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E&M Goniometry and ROM Lecture
E&M DPT2012 UMDNJ
70
Medical
Graduate
10/08/2009

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Cards

Term
ROM Theory and Practice
Definition

ROM is the amount of motion that is available at a given joint.

-AROM is the amount of joint motion attained by VOLUNTARY JOINT MOTION (on their own)

-PROM is the amount of joint motion attained by an EXAMINER without assistance from the client

Term
Why examine ROM?
Definition

Provides info on: Muscle strength, coordination, willingness to move, ability to follow directions, level of consciousness, attention span, joint ROM

May be limited due to: Muscle weakness, PAIN, edema, restricted joint mobility

Term
Why assess PROM?
Definition

Provides info about: Integrity of articular surfaces, joint capsule, ligaments, and muscles

Additional points: PROM is usually slighty greater than AROM

Comparison of AROM and PROM is useful to determine soft tissue vs. bony vs. joint pathology

Term
(With other info provided) ROM data can provide a basis for what?
Definition

-Determining the presence of dysfunction

-Establishing a Dx

-Developing treatment goals

-Evaluating progress

-Modifying treatment if its not working

-Researching effectiveness of therapy

-Determing orthoses or adaptive equipment

Term
General Instructions
Definition

-Introduction, explanation, demonstration

-Place subject in reccomended test position

-Have client/pt perform AROM and observe quality of motion

-Expose joint

-Stabilize proximal joint segment if necessary and move limb through PROM->examine and FEEL

Term
General Instructions continued ->
Definition

-Palpate and identify landmarks

-Align goniometer with its axis on the joint axis

-Stationary arm is aligned parallel to the longitudinal axis of the proximal limb segment

-Moving arm is aligned parallel to the longitudinal axis of the distal limb segment

-Read and record starting position

Term
More General Instructions:
Definition

-Stabilize proximal component

-Move distal component through full AROM/PROM

-Replace and realign goniometer. Palpate landmarks if necessary

-Record AROM/PROM

-Compare ROM to the opposite side

Term
How do you record ROM?
Definition

-Include start and end position to define the joint range

* A motion that begins at 0 and ends at 150 is recorded at 0-150

* A motion that begins at 20 and end at 120 is recorded as 20-120 (some may record as -20 degrees of extension)

* If hyperextension occurs (ex elbow) record as 20-0-150

Term

Quality vs. Quantity

T/F

If you measured a patient's right hip flexor ROM as WNL you can assume that no abnormal stresses are occuring within the joint.

Definition

False

While their total range may be WNLs a disproportionate amount of mobility may be arising from one structure, thus leading to abnormal stresses

For instance, the roles of gastroc and hamstrings for knee flexion

Term

-Distinct Measurements-

Range of joint measurement

Definition
Number of degrees of motion present in a joint
Term

-Distinct Measurements-

Range of muscle length

Definition

Number of degrees of motion in a muscle

In some cases may be measured with a tape measure for instance, distance from table

Term

-One versus two joint muscles-

One joint muscles

Definition
Muslce length range=joint range
Term

- One vs. two joint muslces-

Two joint muscles

Definition

Muscle length range< joint range

May be elongated over one joint, but not over two joints

e.g. hipflexion with knee flexion > hip flexion with knee extension (affected by hamstring muscle length)

Term

ROM/ML (muscle length)

Hip flexor ROM will be greatest in which position of the hip and knee?

Definition

Hip flexion with knee flexion 0-120

versus

Hip flexion with knee extended 0-50

Term

ROM/ ML (muscle length)

Ankle dorsiflexion will be greatest in which position of the ankle and knee?

Definition

Ankle DF and knee flexion

and

Ankle DF and knee extension

Both will produce a DF ROM of 1-10

Term

ROM/ ML (muscle length)

Elbow flexion ROM will be greatest in which position of the elbow and shoulder?

Definition

Elbow flexion with shoulder in neutral 0- 120

versus

Elbow flexion with shoulder in flexion 0- 90

Term

ROM/ ML (muscle length)

Wrist supination ROM will be greatest in what position of the wrist and elbow?

Definition

Wrist supination with elbow flexion 0- 90

versus

Wrist supination with elbow extension 0- 75

Term

A 62 year old woman comes to you complaining of low back pain. She tells you that she is currently taking pain medication and she has osteoporosis. You decide that you would like to test her ROM hip flexion and extension. What factors may you want to consider?

