Assignment Prompt & Instructions
**files (3)**
– ## Attemptfeedback2.docx
– ## CapstonePartIIintrucctions.docx
– ## MSN_Capstone_Part1_Revised1.docx
**## Attemptfeedback2.docx**
Attempt feedback
You are on the right track and did well overall. Choose one clinic setting within Miami-Dade to make it realistic. Missing Conclusion paragraph as per APA.
**## CapstonePartIIintrucctions.docx**
Capstone Part II: Review of Literature
**CAPSTONE: PART II due 10/4/2025 by 11:59pm**
1. Review of Literature:
– Review and discuss literature: Synthesize at least 10 primary research studies and/or systematic reviews; do not include summary articles. This section is all about the scientific evidence rather than someone else's opinion of the evidence. Do not use secondary sources; you need to get the article, read it, and make your own decision about quality and applicability to your question even if you did find out about the study in a review of the literature. This is a synthesis rather than a study-by-study review. Address the similarities, differences, and controversies in the body of evidence.
2. Analyze and apply knowledge directly to your PICOT- The studies that you cite in this section must relate directly to your PICOT question.
3. Provide precise body of evidence for your Practice Change- Include Nurses as leaders in this project, statistics, cost, impact on healthcare.
4. Discuss objectives for your practice change, Why is change necessary?
5. Discuss where the problem exists, why it exists, what is the preposition for change. Include information from your PICOT.
6. Apply all that is relevant to the problem. For example: Pros vs Cons, current state of problem
NOTE: It should not reflect your opinion, but rather Evidence Based Practice should be applied
-After completing a literature search on interventions addressing your chosen health problem, write a review that evaluates the strengths and weaknesses of all the sources you have found, compare anc constrast.
-Use appropriate APA 7th Ed. Scholarly, peer-reviewed, and research articles cited should be within the last five years.
-This section should be minimum 4-6 pages long (not including the title and reference page).
-Use proper in-text citations with a properly formatted reference list.
-All papers must be written APA in the 3rd person.
**Rubric Capstone II.docx**
**Submission**
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**Details & Information**
CRITERIA OUTSTANDING VERY GOOD GOOD UNACCEPTABLE
Integration of
Knowledge
25 points
Thoroughly selected
and present an
appropriate
Evidence Based
Practice for the
health problem and
change.
25
Briefly selected and
present an
appropriate
Evidence Based
Practice for the
health problem and
change.
20
Vaguely selected
and present an
appropriate
Evidence Based
Practice for the
health problem and
change.
15
Did not select and
present an
appropriate
Evidence Based
Practice for the
health problem and
change.
0
Topic Focus
25 points
The health problem
is focused narrowly
enough for the
scope of this
assignment. A topic
statement provides
direction for the
paper. The topic is
consistently well
thought out,
thorough offers
insight into the topic,
and includes cited
evidence to support
the topic.
25
The health problem
is focused but
lacks direction. The
paper is about a
specific topic, but
the writer has not
established a
position. The topic
is somewhat well
thought out, offers
limited insight into
the topic, but does
not include cited
evidence to support
the topic.
20
The health problem
is too broad for the
scope of this
assignment.
15
The health problem
is unclear or
unrelated to the
discussion topic
with little or no
supporting
evidence.
0
Depth of
Discussion and
Cohesiveness
25 points
In-depth discussion
and elaboration in all
sections of the
paper.
Ties together
information from all
sources. Paper flows
from one issue to
the next with no
headings. The
author’s writing
demonstrates an
understanding of the
relationship among
material obtained
from all sources
Mostly, it ties
together information
from all sources.
In-depth discussion
and elaboration in
most sections of
the paper.
Mostly, it ties
together
information from all
sources. Paper
flows with only
some
disjointedness. The
author’s writing
demonstrates an
understanding of
the relationship
among material
obtained from all
sources.
The writer has
omitted content.
Quotations from
others outweigh the
writer’s own ideas
excessively.
Sometimes ties
together
information from all
sources. The paper
does not flow.
Disjointedness is
apparent. The
author’s writing
does not
demonstrate an
understanding of
the relationship
between material
obtained from all
sources.
Cursory discussion
in all the sections
of the paper or brief
discussion in only a
few sections.
It does not tie
together
information. Paper
does not flow and
appears to be
created from
disparate issues.
Headings are
necessary to link
concepts. Writing
does not
demonstrate an
understanding of
any relationship.
25 20
15
0
Spelling and
Grammar
10 points
Fewer than 5
grammatical,
spelling,
capitalization, or
punctuation errors.
Required word count
has been met.
8
More than 5 but
fewer than 10
grammatical,
spelling,
capitalization &
punctuation errors
Required word
count is 25 words
below the minimum
required count.
6
More than 10
grammatical,
spelling,
capitalization &
punctuation errors
Required word
count is 50 words
below the minimum
required count.
5
An unacceptable
number of spelling
and/or grammar
mistakes.
