Range of Motion Gross Screen

Section 1: Range of Motion: Gross Screen INTRODUCTION With more than 200 joints, the human body was designed to move! Movement is central to function, and lack of movement, or lack of efficient movement, is one of the most common patient problems encountered in physical therapy. A screening assessment of the quantity and quality of movements demonstrated by patients is a key component of most physical therapy examinations, regardless of diagnosis or condition. As with many other tests and measures, this assessment can be global, regional, or local. For some conditions, a gross screen of range of motion (ROM) will be adequate, while for others it is important to formally quantify ROM measures with a goniometer (or other device). This section describes concepts and methods of gross screening assessments of active and passive ROM, which is the first step in determining if more detailed measurement should occur. The following section provides a detailed description of the principles and techniques related to goniometric measurement of joint ROM. TABLE 9-1 of Motion Factors That Can Affect Range Age • In children less than 2 years old, mean values differ considerably compared to published means for adults. • In the elderly, it is common to note a slow but progressive loss of available joint motion. Gender • Females tend to have greater tissue extensibility and slightly greater joint ROM compared to age-matched males. Body Mass Index • Excessive soft tissue (muscle or adipose) may impede a joint from reaching its full available range. Disease • Many diseases can cause degeneration or inflammation of the joint surfaces, which has a negative effect on joint motion (e.g., rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, osteoarthritis). Occupation/Recreation © Mandy Godbehear/Shutterstock • Repetitive motions may lead to body adaptations over time that will affect ROM (e.g., a factory worker who repetitively rotates the trunk to the left may present with greater left trunk rotation than observed toward the right). • Frequent stretching of soft tissue structures may lead to excessive ROM (e.g., a baseball pitcher may develop external rotation ROM on the pitching arm well beyond the expected range). Culture • Certain cultural practices may affect joint ROM (e.g., in some cultures, sitting cross-legged on the floor or maintaining a prolonged squatting position is more common than sitting in a chair). Several sources provide an accepted normal ROM for each joint that is capable of being assessed.4,5 Realize that the amount of joint movement an individual needs is relative to his or her desired activities. This relative normal should be considered when determining interventional needs for each patient. For example, a baseball pitcher will require movement well beyond the published ROM norms for shoulder external rotation on the pitching arm to be successful at delivering a variety of pitches. On the other hand, a retiree whose desired activities include daily walks, playing cards, and building birdhouses may need far less than the published ROM norms for unlimited function. If a patient has dysfunction only on one side, then the unaffected side should be the comparative reference. If the dysfunction is bilateral, the accepted norms, in conjunction with the patient’s functional requirements, should serve as the reference. The degree to which any joint can move through its available range depends on a number of factors, including the congruency of the joint surfaces, the pliability of the joint capsule and surrounding ligaments, and the extensibility of Data from Reese N, Bandy W. Joint Range of Motion and Muscle Length Testing. 2nd ed. St. Louis, MO: Saunders Elsevier; 2010; and Norkin D, White D. Measurement of Joint Motion: A Guide to Goniometry. 4th ed. Philadelphia, PA: F.A. Davis; 2009. the muscles that cross the joint.6 TABLE 9-1 lists other factors that can affect joint motion. Active range of motion, which is movement performed solely by the patient with no external assistance, also relies heavily on the force production of the muscles that surround the joint. Therefore, ROM, muscle length, and muscle strength are all intricately related and often need to be considered together during a patient examination. What follows in this section is a discussion of active range of motion (AROM), passive range of motion (PROM), and joint end feels. FUNDAMENTAL CONCEPTS Active Range of Motion Observation of a patient’s AROM provides information about the patient’s willingness to move, coordination and motor control, muscular force production, and potential limiting factors (such as pain or a structural restriction). If a patient demonstrates pain-free, unrestricted AROM within the expected range (considering published norms or the patient’s functional requirements), further assessment of that joint motion is likely not necessary. Any motion that is limited or reproduces the patient’s symptoms requires further investigation. It should be noted that typical assessment of ROM, whether active or passive, grossly or via goniometry, is done using planar motions. For example, shoulder flexion and extension occur in the sagittal plane, shoulder abduction and adduction occur in the frontal plane, and shoulder internal and external rotation (in standard anatomical position) occur in the transverse plane (see FIGURE 9-1). Functional motion, however, typically involves a combination of motion in all three planes. For example, the simple action of reaching the hand to touch the opposite shoulder involves a combination of shoulder flexion, adduction, and internal rotation. It is possible that motion is relatively normal when assessed using planar motions, but abnormal (painful or limited) during multiplanar motion. Limited Active Range of Motion Pain that limits AROM may be due to several factors. Active motion requires contraction of one or more muscles. At times, multiple muscles are called upon, either in the role of the prime mover or in the role of the joint stabilizer. 