DPT6090: Intro to Clinical Measurement

DPT6090: Intro to Clinical Measurement - Week 1

Course Overview

• DPT6090: Intro to Clinical Measurement - 2025
• Course To-Do's:
  • Introduction to the course.
  • Introduction to goniometry.
  • Lab this week:
    • Swelling & Leg Length Discrepancy (LLD).
    • Shoulder Range of Motion (ROM).
  • Lab next Tuesday:
    • Shoulder & Elbow ROM.
• Instructor Goals:
  • Develop observation skills before using measurement tools.
  • Focus on clinical reasoning for ROM or strength tests rather than rote memorization.
• Office Hours:
  • Mondays, 12:00 PM - 12:50 PM or by appointment.
• Course Objectives:
  • Reliability and validity of measurement.
  • Locate and palpate major landmarks for accurate assessment.
  • Identify functional joint ROM for Activities of Daily Living (ADLs).
  • Apply and document goniometry to all joints correctly and effectively.
  • Identify functional strength for ADLs.
  • Apply and document Manual Muscle Testing (MMT) to all major muscle groups correctly and effectively.
• Course Style:
  • Psychomotor skills course with hands-on practice and learning.
  • Independent learning of the basics.
  • Faculty guidance with minimal lecturing.
• Course Coverage: Measurement
  • Edema.
  • Leg Length.
  • ROM & Flexibility.
  • Strength.
  • Sensory.
  • Palpation.
• Visual Schedule:
  • Week 1: Intro, Edema, LLD.
  • Week 2: Upper Extremity (UE) ROM.
  • Week 3: UE ROM.
  • Week 4: Lower Extremity (LE) ROM.
  • Week 5: LE & Spine ROM.
  • Week 6: Exams.
  • Week 7: UE MMT.
  • Week 8: UE MMT.
  • Week 9: Sensory Testing & Alternatives to MMT.
  • Week 10: LE MMT.
  • Week 11: LE & Spine MMT Dress Rehearsal.
  • Week 12: Mock Practicals.
  • Week 13: Exams.
• Reading the Schedule:
  • Flexible schedule, content may be altered.
  • Week 1 topics: Goniometry, ROM, Flexibility, Edema, Leg Length Measurement.
  • Before class: Read the syllabus, get textbooks.
  • Instruction (5/15 9-11 am): Intro to course, Intro to Goniometry, Shoulder & Elbow Palpation & ROM.
  • Lab (5/15):
    • B: 1-3 pm
    • A: 3-5 pm
    • Topics: Intro to Goniometry, edema & leg length measurement.
  • Week 2 topics: UE Range of Motion.
    • Before class: Norkin & White Ch. 1-2, 4-5
    • Lab (5/20): Shoulder & elbow ROM
      • B: 1-3 pm
      • A: 3-5 pm
    • Instruction (5/22 9-11 am):
      • Wrist and hand assessment
  • Week 3: UE Range of Motion
    • Before class: Norkin & White Ch. 6-7
    • Instruction (5/29 9-11 am):
      • Quiz at the start of class
        • (Quiz over UE ROM, Intro to Goniometry, Edema, and Leg Length Measurement)
      • -UE ROM Cases; LE Palpation
    • Lab (5/29):
      • B: 1-3 pm
      • A: 3-5 pm
      • Wrist and Hand ROM
• Textbooks:
  • Measurement of Joint Motion: A Guide to Goniometry by Cynthia C. Norkin and D. Joyce White
  • Muscle Testing: Techniques of Manual Examination and Performance Testing by Daniels and Worthingham
• Assignments and Grading:
  • 5% Average Quiz Grade (4)
  • 5% Average Group Presentation (1)
  • 10% Screen Test Video ROM Assignment
  • 10% Screen Test Video MMT Assignment
  • 15% Written Exam 1
