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Range of Motion and Positioning

Range of Motion and Positioning

LEARNING OBJECTIVES
• Explain the importance of the range of motion (ROM) exercises and proper positioning
• Demonstrate ROM exercises
• Use positioning skills to assist patients with limited mobility

Why Is Motion Important?

Most people take free, comfortable movement for granted. Motion is meant to be smooth and painless. The ligaments, tendons, muscles, and joint capsules that surround each joint in the body work best if they are used regularly.

As people get older, however, muscles gradually lose their strength, endurance, and flexibility. We experience a progressive loss of muscle mass at an average rate of 4% per decade from ages 25 to 50 and 10% per decade thereafter. In addition, the joints in older people change, often becoming stiff and difficult or painful to move. Tissues in the joints sometimes become swollen or inflamed, hindering movement and making the joints more prone to injury.

As a result, people tend to move less as they age. This is the worst thing we can do. Lack of activity worsens the changes that occur with aging. Research confirms that regular exercise can slow or reverse many changes associated with the age-related loss of strength, endurance, and flexibility.

When people are not physically active, every cell and system in the body is affected. The body’s cells and systems begin to lose the ability to perform their specialized functions.
When movement is difficult, people experience a general decline in quality of life. Their self-image often suffers.

Lack of activity and exercise can lead to heart disease, diabetes, stroke, and other health problems. Decreased mobility hinders one’s ability to feed and clothe oneself, grocery shop, and attend to personal hygiene. It promotes mental deterioration and loss of independence. In addition, when muscles are not used, they continue to weaken. Muscle weakness increases the risk of falls and, therefore, fractures. The risk of falling increases with age. Falls are the leading cause of injury or death for people aged 65 and older.

What kinds of motion are best?
There are four types of exercise. They are:
• Strength
• Stretching
• Endurance (also known as cardiovascular)
• ROM

Exercise benefits people of all ages. Regular exercise can slow or reverse decreased mobility which contributes to disease and disability in the elderly.

Strength
Even a small change in muscle size can make a big difference in strength. That’s why strength exercises are so important. Improving muscle size by lifting small weights helps people build their capacity to do such things as walk, climbing stairs, and carrying a package. These kinds of activities can mean the difference between keeping one’s independence and relying on others.

Stretching
Stretching exercises that gently stretch the muscles and tendons help ensure flexibility. Stretching exercises do not build strength or endurance. Clinical research has demonstrated that most elderly, even the frail, benefit from a combination of flexibility and strengthening exercises. It helps them maintain function and mobility, prolong independence, and improve their quality of life.

Endurance
Walking, running, bicycling, and swimming are examples of endurance exercises. By spending time in motion, the body and muscles become able to endure for longer periods of time, and the heart and lungs become stronger.

Range of motion
ROM exercises are designed to increase flexibility. ROM is the normal amount a person’s joints can be moved in certain directions or the range in which you can move a body part around a joint. Limited ROM is a reduction in the normal distance and direction through which a joint can move.

When a joint is not fully extended on a regular basis, over time it will become permanently unable to extend beyond a certain fixed position. To keep the joints, tendons, ligaments, and muscles loose and flexible, ROM exercises are used. These exercises move the joints through a full ROM, helping to prevent stiffening.

Getting Started

By doing a little exercise regularly, even in small 10-minute increments several times per week, it’s possible to offset a variety of health problems. Exercise can help produce new red blood cells, strengthen the immune system, and improve bone density. Physical activity, even at low intensity in short sessions, may reduce the
risk for certain chronic diseases. Exercise also helps relieve depression.

Older adults need to be up and moving seven days per week. They should spend time 3–5 days per week doing flexibility exercises or walking. Daily activities do not move joints through their full ROM. Caregivers can help patients improve their health by encouraging them to exercise.

Exercise tips:
• Move joints through their full ROM 1–2 times per day.
• Do each exercise 3–10 times.
• Move slowly. Do not bounce.
• Breathe while you exercise. Count aloud.
• Begin exercises slowly, doing each exercise a few times and gradually building up.
• Try to achieve full ROM by moving until you feel a slight stretch, but don’t force a movement.
• Stop exercising if you have severe pain.
• Encourage patients with limited mobility to bear weight during transfers from bed to chair and to walk whenever possible.

