Mobility As a basic physiological process, mobility is required for optimal health. Changes in mobility can significantly affect biophysical health, psychosocial health, and functional status. Mobility refers to purposeful physical movement, including gross simple movements, fine complex movements, and coordination. Mobility is dependent on the synchronized efforts of the musculoskeletal and nervous systems as well as adequate oxygenation, perfusion, and cognition. Specifically, mobility requires adequate energy, adequate muscle strength, underlying skeletal stability, joint function, and neuromuscular coordination to carry out the desired movement. Mobility a state or quality of being mobile or movable. Immobility an inability to move. Impaired Physical Mobility a state in which a person has a limitation in physical movement but is not immobile. - Impaired physical mobility, as defined by the North American Nursing Diagnosis Association (NANDA), is a “limitation in independent, purposeful movement of the body or of one or more extremities.” - further differentiates impaired physical mobility by multiple types including impaired bed mobility, impaired wheelchair mobility, impaired standing, impaired transfer ability, and impaired walking. - Although immobility is typically considered a negative state, there are times when immobility or immobilization is therapeutic. For example, the immobilization of a shoulder if it has been dislocated provides desired rest, recovery, and comfort. Deconditioned a loss of physical fitness. - This applies not only to an athlete who fails to maintain an optimal level of training but also to an individual who does not maintain optimal physical activity. - In the context of health care, this term applies to patients who experience extended immobility (e.g., following prolonged bed rest), resulting in an overall deconditioned state of the musculoskeletal and cardiopulmonary systems. This is particularly a problem among older adults. Disuse Syndrome predictable adverse effect on body tissues and functions associated with sedentary lifestyle and inactivity. - Identifying characteristics of the disuse syndrome, as defined by Bortz, included cardiovascular vulnerability, obesity, musculoskeletal fragility, depression, and premature aging. NORMAL PHYSIOLOGICAL PROCESS Optimal mobility relies on bones, joints, articular cartilage, tendons and ligaments, skeletal muscle, and the mechanics of muscle contraction. Underlying these functions is an intact neurologic system whereby signals for all movement are communicated to and from the brain through nerve impulses. Neurologic System All movement is coordinated by the brain through a complex process of sensing internal and external data signals, integrating these data signals, and responding by triggering motor activity. The motor cortex in the frontal lobe of the brain is responsible for voluntary motor activity through a series of nerve impulses sent from the brain, through the spinal cord and peripheral nerves, to the target muscle. The cerebellum, located at the base of the brain, coordinates movement, equilibrium, muscle tone, and proprioception. Musculoskeletal System Bones The skeleton has three overarching roles relating to mobility: It acts as the structural foundation for the body and as leverage to move body parts, supports and protects tissues and internal organs, and provides attachment sites for muscles and ligaments. Bones also serve as a storage center for calcium and as a production center for red blood cells within the bone marrow. The human body has 206 bones classified into two groups: the axial skeleton (bones that comprise the skull, thorax, and spinal column) and the appendicular skeleton (bones that comprise the upper and lower extremities). All structures designed for use over time require ongoing maintenance and intermittent repair. The same is true for the skeletal system. Remodeling is a term that describes an ongoing maintenance of bone tissue through a process in which new bone tissue replaces existing bone tissue in boneremodeling units. The remodeling process also provides the mechanism to repair injured bones (e.g., a fracture). Remodeling requires adequate nutrition, hormonal regulation, and blood supply. The severity of the bone injury and the availability of remodeling elements influence the rate or speed at which injured bone heals. Joints Bones come together at joints. Joints provide stability to bones and allow skeletal movement. Mobility is impacted by the degree of joint freedom; joints allow for skeletal positioning to carry out the desired action. The various types of movement provided by joints include flexion, extension, rotation, adduction, abduction, supination, and pronation. Some of the most common problems associated with mobility arise as a result of joint pain and/or changes in joint function. Three classifications of joints (based on stability and movement) include synarthrosis joints (nonmovable), amphiarthrosis joints (slightly movable), and diarthrosis joints (freely movable). Joints are also classified by structure. Fibrous joints serve to hold bones together in place with connective tissue. For example, the tibia and fibula are held together by a fibrous ligament. Cartilaginous joints feature cartilage