Range Of Motion Assessment
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Goniometry refers to the measurement of joint angles in the human body. It is an important part of a physical examination to determine range of motion, evaluate progress, and modify treatment. There are different types of goniometers used to measure motion in various planes at joints like the shoulder, elbow, wrist, fingers, hip, and spine. Factors like a person's age, joint health, surrounding soft tissues, and pathological conditions can impact the normal range of motion values. Proper positioning, stabilization, and identification of bony landmarks is required to accurately measure and document a joint's range of motion.
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Range Of Motion Assessment
- 1. GONIOMETRY PRESENTED BY : MALEEHA AMJED Final Year Student Bachelors Of Physiotherapy
- 3. What is Goniometry? • The term goniometry is derived from two Greek words : Gonia-metron • Therefore, goniometry refers to the measurement of angles, in particular the measurement of angles created at human joints by the bones. ANGLE MEASURE
- 4. PARTS OF MOTOR EXAMINATION 1. Nutrition Of Muscle 2. Muscle Tone 3. Reflexes 4. Range Of Motion and TCD’s 5. Manual Muscle Testing
- 5. Why Is It Performed ? • Determining the presence of joint impairment • Developing treatment goals. • Evaluating progress or lack of progress. • Modifying treatment. • Motivating the subject. • Research
- 6. JOINT MOTION ARTHROKINEMATIC JOINT PLAY COMPONENT MOVEMENT OSTEOKINEMATIC PHYSIOLOGICAL/ ANATOMICAL MOVEMENT (Functional)
- 7. PLANES AND AXIS • Osteo-kinematic motions are described to be taking place in 3 cardinal planes and axis
- 9. Synovial joint • Most evolved & hence most mobile type of joints • The ends of bony components are free to move in relation to one another • Bony components are indirectly connected to one another by means of a joint capsule that encloses the joint
- 10. Joint Ranges Active ROM Passive ROM • Active motion is the unassisted voluntary movement of a joint. (Quality of ROM) • Passive motion is attained by the examiner without the patient’s assistance. (Quantity of ROM ) • ** Normally, PROM is slightly greater than AROM because joints have a small amount of motion at the end range that is not under voluntary control.
- 12. physiologic motion is limited by a physiologic barrier tension develops within the surrounding tissues (joint capsule, ligaments and connective tissue)
- 13. additional amount of passive range of motion can be performed the anatomic barrier cannot be exceeded without disrupting the joints integrity
- 14. SUBDIVISION OF JROM • Initial ROM • Middle ROM • End ROM
- 15. Subdivision of ROM as per Muscle Work
- 16. ACTIVE INSUFFICIENCY? Flex your wrist completely Attempt to tighten your fist • A muscle cantcontractmaximally across both joints together Much force than in slightly extended position • The multi joint long finger flexors enter active insufficiency when wrist flexes • Shortest possible length of muscle
- 17. PASSIVE INSUFFICIENCY? FLEXION OF THE FINGERS IS A RESULT OF INSUFFICIENT EXTENSIBILTY OF THE FINGER FLEXORS STRETCHED OVER EXTENDED WRIST EXTENSION OF THE FINGERS IS A RESULT OF INSUFFICIENT LENGTH OF THE FINGER EXTENSORS STRETCHED OVER FLEXED WRIST • LONGEST POSSIBLE LENGTH OF MUSCLE • Muscle cant stretch maximally at both joints together
- 18. Other Examples of AI PI In Body and its clinical relevance with Goniometry • BICEPS : At the top of curl, (when biceps begin to smash against forearm), when elbows are lifted **Shortens biceps over both the shoulder & elbow blade • Simultaneously lengthening the TRICEPS • HAMS : When reaching to touch toes **Lengthening felt as a stretch • RECTUS FEMORIS : Hip flexion with knee extension(70 degree) is less than hip flexion with knees bent (120 degree) • GASTROCNEMIUS : Seated calf / heel raise places the gastrocnemius into active insufficiency since the knee flexes too much & ankle performs plantarflexion
