Foundation of Nursing

GNS 221
Nursing Care of Patients with Musculoskeletal injuries

Range of Motion
Range of motion (ROM) means the extent or limit to which a part of the body can be
moved around a joint or a fixed point; the totality of movement a joint is capable of
doing. Range of motion of a joint is gauged during passive ROM (assisted) PROM or
active ROM (independent) AROM.

1. ROM is usually assessed during a physical therapy assessment or treatment.

Normal values depend on the body part, and individual variations.
2. The purpose of ROM exercises are prevention the development of adaptive muscle
shortening, contractures, and shortening of the capsule, ligaments, and tendons.
ROM exercises also provide sensory stimulation.

Types of Range Of Motion

1. Passive range of motion (PROM) is the ROM that is achieved when an outside
force (such as a therapist) exclusively causes movement of a joint and is usually the
maximum range of motion that a joint can move. Usually performed when the
patient is unable or not permitted to move the body part.
2. Active-assisted range of motion (AAROM) is when the joint receives partial
assistance from an outside force. Usually performed when the patient needs
assistance with movement from an external force because of weakness, pain, or
changes in muscle tone
3. Active range of motion (AROM) is the ROM that can be achieved when
opposing muscles contract and relax, resulting in joint movement. For example, the
active range of motion to allow the elbow to bend requires the biceps to contract
while the triceps muscle relaxes. Active range of motion is usually less than passive
range of motion. Usually performed by the patient independently and when the
patient is able to voluntarily contract, control, and coordinate a movement.

Causes of Limited Range of Motion

Limited ROM refers to a joint that has a reduction in its ability to move. Motion may be
limited because of a problem within the joint, swelling of tissue around the
joint, stiffness of the muscles, or pain.

Medical conditions associated with a limited range of motion in the joints include:

 Osteoarthritis (OA)
 Rheumatoid Arthritis (RA)
  Juvenile RA, which is an autoimmune form of arthritis that occurs in children
under the age of 16 years
 Cerebral Palsy (CP)
 Sepsis of the hip and other joints, which is a bacterial infection of the joints
 Congenital Torticollis
 Syphilis, which is a sexually transmitted infection (STI)

Other causes of restricted range of motion include:

 Inflammation of the soft tissues surrounding the joint, or joint swelling

 Muscle Stiffness
 Pain
 Joint Dislocation
 Fractures

Other than pathological causes for restriction of movement, there could be non-
pathological causes such as

 Tight Clothing
 Hypertrophy of muscles due to strength training (e.g biceps brachii hypertrophy
limits the range of elbow flexion)
 Fat

Increasing Range Of Motion

Range of motion can be maintained and gradually increased through the following range
of motion & stretching exercises.

Range of Motion Exercises and Stretching

Range of motion exercise refers to activity aimed at improving movement of a specific

joint. This motion is influenced by several structures: configuration of bone surfaces
within the joint, joint capsule, ligaments, tendons, and muscles acting on the joint.

There are three types of range of motion stretching exercises:

1. Active Range of Motion (AROM): Movement of a joint provided entirely by the

individual performing the exercise. In this case, there is no outside force aiding in
the movement.
2. Passive Range of Motion (PROM): Movement applied to a joint solely by
another person or persons or a passive motion machine. When passive range of
motion is applied, the joint of an individual receiving exercise is completely
 relaxed while the outside force moves the body part, such as a leg or arm,
throughout the available range.
3. Active Assisted Range of Motion (AAROM): Joint receives partial assistance
from an outside force. This range of motion may result from the majority of
motion applied by an exerciser or by the person or persons assisting the
individual. It also may be a half-and-half effort on the joint from each source.

There are many reasons for seeing a Physiotherapist to aid with limited range of motion
at a join. Range of motion therapy benefits include:

 Healing and recovery from soft tissue and joint lesions

 Maintaining existing joint and soft tissue mobility
 Minimizing the effects of contracture formation
 Preventing adhesions between myo-fascia.
 Assisting neuromuscular reduction
 Enhancing synovial movement.