  • 15% Written Exam 2
  • 20% Practical Exam 1
  • 20% Practical Exam 2
• Group Presentations:
  • Purpose:
    • Practice communication of PT skills with patients and peers.
    • Reason through clinical applications of specific tests.
    • Reason through common substitutions of joint motions and muscle groups.
    • Develop exercise protocols specific to joints and muscle actions.
  • Format:
    • Up to 10 minutes.
    • Any medium.
    • Address the following prompts:
      1. Telehealth?: How would you measure this through functional movement and observation?
      2. Can’t attain gold standard: what other positions would you use?
         1. How would you account for the change in position?
         2. Different substitutions?
      3. Name and demo
         1. One AROM therapeutic exercise
         2. One PROM therapeutic exercise
  • Post response to prompts on the forum using photos, gifs, or memes.
  • Schedules:
    • 6/5: Groups A-1, A-2, A-3 (ROM)
    • 6/12: Groups A-4, A-5, A-6 (ROM)
    • 7/10: Groups B-1, B-2, B-3 (Strength)
    • 7/31: Groups B-4, B-5, B-6 (Strength)
• Screen Tests Video Assignments:
  • Submissions on Moodle (Individual).
  • ROM Video due by 6/15 at 11:59 pm.
  • MMT Video due by 8/3 at 11:59 pm.
  • Purpose:
    • To run through a full exam in one take.
    • To practice communicating on a 7th grade level with a client.
    • To constructively critique a peer.
  • Assignments Details:
    • 10% apiece.
    • Full body ROM & MMT.
    • Videotaped.
    • No prompting.
    • Minimize positional changes.
    • List of measurements posted.
    • Assessment Task
      • Assess the video of one peer
      • Complete a rubric for the peer
      • Submit the peer assessment rubric on Moodle
  • Grading:
    1. 75% = Peer’s feedback
    2. 20% =
       • Ave. grade of 6 random videos
       • Scored by 2 instructors
    3. 5% = reflection on activity and peer assessment
• Practical Exams:
  • Practical 1: ROM on 6/18 from 11 AM – 6 PM in student pairs
  • Practical 2: MMT on 8/6 from 9 AM – 5 PM With SP’s
  • Purpose:
    • To demonstrate swift recall of assessment procedures.
    • To practice communication with a patient on a 7th -grade level.
    • To demonstrate appropriate positioning and handling for testing.
    • To clinically reason through a common problem related to testing a patient.
• Syllabus Policies:
  • Respect for Self and Others.
  • Peers.
  • Photography and Videography Assignments.
  • Practical Exams.
  • Consent to touch.
  • Incidental Findings.
  • Lab Attire.
  • Kits & textbooks.
  • Practice
    • Self
    • Others
• Other Course Policies:
  • Individual needs: If you require accommodations.
  • Elon Writing Center.
  • Course Evaluation.
  • No phones.
• Visual Schedule (Repeated):
  • Week 1: Intro, Edema, LLD.
  • Week 2: UE ROM.
  • Week 3: UE ROM.
  • Week 4: LE ROM.
  • Week 5: LE & Spine ROM.
  • Week 6: Exams.
  • Week 7: UE MMT.
  • Week 8: UE MMT.
  • Week 9: Sensory Testing & Alternatives to MMT.
  • Week 10: LE MMT.
  • Week 11: LE & Spine MMT Dress Rehearsal.
  • Week 12: Mock Practicals.
  • Week 13: Exams.

