Evaluation of passive ROM in a child with CMD

Robyn SmithDept. of Physiotherapy

UFS2012

Evaluation of passive ROM in a child with CMD

It is essential to use your observational skills to determine what ROM and muscle lengths need to be assessed in a patientIt is also essential that ROM and muscle lengths are assessed correctly accurately and safelyIt is crucial to note the available ROM in degrees or as a fraction Also clearly not the restricting factor e.g. joint, capsule, muscle, tone etc.

Causes of deformities

The cause of deformities in children with CMD is extensive and deformities may even result due to a combination of the following factors;ImmobilityHypertonicity/ spasticityHypotonicityMuscle weakness and imbalancesAsymmetry Stereotypical (habitual) movement patternsGrowth related factors e.g. difference in bone lengths Biomechanical issuesAbnormal/ pathological reflex activity e.g. TLR, ATNR

Neck

Neck flexion

One hand on occiput

Other hands index finger on the chin and the middle finger under chin

Make sure of the correct alignment of the cervical spine (chin tuck)

Provide slight traction and provide high cervical flexion

Restricted by tight neck extensors

Neck extension

Child in supine

Index finger placed between the vertebrae lift the hand up so that cervical extension is done

Repeat at the various levels of the cervical spine

Restricted by tight neck flexors

Side flexion

Child in supineNeutral position of cervical spineHands are placed both sides of the head/jawDo side flexion of the neckEnsure that no rotation occursMake sure that the child does not compensate with elevation of the shoulder on the side testedRepeat to the other side and compare ROM

Restricted by tight upper fibres of m. trapezius

Neck rotation

Child sitting or in supineHand are placed on sides of the head/jaw to which want to rotate to Other hand on the occiputDo rotation of the neck Make sure that the child is not compensating with lateral flexionOften restricted

Restricted by tight SCM

Trunk

Trunk flexion

Children that have increased tone in their m. pectoralis or those that make excessive use of flexion patterns of the UL and trunk are at an increased risk of developing a thoracic kyphosisChild is to be seated on a block/end of a roller. Allow the child to do trunk flexion, with the head and arm lowered between legsYour hand on the child’s arms and thoracic spineIn the case of a smaller child of an extremely spastic child one can even observe flexion in side lying or picking the child up in a flexed position

Restricted by shortened back extensors e.g. erector spinae and multifidusLimited by excessive extensor tone over the trunk

Trunk extension

In a child neutral spine extension is foundAllow the child to sit over a rollerSupport the arms in 900 shoulder flexion Place one hand on the thoracic spinous process and press downwards towards the pelvis, the arms should naturally lift slightlyIf the child has severe flexor spasticity this can be tested in prone over a roller . In a smaller child the legs can be lifted off the supporting surface with one hand under the hips/pelvis and the other hand on thoracic vertebrae

Restricted by shortened trunk flexors ie. Mm. abdominals, especially rectus abdominus

Lateral flexion

Lateral flexion ROM is greater in the lumbar spine, and less in the thoracic spine area due to the ribcage

Child sitting on roller/block

Neutral position spine

Provide pressure on the lower ribcage in the direction of the opposite hip

Whilst doing a weight shift

In the case of very limited side flexion lift you can do side flexion by giving traction to the arm in ER, give counter pressure to the scapula

Restricted by shortened abductors and quadratus lumborum on the opposite side

Trunk rotation

Rotation in the thoracic spine is approximately 90 0 and less in the lumber region 12 0Child sitting on roller/blockNeutral position spineEnsure that the pelvis is stabilised to prevent pelvic rotation to compensateSit behind the patientPlace one hand on the abdomen and the other on the thoracic spineEvaluate at the various levels of the spine:Arms side = upper trunk rotationArm crossed at 90 0 shoulder = mid trunk rotation and Arms elevated above 90 0shoulder flexion =lumbar rotation

Restricted by vertebral or muscle stiffness

Scapula

Scapula

Child in side lying

Hips and knees flexed, neural spine

Assess scapula elevation, depression, protraction, retraction, and

rotation

Glenohumeral joint

Glenohumeral joint

Shoulder flexion

Child in supine

Observe gleno-humeral and scapula movement

Avoid compensatory shoulder elevation

Elbow should be in extension

Restricted by tight shoulder extensors ie. Latissimus dorsi

Shoulder extension

Child in supine

Observe glenohumeral and scapula movement

Avoid compensatory shoulder elevation

Elbow should be in extension

Restricted by tight shoulder extensors

Medial and lateral rotation

Child in supineShoulder in 450 flexionAvoid compensatory shoulder elevationElbow should be inflexion

Lateral rotation restricted a tight mm. pectoralis, teres major, subscapularis and latissimus dorsi Medial rotation restricted by a tight mm. infraspinatis and teres minor

Horizontal abduction

Child can be in supine or in sittingIf seated ensure trunk is stableArm is to be abducted horizontally prevent compensatory movements of shoulder elevation and protraction

