PT 515 Midterm 1 (Examination, ROM and Joint play)

Philosophy of BU DPT

• Empathetic Patient Centered Care

• Critical Thinking/Clinical Reasoning

• Evidence Informed Practice

• Experts at examination and integration of human
  movement
  

What is Empathetic Patient Centered Care

• Respecting person’s experience and listening to their POV, desires and goals

• NOT top-down

• NO judgment

• Relation w/ you + pt (it is unity in decisions and goals

Critical Thinking/Clinical Reasoning

• Acting upon the missing details

• knowledge + skills + character

• being curious

Experts in Examining Movement

Evidence Informed Practice

Engage with/interpret/implement research to advance the profession

• integrating the best research + clinical experience + pt opinions & expectations

Human Movement System

Movement to guides our clinical reasoning
▪ Task: what is the goal of the movement (stand up)
▪ Environment: conditions of the task
▪ Organism: the human condition

Movement Assessment

International Classification of Functioning, Disability and Health (ICF)

Body structure + fxns:

• physiological + psych functions of body systems

Impairments:

• problems in body fxn or structure that creates major deviation or loss

Activity limitations:

• difficulties of an individual in execution of a task or action by an individual

• (Restriction in Activities of Daily Living)

Participation restrictions:

• problems an individual experience in involvement in life situation

Environmental factors:

• phys, social, and attitudinal environment in which people live and conduct their lives

Step 1 of PT exam

Patient Interview

• Gather information about current condition

• Identify patient's beliefs and expectations about current health condition

• Identify patient's goals for physical therapy

• Establish therapeutic relationship with patient

  • This is where we initiate our collaboration
    

Basic Structure of PT exam

Step 2 of PT Therapy Exam: Movement Assessment

• Observation of mobility or patient engagement in environment/tasks:
  (MOVEMENT ASSESSMENT)

• Appraise movement quality and compare to expectations or
  knowledge of functional anatomy (Critical Thinking/Clinical
  Reasoning)

2 ways of assessing Joint mobility

ROM

• physiological joint (ostekinematic) motion

• examined when NO visible sufficient movement in function and suspect limited mobility

Joint play

• accessory movement (arthrokinematic) motion

• examined when there is abnormal ROM (too little or too much)

Range of Motion

• measure of bone motion/rotation (osteokinematics) in cardinal plane

  • parallel to plane around axis

• Sagittal plane

Sagittal plane of ROM

Flexion/Extension

• dorsiflexion/plantarflexion (ankle)

Axis: Medial/lateral aka horizontal

Frontal plane of ROM

Abduction/Adduction

• Radial/ulnar deviation(wrist)

• Inversion/Eversion (ankle)

• Sidebending (spine)

• Lateral Deviation (jaw)

Axis: Anterior/Posterior aka Anteroposterior

Transverse/Horizontal plane of ROM

Internal/External Rotation

• Pronation/Supination (forearm)

Axis: Vertical

• Through long axis of bone
  

Types of ROM

Passive (PROM aka ROM): measures total amount of available motion at the joint

• Physical therapist does movement

• Standard measurement of joint mobility

Active (AROM): measures how willing the individual is to move, some degree of strength

• neurological integration + individual

• NOT info on joint capacity, but tells us if pt can move

Indications (GO) and Contraindications/Precautions of examination ROM

Indications (GO)

• when joint mobility may contribute to individual’s activity or participation restriction

• for determining health well being of joint

• before measuring strength of muscle

Contraindications/Precautions (STOP)

• passive movement of joint will cause injury

• if limited by health condition (ex. Surgery, fracture)

Tools to measure ROM

• goniometer

• inclinometer (incline amt - used for spine + limb displacement)

• Accelerator

***they have Inter/Intra-rater reliability***

Goniometer

moving arm - is for mobile segment

stationary - non mobile segment

axis - joint bony part

Standardization of Practice

Standard Testing Position

• Maintain Moving Limb in the cardinal plane

• Stabilization of proximal segment

Size and Type of Goniometer

Boney Landmarks

Record Results:

• Include both a quantitative and qualitative component
  
  

ROM - Quantitative

Measurement in degrees

• 2 numbers always: Start and End position

• Normal ROM always starts at 0

Reliability

• +/- 5⁰ Standard Error of Measurement (SEM)

Validity

Range of Motion-Qualitative (NORMAL/TYPICAL)

Hard

• Think Bone…elbow extension

Soft

• Think soft tissue (adipose, muscle approx)…elbow/knee flexion, hip flexion
  

Firm

• Think Capsule….try MCP joint extension

• also ligament, muscle length, tendon

Range of Motion-Qualitative (ABNORMAL/ATYPICAL)

Empty (NOT safe)

• NOT getting to end feel,

• dislocation of joint or pt not wanting to go further

Boggy(“squishy”)

• inflammed joint
  

Crepitant

• crack feel
  

Springy

• muscle guarding or ligament abnormality
  

also ***any one of the normal end feels that is not supposed to be felt at that joint***

