Week 5: ROM MMT Flashcards
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.
The biomechanical
Research shows that improvement of biomechanical components alone does not necessarily improve engagement in occupation.
The biomechanical assumption
Does not provide a lens for understanding “occupational” problems that do not result from musculoskeletal problems…cannot be used in isolation.
The biomechanical
Movement by muscles surrounding the joint
Active Range of Motion (AROM)
Movement by an external force
Passive Range of Motion (PROM)
amount of joint range necessary to perform essential ADLs and IADLs without equipment
Functional Range of Motion
ROM limitations?
Trauma: to joint structures, muscle sprain, cartilage damage, tendon laceration… etc.
Immobilization… secondary problem… scar tissue, shortening…
Joint disease: arthritis, hemophilia (bleeding into the joint), osteochondritis (irreg. blood supply to jt….aka avascular necrosis)
Nutritional, etc.: chronic renal disease -> fractures -> decreased ROM (fractures are secondary problem)
Tumors: any structure of joint…
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.)
Emotion: anxiety, depression… decreased flexibility/activity
Pain: restricts motion.
Defined as the normal resistance to further joint motion
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
Steps to ROM
- Assess less involved side first.
- Assess Proximal to Distal…
- Ask the client to move and observe… (Perform Functional AROM Scan)
- Therapist passively moves part to its limit of motion (if limitations observed during functional AROM scan)
- Stabilize proximally
- Watch for pain! - If no passive limitations: Problem is AROM = muscle strength. (May measure AROM)
- If a limitation is present: Palpate and place goniometer
- Goniometer: Place at starting alignment, then re-examine at ending alignment…
- Document (neutral zero method)
Neutral Zero Method
Most common
Recommended by Committee on Joint Motion of the American Academy of Orthopedic Surgeons
All anatomical positions/given starting positions are recorded as 0
Measurement is taken from the stated starting position to stated end position (zero to 150 degrees elbow flexion)
If client cannot achieve starting position, record as such:
with elbow flexion/extension: starting # indicates limitation in extension
wrist flexion ROM
Joints in which starting position of both joint motions is the same = neutral/zero . Two sets of measurements
elbow flexion/extension ROM
Joints in which ending position of one joint motion is starting position of opposite motion. One set of measurements
Factors that might influence joint ROM
age, sex, body structure, occupation, postural habits
Functional ROM:
: refers to that joint range that is essential to the normal performance of ADL without the use of AE.
After ROM assessment has been completed and evaluation form is filled out,
take note of any limitations which are “significant” or which interfere with function or are producing deformity/causing pain…
Address ROM and relate to function:
Due to severe flexion contractures of the MP (80-90 degrees) and PIP (70-110) and DIP (20-90) joints, the client is unable to extend fingers to grasp objects that are larger than two inches in diameter.”
limitations are present, but client is able to function fairly well
Slight ROM
: limitations are present, interfere with function but client can overcome with use of AE
Moderate ROM
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).
Severe ROM
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 ROM assessment and/or gross MMT assessment.
method for measuring tension in a muscle/group of muscles
MMT
Tension-producing capacity of a muscle/group of muscles; “demonstrating a degree of muscle power when movement is resisted
Strength
MMT based on the following criteria
evidence of muscle contraction
amount of range muscle can move part through
resistance – including gravity
greatest amount of tension a muscle can generate and hold only for a moment
MVC: Maximum Voluntary Contraction
MVC – maximum voluntary contraction…what happens if a muscle (group) contracts beyond 15-20% MVC?
Blood flow decreases
Causes shift to anaerobic metabolism
Limits duration of contraction
Limitation is signaled by symptoms of muscle fatigue
Conditions Resulting in Muscle Strength Limitations?
Lower motor neuron disorders: peripheral neuropathies, peripheral nerve injuries… Spinal cord injury Guillain-Barré syndrome Cranial nerve dysfunction Muscle diseases: muscular dystrophy, myasthenia gravis… Neurological conditions: LMN with paralysis (Can help diagnose) UMN with selective control only!
