Range of movement

Published on 03/03/2015 by admin

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Range of movement

What is range of movement (ROM)?

The function of a joint is to allow full range, friction free movement between its segments. The full range of movement (FROM) of a joint incorporates both the accessory movement (which cannot be produced in isolation by an individual) and the physiological movement.

Active physiological movement

The physiological movement of a joint is the active voluntary movement that a person can perform themselves. When performing an active physiological movement (AROM) there is combined involvement of the joint, muscle and motor control. Therefore these are all potential sources of dysfunction. The more common presentation is that of a reduced ROM, however instability, loss of proprioception and poor control could lead to an excessive ROM. In a neurologically impaired patient the potential causes of altered AROM include:

• Altered muscle tone (S3.21)

• Altered sensation (especially proprioception) (S3.23)

• Altered motor control (S2.7)

• Incoordination/ataxia (S3.26)

• Pain (S3.29)

• Cognitive/perceptual deficit (S3.33)

• Lack of confidence

• Soft tissue contracture

• Weakness (S3.30).

Clinical hints and tips

Remember that AROM may also be influenced by factors such as age, gender, occupation, handedness, time of day, temperature, emotional status and other pathology.

Passive physiological movement

A passive physiological movement (PROM) is defined as a movement within the unrestricted ROM for a segment, which is produced entirely by an external force. In the spinal joints this is referred to as a ‘passive physiological intervertebral movement’ (PPIVM). Although not actively involved in producing the movement, muscles and other soft tissue around the joint may still reduce the PROM. Excessive PROM is common in neurologically impaired patients particularly related to hypotonia, e.g. subluxation of the shoulder. Of course motor control does not have any influence in this case.

Accessory movement

The passive accessory range of movement is vital for FROM to be achieved in all joints. In the spinal joints this is termed a ‘passive accessory intervertebral movement’ (PAIVM).

Why do I need to assess range of movement?

A dysfunction of the neural or musculoskeletal systems may lead to joint hypermobility (excessive movement) or hypomobility (reduced movement) either of which may conclude in soft tissue damage, pain and loss of function. Assessment of ROM allows the therapist to identify a potential limitation to functional ability and when combining the findings of AROM and PROM allows the therapist to begin hypothesizing the structures that may be implicated (differential diagnosis).

How do I assess range of movement?

AROM

AROM should be assessed before the PROM is explored.

Patient

The patient’s position will alter depending upon the joint being tested because where possible, the position must allow for FROM. For example, full ROM of hip flexion (hip extension to hip flexion) is only possible in standing. In circumstances where this is not practical, such as an immobile patient, the movement will need to be assessed in two halves.

Therapist

The therapist will already have observed the patient’s general AROM during the performance of functional activities (S3.18). However, as function involves the combined movement of many joints, a more specific assessment of the individual segments involved may be required. Assessment of all the cardinal planes of movement should be considered although clinical judgement should be used as to whether it is necessary to assess every joint and every direction. For example, at the hip the cardinal planes are flexion, extension, abduction, adduction and medial/lateral rotation.

Clinical hints and tips

Based on the subjective assessment and functional objective assessment the therapist needs to use clinical judgement as to whether it is it necessary to assess every joint and every direction.

Limb testing

1. Stand-by assistance or a plinth alongside the patient may be necessary during assessment of the lower limb.

2. The test should be carried out one limb at a time (the unaffected limb first if this is relevant) and measurements taken using a universal goniometer.

3. Choose the appropriate size goniometer for the joint being measured.

4. Demonstrate the movement to ensure the movement is performed correctly.

5. Position the patient to allow FROM.

6. In the start position, place the axis of the goniometer (centre of protractor) over the joint (Fig. 28.1).

Figure 28.1 Measuring limb ROM: Correct use of the universal goniometer in the start position.

7. Line up the stationary arm of the goniometer with a proximal bony landmark that will not move during the limb movement (Fig. 28.1).

8. Line up the moveable arm with a bony landmark on the limb that will be moving (Fig. 28.1).

9. Ask the patient to perform the limb movement.

10. At the limit of the patient’s ROM, move the moveable arm to line up with the original bony landmark and take the reading (Fig. 28.2).

Figure 28.2 Measuring limb ROM: Correct use of the universal goniometer in finish position.

11. Be sure to read the correct scale from the protractor.

12. The therapist may choose to carry out a repeated movement if the test range is reduced. This may elicit a change in the AROM, an increase as they warm up or a decrease as they fatigue.

Spinal joint testing

Active physiological movements of the spine involve composite movement of each individual vertebral joint and therefore measurement using a goniometer is not possible. Active spinal movements are therefore measured globally using a tape measure.

1. The patient starts in neutral standing.

2. Make three marks (Fig. 28.3):

Figure 28.3 Measuring spinal joint ROM: start position.

• A horizontal line level with the posterior superior iliac spines

• 5 cm above this level

• 10 cm above this level.

