Joint Range of Motion

01/31/2015

Joint ROM the amount of movement that is possible at a

joint.
It is the arc of motion through which a joint passes when
moving within a specific plane.
Active range of motion (AROM) when the joint is moved
by the muscles that act on the joint.
Passive range of motion (PROM) when the joint is moved
by an outside force such as the therapist.
In normal individuals, PROM is slightly greater than AROM
because of the slight elasticity of soft tissue.
The additional PROM that is available at the end of normal
AROM helps protect joint structures because it allows the
joint to give and absorb extrinsic forces.
If PROM is significantly greater than AROM for the same
joint motion, it is likely that muscle weakness is present.
Decreased ROM can cause limited function and interfere with
performance in areas of occupation.
The primary concern of the OT is whether ROM is adequate for
the client to engage in meaningful occupations.
Limitations in ROM may occur as a result of injury to or
disease in the joint itself or the surrounding joint tissue
structures, joint trauma, or joint immobilization.
Inflexibility at a joint may adversely affect both speed and
strength of movement.
A client who constantly has to work to overcome the
resistance of an inflexible joint will probably demonstrate
decreased endurance and fatigue during activity.
The functional motion test, screening tests, and measurement
of joint ROM with a goniometer can all be used to assess ROM.
Methods used to screen limitations in ROM involve the
observation of AROM and PROM.
o To screen for AROM, the therapist asks the client to
perform all the active movements that occur at the
joint.
o To screen for PROM, the therapist moves the joint
passively through all of its motions.

o The purpose of this is to estimate ROM, detect

limitations, and observe the quality of movement,
end-feel, and the presence of pain.
The therapist can then decide at which joints
precise ROM measurement in indicated.
JOINT MEASUREMENT
Body function is a client factor that the occupational
therapist must consider when classifying the clients
underlying abilities.
Joint measurement an assessment tool often used for
physical disabilities that cause limited joint motion.
o Such disabilities include: skin contracture caused by
adhesions or scar tissue; arthritis; fractures; burns,
and hand trauma; displacement of fibrocartilage or
the presence of other foreign bodies in the joint;
bony obstruction or destruction; and soft tissue
contractures, such as tendon, muscle, or ligament
shortening.
o Limited ROM can also be secondary to spasticity,
muscle weakness, pain, and edema.
ROM measurements help the therapist:
o select intervention goals
o appropriate intervention modalities
o positioning techniques
o and other strategies to reduce limitations.
Specific purposes for measuring ROM are to:
o determine limitations that interfere with function or
may produce deformity
o determine additional range needed to increase
functional capacity or reduce deformity
o determine the need for splints and assistive devices
o measure progress objectivity
o record progression or regression.
The use of formal joint measurement will assist in
determining the efficacy of intervention modalities and
may also serve as evidence in assisting the client to see
the outcome of the intervention through quantifiable data.
Normal ROM varies from one person to another.

o The OT can establish norms for each individual by

measuring the analogous uninvolved part if possible.
Otherwise, the therapist uses average ranges listed
in the literature as a guide.
o The therapist should check records and interview the
client to detect the presence of fused joints and
other limitations caused by old injuries.
o Joints should not be forced when resistance is met on
PROM.
o Pain may limit ROM, and crepitation may be heard
with movement in some conditions.
Therefore, before beginning joint measurement
procedures, the therapist must explain what will
be done and ask the client if he or she is
experiencing any joint pain and, if so, where is it
located and how severe it is.
To not cause undue pain, the OT further
explains to the client the importance of
indicating any changes in pain throughout the
procedure.
PRINCIPLES & PROCEDURES IN JOINT MEASUREMENT
Before measuring ROM, the therapist should be familiar
with:
o average normal ROM ranges
o joint structure and function
o normal end-feel
o recommended positioning for self and the client
o bony landmarks related to each joint and joint axis
The therapist should be skilled in correct:
o Positioning and stabilization for measurements
o Palpation
o Alignment and reading of the goniometer
o Accurate recording of measurements
For the most reliable measurements, the same therapist
should asses and reassess the client at the same time of
day with the same instrument and the same
measurement protocol.
VISUAL OBSERVATION

