Evaluation of passive rom in a child with cmd
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Evaluation of passive ROM in a child with CMD. Robyn Smith Dept. of Physiotherapy UFS 2012. 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 patient

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Evaluation of passive ROM in a child with CMD

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Evaluation of passive rom in a child with cmd

Evaluation of passive ROM in a child with CMD

Robyn Smith

Dept. of Physiotherapy

UFS

2012


Evaluation of passive rom in a child with cmd1

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 patient

  • It is also essential that ROM and muscle lengths are assessed correctly accurately and safely

  • It 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

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;

  • Immobility

  • Hypertonicity/ spasticity

  • Hypotonicity

  • Muscle weakness and imbalances

  • Asymmetry

  • Stereotypical (habitual) movement patterns

  • Growth related factors e.g. difference in bone lengths

  • Biomechanical issues

  • Abnormal/ pathological reflex activity e.g. TLR, ATNR


Evaluation of passive rom in a child with cmd

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 flexion


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

Neck extension


Side flexion

Child in supine

Neutral position of cervical spine

Hands are placed both sides of the head/jaw

Do side flexion of the neck

Ensure that no rotation occurs

Make sure that the child does not compensate with elevation of the shoulder on the side tested

Repeat to the other side and compare ROM

Restricted by tight upper fibres of m. trapezius

Side flexion


Neck rotation

Child sitting or in supine

Hand are placed on sides of the head/jaw to which want to rotate to

Other hand on the occiput

Do rotation of the neck

Make sure that the child is not compensating with lateral flexion

Often restricted

Restricted by tight SCM

Neck rotation


Trunk

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 kyphosis

Child 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 legs

Your hand on the child’s arms and thoracic spine

In 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 multifidus

Limited by excessive extensor tone over the trunk

Trunk flexion


Trunk extension

In a child neutral spine extension is found

Allow the child to sit over a roller

Support 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 slightly

If 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

Trunkextension


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

Lateral flexion


Trunk rotation

Rotation in the thoracic spine is approximately 90 0 and less in the lumber region 12 0

Child sitting on roller/block

Neutral position spine

Ensure that the pelvis is stabilised to prevent pelvic rotation to compensate

Sit behind the patient

Place one hand on the abdomen and the other on the thoracic spine

Evaluate at the various levels of the spine:

Arms side = upper trunk rotation

Arm crossed at 90 0 shoulder = mid trunk rotation and

Arms elevated above 90 0shoulder flexion =lumbar rotation

Restricted by vertebral or muscle stiffness

Trunk rotation


Scapula

Scapula


Scapula1

Scapula

  • Child in side lying

  • Hips and knees flexed, neural spine

  • Assess scapula elevation, depression, protraction, retraction, and rotation


Glenohumeral joint

Glenohumeral joint


Glenohumeral joint1

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 flexion


Shoulder extension

Child in supine

Observe glenohumeral and scapula movement

Avoid compensatory shoulder elevation

Elbow should be in extension

Restricted by tight shoulder extensors

Shoulder extension


Medial and lateral rotation

Child in supine

Shoulder in 450 flexion

Avoid compensatory shoulder elevation

Elbow 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

Medial and lateral rotation


Horizontal abduction

Child can be in supine or in sitting

If seated ensure trunk is stable

Arm is to be abducted horizontally

prevent compensatory movements of shoulder elevation and protraction

Restricted by a tight m.pectoralis

Horizontal abduction


Elbow

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

Elbow flexion and extension


Supination and pronation

Supination and Pronation

  • in supine

  • Perform supination and pronation with the elbow flexed and extended


Wrist

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

Wrist flexion, extension and deviation


Evaluation of passive rom in a child with cmd

Hand


Evaluation of passive rom in a child with cmd

Hand

  • Be vary careful when assessing the ROM at the hand

  • Do 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


Pelvis and lower trunk1

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

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

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


Evaluation of passive rom in a child with cmd

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

Abduction


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

Adduction


Internal and external rotation

Supine, leg bent with 900 hip and knee flexion

Use the lower leg as a lever and do IR/ER hip

Be care of excessive IR in cases where there already seems to be excessive ROM as this is an unstable position for the hip

Can 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 & externus

ER restricted by tight gluteus minimus & medius, TFL

Internal and external rotation


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

Flexion


Extension

Side lying with the lower leg bent up in flexion 900

Ensure that the trunk is in a neutral position

Stabilise at the pelvis and extend the hip

Be careful of not getting lumbar extension

Also guard against too much of a posterior pelvic tilt, adjust the degree of hip flexion of the lower leg

Must 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

Extension


Evaluation of passive rom in a child with cmd

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

Knee flexion and extension


Ankle

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 TIP

Ensure 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 foot

It 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

Dorsiflexion and plantarflexion


Evaluation of passive rom in a child with cmd

Foot


Evaluation of passive rom in a child with cmd

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

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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