Range of movement exercises can:

 Increase movement at a joint

 Increase the function of a joint, and the entire limb
 Improve movement efficiency
 Increase independence
 Decrease pain
 Improve and maintain joint integrity
 Improve Balance.

Regaining range of motion in a joint is one of the first phases of injury rehabilitation. A
physiotherapy assessment will be performed prior to prescribing a range of movement
exercises. The assessment looks at the present range and the quality of the movement.

 Joints maintain a balanced range of motion by regular use and stretching of the
surrounding soft tissues. Just 10 minutes of stretching three times a week can help
improve range of motion.
 Quite often strengthening exercises are prescribed alongside or shortly after range of
movement exercises as the increased movement at a joint without increasing the
strength could cause a further injury.

Musculoskeletal Assessment

The musculoskeletal system gives us the ability to move. It is composed of bones, muscles,
joints, tendons, ligaments, and cartilage that support the body, allow movement, and protect
vital organs. An assessment of the musculoskeletal system includes collecting data regarding
the structure and movement of the body, as well the patient’s mobility. The skeleton is
composed of 206 bones that provide the internal supporting structure of the body. The bones
of the lower limbs are adapted for weight-bearing support, stability, and walking. The upper
limbs are highly mobile with large range of movements, along with the ability to easily
manipulate objects with our hands and opposable thumbs

Now that we reviewed the anatomy of the musculoskeletal system and common
musculoskeletal conditions, let’s discuss the components of a routine nursing assessment.

Subjective Assessment

Collect subjective data from the patient and pay particular attention to what the patient is
reporting about current symptoms, as well as past history of musculoskeletal injuries and
disease. Information during the subjective assessment should be compared to expectations for
the patient’s age group or that patient’s baseline. For example, an older client may have
chronic limited range of motion in the knee due to osteoarthritis, whereas a child may have
new, limited range of motion due to a knee sprain that occurred during a sports activity.

If the patient reports a current symptom, If the patient is experiencing acute pain or recent
injury, focus on providing pain relief and/or stabilization of the injury prior to proceeding
with the interview. Use information obtained during the subjective assessment to guide your
physical examination.

Life Span Considerations

When conducting a subjective interview of children, additional information may be obtained

from the parent or legal guardian.

New-borns

 Did your baby experience any trauma during labor and delivery?

 Did the head come first during delivery of your baby? Was the baby in breech
position requiring delivery by Caesarean section?

 Were forceps used during delivery?

 Have you been told your infant has a “click” within the hip(s)?

 Do you have any concern with your baby moving any joints, extremities, or neck
normally? If so, describe.

Paediatric

 Has your child ever had a broken bone? If so, how was it treated?

 Has your child had any dislocation of a joint?

  Have you noticed any abnormality with your child’s spine, toes, feet, or hands? If so,
describe.

 Does your child have any difficulty walking, jumping, or playing? If so, describe.

 Is your child involved in sports or organized physical activities? Do you have any
concerns about your child being physically able to perform these activities?

Older Adults

When assessing older adults, it is important to assess their mobility and their ability to
perform activities of daily living.

 Do you use any assistive devices such as a brace, cane, walker, or wheelchair?

 Have you fallen or had any near falls in the past few months? If so, was there any
injury or did you seek medical care?

 Describe your mobility as of today. Have you noticed any changes in your ability to
complete your usual daily activities such as walking, going to the bathroom, bathing,
doing laundry, or preparing meals? If so, do you have any assistance available?

Objective Assessment

The purpose of a routine physical exam of the musculoskeletal system by a registered nurse is
to assess function and to screen for abnormalities. Most information about function and
mobility is gathered during the patient interview, but the nurse also observes the patient’s
posture, walking, and movement of their extremities during the physical exam.

During a routine assessment of a patient during inpatient care, a registered nurse typically
completes the following musculoskeletal assessments:

 Assess gait

 Inspect the spine

 Observe range of motion of joints

 Inspect muscles and extremities for size and symmetry

 Assess muscle strength

 Palpate extremities for tenderness.