Definition

Precautions for ROM

-The patient mentions that she is taking pain medication which will affect her perception of pain and determination of when you have "pushed too much" increasing risk for injury

- Also, the patient mentions that she has osteoporosis. You must especially be aware of this especially during PROM, for risk of bone fractures.

Term
A 32 year old patient comes to you reporting left knee pain. While testing his knee flexor ROM you note a hard end feel at full flexion. Would this be considereda normal physiological end feel?
Definition

No. With knee and elbow flexion, a physiological soft end feel would be noted as normal.

A hard end feel would be more commonly noted in elbow extension.

Term
A patient comes to you with severe shoulder pain. After testing ROM of the shoulder joint, you note that the patient has decreased external rotation, full abduction range, and limited internal rotation. Could your patient have a frozen shoulder?
Definition

No. A frozen shoulder is considered within the capsular pattern of the shoulder joint:

-Decreased external rotation

-Limited abduction

-Limitation in internal rotation

Term
A patient comes to you complaining of baok and hip pain. You decide to conduct a posture evaluation and observe that the patient hyperextends their knees about 20 degrees . You then take ROM measurement at the hip and knee. Knee flexor ROM came to 110 degrees. How would you notate the patient's knee ROM?
Definition

20-0-110

Include start and end position to define the joint range

If hyperextension occurs, measure motion on both sides of anatomic neutral:

amount of hyperextension (20) -> anatomic neutral (0 )-> knee felxion ROM (120)

Term
A 45 y.o. female comes to your facility for treatment of a frozen shoulder. You find that her shoulder ROM is decreased. Some possible cause of this decrease could be?
Definition
Muscle weakness, pain, edema, restricted joint mobility
Term
A patient comes to your facility with ankle problems. You want to observe their normal ROM at the involved ankle. To do this you would practice what type of ROM theory?
Definition
AROM-active range of motion, the amount of joint motion attained by voluntary joint motion
Term
What are the precautions for ROM for any patient?
Definition

Infection/inflammation at the joint

medications

osteoporosis

joint hypermobility

pain

hemophilia

joint in region of hematoma

Term
A patient comes direct access to our facility complainign of elbow pain. You suspect an untreated fracture is the cause. Would you perform ROM tests on this patient?
Definition

Contraindications for ROM:

regions of dislocation or unhealed fractures;

immediately after surgical procedures to tendon, ligament, muscle, joint capsule; myositis ossificans

Term

You are performing PROM on a patient at the knee in prone. You experience a firm end feel. Is this normal? What could be wrong?

Definition
Knee flexion has a soft end feel. It is possible that there is capsule tightness or ligamentous shortening.
Term

You measure a patient's hip ROM.

You find that their involved side has:

flex/ext, 90-0-20;

their hip IR/ER is 15-0-45;

and their hip abd/add 20-0-30.

The uninvolved side has:

flex/ext, 120-0-30;

IR/ER, 45-0-45;

and abd/add, 45-0-30.

Is this a capsular pattern of joint range limitations?

Definition
Yes.
Term
ROM

End Feels - Definition
Definition
The end feel is the quality of movement perceived by the practitioner at the very end of the available range of motion.

It reveals information about the structure and condition of the joint.
Term
ROM

End Feels - Normal vs. Pathological
Definition
Each joint motion has it's own normal end feel.
What is normal for one movement at a joint may not be normal for another movement done by the same joint.

What is normal at one joint may be pathological at another.

There are some end feels that are only found in pathological joints.
Term
ROM End Feels - Types of end feels
Definition

Most End Feels can by found in normal joints, or in abnormal joints:

Soft Firm Hard

One can be found only in abnormal joints:

Empty

Term
ROM

End Feels - Soft End Feel-Normal
Definition
Caused by soft tissue approximation.

Example: Knee and elbow flexion
Term
ROM End Feels - Firm End Feel-Normal
Definition

Firm end feel is caused when motion is limited by muscular stretch, capsular stretch or ligamentous stretch

Examples:

Straight Leg Raise (muscular stretch)

MCP extension (capsular stretch)

forearm supination (ligamentous stretch)

Term
ROM

End Feels - Hard End Feel-Normal
Definition
Hard end feel is caused by bone on bone limiting motion

Example:
Elbow extension
Term
ROM

End Feels - Soft End Feel-Abnormal
Definition
Occurs sooner or later in the range
than usual

or

In joint that normally has a firm or hard end feel.