o The joint to be measured should be exposed, and the

therapist should observe the joint and adjacent
areas.
o The therapist asks the client to move the part
through the available ROM, if muscle strength is
adequate, and observes the movement.
The therapist should look for:
compensatory motions
posture
muscle contours
skin color and condition
and skin creases
and compare the joint with the non-injured
part, if possible.
o The therapist should then move the part through its
range to see and feel how the joint moves and to
estimate ROM.
PALPATION
o Feeling the body landmarks and soft tissue around
the joint is an essential skill gained with practice and
experience.
o The pads of the index and middle fingers are used for
palpation.
o The thumb is sometimes used.
o The therapists fingernails should not make contact
with the clients skin.
o Pressure is applied gently but firmly enough to detect
underlying muscle, tendons, or bony structures.
o For joint measurement, the therapist must palpate to
locate bony landmarks for placement of the
goniometer.
POSITIONING OF THERAPIST AND SUPPORT OF
LIMBS
o The therapists position varies, depending on the
joints being measured.
When measuring finger or wrist joints, the
therapist may sit next to or opposite the client.

 If sitting next to the client, the therapist

should measure the wrist and finger joints
on that side and then move to the other
side to measure the joints on the clients
opposite side.
This procedure makes the client more
comfortable (eliminating the need to
stretch across the midline) and ensures
more accurate placement of the
goniometer.
When measuring the larger joints of the upper
or lower extremity, the therapist may stand
next to the client on the side being measured.
The client may be seated or lying down.
The therapist needs to use good body
mechanics in posture and in lifting and
moving heavy limbs.
The therapist should use a broad base
of support and stand with the head
upright while keeping the back
straight.
The feet should be shoulder width
apart, with the knees slightly flexed.
The therapists stance should be in
line with the direction of movement.
The limb should be supported at the
level of its center of gravity,
approximately where the upper and
middle thirds of the segment meet.
The therapists hands should be in a
relaxed grasp that conforms to the
contours of the part.
The therapist can provide additional
support by resting the part on his or
her forearm.
PRECAUTIONS AND CONTRAINDICATIONS

o In some instances, measuring joint ROM is

contraindicated or should be undertaken with
extreme caution.
o It is contraindicated if:
there is a joint dislocation or unhealed fracture
immediately after surgery on any soft tissue
structures surrounding joints
in the presence of myositis ossificans
or when ectopic ossification is a possibility.
o Joint measurement must ALWAYS be done carefully.
The following situations call for extreme caution:
The client has joint inflammation or an infection.
The client is taking either medication for pain or
muscle relaxants.
The client has osteoporosis, hypermobility, or
subluxation of a joint.
The client has hemophilia.
The client has a hematoma.
The client ahs just sustained an injury to soft
tissue.
The client has a newly united fracture.
The client has undergone prolonged
immobilization.
Bony ankylosis is suspected.
The client has carcinoma of the bone or any
fragile bone condition.
END-FEEL
o PROM is normally limited by the structure of the joint
and surrounding soft tissues.
Thus, ligaments, the joint capsule, muscle and
tendon tension, contact of joint surfaces, and
soft tissue approximation may limit the end of a
particular ROM.
Each of these structures has a different end-feel
as the therapist moves the joint passively
through its ROM.

o End-feel is the normal resistance to further joint

motion because of stretching of soft tissue,
stretching of ligaments and joint capsule,
approximation of soft tissue, and contact of bone on
bone.
o End-feel is normal when full ROM is achieved and the
motion is limited by normal anatomic structures.
o Abnormal end-feel occurs when ROM is increased or
decreased or when ROM is normal but structures
other than normal anatomy stop the ROM.
o Practice and sensitivity are required for the therapist
to detect different end-feels and to distinguish
normal from abnormal.
o End-feel is normally hard, soft, or firm.
An example of hard end-feel is bone contacting
bone when the elbow is passively extended and
the olecranon process comes into contact with
the olecranon fossa.
Soft end-feel can be detected on knee flexion
when there is soft tissue apposition of the
posterior aspects of the thigh and calf.
A firm end-feel has a firm or springy sensation
that has some give, as when the ankle is
dorsiflexed with the knee in extension and ROM
is limited by tension in the gastrocnemius
muscle.
o In pathologic states, end-feel is abnormal when
PROM is increased or decreased or when PROM is
normal but movement is stopped by structures other
than normal anatomy.
TWO-JOINT MUSCLES
o When the ROM of a joint that is crossed by two-joint
muscle is measured, the ROM of the joint being
measured may be affected by the position of the
other joint because of passive insufficiency.
In other words, joint motion is limited by length
of the muscle.

