Active & passive insufficiency

Muscles categorized according to number of joints they cross to:

- One-joint muscles, Example: brachialis

- Two-joint muscles, Example: biceps brachii and triceps brachii

- Multi-joint muscles, Example: flexor digitorum profundus

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Active insufficiency: The muscle that crosses more than one joint when
produces movement at all this joint and reaches such a shortened position
that is no longer has the ability to develop effective tension.
Passive insufficiency: The multi-joint muscle length is usually not
sufficient to lengthen and allow full ROM at all of the joints the muscle
crosses. So if an examiner assesses a two-joint or multi-joint muscle the
individual must be positioned so the passive tension in the muscle doesn`t
limit the joint ROM.

Joint range of motion

Kinematics is the term given to the study of movement.
• Osteokinematics: gross movements of bones in space (movement
of limbs)
• flexion / extension
• abduction / adduction
• internal rotation / external rotation
• Arthrokinematics: specific movements of joint surfaces.
• roll
• glide (or slide)
• spin

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 Movement Terminology
Angular Movements
Angular motions refer to movements that produce an increase or a
decrease in the angle between the adjacent bones and include flexion,
extension, abduction, and adduction.

- Flexion: bending of a part so the anterior surfaces come closer

together.
- Extension: the straightening of a part and movement is in the
opposite direction to flexion movements.
- Hyperextension: movement that goes beyond the nor mal
anatomical joint position of extension.
- Abduction: movement away from the midline of the body or body
part.
- Adduction: movement toward the midline of the body or body part.
- Internal (medial, inward) rotation: turning of the anterior surface
of a part toward the midline of the body
- External (lateral, outward) rotation: turning of the anterior
surface of a part away from the midline of the body.
Planes and Axes:
Joint movements are more easily described and understood using a
coordinate system that has its central point located just anterior to the

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second sacral vertebra, with the subject standing in the anatomical
position. The coordinate system consists of three imaginary cardinal
planes and axes.
- A plane is an imaginary flat surface running through the body.
- An axis is an imaginary line at right angles to the plane, about which
the body rotates

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 Joint ROM assessment:
Joint ROM is the amount of movement that occurs at a joint to produce
movement of a bone in space.
Main Types of ROM

1. Passive range of motion (PROM) is the ROM that is achieved

when an outside force (such as a therapist or a CPM machine)
exclusively causes movement of a joint and is usually the maximum
range of motion that a joint can move. Usually performed when the
patient is unable or not permitted to move the body part.

2. Active range of motion (AROM Usually performed by the patient

independently and when the patient can voluntarily contract, control,
and coordinate a movement.

Measurement of AROM
When the patient actively moves through the range, emphasize the
exactness of the movement to the patient so that substitute motion at other
joints is avoided.
Assessment of PROM
PROM is usually slightly greater than AROM, owing to the slight elastic
stretch of tissues and in some instances due to the decreased bulk of relaxed
muscles. However, the PROM can also be greater than the AROM in the
presence of muscle weakness.
Assessment of the PROM provides information about the following:
• Amount of movement possible at the joint, whether the range is
full, restricted, or excessive
• Movements that cause or increase pain
• Factors responsible for limiting movement (end feel)
Normal Limiting Factors and End Feels
The factors that normally limit movement and determine the range of the
PROM at a joint include:
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• The stretching of soft tissues (i.e., muscles, fascia, and skin)
• The stretching of ligaments or the joint capsule
• The apposition of soft tissues
• Bone contacting bone
The end feel is the sensation transmitted to the therapist’s hand at the
extreme end of the PROM that indicates the structures that limit the joint
movement.
- The end feel may be normal (physiological) or abnormal
(pathological).
A normal end feel exists when there is full PROM at the joint and the
normal anatomy of the joint stop the movement.
An abnormal end feel exists when there is either a decreased or an
increased passive joint ROM or when there is a normal PROM, but
structures other than the normal anatomy stop joint movement.

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 ROM Measurement
Principles of evaluation:
- Communication:
1. speak slowly. 2. Conduct concise words.
3. Listen carefully. 4. Explain procedures
- Visual observation:
1. The body parts exposed for visual inspection.
2. Visual observation includes fascial expression, body posture,
functional activities, muscle contour and skin color condition and
creases.
- Palpation:
• Palpation is the examination of the body surface by touch.
• It is used to assess skin temperature and texture, soft tissue consistency
and bony irregularity.