T/F MMT should only be done with individuals who have selective, isolated movements…
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True
Manual Muscle Testing:Precautions
Inflammation or pain in region Dislocation or unhealed fracture Recent surgery Myositis ossificans Bone carcinoma/fragile bone condition
Gross Strength Screening?
Examination of medical record…
Observation of the client entering the clinic and moving about
Observation of the client performing functional activities…remove an article of clothing, shaking hands, etc.
Performance of a gross check of bilateral muscle groups (similar to AROM Scan)
Types of muscle testing?
a. Gross Strength Screen
1. Screen strength of muscle groups (a motion)
Indication: should I perform a manual muscle test?
b. Manual Muscle Testing (Individual or Group)
1. Test strength of each individual muscle
Indications: SCI/PNI
- Test strength of muscle groups with similar function
Indications: general strength, orthopedic conditions, arthritis, etc.
c. Functional
1. Test strength to perform certain functions
Indications: Resistance not allowed, assessed through activity
Functional MMT?
want to see if problem with various activities exists…if so, will be targeting for intervention.
Don’t look at muscles/groups, per se. ***cannot measure muscle endurance, motor control or the client’s ability to use the muscles for functional activities
Caution… may be other reasons why client cannot perform…depression, motivation, environment, pain
Example: perform various activities they need to do = pick up a mug of coffee…
NORMAL STRENGTH depends on:
age gender lifestyle muscle size and type and speed of contraction effect of previous training joint position during muscle contraction time of day, temperature, and fatigue
Be mindful regarding factors influencing testing…
Interest and cooperation of patient Experience and tone of voice of tester Posture Fatigue Ability to understand directions Therapist’s definition of muscle grades Test positions
Manual Muscle Test:Specific Procedures
- Determine PROM = “Available range”
- Assess Proximal to Distal…
- Position patient to move (motion) against gravity
Test all muscles in one position before changing position. - Stabilize proximal attachment
- Ask patient to move and observe…
- If able to move through full available range against gravity: Apply resistance on the distal end of moving part at the end of the available range**…
Fair (3), Fair + (3+), Good (4)
Normal (5) - If unable to move through available range: Position with gravity eliminated (decreased).
- If able to move through full available range in gravity-eliminated: Apply resistance at distal end of moving part…
Poor + (2+) Poor (2) - If no motion: palpate prime mover
Tension = Trace grade (1)
No Tension = Zero grade (0)
can complete a full range of motion against only the resistance of gravity…additional resistance, however mild, causes the motion to break.
Grade 3 (Fair)
: takes minimal resistance
Grade 3+ (Fair +
able to complete full range of motion against gravity and can tolerate strong resistance without breaking the test position…”gives” or “yields” to some extent at the end of its range with maximum resistance.
Grade 4 (Good):
can maintain end-point against maximum resistance.
Grade 5 (Normal):
If unable to move through available range…
Position with gravity eliminated (decreased).
If able to move through full available range in gravity-eliminated:
Apply resistance at distal end of moving part…
Takes minimal resistance = Poor + (2+)
Takes no resistance = Poor (2)
Takes minimal resistance gravity eliminated
Poor + (2+
Takes no resistance gravity eliminated
Poor (2)
no movement…can detect visually or by palpation some contractile activity in one or more of the muscles that participate in the movement being tested…or a tendon pops up or becomes tense
Trace grade
Reporting Muscle Strength
Take note of areas that indicate a loss in muscle strength and decreased ability to perform occupation
Take note of grades below F+
Be as concise, accurate, and meaningful as possible with report
Report proximal to distal
Group together muscles with similar grades
Muscle strength - muscle grade is in G (good) range (4-5)
slight
muscle grade is in the F to F+ range 3
moderate
muscle grade is below F 2
severe
T/F: Passive is usually a reflection of muscle strength
False. Active range is usually a reflection of muscle strength
T/F: Passive range determines “available range”
true
T/F: Manual muscle test indicates muscle strength
true
T/:F If client can NOT go through FULL AVAILABLE RANGE of motion ACTIVELY, go to gravity-eliminated.
True
