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Introduction ⬇

Passive range-of-motion (ROM) exercises involve the movement of a joint through partial or complete range of activity with the assistance of a health care provider. Full ROM involves flexion, extension, abduction, adduction, and rotation of the affected joint. ROM exercises are indicated for a patient who has temporary or permanent loss of mobility, sensation, or consciousness. These exercises have been shown to improve or maintain joint mobility, strength, and endurance and prepare the patient for ambulation.1

When included as a key component of care, ROM exercises can enhance patient outcomes, improve gas exchange, reduce rates of ventilator-associated pneumonia, shorten the duration of mechanical ventilation, reduce the risk of contractures,2,3 and enhance long-term functional ability.

The exercises described here treat all joints, but they do not have to be performed in the order given or all at once. You can schedule them over the course of a day, whenever the patient is in the most convenient position. You’ll typically perform these exercises three times for each joint, at least twice a day.1 Perform all exercises slowly, gently, and to the end of the normal ROM or to the point of pain but no further.1 (See Glossary of joint movements.) Hold each position for 1 to 2 seconds. It is important to note that passive ROM exercises require recognition of the patient’s limits of motion and support of all joints during movements.

Passive ROM exercises are contraindicated in patients with septic joints (until infection subsides), bone tumors or metastases, acute myocardial infarction, or recent trauma with possible hidden fractures or internal injuries.1,4

Equipment ⬆ ⬇

Equipment

Optional: gloves, other personal protective equipment (gown, mask and goggle or mask and face shield).

Implementation ⬆ ⬇

Implementation
  • Determine the joints that need ROM exercises.
  • Consult the practitioner or physical therapist about limitations or precautions for specific exercises.
  • Perform hand hygiene.5,6,7,8,9,10
  • Confirm the patient’s identity using at least two patient identifiers.11
  • Provide privacy.12,13,14,15
  • Explain the procedure to the patient and family (if appropriate) according to their individual communication and learning needs to increase their understanding, allay their fears, and enhance cooperation.16
  • Raise the patient’s bed to waist level before providing patient care to prevent caregiver back strain.17
  • Put on gloves and other personal protective equipment, as needed, to comply with standard precautions.18,19,20

Exercising the Neck

  • While supporting the patient’s head with your hands, extend the neck, flex the chin to the chest, and tilt the head laterally toward each shoulder.
  • Rotate the patient’s head from right to left (as shown below).

Exercising the Shoulders

  • Support the patient’s arm in an extended, neutral position; then extend the forearm and flex it back.
  • Abduct the patient’s arm outward from the side of the body, and then adduct it back to the side.
  • Rotate the shoulder so that the patient’s arm crosses the midline, and then bend the elbow so that the hand touches the opposite shoulder and then touches the mattress for complete internal rotation.
  • Return the patient’s shoulder to a neutral position and, with elbow bent, push the patient’s arm backward so that the back of the hand touches the mattress for complete external rotation (as shown below).

Exercising the Elbow

  • Place the patient’s arm at the side with palm facing up.
  • Flex and extend the patient’s arm at the elbow (as shown below).

Exercising the Forearm

  • Stabilize the patient’s elbow, and then twist the hand to bring the palm up (supination, as shown on top right).
  • Twist it back again to bring the palm down (pronation).

Exercising the Wrist

  • Stabilize the patient’s forearm, and then flex and extend the wrist.
  • Rock the patient’s hand sideways for lateral flexion.
  • Rotate the patient’s hand in a circular motion (as shown below).

Exercising the Fingers and Thumb

  • Extend the patient’s fingers, and then flex the hand into a fist; repeat extension and flexion of each joint of each finger and thumb separately.
  • Spread two adjoining fingers apart (abduction, as shown below), and then bring them together (adduction).
  • Oppose each fingertip to the patient’s thumb.
  • Rotate the thumb and each finger in a circle.

Exercising the Hip and Knee

  • Fully extend the patient’s leg, and then bend the hip and knee toward the chest, allowing full joint flexion.
  • Move the patient’s straight leg sideways, out and away from the other leg (abduction), and then back, over, and across it (adduction).
  • Rotate the patient’s straight leg internally toward the midline (as shown below), and then externally away from the midline.

Exercising the Ankle

  • Bend the patient’s foot so that the toes push upward (dorsiflexion), and then bend the foot so that the toes push downward (plantar flexion).
  • Rotate the ankle in a circular motion.
  • Invert the patient’s ankle so that the sole of the foot faces the midline (as shown below), and evert the ankle so that the sole faces away from the midline.

Exercising the Toes

  • Flex the patient’s toes toward the sole, and then extend them back toward the top of the foot.
  • Spread two adjoining toes apart (abduction, as shown below), and bring them together (adduction).

Completing the Procedure

  • Return the bed to the lowest position to prevent falls and maintain patient safety.21
  • Assess the patient’s comfort level and response to ROM.
  • Remove and discard your gloves and other personal protective equipment, if worn.20
  • Perform hand hygiene.5,6,7,8,9,10
  • Document the procedure.22,23,24,25

Special Considerations ⬆ ⬇

Special considerations
  • Because changes in joints can begin within 3 days of immobility, start passive ROM exercises as soon as possible.26
  • Patients on prolonged bed rest or limited activity without profound weakness can also be taught to perform ROM exercises on their own (called active ROM),26 or they may benefit from isometric exercises. (See Learning about isometric exercises.)
  • If a patient who is disabled requires long-term rehabilitation after discharge, consult with a physical therapist and teach a family member or caregiver to perform passive ROM exercises.