- 19. MEASURING JOINT RANGE OF MOTION • Range Of Motion (ROM) is the arc of motion that occurs at a joint or a series of joints. • Three notation systems have been used to define ROM : 1. The 0 to 180 degree system 2. The 180 to 0 degree system 3. The 360 degree system Most commonly used is the 0 to 180 degree notation system
- 20. Prerequisite Knowledge For Measuring ROM a) Normal ROM’s (Range) b) Joint Structure And Function c) Recommended positioning for self and patient d) Bony landmarks related to each joint e) Alignment of Goniometer f) Normal end-feel g) Factors that can alter normal ROM
- 21. FACTORS DETERMINING AMOUNT OF ROM Integrity Of Joint SurfaceRELIABILITY Amount Of Scarring Present AGE GENDER Shape Of Articulating Surface Health Of Joint Various diseases/ pathological conditions Health Of Surrounding Tissues Mobilty & Pliabilty Of Soft Tissue
- 22. Common pathological causes of ROM Restriction • Skin/soft tissue contracture • Arthritis • Fracture • Burns • Muscle weakness/paralysis • Pain • Edema • Spasticity • Presence of foreign body in the joint
- 23. Prerequisite Skills For Measuring ROM • The therapist should be skilled in Correct positioning (Pt/ Pt Jt/ PT And GM) Stabilization for measurement Palpation Alignment Recording measurements accurately Documentation
- 24. • Visual observation of the joint and its adjacent area is important to look for : a) Compensatory motions b) Posture c) Muscle contour d) Skin creases e) Facial expressions
- 25. Testing Procedure PLACE THE SUBJECT IN TESTING POSITION STABILIZE THE PROXIMAL JOINT SEGMENT MOVE THE DISTAL JOINT SEGMENT TO ZERO STARTING POSITION. SLOWLY MOVE THE DISTAL JOINT SEGMENT TO THE END OF PASSIVE ROM AND DETERMINE END FEEL MAKE VISUAL ESTIMATE OF THE ROM RETURN THE DISTAL JOINT SEGMENT TO THE STARTING POSITION PALPATE THE BONY ANATOMICAL LANDMARKS ALIGN THE GONIOMETER
- 26. READ & RECORD THE STARTING POSITION. REMOVE THE GONIOMETER STABILIZE THE PROXIMAL JOINT SEGMENT MOVE THE DISTAL SEGMENT THROUGH FULL ROM REPLACE & REALIGN THE GONIOMETER. PALPATE THE ANATOMICAL LAND MARKS AGAIN IF NECESSARY READ & RECORD THE ROM
- 27. Joint Mobility Scale Hyper Mobility (Mild, Moderate, Severe) Exercise, Bracing surgery Normal mobility Normal function Hypo Mobility (Mild, Moderate, Severe) Exercise, Mobilization, surgery N
- 28. Documentation • Hypo Mobility : A motion that does not start with 0 degree or ends prematurely indicates joint hypomobility Example : if knee joint has 30 degree of hypomobility in flexion, it would be recorded as 30 – 135 deg • Hyper Mobility : Joint hypermobility at the beginning of the range is noted by inclusion of a zero between the starting & ending measurements Example : if the elbow joint has 5 degree of hypermobility in extension and 140 degree of flexion , it would be recorded as 5 – 0 – 140 deg
- 29. Types of Goniometer • Full Circle Manual Universal Goniometer (360) • Half circle manual Goniometer (180) • Gravity Goniometer :- • a) Double Inclinometer (used for spine goniometry) • b) Pendulum Inclinometer • c) Bubble Goniometer • Electrogoniometer • Digital Goniometer • Tape Measurements • Smartphone Devices • Use of malleable wires/sheets (in cases of deformities)
- 33. UNIVERSAL GONIOMETER • A universal Goniometer may be constructed of metal or plastic and it has 3 parts :- 1. Body of Goniometer 2. Stationary arm 3. Movable arm (placed over the Joint being measured) (aligned parallel with the longitudinal axis of the fixed part) (aligned parallel with the longitudinal axis of the movable part)
- 36. Precautions !!! 1. Joint irritability status 2. Presence of Pain 3. Instability 4. Recent trauma 5. Is it really important to assess accurate ROM ??