material that holds the joint together and provides some movement. For example, ribs are attached and held to the sternum by cartilaginous material, allowing movement for the process of breathing but providing chest stability required for the breathing process. Joints that allow the most movement are also the most complex. Synovial joints have multiple elements, including a joint capsule, synovial membrane, joint cavity, synovial fluid, and articular cartilage. Articular cartilage acts as a cushion by distributing joint loads over a wide area, thereby reducing prolonged compression of articulating bones within the joint. Without cartilage, significant friction and pain result from joint movement. Muscles Skeletal muscle differs from other types of muscle in the body in many ways, but one of the most important differences is that it is under voluntary control. Optimal skeletal muscle function depends on the following five factors: nerve impulses reaching the muscle, muscle fibers’ response to nerve stimulus, proprioception, mechanical load, and joint mobility. Impairment of any one of these factors negatively impacts purposeful movement. Nerve impulses reach skeletal muscle from the spinal cord and peripheral nerves via motor neurons. The motor neurons innervate a group of muscle fibers known as the motor or muscle unit. There are many different types of muscle fibers within a muscle unit depending on the function and type of responsiveness required. Muscles that maintain body posture do not have the same need for quick responsiveness as do the ocular muscles, for example, but are less sensitive to fatigue. Muscle movement occurs in response to nerve stimulation of the muscle fibers triggering muscle contraction. On a cellular level, the functional units of muscle contraction are myofibrils. If one group contracts, another group must relax. For example, flexion of the elbow to move the forearm up requires contraction of the biceps muscles and relaxation of the triceps muscles; likewise, extension of the elbow joint requires contraction of the triceps muscles and relaxation of the biceps muscles. If both are contracted at the same time, no movement occurs. Proprioception is the mechanism that provides a sense of position and movement; this process allows for accuracy in the degree of movement with muscle contraction. Mechanical load of movement is associated with having adequate strength within the muscle group to carry out the desired task. For example, most humans would struggle to pick up a 250-pound object and walk 50 feet with it. However, such a feat is entirely possible for individuals who are well conditioned for this. Age-Related Differences Significant changes to the musculoskeletal system occur throughout infancy and childhood as a function of growth and development. The appendicular skeleton (extremities) grows faster than the axial skeleton (head, thorax, and spine)—partly because the appendicular skeleton is disproportionately shorter than the axial skeleton. Throughout infancy, childhood, and adolescence, bones change in composition, grow in length and diameter, and undergo changes in rotation and alignment. Similarly, the size and composition of muscles undergo changes as a result of physical growth and development throughout childhood, and they are a major factor in weight gain during adolescence. A number of musculoskeletal changes occur with aging. In the spinal column, a thinning of vertebral disks, shortening of the spinal column, and onset of kyphosis with spinal column compression occur. Bone density decreases and becomes brittle (particularly in females), leaving older adults more susceptible to fracture. Cartilage becomes rigid and fragile, and there is a loss of resilience and elasticity of ligaments. Muscle mass and tone reduce significantly in late adult years. Cumulatively, these changes result in mobility impairment attributable to reduced range of motion and pain in joints, reduced muscle strength, and increased risk for bone fracture. VARIATIONS AND CONTEXT Variations in mobility are seen among individuals across the lifespan with multiple causative factors and a wide range of degree of impact and duration. Changes in mobility can be temporary, long term, or permanent, and are influenced by general health status, with specific conditions associated with the neurologic or musculoskeletal system. Restrictions in mobility may also be indicated following a medical procedure or diagnostic test. An individual’s general health status has significant influence on mobility. Many conditions lead to changes in mobility, including acute illness or injury (e.g., influenza or fracture), debilitating chronic conditions (particularly cardiovascular and pulmonary conditions leading to fatigue), and conditions involving end-of-life care (e.g., cancer or dementia). Conditions that specifically lead to mobility impairment include neurologic (including the brain, the spinal cord, and the peripheral nerves), musculoskeletal (bones, joints, and muscles), or a combination of both (neuromuscular conditions). Conditions in these three categories can be caused by congenital defects, genetic conditions, injury, inflammation, infection, autoimmune disorders, and neoplasms. Medical procedures (e.g., surgery) and diagnostic