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Lesson 5: Active and Passive Range of Motion Exercises

5-1. INTRODUCTION

The body was designed for motion. Regular exercise contributes to a healthy body; therefore immobility has a negative effect. A joint that has not been moved sufficiently can begin to stiffen within 24 hours and will eventually become inflexible. With longer periods of joint immobility, the tendons and muscles can be affected as well.

Most people move and exercise their joints through the normal activities of daily living. When any joint cannot be moved in this way, the patient or nurse must move it at regular intervals to maintain muscle tone and joint mobility.

Range of motion (ROM) exercises are ones in which a nurse or patient move each joint through as full a range as is possible without causing pain. The effect of both regular exercise and immobility on major body systems are discussed in this lesson.

5-2. THE EFFECTS OF IMMOBILITY

Cardiovascular System.

  1. Venous stasis caused by prolonged inactivity that restricts or slows venous circulation. Muscular activity, especially in the legs, helps move blood toward the central circulatory system.

  2. Increased cardiac workload due to increased viscosity from dehydration and decreased venous return. The heart works more when the body is resting, probably because there is less resistance offered by the blood vessels and because there is a change in the distribution of blood in the immobile person. The result is that the heart rate, cardiac output, and stroke volume increase.

  3. Thrombus and embolus formation caused by slow flowing blood, which may begin clotting within hours, and an increased rate in the coagulation of blood. During periods of immobility, calcium leaves bones and enters the blood, where it has an influence on blood coagulation.

  4. Orthostatic hypotension probably due to a decrease in the neurovascular reflexes, which normally causes vasoconstriction, and to a loss of muscle tone. The result is that blood pools and does not squeeze from veins in the lower part of the body to the central circulatory system. The immobile person is more susceptible to developing orthostatic hypotension. The person tends to feel weak and faint when the condition occurs.

Respiratory System.

  1. Hypostatic pneumonia. The depth and rate of respirations and the movement of secretions in the respiratory tract is decreased when a person is immobile. The pooling secretions and congestion predispose to respiratory tract infections. Signs and symptoms include:

    • Increased temperature.

    • Thick copious secretions.

    • Cough.

    • Increased pulse.

    • Confusion, irritability, or disorientation.

    • Sharp chest pain.

    • Dyspnea.

  2. Atelectasis. When areas of lung tissue are not used over a period of time, incomplete expansion or collapse of lung tissue may occur.

  3. Impaired coughing. Impairment of coughing mechanism may be due to the patient's position in bed decreasing chest cage expansion.

Musculoskeletal System.

  1. Muscle atrophy. Disuse leads to decreased muscle size, tone, and strength.

  2. Contracture. Decreased joint movement leads to permanent shortening of muscle tissue, resistant to stretching. The strong flexor muscles pull tight, causing a contraction of the extremity or a permanent position of flexion.

  3. Ankylosis. Consolidation and immobility of a joint in a particular position due to contracture.

  4. Osteoporosis. Lack of stress on the bone causes an increase in calcium absorption, weakening the bone.

Nervous System.

  1. Altered sensation caused by prolonged pressure and continual stimulation of nerves. Usually pain is felt at first and then sensation is altered, and the patient no longer senses the pain.

  2. Peripheral nerve palsy.

Gastrointestinal System.

  1. Disturbance in appetite caused by the slowing of gastrointestinal tract, secondary immobility, and decreased activity resulting in anorexia.

  2. Altered digestion and utilization of nutrients resulting in constipation.

  3. Altered protein metabolism.

Integumentary System. Risk of skin breakdown, which leads to necrosis and ulceration of tissues, especially on bony areas.

Urinary System.

  1. Renal calculi (kidney stones) caused by stagnation of urine in the renal pelvis and the high levels of urinary calcium.

  2. Urinary tract infections caused by urinary stasis that favors the growth of bacteria.

  3. Decreased bladder muscle tone resulting in urinary retention.

Metabolism.

  1. Increased risk of electrolyte imbalance. An absence of weight on the skeleton and immobility causes protein to be broken down faster than it is made, resulting in a negative nitrogen balance.

  2. Decreased metabolic rate.

  3. Altered exchange of nutrients and gases.

Psychosocial Functioning.

  1. Decrease in self-concept and increase in sense of powerlessness due to inability to move purposefully and dependence on someone for assistance with simple self-care activities.

  2. Body image distortions (depends on diagnosis).

  3. Decrease in sensory stimulation due to lack of activity, and altered sleep-wake pattern.

  4. Increased risk of depression, which may cause the patient to become apathetic, possibly because of decreased sensory stimulation; or the patient may exhibit altered thought processes.

  5. Decreased social interaction.

5-3. THE PURPOSES OF EXERCISE FOR THE IMMOBILE PATIENT

  1. To maintain joint mobility is done by putting each of the patient's joints through all possible movements to increase and/or maintain movement in each joint.

  2. To prevent contracture, atony (insufficient muscular tone), and atrophy of muscles.

  3. To stimulate circulation, preventing thrombus and embolus formation.

  4. To improve coordination.

  5. To increase tolerance for more activity.

  6. To maintain and build muscle strength.

5-4. TYPES OF EXERCISES

  1. Passive. These exercises are carried out by the nurse, without assistance from the patient. Passive exercises will not preserve muscle mass or bone mineralization because there is no voluntary contraction, lengthening of muscle, or tension on bones.

  2. Active Assistive. These exercises are performed by the patient with assistance from the nurse. Active assistive exercises encourage normal muscle function while the nurse supports the distal joint.

  3. Active. Active exercises are performed by the patient, without assistance, to increase muscle strength.

  4. Resistive. These are active exercises performed by the patient by pulling or pushing against an opposing force.

  5. Isometric. These exercises are performed by the patient by contracting and relaxing muscles while keeping the part in a fixed position. Isometric exercises are done to maintain muscle strength when a joint is immobilized. Full patient cooperation is required.

 

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LESSON OBJECTIVES

Identify the effects of immobility.

Identify the purposes of exercise for the immobile patient.

Define the five types of exercises.

Define the nine types of body movement.

Identify guidelines for range-of-motion exercises.