- 37. Functional Ranges of various joint in various activities Walking Stair ascending descending Sitting Squatting Cross leg sitting Self Feeding Back reach Neck reach Etc….
- 38. ROM Required In ADL’s ASCENDING STAIRS REQUIRES BETWEEN 47 - 66 DEGREE OF HIP FLEXION DEPENDING ON STAIR DIMENSION DESCENDING STAIRS REQUIRES AN AVERAGE OF 21 - 36 DEGREE OF DORSIFLEXION, 86.9 - 107 DEGREE OF KNEE FLEXION DEPENDING ON STAIR DIMENSIONS
- 39. Rising from a chair requires a mean range of knee flexion of 90.1 - 95.0 degree and full dorsiflexion ROM depending on height of seat Sitting in a chair with an average seat height requires 112 degrees of hip flexion
- 40. Drinking from a cup requires about 130 degree of elbow flexion 36 to 52 degrees of shoulder flexion Reaching objects on a high shelf require 148 degrees of shoulder flexion
- 41. Using a telephone requires approx 40 degrees of wrist extension Approximately 50 degrees of pronation occur while reading a newspaper Reaching behind the head requires about 112 degrees of abduction of the shoulder
- 42. END-FEEL • The end of each motion at each joint is limited from further movement by particular anatomical structures. • The type of structure that limits a joint motion has a characteristic feel, which may be detected by the therapist performing the passive ROM. • This feeling, which is experienced by the therapist as resistance or a barrier to further motion, is called the end-feel.
- 43. NORMAL END-FEEL DESCRIPTION EXAMPLE Soft Soft Tissue Approximation Knee flexion (contact between soft tissue of posterior leg and posterior thigh) Firm Muscular stretch Capsular stretch Ligamentous stretch Hip flexion with knee straight (passive elastic tension of hamstring muscles) Extension of metacarpophalangeal joints of fingers Forearm supination (tension in the palmar radioulnar ligament of the inferior radioulnar joint) Hard Bone contacting bone Elbow extension (olecranon process of the ulna and olecranon fossa of humerus)
- 44. ABNORMAL END-FEEL DESCRIPTION EXAMPLES Soft Occurs sooner or later in the ROM than is usual or in a joint that normally has a firm or hard end-feel . Feels boggy. Soft tissue edema Synovitis Firm Occurs sooner or later in the ROM than is usual or in a joint that normally has a soft or hard end-feel. Increased muscular tonus Capsular , muscular , ligamentous, and fascial shortening Hard Occurs sooner or later in the ROM than is usual or in a joint that normally has a soft or firm end-feel. A bony grating or bony block is felt. Chondromalacia Osteoarthritis Loose bodies in joint Myositis ossificans Fracture Empty No real end-feel because pain prevents reaching end of ROM. No resistance is felt except for patient’s protective muscle splinting or muscle spasm. Acute joint inflammation Bursitis Abscess Fracture Psychogenic disorder
- 45. JOINT MOTION TESTING POSITION STABILIZATION MEASUREMENTS CERVICAL • FLEXION • EXTENSION • SIDE FLEXION • ROTATION Sitting Shoulder & chest Shoulder & chest to prevent extension of thoracic & lumbar spine To prevent side flexion of thoracic & lumbar spine To prevent rotation of thoracic & lumbar spine 1 cm– 4.3 cm 18.5 cm–22.4cm 10.7cm-12.9cm 11cm-13.2cm TAPE MEASUREMENTS OF THE SPINE