Complications ⬆ ⬇

Complications

Complications may include pain or muscle spasms.1,26

Documentation ⬆ ⬇

Documentation

Document the date and time and the joints that you exercised, the presence of edema or pressure areas, any pain resulting from the exercises, any limitation of ROM, and the patient’s tolerance of the exercises. Document teaching provided to the patient and family (if applicable), their understanding of that teaching, and any need for follow-up teaching.

References ⬆

  1. HinkleJ. L., & CheeverK. H. (2018). Brunner and Suddarth’s textbook of medical-surgical nursing (14th ed.). Philadelphia, PA: Wolters Kluwer.
  2. SkalskyA. J., & McDonaldC. M. (2012). Prevention and management of limb contractures in neuromuscular diseases. Physical Medicine and Rehabilitation Clinics of North America, 23(3), 675–687. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3482407/
  3. AmideiC., & SoleM. L. (2013). Physiological responses to passive exercise in adults receiving mechanical ventilation. American Journal of Critical Care, 22, 337–348. (Level VI)
  4. KisnerC., et al. (2018). Therapeutic exercise:

    Foundations and techniques

    (7th ed.). Philadelphia, PA: F. A. Davis Company.
  5. The Joint Commission. (2021). Standard NPSG.07.01.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace, IL: The Joint Commission. (Level VII)
  6. Centers for Disease Control and Prevention. (2002). Guideline for hand hygiene in health-care settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR Recommendations and Reports, 51(RR-16), 1–45. https://www.cdc.gov/mmwr/pdf/rr/rr5116.pdf (Level II)
  7. World Health Organization. (2009). WHO guidelines on hand hygiene in health care: First global patient safety challenge, clean care is safer care. https://apps.who.int/iris/bitstream/handle/10665/44102/9789241597906_eng.pdf?sequence=1 (Level IV)
  8. Accreditation Association for Hospitals and Health Systems. (2020). Standard 07.01.21. Healthcare Facilities Accreditation Program:

    Accreditation requirements for acute care hospitals

    . Chicago, IL: Accreditation Association for Hospitals and Health Systems. (Level VII)
  9. Centers for Medicare and Medicaid Services, Department of Health and Human Services. (2020). Condition of participation: Infection control. 42 C.F.R. § 482.42.
  10. DNV GL-Healthcare USA, Inc. (2020). IC.1.SR.1. NIAHO® accreditation requirements, interpretive guidelines and surveyor guidance-revision 20.0. Milford, OH: DNV GL-Healthcare USA, Inc. (Level VII)
  11. The Joint Commission. (2021). Standard NPSG.01.01.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace, IL: The Joint Commission. (Level VII)
  12. The Joint Commission. (2021). Standard RI.01.03.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace, IL: The Joint Commission. (Level VII)
  13. Accreditation Association for Hospitals and Health Systems. (2020). Standard 15.01.16. Healthcare Facilities Accreditation Program:

    Accreditation requirements for acute care hospitals

    . Chicago, IL: Accreditation Association for Hospitals and Health Systems. (Level VII)
  14. Centers for Medicare and Medicaid Services, Department of Health and Human Services. (2020). Condition of participation: Patient’s rights. 42 C.F.R. § 482.13(c)(1).
  15. DNV GL-Healthcare USA, Inc. (2020). PR.2.SR.5. NIAHO® accreditation requirements, interpretive guidelines and surveyor guidance-revision 20.0. Milford, OH: DNV GL-Healthcare USA, Inc. (Level VII)
  16. The Joint Commission. (2021). Standard PC.02.01.21. Comprehensive accreditation manual for hospitals. Oakbrook Terrace, IL: The Joint Commission. (Level VII)
  17. WatersT. R., et al. (2009). Safe patient handling training for schools of nursing. https://www.cdc.gov/niosh/docs/2009-127/pdfs/2009-127.pdf (Level VII)
  18. Accreditation Association for Hospitals and Health Systems. (2020). Standard 07.01.10. Healthcare Facilities Accreditation Program:

    Accreditation requirements for acute care hospitals

    . Chicago, IL: Accreditation Association for Hospitals and Health Systems. (Level VII)
  19. SiegelJ. D., et al. (2007, revised 2019). 2007 guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. https://www.cdc.gov/infectioncontrol/pdf/guidelines/isolation-guidelines-H.pdf (Level II)
  20. Occupational Safety and Health Administration. (2019). Bloodborne pathogens, standard number 1910.1030. https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_id=10051&p_table=STANDARDS (Level VII)
  21. GanzD. A., et al. (2013, reviewed 2021). Preventing falls in hospitals: A toolkit for improving quality of care (AHRQ publication no. 13-0015-EF). https://www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/index.html (Level VII)
  22. The Joint Commission. (2021). Standard RC.01.03.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace, IL: The Joint Commission. (Level VII)
  23. Centers for Medicare and Medicaid Services, Department of Health and Human Services. (20209). Condition of participation: Medical record services. 42 C.F.R. § 482.24(b).
  24. Accreditation Association for Hospitals and Health Systems. (2020). Standard 10.00.03. Healthcare Facilities Accreditation Program:

    Accreditation requirements for acute care hospitals

    . Chicago, IL: Accreditation Association for Hospitals and Health Systems. (Level VII)
  25. DNV GL-Healthcare USA, Inc. (2020). MR.2.SR.1. NIAHO® accreditation requirements, interpretive guidelines and surveyor guidance-revision 20.0. Milford, OH: DNV GL-Healthcare USA, Inc. (Level VII)
  26. CravenR. F., et al. (2020). Fundamentals of nursing:

    Concepts and competencies for practice

    (9th ed.). Philadelphia, PA: Wolters Kluwer.