In the Know’s Inservice Club

presents
A Client Care Module:
Passive & Active Range of Motion Exercises

Instructions for the Learner

We hope you enjoy this Inservice, prepared especially for nursing

assistants like you. You work very hard, and we appreciate the effort
you make to complete these educational materials. It shows your
desire to continue learning and growing in your profession!

After finishing this inservice, you will be able to:

• Define range of motion.
• Describe the parts of the musculoskeletal system and how they
work together.
• Discuss the cause and prevention of contractures.
THE INSERVICE CLUB FOR NURSING ASSISTANTS

• Discuss the benefits of range of motion exercises.

• Describe the general guidelines for performing and/or assisting
with range of motion exercises.

If you are studying the inservice on your own, please:

• Read through all the attached materials. You may find it useful to
In the Know

have a highlighting marker nearby as you read. Highlight any

information that is new to you or that you feel is especially
important.
• If you have questions about anything you read, please ask
______________________________________.
• Take the quiz. Think about each statement and fill in the best
answer.
• Check with your supervisor for the right answers. You pass the
quiz with at least eight correct answers! Print your name, write in
the date, and then sign your name.
• Keep the inservice information for yourself, and turn in the quiz
page to _______________________________________ no later
than _________________.
• Show your Inservice Club Membership Card to
______________________________________ so that it can be
initialed.

THANK YOU!
 Keep reading to learn more about:
• The musculoskeletal system.
• The relationship between exercise and healthy joints.
• Ways you can help your clients remain flexible.

Understanding
Range of Motion
Can you imagine what life would You probably work with clients
be like if you had to: who aren’t so flexible. Maybe
• Eat without bending your they’ve had a stroke or they have
arm at the elbow? severe arthritis. Some of their
joints may be stiff and deformed.
• Walk without bending your
These clients need your help to
knees?
keep their joints and muscles as
THE INSERVICE CLUB FOR NURSING ASSISTANTS

• Look behind you without healthy as possible.

turning your head?
There are hundreds of activities
that we perform every day that
would be difficult (or impossible)
without range of motion.
Range of motion is defined as
In the Know
One way that you may be asked
to help is by assisting with
Range Of Motion (ROM)
exercises. These exercises
involve moving the joints into a
variety of positions and then

the normal movements that a gently stretching them. Keep

joint should be able to perform. reading to learn more about
So, for example, the range of joints, muscles and range of
motion for the neck includes: motion!
• Bending the head forward
and backward.
• Tilting the head down toward
each shoulder.
• Turning the head from side to
side.
People who have full range of
motion have the freedom to
move in many different ways.
© 2001 In the Know, Inc.
Their joints are flexible—allowing 306 Brandermill Drive Durham, NC 27713
them to reach the top shelf in www.knowingmore.com

the closet, bend down to tie May be copied for use within each physical location that
purchases materials from the Inservice Club. All other
their shoes or even do the splits! copying or distribution is strictly prohibited.
www.knowingmore.com
PAGE TWO

The Musculoskeletal System

The musculoskeletal system is made • A Synovial
Time For a up of many different parts, including: Membrane creates a
Laugh! • Muscles provide the force and thin lining around a
strength necessary to move the joint and produces
A young boy synovial fluid.
body. (It takes over 200 muscles
was looking just to take one step!) There are
through the • Synovial Fluid is a clear, sticky
about 650 different muscles in the fluid that is secreted around each
family photo body. The largest muscle is the joint to keep it lubricated and
album and “gluteus maximus” (or buttock). protected.
asked his The smallest muscle is a tiny one
mother, inside the ear. • Bursa are little sacs filled with fluid
“Who’s that that create a cushion between
• Bones are made up of minerals
guy with all bones and ligaments. (You’ve
like calcium. They are the hardest probably heard of bursitis. It is
the big living tissues in the body. In fact, caused by an inflamed bursa, often
muscles and the human thigh bone is as strong in an overused joint.)
curly hair as concrete! When two bones
standing on come together in a joint, they All the parts of the musculoskeletal
the beach don’t actually touch each other. system connect together. That’s why
(That would be very painful!) they’re called “connective tissue”. The
with you? Instead, they are cushioned by connective tissue in the body works
cartilage, membranes and fluid. together to create smooth and
rhythmic range of motion.
• Ligaments. These strong elastic
bands of tissue attach one bone to
another and provide support to
the joint. Remember:
His mother
answered, • Tendons. Like ligaments, tendons Bones FORM a joint.
“Why, are bands of tissue. However,
instead of connecting bones to
Muscles MOVE a joint.
that’s your
each other, they connect muscles Ligaments and tendons
father.” to nearby bones. And, they are not STABALIZE a joint.
Looking elastic.
puzzled, the Cartilage, synovial fluid and
• Cartilage. This strong, smooth
little boy bursa CUSHION a joint.
substance (sometimes called
asked, “Then “gristle”) covers the ends of bones
who’s that fat to help reduce the friction
old bald- between them. Over time,
headed man cartilage tends to wear off—
who lives with especially in big joints like the knee
us now?” and the hip—causing the bones to
rub together painfully.
© 2001 In the Know, Inc.
PAGE THREE

