Chiroview presented by:
Sigmund Miller, DC
Dean of Academic Affairs
Texas Chiropractic College
281.998.6059


ChiroView Presents John Gearhardt, MD  Range of Motion. . .

While on the topic of outcome assessment tools, I thought this brief 
overview on ROM would be a nice touch from a specialist who is 
uniquely qualified.

Today¼s author is John J. Gerhardt, MD, a Clinical Associate 
Professor in Orthopedics and Rehabilitation Emeritus, and 
contributing author to the AMA Guides to the Evaluation of 
Permanent Impairment, 4th Edition. I am grateful that he has 
allowed me to provide this information.

One brief note...

For "Member Subscribers" please check-out the information I posted 
today which can be found in the "Talkin' Back section of our site. 
Under "clinical rounds" I just posted information on #2 abdominal 
aortic aneurysm, #39 costochondritis, and #48 prostate cancer. 
Under "Treatment Criteria", I posted #23 guidelines for managing 
rheumatoid arthritis, #25 car safety seats for children, and #26 
screening for adolescent scoliosis. Under "interesting stuff" I posted 
the following articles #29 Episodic Snapping of Triceps Medial Head 
Due To Weight Lifting, #30 Seat Belts Plus Air Bags Reduce Spinal 
Injuries, #32 Decreased Calcium Absorption & Hip Fractures, and 
#33 Medical Realities of Cauda Equina Syndrome Secondary To 
Lumbar Disc Herniation. 

I hope you find this information helpful. 

Before beginning Dr. Gearhardt¼s article on "range of motion", here is 
my „take¾. From a practical perspective, in addition to assessing 
„how far¾ one can, or cannot perform any particular active ROM, 
during examination I recommend noting and recording „how smooth 
and regular that specific range was carried out. For example, with 
lumbar flexion, when returning upright from forward bending, many 
patients with low back pain display motion that is dysrhythmic or 
irregular. That should be  noted in your chart.

I also recommend noting at what point your patient reports 
symptoms. For example, I would note „patient reports low back pain, 
more focal in nature, in and about L5-S1 on the right at 
approximately 15 degrees lateral bending.

Finally, some report spinal ranges of motion by using „percentages 
of normal¾. I did it that way for years and „never went to jail for 
it¾! For example if normal lumbar flexion is 90 degrees and the 
patient went to 45 degrees only, then I would report „lumbar flexion 
was 50% normal excursion¾. 

Here is some additional sample verbiage I have used when describing 
this type of patient... „patient¼s fingertips approached mid-shin [or 
if you choose "14 inches from the floor"], lumbar curve failed to 
fully reverse, patient listed to the left at abbreviated end range, 
patient was dysrhythmic upon returning to upright position and 
required thigh support. You get the idea. As you can see, there are 
lots of ways to effectively record changes of ROM during the course 
of treatment. 

Obviously many of these „qualitative findings¾ can be valuable, and 
should to be noted in addition to recording the degree of motion 
obtained. 

Next week I will broadcast on the Roland Morris outcome assessment 
tool that¼s used for low back pain. It¼s simple to integrate, score and 
interpret. To obtain a copy of this form „member subscribers¾ can go 
to http://www.ChiroViewPresents. Click the „members¾ hyperlink, 
enter your username and password. Click "clinical forms" on the 
"members page" and then click Roland Morris or any of the other 20 
forms just like it. By the way, I will be adding several other 
excellent outcome tools during the next 1-2 weeks, so stay awake!

Now here is what Dr. Gearhardt has to say on the topic. . .

Range of Motion - Impairment - Outcome Assessment

Range of motion has long been used for determination of function and 
to objectify physical examination. As such it was also useful as part 
of evaluation of impairment and disability.

To be of value, range of motion measurements must be objective. 
Objectivity depends on accuracy, reproducibility and comparability 
of measurements. I have spent many years working to develop 
methods to more accurately measure range of motion, and to simply 
and accurately record those measurements. To achieve 
comparability, however, standardization of features of instruments, 
the measuring technique and proper training of investigators and 
practitioners is necessary.

Recording of range of motion and documentation of a patient¼s 
condition in a given moment in time is to a trained and experienced 
practitioner a fairly simple matter. Documenting and assessing a 
patient¼s progress over time, is a more complex issue. Having a 
recognized standard to compare a patient against, such as the AMA 
Guides to the Evaluation of Permanent Impairment, 4th Edition, 1993 
is a very useful tool.

Although the AMA Guides have been designed to evaluate permanent 
impairment, that is, evaluation after the time of maximal medical 
improvement has been reached, it still provides a useful, objective, 
recognized frame of reference to measure the status of the patient 
against during treatment. It is valid to measure a patient¼s ranges of 
motion in an initial examination setting and monitor progress of 
disease or response to treatment over time in follow up 
measurements. These interim measurements can be compared with 
initial measurements to objectively assess a patient¼s progress (or 
regress), if objective measurements have been secured. Once 
patient¼s condition has stabilized and no further progress has been 
shown over an appropriate period of time and a number of 
examinations, then the evaluation of permanent impairment based on 
the AMA Guides can be entertained. To be consistent and comparable 
the Range of Motion Model in the 4th Edition of the Guides must be 
used.

Measurements of Ranges of Motion particularly passive ROM, should 
be omitted or done very carefully in a patient with an acute trauma. 
Measurements should be stopped if the patient expresses even slight 
pain and not taken in the direction in which the injury occurred, for 
example, flexion in a flexion injury or inversion in an inversion 
injury until the tissues have not only healed, but sufficiently healed 
to withstand load without interfering with the full healing process 
or causing additional injury. This is especially important when 
measurements are taken by specialists or practitioners not familiar 
with injuries or the time necessary for proper healing of various 
traumatized structures in the neuro-musculo-skeletal system.

When observing the described precautions, the impairment values in 
the AMA Guides to establish initial and interim impairment data, 
gives the practitioner a valid, objective standard with which to 
measure a patient¼s functional improvement, making it an important 
outcome assessment tool. 

For more information contact John J. Gerhardt MD at P.O. Box 22248	
	
Portland, OR  97269-2248 or send an e-mail to 
Gerhardt@hevanet.com