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
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
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
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 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
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
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 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
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 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
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 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
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
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
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 hypermobilises 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 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
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
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
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 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
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)