ROM Flashcards
This frame of reference addresses musculoskeletal capacity and problems which underlie movement in daily occupational performance
- Range of motion - Strength - Endurance
The Biomechanical Frame of Reference. It is based on principles of kinesiology and is concerned with musculoskeletal capacity, peripheral nerve involvement/dysfunction, cardiopulmonary system dysfunction (related to endurance)
T/F: The biomechanical FOR is best suited for clients with CNS damage
FALSE: The biomechanical FOR is best suited for clients with an intact central nervous system (Pedreti & Pasquinelli, 1990) because clients must be able to perform smooth, isolated movements.
Best suited for clients with isolated/selective motor control
Focus is on movement aspects of occupation – assessment and treatment.
Is the Biomechanical FOR a bottom-up or top-down approach?
Bottom-up approach. Occupational performance requires the ability to move the limbs and the endurance to sustain activity/movement until a goal is accomplished
True or False: After ROM, strength, and endurance are regained, the client will automatically regain function (?)
False: Research shows that improvement of biomechanical components alone does not necessarily improve engagement in occupation.
Purposeful activities can be used to treat loss of ROM, strength, and endurance
What are some limitations of the biomechanical FOR?
Does not provide a lens for understanding “occupational” problems that do not result from musculoskeletal problems…cannot be used in isolation.
Sometimes resolving/remediating these musculoskeletal impairments may not result in changes in occupation.
Once you complete your occupational performance assessment (ADL) and observe during the interview/ADL assessments you can consider:
Client’s goals: ( i.e., fine coordination, difficulty with buttoning pants, tying shoes, etc.)
Observations… What might be interfering with ADL performance? What are you noticing?
Diagnosis: Will indicate suspected problems (I.e., Guillain-Barre–strength; SCI–strength and sensation); but still “screen” for others.
Setting: your involvement/role, insurance coverage, client’s course…
Arc of motion through which a joint moves
Range of Motion
Active Vs. Passive ROM
Passive Range of Motion (PROM): Movement by an external force (like therapist)
Active Range of Motion (AROM): Movement by muscles surrounding the joint. Actively movement. Tells primarily about strength
Amount of joint range necessary to perform essential ADLs and IADLs without equipment
Functional Range of Motion
Do you test AROM or PROM first?
Passive tested FIRST, flexibility, looks @ joint structure itself. Active may be influenced by tendon integrity (hands), may supplement MMT for more specific muscle grading (to document small changes)…
With ROM limitations – is it muscular or tendon related? What’s causing the difference between PROM & AROM? Is it a problem of muscle weakness or tendon integrity in the hands?
Why would you assess ROM?
Determine a limitation that is interfering with occupation
Identify specific areas needing intervention.
-ROM: which joint is causing functional problem?
-Strength: a muscle imbalance leading to deformity?
-Ability to benefit from/use assistive devices?
If you treat it, measure it…you will need a baseline so you can document change/progress/or something’s going on and you are not seeing change: should they go back to the doctor/surgeon?
Range of motion is determined by:
Structure of the joint - mechanics
-type… Example: ball & socket (hip/shoulder) motions
available…
Stretch of joint capsule and ligaments
Muscle tone and tendons
-bulkiness of muscles
Dominance
-hand… more flexible in dominant hand; other studies –
less range on dominant side..?
Temperature/Climate
-warmer… more flexible 2° influence on muscle tone…
Circadian Rhythms
-daily cycle variations… rhythm to patterns of stiffness
(and tone) especially with individuals who have
arthritis, as an example.
Range of Motion Limitations can include:
Primary:
-Skin contracture due to adhesions or scar tissue
-Soft tissue contractures such as tendon, muscle or ligament shortening
-Diseases of the joint, e.g arthritis
-arthritis, hemophilia (bleeding into the joint),
osteochondritis (irreg. blood supply to jt….aka
avascular necrosis)
-Fractures – bony obstruction or destruction
-Burns
-Trauma
-to joint structures, muscle sprain, cartilage damage,
tendon laceration… etc.
-Displacement of fibrocartilage or presence of other
foreign bodies in the joint, e.g. tumor
-any structure of joichronic renal disease -> fractures ->
decreased nt…
-LMN: Guillain-Barre, SCI, myasthenia gravis (chronic progressive muscular weakness), polio, PNI
-UMN: TBI, CVA…especially spasticity without mobility; immobilization caused by decreased voluntary motion
-Iatrogenic disorders…brought on by medical intervention… “physician induced”…tardive dyskinesia (involuntary movement syndrome caused by certain psychotropic drug use, steroids, etc.)
Secondary (All the above can happen and cause below to happen which can lead to decreased voluntary motion):
-Spasticity
-Muscle weakness
-Pain: restricts motion
-Emotion: anxiety, depression… decreased
flexibility/activity
-Edema
-Immobility
-secondary problem… scar tissue, shortening
Feeling that is elicited when joint is brought through the entire available range of motion
End Feel. End-feel is normal when full ROM is achieved and the motion is limited by normal anatomical structures.
