ROM Exercises

Foundational Role of ROM in Restorative Care

Range of Motion (ROM) exercises are a cornerstone of restorative care in nursing assisting. They help maintain or improve joint flexibility, prevent contractures, reduce pain, and enhance circulation in patients who are immobile or have limited mobility.^[1] For the CNA exam, you must know the difference between active, active-assistive, and passive ROM, the correct sequence for performing exercises, and key safety precautions.

Clinical Definitions of ROM Types and Contracture

Range of Motion (ROM)

The full movement potential of a joint, usually measured in degrees. ROM exercises move each joint through its natural arc.^[2]

Types of ROM Exercises

• Active ROM: The patient performs the exercises independently. The CNA encourages and supervises.
• Active-Assistive ROM: The patient performs the movement with some help from the CNA. Used when the patient has partial strength.
• Passive ROM: The CNA completely moves the patient’s joints through the range. Used when the patient is unable to move (e.g., paralyzed, comatose).^[3]

Contracture

A permanent shortening of a muscle or tendon resulting from prolonged immobility. ROM exercises are the primary preventive intervention.^[4]

Systematic ROM Performance and Joint-Specific Movements

General Guidelines for Performing ROM

1. Explain the procedure to the patient and obtain consent.
2. Wash hands and gather supplies (pillows for support, if needed).
3. Position the patient in a comfortable, well-aligned supine position.
4. Expose only the limb being exercised; cover the rest with a sheet or blanket.
5. Work from the head down to the toes, or from the toes up — be consistent.^[5]
6. Support the joint above and below while moving through the range.
7. Move slowly, smoothly, and gently; stop if the patient reports pain or resistance.
8. Repeat each movement 3–5 times per session (per facility policy).^[6]
9. Document the following: type of ROM (active/passive), joints exercised, number of repetitions, patient tolerance, and any changes in joint mobility.^[7]

Joints and Movements

Table adapted from Perry & Potter.^[2]

When to Initiate ROM: Observable Patient Needs

• Decreased joint mobility or stiffness reported by the patient or noted during care.
• Visible muscle atrophy or weakness.
• Prolonged bed rest (e.g., post-surgery, stroke, fracture).
• Presence of edema or poor circulation in extremities.
• Pain or discomfort during positioning or movement.

CNA Responsibilities in ROM Assessment and Reporting

• Observe the patient’s reaction: verbal and nonverbal cues of pain or anxiety.
• Note any abnormal joint sounds (crepitus) – report to the nurse.
• Assess for signs of contracture development, such as resistance to passive movement or a fixed position.
• Evaluate the patient's ability to actively participate (e.g., direct observation of muscle contraction).
• Report changes in joint range, increased pain, or swelling to the licensed nurse promptly.^[8]

Daily Execution and Reinforcement of ROM Exercises

Nursing Assistant Interventions

• Schedule ROM at least twice daily as per the care plan (often during morning care and before bedtime).
• Use pillows or towels to support joints in a neutral position after exercise.
• Encourage active participation as tolerated – even small efforts maintain strength.
• Combine ROM with other care tasks (e.g., bathing, dressing) to maximize efficiency.^[9]
• Provide positive reinforcement and clear, calm instructions.

Critical Risk Mitigation in ROM Application

• Never force a joint beyond its natural resistance – this can cause injury or increase pain.
• Avoid moving a joint through range if the patient has a known fracture, recent surgery, or acute inflammation without specific orders.
• Stop immediately if the patient reports sharp or sudden pain.
• Support the limb adequately to prevent strain on the joint capsule or surrounding muscles.
• Observe for signs of deep vein thrombosis (DVT) – redness, warmth, swelling in the calf – and notify the nurse before proceeding.^[10]
• Monitor blood pressure and pulse if the patient is at risk of orthostatic hypotension during position changes.

Effective Memorization and Test Application for ROM

• Memorize the three types of ROM: Active, Active-Assistive, Passive. On the exam, you may be asked which type is appropriate for a patient with a specific condition (e.g., hemiplegia – passive ROM on the affected side, active-assistive on the unaffected side).
• Remember the “head-to-toe” sequence for performing ROM – many test questions ask about the correct order.
• “Stop at resistance” is a frequent correct answer for safety questions.
• Know the specific movements for each joint (e.g., ankle: dorsiflexion and plantar flexion).
• Understand that ROM exercises help prevent contractures and pressure injuries – these are high-yield outcomes.^[4]
• A typical CNA exam scenario: “The CNA notices the patient grimacing during passive ROM of the shoulder. What should the CNA do?” – Answer: Stop the movement and report to the nurse.
• Memory aid for joint order: “Neck, Shoulder, Elbow, Wrist, Hand, Hip, Knee, Ankle, Toes” – think “NSEWH HKA T.”

References & Sources

1. Centers for Medicare & Medicaid Services. (2023). State Operations Manual: Appendix PP – Guidance to Surveyors for Long Term Care Facilities. Chapter 7, Tag F726 (Restorative Nursing). https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Downloads/Appendix-PP-State-Operations-Manual.pdf [Accessed 15 Oct. 2024].
2. Potter, P.A. & Perry, A.G. (2021). Fundamentals of Nursing. 10th ed. St. Louis: Elsevier. Chapter 33: Activity and Exercise. ISBN: 9780323676873. https://shop.elsevier.com/books/fundamentals-of-nursing/potter/978-0-323-67772-1
3. Sorensen, L. & Luckmann, J. (2019). Medical-Surgical Nursing: A Psychophysiologic Approach. 7th ed. Philadelphia: F.A. Davis. ISBN: 9780803668962. https://soc.tenwekhospitalcollege.ac.ke/bib/1689
4. National Council of State Boards of Nursing (NCSBN). (2023). 2023 NCLEX-PN Test Plan (Item code: 3400). Section: Reduction of Risk Potential – Mobility/Immobility Interventions. https://www.ncsbn.org/public-files/2023_PN_Test%20Plan_FINAL.pdf
5. Morrison, M. & Payne, D. (2020). CNA Certified Nursing Assistant Exam Study Guide. 3rd ed. New York: Kaplan Nursing. Unit 4: Restorative Care Skills. ISBN: 9781506273198. https://www.amcaexams.com/wp-content/uploads/2019/10/AMCA-NAC-Study-Guide.pdf
6. American Red Cross. (2022). Nurse Assistant Training Participant's Manual. Chapter 14: Restorative Care. https://www.redcross.org/take-a-class/lp/certified-nursing-assistant-nat?srsltid=AfmBOoqVB0_Yr5UgQ6Ymp2cA-bE_1AEZYWzhk2AG-n1NwsFAYwWrQfpZ
7. Green, L. & Landry, D. (2023). Mosby's Essentials for Nursing Assistants. 6th ed. St. Louis: Mosby. Chapter 24: Restorative Care and Rehabilitation. pp. 502-515. ISBN: 9780323829309. https://quizlet.com/512024829/mosbys-essentials-for-nursing-assistants-ch-24-review-flash-cards/
8. CNA Testing & Education, Inc. (2024). CNA Skills Checklist: Range of Motion Exercises. https://www.sowela.edu/wp-content/uploads/CNA_Skills-Checklist.pdf
9. Agency for Healthcare Research and Quality (AHRQ). (2017). Preventing Pressure Ulcers in Hospitals: A Toolkit for Improving Quality of Care. Module 5: Daily Skin Assessment and Care. https://www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/index.html
10. Anticoagulation Forum. (2022). DVT Prevention in Hospitalized Patients: Guidelines for Nursing Assistants. https://acforum.org/web/resource_files/1739988420-34123.pdf