ROM

ROM types

• passive

  • passive accessory

  • passive physiologic

• resistive

• Active

ROM assesses ______

• excursion (range)

• end feel (resistance)

• reactivity (pain)

Excursion

• hyper/hypo

end feel

• quality (SFMA)

• type

  • normal/abnormal

reactivity

• is there pain?

• comparable signs?

Which types of tissue can be assessed during AROM?

• contractile

• joint capsule

• nerve

• noncontractile

contractile

• joint capsule - passive accessory

• nerve - neurodynamics, nerve glides

• non-contractile - depends on tissue

AROM limits by physiological barriers

• contractile tissue length

  • antagonist muscle tightness

• nerve length

• non-contractile tissue (joint capsule, ligaments, skin, fascia)

AROM movement analysis

observe how pt moves

• willingness to move

• does movement increase specific pain? - comparable signs?

• where is the pain and when does it occur?

  • painful arc

• how easy is it aggrevated?

  • how quickly does it settle

• pattern

  • capsular vs noncapsular

• compensatory motion

  • quality: effort/rhythm/aberrant movements

• joint noise - clicking/popping

PROM - physiologic

• osteokinematic - bone on bone

• rolling

• volitional (muscles produce these motions)

  • flex/ext

  • abd/add

  • IR/ER

PROM accessory

• arthrokinematic - joint motions

• gliding

• spinning

• NOT volitional

  • glides

  • distractions

  • spins

PROM assessment

observe:

• does movement increase pain level?

  • when/where does pain occur

  • comparable signs

• pattern

  • capsular vs noncapsular: physiological and accessory

• end feel - over pressure

  • quality

• joint noise

PROM end feel

• performed through entire ROM

  • NO muscle contraction

• overpressure at end range

  • end feel

    • physiologic: easy → medium → hard

    • accessory: small → medium → large

  • reactivity

Which of the following end feels are considered normal?

• boggy

• bony

• muscle spasm

• capsular

• empty

• muscular

• soft tissue

• springy

• bony

• capsular

• muscular

• soft tissue

abnormal end feels

• muscle spasm

• boggy - blanching b/c fluid

• springy - rebounds, lots of muscle tension

• empty - usually bad

When performing a muscle length assessment, the point at which the examiner feels the initial onset of tension is known as _____

R1

R1

• first resistance felt

• occurs after you have “taken out all the slack”

R2

• true end feel

• passive resistance of associated structures

Pain prior to R1

high reactivity

pain at R1

• moderate reactivity

• no overpressure yet

pain at R2

• low reactivity

• at full ROM & overpressure

Which of the following scenarios would be considered highly reactive?

• pain during PROM at end range shoulder flexion with overpressure

• pain during passive ROM at 120 deg shoulder flexion

• pain with AROM at 170 deg

• pain during AROM at 90 deg of abduction no pain at end range

• pain during passive ROM at 120 deg shoulder flexion

physiologic ROM properties

• assessing volitionally controlled motions

• overpressure at end range

• measured via goniometer

  • flex/ext

  • abd/add

  • IR/ER

which of the following is correct?

• AROM>PROM

• AROM=PROM

• PROM>AROM

PROM>AROM

• b/c overpressure in PROM

Normal physiological PROM

• PROM>AROM

• no joint noise

• muscle relaxation

• pain free

• normal accessory motion

Dysfunctional physiological PROM

• PROM = or < AROM (b/c fear, guarding)

• joint noise (labrum, intra-articular structures)

• muscle guarding

• painful

• abnormal accessory motion

Which of the following combinations of motions occur when the tibia moves on the femur during knee extension?

