Total Passive ROM

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

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• A positive result occurs when the patient displays a TPM% that is fair or poor in at least one of the digits evaluated.

• 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. 

• 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

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.
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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
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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