If feels boggy-indicates Joint effusion
Term
ROM

End Feels - Firm End Feel-Abnormal
Definition
Occurs sooner or later in range
than usual

or

In joint that normally has a soft or hard end feel
Indicates Capsule tightness or Ligamentous shortening
Term
ROM

End Feels - Hard End Feel-abnormal
Definition
Bony grating or bony block is felt.
"Doorstop" feel.

Occurs sooner or later in range than
usual or in joint that normally has
soft or firm end feel.

Indicates Fracture, osteoarthritis, osteophytes or that a piece of tissue is lodged in the joint
Term
ROM

End Feels - Empty End Feel
Definition
Always abnormal. No real end feel because pain prevents reaching end of range.

No resistance is felt except for muscle
guarding or spasm.

Indicates Acute bursitis, neoplasm, fracture,hysteria
Term
ROM Lecture

Capsular Patterns
Definition
Restrictions in ROM at a joint can be caused by the joint capsule, or something else.

Restriction caused by the capsule will follow a pattern defined for each joint. These are know as 'capsular patterns'

They are different for each joint and must be memorized

Causes include arthritis, prolonged immobilization, acute trauma with effusion
Term
ROM Lecture

Non-capsular Patterns
Definition
When limitations is not caused by the capsule, they do not follow capsular patterns.

Then limitation can be considered a non-capsular pattern.

May be due to:
ligamentous adhesions
internal derangement (fragments in joint)
extra-articular limitation (contractures)
Term
ROM Lecture Capsular Pattern of the Hip
Definition

  • marked restriction in internal rotation
  • limitations in flexion and abduction
  • may be slight limitation in extension
  • no limitations in external rotation or adduction
Term
ROM Lecture Capsular Pattern of the Shoulder
Definition

  • marked restriction in external rotation
  • limitation in abduction
  • may be slight limitation in internal rotation
Term
ROM Lecture Capsular Pattern Examples-Hip
Definition

Hip flexion/extension

Normal 120-0-30

Patient 90-0-20

Restriction in Flexion

Slight Restriction in extention

Hip IR/ER

Normal 45-0-45

Patient 15-0-45

Restriction in IR. ER normal

Hip ABD/ADD

Normal 45-0-30

Patient 20-0-30

Restriction in ABD. ADD normal

This pattern indicates capsular involvement

Term
ROM Lecture Capsular Pattern Examples-Shoulder
Definition

Shoulder flex/ext

Normal 180-0-60

Patient 180-0-20

Limited extension. Normal flexion (C/O pain)

Shoulder IR/ER

Normal 70-0-90

Patient 70-0-80

Normal IR. Slightly restricted ER

Shoulder ABD/ADD

Normal 180-0-30

Patient 180-0-30

Normal ABD/ADD

This pattern doesn't indicate capsular involvement

Term
ROM Lecture Muscle Length Testing
Definition

Technique used to determine if the muscle length is normal, excessive, or limited

Muscles with limited length are usually strong, promoting lengthening of the opposing muscles

Muscles with excessive length are usually weak, allowing for adaptive shortening of the opposing muscle

Term
ROM Lecture

Muscle Imbalance
Definition
Can lead to:
􀂄 injury
􀂄 faulty posture
􀂄 abnormal movement patterns
Is pain on shortened or lengthened side
􀂄 dominant versus non-dominant
􀂄 left side greater than right side
Term
How is ROM defined?
Definition
ROM is defined by the start and end position of a goniometer measurement and is written as 0-150 if ROM is 150 degrees or as 20-0-150 if 20 degrees of hyperextension occurs and 150 degree of flexion occurs.
Term
If joint does not need to be measured with a device how is the ROM recorded?
Definition
If no device is necessary the ROM is recorded as full, WNLs (within normal limits), or WFLs (within functional limits).
Term
True or false: Every space on a ROM form should have a notation.
Definition
True, if certain areas were not tested write "NT" in the space.
Term
Which ROM is recorded first, passive or active ROM?
Definition
Usually, PROM is recorded before AROM (even though AROM is examined first). This would be written: knee flexion = 0-120/10-95, where 0-120 degrees would be PROM and 10-95 degrees would be AROM
Term
Reliability of goniometric measurements is dependent upon 3 factors, what are they?
Definition

