THE EXTREMITY SCREEN MANUAL: A Guide to the Subjective and Objective Outcomes Assessment of the Upper and Lower Extremity

Transcription

1 THE EXTREMITY SCREEN MANUAL: A Guide to the Subjective and Objective Outcomes Assessment of the Upper and Lower Extremity Steven G. Yeomans, DC, FACO

2 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

3 Joint Range of Motion (ROM) Joint flexibility measured with a 2-arm goniometer

4 Joint Range of Motion (ROM) Place in goniometer in the correct plane (frontal, sagittal, or transverse)

5 Frontal Plane (F) Abduction Adduction

6 Sagittal Plane (S) Flexion Extension

7 Transverse Plane (T) External Rotation Internal Rotation

8 Joint Range of Motion (ROM) Place the pivot at the joint level

9 Joint Range of Motion (ROM) Active ROM is measured to the endpoint 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.

10 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.

11 PROCEDURES (Shoulder) Three Planes of ROM Frontal Plane: Abduction If requested measure ROM the scapula 1 st moves

12 PROCEDURES (Shoulder) Three Planes of ROM Frontal Plane: Adduction / Adduction Abduction: 180 Adduction: 50

13 PROCEDURES (Shoulder) Three Planes of ROM Transverse Plane: Internal / External Rotation External Rotation: 90 Internal Rotation: 90

14 PROCEDURES (Shoulder) Three Planes of ROM Sagittal Plane: Flexion / Extension Forward Flexion: 180 Extension: 60

15 * From text: The Clinical Application of Outcomes Assessment. ED SG Yeomans. Appleton & Lange, Shoulder Hoppenfeld [i] AMA [ii] Guides Magee [iii] [AROM] Matsen, et al [iv] [81 normal subjects years] Souza [v ] Kapandji [vi] Abduction M: F: Adduction Flexion Extension Internal [medial] rotation M: reach to T6 2 F: reach to T with arm at side 50 with arm abducted 95 External [lateral] rotation M: F: with arm at side 50 with arm abducted 80 Elevation through the plane of the scapula Horizontal adduction/ Abduction Circumduction

16 PROCEDURES (ELBOW) Two Planes of ROM Sagittal Plane: Flexion / Extension Extension: 0 Flexion 150

17 PROCEDURES (ELBOW) Two Planes of ROM Transverse Plane: Pronation & Supination Pronation: 90 Supination: 90

18 From: Clin Applic of OATs, Chapter 15, pg 249, Table Elbow ROM from various sources* Elbow Hoppenfeld AMA Guides Magee [AROM] Ombregt, et al [i]. [PROM] Kapandji Morrey Evans [ii] Flexion AROM: 145 PROM: Extension 0 to 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 Pronation

19 PROCEDURES (WRIST) Two Planes of ROM Sagittal Plane: Flexion / Extension (Palmar Flexion / Dorsiflexion) Palmar Flexion: 80 Dorsiflexion: 70

20 PROCEDURES (WRIST) Two Planes of ROM Frontal Plane: Ulnar and Radial Deviation Ulnar Deviation: 30 Radial Deviation 20

21 From: Clin Applic of OATs, Chap. 15, pg 251, Table Wrist ROM from various sources* Wrist Hoppenfeld AMA Guides [i] Magee [AROM] Kapandji Evans Gerhardt [ii] Flexion Extension Ulnar deviation Radial deviation

22 PROCEDURES (Hip) Three Planes of ROM Sagittal Plane: Flexion / Extension Hip Flexion: 130 Extension: 30

23 PROCEDURES (Hip) Three Planes of ROM Frontal Plane: Abduction / Adduction Abduction: 50 Adduction: 30

24 PROCEDURES (Hip) Three Planes of ROM Transverse Plane: Internal & External Rotation Internal Rotation: 40 External Rotation: 60

25 From: Clin Applic of OATs, Chap. 15, pg 251, Table Wrist ROM from various sources* Hip Hoppenfeld Steinberg [i] Magee Ombregt, et al [PROM] Evans Gerhardt Flexion to knee flexed; with knee extended 120 Extension normal if pelvis is not adequately fixed 15 Abduction Abduction [in flexion] Adduction Internal [medial] rotation External [lateral] rotation

26 PROCEDURES (Knee) Two Plane of ROM: Sagittal & Transverse Sagittal Plane: Flexion & Extension Knee Extension: 0 Knee Flexion: 148

27 PROCEDURES (Knee) Two Planes of ROM Transverse Plane: Internal & External Rotation? Internal Rotation: 10 External Rotation: 10

