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Functional Assessment in OT Study Notes

Scope and Purpose of Functional Assessment in OT

  • Define functional assessment in Occupational Therapy (OT) as a process to evaluate how impairments affect a patient’s ability to perform daily activities and participate in life roles.
  • Objectives covered in the lecture:
    • Determine presence or absence of impairments involving muscles, bones, and related structures.
    • Identify the specific tissues causing impairment.
    • Help formulate therapeutic goals, expected outcomes, and intervention plans.
    • Determine the orthotic and adaptive equipment needed for functional daily living.
    • Assess the effectiveness of rehabilitation, medical, or surgical management.
    • Motivate the patient and engage them in the recovery process.
  • Emphasis on linking assessment outcomes to treatment planning and patient engagement.

Examination Procedures in Functional Assessment

  • Patient history and interview
  • Vital signs
  • Mental status
  • Observations/inspection
  • Palpation
  • Anthropometric characteristics:
    • Extremity circumference
    • Length measurement
  • Range of motion (ROM) assessment:
    • Measurement of ROM
    • Active Range of Motion (AROM) test
    • Passive Range of Motion (PROM) test

Musculoskeletal Joints: Definitions and Classifications

  • Joint (articulation): the junction between two or more bones or parts of bones in the skeleton.
  • Types of joints:
    • Immovable joints (synarthroses)
    • Slightly movable joints with limited movement (amphiarthroses)
    • Freely movable joints (diarthroses) permitting various movements

Degrees of Freedom (DOF) in Joints

  • Uniaxial (one DOF): movement in one plane (e.g., ankle joint allows only flexion and extension).
  • Biaxial (two DOF): movements in two planes (e.g., knee joint allows flexion/extension and medial/lateral rotation of leg on thigh).
  • Multiaxial (three DOF): movement around horizontal, transverse, and sagittal planes (e.g., hip and shoulder joints).

Terminology for Joint Motions

  • Flexion: decrease in the angle between two bones heta_{flex} o 0^ o ext{(decrease in angle)}
  • Extension: increase in the angle between two bones
  • Abduction: movement away from the midline
  • Adduction: movement toward the midline
  • Rotation: movement around an axis (inward/medial or outward/lateral)
  • Circumduction: distal end moves in a circle while proximal end remains stationary
  • Lateral flexion: bending sideways
  • Plantar flexion: pointing the foot downward
  • Dorsiflexion: bending the foot upward toward the tibia
  • Pronation: palm faces downward
  • Supination: palm faces upward

Joint Movements by Region (Possible Movements)

  • Shoulder: Flexion & extension, abduction & adduction, internal & external rotation, circumduction
  • Elbow: Flexion & extension
  • Radio-Ulnar: Pronation & supination
  • Wrist: Flexion & extension, abduction & adduction, circumduction
  • Spine: Flexion & extension, lateral flexion, internal & external rotation
  • Hip: Flexion & extension, adduction & abduction, internal & external rotation, circumduction
  • Knee: Flexion & extension, internal & external rotation
  • Ankle: Dorsiflexion & plantarflexion

Anatomical Directional Terms

  • Anterior: toward the front
  • Posterior: toward the back
  • Distal: away from the origin
  • Proximal: near the origin
  • Superior: above
  • Inferior: below
  • Lateral: away from the midline; towards the sides
  • Medial: toward the midline; toward the center

Anatomical Planes and Axes

  • Planes (imagined flat surfaces for describing sections of the body):
    • Sagittal plane: divides body into left and right portions; flexion and extension occur in this plane.
    • Frontal (coronal) plane: divides into anterior and posterior portions; abduction and adduction occur in this plane.
    • Horizontal (transverse) plane: divides into superior and inferior portions; rotational movements occur in this plane.
  • Axes (lines about which movement occurs, perpendicular to planes):
    • Sagittal axis
    • Frontal axis
    • Horizontal axis

Movement and Planes/Axes Associations

  • Flexion & extension: occur in the sagittal plane around the frontal axis.
  • Abduction & adduction: occur in the frontal plane around the sagittal axis.
  • Rotation: occurs in the horizontal plane around the longitudinal axis.
  • Movement sequence examples (sagittal plane around frontal axis): flexion, extension, hyperextension, with possible dorsiflexion/plantarflexion terms noted in certain joints.
  • Movement in the frontal plane around the sagittal axis includes actions such as adduction, abduction, radial deviation, ulnar deviation, inversion, eversion, and lateral flexion.
  • Movement in the transverse plane around the vertical axis includes external rotation, internal rotation, horizontal abduction/adduction, rotation to the right/left, and pronation/supination.

ROM Measurement: Goniometry and Tools

  • Goniometry definition: technique to measure joint range of motion; derived from Greek words gonia (angle) and metron (measure).
  • Universal Goniometer: main instrument to measure joint ROM angles; features a moving arm, a stationary arm, and a fulcrum; scale from 0^ o180^ frac{ }{ ext{deg}}.
  • Other tools:
    • Inclinometer: measures angles, often gravity-referenced; bubble/needle indicates degrees; can be mounted on frames (e.g., CROM, BROM) or handheld.
    • Tap measurement: used for the spine.
    • Ruler & caliper: used for TMJ assessment.
    • Radiographs and photographs: supplementary ROM assessment tools.