tests may require temporary restrictions on mobility to reduce complications. CONSEQUENCES Attaining and/or maintaining mobility is paramount to health. The human body was designed to move; thus, when movement is limited, consequences occur. The degree of consequence is largely dependent on the degree of mobility impairment and length of time the impairment exists. As a general rule, the greater the extent and length of time, the greater the physiological consequences. A state of complete immobility has a significant impact on the entire body; literally all body systems are affected. Cardiovascular Complications Cardiovascular complications occur both with central and with peripheral perfusion. A lack of physical activity results in reduced cardiac capacity. According to one study, a 15% reduction in muscle mass will occur after 12 weeks of complete immobility. This translates to reduced force of cardiac contraction and a reduction in cardiac output. The loss of endurance and the deconditioned state present challenges when the resumption of physical activity is desired. Problems also occur within the vascular system. Decreased efficiency of orthostatic neurovascular reflexes and diminished vasopressor mechanism cause orthostatic hypotension intolerance when an individual attempts to attain an upright position because of blood pooling in the extremities. Adequate perfusion and venous return depend on skeletal muscle contraction and frequent changes in body position. Because muscular contraction (particularly in the legs) facilitates venous return, venous stasis occurs during periods of inactivity. Slowed blood flow provides an opportunity for the formation of blood clots. Deep vein thrombosis is a relatively common complication associated with immobility. Respiratory Complications Physical activity is associated with full lung expansion, particularly among those engaging in exercise. Immobility contributes to reduced lung expansion and eventually leads to atelectasis (an airless state of the alveoli) and reduced capacity for gas exchange. Pooling of respiratory secretions, coupled with a reduced cough effort, places the immobilized patient at risk for stasis pneumonia. Musculoskeletal Complications Muscle tone, joint movement, and maintenance of bone density require active skeletal contraction and weight bearing. Skeletal muscle adapts to nonuse by reducing mass. Thus, prolonged immobility leads to significant reductions in muscle mass and atrophy; in fact, an average loss of 25% muscle mass occurs with permanent immobility. The lack of activity leads to contracture in the joint, primarily as a result of muscle shortening. Muscle atrophy and joint contraction are particularly concerning because together these negatively affect functional ability. The lack of weight bearing leads to bone demineralization and calcium loss from the skeletal system. The degree of bone demineralization and calcium depletion is related to the severity and duration of immobility as well as the degree of weight-bearing ability. Over time, osteoporosis can develop in response to immobility. Integument System Sustained pressure on the skin reduces perfusion to the tissues. A reduced flow of oxygenated blood causes hypoxemia of the tissues and increases the risk for skin breakdown. Individuals who lack the ability to move in bed have increased risk not only because of pressure but also because of shearing forces that often accompany certain positions or occur during transfers. These problems are further exacerbated if the patient has a poor nutritional status and is incontinent. Development of pressure ulcers commonly results. Gastrointestinal Complications Constipation is a frequently reported complication of immobility for several reasons. - First, not being able to assume an optimal upright position makes having a bowel movement more challenging; for many people, relying on the assistance of others to have a bowel movement is embarrassing and may lead to reluctance in acting on the urge. - From a physiological standpoint, the gastrointestinal tract slows during states of immobility, resulting in reduced peristaltic motility. - Constipation, reduced appetite, and anorexia negatively impact nutritional status. Urinary Complications Immobility leads to three common problems that occur within the urinary system: - renal calculi - urinary stasis infection. Renal calculi result from stasis of urine in the renal pelvis and because of increased circulating serum calcium levels (as a result of bone reabsorption mentioned previously). The bladder loses tone, making it difficult to completely empty the bladder, particularly in a lying position for voiding. This often results in urinary tract infection because the presence of urinary stasis provides an optimal environment for the growth of bacteria. Psychological Effects Acute and chronic psychological conditions that result from immobility include boredom, depression, feelings of helplessness/hopelessness, grieving, anxiety, anger, disturbed body image, and decreased verbal and nonverbal communication. Individuals who are unable to work or are even unable to meet basic activities of daily living often experience a loss of self-worth or value associated with the role change. Social isolation and mood disturbances