Required word
count is more than
50 words below the
minimum required
count.
0
Sources
10 points
Over 5 current
sources, of which at
least 3 are peer-
review journal
articles or scholarly
books. Sources
include both general
background sources
and specialized
sources. Special-
interest sources and
popular literature
and acknowledged
as such if they are
cited. All websites
utilized are
authoritative.
5 current sources,
of which at least 2
are peer-review
journal articles or
scholarly books. All
websites utilized
are authoritative.
Fewer than 5
current sources or
fewer than 2 of 5
are peer-reviewed
journal articles or
scholarly books. All
websites utilized
are credible.
Fewer than 5
current sources or
fewer than 2 of 5
are peer-reviewed
journal articles or
scholarly books.
Not all websites
utilized are credible,
and/or sources are
not current.
Citations
5 points
Fewer than 5
incomplete citations
and/or quotations,
and APA format
errors
5
More than 5 but
fewer than 10
incomplete
citations and/or
quotations, and
APA format errors.
4
More than 10
incomplete
citations and/or
quotations, or APA
format errors.
3
The citation style is
inconsistent or
incorrect. It does
not cite sources.
**## MSN_Capstone_Part1_Revised1.docx**
1
**Reducing Muscle Stiffness Through a Brief Stretching Intervention:** **A Capstone PICOT Proposal**
Alex De Cardenas
Florida National University
MSN Capstone Project-DAX-DL01
Dr. Carmen Lazo
May 21, 2026
**Abstract**
Mild muscle stiffness is a common musculoskeletal issue that is seen in primary care and community health settings and is associated with working-age and older adults, often related to physical inactivity, prolonged postures at work and sedentary lifestyles. Although these conditions are common and have significant health service utilization and cost (likely in the United States, over $200 billion per year for all musculoskeletal conditions), self-management interventions are underutilized in community and primary care settings. This culminating proposal is an evidence-based program to decrease self-reported muscle stiffness through education and implementation of a short five minute stretching routine daily and is nurse-led. The target population for this study is adults in Miami-Dade County, FL who visit primary care providers and/or community health services and are experiencing mild muscle stiffness. The intervention will be assessed with a numeric stiffness rating scale at baseline and week 8. This program is designed to increase the self-efficacy of patients, minimize need for analgesic medications, minimize avoidable use of healthcare resources and optimize functional quality of life for a socioeconomically diverse and vulnerable patient population based on Dorothea Orem's Self-Care Deficit Nursing Theory and the Iowa Model of Evidence Based Practice.
Keywords:
_muscle stiffness, stretching, self-care, nurse-led education, primary care, community health, Miami-Dade_
**Reducing Muscle Stiffness Through a Brief Stretching Intervention:** **A Capstone PICOT Proposal**
Muscle stiffness is an increasingly common but undertreated health problem in adults in community and primary care practices. Muscle stiffness is often linked to sedentary lifestyle and unhealthy occupational postures, as well as physical inactivity, and is not only a problem for mobility but also for comfort and functional status (Zvetkova et al., 2023). While it's not a serious health condition, ongoing stiffness can be a significant quality-of-life problem and can over time lead to increased use of healthcare and a loss of independence. Musculoskeletal conditions, such as muscle, tendon, and connective tissue related to stiffness, impact the lives of about 126.6 million Americans annually with over $213 billion in treatment expenses, lost wages and economic burden (United States Bone and Joint Initiative, 2021). These statistics emphasize the need for strategies that prevent and intervene early in the course of musculoskeletal issues to prevent them from becoming chronic and expensive.
Miami-Dade County is a uniquely burdened area for MS complaints at the local level. Florida is one of the highest states for musculoskeletal-related visits to the emergency department and primary care providers, and many of these visits are due to work-related musculoskeletal disorders among service-sector and manual labor employees (Florida Department of Health, 2022). These factors combine to decrease the chances residents have for timely, organized musculoskeletal care, with the Miami-Dade County uninsured rate estimated at about 19%, compared to the national average of 9.2% (U.S. Census Bureau, 2023). Uncontrolled muscle stiffness in this population comes with direct costs (such as increased consumption of pain medications) and indirect costs (such as unnecessary clinic visits, loss of working time, and exacerbated chronic pain problems). Minimally costly and specialized equipment-free nurse-led interventions, which are evidence-based and fiscally-sound, are strategies to reduce this burden.
The aim of this proposed program is to determine if a nurse-led structured 5-minute daily stretching education program can significantly decrease muscle stiffness in adults over an 8 week period in a primary care or community health care setting. The expected results are clinically relevant decreases in stiffness scores (measured by patient-reported outcomes) at the end of the eight-week intervention period. The importance of this program is not just to reducing unnecessary clinic visits, but also less use of analgesic medicines and long-term functional health of a vulnerable adult population.
