the extremity screen manual: a guide to the … · a guide to the subjective and objective outcomes...

THE EXTREMITY

SCREEN MANUAL:

A Guide to the Subjective and Objective

Outcomes Assessment of the Upper and

Lower Extremity

Steven G. Yeomans, DC, FACO

INTRODUCTION: • Objective screen for the extremities (ROM using a goniometer)

• To track patient progress

• Couple with the subjective OATs

• Refer to the Extremity Physical Exercise Manual for the exercise options

Joint Range of Motion (ROM)

• Joint flexibility measured with a 2-arm goniometer


• Place in goniometer in the correct plane (frontal, sagittal, or transverse)

Frontal Plane (F)

• Abduction

• Adduction

Sagittal Plane (S)

Flexion Extension

Transverse Plane (T)

Internal

Rotation External

Rotation


• Place the pivot at the joint level


• Active ROM is measured to the end-point and reported.

• Active motion is the patient's movement of the joint

through a specified ROM.

• Passive motion is the examiner's movement of the

extremity/joint through a specified ROM.

PURPOSE

(EXTREMITY ROM SCREEN)

• To practice screening the ROMs of the major joints of the body using a double-armed goniometer.

• Students need to memorize the ROM terminology used to describe different joint motions allowed at the major joints of the body.

PROCEDURES

(Shoulder)

• Three Planes of ROM

– Frontal Plane: Abduction

• If requested measure ROM the scapula 1st moves

PROCEDURES

(Shoulder)


– Frontal Plane: Adduction / Adduction

Abduction: 180 Adduction: 50

PROCEDURES

(Shoulder)


– Transverse Plane: Internal / External Rotation

External Rotation: 90 Internal Rotation: 90

PROCEDURES

(Shoulder)


– Sagittal Plane: Flexion / Extension

Forward Flexion: 180 Extension: 60

Shoulder Hoppenfeld[i] AMA[ii]

Guides

Magee[iii]

[AROM]

Matsen, et al[iv]

[81 normal subjects

60-70 years]

Souza[v] Kapandji[vi]

Abduction 180 180 170-180 M: 160 8

F: 167 7 180 180

Adduction 45 50 50-75 75 30-45

Flexion 90 180 160-180 180 180

Extension 45 50 50-60 60 45-50

Internal

[medial] rotation

55 90 60-100 M: reach to T6

2

F: reach to T5

2

80 with arm at side

50 with arm

abducted

95

External

[lateral] rotation

40-45 90 80-90 M: 72 13

F: 78 15

60 with arm at side

50 with arm

abducted

80

Elevation through

the plane of the

scapula

170-180 170-180

Horizontal

adduction/

Abduction

130 130

Circumduction 200

* From text: The Clinical Application of Outcomes Assessment. ED SG Yeomans. Appleton & Lange, 2000.

PROCEDURES

(ELBOW)

• Two Planes of ROM


Extension: 0 Flexion 150

PROCEDURES

(ELBOW)


– Transverse Plane: Pronation & Supination

Pronation: 90 Supination: 90

From: Clin Applic of OATs, Chapter 15, pg 249, Table 15-9. Elbow ROM from various sources*

Elbow

Hoppenfeld AMA

Guides

Magee

[AROM]

Ombregt, et

al[i]. [PROM]

Kapandji Morrey Evans[ii]

Flexion 135+ 140 140-150 160 AROM: 145

PROM: 160 145 140-150

Extension 0 to –5 0 0 to 10 0 to 10 0 normal

5 to 10 in

subjects with

great laxity of

ligaments

0 0 normal up to 10 of

hyperextensio

n may be seen

especially in

women.

Supination 90 80 90 90 90 85 90

Pronation 90 80 80-90 85 85 75 80-90

PROCEDURES

(WRIST)



(Palmar Flexion / Dorsiflexion)

Dorsiflexion: 70 Palmar Flexion: 80

PROCEDURES

(WRIST)


– Frontal Plane: Ulnar and Radial Deviation

Ulnar Deviation: 30 Radial Deviation 20

From: Clin Applic of OATs, Chap. 15, pg 251, Table 15-12. Wrist ROM from various sources*

Wrist

Hoppenfeld AMA

Guides[i]

Magee

[AROM]

Kapandji Evans Gerhardt[ii]

Flexion 80 60 80-90 85 80-90 50

Extension 70 60 70-90 85 70-90 60

Ulnar

deviation 30 30 30-45 45 30-45 20

Radial

deviation 20 20 15 15 15 30

PROCEDURES

(Hip)



Hip Flexion: 130 Extension: 30

PROCEDURES

(Hip)


– Frontal Plane: Abduction / Adduction

Abduction: 50 Adduction: 30

PROCEDURES

(Hip)


– Transverse Plane: Internal & External Rotation

Internal Rotation: 40 External Rotation: 60

Hip Hoppenfeld Steinberg[i] Magee Ombregt,

et al

[PROM]

Evans Gerhardt

Flexion 120 110 to 120 110-120

135° 140 120 knee flexed;

