7.2 Range of Motion & Assistive Devices

Range of Motion & Assistive Devices

Restorative Care and Rehabilitation

Restorative care and rehabilitation are distinct but complementary components of resident care in Oregon long-term care facilities. Rehabilitation is an intensive program led by licensed specialists, such as physical therapists (PT), occupational therapists (OT), and speech-language pathologists (SLP), aimed at helping a resident regain skills or functions lost due to illness or injury. In contrast, restorative care is an ongoing program managed by the nursing department—where Certified Nursing Assistants (CNAs) play the most active role. The goal of restorative care is to maintain the resident’s current level of physical and cognitive function, prevent complications of inactivity (such as muscle atrophy and joint contractures), and promote maximum independence. Under Oregon State Board of Nursing (OSBN) guidelines, CNAs are responsible for integrating restorative goals into daily care, which includes encouraging residents to perform self-care tasks independently rather than doing everything for them.

Principles of Range of Motion (ROM)

Range of Motion (ROM) refers to the distance and direction a joint can move. Regular ROM exercises are vital for preserving joint mobility, improving circulation, and preventing contractures, which are permanent shortenings of muscles or tendons that lead to deformed, non-functional joints. The three types of ROM exercises include:

• Active Range of Motion (AROM): The resident performs the exercises independently. The CNA's role is to provide verbal instructions, encouragement, and cueing.
• Active-Assistive Range of Motion (AAROM): The resident performs the movements with partial assistance from the CNA. This is common when a resident has hemiparesis (one-sided weakness) or tires easily.
• Passive Range of Motion (PROM): The resident is unable to move the joint independently, and the CNA performs the exercises. The resident's muscles remain completely relaxed during the movements.

Guidelines for Performing Passive ROM (PROM)

When performing PROM, the CNA must follow strict clinical guidelines to ensure safety and comfort. Key principles include:

1. Support the Joints: The CNA must support the limb by placing one hand proximal (above) and one hand distal (below) to the joint being exercised. For example, when exercising the elbow, support the upper arm and the wrist. Never grip the joint itself or allow the limb to dangle unsupported.
2. Move Smoothly and Gently: Move the joint slowly and smoothly through its natural range. Never force a joint past its point of resistance. If the joint feels stiff or does not move easily, stop the movement.
3. Stop Immediately if Pain Occurs: The CNA must ask the resident if they feel any pain before starting and during the exercises. If the resident reports pain, or if the CNA notices non-verbal signs of pain (such as grimacing, wincing, tensing, or vocalizations), the exercise must be stopped immediately, and the nurse must be notified.
4. Perform Repetitions: Each exercise must be repeated at least three times (or as specified in the care plan).
5. Work Systematically: Perform exercises in a logical order, usually from head to toe, focusing on the shoulders, elbows, wrists, fingers, hips, knees, ankles, and toes.

Oregon Headmaster/TMU Clinical Skills Testing for PROM

During the Oregon Headmaster/TMU clinical skills evaluation, candidates are frequently tested on PROM for either the shoulder or the knee and ankle. To pass these skills, the candidate must execute specific critical steps:

• Explain and Prepare: Introduce yourself, explain the procedure, and ask if the resident has any pain before starting.
• Support Joints Correctly: For the shoulder, support the arm at the elbow and wrist. For the knee and ankle, support the leg under the knee and under the ankle.
• Perform Correct Movements: For the shoulder, perform flexion (raising the arm above the head) and extension, followed by abduction (moving the arm away from the side) and adduction. For the knee/ankle, perform knee flexion (bending the knee) and extension, and ankle dorsiflexion (pulling toes upward) and plantar flexion (pointing toes downward).
• Verify Comfort: Ask the resident at least once during the exercise if they feel any pain or discomfort, and stop immediately if they do.

Assistive and Restorative Devices

Assistive devices help residents perform activities of daily living (ADLs) and maintain mobility safely:

• Canes: Canes are used to assist with balance and distribute weight. They must be held on the resident’s stronger (unaffected) side. The cane is advanced forward about 6 to 10 inches, then the weaker (affected) leg is moved forward to meet it, followed by the stronger leg. The CNA should walk on the resident's weaker side and slightly behind them to provide support. Cane handles should align with the resident's hip joint, and the elbow should bend at a 15-to-30-degree angle.
• Walkers: A walker provides maximum stability. The resident stands inside the frame, moves the walker forward about 6 inches, steps forward with the weaker leg first, and then steps with the stronger leg. The CNA must ensure the resident does not use the walker to pull themselves up from a sitting position, as this can cause the walker to tip over. Instead, the resident must push up from the chair’s armrests.
• Prosthetic Devices: Prosthetics are artificial replacements for missing body parts (e.g., limbs, eyes, teeth). CNAs assist with cleaning, applying, and removing prostheses. A critical responsibility is inspecting the skin of the residual limb (stump) for redness, breakdown, or irritation. Any skin abnormalities must be reported to the nurse immediately, and the prosthesis must not be reapplied until the nurse evaluates the skin.