physiologic barrier tension develops within the surrounding tissues (joint capsule, ligaments and connective tissue)

11. additional amount of passive range of motion can be performed the anatomic barrier cannot be exceeded without disrupting the joints integrity

12. SUBDIVISION OF JROM Initial ROM Middle ROM End ROM

13. Subdivision of ROM as per Muscle Work

14. ACTIVE INSUFFICIENCY? Shortest possible length of muscle

15. PASSIVE INSUFFICIENCY? LONGEST POSSIBLE LENGTH OF MUSCLE Muscle cant stretch maximally at both joints together

16. Other Examples of AI PI In Body and its clinical relevance with Goniometry BICEPS : At the top of curl, (when biceps begin to smash against forearm ), when elbows are lifted ** Shortens biceps over both the shoulder & elbow blade Simultaneously lengthening the TRICEPS HAMS : When reaching to touch toes **Lengthening felt as a stretch RECTUS FEMORIS : Hip flexion with knee extension(70 degree) is less than hip flexion with knees bent (120 degree) GASTROCNEMIUS : Seated calf / heel raise places the gastrocnemius into active insufficiency since the knee flexes too much & ankle performs plantarflexion

17. MEASURING JOINT RANGE OF MOTION Range Of Motion (ROM) is the arc of motion that occurs at a joint or a series of joints. Three notation systems have been used to define ROM : The 0 to 180 degree system The 180 to 0 degree system The 360 degree system Most commonly used is the 0 to 180 degree notation system

18. Prerequisite Knowledge For Measuring ROM Normal ROM’s (Range) Joint Structure And Function Recommended positioning for self and patient Bony landmarks related to each joint Alignment of Goniometer Normal end-feel Factors that can alter normal ROM

19. FACTORS DETERMINING AMOUNT OF ROM Integrity Of Joint Surface RELIABILITY Amount Of Scarring Present AGE GENDER Shape Of Articulating Surface Health Of Joint Various diseases/ pathological conditions Health Of Surrounding Tissues Mobilty & Pliabilty Of Soft Tissue

20. Common pathological causes of ROM Restriction Skin/soft tissue contracture Arthritis Fracture Burns Muscle weakness/paralysis Pain Edema Spasticity Presence of foreign body in the joint

21. Prerequisite Skills For Measuring ROM The therapist should be skilled in Correct positioning (Pt/ Pt Jt / PT And GM) Stabilization for measurement Palpation Alignment Recording measurements accurately Documentation

22. Visual observation of the joint and its adjacent area is important to look for : Compensatory motions Posture Muscle contour Skin creases Facial expressions

23. Testing Procedure

24. Joint Mobility Scale Hyper Mobility (Mild, Moderate, Severe) Exercise, Bracing surgery Normal mobility Normal function Hypo Mobility (Mild, Moderate, Severe) Exercise, Mobilization, surgery N

25. Documentation Hypo Mobility : A motion that does not start with 0 degree or ends prematurely indicates joint hypomobility Example : if knee joint has 30 degree of hypomobility in flexion, it would be recorded as 30 – 135 deg Hyper Mobility : Joint hypermobility at the beginning of the range is noted by inclusion of a zero between the starting & ending measurements Example : if the elbow joint has 5 degree of hypermobility in extension and 140 degree of flexion , it would be recorded as 5 – 0 – 140 deg

26. Types of Goniometer Full Circle Manual Universal Goniometer (360) Half circle manual Goniometer (180) Gravity Goniometer :- a) Double Inclinometer (used for spine goniometry) b) Pendulum Inclinometer c) Bubble Goniometer Electrogoniometer Digital Goniometer Tape Measurements Smartphone Devices Use of malleable wires/sheets (in cases of deformities)

27. Spinal Goniometer

28. UNIVERSAL GONIOMETER A universal Goniometer may be constructed of metal or plastic and it has 3 parts :- 1. Body of Goniometer 2. Stationary arm 3. Movable arm (placed over the Joint being measured) (aligned parallel with the longitudinal axis of the fixed part) (aligned parallel with the longitudinal axis of the movable part)

29. Demonstration Shoulder Knee Cervical spine

30. Precautions !!! Joint irritability status Presence of Pain Instability Recent trauma Is it really important to assess accurate ROM ??

31. Functional Ranges of various joint in various activities Walking Stair ascending descending Sitting Squatting Cross leg sitting Self Feeding Back reach Neck reach Etc….

32. ROM Required In ADL’s ASCENDING STAIRS REQUIRES BETWEEN 47 - 66 DEGREE OF HIP FLEXION DEPENDING ON STAIR DIMENSION DESCENDING STAIRS REQUIRES AN AVERAGE OF 21 - 36 DEGREE OF DORSIFLEXION, 86.9 - 107 DEGREE OF KNEE FLEXION DEPENDING ON STAIR DIMENSIONS

33. Rising from a chair requires a mean range of knee flexion of 90.1 - 95.0 degree and full dorsiflexion ROM depending on height of seat Sitting in a chair with an average seat height requires 112 degrees of hip flexion

34. Drinking from a cup requires about 130 degree of elbow flexion 36 to 52 degrees of shoulder flexion Reaching objects on a high shelf require 148 degrees of shoulder flexion

35. Using a telephone requires approx 40 degrees of wrist extension Approximately 50 degrees of pronation occur while reading a newspaper Reaching behind the head requires about 112 degrees of abduction of the shoulder

36. END-FEEL The end of each motion at each joint is limited from further movement by particular anatomical structures. The type of structure that limits a joint motion has a characteristic feel , which may be detected by the therapist performing the passive ROM. This feeling, which is experienced by the therapist as resistance or a barrier to further motion, is called the end-feel .