75-90+ with knee

extended

120

Extension 5-10 20-30

10-15 30 15 normal

30-40 if pelvis is not

adequately fixed

15

Abduction 45-50 40-50 30-50

40-45 45

Abduction

[in flexion]

- 45-60 -

Adduction 20-30 20-40 30 30 20-30 35

Internal

[medial]

rotation

35 25-45

43

30-40 45 40 45

External

[lateral]

rotation

45 45-50

42

40-60 60 45 45

From: Clin Applic of OATs, Chap. 15, pg 251, Table 15-12. Wrist ROM from various sources*

PROCEDURES

(Knee)

• Two Plane of ROM: Sagittal & Transverse

– Sagittal Plane: Flexion & Extension

Knee Extension: 0 Knee Flexion: 148

PROCEDURES

(Knee)


– Transverse Plane: Internal & External Rotation

Internal Rotation: 10 External Rotation: 10

?

From: Clin Applic of OATs, Chapter 15, pg 264, Table 15-19. Knee ROM from various sources*

Knee

Hoppenfeld Logan Magee

[AROM]

Evans Scott Gerhardt

Flexion

148

135 120 active

140 with hip flexed

160 passive

0 to 135 130-150 110 0-130

Extension 0 5-10 0 to 15 0-15 10 0-10

Rotation 10 internal

10 external

At 0 flexion:

10 lateral rotation

5 medial rotation

At 100 flexion:

15 lateral rotation

10 medial rotation

At full knee flexion:

0 lateral rotation

10 medial rotation

20-30 medial

rotation of tibia on

femur

30-40 lateral

rotation of tibia on

femur

- - -

PROCEDURES

(Ankle)


– Sagittal Plane: Plantar & Dorsiflexion

Plantar flexion: 50 Dorsiflexion: 20

PROCEDURES

(Ankle)


– Frontal Plane: Inversion & Eversion

Inversion: 35 Eversion: 15

From: Clin Applic of OATs, Chapter 15, pg 270, Table 15-23. Ankle ROM from various sources*

Ankle

Hoppenfeld Logan Jahss Magee

[AROM]

Ombregt, et al Evans

Dorsiflexion 20 20 To an angle of 90

with the knee

extended

20 Angle between dorsum

of the foot and the tibia

< 90

20

Plantar flexion 50 30-50 Limitation is of

no clinical

significance in the

elderly.

50 Dorsal aspect of foot

falls into line with the

leg.

40

Inversion 35° 5 subtalar - - 30

Eversion 15° 5 subtalar - - 20

Supination 45-60

Pronation 15-30

Summary

• Improving joint flexibility is essential for injury prevention.

• One may increase joint flexibility (range of motion) by regular stretching.

• Table 1 summarizes the average ROMs published. Note the differences between references.

TABLE. 1 Average ROMs (Adapted from Luttgens & Hamilton, 1997)

Joint/Segment Movement Source

1*

Source

2*

Source

3*

Source

4*

Elbow Flexion 150° 140 145 145 145

Hyperextension 0 0 0 0-10

Forearm Pronation 80 90 90 80

Supination 80 85 90 90

Wrist

Extension (Dorsiflexion) 60 70 70 50

Flexion (Palmar flexion) 80° 60 90 - 60

Radial Deviation 20° 20 20 20 20

Ulnar Deviation 30° 30 30 35 30

Shoulder

Flexion 180° 180 170 130 180

Hyperextension 60° 50 30 80 60

Abduction 180° 180 170 180 180

Adduction 75° 50 - - -

Shoulder

w/ Abducted Arm

Internal Rotation 90° 90 90 70 60-90

External Rotation 90° 90 90 70 90

Horizontal Adduction NA - - - 135

Horizontal Adduction NA - - - 45

TABLE. 1 Average ROMs (Adapted from Luttgens & Hamilton, 1997) (Continued)

Hip

Flexion 135° 100 120 125 120

Hyperextension 30 10 10 30

Abduction 50° 40 45 45 45

Adduction 30° 20 - 10 0-25

Extended Hip Internal Rotation 40 35 45 40-45

External Rotation 50 45 45 45

Knee Flexion 135° 150 120 140 130

Ankle Plantar flexion 50° 20 45 45 50

Dorsiflexion 30 15 20 20

Joint/Segment Movement Source 1* Source 2* Source 3* Source 4*

If manual muscle testing is utilized as part of the screen, the

following table defines the classic definitions of each grade

(reported as ____ / 5; example = 4/5)

Table 15-1: Muscle Strength Testing Grades (0-5/5 scale).

Numerical

grade

Description

0 Zero: No contraction

1 Trace: Muscle palpably tightens, but does not move the joint

2 Poor: Joint movement is produced only with gravity eliminated

3 Fair: Ability to produce joint movement against gravity only

4 Good: Full contraction, producing joint movement against some external resistance

5 Normal: Full contraction, producing joint movement against external resistance

without notable fatigue

* From text: The Clinical Application of Outcomes Assessment. ED SG Yeomans. Appleton & Lange, 2000.

NOT THE CT’s JOB!