What are the three types of end-feel?
- Hard: bone on bone (olecranon process/fossa) with elbow extension
- Soft: elbow flexion… soft tissue opposition of biceps/supinator and radial wrist flexors
- Firm: firm or springy sensation that has some give, as in shoulder flexion
- End-feel is abnormal when movement is stopped by structures other than normal anatomy
It is important to know what before measuring ROM?
- General knowledge of typical ranges
- What is functional
- Specific knowledge regarding how client’s condition may affect range of motion
- Know precautions
T/F: When performing ROM testing, you should assess the more involved side first and assess distal to proximal
False! Assess less involved side first and assess proximal to distal
T/F: Therapist should always perform PROM testing before performing functional AROM scan
First perform functional AROM scan (ask client to move and observe) and if limitations observed, passively move part to its limit of motion
In PROM testing, if there are no passive limitations, but AROM limitations the problem is mostly likely…
Muscle strength!
If you find no passive limitations in PROM, you can then…
Measure AROM
Refers to that joint range that is essential to the normal performance of ADL without the use of AE.I.e. client seated, reach up to ceiling, out to side, forward, touch back of head (proximal to distal). This is an example of…
Functional AROM
May not want to have client actively move before you check range if…
Painful, motor control deficits (concern over biomechanics/stability), postural deficits
T/F: When assessing ROM, always observe compensations, posture, skin color changes, creases
True!
If you find limitation in PROM, then you should…
Palpate and place goniometer. Document “0 to…” . Note additional observations
ROM steps:
- Assess less involved side first
- Assess proximal to distal
- Ask client to move and observe…(Functional AROM scan)
- Therapist passively moves part to its limit of motion (if limitations observed during functional AROM scan)
-stabilize proximally, watch for pain
*Steps 3 and 4 can be considered screening for both
AROM and PROM. Can then decide at which joints
precise ROM measurement is indicated - If no passive limitations: problem is AROM=muscle strength. (May measure AROM)
- If limitation is present: palpate and place goniometer
- Goniometer: Place at starting alignment, then reexamine at ending alignment
- Document and note any additional observations
The most common method of documenting ROM is…
The “Neutral Zero Method” or “180-degree system”:
All joint motions begin at 0 degree and increase toward 180 degrees.
T/F: Joints in which ending position of one joint motion is starting position of opposite motion e.g., elbow flexion/extension require two sets of measurements
False. They only require one measurement
T/F: Joints in which starting position of both joint motions is the same (neutral/zero) e.g., wrist flexion/extension require two sets of measurements
True, yo!
T/F: To document ROM for hyperextension, you should document separately for clarity as 0 to X of hyperextension
True
What are some factors that may influence joint ROM?
age, sex, body structure, occupation, postural habits
T/F: ROMs that fall above the accepted functional ranges are those that the OT should deal with first
False. Ranges that fall below the accepted functional ranges should be dealt with first
Considerations/questions to think about when establishing treatment for ROM include:
Is loss of ROM causing pain?
Is there a consistent/progressive loss of ROM in the same joint(s)?
Is loss of ROM interfering with the use of “normal muscles?”
Is loss of ROM preventing client from doing an activity he/she might otherwise be capable of doing if loss of range could be alleviated?
Is loss of ROM interfering with the client’s ability to be cared for hygienically by hospital staff?
Does ROM have to be increased before client can be fitted with a piece of AE (w/c, hand splint, etc.)?
Is loss of ROM preventing client from doing an activity that he/she might otherwise be capable of doing if loss of range could be alleviated?
T/F: When reporting ROM, you should always report distal to proximal
False. Should report proximal to distal
When reporting ROM, you should always report each joint separately
False. If several joint ranges have similar measurements, group them together i.e., shoulder and elbow present with normal ROM; wrist flexion is 0-45 degrees after surgery. Address ROM and relate to function
Slight, Moderate, and Severe in reporting ROM
Slight: limitations are present, but client is able to function fairly well
Moderate: limitations are present, interfere with function but client can overcome with use of AE
Severe: limitations severely limit function, contractures present, difficult for client to function even with AE (lacks half or more of normal range usually available at joint).
What is the first step in assessing ROM?
Observe the client completing occupations/functional activities. Is the observed range of motion and/or strength sufficient for the client’s functional needs? If yes, no further assessment needed. If no, proceed to range of motion assessment and/or gross manual muscle testing assessment. From there, is the info is sufficient to write an appropriate intervention plan? If yes, no further assessment. If no, proceed with isolated muscle test
Decision Tree for ROM testing
- Observe the client completing occupations/functional activities
- Is the observed ROM and/or strength sufficient for the client’s functional needs? If yes, no further assessment
- If no, proceed to range of motion assessment and/or gross manual muscle testing
- Is the information sufficient to write an appropriate intervention plan? If yes, no further assessment
- If no, proceed with isolated muscle test.
