Manual Resistance

Range of Motion Assessment (& Manual Resistance) – Low Back & Pelvis

This blog post article is part of a series of articles on assessment of the low back and pelvis. Scroll to the end of this article to see the others in this series.

Range of Motion

Range of motion (ROM) assessment is usually performed directly after postural assessment. There are two types:

  • Active ROM (AROM)
  • Passive ROM (PROM)

Active ROM and Passive ROM

Figure 2. Active and passive ROM. (A) The client is actively moving the right thigh into flexion. (B) The client’s right thigh is being passively moved into flexion by the therapist. Permission Joseph E. Muscolino. Manual Therapy for the Low Back and Pelvis – A Clinical Orthopedic Approach (2015)

Active ROM is performed by asking the client to actively contract the muscles of the low back, pelvis, and hip joint to move through the cardinal plane ROMs (Fig. 2A). Passive ROM is performed by passively moving the client through these cardinal plane ROMs (Fig. 2B). Note: Oblique plane ROMs can and often should also be assessed. The six cardinal plane ROMs for the lumbar spine and hip joint are as follows:

  • Sagittal plane: flexion and extension
  • Frontal plane: right lateral flexion and left lateral flexion for the lumbar spine; abduction and adduction for the hip joint
  • Transverse plane: right rotation and left rotation for the lumbar spine; lateral rotation and medial rotation for the hip joint

Evaluation Range of Motion

When performing ROM assessment, two important factors should be considered:

  • The presence of pain at any point during the ROM
  • The actual amount of the ROM measured in degrees

The discussion that follows illustrates how critical reasoning is used when performing ROM assessment.

Active Range of Motion

If pain is present with active ROM, the assessment is considered positive. The presence of pain indicates that three possible circumstances exist:

  1. The “mover” muscles that are contracting to create the motion are strained, causing the client to experience pain when contracting them.
  2. The ligaments/joint capsules of the joint(s) being moved are sprained, causing the client to feel pain when these structures are moved.
  3. The (antagonist) muscles on the other side of the joint from the direction of motion performed are strained and/or spasmed, causing the client to feel pain when these muscles are stretched.

Therefore, pain with active ROM can result from a strain of the mover musculature, a sprain of the joint(s), and/or a strain or spasm of the antagonist muscles. One or any combination of these conditions can exist. Conversely, if no pain is present, then the client does not have any of these conditions.

Note: Unhealthy Joint Surfaces

In addition to strain of mover musculature, sprain of ligaments and joint capsules, and strain/spasm of antagonist musculature, a fourth condition can cause pain with active or passive ROM: an unhealthy joint surface at the joint being moved. For example, if there is degenerative joint disease (DJD) (osteoarthritis) of a joint surface, then motion at that joint may result in compression of that joint surface with resultant pain.

Passive Range of Motion

If the client has pain with one or more active ROMs, then it is necessary to repeat these motions passively. If the client also experiences pain with passive motion, then the client has either a sprain, because ligaments and joint capsules are still being moved, or a strain or spasm of the antagonist muscles, because they are still being stretched. During passive ROM, mover muscles are no longer contracting, so pain with passive ROM does not indicate a strain of the mover musculature of that motion.

The process of elimination leads to the conclusion that if active motion causes pain and passive motion does not, then the client must have a strain of the mover musculature. If the client experiences pain with both active and passive motion, then the client at least has a sprain and/or a problem with the antagonist muscles.

Manual Resistance

Manual Resistance

Figure 3. The therapist is providing manual resistance to the client’s thigh as the client attempts to move the thigh into flexion. Manual Therapy for the Low Back and Pelvis – A Clinical Orthopedic Approach (2015)

To now determine whether the client also has a strain of the mover musculature, a third assessment procedure must be performed: manual resistance (MR) assessment. The client attempts to perform the ROM that caused pain while the therapist provides resistance to prevent the client from actually moving the joint(s). This causes the client’s mover musculature to contract isometrically (Fig. 3). Both the therapist and the client should exert a moderately strong force that is enough to challenge the mover muscles and determine if they are healthy. Pain with resisted motion indicates a strain of the mover musculature because the mover muscles are working in this scenario. Given that the ligaments/joint capsules and the antagonist muscles are not moved with an isometric contraction, pain with resisted motion does not indicate a ligament sprain or strain/spasm of the antagonist muscles.