6 When a muscle contracts, stress is placed on the muscle tissue itself, the musculotendinous junction, the tendon, and the bone-tendon junction. The presence of inflammation or injury within any of these structures may lead to pain upon contraction, which, in turn, may limit active motion. In theory, if painful contractile tissues are the limiting factor during AROM, moving the limb through the range without the muscles’ contracting (PROM) should allow for greater, or even full, motion. Much depends on how irritable or acute the patient’s condition is; highly inflamed tissues may be quite painful whether motion is active or passive. Irritated noncontractile tissues, including ligament, joint capsule, cartilage, neural tissue, bursa, fascia, and skin, may also be stretched or pinched during active motion. If a patient reports pain during active motion, asking for a description of the pain may help determine its source. In addition, it is imperative to determine if the pain felt during the active motion was a reproduction of the patient’s typical pain or something different. For example, a patient being seen for left-sided “sharp and deep” lower back pain may report that both left and right lateral flexion of the trunk are painful during AROM assessment. An error common to novice physical therapy students is to assume that both motions reproduced the patient’s symptoms. Asking the patient to describe the pain, however, might reveal that lateral flexion to the left reproduced the sharp and deep pain on the left, while lateral flexion to the right caused a painful pulling sensation in the left-sided lower back muscles (see FIGURE 9-2). From this information, an experienced Medial Dorsal Lateral Lateral Ventral Sagittal plane Cranial Coronal plane Proximal Transverse plane Distal Proximal Distal Caudal FIGURE 9-1 Standard planes of human motion. Pulling pain Sharp pain FIGURE 9-2 Differentiating the type of pain felt with each motion is important in determining the source of pain or dysfunction. clinician might hypothesize the left lateral flexion caused compression of irritated articular structures on the left while the pain felt during right lateral flexion may have been caused by left-sided muscular tightness that developed from protective guarding. The focus of the remaining portion of the exam would then be on the hypothesized source of symptoms (articular structures on the left) with secondary attention paid to the left-sided muscular tightness that may have developed as a result of the articular dysfunction. Factors other than pain also can limit range of motion. These include intra-articular blocks (such as a bone fragment, cartilage flap, or a bony malformation), joint effusion, edema, capsular tightness, lack of muscle length, excessive muscular or adipose tissue, and inadequate force production of the prime movers. Each of these problems will feel different to a patient and will appear different upon observation. It is therefore crucial that you continually seek information from the patient and critically evaluate the patient’s movements in the presence of limitations. By paying close attention to the patient’s history, how the patient describes the limitation, and observing the quality of movement and movement patterns, it is usually possible to narrow the potential sources of the limitation. With a narrowed list, more focused testing can provide additional data. Passive Range of Motion Passive range of motion can provide information about the integrity of joint surfaces; the extensibility of the capsule, ligaments, and muscle surrounding the joint; the irritability of local tissues; and the full excursion allowed by a joint for any given motion. In most joints and for most motions, greater PROM can be expected compared to AROM. This is because there is a small degree of available motion outside of volitional control.7 If a limitation is noted during AROM, passive assessment of that motion should occur. Passive motion requires that the patient be as relaxed as possible and avoid assisting with the movement. To achieve and maintain this relaxed state, especially when the patient is in pain, he or she must have considerable trust in you to perform the motion. Much of this trust is gained when a patient is able to sense gentle but confident handling and support through the clinician’s hands. This takes a great deal of practice to develop. Although practicing on classmates, friends, or family is certainly helpful, it is not until you have worked with real patients (who have real pain and real limitations) that this experience will be gained. Sometimes PROM can be performed in the same position that AROM was assessed. This is joint and symptom dependent. For example, AROM of ankle (subtalar) inversion may be grossly assessed with the patient seated on an examination table. If a limitation in AROM is observed, you can ask the patient to return the ankle to the resting position, gently grasp the lateral aspect of the foot (with your opposite hand stabilizing at the distal tibia), ask the patient to relax and avoid assisting, then slowly move