evaluation of passive rom in a child with cmd
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Evaluation of passive ROM in a child with CMD
Robyn SmithDept. of Physiotherapy
UFS2012
Evaluation of passive ROM in a child with CMD
It is essential to use your observational skills to determine what ROM and muscle lengths need to be assessed in a patientIt is also essential that ROM and muscle lengths are assessed correctly accurately and safelyIt is crucial to note the available ROM in degrees or as a fraction Also clearly not the restricting factor e.g. joint, capsule, muscle, tone etc.
Causes of deformities
The cause of deformities in children with CMD is extensive and deformities may even result due to a combination of the following factors;ImmobilityHypertonicity/ spasticityHypotonicityMuscle weakness and imbalancesAsymmetry Stereotypical (habitual) movement patternsGrowth related factors e.g. difference in bone lengths Biomechanical issuesAbnormal/ pathological reflex activity e.g. TLR, ATNR
Neck
Neck flexion
One hand on occiput
Other hands index finger on the chin and the middle finger under chin
Make sure of the correct alignment of the cervical spine (chin tuck)
Provide slight traction and provide high cervical flexion
Restricted by tight neck extensors
Neck extension
Child in supine
Index finger placed between the vertebrae lift the hand up so that cervical extension is done
Repeat at the various levels of the cervical spine
Restricted by tight neck flexors
Side flexion
Child in supineNeutral position of cervical spineHands are placed both sides of the head/jawDo side flexion of the neckEnsure that no rotation occursMake sure that the child does not compensate with elevation of the shoulder on the side testedRepeat to the other side and compare ROM
Restricted by tight upper fibres of m. trapezius
Neck rotation
Child sitting or in supineHand are placed on sides of the head/jaw to which want to rotate to Other hand on the occiputDo rotation of the neck Make sure that the child is not compensating with lateral flexionOften restricted
Restricted by tight SCM
Trunk
Trunk flexion
Children that have increased tone in their m. pectoralis or those that make excessive use of flexion patterns of the UL and trunk are at an increased risk of developing a thoracic kyphosisChild is to be seated on a block/end of a roller. Allow the child to do trunk flexion, with the head and arm lowered between legsYour hand on the child’s arms and thoracic spineIn the case of a smaller child of an extremely spastic child one can even observe flexion in side lying or picking the child up in a flexed position
Restricted by shortened back extensors e.g. erector spinae and multifidusLimited by excessive extensor tone over the trunk
Trunk extension
In a child neutral spine extension is foundAllow the child to sit over a rollerSupport the arms in 900 shoulder flexion Place one hand on the thoracic spinous process and press downwards towards the pelvis, the arms should naturally lift slightlyIf the child has severe flexor spasticity this can be tested in prone over a roller . In a smaller child the legs can be lifted off the supporting surface with one hand under the hips/pelvis and the other hand on thoracic vertebrae
Restricted by shortened trunk flexors ie. Mm. abdominals, especially rectus abdominus
Lateral flexion
Lateral flexion ROM is greater in the lumbar spine, and less in the thoracic spine area due to the ribcage
Child sitting on roller/block
Neutral position spine
Provide pressure on the lower ribcage in the direction of the opposite hip
Whilst doing a weight shift
In the case of very limited side flexion lift you can do side flexion by giving traction to the arm in ER, give counter pressure to the scapula
Restricted by shortened abductors and quadratus lumborum on the opposite side
Trunk rotation
Rotation in the thoracic spine is approximately 90 0 and less in the lumber region 12 0Child sitting on roller/blockNeutral position spineEnsure that the pelvis is stabilised to prevent pelvic rotation to compensateSit behind the patientPlace one hand on the abdomen and the other on the thoracic spineEvaluate at the various levels of the spine:Arms side = upper trunk rotationArm crossed at 90 0 shoulder = mid trunk rotation and Arms elevated above 90 0shoulder flexion =lumbar rotation
Restricted by vertebral or muscle stiffness
Scapula
Scapula
Child in side lying
Hips and knees flexed, neural spine
Assess scapula elevation, depression, protraction, retraction, and
rotation
Glenohumeral joint
Glenohumeral joint
Shoulder flexion
Child in supine
Observe gleno-humeral and scapula movement
Avoid compensatory shoulder elevation
Elbow should be in extension
Restricted by tight shoulder extensors ie. Latissimus dorsi
Shoulder extension
Child in supine
Observe glenohumeral and scapula movement
Avoid compensatory shoulder elevation
Elbow should be in extension
Restricted by tight shoulder extensors
Medial and lateral rotation
Child in supineShoulder in 450 flexionAvoid compensatory shoulder elevationElbow should be inflexion
Lateral rotation restricted a tight mm. pectoralis, teres major, subscapularis and latissimus dorsi Medial rotation restricted by a tight mm. infraspinatis and teres minor
Horizontal abduction
Child can be in supine or in sittingIf seated ensure trunk is stableArm is to be abducted horizontally prevent compensatory movements of shoulder elevation and protraction
Restricted by a tight m.pectoralis
Elbow
Elbow flexion and extension
in supine
Stabilise the upper arm
Do elbow flexion and extension
If elbow extension is limited it most likely due to tight m. biceps
Supination and Pronation
in supine
Perform supination and pronation with the elbow flexed and extended
Wrist
Wrist flexion, extension and deviation
Stabilise the forearm
Provide traction, especially in the case of a stiff wrist
When assessing wrist extension make sure that you grasp close to the wrist joint, if you grasp the distal hand you run the risk of hyper-mobilising the carpal bones
Wrist extension is often restricted by shortening of the long flexor muscles especially in the case of patients with increased flexor tone and fisting
Hand
Hand
Be vary careful when assessing the ROM at the handDo not do supination of the hand as this may damage the carpal bones and/or hyper-mobilise them In a closed or fisted hand where the long flexors are shortened or there is excessive flexor spasticity do not pull the finger out as the MCF joint is easily hyper-mobilised and the muscles overstretched, first make use of sweep taping to inhibit the flexor tone. Once you have got the hand slight open one can then work from the inside of the hand out.In case of palmar thumbing be careful not to pull the thumb out of the palm of the hand this hyper-mobilises the MCF joint. Provide enough stability to ensure that the correct joint and movement is being assessed.
