Assessing Range of Motion: Difference between revisions
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**Infectious or acute inflammatory process | **Infectious or acute inflammatory process | ||
**Myositis Ossificans or Ectopic Ossification | **Myositis Ossificans or Ectopic Ossification | ||
* Post | * Post Surgery | ||
** Range of Motion has potential to disrupts the healing process | ** Range of Motion has potential to disrupts the healing process | ||
* Osteoporosis or Bone Fragility | * Osteoporosis or Bone Fragility | ||
| Line 71: | Line 71: | ||
* Hypermobility or Instability | * Hypermobility or Instability | ||
* Haemophilia | * Haemophilia | ||
* Bony | * Bony Ankylososis | ||
* After Prolonged Immobilisation | |||
* After | |||
== Measuring Range of Motion == | == 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.<ref>Norkin CC, White DJ. Measurement of joint motion: a guide to goniometry. FA Davis; 2016 Nov 18.</ref> 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. <ref>Gajdosik RL, Bohannon RW. Clinical measurement of range of motion: review of goniometry emphasizing reliability and validity. Physical therapy. 1987 Dec 1;67(12):1867-72.</ref> | 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.<ref>Norkin CC, White DJ. Measurement of joint motion: a guide to goniometry. FA Davis; 2016 Nov 18.</ref> 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. <ref name=":5">Gajdosik RL, Bohannon RW. Clinical measurement of range of motion: review of goniometry emphasizing reliability and validity. Physical therapy. 1987 Dec 1;67(12):1867-72.</ref> | ||
=== Goniometry === | === 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 ' | 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''<nowiki/>' meaning angle and '<nowiki/>''metron''<nowiki/>' 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. Greater reliability is obtained when measures are taken by a consistent therapist and when using a standardised method.<ref name=":0" /><ref name=":5" /><ref>Blonna, D., Zarkadas, P. C., Fitzsimmons, J. S., & O'Driscoll, S.W. (2012). Accuracy and inter-observer reliability of visual estimation compared to clinical goniometry of the elbow. Knee Surgery, Sports Traumatology, Arthroscopy, 20(7), 1378-85. </ref> <ref>Boone, D. C., Azen, S. P., Lin, C., Spence, C., Baron, C., & Lee, L. (1978). Reliability of goniometric measurements. Physical Therapy, 58(11), 1355-1360. </ref> | ||
* Versatile: Measures joint position and range of motion at almost all joints of the body | * Versatile: Measures joint position and range of motion at almost all joints of the body | ||
| Line 108: | Line 107: | ||
=== End-Feel === | === End-Feel === | ||
[[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. <ref name=":1" /> | [[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. <ref name=":1" /> A normal end feel exists when there is full passive range of motion at the joint, which is stopped by the normal anatomy of the joint, an abnormal end feel exists when there is either a decreased or an increased passive range of motion or when there is a normal passive range of motion, but structures other than the normal anatomy stop joint movement.<ref name=":3" /> | ||
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. | 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. | ||
{| width="800" border="1" cellpadding="1" cellspacing="1" | {| width="800" border="1" cellpadding="1" cellspacing="1" | ||
|+'''Table.1''' Normal End-feel <ref name=":0" /><ref name=":2">Magee D. Orthopaedic Physical Assessment WB Saunders. pg. 2002;478:483-631.</ref> | |+'''Table.1''' Normal End-feel <ref name=":0" /><ref name=":2">Magee D. Orthopaedic Physical Assessment WB Saunders. pg. 2002;478:483-631.</ref> | ||
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* Shoulder 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. <ref name=":0" /><ref name=":2" /> | 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. <ref name=":0" /><ref name=":2" /> | ||
=== | === Pattern of Limitation or Restriction === | ||
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 of loss. | |||
# Capsular Pattern | # Capsular Pattern | ||
#* Restriction is a limitation of pain and movement in a joint specific ratio, which is usually present with [[Osteoarthritis|arthritis]], or following prolonged immobilisation. | #* If there is a lesion of the joint capsule or a total joint reaction is present, a characteristic pattern of restriction in the PROM will occur: Restriction is a limitation of pain and movement in a joint specific ratio, which is usually present with [[Osteoarthritis|arthritis]], or following prolonged immobilisation. | ||
# Non-capsular | #* The capsular pattern manifests as a proportional limitation of joint motions that are characteristic to each joint; for example, the capsular pattern of the elbow joint differs from the pattern of restriction at the ankle joint. | ||
# Non-capsular Pattern | |||
## 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. | ## 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. | ||
Revision as of 02:02, 10 June 2023
