Assessing Joint Mobility and Muscle Function: A Comprehensive Guide, Sintesi del corso di Fisioterapia

Scarica Assessing Joint Mobility and Muscle Function: A Comprehensive Guide e più Sintesi del corso in PDF di Fisioterapia solo su Docsity! VALUTAZIONE ARTICOLARE E MUSCOLARE Manuela Vanoli Kendall Clarkson  MOVIMENTI: - FLESSIONE - ESTENSIONE - ABDUZIONE - ADDUZIONE - ROTAZIONE ESTERNA - ROTAZIONE INTERNA - PRONAZIONE/EVERSIONE - SUPINAZIONE/INVERSIONE ATTENZIONE! I MOVIMENTI CHE UN'ARTICOLAZIONE PUO' COMPIERE SONO DETERMINATI DALLA FORMA DELLE SUPERFICI ARTICOLARI, QUINDI NON TUTTE LE ARTICOLAZIONI COMPIONO GLI STESSI MOVIMENTI. CONTRAZIONI: - ISOMETRICA o STATICA (non c’è spostamento articolare, non varia la lunghezza muscolare)‏ - ISOTONICA o DINAMICA (tensione costante con spostamento articolare)‏: ¾ CONCENTRICA (in accorciamento, le inserzioni si avvicinano)‏ ¾ ECCENTRICA (in allungamento, le inserzioni si allontanano)‏ SCALA di VALUTAZIONE della FORZA MUSCOLARE: - 0 assenza di contrazione - 1 accenno di contrazione - 2 contrazione che consente un'escursione articolare completa a favore di gravità - 3 contrazione contro gravità - 4 contrazione contro resistenza - 5 contrazione contro massima resistenza Medical Research Council, 1976 VALUTAZIONE: - OSSERVAZIONE GENERALE (informale) - ANAMNESI - OSSERVAZIONE SPECIFICA (formale) - VALUTAZIONE dei MOVIMENTI ATTIVI - VALUTAZIONE ARTICOLARE - VALUTAZIONE MUSCOLARE - VALUTAZIONE del SISTEMA NERVOSO OSSERVAZIONE INFORMALE: OSSERVO IL VISO DEL PZ, IL CAMMINO E COME SI MUOVE SENZA CHE LUI SAPPIA DI ESSERE OSSERVATO MOVIMENTI ATTIVI: - MOTILITA':QUALITA' e AMPIEZZA del MOVIMENTO - CONFRONTO CON CONTROLATERALE - ANDAMENTO del DOLORE VALUTAZIONE ARTICOLARE PASSIVA: - MOBILITA' dell'ARTICOLAZIONE: ROM (misuro l'ampiezza del movimento in gradi con il goniometro) - DOLORE - END-FEEL 12 SECTION I Principles and Methods ASSESSMENT AND MEASUREMENT OF JOINT RANGE OF MOTION Contraindications and Precautions AROM or PROM must not be assessed or measured if con- traindications to these assessment procedures exist. In special instances, the assessment techniques may have to be performed with a modifi ed approach to be employed safely. AROM and PROM assessment techniques are contrain- dicated where muscle contraction (i.e., in the case of AROM) or motion of the part (i.e., in the case of either AROM or PROM) could disrupt the healing process or result in injury or deterioration of the condition. A few examples are the following: 1. If motion to the part will cause further damage or interrupt the healing process immediately after injury or surgery. 2. If the therapist suspects a subluxation or dislocation or fracture. 3. If myositis ossifi cans or ectopic ossifi cation is sus- pected or present, AROM and PROM should not be undertaken without fi rst ensuring the patient is assessed by a professional who has expertise in the management of these conditions. 14 After ensuring no contraindications to AROM or PROM exist, the therapist must take extra care when assessing AROM and PROM if movement to the part might aggra- vate the condition. A few examples are as follow: 1. In painful conditions. 2. In the presence of an infl ammatory process in a joint or the region around a joint. 3. In patients taking medication for pain or muscle relaxants, because the patient may not be able to respond appropriately and movement may be per- formed too vigorously. 4. In the presence of marked osteoporosis or in condi- tions where bone fragility is a factor, perform PROM with extreme care or not at all. 5. In assessing a hypermobile joint. 6. In patients with hemophilia. 7. In the region of a hematoma, especially at the elbow, hip, or knee. 8. In assessing joints if bony ankylosis is suspected. 9. After an injury where there has been a disruption of soft tissue (i.e., tendon, muscle, ligament). 10. In the region of a recently healed fracture. 11. After prolonged immobilization of a part. After ensuring no contraindications to AROM or PROM exist, the therapist must take extra care when performing AROM assessment where strenuous and resisted movement could aggravate or worsen the patient’s condition. A few examples are as follow: 1. Following neurosurgery 15 or recent surgery of the abdomen, intervertebral disc, or eye 16 ; in patients with intervertebral disc pathology, 15 or herniation of the abdominal wall; or in patients with a history or risk of cardiovascular problems (e.g., aneurysm, fi xed- rate pacemaker, arrhythmias, thrombophlebitis, recent embolus, marked obesity, hypertension, car- diopulmonary disease, angina pectoris, myocardial infarctions, and cerebrovascular disorders). Instruct these patients to avoid the Valsalva maneuver during the strength testing procedure. Kisner and Colby 15 describe the sequence of events in the Valsalva maneuver, which consists of an expi- ratory effort against a closed glottis during a strenu- ous and prolonged effort. A deep breath is taken at the beginning of the effort and held by closing the glottis. The abdominal muscles contract, causing an increase in the intra-abdominal and intrathoracic pressures, and blood is forced from the heart, causing a