Pelvis and lower trunk
Pelvis and lower trunk
Child in supine with his hips flexed to 900
Physiotherapist in half kneeling supporting the legs.
Ensure that the pelvis is in a neutral position
Move the legs laterally to the sides using leg/arms
Posterior and anterior pelvic tilt
Child in supine with his hips flexed to 900
Physiotherapist in half kneeling supporting the legs.
This evaluates the posterior pelvic tilt
Lowe the legs to assess anterior tilt
Lumbosacral rotation
Child in supine with his hips flexed to 900
Physiotherapist in half kneeling supporting the legs.
Do rotation to the left and right
Test in controlled manner
Be careful in the patient with already evident hyper-mobility of the lumbosacral joint
Hip
Abduction
Child in supine
If child has a severe lordosis bend the other leg up
Do abduction of the hip
Be careful avoid compensation by using ER
Abduction may be restricted by severe adductor spasticity and shortening of the adductors
Adduction
Test the length of the TFL
Supine
If the left leg is being tested, lift the right hip and move it into adduction, this helps to stabilise the pelvis
Now lift the left leg and move it into adduction
Adduction might be restricted by tight m.gluteus medius
Internal and external rotation
Supine, leg bent with 900 hip and knee flexionUse the lower leg as a lever and do IR/ER hipBe care of excessive IR in cases where there already seems to be excessive ROM as this is an unstable position for the hipCan also be done in prone as above, just ensure that the rotation of the femur is neutral
IR restricted by tight lateral rotators of the hip ie. mm. piriformis, quadratus femoris and obturator internus & externusER restricted by tight gluteus minimus & medius, TFL
Flexion
Supine or side lying
Hip flexion with knee flexion
Can also test the length of m. hamstrings in supine. It is important to observe if the opposite legs pelvis/hip lifts
Can be restricted by tight m. gluteus maximus
Extension
Side lying with the lower leg bent up in flexion 900
Ensure that the trunk is in a neutral positionStabilise at the pelvis and extend the hip Be careful of not getting lumbar extensionAlso guard against too much of a posterior pelvic tilt, adjust the degree of hip flexion of the lower legMust differentiate whether m. quadriceps (with knee in flexion) or m. iliopsoas (with knee in extension) is restricting restricting
Extension can be restricted by a tight m. iliopsoas or m. quadriceps over the hip
Knee
Knee flexion and extension
Can be tested in sitting over end plinth or sitting on a block
Extension can be limited by shortened m. hamstring
Flexion of the knee can be limited by m. quadriceps
Ankle
Dorsiflexion and plantarflexion
Can be tested in prone or in supine. Prone is often a more effective position to use especially in the case of severe extensor spasticity as this is a TIPEnsure that the foot is correctly aligned Grasp the heel to ensure that the DF movement actually takes place at the ankle and not the mid footIt important to test DF as well, especially in cases where the child constantly wears AFO’s
DF restricted by a tight m. gastrognemius PF can be restricted by a tight m. tibialis anterior
Foot
Foot
In supine evaluate rear foot mobility
Also look at midfoot pronation and supination
Also evaluate the length of the long toe flexors
Look out for shortening of the plantar fascia
Observe for foot abnormalities and biomechanical alignment issues
References
Kendall, F.P., Kendall McCreary and Provance, P.G. 1983. Muscle testing and function. 4ed. Williams & Wilkins. Baltimore
Kriel, H. 2007. Cerebral Motor disturbances (lecture notes, UFS: unpublished)
Smith, R. 2009. Paediatric Dictate (lecture notes, UFS: unpublished
Images courtesy of Google images (2009)
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