**PICOT**
In adults with mild muscle stiffness (P), does teaching a simple five-minute daily stretching routine (I), compared to usual care without structured stretching education (C), reduce self-reported muscle stiffness (O) over eight weeks (T)?
The population of this project is adults with mild muscle stiffness, who are commonly seen in primary and community health services. This population includes individuals who are working age who have sedentary work, those who are older who have lower levels of physical activity and those who have discomfort in their musculoskeletal system, which is in early stages. Chronic musculoskeletal pain or stiffness is reported by about 54 million adults in the United States, and prevalence is higher among older people and those who are sedentary in their occupations (Theis et al., 2021). Low access to physical therapy, low health literacy, and lack of guidance on self-management strategies (Çimen, 2023) make this population vulnerable.
Proposed intervention is a five-minute, standardized, nurse delivered stretching program done at the end of the visit with emphasis on major muscle groups that tend to become stiff when injured, such as the neck, shoulders, lower back and lower extremities. Systematic reviews provide evidence of the significant benefits of regular static and dynamic stretching programs, including decreases in musculoskeletal pain severity, range of motion, and perceived muscle stiffness in adults. (Behm et al., 2023) The briefness of the routine is deliberate because shorter structured exercise programs have been shown to have greater sustained patient adherence versus longer programs that utilize equipment or gym access.
The comparison intervention is usually care plus verbal advice or referring to physical therapy for self-management training, but not providing a formal self-management program. There is a consistent body of evidence of less enduring improvement in musculoskeletal symptoms associated with passive care approaches compared to active, patient-centerd approaches like structured exercise or stretching education (Behm et al. 2023). The project is expected to yield statistically and clinically meaningful improvement of self-reported muscle stiffness scores (measured by a validated Numeric Rating Scale) at the end of the 8 weeks when compared to the baseline score. The eight-week duration is long enough to establish a pattern of stretching and to demonstrate measurable changes in muscle physiology such as increased tissue extensibility and decreased resting muscle tension (Zvetkova et al., 2023).
**Vulnerable Population and Setting**
The target population for this project are adults (ages 18) who live in Miami-Dade County, Florida, and present to their primary care clinics or community health centers with complaints of mild muscle stiffness. Miami-Dade is a diverse urban area with a concentration of population where most residents have sedentary service jobs and earn low wages in manual jobs. The two occupations are related to high levels of musculoskeletal complaints from the static position and repetitive motion patterns (Çimen, 2023). The occupational dimension of musculoskeletal disorder occurrence in and susceptibility of workers is demonstrated by the fact that service and manual labor workers make up a disproportionate share of the estimated 544,900 reported cases of MSDs that result in days away from work annually in the United States (BLS, 2022).
The musculoskeletal burden of this population is heavily influenced by social determinants of health. Around 19% of Miami-Dade County residents do not have health insurance, which reduces their access to specialist musculoskeletal care, physical therapy referrals, and preventive health services (U.S. Census Bureau, 2023). Low income also makes it harder to join gyms, get ergonomic workstations, and access evidence-based self-care resources. Difficulty with language may impede seeking help and compliance to health guidelines in Spanish-speaking and Haitian Creole-speaking populations. In addition, long work hours and caregiving duties limit physical activity time which also contributes to stiffness and functional decline. Cultural and low barrier approaches to addressing social disadvantage are essential for these compounded social disadvantage groups (Zvetkova et al., 2023).
Unless stiffness is treated early, it's likely to become a chronic pain problem, to result in reduced range of motion, and to be a fall risk, especially for older individuals in this group. In Miami-Dade, chronic musculoskeletal pain has been linked to emergency department visits that have an average cost of $1,389 per visit, while a structured nurse-led primary care intervention has average costs of about $120 per visit, indicating the cost-effectiveness of early preventive programming (Florida Department of Health, 2022). The differences highlight the need for proactive nursing interventions based in the community as a clinical priority and also a cost-effective approach to the healthcare system in Miami Dade.
**Proposal**
The proposed intervention is a nurse-led patient education program that will be delivered in a primary care or community health clinic in Miami-Dade County. If adults are identified on a regular basis in clinics for having mild muscle stiffness, a trained registered nurse or advanced practice registered nurse will provide a structured 15-minute educational session where the patient will be taught a standardized 5-minute stretching exercise. The routine concentrates on the cervical spine, shoulders, thoracic back, lumbar spine, hip flexors and hamstrings, each stretch being bilaterally performed for 30-60 seconds. A laminated take home reference card with illustrated instructions will be provided for patients to use independently each day. The evidence supports this educational approach, as Galmarini et al., (2024) showed that self-directed stretching programs that are supplemented with visual instructional materials are more likely to lead to improved patient adherence and musculoskeletal outcomes than verbal instruction alone.