are common. Psychological effects of immobility are especially concerning among children. For children, physical activity is integral to daily activity. Not only is it essential for physical growth and development but also it is central to expression, communication, and making sense of the world around them. Immobilization can interfere with intellectual and psychomotor function. Emotional responses range from anger and aggressive behavior to passive quiet demeanor and withdrawal. Developmental regression is common. Children often become less communicative and may experience depression; in some cases, hallucinations occur. Populations at Risk All individuals are potentially at risk for altered mobility regardless of age, ethnicity, race, or socioeconomic status. Because of the effects of aging, the population group at greatest risk for impaired mobility is older adults. These changes predispose older individuals to a greater incidence of falls and greater challenges regaining full mobility following a period of impaired mobility. Individual Risk Factors Individual risk factors for changes in mobility are often attributed to acute and chronic conditions, chronic pain, and injury/trauma. Specifically, individuals with orthopedic injury, congenital deformities, neurologic disorders, strokes, head injury, spinal injury or deformities, nutritional deficiencies, cardiopulmonary conditions, and end-stage cancer are particularly susceptible. Side effects and adverse effects of many medications (e.g., corticosteroids and chemotherapy) and medical treatments can also affect mobility. Substance use disorders are more prevalent in major trauma patients than the general population also representing risk for mobility impairment. Primary Prevention Regular physical activity is associated with multiple health benefits and is foundational to primary prevention measures. Regular physical activity possible along with optimal nutrition, keeping an ideal body weight, and getting adequate rest. Taking measures to prevent injury and trauma are also considered primary prevention strategies. Nutrition, as a primary prevention strategy, links to musculoskeletal development. During infancy, childhood, and adolescence, adequate protein and calcium in the diet are critical for the musculoskeletal development described previously. Adequate calcium intake is also necessary to prevent osteoporosis among older individuals. Maintaining a healthy body weight prevents excessive joint strain and is associated with fewer problems with back pain. Falls represent one of the most common mobility problems among older adults; thus, fall prevention is an important aspect of primary prevention. Strategies include participating in regular physical activity (to maintain muscle strength and balance), making the environment safer (e.g., avoiding hazards, using hand rails, wearing sturdy shoes with nonslip soles, and having adequate lighting), and optimizing vision. Secondary Prevention (Screening) The primary areas to highlight related to mobility and screening are osteoporosis, mobility screening, and fall risk assessment. For osteoporosis screening, the U.S. Preventive Services Task Force (USPSTF) recommends screening women age 65 years or older for osteoporosis with bone measurement testing to prevent osteoporotic fractures. Among postmenopausal women under 65, screening is recommended for those with increased risk of osteoporosis. In younger women who have increased fracture risk, dual-energy x-ray absorptiometry (DXA) of the hip and spine is the recommended method to measure bone density. There is no recommendation for the screening interval. Furthermore, USPSTF concludes that evidence is insufficient to recommend screening for men. A large number of mobility and fall risk assessment screening tools are available. A recent study evaluating tools for assessing fall risk in the elderly concluded that two assessment tools used together (as opposed to using a single tool) provide a better evaluation of fall risk among older adults. One of the most common screening tests is the Timed Get Up and Go test, which measures mobility in people who are able to walk on their own (assistive devices allowed). Another common screening is the Performance-Oriented Mobility Assessment test, which aids in the identification of gait and balance impairments. Mobility scales, such as the Greenville Early Mobility Scale, are used in inpatient settings to track the status and progress of a patient’s mobility, thus enhancing the effectiveness of mobility interventions among interdisciplinary teams. Collaborative Interventions From a conceptual perspective, a general discussion of interventions delivered by various members of the healthcare team that address mobility impairments includes several categories, such as care of the immobilized patient, exercise therapy, pharmacologic agents, surgical interventions, immobilization, and assistive devices. Care of Immobilized Patient An important overarching principle to emphasize is the need for early mobility. Early mobility requires a cultural mindset among interdisciplinary teams to overcome challenges and barriers associated with patient mobility. A study assessing barriers to early mobility among patients in an intensive care unit found that about 