37. NORMAL END-FEEL DESCRIPTION EXAMPLE Soft Soft Tissue Approximation Knee flexion (contact between soft tissue of posterior leg and posterior thigh) Firm Muscular stretch Capsular stretch Ligamentous stretch Hip flexion with knee straight (passive elastic tension of hamstring muscles) Extension of metacarpophalangeal joints of fingers Forearm supination (tension in the palmar radioulnar ligament of the inferior radioulnar joint) Hard Bone contacting bone Elbow extension ( olecranon process of the ulna and olecranon fossa of humerus )

38. ABNORMAL END-FEEL DESCRIPTION EXAMPLES Soft Occurs sooner or later in the ROM than is usual or in a joint that normally has a firm or hard end-feel . Feels boggy. Soft tissue edema Synovitis Firm Occurs sooner or later in the ROM than is usual or in a joint that normally has a soft or hard end-feel. Increased muscular tonus Capsular , muscular , ligamentous , and fascial shortening Hard Occurs sooner or later in the ROM than is usual or in a joint that normally has a soft or firm end-feel. A bony grating or bony block is felt. Chondromalacia Osteoarthritis Loose bodies in joint Myositis ossificans Fracture Empty No real end-feel because pain prevents reaching end of ROM. No resistance is felt except for patient’s protective muscle splinting or muscle spasm. Acute joint inflammation Bursitis Abscess Fracture Psychogenic disorder

39. JOINT MOTION TESTING POSITION STABILIZATION MEASUREMENTS CERVICAL FLEXION EXTENSION SIDE FLEXION ROTATION Sitting Shoulder & chest Shoulder & chest to prevent extension of thoracic & lumbar spine To prevent side flexion of thoracic & lumbar spine To prevent rotation of thoracic & lumbar spine 1 cm– 4.3 cm 18.5 cm–22.4 cm 10.7cm-12.9cm 11cm-13.2cm TAPE MEASUREMENTS OF THE SPINE

40. JOINT MOTION TESTING POSITION STABILIZATION MEASUREMENTS THORACIC FLEXION EXTENSION LATERAL FLEXION ROTATION STANDING If the subject has balance problems or muscle weakness in the LE, measurement can be taken in prone/side lying SITTING PELVIS To prevent anterior tilting To prevent posterior tilting To prevent lateral tilting To prevent rotation 10 cms (4 inches) 15.9cm for rt LF 16.9cm for lt LF 45 degree (universal goniometer )

41. JOINT MOTION TESTING POSITION STABILIZATION MEASUREMENTS LUMBAR FLEXION EXTENSION LATERAL FLEXION STANDING PELVIS To prevent anterior tilting To prevent posterior tilting To prevent lateral tilting 6.7cm in males 5.8cm in females Average 6.3cm-6.9cm (Modified Schober test) 1.6cm (Modified Schober Test) 25 – 30 degree by AMA (double inclinometer)

42. Demonstration Schober’s Test For Lumbar Spine Flexion

43. Capsular & Non-capsular Pattern Of Movement Restriction Cyriax proposed that pathological conditions involving the entire joint capsule cause a particular pattern of restriction involving most of the passive motions of the joint. This pattern is called as capsular pattern Restriction caused by condition involving structures other than the entire joint capsule is called as non-capsular pattern Example – Adhesive Capsulitis Shoulder

44. HFD Thomas Test

45. KFD

46. Equinus

47. TF Malalignment

48. Genu Recurvatum

49. CERVICAL SPINE JOINT ROM Flexion º to 45 º Extension º to 45 º Lateral flexion º to 45 º Rotation º to 60 º THORACIC AND LUMBAR SPINE JOINT ROM Flexion º to 80 º Extension º to 30 º Lateral flexion º to 40 º Rotation º to 45 º AVERAGE ROM

50. SHOULDER JOINT ROM Flexion º to 180 º Extension º to 60 º Abduction º to 180 º Adduction º Horizontal abduction º to 40 º Horizontal Adduction º to 130 º Internal rotation   Arm in Abduction º to 70 º Arm in Adduction º to 60 º External rotation   Arm in Abduction º to 90 º Arm in Adduction º to 80 º

51. ELBOW JOINT ROM Flexion º to 135 º - 150º Extension º FOREARM JOINT ROM Pronation º to 80 º - 90º Supination º to 80 º - 90º

52. WRIST JOINT ROM Flexion º to 80 º Extension º to 70 º Ulnar deviation (adduction) º to 30 º Radial deviation (abduction) º to 20 º THUMB JOINT ROM DIP flexion º to 80 º - 90º MCP flexion º to 50 º Adduction, radial and palmar º Palmar abduction º to 50 º Radial abduction Opposition º to 50 º

53. FINGERS JOINT ROM MCP flexion º to 90 º MCP hyperextension º to 15 º - 45º PIP flexion º to 110 º DIP flexion º to 80 º abduction º to 25 º

54. HIP JOINT ROM Flexion º to 120 º (bent knee) Extension º to 30 º Abduction º to 40 º Adduction º to 35 º Internal rotation º to 45 º External rotation º to 45 º KNEE JOINT ROM Flexion º to 135 º

55. ANKLE AND FOOT JOINT ROM Plantar flexion º to 50 º Dorsiflexion º to 15 º Inversion º to 35 º Eversion º to 20 º

56. SOURCES Measurement of Joint Motion : A Guide to Goniometry, 4th Edition, by Cynthia C.  Norkin Physical Rehabilitation 6th Edition SuSan B. O’Sullivan Magee (2002). Orthopedic physical Assessment (4th ed.). Phil: Saunders. Kisner C, & Colby LA (2002). Therapeutic exercise: Foundations and techniques (4th ed.). PA: FA Davis . The Principles of Exercise Therapy (Fourth Edition): M. Dena Gardiner.