3. Ask the patient to move to the finish position (e.g. spinal flexion).

4. At the finish position, re-measure the distances from the posterior superior iliac spine/s (PSIS) level and record (Fig. 28.4).

Figure 28.4 Measuring spinal joint ROM: finish position.

5. The same procedure can be repeated for extension and side flexion.

Note: Spinal measurements can also be taken from the tip of the third finger to the floor.

Does the patient achieve full active range of movement? This requires the therapist to know the normal values for full AROM of all joints.

Is the AROM excessive or reduced from normal limits?

Is the movement pattern normal? Gross movement patterns may indicate spasticity (S3.21).

Is there any evidence of pain behaviour prior to, during or after the movement? Nociceptive pain may present as avoidance in all or part of the range, facial grimace or verbalization of pain. Neurogenic pain may show no particular link to movement (S3.29).

Are there any compensatory movements used to achieve the range of movement? Compensatory activity may be used in circumstances where the usual muscle/s is/are unable to complete the task (hypotonia, hypertonia, weakness) or the range of the joint is altered (soft tissue adaptation).

PROM

Patient

The patient’s position will alter depending upon the joint being tested as where possible, the position must allow for FROM.

Therapist

Spinal joint testing

If a restriction of spinal joint movement is suspected, the therapist should explore the region further using passive physiological intervertebral movements (PPIVMs) and passive accessory intervertebral movements (PAIVMs). These assessment techniques are not covered in this text.

Limb testing

Assessment of all the cardinal planes of movement should be considered, although clinical judgement should be used as to whether it is necessary to assess every joint and every direction. Carrying out PROM is identified as a high-risk manual handling task and therefore consideration of the environment/bed height is essential.

1. The therapist should explain that the movement is to be performed entirely by the therapist.

2. Hold the limb firmly and confidently to allow the patient to relax fully.

3. The therapist should move each segment through the full available ROM.

4. Once the therapist considers they have reached the limit of the patient’s ROM, a measurement should be taken accurately and objectively using a universal goniometer. However, more experienced therapists do use visual estimation. Instructions for the correct use of a goniometer are as for AROM.

Can the therapist achieve full passive range of movement? This requires the therapist to know the normal values for full PROM for all joints.

Is the range of PROM different to that of the AROM? Yes. See analysis section.

Is there any evidence of pain behaviour prior to, during or after the movement? Nociceptive pain may present with guarding/muscle spasm during the testing of PROM. Neurogenic pain may show no particular link to movement (S3.29).

End feel

If a reduced PROM is identified using passive physiological movements and the patient’s pain symptoms are not severe, the therapist may continue to investigate the end feel of the joint so that the structures limiting the ROM can be differentiated during analysis.

1. At the end of the available range the therapist should apply overpressure to the joint in the same direction as the test movement.

2. This additional force must be applied slowly, smoothly and accurately.

3. The therapist should compare the end feel with what they understand to be the normal end feel for that joint. The normal end feels are different according to the structures limiting the joint (Magee 2006).

a. Soft end feel: Related to soft tissue apposition (e.g. knee flexion)

b. Hard end feel: Related to bone to bone (e.g. elbow extension)

c. Firm/springy end feel: Related to tissue stretch (e.g. ankle dorsiflexion)

d. Capsular restriction (e.g. in shoulder and hip lateral rotation).

Note: Hypertonia may restrict the AROM well before the end of PROM. If possible the therapist still needs to investigate the end feel beyond the hypertonic restriction to explore the existence of any soft tissue adaptation.

What is the end feel of the joint at the end of its range? The resistance is considered abnormal if the normal end feel is not present or the resistance is felt too early in the normal range (Petty 2006).

Recording

The recording of this data could be extensive. It may therefore be wise to note the findings in a list or table form.

Analysis

The therapist’s analysis of ROM will inform other areas of the objective assessment. For example, reduced AROM of the ankle dorsiflexors may explain abnormal gait and poor balance. The aim of this assessment tool is to establish the patient’s ROM and to begin hypothesizing about any possible limiting factors. In the case of a reduced ROM, this can be achieved by comparing the findings from both AROM and PROM assessments. For example, if PROM is greater than AROM then a deficit of muscle contraction should be suspected. This could be caused by muscle weakness, hypotonia, hypertonia or sensory loss. However, if both PROM and AROM are reduced, the limit is more likely to be linked with a soft tissue adaptation. Note: Pain could be a causal factor in both these scenarios and needs further investigation (S3.29).

Outcome measures

Research

• Silicon COACH

Clinical

• Silicon COACH.

References and Further Reading

Fox, J, Day, R. A physiotherapist’s guide to clinical measurement. Edinburgh: Churchill Livingstone/Elsevier; 2009.

Magee, DJ. Orthopaedic physical assessment, ed 4. Canada: Elsevier Sciences; 2006.

Petty, NJ. Neuromusculoskeletal examination and assessment: a handbook for therapists. Edinburgh: Churchill Livingstone; 2006.

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Neurological Assessment A Clinicians Guide