Information About Joints

A joint is a place in the body where • Ball & Socket. In a ball and socket
What Does It two or more bones come together. joint, one bone has a big rounded
Mean to Be They provide a flexible connection head (the ball) and the other bone
Double- between bones—allowing our bodies has a cupped area (the socket).
Jointed? to move in many different ways. There These joints allow body parts to
Do you know are many different kinds of joints in the twist and turn. Examples of a ball
people who body, including: and socket joint
can bend a • Hinge. A hinge joint works like are the shoulder,
finger or an the hinge on a door. Hinge joints the hip and the
allow body parts to bend and base of the
arm in an thumb.
unusual way? straighten. The elbow, knee, ankle
and fingers are all examples of
Or maybe hinge joints. • Pivot. A pivot
they seem to joint allows body
be able to • Gliding. A joint that allows two parts to swivel
bend their flat bones to slide over each other around each
bodies in are called gliding joints. You can other—like when you turn your
half—the find these joints in the foot and head to the side.
wrong way? the wrist.
These people
may be
double-
jointed.
Does that
Interesting Facts About Bones!
mean that
they have • When babies are born, • The shoulder is the most flexible
extra joints? their bones are like joint in the body. It can move in
No. It means rubber! Even if they any direction—sort of like a
that they knew how to stand up, shower head!
their legs wouldn’t be
have very able to support them. • Bones are alive and can repair
long, stretchy themselves if necessary.
ligaments, • The body has 212
bones in it. The largest bone is the • Bones are not solid. If they were,
allowing
thigh bone. The smallest bone is they’d be heavy as rocks!
their joints to
move farther in the ear. • The inside of a bone is a spongy,
than normal. • Over half the bones in the body fatty substance called bone
are in the hands and feet! marrow. The bone marrow is
where new blood cells develop.
• Every bone in the body connects
• Like any other living tissue, bones
to a joint except the hyoid bone in
bleed when they are injured.
the throat.

© 2001 In the Know, Inc.

PAGE FOUR

More About Hip Joints

• The hip joint is located at the top • For some people, this repetitive
of the thigh—where the thigh stress causes stiffness to develop
Silly bone connects to the pelvis. in the hip joint. They may begin to
Quotes lose their normal
• Surrounding the hip are the range of motion.
About
biggest ligaments and muscles in
Exercise! the body. They help the hip • Gentle exercises,
• I joined a survive all the walking, running such as walking and
health club and jumping that people do every stretching, are great
last year, day. treatments for
and have minor hip stiffness.
spent
about
$400. But, I
haven’t lost More About Knee Joints
a pound.
Apparently,
you have to • The knee is one of the most • The knee joint allows the leg to
show up. complex joints in the body...and bend, straighten and even rotate a
it’s the one most likely to be injured. little bit.
• I have to • Four bones are part of the knee • Regular exercise may prevent
exercise joint: the thigh bone, two lower some knee problems from
early in the leg bones and the knee cap (also developing.
morning called the patella).
• People who are overweight may
before my
be able to prevent or eliminate
brain
knee problems by losing weight.
figures out
what I am
doing.
• I don’t What About Joint Replacement Surgery?
exercise at • Joint replacement surgery involves removing a diseased or damaged joint
all. If God and replacing it with an artificial joint. The new joint is made of metal and/or
meant for plastic. With proper care, most artificial joints last about 20 years.
us to touch
• The most common reason for joint replacement surgery is osteoarthritis
our toes, he
(which causes wear and tear on joints, especially the hips and knees).
would have
put them • Joint replacements have been performed for about 30 years.
further up Today, they are fairly common. For example, over 150,000 hip
our bodies. replacement operations are performed every year, mostly on
women over age 65.