ROM exercises that can be done while seated:
• Neck (breath with the movements, breathing out when the head moves down, breathing in when it moves up; don’t let shoulders or upper body sway to the side):
–– Turn your head slowly to the right and then to the left. Repeat 3–4 times.
–– Tilt head toward one shoulder and then toward the other shoulder. Repeat 3–4 times.
• Arms and shoulders:
–– Raise shoulders up toward ears and hold. Make full circles: up, forward, down, and back.
–– Take a deep breath, and extend your arms overhead. Exhale slowly, dropping arms.
• Hands and fingers:
–– Massage each hand, one at a time. Take your time; go in between each finger.
–– Raise hands up and back. Slowly rotate hands down and around in circles.
–– Close hand in a fist. Open hands fully, stretching fingers and thumbs out wide.
• Chest and upper body:
–– With hands-on waist, tilt to the right, return to center, and then tilt to the left and return to center. Exhale as the movement goes down; inhale as the movement comes up. Don’t allow the upper body to tilt forward. Don’t try to hold your head up; instead, let it relax to the side.
–– Sit straight in the chair with hands on your hips. Gently rock hips from side to side.
• Legs:
–– Raise right leg up and forward. Repeat with left leg.
–– Sit up straight, knees together, with legs extended forward as far as possible, keeping feet on the floor. Slowly stretch forward, sliding both hands down to the ankles. Hold 10–15 counts.
–– Grasp one knee with both arms, pull to the chest, and hold for five counts. Repeat with the opposite leg.
• Ankle and foot:
–– Point toes toward the floor. Point toes toward the ceiling. Slowly rotate feet in circles.
–– Cross right leg over the left knee. Rotate the foot slowly, making large complete circles—10 rotations to the right, 10 to the left. Repeat for the left leg.

Passive Range of Motion Exercises

When an individual is able to perform ROM exercises with minimal assistance, the person is doing active ROM. When an individual is unable to perform ROM exercises, a caregiver should move the person’s joints in passive ROM exercises at least once or twice per day.

Use the chart in Figure 40.1 to guide you in moving every joint in the body through its full ROM. Go slowly and be very gentle. Do not force any body part to move in any way that creates resistance or causes discomfort.

Positioning

Everyone positions themselves when they sit, stand, move, and lie down. The position we use for these activities affects circulation, joint pressure, and muscle use. People with limited mobility who sit or lie down for long periods of time are prone to skin breakdown and deterioration of muscles or nerves. Using correct positioning can prevent these problems. It is important to limit pressure over bony parts of the body by changing positions. Use pillows to keep knees and/or ankles from touching each other. Patients who are bedridden should avoid lying directly on their hip bones when on their sides. Assist patients to use positions that spread weight and pressure evenly, with pillows placed to
provide support and comfort.

A person in a chair or wheelchair should use a cushion. Avoid donut-shaped cushions because they reduce blood flow and cause tissue to swell. People sitting in chairs or wheelchairs should change positions every hour. Good posture and comfort are both important.

Some basic rules of positioning

• Always be familiar with a patient’s plan of care. Specific issues such as fractures, skin integrity, and health conditions will determine the type of positioning that should be done.
• Turn individuals who cannot turn themselves at least every two hours when in bed. A person in a wheelchair should change positions at least every hour. External pressure from staying in one position compresses the skin’s blood vessels and obstructs circulation, especially over the bones, leading to skin breakdown.
• When moving a patient, lift rather than drag. Dragging creates friction and heat, which can lead to skin breakdown.
• Straighten sheets and clothing to remove wrinkles.

Bed positioning tips
• Position the spine in alignment
• Position the hips straight without leg rotation
• Position the upper extremities away from the body
• Support the arms when the patient is lying on his or her side
• Keep the knee joints flexed 15 degrees when the patient is supine (lying on the back)
• Turn the patient from side to side and prone (lying face down) on a scheduled basis
• Keep the head in a straight, midline position

Positions
• Supine (on back)
–– Place a pillow under the head.
–– Place pillows under both arms. When bedridden patients lie on their back with forearms and palms facing down, pressure can damage wrist nerves.
–– Place pillows under legs from midcalf to ankle to keep heels off the bed. Do not put a pillow under the knees only, as this will cause the heel to rub against the bed.
–– Hand rolls (roll washcloths and place in hands to prevent freezing of finger joints).
–– Use foot-positioning devices such as shoes, boots, and footboards.
• Lying on the side
–– Position patient up in bed if needed.
–– Position the patient on one side of the bed. Turn patient by sliding an arm under the shoulders and head; lift upper body over, and then move hips and legs.
–– Cross the patient’s top ankle over the bottom ankle, or flex the top knee.
–– Turn the patient by placing one hand on the shoulder and one hand on the hip.
–– Place a pillow under the head and another behind patient’s back.
–– Support flexed extremities with pillows and positioning devices.
–– Ensure proper body alignment.
• Prone (on stomach)
–– Lift the patient toward you
–– Bend arm up around the head
–– Place another arm on the side
–– Place a pillow under abdominal muscles
–– Roll patient on stomach
–– Support ankles with pillows
• Positioning while seated
–– Seat the patient in a chair that supports the back
–– Keep ears in line with the hips
–– Support the curve of the lower back with a rolled-up towel or lumbar roll
–– Knees should be level with the hips
–– Feet should be flat on the floor or on a footrest
• Positioning while standing (to help patients learn to balance when using walkers or canes)
–– Position the feet a few inches apart
–– Position the hips in front of the ankles
–– Position the shoulders over the hips
–– Keep the head balanced over the hips
–– Keep the spine straight

 

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