o A two-joint muscle feels taut when it is at its full

length over both joints that it crosses and before it
reaches the limits of the normal ROM of both joints.
For example, when the wrist is in full extension,
passive finger extension is normally limited
because of passive insufficiency of the finger
flexors that cross the wrist and finger joints.
o When joints crossed by two-joint muscles are being
measured, it is necessary to place the joint not being
measured in a neutral or relaxed position to place the
two-joint muscle on slack.
For example, when finger extension is being
measured, the wrist should be placed in neutral
position to avoid full stretch of the finger flexors
over all of the joints that they cross.
Similarly, when hip flexion is being measured,
the knee should also be flexed to place the
hamstrings in the slackened position.
METHODS OF JOINT MEASUREMENT
THE 180-DEGREE SYSTEM
o In the 180-degree system of joint measurement, 0
degree is the starting position for all joint motions.
o For most motions, the anatomic position is the
starting position.
o The body of the measuring instrument, the
goniometer, is a half-circle protractor with an axis
and two arms.
It is superimposed on the body in the plane at
which the motion is to occur.
The axis of the instrument is aligned with the
axis of the joint.
o All joint motions begin at 0 degree and increase
toward 180 degrees.
o The 180-degree system is used most often and is the
one used later in this chapter to describe procedures
for joint measurement.
THE 360-DEGREE SYSTEM

o The 360-degree system of joint measurement is used

less frequently than the 180-degree system.
o The goniometer is a full-circle, 360-degree protractor
with two arms.
o Movements occurring in the coronal and sagittal
planes are related to the full circle.
o When the body is in the anatomic position, the circle
is superimposed on it in the same plane in which the
motion is to occur, with the joint axis being the
pivotal point.
o The 0-degree (360-degree) position will be overhead
and the 180-degree position will be toward the feet.
For example, shoulder flexion and abduction are
movements that proceed toward 0 degree, and
shoulder adduction and extension proceed
toward 360 degrees.
The average normal ROM for shoulder flexion is
170 degrees.
Therefore, in the 360-degree system, the
movement would start at 180 degrees and
progress toward 0 to 10 degrees. The ROM
recorded would be 10 degrees.
Shoulder extension that has a normal ROM of 60
degrees would begin at 180 degrees and
progress toward 360 to 240 degrees, and 240
degrees would be the ROM recorded.
The total ROM of extension to flexion would be
240 to 10 degreesthat is, 230 degrees.
o Some motions cannot be related to the full circle.
In these instances, a 0-degree starting position
is designated, and the movements are
measured as increases from 0 degree.
These motions occur in a horizontal plane
around a vertical axis.

 They are forearm pronation and supination, hip

internal and external rotation, wrist radial and
ulnar deviation, and thumb palmar and radial
abduction (carpometacarpal flexion and
extension).
GONIOMETERS
Usually made of metal or plastic, goniometers come in
several sizes and types and are available from medical
and rehabilitation equipment companies.
The word goniometer is derived from the Greek gonia,
which means angle, and metron, which means measure.
o Thus, goniometer literally means to measure
angles
The universal goniometer consists of a body, a stationary
(proximal) bar, and a movable (distal) bar.
o The stationary bar is attached to the body of the
goniometer.
o The body is a half-circle or a full-circle protractor
printed with a scale of degrees from 0 to 180 for the
half-circle and 0 to 360 for the full-circle goniometer.
o The movable bar is attached at the center, or axis, of
the protractor and acts as a dial.
o As the movable bar rotates around the protractor,
the dial points to the number of degrees on the
scale.
Two scales of figures are printed on the half circle.
o Each starts at 0 degree and progresses toward 180
degrees, but in opposite directions.
Because the starting position in the 180-degree
system is always 0 degree and increases toward
180 degrees, the outer row of figures is read if
the bony segments being measured are end to
end, as in elbow flexion.
The inner row of figures is read if the bony
segments being measured are alongside one
another, as in shoulder flexion.
Review the different types of goniometers on page 502 in
Figure 21-1.

