7.3 Range of Motion (ROM) & Rehabilitation

Range of Motion (ROM) & Rehabilitation

Rehabilitation and restorative care are vital components of nursing assistant practice designed to help residents maintain their optimal physical functioning, prevent complications of immobility, and preserve self-esteem and independence.

Rehabilitation vs. Restorative Care

CNAs must understand the distinction between these two philosophies of care:

• Rehabilitation: An intensive, goal-oriented program designed to restore a resident to their highest possible level of functioning after an illness, injury, or surgery (e.g., after a stroke or hip replacement). It is directed by licensed physical, occupational, or speech therapists.
• Restorative Care: Care focused on maintaining the resident's current level of functioning, preventing further physical decline, and promoting independence. It is provided daily by the nursing staff (primarily CNAs) and reinforces the skills learned in rehabilitation.

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Complications of Immobility

When a resident is inactive, their body systems quickly begin to deteriorate. The primary musculoskeletal complications include:

1. Muscle Atrophy: The wasting away, thinning, and weakening of muscle tissue due to lack of physical use.
2. Contractures: The permanent shortening of a muscle, tendon, or ligament, which freezes a joint in a bent position. Contractures cause severe pain, permanently limit mobility, and make hygiene care (like washing the palm of a contracted hand) extremely difficult.
   • Example: Foot drop is a contracture in which the foot permanently bends downward at the ankle (plantar flexion), preventing the resident from walking normally.

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Types of Range of Motion (ROM) Exercises

Range of motion (ROM) exercises involve moving joints through their full physiological pathways to maintain flexibility and blood circulation.

• Active Range of Motion (AROM): Executed entirely by the resident without physical assistance. The CNA's role is to supervise, encourage, and provide verbal cues.
• Active-Assistive Range of Motion (AAROM): The resident performs the movement with partial physical assistance from the CNA, often due to weakness or fatigue.
• Passive Range of Motion (PROM): The resident is unable to move their limbs independently. The CNA performs the exercises for the resident, moving the joints gently without the resident's active muscle effort.

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Key Terms in Joint Movement

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Safety Standards for PROM (UNAR Skill Check)

When performing PROM on a resident, you must follow strict safety standards to prevent injury:

• Support the Joint: Always support the limb being exercised by placing one hand under the joint and one hand below it (e.g., when exercising the knee, support the knee and the ankle; when exercising the shoulder, support the elbow and the wrist).
• Work Slowly and Gently: Move the joint slowly, smoothly, and gently. Avoid rapid or jerky movements.
• Check for Pain: Ask the resident if they feel any pain during the movements. Watch their face closely for non-verbal signs of pain, such as grimacing, gasping, or pulling away.
• Never Force a Joint: Move the joint only to the point of resistance or pain. If you feel resistance or if the resident reports pain, stop immediately and return the limb to a neutral position.
• Repetitions: Perform each movement three times (or as specified in the care plan).

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Promoting Independence & Self-Care

Restorative care requires CNAs to resist the urge to perform tasks for residents simply because it is faster. Doing so fosters dependency and accelerates physical decline.

• Encourage Self-Care: Allow residents to perform as much of their ADLs as possible, even if it takes them longer.
• Provide Assistive (Adaptive) Devices:
  • Built-up handles: Thick-handled spoons and forks for residents with arthritis or poor grip.
  • Plate guards: Raised rims on plates to help residents scoop food.
  • Long-handled shoehorns/button hooks: Assist with dressing without excessive bending or fine-motor strain.
  • Sock aids: Help slide socks onto feet without bending.

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Step-by-Step Skill Execution: PROM for the Shoulder (UNAR Skill Checklist)

1. Initial Steps: Knock, identify, explain, wash hands, and drape the resident for privacy.
2. Support Joint: Place one hand under the resident's elbow and the other hand under their wrist.
3. Flexion/Extension: Raise the arm straight up toward the head of the bed (flexion) and bring it back down to the side (extension). Repeat 3 times.
4. Abduction/Adduction: Move the arm out away from the side of the body to shoulder level (abduction) and bring it back to the side (adduction). Repeat 3 times.
5. Observation: Ask if they feel any pain, and observe their face for grimacing.
6. Closing Steps: Remove drape, lower the bed, place the call light in reach, wash hands, and document.

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Restorative Ambulation and Exercises

Restorative care plans may also include specific exercises to prevent muscle atrophy and maintain joint mobility, such as:

• Range of Motion for Hip and Knee: Supported at the knee and ankle, performing flexion and extension (bending the knee and hip toward the chest, then straightening) and abduction and adduction (moving the leg away from the midline and back).
• Deep Vein Thrombosis (DVT) Prevention: Incorporating regular ankle rotation and dorsiflexion/plantar flexion exercises for bed-bound residents to promote venous return and prevent blood clots.
• Cognitive Encouragement: Explaining each exercise in simple terms to gain cooperation and using positive reinforcement to celebrate small achievements, which builds confidence.

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Teaching Focus: ROM Instruction

When teaching PROM or coaching AROM, name each movement in plain language ("I'm bending your elbow," "I'm moving your arm away from your body") while supporting the joint above and below. Move slowly through three repetitions unless the care plan states otherwise. Stop at the first report or facial sign of pain, return the limb to a comfortable position, and report to the nurse—never force past resistance. Pair ROM with restorative goals: offer built-up utensils and plate guards at meals so the resident practices grip and coordination rather than being fed by default.