© 2001 In the Know, Inc.

PAGE FIVE

What Happens As People Get Older?

A number of common changes in the • With age, some people walk and
musculoskeletal system happen as move more slowly. They may lose
people get older, such as: their balance more easily—putting
• The body tends to lose calcium, them at risk for falls.
causing the bones to become
weak, brittle and easily broken. Getting older doesn’t sound like much
It’s True! It’s common to see older people fun, does it? Well, the good news is
with fractures of the wrist, hip and that all these age-related changes can
You’ve back. be slowed down by making these
probably healthy choices:
heard the • Joints begin to wear down. Many • Exercising regularly.
saying, “Use it people develop arthritis
or lose it.” (inflammation of the joints). • Eating a well-balanced diet.
When it Arthritis may cause the joints to
comes to become stiff, painful to move and • Avoiding cigarettes and alcohol.
muscles and deformed.
joints, it’s • And, for
• Muscles begin to decrease in size
true. People women only,
and strength—starting slowly at taking a
who don’t the age of 20!
exercise lose hormone
replacement
strength and • The disks between the bones of after
flexibility— the spine become thinner— menopause.
and tend to causing people to “shrink” a little
age faster in height.
than people
who do
exercise. Musculoskeletal Problems
However, the
following is
also true: • Injuries and diseases of the • Some common musculoskeletal
“It’s never too musculoskeletal system are the problems include:
late!” People number one reason that people • Bursitis (inflammation of the
visit their doctors. bursa).
can enjoy the
benefits of • One out of seven Americans has • Arthritis (inflammation of the
exercise at some kind of musculoskeletal joint).
any age— problem. • Tendonitis (inflammation of
even if they the tendons).
• Problems with muscles, bones and
haven’t joints cause U.S. workers to miss • Fractures (broken bones).
exercised in 147 million work days—and cost • Herniated disks (“slipped”
years. $215 billion—every year. disks in the spinal column).
© 2001 In the Know, Inc.
PAGE SIX

The Facts About Bed Rest

What is Imagine this: John is a It will take John about 4 to 6 weeks of
healthy, athletic young working out to reverse the effects of
Disuse man, aged 22. An injury just three weeks of bed rest!
Syndrome? forces him to stay in bed
for three weeks. When Now, imagine what happens when
• Disuse he’s allowed to get out of frail, elderly people have to stay in
syndrome is bed after three weeks, John: bed. They’ll have all the problems
a group of • Gets dizzy every time he stands up that John experienced—and probably
problems and has trouble keeping his more. And, the problems will develop
that balance. faster and take longer to go away!
develop
when • Has lost half of his overall muscle
people strength.
don’t move Remember, it’s better to:
around • Has lost bone strength at a rate 50 • Sit than to lie down.
enough. times faster than normal. • Stand than to sit.
• Seems confused and mentally • Walk than to stand.
• People on
bed rest are slow at times.
at high risk
for
developing
disuse The Difference Between PT & OT
syndrome.
• Keep in Both types of therapists may develop Occupational Therapists:
mind that exercise programs (including range of • Focus on helping clients function
the health motion) for your clients. in everyday life. This means
problems Physical Therapists: helping them learn new or better
caused by • Work to get people back to the ways to perform the activities
disuse same physical level they used to necessary for home and/or work.
syndrome be...or help people accept and live • Work to help clients regain,
can be with a disability. recover or maintain their daily
much • Help their clients improve joint living skills.
worse than motion, strengthen their muscles • Provide assistive devices—such as
whatever and learn how to manage transfers splints or special cookware—to
caused the and ambulation without injury. make these daily tasks easier.
person to • Tend to work with the large • Tend to work with smaller muscle
stay in bed muscle groups, helping their groups, helping their clients
in the first clients move safely through their function safely in their daily lives.
place! environment.
© 2001 In the Know, Inc.
PAGE SEVEN