50% of barriers were patient-related factors (excessive sedation or delirium, morbid obesity, and multiple invasive devices) while a variety of care delivery factors represented other barriers including structural, intensive care unit culture, and process-related barriers such as fragmented care, availability of adequate equipment, time constraints, adequate number of providers, and concerns for patient safety. Many nursing interventions are incorporated into care for the immobilized patient, regardless of the underlying condition. Progressive mobility refers to the application of a mobility plan involving a series of gradual progressive interventions and activities that include positioning, turning, continuous lateral rotation therapy (CLRT), range-of-motion exercise, head elevation, tilt table, chair position, dangling, and ambulation. The patient should be positioned with appropriate body alignment. This is important to prevent injury to extremities and joints and is critical to prevent pulmonary complications. For example, pillows are commonly used to support the body alignment of a patient placed in a Sims position. The patient should be repositioned at least once every 2 hours. Principles of safe patient handling should be applied when patients are moved for repositioning. The patient dependent on caregivers for positioning is at significant risk for skin breakdown because of prolonged pressure over bony prominences. Thus, skin care is a priority for immobilized patients; the skin should be kept clean, dry, and protected to prevent skin breakdown. The skin is regularly monitored and examined for evidence of adequate circulation. Because immobilized patients are at risk for stasis pneumonia, coughing and deep breathing are part of the standard treatment plan. Patients with adequate cognition are encouraged to use an incentive spirometer every hour to maintain ventilator capacity. Rotational bed therapy and CLRT have been shown to reduce the incidence of pneumonia among patients receiving mechanical ventilation in intensive care settings. Bed exercises should be encouraged to the extent possible to minimize atrophy and maintain joint movement. Many types of exercise can be done, including flexion and extension of the foot to promote venous blood return and to prevent venous stasis. If a patient has a trapeze bar over the bed, pull-up exercise should be encouraged if he or she is able. Range-ofmotion (ROM) exercise is critical to promote circulation and to minimize complications to the joints. Active ROM is performed by the patient; assisted ROM involves a patient doing most of the exercise but under the guidance/assistance of a health professional. Passive ROM involves the nurse taking each affected joint through the full range of motion. It is important not to force the joints past the point of resistance. If tolerated, patients should be encouraged to stand at the side of the bed to promote weight bearing. Doing this a few times a day for a few minutes helps to reduce bone demineralization. Exercise Therapy The overall goal of exercise therapy is rehabilitative (relieving symptoms and/or improving/restoring ROM, strength, and balance) or preventive. Several forms of exercise therapy exist, including the following: Exercise Therapy: Ambulation; Exercise Therapy: Joint Mobility; Exercise Therapy: Stretching; and Exercise Therapy: Balance. Specific examples of exercise therapy include ROM exercises mentioned previously, stretching, weight lifting, water exercise, and gait training. Specific exercise therapy interventions are planned, structured, and repetitive; these are customized to address the needs of each patient. Exercise therapy is performed by nurses, occupational therapists, and physical therapists in acute care, community-based, and home care settings. Pharmacologic Agents Many of the drugs used to treat mobility problems are for the relief of pain or inflammation or to treat underlying conditions o Anti-inflammatory agents. - Oral antiinflammatory agents, such as corticosteroids and nonsteroidal antiinflammatory drugs (NSAIDs), are by far the most commonly used agents. Corticosteroid injections into a joint space (such as ankle, knee, hip, wrist, elbow, shoulder, and spine) may be effective in reducing inflammation (and subsequently pain) associated with a number of conditions. However, because repeated corticosteroid injections might cause damage to cartilage, the number of injections into a joint is typically limited. - Another group of agents used to reduce inflammation are the immunomodulators. These function to weaken or modulate the activity of the immune system, thereby decreasing the inflammatory response. o Analgesics. - Agents that are specific for analgesia include opioids (e.g., morphine), NSAIDs, and aspirin. o Muscle relaxants. - Several medications are used to provide relief from discomfort associated with skeletal muscle spasms. - These agents act as central nervous system depressants and reduce nerve transmission to skeletal muscles, thus promoting muscle relaxation. - The most common indication for muscle relaxants is for acute, non-specific low back pain. - Common agents include baclofen, chlorazoxazone, carisoprodol, cyclobenaprine, dantrolene, and tizanidine. o Supplements. - In addition to