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Factors affecting range of motion:
1. Age: Studies have found that older adult groups have somewhat less
ROM than younger adult groups due to decrease joint flexibility with
aging.
2. Gender: The effects of gender on the ROM appeared to be joint and
motion related. If gender differences in the amount of ROM are found,
adult females are reported to have slightly greater ROM than adult
males.
3- Other factors as:
- Integrity of joint surfaces
- Shape of articulating surfaces
- Health of the joint
- Health of the surrounding tissues
- Mobility & pliability of soft tissues
- Various diseases & pathological conditions as:
o Ankylosing Spondylitis.
o Osteoarthritis (OA)
o Rheumatoid Arthritis

Instrumentation of ROM Measurement

- A goniometer is an apparatus used to measure joint angles. The
goniometer chosen to assess joint ROM depends on the degree of
accuracy required in the measurement, the time, and resources
available to the clinician, and the patient’s comfort and well-being.
- Goniometry' is derived from the Greek words: 'gonia' meaning angle
and 'metron' meaning measure, Therefore, goniometry refers to the
measurement of angles created at human joints by the bones of the
body.
- When doing clinical research, the therapist should investigate
alternative instruments that will offer a more stringent assessment of
joint ROM, Radiographs, digital images, photographs, photocopies,
and the use of the electro goniometer may give objective, valid, and
reliable me sures of ROM but are not always practical or available
in the clinical setting.

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 - In the clinical setting, the universal goniometer is the goniometer
most frequently used to measure ROM for the extremity joints.
Types of Goniometers
1- Universal Goniometer The universal goniometer is a 180 ° or 360 °
protractor with one axis that joins two arms. One arm is stationary,
and the other arm is movable around the axis or fulcrum of the
protractor. The size of universal goniometer used is determined by
the size of the joint being assessed. Larger goniometers are usually
used for measurement of joint range at large joints.

2- Gravity Goniometer/Inclinometer
Inclinometers are like universal goniometers, but they have only one
arm with a weighted pointer. This pointer remains vertical under the
influence of gravity, making it easy to measure the angle of
inclination at a joint.

3 -Electro goniometers (Single Axis --Twin Axis): Electro goniometers are

electronic devices that use sensors to measure the range of motion at a joint.
They are more accurate than traditional goniometers, but they can also be
more expensive and difficult to use.

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Twin Axis is designed specifically for measurement of joint motion in two
planes and is available as a wireless or wired sensor.
Single Axis is designed to measure angles in one plane only like
flexion/extension of finger joints and is available as a wireless or wired
sensor.

4-A smartphone as a digital goniometer has several benefits like

availability, ease of measurement, application-based tracking of
measurements, and one-hand use. These goniometers use the camera on
your device to track the movement of markers placed on the skin over the
joint. They are easy to use and relatively inexpensive, but they may not be
as accurate as electro goniometers.

4-Arthrodial Goniometer are specialized goniometers that are used to

measure the range of motion at specific joints, such as the
temporomandibular joint (TMJ) or the shoulder joint. They are typically
larger than universal goniometers and have features that make them easier
to use for measuring the range of motion at these complex joints.
some examples of how arthrodial goniometers are used:
1 -TMJ range of motion: To measure TMJ range of motion, the arthrodial
goniometer is placed on the patient's chin and jaw. The patient is then asked

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to open their mouth as wide as possible, and the angle of the jaw is
measured.
2- Shoulder range of motion: To measure shoulder range of motion, the
arthrodial goniometer is placed on the patient's shoulder. The patient is then
asked to move their arm in different directions, and the angle of the arm is
measured at different points in the range of motion.

Contraindications
Conditions for which a goniometer ought not to be used to measure active
range of motion include the following:
- Joint dislocation
- Unhealed fracture
- Post-surgery if movement disrupts the healing process
- Regions of osteoporosis or bone fragility, as forced measurements
may cause iatrogenic injury
- Immediately following an injury where disruption of soft tissue is
likely
precautions
- Infection or inflammation around a joint
- Severe pain aggravated by movement
- Hypermobility or instability
Complications
Complications related to goniometry are limited and mainly due to faulty
techniques. They are as follows:
- The error of measurement inaccurate measurements due to faulty
technique can have a drastic effect on the patient's treatment.

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Goniometer measurement guidelines
- goniometer can evaluate both active as well as passive range of
motion.
- Positioning plays a vital part in goniometry because it helps to place
the joints in a zero starting position or a neutral position and helps
to stabilize the proximal joint segment. The examiner stabilizes the
proximal joint component and then carefully moves the distal
component of the joint through its entire available range of motion
until reaching the end feel.
- The same goniometer should always be used to reduce the chances
of instrumental error.
Steps
- After estimating the available range of motion and the examiner
returns the distal component to the starting position. The examiner
palpates the relevant bony landmarks and aligns the goniometer.
- The examiner records the starting measurement and removes the
goniometer, and the patient moves the joint through the available
range of motion.
- Once the joint has run through the available range of motion, the
examiner replaces and realigns the goniometer and reads and records
the measurement.
- The examiner repeats the measurement three times and calculates
the average; this is the active range of motion measurement.
- The examiner compares the reading with the contralateral side.
- The joint is then moved passively through its passive range of
motion (PROM), and the steps mentioned above are repeated to
measure PROM accurately.
- Care is necessary to make sure the patient does not move his body
while moving the joint, thereby ensuring accurate measurement.

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