Goniometry Basics

• Objectives:
  • Goniometry basics.
  • ROM.
  • End-feel.
  • Muscle length testing.
  • Instruments.
  • Positioning.
  • UE Palpation.
• Empty ROM Chart:
  • Includes Joint, Motion, Position, Stabilization, Axis (Stationary/proximal arm, Moving/distal arm), End feel, AAOS ROM norms, Common substitutions, Functional example, Plane of movement.

Goniometry

• Measurement of angles created at joints.
• Part of the examination of joints and surrounding soft tissue.
• Measures:
  • Active joint motion.
  • Passive joint motion.
  • Abnormal fixed joint positions.

Cardinal Planes & Corresponding Axes

• Sagittal Plane:
  • Motions: Flexion/Extension.
  • Axis: Medial-Lateral axis.
• Transverse Plane:
  • Motions: Rotation.
  • Axis: Vertical Axis (cranial to caudal).
• Frontal Plane:
  • Motions: Abduction/Adduction.
  • Axis: Anterior-Posterior axis.
• Example: Shoulder Internal Rotation (IR) & External Rotation (ER) is in the transverse plane about the vertical (longitudinal) axis.

Testing Position

• Shoulder ER & IR testing occurs in the sagittal plane around the medial-lateral (horizontal) axis.
• Forearm pronation/supination occurs in the transverse plane about the vertical (longitudinal) axis.
• Testing position: Forearm pronation/supination testing occurs in the frontal plane around the anterior-posterior axis.

Range of Motion (ROM)

• Arc of motion.
• The degrees between the beginning & end of a motion in a specific plane.
• Occurs either at a single joint or at a series of joints.
• Degrees of freedom:
  • Number of axes or planes at which the bone in a joint can move.

Notation Systems – Define ROM

• 0 to 180° notation system.
  • aka Neutral zero method.
  • 0^\circ for anatomical neutral.
  • Most widely used worldwide.
  • 180 to 0° system.
  • 360° system.
    • ie: Shoulder flexion ROM = 0^\circ - 180^\circ
    • Start in anatomical position (0^\circ) and ends with the arm overhead in full flexion (180^\circ).

Examples of ROM Measurements

• A: 0^\circ-50^\circ (0-50° of flexion)
• B: 20^\circ-70^\circ (20-70° of flexion)
• 20^\circ-0^\circ-140^\circ (20-0-140° of flexion)

Active ROM

• Voluntary arc of motion.
• Produced by unassisted muscle contraction.
• Provides information about:
  • Willingness to move.
  • Coordination.
  • Muscle strength.
  • Joint ROM.
• Active assistive ROM:
  • Voluntary arc of motion assisted by an external force.
  • By the examiner, unimpaired region of the body, or a mechanical device.

Passive ROM

• Passive arc of motion.
• Produced by an external force.
  • Examiner.
  • External object.
• Provides information about:
  • Integrity of the joint surfaces.
  • Extensibility of the joint capsule, ligaments, muscles, fascia, and skin.
• Typically, Passive ROM ≥ Active ROM.

Example Scenario

• No AROM: Lack of muscle strength prevents active motion at the joint.
• Full PROM at the same joint: The joint capsule, ligaments, muscles, tendons, fascia, and skin allow full PROM.
  • ie: Individual with a muscle paralysis

End-Feel

• End-feel of PROM.
• Feeling of a barrier to further motion.
• The examiner feels what is the barrier to further motion.

Normal End-Feel

• Soft:
  • Description: Soft Tissue Approximation.
  • Example: Knee flexion (contact between soft tissue of the posterior leg and posterior thigh).
• Firm:
  • Description:
    • Muscular stretch.
    • Capsular stretch.
    • Ligamentous stretch.
  • Example:
    • Hip flexion with knee straight (passive elastic tension of hamstring muscles).
    • Extension of metacarpophalangeal joints of fingers.
    • Forearm supination (tension in the palmar radioulnar ligament of the inferior radioulnar joint).
• Hard:
  • Description: Bone contacting bone.
  • Example: Elbow extension (olecranon process of the ulna and olecranon fossa of the humerus).

Abnormal End-Feel

• Soft:
  • Description: Occurs sooner or later in the ROM than is usual or in a joint that normally has a firm or hard end-feel. Feels boggy.
  • Examples: Soft tissue edema, Synovitis.
• Firm:
  • Description: Occurs sooner or later in the ROM than is usual or in a joint that normally has a soft or hard end-feel.
  • Examples: Increased muscular tonus, Capsular, muscular, ligamentous, and fascial shortening.
• Hard:
  • Description: Occurs sooner or later in the ROM than is usual or in a joint that normally has a soft or firm end-feel. A bony grating or bony block is felt.
  • Examples: Chondromalacia, Osteoarthritis, Loose bodies in joint, Myositis ossificans, Fracture.
• Empty:
  • Description: No real end-feel because pain prevents reaching end of ROM. No resistance is felt except for the patient's protective muscle splinting or muscle spasm.
  • Examples: Acute joint inflammation, Bursitis, Abscess, Fracture, Psychogenic disorder.