adequate dietary intake, nutritional supplementation with vitamin D and calcium is a useful prevention and treatment measure for osteoporosis, particularly for postmenopausal women. - Bisphosphonates are antiresorptive agents that slow or stop the reabsorption of calcium from the bone, resulting in maintained or increased bone density and strength. These agents are used to treat osteoporosis. o Surgical Interventions - Surgical intervention can be either curative or palliative, depending on the underlying cause. Examples of surgical interventions related to mobility/immobility include arthroscopic procedures, open and/or closed reduction of a fracture with or without external and/or internal fixation, amputation, synovectomy, osteotomy, debridement, arthroplasty, arthrodesis, diskectomy, and spinal fusion. o Immobilization - Following an injury or surgery, immobilization of a joint or bone is often necessary to provide stability and hold the appendage in place so that healing can occur. - Following a fracture, for example, bone remodeling takes several weeks before the fracture is stable. Immobilization is necessary to enhance the healing process, to protect the bone from further injury, and to provide comfort to the patient. - Assessment to verify adequate perfusion (the presence of pulse and/or rapid capillary refill in nail beds), movement, and sensation is critical. - Another indication for immobilization is to prevent injury. For example, for all patients with suspected spinal injury, spinal immobilization is routinely applied in the prehospital setting by strapping the patient on a backboard and using a cervical collar to prevent head rotation. o Assistive Devices and Patient Handling Technology - Common assistive devices to enhance mobility include canes, crutches, walkers, wheelchairs, grabbing/reaching devices, power-operated vehicles, prostheses. Patients must be taught to use these devices correctly to avoid injury. - Patient handling technology refers to a variety of equipment in the care environment designed to assist with the handling and movement of patients. Examples include transfer mats, slings, and lifts. Other Therapies o Transcutaneous electric nerve stimulation. - Transcutaneous electric nerve stimulation (TENS) is a therapeutic intervention involving low-voltage electrical current for the relief of pain. - Electrodes are placed on the patient’s skin near the area of pain; the electrical current creates electrical impulses that travel along the nerve fiber, which is thought to send a signal to the brain that blocks pain signals. o Thermotherapy. - Heat therapy involves the application of moist or dry heat (heating pad, warm water bottle, warm bath) to the skin surface. - The heat causes a dilation of blood vessels that promotes blood flow and helps to relax muscles that are tight. It is particularly effective for symptomatic relief muscle pain and inflammation (e.g., osteoarthritis, strains, tendonitis, pain or spasms in the back or neck), but is not indicated for a new injury or open wound. - Cold therapy involves the application of a cold compress (or immersion in cold water) to an area of inflammation. It causes vasoconstriction of underlying blood vessels to reduce inflammation and is most effective for recent injuries (e.g., a pulled muscle, muscle strain, or sprain). - Cold therapy should not be used on an open wound or with vascular disease or injury, and is not generally recommended for low back pain. Bone Fracture Bone fracture refers to a partial or complete disruption in the bone structure. Interruption of bone structure leads to a reduction or loss in movement and pain. Although fractures are usually the result of traumatic injury, spontaneous fractures can occur in the presence of bone disease (e.g., osteoporosis or a neoplasm). Fractures occur at any age, but they are unusual during infancy. Most fractures occur in children and adolescents and adults older than age 65 years (wrist and hip fractures as a result of falls). Parkinson Disease Parkinson disease (PD) is a neurologic disorder associated with a loss of dopamine production in the brain. This disorder leads to changes in mobility resulting from muscular tremor, rigidity of the extremities and trunk, slowness of movement, and impaired coordination and balance. Mobility impairment increases with disease progression. Typically, PD affects adults older than age 50 years, with a higher incidence among men than women. Children in pain resist any activity that increases their pain. The child is more likely to cooperate with activities that promote recovery if pain is being addressed. Muscles and joints should be assessed for size, symmetry, strength, range of motion, and stability. Comparisons are made between right and left sides. Assessment of muscle strength is done utilizing a muscle strength scale (0 = no detection of muscular contraction; 5 = full muscle strength). Findings considered abnormal include observed deformity of bone or joint, edema, ecchymosis, localized warmth and redness, a loss of function, numbness, guarding (due to pain), and limitations in movement or mobility. Ball-and-socket joints permit movement in any direction. Pivot joints permit rotation. Hinge joints allow motion in one plane. Biaxial joints permit gliding