What Is a Contracture?
The best • A contracture is a chronic • The most common condition
treatment tightening or shortening of leading to contractures is a stroke.
for muscles. It Your clients with multiple sclerosis,
contractures causes the dementia, cerebral palsy, head
involved joint to trauma and burns are also at risk—
is to prevent
become stiff. as is any client on bed rest.
them! How?
Try these tips: • Contractures • Contractures make it very painful
• Help your can develop in to move a joint. Since it hurts,
small joints such people with contractures stop
clients
as fingers and in trying to move the affected joint.
reposition large joints such as hips or knees. Of course, this makes the situation
themselves worse since the muscles around
frequently. • A finger with a contracture will the stiffened joint get less and less
Joints get probably be curled in toward the exercise!
stiff (and palm. A contracted knee will
muscles probably be bent back, unable to
get short) completely straighten.
when held • Any illness or injury that causes
in the same decreased mobility can lead to
position for contractures. When a muscle
too long. moves less, it shrinks—tightening
itself around the joint.
• Encourage
your clients
to
participate
in regular Preventing Contractures
personal
care
activities There are a number of ways to treat a Massage. A therapist may also
such as contracture, including: perform regular massage of the
brushing affected muscles. This helps keep
Physical therapy. This might include them “loose”.
hair or either passive or active range of
getting motion exercises. Medication. A doctor might
dressed. prescribe certain medications such as
Orthotics. These are muscle relaxants.
• Assist with devices such as splints
range of and braces that help Surgery. An operation may be
motion keep joints and needed if the contracture is severe or
exercises as muscles stretched. is causing constant pain.
ordered.
© 2001 In the Know, Inc.
PAGE EIGHT

Types of Exercise
There are four basic types of exercises • Strength. These activities—such
Here’s a that are important for people who as weight lifting—build muscles
Chuckle or want to age in good health. and strength. Studies suggest that
Two! • Flexibility. This includes range of strength exercises may also help
motion exercises (see below). prevent osteoporosis.
My
• Endurance. These are activities • Balance. Activities such as yoga
grandma improve
that increase your breathing and
started heart rate—such as walking or balance and
walking 5 jogging. They improve the health help prevent
of the heart, lungs, and circulatory falls—a
miles a day common
system—and help prevent many
when she diseases including diabetes and problem in
was 60. strokes. older adults.
She is 97
now and
we have The Benefits of ROM Exercises
no idea
where she One obvious benefit of If your clients need more motivation
is! range of motion exercises to perform their range of motion
is that the joints remain exercises, share this information with
flexible. However, there them:
are other benefits to these • Studies have shown that many
gentle stretching
people—age 90 and older—who
exercises, including:
have become physically frail from
• Increased physical inactivity can more than double
fitness their strength through simple
Q: Why do exercises in a fairly short time.
witches • Relaxation
• For some, that means being able
have stiff • Body awareness
to get up from a chair by
joints? • Lubrication of tendons and themselves instead of having to
ligaments wait until someone is available to
help them.
• Decreased risk of injury to joints,
• In one study, some 80 year olds
broomatism!
of their
A: It’s because

muscles and tendons

were able to progress from using
• Decreased muscle soreness and walkers to using canes
tension after doing simple
• Reduced pain muscle-building
exercises for just 10
• Improved posture and balance weeks!
© 2001 In the Know, Inc.
PAGE NINE

Range of Motion Exercises

The goal of range of motion exercises is • There are also special machines
Did You to improve the movement and flexibility that perform passive range of
Know? of specific joints. motion exercises by gently
moving a joint through as normal
Therapists • Some clients are unable to a motion as possible.
use a special perform range of motion exercises
tool— a by themselves. They need • If your clients are able to perform
goniometer— someone else—like a therapist, range of motion exercises by
family member or you—to guide themselves, the exercises are
to measure their muscles and joints through
the range of considered active. Your clients
the exercises. These exercises are may need your assistance or
motion of called passive range of motion encouragement, but basically,
specific because the client is not doing the they are doing the work. (You
joints. A work. Instead, he or she might hear it called active assisted
goniometer concentrates on being completely range of motion if your client
has two arms relaxed. needs a little help during the
that are exercises.)
joined at a
protractor • It’s important to know how to
that perform range of motion exercises
properly. Generally, nursing
measures the
assistants follow a specific exercise
angle of joint plan developed for a client by a
mobility. physical or occupational therapist.

