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
Joint Range of Motion (ROM) Place in goniometer in the correct plane (frontal, sagittal, or transverse)
Frontal Plane (F) Abduction Adduction
Sagittal Plane (S) Flexion Extension
Transverse Plane (T) External Rotation Internal Rotation
Joint Range of Motion (ROM) Place the pivot at the joint level
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.
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 1 st moves
PROCEDURES (Shoulder) Three Planes of ROM Frontal Plane: Adduction / Adduction Abduction: 180 Adduction: 50
PROCEDURES (Shoulder) Three Planes of ROM Transverse Plane: Internal / External Rotation External Rotation: 90 Internal Rotation: 90
PROCEDURES (Shoulder) Three Planes of ROM Sagittal Plane: Flexion / Extension Forward Flexion: 180 Extension: 60
* From text: The Clinical Application of Outcomes Assessment. ED SG Yeomans. Appleton & Lange, 2000. 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 Circumduction 130 200 130
PROCEDURES (ELBOW) Two Planes of ROM Sagittal Plane: Flexion / Extension Extension: 0 Flexion 150
PROCEDURES (ELBOW) Two Planes of ROM 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) Two Planes of ROM Sagittal Plane: Flexion / Extension (Palmar Flexion / Dorsiflexion) Palmar Flexion: 80 Dorsiflexion: 70
PROCEDURES (WRIST) Two Planes of ROM 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 Radial deviation 30 30 30-45 45 30-45 20 20 20 15 15 15 30
PROCEDURES (Hip) Three Planes of ROM Sagittal Plane: Flexion / Extension Hip Flexion: 130 Extension: 30
PROCEDURES (Hip) Three Planes of ROM Frontal Plane: Abduction / Adduction Abduction: 50 Adduction: 30
PROCEDURES (Hip) Three Planes of ROM Transverse Plane: Internal & External Rotation Internal Rotation: 40 External Rotation: 60
From: Clin Applic of OATs, Chap. 15, pg 251, Table 15-12. Wrist ROM from various sources* 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
PROCEDURES (Knee) Two Plane of ROM: Sagittal & Transverse Sagittal Plane: Flexion & Extension Knee Extension: 0 Knee Flexion: 148
PROCEDURES (Knee) Two Planes of ROM 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) Two Planes of ROM Sagittal Plane: Plantar & Dorsiflexion Plantar flexion: 50 Dorsiflexion: 20
PROCEDURES (Ankle) Two Planes of ROM 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 Eversion 15 5 subtalar - - 30 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 Forearm Flexion 150 140 145 145 145 Hyperextension 0 0 0 0-10 Pronation 80 90 90 80 Supination 80 85 90 90 Extension (Dorsiflexion) 60 70 70 50 Wrist 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 - - - Internal Rotation 90 90 90 70 60-90 Shoulder w/ Abducted Arm 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) Joint/Segment Movement Source 1* Source 2* Source 3* Source 4* Flexion 135 100 120 125 120 Hip 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
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.
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)
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;259-266.
Upper Extremity Functional Index (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
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, 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)
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 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
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, 855-862, 1993, with permission from Elsevier Science.
HIP Range of Motion 4) ROM (active, active assisted and/or passive) (visual, goniometer, inclinometer, other: )
KNEE Range of Motion
ANKLE Range of Motion
NEUROLOGICAL EXAMINATION NOT THE CT s JOB!
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
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