Assessing Range of Motion

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Original Editors - Naomi O'Reilly and Tarina Van Der Stockt

Top Contributors - Naomi O'Reilly, Jess Bell, Ewa Jaraczewska and Tarina van der Stockt      

Introduction

Range of motion is an fundamental part of human movement essential for your body’s functional mobility and as such forms an integral part of patient assessment in all settings.  Efficient movement with minimal effort relies on adequate range of motion, which will allow the joints to adapt more readily to stresses imposed on the body. Joint range of motion is the arc of motion available at a single joint or series of joints and is the angle through which a joint moves from the anatomical position to the extreme limit of its motion in a particular direction. Effectively range of motion is the extent or limit to which a part of the body can be moved around a joint or a fixed point providing you with the totality of movement a joint is capable of.

Range of motion is typically measured in degrees and can be influenced by the associated bony structure and physiological characteristics of the connective tissues such as ligaments and joint capsule that surround the joint. If you have limited range of motion in one or more joints, your body may compensate by placing stress on other joints or muscles, which may result in muscle imbalance and improper body alignment. Poor alignment and muscle imbalance present a greater risk of injury and pain and reduce functional mobility.

Types of Range of Motion

Active Range of Motion

• Active range of motion (AROM) is the range of movement that can be achieved when opposing muscles contract and relax, resulting in joint movement. It is the arc of motion produced by a patient during a voluntary, unassisted muscle contraction, which provides us with information about levels of consciousness, willingness to move, ability to follow instructions, attention span, coordination, muscle strength, joint range of motion, movements that cause pain and ability to perform functional activities.
• It should be performed by the patient independently and when the patient is able to voluntarily contract, control, and coordinate a movement.
• For example, the active range of motion to allow the elbow to bend requires the biceps to contract while the tricep muscle relaxes.
• Active range of motion is typically less than passive range of motion as each joint has a small amount of available motion that is not under voluntary control.

Active-assisted Range of Motion

• Active-assisted range of motion (AAROM) is the range of movement that can be achieved when the joint receives partial assistance from an outside force. It is the arc of motion produced by a patient during a voluntary muscle contraction to the extent they are able assisted by an external force applied manually, mechanically, or gravity assistance.
• Typically performed when the patient needs assistance with a movement from an external force because of weakness, pain, or changes in muscle tone.
• For example, the patient using their left arm to assist them to lift their right arm to bend the elbow.

Passive Range of Motion

• Passive range of motion (PROM) is the range of movement that is achieved when an outside force exclusively causes movement of a joint. It is the arc of motion produced by the examiner without assistance from the patient, which provides us with information about the integrity of the joint surfaces and extensibility of the joint capsule and surrounding ligaments, muscle, fascia and skin.
• Typically performed when the patient is unable or not permitted to move the body part. It is also performed when the patient needs assistance with movement from an external force because of weakness, pain, or changes in muscle tone and plays no active role in producing the movement. The assistance may be applied mechanically or manually.
• For example, continuous passive motion device to performs repetitive passive motion to move the joint to a set of number of degrees and movement speed.
• Passive range of motion is typically greater than passive range of motion due to the stretch of the tissues surrounding the joint and the reduced bulk of relaxed muscles compared to contracting muscle, which helps to protect joint structures by absorbing extrinsic forces. It is for this reason that measurement of joint range of motion as a rule uses passive range of motion.

Factors Impacting Range of Motion

Range of motion varies among individuals and can be influenced by a wide range of factors including age, gender, physical constitution such as body mass index, occupational and recreational activities, and test procedures such as instrument used, test position, number of repeated tests, time of day tests performed or whether the motion is performed actively or passively.

Age

Significant research has explored the impact of age on range of motion, with gender typically having no impact on range of motion in new borns, infants and toddlers up to about 2 years of age, who tend to have more hip flexion, hip abduction, hip external rotation, ankle dorsiflexion and elbow motion in comparison to adolescents and adults, but show limitations in hip extension, knee extension and plantarflexion, typically linked to the effects of positioning in utero, which are modified only with growth. On the other hand older age is significantly associated with lower range of motions than younger adults most commonly in shoulder external rotation and horizontal flexion, elbow extension, wrist flexion and extension, although these changes may affect men and women differently. Increasing loss of active range of motion in the neck, thoracic and lumbar spine occur with every decade passing decade, with the greatest change seen in thoracolumbar mobility with up to research suggesting up to an 8° reduction each decade.

Gender

As with age, the effects of gender on joint range of motion appear to be joint and motion specific. Typically females are reported to have greater range of motion then males, with these differences more prevalent in adolescents and adults than in younger children. Females show significantly increased range of motions in the limb joints including shoulder flexion, internal rotation and horizontal flexion, elbow flexion and extension, wrist extension, and hip flexion, adduction, and internal rotation, while males have higher range of motions for hip extension and external rotation, and trunk flexion and rotation.