ROM - Standard Procedure

• Explain the test to the patient-using non-threatening language

• Position the patient in the starting position(Standard Test)

• Stabilize the proximal joint segment

• Passively move the joint through the ROM and determine the end-feel

• Eyeball the degrees of motion-vocalize your estimate

• Return the limb to the starting position

• Palpate the bony landmarks, align the goniometer and record starting position

• Move the limb passively through the ROM

• Re-palpate and align the goniometer

• Read the value on the limb and record the reading

Examination of Joint play

• motions of bones relative to other bones aka joint surfaces (Arthrokinematics)

• it is passive

Arthrokinematics

• Requires forces either passive (external) or muscle (internal)

• Constrained by anatomy and joint structure

• Axis of rotation of any joint partner is always within the center of the convex bone surface
  
  

Arthrokinematics (Treatment plane)

Treatment plane

• is parallel to the deepest part of concavity

• is perpendicular to the line running from the axis of rotation in the convex joint partner

Glide in athrokinematics

is always parallel to treatment plane

Arthrokinematics (Traction)

• applied perpendicular and away from treatment plane

• entire bone is moved for joint surfaces to be separated

When do we assess joint play

• when there is abnormal ROM

• it’ll assess capsular mobility, sensitivity to shear, load, and distraction

Indications (GO) and Contraindications (STOP) for Joint play assessment

Indications (GO):

• Make inference about joint function

• Determine the type of resistance between joint surfaces

• Determine any tissue injury or inflammatory process

• Determine level of patients pain/ tolerance to movement (doing movements to see if it provides relief or pain)
  

Contraindications (STOP):

• Fear on the part of the patient or therapist

• Red Flags including signs of neoplasm, fracture, or systemic disturbance (that prevents passive movement)

• Rheumatoid collagen disease (if untreated)
  

• There are more… you will learn as we get more into pathologies

What do we assess for in Joint play

• Available mobility of the capsule and supporting
  ligaments(glides, traction)

• Pain provocation

• Pain Alleviation

• muscle tension

Loose packed position v Closed packed position

Loose pack (RESTING):

• point in joint’s range where capsule + ligaments have least restraint to passive sliding

• least bony congruency + most lax

Closed pack:

• where the ligaments and capsule are maximally taut.

• usually (but not always) at the end of a joint’s ROM

• greatest joint stability, and most resistant to distraction forces that cause separation of the joint surfaces

• little or no joint play is possible

Joint Play Standard procedure

• Explain the test to the patient

• Position the patient comfortably to minimize muscle tension

• Stabilize the proximal joint segment with your stabilizing hand

• Grip the moving segment as close to the joint line as possible

• Position the patient in the resting position (loose pack) for the joint

• Perform the joint play assessment by moving the moving segment either parallel or perpendicular to the treatment plane and determine the end-feel

• Compare to the opposite side and determine normal, hypomobility, or hypermobility

  • compare to other limb

  • compare to historical normal if person has NO other limb

Joint play measurement

Qualitative:

• Normal-Motion: feels the same as the other side

• Hypomobile: Motion is limited compared to other side

• Hypermobile: Motion is excessive compared to the other side

Joint Play-Measurement (Descriptor)

Normal End/Feel

• firm

Abnormal End/Feel —> pain

• soft, hard, empty, baggy (squishy), crepitant, springy

Loose pack position, Treatment Plan for Tibiofemoral joint

Loose Pack Position: 30 dg flexion

Treatment Plane: Concave surface of the tibia.

Loose pack position, Treatment Plan for Patellofemoral joint play

Loose Pack Position: 0° of tibiofemoral flexion / extension.

Treatment Plane: Underside of the patella.

Normative values for Tibiofemoral ROM (ext + flex)

Flexion: 0-135 dgs

Extension: 0-10 dgs

Normal end feels for Tibiofemoral ROM (ext + flex)

Flexion: Soft/ Firm

Extension: Firm

Normal end feels for Femoroacetabular joint ROM (ext + flex + IR + ER + ABD + ADD)

Flexion: Soft / Firm

Extension: Firm

Internal Rotation: Firm

External Rotation: Firm

Abduction: Firm

Adduction: Soft / Firm

Normative values for Femoroacetabular Joint ROM (ext + flex + IR + ER + ABD + ADD)

Flexion: 0-120 dg

Extension: 0-30 dg

Internal Rotation: 0-45 dg

External Rotation: 0-45 dg

Abduction: 0-45 dg

Adduction: 0-30 dg

loose pack and closed pack positions for femoroacetabular

loose pack:

• 30 dg flexion, slight ER, 30 dg abduction

closed pack:

• full extension, slight IR, slight abduction

loose pack and closed pack positions for humeroulnar joint

loose pack: 70 dg flexion, 10 dg supination

closed pack: full extension, full supination

loose pack and closed pack positions for metacarpophalangeal joint

loose pack: slight flexion

closed pack: full extension