temporary and abrupt rise in the arterial blood pres- sure. The abdominal muscle contraction may also put unsafe stress on the abdominal wall. To avoid the Valsalva maneuver, instruct the patient not to hold his or her breath during the assessment of AROM. Should this be diffi cult, instruct the patient to breathe out 17 or talk during the test. 15 2. If fatigue may be detrimental to or exacerbate the patient’s condition (e.g., extreme debility, malnutri- tion, malignancy, chronic obstructive pulmonary dis- ease, cardiovascular disease, multiple sclerosis, polio- myelitis, postpoliomyelitis syndrome, myasthenia gravis, lower motor neuron disease, and intermittent claudication), strenuous testing should not be carried out. Signs of fatigue include complaints or observa- tion of tiredness, pain, muscular spasm, a slow response to contraction, tremor, and a decreased abil- ity to perform AROM. 3. In situations where overwork may be detrimental to the patient’s condition (e.g., patients with certain neuromuscular diseases or systemic, metabolic, or infl ammatory disease), care should be used to avoid fatigue or exhaustion. Overwork 15 is a phenomenon that causes a temporary or permanent loss of strength in already weakened muscle due to exces- sively vigorous activity or exercise relative to the patient’s condition. Assessment of AROM Assessment of the AROM can provide the following patient information: • Willingness to move • Level of consciousness • Ability to follow instructions LWBK979-C01-p1-54.indd 12 17/11/11 10:13 PM 15CHAPTER 1 Principles and Methods Normal Limiting Factors and End Feels The unique anatomical structure of a joint determines the direction and magnitude of its PROM. The factors that nor- mally limit movement and determine the range of the PROM at a joint include: • 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 When assessing the PROM of a joint, observe whether the range is full, restricted, or excessive, and by feel determine which structure(s) limits the move- ment. 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 move- ment. 18 The end feel may be normal (physiological) or abnormal (pathological). 19 A normal end feel exists when there is full PROM at the joint and the normal anatomy of the joint stops 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. Normal and abnormal end feels are pre- sented in Tables 1-3 and 1-4 . The end feel(s) for joint move- ments are documented in subsequent chapters based on knowledge of the anatomy of the region, clinical experience, and available references. Although several different end feels may be possible for a particular joint motion, only one end feel will be present. When several different end feels are pos- sible at a joint, this will be indicated using a “/” between each possible end feel. For example, the end feel for elbow fl exion may be soft/fi rm/hard (i.e., soft, fi rm, or hard). Method to Assess End Feel Movement is isolated to the joint being assessed ( Fig. 1-25 A). With the patient relaxed, stabilize the proximal TABLE 1-3 Normal (Physiological) End Feels 18 – 20 End Feel General Terminology (Specific Terminology) Description Hard (Bony) A painless, abrupt, hard stop to movement when bone contacts bone; for example, passive elbow extension, the olecranon process contacts the olecranon fossa. Soft (Soft tissue apposition) When two body surfaces come together a soft compression of tissue is felt; for example, in passive knee flexion, the soft tissue on the posterior aspects of the calf and thigh come together. Firm (Soft tissue stretch) A firm or springy sensation that has some give when muscle is stretched; for example, passive ankle dorsiflexion performed with the knee in extension is stopped due to tension in the gastrocnemius muscle. (Capsular stretch) A hard arrest to movement with some give when the joint capsule or ligaments are stretched. The feel is similar to stretching a piece of leather; for example, passive shoulder external rotation. A Moves humerus Stabilizes scapula B Assesses end feel Figure 1-25 Assessment of passive range of motion (PROM) using glenohumeral joint extension as an example. A. The patient is comfortable, well supported, and relaxed with the joint in the anatomical position. The therapist manually stabilizes the proximal joint segment (e.g., scapula) and moves the distal joint segment (e.g., humerus). B. The distal joint segment is moved to the end of PROM and gentle overpressure is applied to determine the end feel. LWBK979-C01-p1-54.indd 15 17/11/11 10:13 PM END-FEEL sensazione di fine corsa - OSSEO: arresto brusco e duro - CAPSULARE: arresto rigido ma cedevole - TESSUTI MOLLI: arresto elastico dovuto al contatto tra masse muscolari o allo stiramento di parti molli PATTERN CAPSULARE: riduzione dell'escursione articolare passiva secondo modalità specifiche per ogni articolazione. La presenza di P.C. indica una lesione capsulare o una reazione che coinvolge l'articolazione nel suo insieme. PATTERN NON CAPSULARE: la limitazione articolare non rispetta le proporzioni tipiche del P.C. e può essere dovuta ad aderenze legamentose, disturbo intrarticolare o lesione extrarticolare. 