The resources needed for implementation are the printed patient education materials, an area in the clinical setting for demonstration and nurse time of 20 minutes per patient encounter. The estimated cost of the intervention is $15-$25, per patient, which is very practical in resource-limited community settings (Theis et al., 2021). Multilingual patient materials in English, Spanish and Haitian Creole will be developed to meet the language needs of Miami-Dade's diverse population and ensure equitable access to the intervention. Furthermore, the short duration of the routine and its ease of implementation will contribute to patient compliance.In addition, the routine is brief and straightforward, making it easier to implement.
The program will take a total of 10 weeks: 2 weeks of staff training and program preparation, 8 weeks of open enrolment of patients and delivery of the intervention, and 8 weeks concurrently for outcome assessments, with a standardized numeric stiffness rating scale used at baseline and week 8. Advanced practice nurse overseeing program will review outcome data at 4 weeks to determine the progress that has been made and to discuss any challenges to adherence as needed (Behm et al., 2023). If the 8-week outcome data show statistical difference in stiffness scores, presentation will be made to clinic leadership for further consideration of wider program implementation.
**Theoretical Framework**
This Capstone project is designed and implemented through a pair of complementary frameworks: Dorothea Orem's Self-Care Deficit Nursing Theory and the Iowa Model of Evidence-Based Practice. These frameworks offer a clear and comprehensive basis for patient-centered education and for integrating evidence in clinical practice.
In accordance with Orem's Self-Care Deficit Nursing Theory, patients have a natural ability for self-care and nursing can support, educate, and empower patients when their self-care ability falls short of their therapeutic needs (Tanaka, 2022). The five-minute stretching exercise is a self-care behavior and this theory can be directly applied to the proposed intervention. There is a lack of structured knowledge among adults in case of mild muscle stiffness, which can be compensated by nursing education and leads to a lack of self-care. The role of the nurse in this project is an educative-supportive role as the nurse provides patients with the knowledge, skill, and motivation to perform the daily stretches alone. The preventive focus of the intervention is also understood through Orem's framework; in doing so, the skills needed to successfully implement self-care behavior are introduced, thereby decreasing reliance on healthcare services and decreasing the accumulation of health deficits over time.
The Iowa Model of Evidence-Based Practice offers a systematic approach to moving from evidence to practice. Based on the Iowa Model, Cullen et al. (2022) offer practitioners guidance for problem identification, evidence appraisal, pilot implementation, and outcome evaluation. Muscle Stiffness is determined as a clinically relevant trigger of practice change in this Capstone project. Systematic reviews and RCTs published and supporting stretching interventions are appraised and included in intervention design. A standardised 5 minute routine is rehearsed in the clinic and the patient's outcome is formally assessed at 8 weeks. When outcomes data show positive results, the model can be used to share the results and to consider the broader implementation at the healthcare organization level. This is a well-structured intervention that is theory driven, operationally astute, and can produce transferable clinical knowledge.
**References**
Behm, D. G., Alizadeh, S., Daneshjoo, A., Anvar, S. H., Graham, A., Zahiri, A., & Konrad, A. (2023). Acute effects of various stretching techniques on range of motion: A systematic review with meta-analysis.
_Sports Medicine-Open, 9_(1), 107. https://doi.org/10.1186/s40798-023-00652-x
Bureau of Labor Statistics. (2022).
_Employer-reported workplace injuries and illnesses — 2021._ U.S. Department of Labor. https://www.bls.gov/news.release/osh.nr0.htm
Çimen, O. (2023). The efficiency of ergonomics, active break and stretching exercise program in office workers with chronic neck and back pain.
_Deneysel ve Klinik Tıp Dergisi, 40_(2), 329–332. https://dergipark.org.tr/en/pub/omujecm/issue/79274/1282408
Cullen, L., Hanrahan, K., Farrington, M., Tucker, S., & Edmonds, S. (2022).
_Evidence-based practice in action: Comprehensive strategies, tools, and tips from University of Iowa Hospitals & Clinics._ Sigma Theta Tau.
Florida Department of Health. (2022).
_Florida musculoskeletal health data and statistics._ https://www.floridahealth.gov
Theis, K. A., Murphy, L. B., Guglielmo, D., Boring, M. A., Okoro, C. A., Duca, L. M., & Barbour, K. E. (2021). Prevalence of arthritis and arthritis-attributable activity limitation — United States, 2016–2018.
_Morbidity and Mortality Weekly Report, 70_(40), 1401–1407.
[https://doi.org/10.15585/mmwr.mm7040a2](https://doi.org/10.15585/mmwr.mm7040a2)
Galmarini, E., Marciano, L., & Schulz, P. J. (2024). The effectiveness of visual-based interventions on health literacy in health care: A systematic review and meta-analysis.
_BMC Health Services Research_,
_24_(1), 1–10. https://doi.org/10.1186/s12913-024-11138-1
Tanaka, M. (2022). Orem's nursing self-care deficit theory: A theoretical analysis focusing on its philosophical and sociological foundation.
_Nursing Forum, 57_(3), 480–485. https://doi.org/10.1111/nuf.12696
U.S. Census Bureau. (2023).
