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. 522-527Joint Range of Motion 1/31/15 4:22 PM

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