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Total Passive ROM

Exams and Signs

Historical Overview

  • Range of motion (ROM) is an essential component of hand function evaluation and one of the most commonly measured variables by hand surgeons.1,2
  • Historically, physicians used a metric ruler or goniometer to measure passive ROM.3 Manual goniometers can measure joints efficiently, but their use may result in up to 10° of inaccuracy.4By 2006, a new goniometer was developed, particularly for the measurement of small joints.5

Description

  • Total passive ROM, or total passive motion (TPM), is the sum of the passive metacarpophalangeal (MP), proximal interphalangeal (PIP), and distal interphalangeal (DIP) arc of motion in degrees of an individual digit. This value is calculated after passively extending and flexing each finger, and can then be compared with that of the contralateral hand or a normative value to provide a more accurate assessment of the digit’s passive ROM.6,7

Pathophysiology

  • There are a number of conditions that may contribute to loss of TPM, including rheumatoid arthritis (RA), osteoarthritis (OA), trigger finger, trigger thumb, Dupuytren’s disease, cerebral palsy, and neurological injuries.8,9
  • TPM can also be restricted by pain, fracture, or tenosynovitis, and in patients recovering from hand surgery.7,10
  • There will be a typical pattern of tenodesis when a patient loses motion from a neurological injury.8
  • In infants and children with cerebral palsy, it is helpful to exercise with passive ROM so that the patient does not develop further fixed-joint stiffness.9

Instructions

  1. Obtain an accurate and complete patient history, including any sports-related injuries. Ask the patient to rate the amount of pain s/he normally experiences in their fingers on a scale from 1-10.
  2. Assist the patient in placing the MP, PIP, and DIP joints of each finger in maximum passive flexion and extension, and measure values for each joint separately with a goniometer.11
  3. Calculate the TPM by subtracting the total passive flexion of the MP, PIP, and DIP joints from the total extension deficit of the same joints.7
  4. Repeat the same steps to the corresponding joints of the contralateral hand.
  5. Calculate TPM% by dividing the TPM of the injured finger by the TPM of the contralateral finger.7

Variations

  • Passive ROM also evaluates flexion and extension, as well as pronation, supination, abduction, adduction, and rotation of affected joints in the hand, wrist, and/or elbow, and it does not summate the values for finger flexion and extension. Passive ROM is more effective for determining if a joint is stiff or not, while TPM indicates if the functional unit of a finger lacks motion.1
  • Another technique to evaluate lack of overall finger flexion is measuring the distance between the finger pulp and distal palmar crease while the hand is in fisted position.1

Related Signs and Tests

  • Pulp-to-palm, passive
  • Passive stretch test
  • Range of motion: Active
  • Range of motion: Passive
  • Total active ROM
  • Neuromuscular testing (Culp)
  • Nerve conduction studies
  • Grip strength
  • Radiographs
  • Magnetic resonance imaging (MRI)

Diagnostic Performance Characteristics

Approximate Typical Passive ROM Values10,12

Joint

Motion

Degrees (°)

MP

Extension

0

Flexion

90

PIP

Extension

0

Flexion

120

DIP

Extension

0

Flexion

40-50

 

TPM Evaluation System7

Score

TPM%

Excellent

Normal

Good

<75

Fair

50-75

Poor

<50

 

Diagnoses

  • RA
  • OA
  • Trigger finger
  • Trigger thumb
  • Cerebral palsy
  • Dupuytren’s disease
  • Tenosynovitis
  • Metacarpal fracture
  • Phalanx fracture
  • Extensor tendon laceration

Additional Information

Presentation Photos and Related Diagrams
Measuring Range of Motion with Digital Goniometer
  • Digital Goniometer
    Digital Goniometer
  • Measuring MP joint range of motion with the digital goniometer.
    Measuring MP joint range of motion with the digital goniometer.
  • Measuring PIP joint range of motion with the digital goniometer.
    Measuring PIP joint range of motion with the digital goniometer.
Definition of Positive Result
  • A positive result occurs when the patient displays a TPM% that is fair or poor in at least one of the digits evaluated.
Definition of Negative Result
  • A negative result occurs when the patient displays a TPM% that is either good or excellent in every digit evaluated i.e. the finger has a normal range of motion. 
Comments and Pearls
  • Range of motion can be assessed as either active or passive.  When doing a passive range of motion assessment, the examiner places the joint in the maximum position allowed by the soft tissue constraints of the joint without the patient’s muscle power.
  • In order to assess finger ROM thoroughly, the wrist must be in neutral position to allow tendon excursion of the fingers’ long flexors and extensors. Flexion of one finger is measured by maximally flexing the other three fingers, and extension of one finger is measured by maximally extending the other three fingers actively.1
  • If there is a difference between joint active and passive ROM, this is called active-passive mismatch, which may be caused by a tendon adhesion.3
  • For patients with RA, therapy gloves may improve active ROM.13
Diagnoses Associated with Exams and Signs
References
  1. Dincer, F and Samut, G. Physical Examination of the Hand. Hand Function: A Practical Guide to Assessment. New York: Springer Science and Business Media, 2014.
  2. Macedo, LG and Magee, DJ. Effects of age on passive range of motion of selected peripheral joints in healthy adult females. Physiother Theory Pract 2009;25(2):145-64. PMID: 19212902
  3. Culp R, and Jacoby S. Musculoskeletal Examination of the Elbow, Wrist and Hand: Making the Complex Simple. New Jersey: SLACK Incorporated, 2012.
  4. Carter, TI, Pansy, B, Wolff, AL, et al. Accuracy and reliability of three different techniques for manual goniometry for wrist motion: a cadaveric study. J Hand Surg Am 2009;34(8):1422-8. PMID: 19703734
  5. Stam, HJ, Ardon, MS, den Ouden, AC, et al. The compangle: a new goniometer for joint angle measurements of the hand. A technical note. Eura Medicophys 2006;42(1):37-40. PMID: 16565684
  6. Pratt, AL and Ball, C. What are we measuring? A critique of range of motion methods currently in use for Dupuytren's disease and recommendations for practice. BMC Musculoskelet Disord 2016;17:20. PMID: 26762197
  7. Libberecht, K, Lafaire, C and Van Hee, R. Evaluation and functional assessment of flexor tendon repair in the hand. Acta Chir Belg2006;106(5):560-5. PMID: 17168270
  8. Kenney, RJ and Hammert, WC. Physical examination of the hand. J Hand Surg Am 2014;39(11):2324-34. PMID: 25442747
  9. Bunata, R and Icenogle, K. Cerebral palsy of the elbow and forearm. J Hand Surg Am 2014;39(7):1425-32. PMID: 24969499
  10. Rayan G, and Akelman E. The Hand: Anatomy, Examination, and Diagnosis. Philadelphia: Lippincott Williams & Wilkins, 2012.
  11. Hays, PL and Rozental, TD. Rehabilitative strategies following hand fractures. Hand Clin 2013;29(4):585-600. PMID: 24209956
  12. Adams, BD, Grosland, NM, Murphy, DM, et al. Impact of impaired wrist motion on hand and upper-extremity performance(1). J Hand Surg Am 2003;28(6):898-903. PMID: 14642503
  13. Nasir, SH, Troynikov, O and Massy-Westropp, N. Therapy gloves for patients with rheumatoid arthritis: a review. Ther Adv Musculoskelet Dis 2014;6(6):226-37. PMID: 25435925
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