28 From: Clin Applic of OATs, Chapter 15, pg 264, Table Knee ROM from various sources* Knee Hoppenfeld Logan Magee [AROM] Evans Scott Gerhardt Flexion active 140 with hip flexed 160 passive 0 to Extension to 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 medial rotation of tibia on femur lateral rotation of tibia on femur - - -

29 PROCEDURES (Ankle) Two Planes of ROM Sagittal Plane: Plantar & Dorsiflexion Plantar flexion: 50 Dorsiflexion: 20

30 PROCEDURES (Ankle) Two Planes of ROM Frontal Plane: Inversion & Eversion Inversion: 35 Eversion: 15

31 From: Clin Applic of OATs, Chapter 15, pg 270, Table Ankle ROM from various sources* Ankle Hoppenfeld Logan Jahss Magee [AROM] Ombregt, et al Evans Dorsiflexion To an angle of 90 with the knee extended 20 Angle between dorsum of the foot and the tibia < Plantar flexion Limitation is of no clinical significance in the elderly. 50 Dorsal aspect of foot falls into line with the leg. 40 Inversion 35 Eversion 15 5 subtalar subtalar Supination Pronation 15-30

32 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.

33 TABLE. 1 Average ROMs (Adapted from Luttgens & Hamilton, 1997) Joint/Segment Movement Source 1* Source 2* Source 3* Source 4* Elbow Forearm Flexion Hyperextension Pronation Supination Extension (Dorsiflexion) Wrist Flexion (Palmar flexion) Radial Deviation Ulnar Deviation Shoulder Flexion Hyperextension Abduction Adduction Internal Rotation Shoulder w/ Abducted Arm External Rotation Horizontal Adduction NA Horizontal Adduction NA

34 TABLE. 1 Average ROMs (Adapted from Luttgens & Hamilton, 1997) (Continued) Joint/Segment Movement Source 1* Source 2* Source 3* Source 4* Flexion Hip Hyperextension Abduction Adduction Extended Hip Internal Rotation External Rotation Knee Flexion Ankle Plantar flexion Dorsiflexion

35 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) Numerical grade Table 15-1: Muscle Strength Testing Grades (0-5/5 scale). 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 NOT THE CT s JOB! * From text: The Clinical Application of Outcomes Assessment. ED SG Yeomans. Appleton & Lange, 2000.

36 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:

37 Upper Extremity Functional Index (Continued)

38 Upper Extremity Functional Index (Continued) Score /80 MDC (minimum detectable change) = 9 pts /15% Error +/- 5 scale points Stratford PW, Binkley JM, Stratford DM. Development and initial validation of the upper extremity functional index. Physiotherapy Canada Fall 2001;

39 Upper Extremity Functional Index (Continued) Scoring Method FORMULA: PT Score / TOTAL possible (80) TIMES (X) 100 = % EXAMPLE: 43 / 80 =.56 x 100 = 56%

40 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 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

41 Quadruple Visual Analogue Scale (QVAS) 3) Pain Level (QVAS): Right Now: / 10 Usual / Typical: / 10 At Best: / 10 At Worst: / 10 Spine, 18, Von Korff M, Deyo RA, Cherkin D, Barlow SF, Back pain in primary care: Outcomes at 1 year, , 1993, with permission from Elsevier Science.

42 FOR OFFICE USE ONLY: 4) ROM (active, active assisted and/or passive) (visual, goniometer, inclinometer, other: )

43 ELBOW RANGE OF MOTION TABLE

44 WRIST RANGE OF MOTION TABLE

45 NEUROLOGICAL EXAMINATION

46 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:

47 Lower Extremity Functional Index (Continued)

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

49 Lower Extremity Functional Scale (Continued) Scoring Method FORMULA: PT Score / TOTAL possible (80) TIMES (X) 100 = % EXAMPLE: 43 / 80 =.56 x 100 = 56%

50 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 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

51 Quadruple Visual Analogue Scale (QVAS) 3) Pain Level (QVAS): Right Now: / 10 Usual / Typical: / 10 At Best: / 10 At Worst: / 10 Spine, 18, Von Korff M, Deyo RA, Cherkin D, Barlow SF, Back pain in primary care: Outcomes at 1 year, , 1993, with permission from Elsevier Science.

52 HIP Range of Motion 4) ROM (active, active assisted and/or passive) (visual, goniometer, inclinometer, other: )

53 KNEE Range of Motion

54 ANKLE Range of Motion

55 NEUROLOGICAL EXAMINATION NOT THE CT s JOB!

56 CONCLUDING REMARKS 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

57 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

58