 One important feature of the goniometer is the fulcrum.

o The nut or rivet that acts as the fulcrum must move
freely yet be tight enough to remain where it was set
when the goniometer is removed after measurement
of the joint.
For easy, accurate readings, some goniometers
have a locking nut that is tightened just before
the goniometer is removed.
RECORDING MEASUREMENTS
When using the 180-degree system, the evaluator should
record the number of degrees at the starting position and
the number of degrees at the final position after the joint
has passed through the maximally possible arc of motion.
Normal ROM always starts at 0 degree and increases
toward 180 degrees.
o When it is not possible to start the motion at 0
degree because of limitation of motion, ROM is
recorded by writing the number of degrees at the
starting position followed by the number of degrees
at the final position.
For example, elbow ROM limitations can be
noted as follows:
Normal: 0 to 140 degrees
Extension limitation: 15 to 140 degrees
Flexion limitation: 0 to 110 degrees
Flexion and extension limitation: 15 to 110
degrees
o Abnormal hyperextension of the elbow may be
recorded by indicating the number of degrees of
hyperextension below the 0-degree starting position
with a minus sign, followed by the 0-degree position
and then the number of degrees at the final position.
This may be noted as follows:
Normal: 0 to 140 degrees
Abnormal hyperextension: -20 to 0 to 140
degrees
There are alternative methods of recording ROM.

o The evaluator is advised to learn and adopt the

particular method required by the health care facility.
A sample form for recording ROM measurements is shown
in Figure 21-2 (p. 504). Average normal ROM for each joint
motion is listed on the form and in Table 21-1 (p. 505).
o When measurements are being recorded, every
space on the form should be filled in.
o If the joint was not test, NT should be entered in
the space.
It should be noted that scapula movement accompanies
movements of the shoulder (glenohumeral) joint, as
outlined.
o The range of glenohumeral joint motion is highly
dependent on scapula mobility, which gives the
shoulder its flexibility and wide ranges of motion.
o Although it is not possible to measure scapula
movement with the goniometer, the evaluator should
assess scapula mobility by observation of active
motion or passive movement before proceeding with
shoulder joint measurements.
o Scapular ROM is noted as full or restricted.
If scapular motion is restricted, as when the
musculature is in a state of spasticity or
contracture, and the shoulder joint is moved
into extreme ranges of motion (for example,
above 90 degrees of flexion or abduction),
glenohumeral joint damage can result.
When joint measurements may be performed in more than
one position (e.g., as in shoulder internal and external
rotation), the evaluating OT should note on the record the
position in which the measurement was taken.
o The therapist should also note any pain or discomfort
experienced by the client, the appearance of
protective muscle spasm, whether AROM or PROM
was measured, and any deviations from
recommended testing procedures or positions.
RESULTS OF ASSESSMENT AS THE BASIS FOR PLANNING
INTERVENTION

 After joint measurement, the therapist should analyze the

results in relation to the clients life role requirements.
The therapists first concern should be to correct ROM that
is below functional limits.
Many ordinary ADLs do not require full ROM.
Functional ROM refers to the amount of joint range
necessary to perform essential ADLs and IADLs without
the use of special equipment.
The first concern of intervention is to attempt to increase
to functional levels any ROM that is limiting performance
of self-care and home maintenance tasks.
o For example, severe limitation of elbow flexion
affects eating and oral hygiene.
Therefore, it is important to increase elbow
flexion to nearly full ROM for function.
o Likewise, severe limitation of forearm pronation
affects eating, washing the body, telephoning, caring
for children, and dressing.
o Because sitting comfortably requires hip ROM of at
least 0 to 100 degrees, a first goal might be to
increase flexion to 100 degrees if it is limited.
Of course, if additional ROM can be gained, the
therapist should plan the progression of
intervention to increase ROM to the normal
range.
Some limitations in ROM may be permanent.
o The role of the therapist in such cases is to work out
methods to compensate for the loss of ROM.
Possibilities include assistive devices, such as a
long-handled comb, brush, shoehorn, and
device to apply stockings, or adapted methods
of performing a particular skill.
In many conditions, such as burns and arthritis, loss of
ROM can be anticipated.
o The goal of intervention is to prevent joint limitation
with splints, positioning, exercise, activity, and
application of the principles of joint protection.