_American Community Survey: Health insurance coverage in the United States._ https://www.census.gov/topics/health/health-insurance.html
United States Bone and Joint Initiative. (2021).
_The burden of musculoskeletal diseases in the United States: Prevalence, societal and economic cost (4th ed.)._ https://www.bmus-ors.org/
Zvetkova, E., Koytchev, E., Ivanov, I., Ranchev, S., & Antonov, A. (2023). Biomechanical, healing and therapeutic effects of stretching: A comprehensive review.
_Applied Sciences, 13_(15), 8596. https://doi.org/10.3390/app13158596
**## MSN_Capstone_Part1_Revised1.docx**
1
**Reducing Muscle Stiffness Through a Brief Stretching Intervention:** **A Capstone PICOT Proposal**
Alex De Cardenas
Florida National University
MSN Capstone Project-DAX-DL01
Dr. Carmen Lazo
May 21, 2026
**Abstract**
Mild muscle stiffness is a common musculoskeletal issue that is seen in primary care and community health settings and is associated with working-age and older adults, often related to physical inactivity, prolonged postures at work and sedentary lifestyles. Although these conditions are common and have significant health service utilization and cost (likely in the United States, over $200 billion per year for all musculoskeletal conditions), self-management interventions are underutilized in community and primary care settings. This culminating proposal is an evidence-based program to decrease self-reported muscle stiffness through education and implementation of a short five minute stretching routine daily and is nurse-led. The target population for this study is adults in Miami-Dade County, FL who visit primary care providers and/or community health services and are experiencing mild muscle stiffness. The intervention will be assessed with a numeric stiffness rating scale at baseline and week 8. This program is designed to increase the self-efficacy of patients, minimize need for analgesic medications, minimize avoidable use of healthcare resources and optimize functional quality of life for a socioeconomically diverse and vulnerable patient population based on Dorothea Orem's Self-Care Deficit Nursing Theory and the Iowa Model of Evidence Based Practice.
Keywords:
_muscle stiffness, stretching, self-care, nurse-led education, primary care, community health, Miami-Dade_
**Reducing Muscle Stiffness Through a Brief Stretching Intervention:** **A Capstone PICOT Proposal**
Muscle stiffness is an increasingly common but undertreated health problem in adults in community and primary care practices. Muscle stiffness is often linked to sedentary lifestyle and unhealthy occupational postures, as well as physical inactivity, and is not only a problem for mobility but also for comfort and functional status (Zvetkova et al., 2023). While it's not a serious health condition, ongoing stiffness can be a significant quality-of-life problem and can over time lead to increased use of healthcare and a loss of independence. Musculoskeletal conditions, such as muscle, tendon, and connective tissue related to stiffness, impact the lives of about 126.6 million Americans annually with over $213 billion in treatment expenses, lost wages and economic burden (United States Bone and Joint Initiative, 2021). These statistics emphasize the need for strategies that prevent and intervene early in the course of musculoskeletal issues to prevent them from becoming chronic and expensive.
Miami-Dade County is a uniquely burdened area for MS complaints at the local level. Florida is one of the highest states for musculoskeletal-related visits to the emergency department and primary care providers, and many of these visits are due to work-related musculoskeletal disorders among service-sector and manual labor employees (Florida Department of Health, 2022). These factors combine to decrease the chances residents have for timely, organized musculoskeletal care, with the Miami-Dade County uninsured rate estimated at about 19%, compared to the national average of 9.2% (U.S. Census Bureau, 2023). Uncontrolled muscle stiffness in this population comes with direct costs (such as increased consumption of pain medications) and indirect costs (such as unnecessary clinic visits, loss of working time, and exacerbated chronic pain problems). Minimally costly and specialized equipment-free nurse-led interventions, which are evidence-based and fiscally-sound, are strategies to reduce this burden.
The aim of this proposed program is to determine if a nurse-led structured 5-minute daily stretching education program can significantly decrease muscle stiffness in adults over an 8 week period in a primary care or community health care setting. The expected results are clinically relevant decreases in stiffness scores (measured by patient-reported outcomes) at the end of the eight-week intervention period. The importance of this program is not just to reducing unnecessary clinic visits, but also less use of analgesic medicines and long-term functional health of a vulnerable adult population.
**PICOT**
In adults with mild muscle stiffness (P), does teaching a simple five-minute daily stretching routine (I), compared to usual care without structured stretching education (C), reduce self-reported muscle stiffness (O) over eight weeks (T)?
The population of this project is adults with mild muscle stiffness, who are commonly seen in primary and community health services. This population includes individuals who are working age who have sedentary work, those who are older who have lower levels of physical activity and those who have discomfort in their musculoskeletal system, which is in early stages. Chronic musculoskeletal pain or stiffness is reported by about 54 million adults in the United States, and prevalence is higher among older people and those who are sedentary in their occupations (Theis et al., 2021). Low access to physical therapy, low health literacy, and lack of guidance on self-management strategies (Çimen, 2023) make this population vulnerable.