the ankle into inversion. With many passive motions, especially in the presence of pain, it may be helpful to have the patient lie down (usually in supine). This helps with patient relaxation as well as clinician support of the body part. For example, gross AROM of shoulder abduction often is assessed with the patient seated. If this motion is limited and quite painful, it may be very difficult for the patient to maintain a relaxed state if you attempt PROM in the same position. Moving the patient to supine, where the trunk and head are fully supported, may allow for greater patient relaxation and more accurate assessment of PROM. This is especially true for PROM assessment of the cervical spine; “letting go” of the neck is quite challenging for most patients in a seated position. Greater ROM can be expected for a number of motions when patients are supine versus seated,8,9 and this should be kept in mind in the clinical decision-making process. Regardless of the position in which PROM is performed, it should be carried out with caution and with close attention to the patient’s words, facial expressions, muscular resistance (intentional or reflexive), and quality of motion felt through your hands. As with AROM, if a limitation in PROM is found, the patient should be asked what he or she feels is limiting the motion. Assumptions about the presence, location, or type of pain should be avoided. Consider the following example: A patient has sought physical therapy examination for Ⓡ anterior knee pain. She describes intense pain in the patellar area when going up stairs or when running. Visual observation shows that the Ⓡ knee is moderately effused (swollen). During AROM assessment of Ⓡ knee flexion, the patient reports onset of her typical anterior knee pain and stops the motion at approximately 75% of the expected normal range. When the clinician performs PROM of knee flexion, the patient asks that the motion be stopped at nearly full range because of pain. However, when asked, the patient reports her pain to be primarily in the posterior aspect of the knee (likely due to the effusion). Had the patient not been asked, the clinician might have assumed that both AROM and PROM reproduced the patient’s anterior knee pain. Joint End Feel Joint end feel can be described as the quality of resistance to movement felt by the examiner while passively moving a joint to its end range. Assessment of joint end feels can help the clinician narrow the type of pathology present, determine the severity or acuity of the condition, and hypothesize about the patient’s prognosis.10 While several classification systems have been published,11,12 the Cyriax system13 is most descriptive of both normal and pathological end feels and is described in TABLE 9-2. Even in healthy joints, the “feel” of the end feel will differ from person to person for any given motion. Individuals who are naturally hypermobile may have considerably more give at the end range of a joint as compared to someone who is naturally hypomobile. Because of these differences, performing an end feel assessment on a patient’s uninvolved side can provide helpful information about that patient’s own “normal” end feel. For efficiency and to avoid the possibility of invoking pain twice, you should assess end feel at the same time PROM is performed. If the end range of PROM is not painful, you will be able to apply a moderate amount of force, or overpressure, to assess the true end point of motion. However, in the presence of pain, you must proceed with TABLE 9-2 Normal and Abnormal End Feels* End Feel Name and Description Example Normal End Feels Bone-to-Bone A hard, painless sensation with no “give.” Elbow extension Soft Tissue Approximation A mushy, forgiving sensation that stops further motion. Elbow or knee flexion Tissue Stretch The most common type of normal end feel, felt when the primary restraints for further movement are ligament or capsule. May be further divided into elastic (soft) in which there is significant spring or “give” at the end range, or capsular (hard) in which a definite end point is felt. Elastic (soft): wrist flexion, shoulder internal rotation Capsular (hard): knee extension Abnormal End Feels Bone-to-Bone Similar to the feel of the normal bone-to-bone end feel but often painful and occurs before the normal expected ROM or in joints where a bone-to-bone end feel is not expected. Elbow flexion in the presence of excess bone formation (heterotopic ossification) following a fracture of the coronoid process Springy Block A forgiving (rebound) feeling, similar to a tissue stretch but often is painful and felt before the normal end ROM is achieved or in joints where this end feel is not expected. Typically found in the knee joint and often indicative of a meniscus tear. Knee extension in the presence of a meniscus tear (extension is limited or blocked by the tear) Capsular Feels similar to a capsular tissue stretch end feel but can invoke pain and occurs before the normal end ROM is achieved or in joints where this end feel is not expected. Shoulder abduction in the presence of adhesive capsulitis (frozen shoulder) Muscle Spasm Involves a brief, involuntary muscle spasm that occurs in response to pain; is the body’s attempt to protect injured or inflamed tissues. Cervical lateral flexion following a whiplash injury Empty Involves no sensation of resistance felt by the examiner, but the patient indicates (verbally or through facial expression) that motion must stop due to intense pain. Shoulder flexion or abduction in the presence of acute subacromial bursitis