Positive Passive Range of Motion…

The challenge is discerning pain that occurs from a sprain (resulting from ligaments/joint capsules being moved) from pain that occurs from a strain/spasm of the antagonist muscles (resulting from the antagonist muscles being moved/stretched). Each of these conditions can cause pain with both active and passive ROM, and neither condition causes pain with resisted motion. The best way to differentiate between them is to ask the client where the pain is occurring, if pain is present. Pain that is located in soft tissue on the other side of the joint where the antagonist muscles are located indicates strain/spasm of the antagonist muscles. If the pain is located deep in the joint, it indicates a sprain of the ligamentous and joint capsule tissues of the joint. Another approach is to have the client isometrically contract the antagonist muscles against your resistance. This will stress the antagonist muscles but not the ligaments/joint capsules (because the joint did not move).

In addition to the presence of pain, the other factor to consider when performing ROM assessment is the actual ROM—that is, the joint’s degree of movement in each direction. In effect, ROM assessment is an assessment of the ability of the tissues to stretch when being moved. The amount of movement that the client exhibits can be compared to the standard ideal ROMs that are listed in Chapter 1. This comparison helps determine if the client’s motion is normal and healthy or if the joints are hypermobile or hypomobile. If the client’s ROM is greater than the standard ROM, the joint is hypermobile, usually indicating lax ligaments and joint capsules. If the client’s ROM is less than standard, the joint is hypomobile, indicating overly contracting muscles (muscle spasming), excessively taut ligaments/joint capsule, fibrous adhesions within the soft tissues, and/or joint dysfunction.

Note: Evaluating Range of Motion

It is important to keep an open mind when comparing a client’s ROMs with the standard ROMs presented in the table in Chapter 1. The standard values are an average across the population, so a difference of the client’s motion by a few degrees is not necessarily important. In addition, younger clients usually have greater ROMs than do older clients.

In addition to evaluating the absolute measure (in degrees) of motion at the joint, it is also important to compare the motion of the client’s lumbar spine to the right with its motion to the left. This should be done for lateral flexions in the frontal plane and rotations in the transverse plane. If motion to one side is decreased, then assuming that the other side is healthy, the therapist knows what normal ROM for the client is and can determine what the treatment goal is when working to restore motion to the hypomobile side. Similarly, motions of the thighs at the right and left hip joints can be compared; this can be done for all three cardinal plane motions. Note: The client’s other side is not always healthy; this can usually be determined by evaluating the client’s history.

Active ROM, passive ROM, and MR are extremely valuable techniques when assessing a client’s low back and pelvis. These procedures assess strains, sprains, and spasmed muscles, all of which are common musculoskeletal conditions that lead clients to consult manual and movement therapists.

(Click here for a blog post article on range of motion and manual resistance of the neck.)

This blog post article is the 5th in a series of 18 blog posts on the subject of assessment of the low back and pelvis.

The blog post articles in this series are:

  1. Introduction to Assessment of the Low Back and Pelvis
  2. Health History
  3. Introduction to Physical Assessment Examination of the Low Back and Pelvis
  4. Postural Assessment of the Low Back and Pelvis
  5. Range of Motion and Manual Resistance Assessment of the Low Back and Pelvis
  6. Muscle and Bone Palpation of the Low Back and Pelvis
  7. Joint Motion Palpation Assessment
  8. Overview of Special Orthopedic Assessment Tests of the Low Back and Pelvis
  9. Straight Leg Raise Tests for Space-Occupying Lesions
  10. Cough Test and Valsalva Maneuver
  11. Slump Test
  12. Piriformis Stretch Test
  13. Straight Leg Raise and Manual Resistance Tests for Strains and Sprains
  14. Nachlas and Yeoman’s Tests
  15. Sacroiliac Joint Medley of Tests
  16. Treatment Strategy for the Low Back and Pelvis
  17. Self-Care Advice for the Client with a Low Back / Sacro-Iliac Joint Condition
  18. Brief Review of Assessment and Treatment of Conditions of the Low Back and Pelvis