movement. Arthroscopy is a diagnostic test that uses an arthroscope to directly visualize the ligaments, menisci, and articular surfaces of a joint. A muscle biopsy is conducted to diagnose atrophy and inflammation. An ultrasonography is used to view soft tissue disorders, traumatic joint injuries, and osteomyelitis. An electromyography may be performed to evaluate diffuse or localized muscle weakness. The bones of toddlers can withstand falls better than those of older adults. Toddlers’ bones are more pliable than those of older persons. Toddlers have greater amounts of cartilage and are highly flexible as compared with the cartilage of young adults. Phalen’s test is used to detect carpal tunnel syndrome. Patellar reflex, performed in this figure, is done by striking the patellar tendon just below the patella. The biceps reflex is performed with the client’s arms partially flexed and palms up, by placing the thumb over the biceps tendon. The triceps reflex is performed by striking the triceps tendon above the elbow while the client’s arm is flexed. The brachioradialis reflex is performed by striking the radius 3 to 5 cm above the wrist while the client’s arm is reflexed. Bones are the framework of the body; they support and protect internal organs. They also help in stem cell production from bone marrow, and they store minerals. Joints (articulations) help articulate the bones. Muscles are the bundles of fibrous tissue that contract to produce movement and maintain body posture. Cartilage is a hyaline, elastic, and fibrous tissue that often functions as a shock absorber. A corn is a foot disorder caused by continual pressure over bony prominences. Injuries in various stages of healing are the classic sign of child abuse. According to the Lovett score, a full range of motion against gravity with some resistance can be categorized as G (good). F (fair) can be given if the client exhibits a full range of motion with no resistance. T (trace) score is given when the client exhibits slight contractility with no movement. N (normal) on the Lovett scale indicates full range of motion against gravity with full resistance. Change of position at least every 1 or 2 hours helps prevent the respiratory, urinary, and cutaneous complications of immobility. Acute postoperative pain always requires the use of analgesics, but nonpharmacological interventions such as repositioning the client can help relieve pain. Aging causes a lowering of the physiological coping reserve of various systems of the body. A bone scan is a radionuclide test in which radioactive material is injected so that the client’s entire skeleton can be viewed. Active range-of-motion (ROM) exercises increase venous return in the unaffected leg, preventing complications of immobility, including thrombophlebitis. When serum calcium levels lower, secretion of PTH increases and stimulates bones to promote osteoclastic activity, which promotes bone resorption. Estrogens stimulate osteoblastic (bonebuilding) activity and inhibit PTH. Calcitonin inhibits bone resorption and increases the renal excretion of calcium and phosphorus as needed to maintain balance in the body. Growth hormones secreted by the anterior lobe of the pituitary gland are responsible for increasing bone length. The physiological changes of the musculoskeletal system related to aging are slowed movements, cartilage degeneration, increased bone prominence, decreased bone density, and decreased range of motion. In the immediate postoperative period, mobility is encouraged because veins require the assistance of the surrounding muscle beds to help pump blood toward the heart. This reduces venous stasis and the risk of thrombophlebitis. A client with a second-degree sprain may have a deeply torn ankle ligament with swelling and tenderness. Elevation of the injured lower limb above heart level helps mobilization of the excess fluid from the area and prevents further edema. The toddler has poor depth perception, which increases the risk of falling. A goniometer is a device that measures the angle of a joint and is used to assess range of motion. Abduction reduces stress on anatomic structures and maintains the head of the femur in the acetabulum Joint fluid is normally transparent and colorless or straw-colored. Nalidixic acid can cause cartilage erosion in pediatric clients. An exercise program and a brace are the treatments of choice for mild structural scoliosis. Although compliance will affect the ultimate outcome of treatment, exercises alone are not helpful in this type of scoliosis. Exercises are to be encouraged, regardless of the type or extent of scoliosis. Exercises alone are used only with postural-related, not structural-related, scoliosis. To prevent footdrop (plantar flexion of the foot because of weakness or paralysis of the anterior muscles of the lower leg) in a client with a cast, the foot should be supported with 90 degrees of flexion. An incomplete fracture with one side splintered and the other side bent indicates a greenstick fracture. A fracture with more than two fragments that appear to be floating is known as a comminuted fracture. A pathological fracture is a spontaneous fracture found at the site of bone disease. A transverse fracture extends across the longitudinal axis of the bone shaft.