Upper Extremity Functional Index Name________________________________ Date__________DOI__________ (Key: LEFT/RIGHT)

We are interested in knowing whether you are having any difficulty at all with the activities listed below because of your

upper limb problem for which you are currently seeking attention. Please check (√) an answer for each activity.

Today, do you or would you have any difficulty at all with:

Upper Extremity Functional Index (Continued)


Stratford PW, Binkley JM, Stratford DM. Development and initial validation of the upper

extremity functional index. Physiotherapy Canada Fall 2001;259-266.

Score /80 MDC (minimum detectable change) = 9 pts /15% Error +/- 5 scale points


• Scoring Method – FORMULA: PT Score / TOTAL possible (80) TIMES

(X) 100 = ______%

– EXAMPLE: 43 / 80 = .56 x 100 = 56%

2: Use IF previously treated:

Patient’s Global Impression of Change (PGIC) (Bolton, et al):

Since beginning treatment at this clinic, how would you describe the change (if

any) in ACTIVITY LIMITATIONS, SYMPTOMS, EMOTIONS, and OVERALL

QUALITY OF LIFE, related to your painful condition? (Circle one number):

Much Better No Change Much Worse

______________________________________________________________________

0 1 2 3 4 5 6 7 8 9 10

SCORE: 0-2/10 = A meaningful, satisfying change

Hurst H, Bolton J. Assessing the clinical significance of change scores recorded on subjective

outcome measures. J Manipulative Physiol Ther 2004;27:26-35

3) Pain Level (QVAS):

Right Now: _______ / 10

Usual / Typical: _______ / 10

At Best: _______ / 10

At Worst: _______ / 10

Quadruple Visual Analogue Scale (QVAS)

Spine, 18, Von Korff M, Deyo RA, Cherkin D, Barlow SF, Back pain in primary care:

Outcomes at 1 year, 855-862, 1993, with permission from Elsevier Science.

FOR OFFICE USE ONLY:

4) ROM (active, active assisted and/or passive) (visual, goniometer, inclinometer, other:_____)

ELBOW RANGE OF MOTION TABLE

WRIST RANGE OF MOTION TABLE

NEUROLOGICAL EXAMINATION

Lower Extremity Functional Scale Name________________________________ Date__________DOI__________ (Key: LEFT/RIGHT)

We are interested in knowing whether you are having any difficulty at all with the activities listed below because

of your lower limb problem for which you are currently seeking attention. Please check (√) an answer for each activity.

Today, do you or would you have any difficulty at all with:

4 3 2 1 0

Lower Extremity Functional Index (Continued)

Binkley JM, Stratford POW, Lott SA, Riddle DL. The lower extremity functional scale (LEFS): Scale development, measurement

properties, and clinical application. Physical Therapy 1999;79:371-383.

Score /80 MDC (minimum detectable change) = 9 pts / 15 Error +/- 5 scale points

Lower Extremity Functional Index (Continued)

Lower Extremity Functional Scale (Continued)

• Scoring Method – FORMULA: PT Score / TOTAL possible (80) TIMES

(X) 100 = ______%

– EXAMPLE: 43 / 80 = .56 x 100 = 56%

2: Use IF previously treated:

Patient’s Global Impression of Change (PGIC) (Bolton, et al):

Since beginning treatment at this clinic, how would you describe the change (if

any) in ACTIVITY LIMITATIONS, SYMPTOMS, EMOTIONS, and OVERALL

QUALITY OF LIFE, related to your painful condition? (Circle one number):

Much Better No Change Much Worse

______________________________________________________________________

0 1 2 3 4 5 6 7 8 9 10

SCORE: 0-2/10 = A meaningful, satisfying change

Hurst H, Bolton J. Assessing the clinical significance of change scores recorded on subjective

outcome measures. J Manipulative Physiol Ther 2004;27:26-35

3) Pain Level (QVAS):

Right Now: _______ / 10

Usual / Typical: _______ / 10

At Best: _______ / 10

At Worst: _______ / 10

Quadruple Visual Analogue Scale (QVAS)

Spine, 18, Von Korff M, Deyo RA, Cherkin D, Barlow SF, Back pain in primary care:

Outcomes at 1 year, 855-862, 1993, with permission from Elsevier Science.

4) ROM (active, active assisted and/or passive) (visual, goniometer, inclinometer, other:______________)

HIP – Range of Motion

KNEE – Range of Motion

ANKLE – Range of Motion

NEUROLOGICAL EXAMINATION

NOT THE CT’s JOB!

• Screening procedures – range of motion (ROM) utilizing a

goniometer to measure the range of motion of the peripheral

joints

• Objective method of tracking progress of patients during the

active care/physical exercise portion of case management

• Subjective outcomes assessment tools located on pages 16 and

18 (upper and lower extremity, respectively), track activity

tolerance

CONCLUDING REMARKS

• Use BOTH the subjective and objective outcome measures

regardless of the clinical diagnosis or specific functional loss

• Use the ROM screen when assessing patients before the

initiation of active care/physical exercise

•Use the Extremity Physical Exercise Manual when utilizing

active care with patients in the clinical setting

CONCLUDING REMARKS

the extremity screen manual: a guide to the … · a guide to the subjective and objective outcomes...

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