Proposed intervention is a five-minute, standardized, nurse delivered stretching program done at the end of the visit with emphasis on major muscle groups that tend to become stiff when injured, such as the neck, shoulders, lower back and lower extremities. Systematic reviews provide evidence of the significant benefits of regular static and dynamic stretching programs, including decreases in musculoskeletal pain severity, range of motion, and perceived muscle stiffness in adults. (Behm et al., 2023) The briefness of the routine is deliberate because shorter structured exercise programs have been shown to have greater sustained patient adherence versus longer programs that utilize equipment or gym access.
The comparison intervention is usually care plus verbal advice or referring to physical therapy for self-management training, but not providing a formal self-management program. There is a consistent body of evidence of less enduring improvement in musculoskeletal symptoms associated with passive care approaches compared to active, patient-centerd approaches like structured exercise or stretching education (Behm et al. 2023). The project is expected to yield statistically and clinically meaningful improvement of self-reported muscle stiffness scores (measured by a validated Numeric Rating Scale) at the end of the 8 weeks when compared to the baseline score. The eight-week duration is long enough to establish a pattern of stretching and to demonstrate measurable changes in muscle physiology such as increased tissue extensibility and decreased resting muscle tension (Zvetkova et al., 2023).
**Vulnerable Population and Setting**
The target population for this project are adults (ages 18) who live in Miami-Dade County, Florida, and present to their primary care clinics or community health centers with complaints of mild muscle stiffness. Miami-Dade is a diverse urban area with a concentration of population where most residents have sedentary service jobs and earn low wages in manual jobs. The two occupations are related to high levels of musculoskeletal complaints from the static position and repetitive motion patterns (Çimen, 2023). The occupational dimension of musculoskeletal disorder occurrence in and susceptibility of workers is demonstrated by the fact that service and manual labor workers make up a disproportionate share of the estimated 544,900 reported cases of MSDs that result in days away from work annually in the United States (BLS, 2022).
The musculoskeletal burden of this population is heavily influenced by social determinants of health. Around 19% of Miami-Dade County residents do not have health insurance, which reduces their access to specialist musculoskeletal care, physical therapy referrals, and preventive health services (U.S. Census Bureau, 2023). Low income also makes it harder to join gyms, get ergonomic workstations, and access evidence-based self-care resources. Difficulty with language may impede seeking help and compliance to health guidelines in Spanish-speaking and Haitian Creole-speaking populations. In addition, long work hours and caregiving duties limit physical activity time which also contributes to stiffness and functional decline. Cultural and low barrier approaches to addressing social disadvantage are essential for these compounded social disadvantage groups (Zvetkova et al., 2023).
Unless stiffness is treated early, it's likely to become a chronic pain problem, to result in reduced range of motion, and to be a fall risk, especially for older individuals in this group. In Miami-Dade, chronic musculoskeletal pain has been linked to emergency department visits that have an average cost of $1,389 per visit, while a structured nurse-led primary care intervention has average costs of about $120 per visit, indicating the cost-effectiveness of early preventive programming (Florida Department of Health, 2022). The differences highlight the need for proactive nursing interventions based in the community as a clinical priority and also a cost-effective approach to the healthcare system in Miami Dade.
**Proposal**
The proposed intervention is a nurse-led patient education program that will be delivered in a primary care or community health clinic in Miami-Dade County. If adults are identified on a regular basis in clinics for having mild muscle stiffness, a trained registered nurse or advanced practice registered nurse will provide a structured 15-minute educational session where the patient will be taught a standardized 5-minute stretching exercise. The routine concentrates on the cervical spine, shoulders, thoracic back, lumbar spine, hip flexors and hamstrings, each stretch being bilaterally performed for 30-60 seconds. A laminated take home reference card with illustrated instructions will be provided for patients to use independently each day. The evidence supports this educational approach, as Galmarini et al., (2024) showed that self-directed stretching programs that are supplemented with visual instructional materials are more likely to lead to improved patient adherence and musculoskeletal outcomes than verbal instruction alone.
The resources needed for implementation are the printed patient education materials, an area in the clinical setting for demonstration and nurse time of 20 minutes per patient encounter. The estimated cost of the intervention is $15-$25, per patient, which is very practical in resource-limited community settings (Theis et al., 2021). Multilingual patient materials in English, Spanish and Haitian Creole will be developed to meet the language needs of Miami-Dade's diverse population and ensure equitable access to the intervention. Furthermore, the short duration of the routine and its ease of implementation will contribute to patient compliance.In addition, the routine is brief and straightforward, making it easier to implement.