 Limited ROM, its causes, and the prognosis for increasing

ROM will suggest intervention approaches.
o Such methods include stretching exercise, resistive
activity and exercise, strengthening of antagonistic
muscle groups, activities that require active motion
of the affected joints through the full available ROM,
splints, and positioning.
To increase ROM, the physician may perform surgery or
manipulate the part while the client is under anesthesia.
The PT or certified hand therapist may use joint
mobilization techniques such as manual stretching with
heat and massage.
PROCEDURE FOR MEASURING PASSIVE RANGE OF
MOTION
Average normal ROM for each joint motion is listed in
Table 21-1, in Figure 21-2, and before each of the following
procedures used for measurement.
Keep in mind that these are averages; ROM may vary
considerably among individuals.
Normal ROM is affected by age, gender, and other factors,
such as lifestyle and occupation.
In the illustrations, the goniometer is shown in such a way
that the reader can most easily see its positioning.
o However, the OT may not always be in the best
position for the particular measurement.
o For the purposes of clear illustration, the therapist is
necessarily shown off to one side and may have one
hand, rather than two, on the instrument.
o Many of the motions require that the therapist
actually be in front of the client or that the
therapists hands obscure the goniometer.
o How the therapist holds the goniometer and supports
the part being measured is determined by factors
such as the position of the client, amount of muscle
weakness, presence or absence of joint pain, and
whether AROM or PROM is being measured.

o Both the therapist and the client should be

positioned for the greatest comfort, correct
placement of the instrument, and adequate
stabilization of the part being tested to ensure the
desired motion in the correct plane.
GENERAL PROCEDURE180-DEGREE METHOD OF
MEASUREMENT
o 1. The client should be comfortable and relaxed in
the appropriate position (described later) for the joint
measurement.
o 2. Uncover the joint to be measured.
o 3. Explain and demonstrate to the client what you
are going to do, why, and how you expect him or her
to cooperate.
o 4. If there is unilateral involvement, assess PROM on
the analogous limb to establish normal ROM for the
client.
o 5. Establish and palpate bony landmarks for the
measurement.
o 6. Stabilize joints proximal to the joint being
measured.
o 7. Move the part passively through ROM to assess
joint mobility and end-feel.
o 8. Return the part to the starting position.
o 9. To measure the starting position, place the
goniometer just over the surface of and lateral to the
joint. Place the axis of the goniometer over the axis
of the joint by using the designated bony prominence
or anatomic landmark. Place the stationary bar on or
parallel to the longitudinal axis of the proximal or
stationary bone and the movable bar on or parallel to
the longitudinal axis of the distal or moving bone. To
prevent the indicator on the movable bar from going
off the protractor dial, always face the curved side
away from the direction of motion, unless the
goniometer can be read after movement in either
direction.

o 10. Record the number of degrees at the starting

position and remove (or back off) the goniometer. Do
not attempt to hold the goniometer in place while
moving the joint through ROM.
o 11. To measure PROM, hold the part securely above
and below the joint being measured and gently move
the joint through ROM. Do not force the joint. Watch
for signs of pain and discomfort. (Note: PROM may
also be measured by asking the client to move
actively through ROM and hold the position. The
therapist then moves the joint through the final few
degrees of PROM.)
o 12. Reposition the goniometer and record the
number of degrees at the final position.
o 13. Remove the goniometer and gently place the
part in the resting position.
o 14. Record the reading at the final position and any
notations on the evaluation form.
DIRECTIONS FOR JOINT MEASUREMENT180-DEGREE
SYSTEM
SPINE
o Found on pp. 506-510
UPPER EXTREMITY
o Found on pp. 510-522
LOWER EXTREMITY
o Found on pp. 522-527