Factors Affecting ROM

  • Internal influences:
    • Type of joint
    • Bony structures that limit movement
    • Elasticity of muscle tissue, tendons, ligaments, and skin around the joint
    • Ability of a muscle to relax and contract to achieve the greatest ROM
  • External influences:
    • Temperature (warmer temperature increases flexibility)
    • Time of day (flexibility typically greater in the afternoon)
    • Age (pre-adolescents more flexible than adults)
    • Gender (females generally more flexible than males)
    • Clothing or equipment restrictions
    • Types of motion (active vs passive)

PROM vs AROM: Differences and Implications

  • PROM is typically slightly greater than AROM because there is end-range motion at the very end of the range not under voluntary control.
  • The extra range in PROM helps protect joint structures by absorbing extrinsic forces.

AROM vs PROM Tests: What They Reveal

  • PROM: performed by therapist; reflects joint integrity rather than muscle integrity.
  • AROM: performed by patient; reflects muscle integrity rather than joint integrity.
  • Pain during AROM often indicates issues with contraction or stretching of contractile/non-contractile tissues.
  • Pain during PROM often indicates a problem within the joint itself.

End Feel: What the Therapist Feels at End Range

  • End feel: sensation at the end of passive ROM indicating tissues that limit movement; can be normal (physiological) or abnormal (pathological).
  • Normal End Feel (Physiological) types:
    • Hard (bony): brief, abrupt stop; painless (e.g., elbow extension; knee extension)
    • Soft (soft tissue approximation): soft compression of tissue (muscle); e.g., knee and elbow flexion
    • Firm (soft tissue stretch): firm or springy with slight give; e.g., dorsiflexion with extended knee (gastrocnemius); also described as capsular stretch end feel
  • Abnormal (Pathologic) End Feels:
    • Hard (bony): abrupt hard stop or bony grating; may involve loose bodies, degenerative joint disease, dislocations, or fracture
    • Soft (boggy): synovitis or soft tissue edema
    • Firm (leathery end feel, capsular stretch): springy end feel with some give due to muscular, capsular, or ligamentous shortening
    • Springy Block (internal derangement): rebound indicating internal derangement (e.g., knee with torn meniscus)
    • Empty end feel: no sensation before the end of passive ROM due to pain; may occur with abscess, acute bursitis, or joint inflammation; Spasm (protective): hard sudden stop with pain suggesting acute or subacute arthritis or severe active lesion

ROM Measurement Instruments and Procedures

  • Common instruments:
    • Universal Goniometer: primary instrument for measuring joint ROM
    • Inclinometer: second instrument for ROM measurement
    • Tap measurement: spine-specific
    • Ruler & caliper: TMJ assessment
    • Radiographs and photographs: supplementary
  • Goniometer specifics:
    • The goniometer has a moving arm, stationary arm, and a fulcrum.
    • The fulcrum is placed over the joint being measured.
    • The stationary arm aligns with the inactive part of the joint; the moving arm aligns with the moving segment.
    • Scale typically ranges from 0^ o180^ frac{ }{ ext{deg}}.
  • Inclinometer specifics:
    • Contains a circular, fluid-filled disk with a bubble or weighted needle indicating degrees on a protractor scale.
    • Calibrated to gravity; starting position is consistently identified due to gravity reference.
    • Sometimes mounted on a frame (e.g., CROM for cervical ROM, BROM for back ROM).

Cervical Range of Motion (CROM)

  • Mentioned as a specific inclinometer application for cervical ROM assessment; often implemented in clinical settings with dedicated frames.

Validity and Reliability of ROM Measurements

  • Validity: whether the measurement truly reflects what it is supposed to measure (i.e., true joint ROM); validity can decrease due to poor stabilization during measurement.
  • Reliability: consistency and repeatability of measurements across trials and/or testers.
    • Intratester reliability: the same tester on different occasions; acceptable measurement error often < 5^ frac{^ ext{o}}{ ext{deg}}
    • Intertester reliability: different testers; measurement error may be greater than 5^ frac{^ ext{o}}{ ext{deg}}
  • To maximize reliability:
    • Use the same goniometer
    • Maintain consistent positioning
    • Follow the same procedure
    • Involve the same examiner

Summary Takeaways

  • ROM assessment via AROM and PROM provides complementary information about muscle integrity and joint integrity, respectively.
  • End feels guide the clinician in distinguishing between normal and pathological limitations.
  • Accuracy and consistency in ROM measurement depend on instrument choice, patient positioning, and standardized procedures.
  • Understanding planes, axes, and directional terms is essential for accurate description of movements and for documenting ROM findings.
  • ROM measurements are influenced by internal and external factors, including temperature, time of day, age, gender, and clothing.