Weight

Higher lean body mass has been shown to be significantly related to reduced range of motion in shoulder external rotation and horizontal extension, but increase range of motion for wrist flexion and hip adduction. On the other hand increased body fat % has been associated with decreased shoulder external rotation, shoulder horizontal flexion, and elbow flexion and extension, but positively associated with increased trunk flexion and rotation, and hip extension and external rotation. Negative correlations between body fat % and several joint motions may be as a result of physical obstruction by fat tissue caught between the bones constituting the joint such as in shoulder horizontal flexion.

Dominant versus Non Dominant Side

Range of motion differences between dominant and non-dominant sides were significant with increased range of motion seen in shoulder internal rotation, hip abduction, and ankle plantar flexion on the non-dominant side, while increased shoulder external rotation, wrist flexion, and hip adduction was observed in the dominant side, which suggests that daily activities (occupational or recreational) can lead to some variation in range of motion. Asymmetry of posture has been associated with side dominance so could account for differences seen between dominant and non-dominant sides, alternatively, these differences may be attributed to muscle mass, that is a forced and continuous motion on the dominant side that increases its range of motion by stretching the muscles antagonistic to the motion.

Test Procedures

Currently there is limited agreement in the research on the number of repetitions to be measured or warm-up protocols to use prior to during range of motion assessment. Evidence on stretching has shown an increase in mobility, stretch tolerance and reduced passive torque during acute stretch training after only a few repetitions of a stretch, and that this acute effect also occurs during range of motion assessment, therefore, differences in the measurement protocol with regard to the measured repetitions and warm-up exercises, can lead to different measurement results of up to 6°. To counteract the impact of testing procedures use of a consistent protocol around warm up before testing, number of repeated measures and type of motion used is vital.

Contraindications

Conditions where active range of motion may be contraindicated include the following;

• Suspected or Confirmed
  • Joint dislocation or subluxation
  • Unhealed or unstable bone fracture
  • Rupture of tendon or ligament
  • Infectious or acute inflammatory process
• Post-surgery if movement disrupts the healing process
• Regions of osteoporosis or bone fragility, as forced measurements may cause iatrogenic injury  

Precautions

Conditions where measurement of range of motion is appropriate with added precautions include the following;

1. Infection or inflammation around a joint
2. Severe pain aggravated by movement
3. Hypermobility or instability
4. Presence of pain or muscle spasms

Measuring Range of Motion

There are different instruments used to measure ROM. The choice of instrument depends on the purpose of the measurement, the movement to be measured, the instrument’s accuracy, availability, cost, ease of use, size and its validity and reliability. Reliability of range of motion is influenced by the types of measurement instrument used and procedures, differences among joint actions and body regions, passive versus active measurements, intra-tester versus inter-tester measurements, and different patient types.

Goniometry

A goniometer is the most common instrument used to measure range of motion in the clinical setting. The term 'goniometry' is derived from the greek words 'gonia' meaning angle and 'metron' meaning measure, therefore goniometry refers to the measurement of angles, which in rehabilitation settings refers to the measurement of angles in each plane at the joints of the body. Generally the universal goniometer has been shown to have good to excellent reliability but is considered of limited use in movement analysis as it gives you a static end range measurement only. Overall, research shows high intra- and inter-rater reliability of the universal goniometer, with reliability in non-expert examiners improved with clear instructions on goniometric alignment. Reliability & validity of hand-held goniometry has been shown to be good to excellent but has limited use in movement analysis as it gives you a static end range measurement only, but is helpful as an outcome measure to assess effect of treatment in conjunction with functional testing.

• Versatile: Measures joint position and range of motion at almost all joints of the body
• Construction: Typically plastic, contains a body (similar to a protractor) and two lever arms (stationary and movable)
• Alignment: Arms align with proximal and distal segments of the individual’s joints
• Cost: Varies from $5 to $100

Smart Phones

Can be loaded with appropriate software applications

• Allows smartphones to function as inclinometers by using built-in tilt-sensitive systems
• Data on reliability and validity are currently insufficient to support use in the clinical setting

Visual Estimation

Yields only subjective information in contrast to objective goniometric measurements so not recommended. Visual estimates made prior to goniometric measurements may help to reduce errors attributable to incorrect reading of the goniometer, however, knowledge of the estimate has been shown to influence goniometric measurement results.