57CHAPTER 2 Relating Assessment to Treatment TABLE 2-1 Comparing of Assessment and Treatment Active Movement Passive Movement Resisted Movement Key Steps Assessment Treatment Assessment Treatment Assessment Treatment Assessment Treatment Active ROM (AROM) Active Exercise Passive ROM (PROM) Relaxed Passive Movement Muscle Length Prolonged Passive Stretch Muscle Strength Resisted Exercise PURPOSE Assessment of: Treatment to maintain/ increase: Assessment of: Treatment to maintain/ increase: Assessment of: Treatment to maintain/ increase: Assessment of: Treatment to maintain/ increase: • AROM • Muscle strength (grades 0 to 3) • Ability to perform ADL • Joint ROM muscle strength • Ability to perform ADL • Joint PROM • End feel • Joint ROM • Muscle length • Muscle length • Muscle strength (grades >3) • Muscle strength COMMON TECHNIQUE Explanation/ Instruction Verbal (clear, concise), demonstration and/or passive movement Expose Area Expose area and drape as required Start Position • Safe, comfortable, adequate support • Consider effect of gravity • Safe, comfortable, adequate support, relaxed • Safe, comfortable, adequate support • Consider effect of gravity Stabilization * • Proximal joint segment(s) • Muscle origins • Proximal joint segment(s) • Muscle origin(s) • Muscle origin(s) Movement a • Distal joint segment(s) • Distal joint segment(s) • Joint(s) crossed by muscle(s) • At joint(s) crossed by muscle(s), or none if resist isometric contraction Assistance/ Resistance n/a • Assistance applied at distal end of distal joint segment(s) • Assistance applied at distal end of segment muscle(s) inserts into • Resistance applied at distal end of segment muscle(s) inserts into End Position • End of full or available AROM • End of full available PROM • Muscle(s) on full stretch • End of full available ROM, or • Start position if isometric contraction Substitute Movement Ensure no substitute movement PURPOSE- SPECIFIC PROCEDURE • Estimate and/or measure AROM • Active movement performed according to exercise prescription • Observe and/or measure joint PROM • Note end feel • Passive movement performed according to treatment prescription • Visually observe and/ or measure joint position at maximum stretch of muscle • Joint held at position of maximal muscle stretch for prescribed length of time • Determine the amount of resistance that can be applied and allow patient to move through movement, or hold position • Resisted movement performed or position held against resistance according to exercise prescription (continues) LWBK979-C02-p55-62.indd 57 17/11/11 6:23 PM 58 SECTION I Principles and Methods Purpose-Specific Procedure After applying the common technique, specifi c procedure is used to provide outcomes that meet the specifi c pur- pose of the assessment or treatment. Purpose-specifi c procedures include measuring AROM, PROM, noting the end feel, grading muscle strength, changing the number of times a movement is performed, changing the length of time a position is held, and/or changing the magni- tude of the resistance used. Charting For assessment, deviations from standardized testing pro- cedure and the fi ndings are noted in the chart. For treat- ment, details of the exercise or treatment prescription used and any change in the patient’s condition are noted in the chart. Active Movement Passive Movement Resisted Movement Key Steps Assessment Treatment Assessment Treatment Assessment Treatment Assessment Treatment Active ROM (AROM) Active Exercise Passive ROM (PROM) Relaxed Passive Movement Muscle Length Prolonged Passive Stretch Muscle Strength Resisted Exercise CHARTING • Joint AROM • MMT grade • Describe exercise prescribed • Note any change in patient’s condition • Joint PROM • End feel • Describe treatment prescribed • Note any change in patient’s condition • Joint position • End feel • Describe position and duration of stretch • Note any change in patient’s condition • MMT grade • Describe exercise prescribed • Note any change in patient’s condition * For ease of explanation and understanding, the proximal joint segment or site of attachment of the muscle origin is stabilized and the distal joint segment or site of attachment of the muscle insertion is described as the moving segment. ADL, activities of daily living; MMT, manual muscle testing. NOTE: The area shaded in orange highlights COMMON TECHNIQUE that is the same for similar assessment and treatment. EXAMPLES OF SIMILAR ASSESSMENT AND TREATMENT METHODS Specifi c joint movements and muscles are used as exam- ples to illustrate similar assessments and treatments using active, passive, or resisted movement. In the examples, note that for assessment and treat- ment which use a similar type of movement, the “Common Technique” is the same, but the “Purpose,” “Purpose- Specifi c Procedure,” and “Charting” are different. In Table 2-1 and in these examples, for ease of explana- tion and understanding, the proximal joint segment or site of attachment of the origin of the muscle is stabilized and the distal joint segment or site of attachment of the inser- tion of the muscle is described as the moving segment. TABLE 2-1 Continued LWBK979-C02-p55-62.indd 58 17/11/11 6:23 PM