Stiffness
What is the International Classification of Functioning, Disability and Health (ICF) and its components?
--> classification framework developed by the WHO to provide a comprehensive & standardized way of describing health and health-related states, beyond the traditional medical model of focusing solely on diseases and impairments, considers broader context of health in 5 categories :
body functions + structures of people, and impairments thereof (functioning at the level of the body)
activities of people (functioning at the level of the individual) & activity limitations experienced
participation/involvement of people in all areas of life, & participation restrictions experienced (functioning of a person as a member of society)
environmental factors which affect these experiences (and whether these factors are facilitators or barriers)
Personal factors (not formally part of classification) like age, gender, lifestyle etc
What is Active range of motion?
Actively performed by client, achieved when opposing muscles contract & relax, resulting in joint movement
provides info about :
--> Physiological range of movement client can perform on their own
--> Patient willingness to move
--> Ability of muscles to contract & coordinate the movement
--> Movements that cause/increase/decrease pain
--> Muscle activation/strength
--> Ability to follow instructions
--> Perform functional activities
What is the 6 step procedure for assessing AROM and PROM?
1) Observe each movement one at a time, bilaterally and symmetrically (unaffected side first), or where appropriate both sides at the same time (for AROM only)
2) Good instructions
3) Proper patient positioning
4) Adequate control/stabilisation of proximal joint segments
5) Learn and recognise trick or substitute movements a patient could use
6) Question for symptoms
• The starting position for measuring ROM is in the anatomical position (except rotations in the transverse plane)
• Use neutral zero method (measure 0-180°) where the anatomical position is 0°
What are the 4 different types of validity?
1. Face validity - does it appear to assess what we want to assess?
2. Criterion validity - how accurately a test measures the outcome it was designed to measure
3. Content validity - how well does the test cover all relevant parts of the topic/construct/behaviour it aims to measure?
4. Construct validity - the extend to which your test or measure accurately assesses what it's supposed to
Step 1
1. Explain the procedure, provide warnings
What are the causes of stiffness?
Immobilisation of joints, muscles & connective tissue (muscles immobilised in a shortened position => decreased number of sarcomeres)
Disuse
Disorders of brain, nerve, muscle, joints and connective tissue
What is Passive range of motion?
achieved when outside force (therapist or CPM machine) causes movement of a joint and is usually the maximum range of motion that a joint can move
provides info about :
--> Amount of movement possible at joint --> ability of client to relax
--> end feel of joint*
--> presence of pain/change in pain
How do you assess and measure muscle length?
1 joint : the joint crossed by the muscle is positioned so that the muscle is lengthened across the joint.
2 joints : one of the joints the muscle crosses is positioned so that the muscle is lengthened across the joint. This joint position is held and the therapist moves the second joint as far as possible through ROM to maximally lengthen/stretch the muscle
What are the 2 types of reliability?
1. Inter-rater reliability - consistency of measures between 2 raters
2. intra-rater reliability - consistency of measure at different times by same rater
Step 2
AROM: Client performs movement
• Observe (and measure) ROM
• Assess quality as well as quantity of movement + end feel
• Compare sides
How do we assess stiffness?
--> by assessing range of motion as part of your objective assessment
--> goniometers, inclienometer, tape measure, apps
What are indications, contraindications and precautions?
Indications : informed consent + potential neurological or musculoskeletal reason for signs & symptoms
Contraindications : medical red flags (indicators of possible serious pathology) ie. Non mechanical symptoms, unremitting night pain, malaise, fever, recent unexplained weight loss, cauda equine syndrome, fracture
Precautions :
- Presence of infectious or inflammatory process
- Patients taking pain or muscle relaxant medication
- Osteoporosis or bone fragility
- Instability, hypermobility or subluxed joint/s
- Painful conditions where assessment may aggravate - Recent injuries, including after soft tissue injury or newly united fracture.
- Suspicion of VBI symptoms
Describe what AROM and PROM results show
AROM = PROM : more likely inert structure
AROM < PROM = more likely contractile structure
AROM should never be > than PROM
What is the goniometry measurement error?
Digital goniometers & manual long-arm goniometers both have high inter and intra-rater reliability.
- Standard errors of measurements range from 2.4 to 4.9 degrees for goniometry (fingers) to up to 6-10 degrees (knees)
- When measuring/recording measurements it is ok to round to the nearest 5 degrees
Step 3
Overpressure
OP when indicated (if AROM is clear) using sensitive, controlled handling and appropriate body mechanics
• May be associated with discomfort.
• Must be aware of possible signs of hypermobility or
instability in your client before proceeding.
What are the aims in assessing stiffness?
- Aid in diagnosis (what tissues are affected, what is causing the movement restriction)
- Quantify the impairment
- Plan to change it, monitor it or ignore it
- Evaluate using outcome measures within session & between sessions
What is end feel?
--> sensation examiner is able to feel at end of available passive range of motion
- can give idea of which structure may be limiting joint range of motion
- soft, capsular, bony, firm, hard, spasm, springy, or not there (empty)
- what is normal (physiological) or abnormal (pathological)?
How can you increase reliability of AROM and PROM?
• Universal goniometer better than eyeballing
• Use same tool
• Ensure clothes don’t inhibit movement
• Same time each day, including with relation to
medication (eg Parkinson’s Disease- rigidity will
fluctuate with on dose/off dose phenomena)
• Same patient position
• Same bony landmarks
Step 4
PROM (if AROM painful or not full) : Therapist performs movement using sensitive, controlled handling & appropriate body mechanics
• Measure ROM
• Assess quality as well as quantity of movement + end feel
• Compare sides
What are the 5 subsets of the musculoskeletal system?
Inert : Bone, ligament, joint capsule, synovium, cartilage, fascia, skin
Contractile : Muscle, tendon, tenoperiosteal junctions
Neurological : Peripheral nerves, spinal cord, nerve roots, brain
Vascular : Capillaries, arteries, veins
Integration of systems : Interplay of these systems
Step 5
RISOM: Provide resistance to an isometric muscle contraction with the joint at mid-range