Hypomobility & Hypermobility

• Hypomobility:
  • Decrease in ROM, substantially less than normal values.
• Hypermobility:
  • Increased ROM beyond normal limits.
  • Possible causes: Laxity of soft tissue structures, Abnormalities of the joint surfaces, Hereditary disorders of connective tissue.

Beighton Hyper-mobility Score

• Specific joint laxity
  1. Passive apposition of thumb to forearm
  2. Passive hyperextension of V-MCP > 90^\circ
  3. Active hyperextension of elbow >10^\circ
  4. Active hyperextension of knee >10^\circ
  5. Ability to flex spine placing palms to floor without bending knees
• Each "YES" is 1 point. A score ≥ 4 out of 9 is generally considered an indication of JH. (MCP: metacarpophalangeal).

Factors That Affect ROM

• Age:
  • Children have more: Hip flexion, abduction, ER Ankle dorsiflexion Elbow motion
• Biological sex:
  • Individuals with > estrogen have slightly greater ROM than those with less estrogen
• Practice
• Function

Muscle Length Testing

• Maximal muscle length is the greatest extensibility of a muscle-tendon unit.
• Passive insufficiency:
  • Inability of a muscle to lengthen & allow full ROM at all the joints the muscle crosses.
  • Muscle is put on slack by passively approximating the origin and insertion of the muscle.
  • To assess the length of a two-joint muscle: the muscle is lengthened over proximal & distal joint muscle crosses.
• Example: Triceps testing, when assessing elbow flexion ROM, the shoulder must be neutral. But when assessing triceps length, the shoulder is in full flexion, and the elbow is flexed until a firm end-feel.

Testing Position

• Body positions recommended.
• Joints in a zero-starting position.
• Stabilize the proximal joint segment.
  • Positional.
  • Manual Stabilization.
• The comfort of the examiner and individual being measured is important.

Instruments

• Tape measures.
• Manual universal and digital goniometers.
• Manual and digital inclinometers.
• Cameras.
• Electrogoniometers and gyroscopes.
• Motion analysis systems.
• Smartphones.

Universal Goniometer

• Most common instrument used in the clinic.
• Best reliability.
• Use the correct size and shape for the testing site.
• Use the same device at successive visits.
• Parts of a goniometer: Moving arm, Body (Axis), Stationary arm

Inclinometer

• Gravity Dependent Goniometer

Visual Estimation

• Subjective info.
• Made prior to goniometric measurements.
• Help reduce errors attributable to incorrect reading of the goniometer.
• Knowledge of estimate may influence measurement results.

Precautions to ROM & Muscle Length Testing

• Suspected or confirmed:
  • Joint dislocation or subluxation.
  • Unstable bone fracture.
  • Rupture of tendon or ligament.
  • Infectious or acute inflammatory process.
  • Severe osteoporosis.
  • Acute injury or recent surgery.
  • Presence of pain or muscle spasms.
  • Immobilized joints (e.g., cast).

Procedures

• Determine whether there are contraindications or precautions.
• Determine joints and motions to be tested.
• Organize the testing sequence by body position.
• Gather the necessary equipment

Explanation of Procedures

• Explain:
  • Purpose of the measurement.
  • How the goniometer/inclinometer works.
  • Testing position.
  • Examiner and individual’s role.
• Demonstrate what you are going to do.
• Confirm the individual’s understanding and willingness to participate.

12-Step Sequence

1. Position the client.
   • Recommended testing position-Close to the side of the bed or plinth as possible.
   • Watch pt do AROM.
2. Stabilize proximal joint segment.
3. Move distal joint segment to zero-starting position.
   • If the joint cannot start at zero, move as close to zero.
4. Slowly move distal joint segment to the end of PROM.
   • Determine end-feel.
   • Ask about discomfort during motion
5. Visually estimate ROM.
6. Return joint to the starting position.
7. Palpate bony anatomical landmarks.
8. Align the goniometer.
   • Stabilize proximal joint segment with the goniometer
9. Read the starting position.
10. Move the distal segment through the full ROM.
11. Realign the goniometer.
    • Re-palpate landmarks
12. Read and record the ROM.