Joint Rotations
For example, You may be asked to oversee or assist • This rotating motion is usually the
a healthy your clients with joint rotation exercises. best way to prepare for other
elbow joint forms of exercise—including
• These are slow circular range of motion and walking.
should be movements, performed in both
able to flex to clockwise and counterclockwise
a 150 degree directions.
angle (from
straight out • Joint rotations are performed to
until it help warm and loosen up the
touches the joints. The circular movement of
each rotation helps lubricate a
upper arm).
joint with synovial fluid.

© 2001 In the Know, Inc.

PAGE TEN

The Basic Procedure for ROM Exercises

Documenting Your workplace has its own policy and In addition to these steps, be sure to
Range of procedure for performing range of remember these basic safety
Motion motion exercises. You may want to guidelines:
Exercises review it to be sure you know all the • You should use both hands to
After helping a steps. However, it probably contains
client with the following actions: support a joint as you are
range of motion exercising it. In general, one hand
exercises, you 1. Review the client’s care should be above the joint and one
might need to plan so that you know hand below it. (But, don’t grab the
document the which joints should be “meat” of your client’s arm or leg.)
following: exercised and how
much the client is able • Each exercise should be done
• Vital signs
to help. slowly and steadily—without
(taken before
and/or after
bouncing. The goal is to make the
the 2. Identify the client and explain exercises pleasant and relaxing.
exercises). what you are about to do.
• Be sure to stop if you feel
• Any changes 3. Wash your hands before and after resistance or tightness in the joint
you noticed performing the exercises. (And, if or if the client tells you it hurts.
in the client’s necessary, wear gloves.) (Keep an eye out for nonverbal
skin. signs of pain such as grimacing.)
4. Protect your client’s privacy. Keep
• The range of Let your supervisor know if your
your client as covered up as
motion client seems to be in pain.
possible by only exposing each
exercises that
you
body part as you are working with • Every client is an individual—with
performed, it. his or her own level of fitness and
including
5. Protect yourself from injury by tolerance. For some,
which joints, you may be asked to
how many
paying attention to body
mechanics. If possible, raise the repeat each exercise
times you did 10 times. For others, 2
each exercise client’s bed to a comfortable
working height. If the bed has or 3 times may be all
and how
wheels, make sure they are locked. they can handle.
much the
client was
6. Ask the client to lie on his or her • If you find that one or more of
able to help.
back, head on a pillow. your client’s joints are red, hot and
• If the client swollen, tell your supervisor. Don’t
seemed to 7. Follow the correct procedure for perform range of motion exercises
experience exercising each joint— on these joints unless your
any pain. as you have been supervisor says it’s okay.
Be sure to shown by a therapist or
follow your your supervisor. • Your workplace may not allow you
workplace to perform range of motion
8. Leave the client in a exercises on a client’s neck. If this
policy for
documenting
safe, warm comfortable position is true at your workplace, let the
client care.
and document your work. therapist handle those exercises!
© 2001 In the Know, Inc.
PAGE ELEVEN

More About ROM Exercises

Remember! There are a number of terms that you • Pronation is turning
might hear when range of motion the joint down.
• If they are exercises are being discussed. They
include: • Supination is turning
done
the joint up.
improperly, • Abduction moves
range of a body part away
motion Think of it like this:
from the body.
exercises Turning your hand so that the palm
• Adduction moves is face down is pronation. Turning
can cause
a body part toward the body. your hand so the palm is face up is
injury.
supination.
• You should Think of it like this:
never The first part of a leg lift is abduction
perform because you move your leg away • Rotation is turning the joint in a
ROM from your body. The second part of a circular motion.
leg lift is adduction because you
exercises
bring your leg back down to your • Internal rotation turns the joint
unless you body. inward—toward
have been the center of the
instructed body.
in the • External rotation
proper • Extension is the
straightening of a turns the joint
procedure outward—away from the center of
by a body part.
the body.
therapist or • Flexion is the bending
nurse. of a limb or body part. Think of it like this:
• Be When you swim and you turn your
Think of it like this: head to take a breath, you are
cautious— externally rotating your neck.
and very It’s considered extension when you When you turn your head back into
gentle. straighten your arm to reach for a the water, you are internally
glass of water. But, it’s flexion when rotating it.
• Never you bend your arm to take a sip
move a from your glass.
joint past
the point of
resistance
or pain! Hyperextension is when a joint is straightened past the normal position.
This is done to give an extra stretch to the muscles and connective tissue.
Hyperextension exercises must be done very carefully
and are probably best handled by a therapist.