- 46. JOINT MOTION TESTING POSITION STABILIZATION MEASUREMENTS THORACIC • FLEXION • EXTENSION • LATERAL FLEXION • ROTATION STANDING •If the subject has balance problems or muscle weakness in the LE, measurement can be taken in prone/side lying SITTING PELVIS To prevent anterior tilting To prevent posterior tilting To prevent lateral tilting To prevent rotation 10 cms (4 inches) 15.9cm for rt LF 16.9cm for lt LF 45 degree (universal goniometer)
- 47. JOINT MOTION TESTING POSITION STABILIZATION MEASUREMENTS LUMBAR • FLEXION •EXTENSION •LATERAL FLEXION STANDING PELVIS To prevent anterior tilting To prevent posterior tilting To prevent lateral tilting 6.7cm in males 5.8cm in females Average 6.3cm-6.9cm (Modified Schober test) 1.6cm (Modified Schober Test) 25 – 30 degree by AMA (double inclinometer)
- 48. Demonstration Schober’s Test For Lumbar Spine Flexion
- 49. Capsular & Non-capsular Pattern Of Movement Restriction • Cyriax proposed that pathological conditions involving the entire joint capsule cause a particular pattern of restriction involving most of the passive motions of the joint. This pattern is called as capsular pattern • Restriction caused by condition involving structures other than the entire joint capsule is called as non-capsular pattern • Example – Adhesive Capsulitis Shoulder
- 59. HFD Thomas Test
- 60. KFD
- 61. Equinus
- 62. TF Malalignment
- 63. Genu Recurvatum
- 64. CERVICAL SPINE JOINT ROM Flexion 0º to 45º Extension 0º to 45º Lateral flexion 0º to 45º Rotation 0º to 60º THORACIC AND LUMBAR SPINE JOINT ROM Flexion 0º to 80º Extension 0º to 30º Lateral flexion 0º to 40º Rotation 0º to 45º
- 65. SHOULDER JOINT ROM Flexion 0º to 180º Extension 0º to 60º Abduction 0º to 180º Adduction 0º Horizontal abduction 0º to 40º Horizontal Adduction 0º to 130º Internal rotation Arm in Abduction 0º to 70º Arm in Adduction 0º to 60º External rotation Arm in Abduction 0º to 90º Arm in Adduction 0º to 80º
- 66. ELBOW JOINT ROM Flexion 0º to 135º - 150º Extension 0º FOREARM JOINT ROM Pronation 0º to 80º - 90º Supination 0º to 80º - 90º
- 67. WRIST JOINT ROM Flexion 0º to 80º Extension 0º to 70º Ulnar deviation (adduction) 0º to 30º Radial deviation (abduction) 0º to 20º THUMB JOINT ROM DIP flexion 0º to 80º - 90º MCP flexion 0º to 50º Adduction, radial and palmar 0º Palmar abduction 0º to 50º Radial abduction Opposition 0º to 50º
- 68. FINGERS JOINT ROM MCP flexion 0º to 90º MCP hyperextension 0º to 15º - 45º PIP flexion 0º to 110º DIP flexion 0º to 80º abduction 0º to 25º
- 69. HIP JOINT ROM Flexion 0º to 120º (bent knee) Extension 0º to 30º Abduction 0º to 40º Adduction 0º to 35º Internal rotation 0º to 45º External rotation 0º to 45º KNEE JOINT ROM Flexion 0º to 135º
- 70. ANKLE AND FOOT JOINT ROM Plantar flexion 0º to 50º Dorsiflexion 0º to 15º Inversion 0º to 35º Eversion 0º to 20º
- 71. SOURCES • Measurement of Joint Motion : A Guide to Goniometry, 4th Edition, by Cynthia C. Norkin • Physical Rehabilitation 6th Edition SuSan B. O’Sullivan • Magee (2002). Orthopedic physical Assessment (4th ed.). Phil: Saunders. • Kisner C, & Colby LA (2002). Therapeutic exercise: Foundations and techniques (4th ed.). PA: FA Davis. • The Principles of Exercise Therapy (Fourth Edition): M. Dena Gardiner.