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[edit | edit source]
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.[1] 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.[2] 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. [3]
Types of Range of Motion[edit | edit source]
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. [3][4]
- 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.[3]
- 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. [3]
- 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.[5]
- 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.[3]
Factors Impacting Range of Motion[edit | edit source]
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[edit | edit source]
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. [3] 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. [3][6] 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.[3]
Gender[edit | edit source]
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. [6]
Weight[edit | edit source]
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.[6]
Dominant versus Non Dominant Side[edit | edit source]
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.[6]
Test Procedures[edit | edit source]
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[7][8][9][10], 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°. [11] 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[edit | edit source]
AROM and PROM assessment techniques are typically contraindicated where muscle contraction (i.e., in the case of active or active assisted motion) or motion of the part of the body could disrupt the healing process or result in injury or deterioration of the condition. Some examples of conditions where range of motion may be contraindicated are listed below.
- Suspected or Confirmed
- Joint dislocation or subluxation
- Unhealed or unstable bone fracture
- Rupture of tendon or ligament
- Infectious or acute inflammatory process
- Myositis Ossificans or Ectopic Ossification
- Post Surgery
- Range of Motion has potential to disrupts the healing process
- Osteoporosis or Bone Fragility
- Forced measurements may cause iatrogenic injury
Precautions[edit | edit source]
Conditions where measurement of range of motion may be appropriate with added precautions if movement to the part might aggravate the condition include the following;
- Presence of Pain
- Infection or inflammation around a Joint
- Hypermobility or Instability
- Haemophilia
- Bony Ankylososis
- After Prolonged Immobilisation
Measuring Range of Motion[edit | edit source]
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.[12] 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. [13]
Goniometry[edit | edit source]
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. Greater reliability is obtained when measures are taken by a consistent therapist and when using a standardised method.[3][13][14] [15]
- 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[edit | edit source]
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[edit | edit source]
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[edit | edit source]
Positioning[edit | edit source]
- 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[edit | edit source]
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. [1] A normal end feel exists when there is full passive range of motion at the joint, which is stopped by the normal anatomy of the joint, an abnormal end feel exists when there is either a decreased or an increased passive range of motion or when there is a normal passive range of motion, but structures other than the normal anatomy stop joint movement.[4]
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.
| End-feel | Description | Example |
|---|---|---|
| Soft | Soft Tissue Approximation
|
Knee Flexion;
Contact between soft tissue of posterior leg and posterior thigh |
| Firm | Muscular End Feel
|
Hip Flexion with Knee Straight (SLR);
Passive elastic tension of the Hamstring Muscles |
Ligamentous End Feel
|
Forearm Supination;
Tension in the Palmar Radioulnar Ligament of the Inferior Radioulnar Joint, Interosseous Membrane, Oblique Cord | |
Capsular End Feel
|
Extension of Metacarpophalangeal Joints Tension in the Anterior Capsule | |
| Hard | Bone on Bone
|
Elbow Extension;
Contact between Olecranon Process of the Ulna and the Olecranon Fossa of the Humerus |
| End-feel | Description | Example |
|---|---|---|
| Empty |
|
|
| Soft |
|
|
| Firm |
|
|
| Hard |
|
|
| Springy |
|
|
| Spasm |
|
|
| Loose |
|
|
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. [3][16]
Pattern of Limitation or Restriction[edit | edit source]
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 of loss.
- Capsular Pattern
- If there is a lesion of the joint capsule or a total joint reaction is present, a characteristic pattern of restriction in the PROM will occur: Restriction is a limitation of pain and movement in a joint specific ratio, which is usually present with arthritis, or following prolonged immobilisation.