1) Type of joint

2) Motion of the joint

3) Test position

Term
Which type of joint is most reliable when taking a goniometric measurement?
Definition
Hinge joints such as the knee and elbow are more reliable than multiaxis joints such as the shoulder and ankle
Term
Which motions are more reliable goniometric measurements in the shoulder and ankle joints?
Definition
Shoulder flexion and abduction are more reliable than shoulder extension. Ankle dorsiflexion and plantarflexion are more reliable than inversion and eversion.
Term
How does goniometric reliability depend on test position?
Definition

Straight leg raise changes with opposite leg position.

Shoulder range in sitting versus supine.

Term
What is the intratester reliability for goniometry?
Definition
0.74-0.90
Term
Which type of reliability is always higher for goniometry; intertester or intratester reliability?
Definition
Intratester reliability is always higher than intertester reliability.
Term
What are 4 methods to improve reliability for goniometry?
Definition

1) Standardize positions

2) Stabilize proximal body parts

3) Use bony landmarks to align goniometer

4) Use same examiner (intratester reliability)

Term
What are 4 factors that affect ROM measurement?
Definition

1) Pathological conditions such as pain and inflammation

2) Fear

3) Age

4) Gender

Term
Why is it important to be cautious with patients on medications for muscle relaxation and pain when measuring ROM?
Definition
As a PT it is easier to tear or pop muscle or other soft tissue due to the patient's inability to feel tension approaching failure.
Term
What are important precautions when measuring ROM?
Definition

1) infection or inflammatory process in joint

2) meds for muscle relaxation or pain 3)osteoporosis

4) joint hypermobility

5) pain

6) hemophilia (abnormal clotting system)

7) joint in region of hematoma

8) immediately after injury, where disruption of soft tissue is suspected

9) cervical sprain

Term
What are 3 factors/contraindications of when ROM shouldn't be measured?
Definition

1) on a region of dislocation or unhealed fracture

2) immediately after surgery on a tendon, ligament, muscle, or joint capsule

3) Myositis ossificans (condition that forms abnormal bone formation in deep muscle tissue)

Term
you are trying to get baseline ROM measurements for a new patient you are seeing. then you get to their ankle you notice that it is a little warm. why would this not be a good baseline for ankle ROM?
Definition
when a joint is hot it indicates that there is edema and therefore the joint would not move in ti's full range.
Term
you are finding a pt's PROM in their hip, when you hear a grinding type sound. what does this tell you?
Definition
the joint surfaces are roughened (crepitus)
Term
another PT refers a pt to you. when reviewing the chart you see that the pt has equal measurements for PROM and AROM, what might this indicate to you?
Definition
when PROM and AROM are the same it typically means that there is something wrong with the non-contractile tissue.
Term

Case:

 

 Hip Flexion with kneed flexed 0-120

 

Hip flexion with knee extended 0-50

Definition

 

Answer:

 

Tight Hamstrings

Term

Case:

 

Ankle dorsiflexion with knee flexed 0-10

 

Ankle dorsiflexion with knee extended 0-10

Definition

 

Answer:

 

Joint Tightness

Term

Case:

 

Elbow flexion with shoulder flexed 0-90

 

Elbow felxion with shoulder in neutral 0-120

Definition

Answer:

 

Tight Triceps

Term

Case:

 

Wrist supination with elbow extended 0-75

 

Wrist supination with elbow flexed 0-90

Definition

 

Answer:

 

Tight Biceps

Term

MMT Case:

 

Supine

Flex hip to 90 degrees

Bring knee into extension

 

Measure knee extention angle

Definition

 

Popliteal angle Hamstrings

 

Knee extension angle: Norm = 0-10

Term

Case:

 

 Pt. Supine

One hip/knee flexed, other leg hanging down but hamstrings not touching the table.

Definition

 

Positive Thomas Test 

(tight hip flexors)

 

Measure hip flexion

 

Term

Case:

Pt. sidelying

Leg into abduction, extension of hiip, and lower leg toward adduction

 

Hip does not pass neutral

 

Definition

 

Positive Ober TFL test

 

watch for pelic movement

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