Principles of Measurement

Positioning

• Testing Position
  • Body positions recommended for obtaining goniometric and muscle length measurements
  • Places the joints in a zero starting position when measuring range of motion (ROM)
  • Helps to stabilise the proximal joint segment
  • Important for the comfort of the examiner and individual being measured
  • Stabilises the body and proximal joint segment
  • Isolates the motion to one joint to ensure that a true measurement of the motion is obtained

End-Feel

End-feel is the quality of the tissue resistance to motion at the end of passive range of motion. Each joint has a unique structure and this determines the amount of passive range of motion available to that specific joint. In some joints the joint capsule limits the amount of movement in certain directions, while in other joints the ligaments or the bones limit the movement because of the joint structure.

When the therapist performs the passive range of motion the end feel is the barrier the therapist feels when slight over pressure is applied at the end of the joint motion that prevents further movement, which takes practice and sensitivity to develop the ability to determine the character of the end-feel.

Table.1 Normal End-feel

End-feel	Description	Example
Soft	Soft Tissue Approximation Occurs when two soft tissue masses meet one another, limiting further movement. The quality of the resistance is soft, with a gradual increase in resistance as soft tissue is compressed between body parts	Knee Flexion; Contact between soft tissue of posterior leg and posterior thigh
Firm	Muscular End Feel Occurs when muscular tension limits the range of motion at a joint. The quality of the resistance felt is firm, although not as firm as with the capsular end-feel, and somewhat springy. Feels like stretching a bicycle tyre inner tube	Hip Flexion with Knee Straight (SLR); Passive elastic tension of the Hamstring Muscles
	Ligamentous End Feel Occurs when tension in the ligaments surrounding the joint limits the range of motion at a joint. The quality of the resistance felt is firm, although not as firm as with the capsular end-feel, and somewhat springy. Feels like stretching a leather belt.	Forearm Supination; Tension in the Palmar Radioulnar Ligament of the Inferior Radioulnar Joint, Interosseous Membrane, Oblique Cord
	Capsular End Feel Occurs when the joint capsule and the surrounding non-contractile tissues limit the range of motion at a joint. The quality of the resistance felt is firm but not hard. There is a slight "give" to the movement. Feels like stretching a leather belt, more resistance than ligament.	Extension of Metacarpophalangeal Joints Tension in the Anterior Capsule
Hard	Bone on Bone Occurs when the approximation of two bones stops the range of motion at a joint. The quality of the resistance felt is very hard and abrupt, and further motion is impossible.	Elbow Extension; Contact between Olecranon Process of the Ulna and the Olecranon Fossa of the Humerus

Table.2 Abnormal End-feels

End-feel	Description	Example
Empty	No real end-feel with no mechanical limitation to the end of the range Pain typically prevents the body part from moving through available range of motion No resistance is felt	Fracture Abscess Bursitis Acute Joint Inflammation Psychogenic Disorder
Soft	Occurs sooner or later in the Range of Motion than is usual or in a joint that normally has a firm or hard end-feel. Feels Boggy	Soft Tissue Oedema Synovitis
Firm	Occurs sooner or later in the range of motion than is usual or in a joint that normally has a soft or hard end feel.	Increased Muscle Tone Connective Tissue Shortening e.g. capsular, muscle, ligament and fascia
Hard	Occurs sooner or later in the range of motion than is usual or in a joint that normally has a soft or firm end feel. A bony grating or bony block is felt.	Fracture Osteoarthritis Chrondromalacia Myositis Ossificans Loose Bodies in Joint
Springy	A rebound is seen or felt during the movement	Internal Derangement Torn Meniscus
Spasm	Involuntary muscle contraction that prevents normal range of motion Often accompanied by pain more indicative of an acute or sever lesion Where no pain is present it may be an increase in muscle tone secondary to Central Nervous System involvement	Acute Protective Spasm Acute Arthritis Fracture Lesion of Central Nervous System
Loose	Movement beyond expected anatomical limits	Extreme Hypermobility Ankle Instability Shoulder Instability

Determination of the end-feel must be carried out slowly to enable detection of the end of the range of motion and distinguish among the various normal (physiological) and abnormal (pathological) end-feels, and requires repeated practice. Where there is a decrease in passive range of motion, it will be important to then assess the pattern of joint movement restriction, to determine whether there is a capsular or non- capsular pattern.

Capsular versus Non-Capsular Patterns

Broadly speaking, there are two patterns of range of motion used in the interpretation of loss of joint range of motion:

1. Capsular Pattern
   • Restriction is a limitation of pain and movement in a joint specific ratio, which is usually present with arthritis, or following prolonged immobilisation.
2. Non-capsular pattern
   1. Restriction is a limitation in a joint in any pattern other than a capsular one, and may indicate the presence of either a derangement, a restriction of one part of the joint capsule, or an extra-articular lesion, that obstructs joint motion.

Clinical Significance

Resources

References