- The capsular pattern manifests as a proportional limitation of joint motions that are characteristic to each joint; for example, the capsular pattern of the elbow joint differs from the pattern of restriction at the ankle joint.
- Non-capsular Pattern
- 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[edit | edit source]
Resources[edit | edit source]
References [edit | edit source]
- ↑ 1.0 1.1 Reese NB, Bandy WD. Joint Range of Motion and Muscle Length Testing-E-book. Elsevier Health Sciences; 2016 Mar 31.
- ↑ Cox R. Oxford Dictionary of Sports Science and Medicine. Reference Reviews. 2007 Sep 25;21(7):50-.
- ↑ 3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 3.10 3.11 Norkin CC, White DJ. Measurement of joint motion: a guide to goniometry. FA Davis; 2016 Nov 18.
- ↑ 4.0 4.1 4.2 Clarkson HM. Musculoskeletal assessment: joint motion and muscle testing. 2013.
- ↑ Gil-González S, Barja-Rodríguez RA, López-Pujol A, Berjaoui H, Fernández-Bengoa JE, Erquicia JI, Leal-Blanquet J, Pelfort X. Continuous passive motion not affect the knee motion and the surgical wound aspect after total knee arthroplasty. Journal of Orthopaedic Surgery and Research. 2022 Jan 15;17(1):25.
- ↑ 6.0 6.1 6.2 6.3 Moromizato K, Kimura R, Fukase H, Yamaguchi K, Ishida H. Whole-body patterns of the range of joint motion in young adults: masculine type and feminine type. Journal of physiological anthropology. 2016 Dec;35:1-2.
- ↑ Glück S, Hoffmann U, Schwarz M, Wydra G. Range of motion, traction force and muscle activity in self- and external-regulated stretching. Deutsche ZeitschriftfürSportmedizin. 2002;53:66–71.
- ↑ Magnusson SP, Simonsen EB, Aagaard P, Kjaer M. Biomechanical responses to repeated stretches in human hamstring muscle in vivo. Am. J. Sports Med. 1996;24:622–628. doi: 10.1177/036354659602400510.
- ↑ Boyce D, Brosky JA. Determining the minimal number of cyclic passive stretch repetitions recommended for an acute increase in an indirect measure of hamstring length. Physiother. Theory Pract. 2008;24:113–120. doi:
- ↑ Nakamura M, Ikezoe T, Takeno Y, Ichihashi N. Time course of changes in passive properties of the gastrocnemius muscle–tendon unit during 5 min of static stretching. Manual Therapy. 2013;18:211–215. doi: 10.1016/j.math.2012.09.010.
- ↑ Holzgreve F, Maurer-Grubinger C, Isaak J, Kokott P, Mörl-Kreitschmann M, Polte L, Solimann A, Wessler L, Filmann N, van Mark A, Maltry L. The acute effect in performing common range of motion tests in healthy young adults: a prospective study. Scientific Reports. 2020 Dec 10;10(1):1-9.
- ↑ Norkin CC, White DJ. Measurement of joint motion: a guide to goniometry. FA Davis; 2016 Nov 18.
- ↑ 13.0 13.1 Gajdosik RL, Bohannon RW. Clinical measurement of range of motion: review of goniometry emphasizing reliability and validity. Physical therapy. 1987 Dec 1;67(12):1867-72.
- ↑ Blonna, D., Zarkadas, P. C., Fitzsimmons, J. S., & O'Driscoll, S.W. (2012). Accuracy and inter-observer reliability of visual estimation compared to clinical goniometry of the elbow. Knee Surgery, Sports Traumatology, Arthroscopy, 20(7), 1378-85.
- ↑ Boone, D. C., Azen, S. P., Lin, C., Spence, C., Baron, C., & Lee, L. (1978). Reliability of goniometric measurements. Physical Therapy, 58(11), 1355-1360.
- ↑ 16.0 16.1 16.2 Magee D. Orthopaedic Physical Assessment WB Saunders. pg. 2002;478:483-631.
