Draping and ROM

Draping considerations

• trauma-informed care

• culturally sensitive care

• covering with clinical attire

• covering with linens

• position-specific draping

• maximizing patient comfort and dignity

appropriate draping provides:

• access to areas of body for exam or treatment

• protection of pt.'s modesty and dignity

• pt. comfort and warmth

• protection of vulnerable sites

• protection of pt.’s clothing

providing trauma-informed care

• exposure may trigger intense emotional reactions

• not always possible to know which pts have a history of abuse or trauma

for best outcomes: trauma informed care

• good communication skills

• informed consent

• respect for boundaries

• active patient involvement

• monitoring for signs of discomfort throughout the session

cultural sensitivity

members of cultures may:

• have clothing that should not be removed

• find a hospital gown extremely embarrassing

• prefer a same-gender healthcare provider

maximize comfort and dignity

• communicate clearly with the patient

• provide privacy for changing into and out of garments

• include a chaperone who is the same gender as the patient when appropriate

covering the patient: clinical attire

• gowns… can cover opening in back with another gown on top

• pants and tops

  • drawstring tie pants

  • appropriate size

covering the patient: linens

• expose only one area at a time

• layering linens can help minimize exposure

• secure edges

• dispose of soiled linens appropriately

capacity for mobility

1. joint ROM

2. involves bones, muscles, ligaments, tendons, cartilage, and surrounding soft tissue

3. ROM is NOT stretching

joint ROM

assessment: amount of movement available between two bony levers

treatment = therapeutic intervention of moving a joint through its available range

ROM vs stretching

ROM = moving what you can that’s available

stretching = moving past your ROM to stretch tissues

what does ROM require

1. osteokinematics

2. arthrokinematics

Osteokinematics

• movement of one bone in relation to another

• a long bone moving around a joint axis

• ex) elbow flexion

Arthrokinematics

motions within the joint that are necessary for osteokinematics to occur

sagittal plane movement

flexion and extension

frontal plane movement

abduction and adduction, lateral flexion of the spine, wrist ulnar and radial deviation

transverse plane movement

internal and external rotation, spinal rotation, forearm supination and pronation

triplanar motion

foot inversion and eversion

diagonal ROM

• borrowed from proprioceptive neuromuscular facilitation (PNF)

• one component from each cardinal plane

  • flexion/extension

  • abduction/adduction

  • internal/external rotation

• named for the ending position of the proximal joint

• functional motion

muscle excursion or length

if a muscle crosses more than one joint (bi-articular)

• lengthen over both joints simultaneously

  • assess muscle range

    • hip flexion is limited by hamstring tightness

• slacken over one joint

  • assess joint range

    • flex the knee to get more hip flexion

PROM

= passive range of motion

• external force moves the joint

AROM

= active range of motion

• internal muscular force moves joint

AAROM

= active-assisted range of motion

• requires external force through part of the range

types of joint ROM

1. PROM

2. AROM

3. AAROM

benefits of PROM

• decreases local edema

• stimulates tissue healing

• prevents adhesions and joint stiffness

benefits of AROM

• decreases local edema

• stimulates tissue healing

• prevents adhesions and joint stiffness

• helps maintain health, integrity, and elasticity of tissues

• increases sensory input

• promotes tissue alignment

• “skeletal muscle pump” enhances local circulation

when to use PROM:

• assessment technique

• intervention when pt’s own muscle force cannot produce safe, effective joint movement

• intervention when active muscle contraction would be harmful

• educate pt on correct movement before AROM

PROM contradictions

• without consent

• when motion will interfere with tissue healing

• in presence of extreme muscle guarding

• when strong muscle guarding is accompanied by increased pain

PROM precautions

• temporarily increases pt’s pain

• elicits undesired muscle tone

SINSS

characteristics that inform clinical judgement regarding use of PROM

• Severity

• Irritability

• Nature

• Stage

• Stability

stretching to increase ROM

• passive static stretching

• dynamic stretching

• ballistic stretching

• PNF stretches

PROM dosage

• clinically determined

• higher frequencies for early tissue healing

• neuro conditions:

  • slower repetitions with 20 to 60 second hold at end range

  • if PROM increases muscle tone

AROM contradictions

• without consent

• when motion will interfere with tissue healing

• in presence of extreme muscle guarding

• when strong muscle guarding is accompanied by increased pain

• pain throughout motion and/or persisting after the activity

• development of dysfunctional muscle tone

• cardiac distress

• other adverse exercise responses (inflammation, effusion, etc)

AROM precautions

• temporarily increases pt’s pain

• elicits undesired muscle tone

• generates undesired movements

• physiological demands increase patient risk

AROM dosage

• determined by patient responses

• watch for:

  • fatigue

  • pain

  • changes in quality or accuracy of movement

  • changes in vital signs

choosing a straight plane of motion

• more specific

• allows isolation of movements

• appropriate for examination and treatment

choosing a diagonal plane of motion

• closer to daily functional movement patterns

• not appropriate for examination

  • no isolation of movementss

ROM procedure: body mechanics

• have pt. close to you

• stand with a wide base of support

• face in the direction of movement

• if supervising AROM

  • PT position to allow full AROM

  • while monitoring activity and guard as needed

ROM Procedure

• stabilize the proximal segment

• use a lumbrical grip

• control passive movements centrally

• direct active movements distally

• AMAP/ANAP

• use a systematic approach

PROM procedure

• move through range slowly and with hold at end range

• light overpressure at end range as appropriate

• don’t stretch a flaccid muscle

AROM procedure

• instruct patient in movement

  • demonstrate movement

  • attempt on uninvolved side first

• watch for movement form and quality

• monitor pt’s response to activity

• adjust as needed

observation and findings of ROM

• quantity of movement

• quality of movement

• patterns of movement

• end feels

• pain

• muscle tone, spasms, guarding

• audible sounds

patterns of movement

1. joint capsular patterns

2. noncapsular patterns

3. poorly coordinated movements

Joint capsular patterns

limitations from capsular structures: joint capsule, synovial membrane, arthritis

Noncapsular patterns

limitations from noncapsular structures: ligaments, meniscus, fracture

End feels

determined by applying light overpressure at the end of the joint range

1. soft

2. firm

3. hard

soft end feel

elbow flexion, stop when you hit your bicep —> tissue hitting other tissue

firm end feel

muscles are tightening up/stretching —> ankle dorsiflexion

hard end feel

bony block —> elbow extension, bone stops you from continuing to extend

abnormal end feel

one that is inappropriate for that joint

“empty” end feel

• range stopped because of pain

• always abnormal

which ROM typically yields a larger quantity of motion?

PROM

self-range of motion

use equipment or other extremity to perform PROM or assist in AAROM

typical progression of ROM

PROM —> AAROM —> AROM