© 2001 In the Know, Inc.

PAGE TWELVE

Tips For Helping Your Clients Stay Flexible

• Keep in mind that the movement • Make sure your clients’ feet are
It’s A Fact! that occurs during daily activities supported whenever they are
• Girls tend helps keep joints flexible. For seated. Dangling feet are more
to be more example, Mrs. Taylor uses her likely to develop contractures.
flexible shoulder, elbow, wrist and finger
than boys. joints to brush her hair • If you notice your clients
• People are every day. If your exercising their joints, encourage
clients are them to exercise both sides of
more independent and/or their body. For example, it’s best
flexible active in their personal to exercise both knees or both
until their care, they’ll have a shoulders rather than just one.
teenage better chance of
years. staying flexible. • Encourage your clients to use
Then, they good body mechanics every day.
begin to • A fun way to exercise the wrist and For example, teach them to bend
gradually finger joints is to have your clients at the knees rather than at the
lose their make shadow puppets. waist and to stand and sit with
flexibility. (Remember how to do that? Make good posture.
your hands into shapes that show
• People who up as shadows on the wall.) • Remember that it’s normal to be
are inactive stiffer some days than others.
are less • Another way to exercise hand and Don’t let your clients get
flexible finger joints is to have your clients discouraged if they’re not able to
than squeeze a washcloth or sponge move as freely from one day to the
people who while soaking their hands in a next.
exercise. basin of warm water. This is
especially good for people who • Remind your clients to move their
• Most have arthritis in their hands. joints frequently. For example, if
people are they are watching television, tell
more • Do your clients need more them to get up and move around
flexible in motivation to complete their every 30 minutes.
the range of motion exercises? Try
afternoon strapping a small bell • Help your clients balance periods
—from to an arm or leg so that of exercise with periods of rest.
about 2:30 it jingles every time
they complete an • Encourage your clients to exercise
to 4:00 pm.
exercise! with friends or family members (or
• It’s easier to to join an exercise group at your
be flexible • If your clients are able to stand, facility). It’s always more fun to
in warm encourage them to perform exercise with other people than to
weather balance exercises, too. Have them go it alone. You might even want
than in cold hold on to you while standing on to join in—to keep your joints
weather. one foot at a time. flexible!

© 2001 In the Know, Inc.

 Are You “In the Know” About
Range of Motion Exercises?

Finish each statement with one of the words from the list below.
Then check your answers with your supervisor!
(Hint: You will not use every word on the list.)

Bones Muscles Active

Ligaments Joint Exercise
Tendons Stabilize Bed rest
Ball & Socket Cushion Abduction
Hinge Shoulder Adduction
Knee Contracture Pain

1. Range of motion is the normal movement that a ______________ should be

able to perform.
THE INSERVICE CLUB FOR NURSING ASSISTANTS

2. A bone is connected to another bone by one or more _____________.

3. Cartilage is a smooth substance that covers the ends of bones and helps
________________ them.
4. The hip is one example of a ______________________ joint.
5. The _____________ is the joint in the body that’s most likely to be injured.
In the Know

6. Regular _______________ helps slow the effects that aging has on muscles
and joints.
7. When muscles and joints aren’t used enough, a painful ______________
might develop.
8. When people are able to perform their own range of motion exercises
without assistance, it’s known as ________________ range of motion.
9. When a body part is moved away from the body, it’s called
_________________.
10. Range of motion exercises should never be done past the point of ________.

EMPLOYEE NAME_____________________________________ DATE______________________

I understand the information presented in this inservice. I have completed

this inservice and answered at least eight of the test questions correctly.

Employee Signature__________________________________________ Inservice Credit: 1 hour

Supervisor Signature_________________________________________ Self Study _____
File completed test in employee’s personnel file. Group Study _____