Restricted by a tight m.pectoralis

Elbow

Elbow flexion and extension

in supine

Stabilise the upper arm

Do elbow flexion and extension

If elbow extension is limited it most likely due to tight m. biceps

Supination and Pronation

in supine

Perform supination and pronation with the elbow flexed and extended

Wrist

Wrist flexion, extension and deviation

Stabilise the forearm

Provide traction, especially in the case of a stiff wrist

When assessing wrist extension make sure that you grasp close to the wrist joint, if you grasp the distal hand you run the risk of hyper-mobilising the carpal bones

Wrist extension is often restricted by shortening of the long flexor muscles especially in the case of patients with increased flexor tone and fisting

Hand

Hand

Be vary careful when assessing the ROM at the handDo not do supination of the hand as this may damage the carpal bones and/or hyper-mobilise them In a closed or fisted hand where the long flexors are shortened or there is excessive flexor spasticity do not pull the finger out as the MCF joint is easily hyper-mobilised and the muscles overstretched, first make use of sweep taping to inhibit the flexor tone. Once you have got the hand slight open one can then work from the inside of the hand out.In case of palmar thumbing be careful not to pull the thumb out of the palm of the hand this hyper-mobilises the MCF joint. Provide enough stability to ensure that the correct joint and movement is being assessed.

Pelvis and lower trunk

Pelvis and lower trunk

Child in supine with his hips flexed to 900

Physiotherapist in half kneeling supporting the legs.

Ensure that the pelvis is in a neutral position

Move the legs laterally to the sides using leg/arms

Posterior and anterior pelvic tilt

Child in supine with his hips flexed to 900

Physiotherapist in half kneeling supporting the legs.

This evaluates the posterior pelvic tilt

Lowe the legs to assess anterior tilt

Lumbosacral rotation

Child in supine with his hips flexed to 900

Physiotherapist in half kneeling supporting the legs.

Do rotation to the left and right

Test in controlled manner

Be careful in the patient with already evident hyper-mobility of the lumbosacral joint

Hip

Abduction

Child in supine

If child has a severe lordosis bend the other leg up

Do abduction of the hip

Be careful avoid compensation by using ER

Abduction may be restricted by severe adductor spasticity and shortening of the adductors

Adduction

Test the length of the TFL

Supine

If the left leg is being tested, lift the right hip and move it into adduction, this helps to stabilise the pelvis

Now lift the left leg and move it into adduction

Adduction might be restricted by tight m.gluteus medius

Internal and external rotation

Supine, leg bent with 900 hip and knee flexionUse the lower leg as a lever and do IR/ER hipBe care of excessive IR in cases where there already seems to be excessive ROM as this is an unstable position for the hipCan also be done in prone as above, just ensure that the rotation of the femur is neutral

IR restricted by tight lateral rotators of the hip ie. mm. piriformis, quadratus femoris and obturator internus & externusER restricted by tight gluteus minimus & medius, TFL

Flexion

Supine or side lying

Hip flexion with knee flexion

Can also test the length of m. hamstrings in supine. It is important to observe if the opposite legs pelvis/hip lifts

Can be restricted by tight m. gluteus maximus

Extension

Side lying with the lower leg bent up in flexion 900

Ensure that the trunk is in a neutral positionStabilise at the pelvis and extend the hip Be careful of not getting lumbar extensionAlso guard against too much of a posterior pelvic tilt, adjust the degree of hip flexion of the lower legMust differentiate whether m. quadriceps (with knee in flexion) or m. iliopsoas (with knee in extension) is restricting restricting

Extension can be restricted by a tight m. iliopsoas or m. quadriceps over the hip

Knee

Knee flexion and extension

Can be tested in sitting over end plinth or sitting on a block

Extension can be limited by shortened m. hamstring

Flexion of the knee can be limited by m. quadriceps

Ankle

Dorsiflexion and plantarflexion

Can be tested in prone or in supine. Prone is often a more effective position to use especially in the case of severe extensor spasticity as this is a TIPEnsure that the foot is correctly aligned Grasp the heel to ensure that the DF movement actually takes place at the ankle and not the mid footIt important to test DF as well, especially in cases where the child constantly wears AFO’s

DF restricted by a tight m. gastrognemius PF can be restricted by a tight m. tibialis anterior

Foot

Foot

In supine evaluate rear foot mobility

Also look at midfoot pronation and supination

Also evaluate the length of the long toe flexors

Look out for shortening of the plantar fascia

Observe for foot abnormalities and biomechanical alignment issues

References

Kendall, F.P., Kendall McCreary and Provance, P.G. 1983. Muscle testing and function. 4ed. Williams & Wilkins. Baltimore

Kriel, H. 2007. Cerebral Motor disturbances (lecture notes, UFS: unpublished)

Smith, R. 2009. Paediatric Dictate (lecture notes, UFS: unpublished

Images courtesy of Google images (2009)