The program will take a total of 10 weeks: 2 weeks of staff training and program preparation, 8 weeks of open enrolment of patients and delivery of the intervention, and 8 weeks concurrently for outcome assessments, with a standardized numeric stiffness rating scale used at baseline and week 8. Advanced practice nurse overseeing program will review outcome data at 4 weeks to determine the progress that has been made and to discuss any challenges to adherence as needed (Behm et al., 2023). If the 8-week outcome data show statistical difference in stiffness scores, presentation will be made to clinic leadership for further consideration of wider program implementation.
**Theoretical Framework**
This Capstone project is designed and implemented through a pair of complementary frameworks: Dorothea Orem's Self-Care Deficit Nursing Theory and the Iowa Model of Evidence-Based Practice. These frameworks offer a clear and comprehensive basis for patient-centered education and for integrating evidence in clinical practice.
In accordance with Orem's Self-Care Deficit Nursing Theory, patients have a natural ability for self-care and nursing can support, educate, and empower patients when their self-care ability falls short of their therapeutic needs (Tanaka, 2022). The five-minute stretching exercise is a self-care behavior and this theory can be directly applied to the proposed intervention. There is a lack of structured knowledge among adults in case of mild muscle stiffness, which can be compensated by nursing education and leads to a lack of self-care. The role of the nurse in this project is an educative-supportive role as the nurse provides patients with the knowledge, skill, and motivation to perform the daily stretches alone. The preventive focus of the intervention is also understood through Orem's framework; in doing so, the skills needed to successfully implement self-care behavior are introduced, thereby decreasing reliance on healthcare services and decreasing the accumulation of health deficits over time.
The Iowa Model of Evidence-Based Practice offers a systematic approach to moving from evidence to practice. Based on the Iowa Model, Cullen et al. (2022) offer practitioners guidance for problem identification, evidence appraisal, pilot implementation, and outcome evaluation. Muscle Stiffness is determined as a clinically relevant trigger of practice change in this Capstone project. Systematic reviews and RCTs published and supporting stretching interventions are appraised and included in intervention design. A standardised 5 minute routine is rehearsed in the clinic and the patient's outcome is formally assessed at 8 weeks. When outcomes data show positive results, the model can be used to share the results and to consider the broader implementation at the healthcare organization level. This is a well-structured intervention that is theory driven, operationally astute, and can produce transferable clinical knowledge.
**References**
Behm, D. G., Alizadeh, S., Daneshjoo, A., Anvar, S. H., Graham, A., Zahiri, A., & Konrad, A. (2023). Acute effects of various stretching techniques on range of motion: A systematic review with meta-analysis.
_Sports Medicine-Open, 9_(1), 107. https://doi.org/10.1186/s40798-023-00652-x
Bureau of Labor Statistics. (2022).
_Employer-reported workplace injuries and illnesses — 2021._ U.S. Department of Labor. https://www.bls.gov/news.release/osh.nr0.htm
Çimen, O. (2023). The efficiency of ergonomics, active break and stretching exercise program in office workers with chronic neck and back pain.
_Deneysel ve Klinik Tıp Dergisi, 40_(2), 329–332. https://dergipark.org.tr/en/pub/omujecm/issue/79274/1282408
Cullen, L., Hanrahan, K., Farrington, M., Tucker, S., & Edmonds, S. (2022).
_Evidence-based practice in action: Comprehensive strategies, tools, and tips from University of Iowa Hospitals & Clinics._ Sigma Theta Tau.
Florida Department of Health. (2022).
_Florida musculoskeletal health data and statistics._ https://www.floridahealth.gov
Theis, K. A., Murphy, L. B., Guglielmo, D., Boring, M. A., Okoro, C. A., Duca, L. M., & Barbour, K. E. (2021). Prevalence of arthritis and arthritis-attributable activity limitation — United States, 2016–2018.
_Morbidity and Mortality Weekly Report, 70_(40), 1401–1407.
[https://doi.org/10.15585/mmwr.mm7040a2](https://doi.org/10.15585/mmwr.mm7040a2)
Galmarini, E., Marciano, L., & Schulz, P. J. (2024). The effectiveness of visual-based interventions on health literacy in health care: A systematic review and meta-analysis.
_BMC Health Services Research_,
_24_(1), 1–10. https://doi.org/10.1186/s12913-024-11138-1
Tanaka, M. (2022). Orem's nursing self-care deficit theory: A theoretical analysis focusing on its philosophical and sociological foundation.
_Nursing Forum, 57_(3), 480–485. https://doi.org/10.1111/nuf.12696
U.S. Census Bureau. (2023).
_American Community Survey: Health insurance coverage in the United States._ https://www.census.gov/topics/health/health-insurance.html
United States Bone and Joint Initiative. (2021).
_The burden of musculoskeletal diseases in the United States: Prevalence, societal and economic cost (4th ed.)._ https://www.bmus-ors.org/
Zvetkova, E., Koytchev, E., Ivanov, I., Ranchev, S., & Antonov, A. (2023). Biomechanical, healing and therapeutic effects of stretching: A comprehensive review.