• roll & glide occur in same directions

• roll & glide occur in opposite directions

roll & glide occur in the same directions - concave on convex

PROM - accessory motion parameters

• identify treatment plane

• open packed position - where there is least amount of resistance in the joint

• patient relaxed

• appropriate stabilization

• PT contact and force

PROM - accessory motion

• treatment plane - open packed position

• glides - parallel

• distraction - perpendicular

Accessory motion: assessment vs intervention

• assessment: small, medium, large

• intervention: grades 1,2,3,4

• paris scale/maitland mobilizations

Maitland - Grade I

small amplitude rhythmic oscillating mobilization in early range of movement

Maitland - Grade II

large amplitude rhythmic oscillating mobilization in mid-range of movement

Maitland - Grade III

large amplitude rhythmic oscillating mobilization to point of limitation in range of movement

• mid → end range

Maitland - Grade IV

small amplitude rhythmic oscillating mobilization at end range of movement

Maitland - Grade V

small amplitude, quick thrust at end of range of movement

• thrust manipulation

Which of the following types of interventions is MOST appropriate for a patient whose joint mobility is assessed as 5/6?

• bird dogs

• contract relax stretching for 5 repetitions

• grade 5 manipulations

• patient presents with normal joint mobility

• bird dogs - stability exercise

muscular end feels

• rubbery

• firm

• elastic

• ex: achilles, scap

Capsular end feels

• firm

• leathery

leathery end feel

• like stretching an old belt - some give but not elastic

• ex: PIP

muscle spasm end feel

• abnormal

• abrupt, sudden

• rebound: possible guarding

• often painful

springy end feel

• abnormal

• intra-articular issues

• similar to soft tissue

• prior to expected end range

boggy end feel

• abnormal

• soft, mushy

empty end feel

• abnormal

• pain

• no resistance appreciated

• may be serious issue

which of the following scenarios are considered an abnormal assessment during over pressure?

• soft end feel when assessing knee flexion

• firm end feel with wrist extension

• bony end feel with knee extension

• rubbery end feel with elbow extension

• bony end feel with knee extension (should be firm)

• rubbery end feel with elbow extension (possibly from bicep contracture)

atypical end feel

• if end feel does not match expected end feel

• if end feel occurs before expected range

• results can be perceived as abnormal or atypical

• ex: elbow flexion

  • normal end feel: soft tissue

  • atypical end feel: bony

capsular pattern

• consistent pattern of limitation

  • entire capsule is involved

• loss of motion

  • identify compensations during AROM

  • confirm with PROM

  • specific to that joint

  • usually not acute

• ratio of motion loss

• ex: frozen shoulder

noncapsular pattern

• limitation does not correspond to classic capsular pattern

• specific portion of capsule is involved

• intra-articular issue

• extra-articular issue

capsular pattern present

• most likely fibrotic capsule

  • inflamed, thickened, contracted

capsular pattern not present

• possibly isolated adhesion

  • results from AROM help differentiate

  • continue to PROM & RROM

Which of the following conditions would most likely cause a noncapsular pattern of limitation?

• adhesive capsulitis of the glenohumeral joint

• carpal tunnel syndrome

• labral tear of the hip

• sciatic nerve irritation under the piriformis

• labral tear of the hip

• sciatic nerve irritation under the piriformis

• both are acute, capsular patterns are more chronic

which of the following characteristics are being assessed during RROM?

• end feel

• excursion

• pain

• strength

• pain

• strength

RROM

• not mmt

• not intended to score strength

RROM - strong & pain free

no lesion of contractile tissue

RROM - strong & painful

local, minor lesion of muscle and/or tendon

RROM - weak & painful

more severe lesion of muscle and/or tendon

RROM - weak & painfree

possible rupture of muscle and/or tendon

RROM technique

• isolate movement

• isometric

• gradually increase force (stop at pain)

RROM procedure

• isolate movement

  • one joint at a time

• position

  • patient comfort

  • mid-range

    • not open-packed

    • not closed-packed

• Isometric

  • no movement

  • “meet my resistance, don’t let me move you”

RROM application

• increase resistance slowly

• begin with light resistance

• gradually build

• work to maximal contraction

  • unless pain is produced