El arte en la posmodernidad y sus interrogantes

Patient Position. Ensure the patient is:

• Comfortable.

• Well supported.

Position the patient so that the:

• Joint to be assessed is in the anatomical position.

• Proximal joint segment can be stabilized to allow only the desired motion.

• Movement can occur through the full ROM unrestricted.

• Goniometer can be properly placed to measure the ROM. If the patient’s position varies from the standard assessment position outlined in this text, make a special note on the ROM assessment form.

Substitute Movements. When assessing and measuring AROM and PROM, ensure that only the desired movement occurs at the joint being assessed. Substitute movements may take the form of additional movements at the joint being assessed or at other joints, thus giving the appear- ance of having a greater joint ROM than is actually pres- ent. An example of substitute movements used when per- forming a functional activity is illustrated in Figure 1-32 .

A

B

Figure 1-32 A. Patient reaches into a back pocket using normal right upper extremity. B. Substitute motions at the left shoulder girdle and trunk compensate for restricted left shoulder joint range of motion (ROM) as the patient attempts to reach into a back pocket.

When assessing and measuring AROM and PROM, try to eliminate substitute movements. For AROM, this may be accomplished through adequate explanation and instruction to the patient regarding the movement to be performed and the substitute movement(s) to be avoided. In addition, substitute motion(s) may be avoided for AROM and PROM by the following:

• Using proper patient positioning

• Adequately stabilizing the proximal joint segment as required

• Acquiring substantial practice in assessing AROM and PROM

To assess joint ROM accurately, the therapist must know and recognize the possible substitute movements. If the presence of substitute movements results in inac- curate AROM or PROM assessment and measurement, the treatment plan may be inappropriate.

Stabilization. Stabilize the proximal joint segment to limit movement to the joint being assessed or measured and prevent substitute movement for lack of joint range by making use of the following:

1. The patient’s body weight. Examples:

• To measure shoulder elevation through fl exion PROM, position the patient supine on a fi rm plinth so that the weight of the trunk stabilizes the shoul- der girdle ( Fig. 1-33 ).

• To assess hip internal rotation PROM, position the patient supine on a fi rm plinth so that the weight of the body stabilizes the pelvic girdle (see Fig. 1-34 ).

2. The patient’s position. Example:

• To assess hip abduction ROM ( Fig. 1-35 ), position the patient supine on a fi rm plinth with the contra- lateral leg over the opposite side of the plinth and the foot resting on a stool. This leg position prevents the tilting or shifting of the pelvis toward the test side, which would give the appearance of a greater hip abduction PROM than actually exists.

3 . External forces in the form of external pressure applied directly by the therapist and devices such as belts or sandbags. Ensure that manual contacts or devices avoid tender or painful areas, for example, in some viral dis- eases (i.e., poliomyelitis) muscle bellies may be tender. Examples:

• Manually stabilize the pelvis to assess hip extension PROM ( Fig. 1-36 ) and employ a belt to stabilize the pelvis when both hands are needed to place the goni- ometer to measure hip extension PROM ( Fig. 1-37 ).

• Manually stabilize the tibia and fi bula to assess ankle (i.e., talocrural) joint dorsifl exion and plantarfl exion PROM ( Fig. 1-38 ).

Assessment of Passive ROM and End Feel. With the patient relaxed, positioned comfortably on a fi rm surface, and the joint in anatomical position:

• Stabilize the proximal joint segment (see Fig. 1-39 A)

• Move the distal joint segment to the end of the PROM for the test movement (see Fig. 1-39 B and apply slight (i.e., gentle) overpressure at the end of the PROM

• Visually estimate the PROM

• Note the end feel, presence of pain

• Return the limb to the start position

• Following the assessment of the PROM for all move- ments at a joint, determine the presence of a capsular or noncapsular pattern of movement.

Measurement . It is not necessary to measure the joint ROM when the involved joint has a full AROM and PROM. Record the full ROM as full, normal (N), or within normal limits (WNL).

The neutral zero method 57 _{is used to assess and measure} joint ROM. All joint motions are measured from a defi ned

Figure 1-33 The weight of the trunk on the plinth serves to stabilize the scapula as the therapist measures the passive range of motion (PROM) of shoulder elevation through flexion.

Figure 1-34 The weight of the trunk and position of the pelvis on a firm surface serves to stabilize the pelvis as the therapist assesses hip internal rotation passive range of motion (PROM) and end feel.

Figure 1-35 The position of the patient’s nontest leg stabilizes the pelvis when testing hip abduction passive range of motion (PROM).

Figure 1-36 The therapist applies external pressure to stabilize the pelvis to assess hip extension passive range of motion (PROM).

Figure 1-37 A belt may be used to stabilize the pelvis to measure hip joint extension passive range of motion (PROM).

Figure 1-38 The therapist manually stabilizes the tibia and fibula proximal to the ankle joint to measure ankle dorsiflexion and plantarflexion passive range of motion (PROM).

B

Assesses end feel

Figure 1-39 Assessment of passive range of motion (PROM) using glenohumeral joint extension as an example. A. The patient is comfortable, well supported, and relaxed with the joint in the anatomical position. The therapist manually stabilizes the proximal joint segment (e.g., scapula) and moves the distal joint segment (e.g., humerus). B. The distal joint segment is moved to the end of joint PROM and gentle overpressure is applied to determine the end feel.

A

Stabilizes scapula Moves

zero position, either the anatomical position (see Figs. 1-14 to 1-16 ) or a position specifi ed as zero. Any move- ment on either side of zero is positive and moves toward 180 ° .

Measurement Procedure—Universal