While assessing an older adult, keep in mind they may have limited mobility and range of
motion due to age-related degeneration of joints and muscle weakness. Be considerate of
these limitations and never examine any areas to the point of pain or discomfort. Support the
joints and muscles as you assess them to avoid pain or muscle spasm. Compare bilateral sides
simultaneously and expect symmetry of structure and function of the corresponding body
area.
Inspection

General inspection begins by observing the patient in the standing position for postural
abnormalities. Observe their stance and note any abnormal curvature of the spine such as
kyphosis, lordosis, or scoliosis. Ask the patient to walk away from you, turn, and walk back
toward you while observing their gait and balance.

Ask the patient to sit. Inspect the size and contour of the muscles and joints and if the
corresponding parts are symmetrical. Notice the skin over the joints and muscles and observe
if there is tenderness, swelling, erythema, deformity, or asymmetry. Observe how the patient
moves their extremities and note if there is pain with movement or any limitations in active
range of motion (ROM). Active range of motion is the degree of movement the patient can
voluntarily achieve in a joint without assistance.

Palpation

Palpation is typically done simultaneously during inspection. As you observe, palpate each
joint for warmth, swelling, or tenderness. If you observe decreased active range of motion,
gently attempt passive range of motion by stabilizing the joint with one hand while using the
other hand to gently move the joint to its limit of movement. Passive range of motion is the
degree of range of motion demonstrated in a joint when the examiner is providing the
movement. You may hear crepitus as the joint moves. Crepitus sounds like a crackling,
popping noise that is considered normal as long as it is not associated with pain. As the joint
moves, there should not be any reported pain or tenderness.

Assess muscle strength. Muscle strength should be equal bilaterally, and the patient should be
able to fully resist an opposing force. Muscle strength varies among people depending on
their activity level, genetic predisposition, lifestyle, and history. A common method of
evaluating muscle strength is the Medical Research Council Manual Muscle Testing Scale.
This method involves testing key muscles from the upper and lower extremities against
gravity and the examiner’s resistance and grading the patient’s strength on a 0 to 5 scale. For
the muscle strength testing scale.

Muscle Strength Scale

0 - No muscle contraction

1 – Trace muscle contraction, such as a twitch

2 – Active movement only when gravity eliminate

3 – Active movement against gravity but not against resistance

4 – Active movement against gravity and some resistance

5 – Active movement against gravity and examiner’s full resistance

Assessing Hand Grips and Upper Extremity Strength

To assess upper extremity strength, first begin by assessing bilateral hand grip strength.
Extend your index and second fingers on each hand toward the patient and ask them to
squeeze them as tightly as possible. Then, ask the patient to extend their arms with their
palms up. As you provide resistance on their forearms, ask the patient to pull their arms
towards them. Finally, ask the patient to place their palms against yours and press while you
provide resistance.

Assessing Lower Extremity Strength

To assess lower extremity strength, perform the following maneuvers with a seated patient.
Place your palms on the patient’s thighs and ask them to lift their legs while providing
resistance. Secondly, place your hands behind their calves and ask them to pull their legs
backwards while you provide resistance. Place your hands on the top of their feet and ask
them to pull their feet upwards against your resistance. Finally, place your hands on the soles
of their feet and ask them to press downwards while you provide resistance, instructing them
to “press downwards like pressing the gas pedal on a car.”

Table below shows a comparison of expected versus unexpected findings when assessing the
musculoskeletal system.

Expected Versus Unexpected Findings on Musculoskeletal Assessment

Unexpected Findings (document

Assessment Expected Findings and notify provider if a new
finding*)

Erect posture with good balance

Spinal curvature is present. Poor
and normal gait while walking.
balance or unsteady gait while
Joints and muscles are
walking. Swelling, bruising,
symmetrical with no swelling,
Inspection erythema, or tenderness over joints
redness, or deformity. Active
or muscles. Deformity of joints.
range of motion of all joints
Decreased active range of motion.
without difficulty. No spine
Contracture or foot drop present.
curvature.

Auscultation Not applicable Crepitus associated with pain on

 Unexpected Findings (document
Assessment Expected Findings and notify provider if a new
finding*)

movement.