Reliability

• Universal goniometer: Good-to-excellent reliability.
• To improve reliability:
  • Be consistent in how you test.
  • Stabilize proximal segment to prevent unwanted movements.
  • Palpate to align the goniometer.
  • Use the same amount of force for PROM.
  • Be consistent in your directions to the client.
  • Use the same device for the same joint measurements.
  • Use the correct device.
  • Novice?: Take the average of multiple measurements.
  • Calibrate instruments.

UE Palpation - Shoulder

• Lateral border of the Scapula
• Inferior angle of the scapula
• Spine of the Scapula
• Acromion
• Coracoid process
• Clavicle
• Greater tubercle of the humerus
• Midline of the humerus
• Lateral epicondyle of the humerus

UE Palpation - Elbow

• Olecranon Process of the ulna
• Ulna styloid Process
• Radius
• Radial styloid proces
  *Acromion process of scapula
  *Humerus
  *Lateral condyle of humerus
  *Radial head
  *Scapula
  *Radial styloid Process
  *Radius
  *Ulna
  *Olecranon process
  *Ulnar styloid process

Shoulder Complex - Flexion

• Position: Hooklying; Arm anatomical neutral; Elbow extension
• Stabilization: Stabilize the thorax to prevent spine extension & rib movement; PT - supports the arm while measuring so it won't drop
• Axis: Lateral aspect of Greater Tubercle
• Stationary/ proximal arm: Midaxillary arm of the thorax
• Moving/ distal arm: Lateral midline of the humerus to the lateral epicondyle of the distal humerus
• End feel: Firm
• AAOS ROM norms: 0-180
• Common substitutions: Trunk extension, elbow flexion, scap retraction
• Plane of movement: Sagittal plane; Medial-lateral axis

Glenohumeral- Flexion

• Position: Hooklying; Arm anatomical neutral; Elbow extension
• Stabilization: Stabilize the scapula to prevent tilting, upward rotation, & elevation PT - supports the arm while measuring so it won't drop
• Axis: Lateral aspect of Greater Tubercle
• Stationary/ proximal arm: Midaxillary arm of the thorax
• Moving/ distal arm: Lateral midline of the humerus to the lateral epicondyle of the distal humerus
• End feel: Firm
• AAOS ROM norms: 0-100/115 but no norms
• Common substitutions: Trunk extension, elbow flexion, scap retraction
• Plane of movement: Sagittal plane; Medial-lateral axis

Shoulder Complex - Extension

• Position: Prone, Face turned away from the testing arm, no pillow, Arm in anatomical neutral, elbow in slight flexion to relax biceps tension
• Stabilization: Table blocks movement; PT lifts the forearm into extension
• Axis: Lateral aspect of Greater Tubercle
• Stationary/ proximal arm: Midaxillary arm of the thorax
• Moving/ distal arm: Lateral midline of the humerus to the lateral epicondyle of the distal humerus
• End feel: Firm
• AAOS ROM norms: 0-60
• Common substitutions: Trunk forward flexion & spine rotation
• Plane of movement: Sagittal plane; Medial-lateral axis

Glenohumeral- Extension

• Position: Prone, Face turned away from testing arm, no pillow, Arm in anatomical neutral, elbow in slight flexion to relax biceps tension
• Stabilization: Stabilize the scapula at the inferior angle to prevent anterior tilting & elevation PT - supports the arm while measuring so it won't drop
• Axis: Lateral aspect of Greater Tubercle
• Stationary/ proximal arm: Midaxillary arm of the thorax
• Moving/ distal arm: Lateral midline of the humerus to the lateral epicondyle of the distal humerus
• End feel: Firm
• AAOS ROM norms: 0-20/25 but no norms
• Common substitutions: Trunk forward flexion & spine rotation
• Plane of movement: Sagittal plane; Medial-lateral axis