No palpable tenderness or warmth Warmth or tenderness on palpation

of joints, bones, or muscles. of joints, bones, or muscles.
Palpation
Muscle strength 5/5 against Decreased passive range of motion.
resistance. Muscle strength of 3/5 or less.

*CRITICAL
Hot, swollen, painful joint.
CONDITIONS to
Suspected fracture, dislocation,
report
sprain, or strain.
immediately

Sample Documentation of Expected Findings

Patient reports no previous history for bone trauma, disease, infection, injury, or deformity.
No symptoms of joint stiffness, pain, and swelling, limited function, or muscle weakness.
Patient is able to perform and manage regular daily activities without limitations and reports
consistent exercise consisting of walking 2 miles for 5 days a week. Joints and muscles are
symmetrical bilaterally. No swelling, deformity, masses, or redness upon inspection. Non
tender palpation of joints without crepitus. Full ROM of the arms and legs with smooth
movement. Upper and lower extremity strength is rated at 5 out of 5. Patient is able to
maintain full resistance of muscle without tenderness or discomfort.

Sample Documentation of Unexpected Findings

Patient reports “I felt a pop in my right ankle while playing basketball this afternoon” and
“My right ankle hurts when trying to walk on it.” Pain is constant and worsens with weight-
bearing. Patient rates pain at 4/10 at rest and 9/10 with walking and describes pain as an
“aching, burning feeling.” Ibuprofen and ice decrease pain. Right ankle is moderately
swollen laterally and anteriorly with tenderness to palpation but no erythema, warmth, or
obvious deformity. Color, motion, and sensation are intact distal to the ankle. ROM of the
right ankle is limited and produces moderate pain. Minimal eversion and inversion
demonstrated. Patient is unable to bear weight on the right ankle.
Nursing Interventions for Impaired Physical Mobility

1. Encourage the patient to do as much as they can.

Once the nurse has assessed the degree of immobility, they should encourage independence
aligned with the patient’s capabilities. This decreases dependence on others and increases
the patient’s self-esteem.

2. Medicate for pain.

If pain and discomfort are barrier, the nurse can provide analgesics prior to performing
exercises or planned ADLs. Even simple interventions such as a heating pad or ice packs
may alleviate muscle and joint pain and increase movement.

3. Schedule activities around rest periods.

Allow the patient to determine the best times for exercise or movement related to their energy
levels. Do not overwhelm or exhaust and allow periods of rest between activities.

4. Provide adaptive equipment.

Provide equipment that allows for maximum movement related to the patient’s capabilities.
For example, if bed-bound but able to use upper extremities, a trapeze bar can help the
patient can pull themselves up.

5. Provide passive ROM.

If the patient is unable to perform exercises independently, the nurse should provide passive
ROM several times per day to prevent contractures and muscle weakness.

6. Promote proper nutrition and hydration.

Malnourishment prevents recovery and contributes to a higher risk of functional disability.
Adequate caloric intake is required for energy with high-protein foods supporting muscle
mass and strength. Hydration will prevent dehydration and promote circulation and keep
skin, tissues, and muscles hydrated.

7. Incorporate family and caregivers.

Patients who feel supported by their families and spouses will feel committed to increasing
their mobility. Families may need education on how to best support their loved ones, how to
keep them safe, and how to use equipment.

8. Consult with the multidisciplinary team.

Impaired mobility may require the support of PT and OT to instruct on exercises and
perform activities that stimulate muscle control and fine motor movement.
9. Coordinate ongoing support at discharge.
Patients may require ongoing support either at home through home health services or at a
rehab center. Coordinating with the case manager to ensure the patient receives the
appropriate care at discharge is vital to preserving their progress.

10. Set goals.

Patients may feel overwhelmed or hopeless if their barriers seem impossible. Helping them
choose small goals, such as brushing their hair or sitting up in bed, gives them the
motivation to keep going.

11. Provide positive reinforcement.

A patient that is making an effort, no matter how small will be more inclined to continue
when their accomplishments are noticed and praised.