_Applied Sciences, 13_(15), 8596. https://doi.org/10.3390/app13158596
**## Attemptfeedback2.docx**
Attempt feedback
You are on the right track and did well overall. Choose one clinic setting within Miami-Dade to make it realistic. Missing Conclusion paragraph as per APA.
**## CapstonePartIIintrucctions.docx**
Capstone Part II: Review of Literature
**CAPSTONE: PART II due 10/4/2025 by 11:59pm**
1. Review of Literature:
– Review and discuss literature: Synthesize at least 10 primary research studies and/or systematic reviews; do not include summary articles. This section is all about the scientific evidence rather than someone else's opinion of the evidence. Do not use secondary sources; you need to get the article, read it, and make your own decision about quality and applicability to your question even if you did find out about the study in a review of the literature. This is a synthesis rather than a study-by-study review. Address the similarities, differences, and controversies in the body of evidence.
2. Analyze and apply knowledge directly to your PICOT- The studies that you cite in this section must relate directly to your PICOT question.
3. Provide precise body of evidence for your Practice Change- Include Nurses as leaders in this project, statistics, cost, impact on healthcare.
4. Discuss objectives for your practice change, Why is change necessary?
5. Discuss where the problem exists, why it exists, what is the preposition for change. Include information from your PICOT.
6. Apply all that is relevant to the problem. For example: Pros vs Cons, current state of problem
NOTE: It should not reflect your opinion, but rather Evidence Based Practice should be applied
-After completing a literature search on interventions addressing your chosen health problem, write a review that evaluates the strengths and weaknesses of all the sources you have found, compare anc constrast.
-Use appropriate APA 7th Ed. Scholarly, peer-reviewed, and research articles cited should be within the last five years.
-This section should be minimum 4-6 pages long (not including the title and reference page).
-Use proper in-text citations with a properly formatted reference list.
-All papers must be written APA in the 3rd person.
**Rubric Capstone II.docx**
**Submission**
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_Word count: 0_
**Drag files here**
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**Details & Information**
CRITERIA OUTSTANDING VERY GOOD GOOD UNACCEPTABLE
Integration of
Knowledge
25 points
Thoroughly selected
and present an
appropriate
Evidence Based
Practice for the
health problem and
change.
25
Briefly selected and
present an
appropriate
Evidence Based
Practice for the
health problem and
change.
20
Vaguely selected
and present an
appropriate
Evidence Based
Practice for the
health problem and
change.
15
Did not select and
present an
appropriate
Evidence Based
Practice for the
health problem and
change.
0
Topic Focus
25 points
The health problem
is focused narrowly
enough for the
scope of this
assignment. A topic
statement provides
direction for the
paper. The topic is
consistently well
thought out,
thorough offers
insight into the topic,
and includes cited
evidence to support
the topic.
25
The health problem
is focused but
lacks direction. The
paper is about a
specific topic, but
the writer has not
established a
position. The topic
is somewhat well
thought out, offers
limited insight into
the topic, but does
not include cited
evidence to support
the topic.
20
The health problem
is too broad for the
scope of this
assignment.
15
The health problem
is unclear or
unrelated to the
discussion topic
with little or no
supporting
evidence.
0
Depth of
Discussion and
Cohesiveness
25 points
In-depth discussion
and elaboration in all
sections of the
paper.
Ties together
information from all
sources. Paper flows
from one issue to
the next with no
headings. The
author’s writing
demonstrates an
understanding of the
relationship among
material obtained
from all sources
Mostly, it ties
together information
from all sources.
In-depth discussion
and elaboration in
most sections of
the paper.
Mostly, it ties
together
information from all
sources. Paper
flows with only
some
disjointedness. The
author’s writing
demonstrates an
understanding of
the relationship
among material
obtained from all
sources.
The writer has
omitted content.
Quotations from
others outweigh the
writer’s own ideas
excessively.
Sometimes ties
together
information from all
sources. The paper
does not flow.
Disjointedness is
apparent. The
author’s writing
does not
demonstrate an
understanding of
the relationship
between material
obtained from all
sources.
Cursory discussion
in all the sections
of the paper or brief
discussion in only a
few sections.
It does not tie
together
information. Paper
does not flow and
appears to be
created from
disparate issues.
Headings are
necessary to link
concepts. Writing
does not
demonstrate an
understanding of
any relationship.
25 20
15
0
Spelling and
Grammar
10 points
Fewer than 5
grammatical,
spelling,
capitalization, or
punctuation errors.
Required word count
has been met.
8
More than 5 but
fewer than 10
grammatical,
spelling,
capitalization &
punctuation errors
Required word
count is 25 words
below the minimum
required count.
6
More than 10
grammatical,
spelling,
capitalization &
punctuation errors
Required word
count is 50 words
below the minimum
required count.
5
An unacceptable
number of spelling
and/or grammar
mistakes.
Required word
count is more than
50 words below the
minimum required
count.
0
Sources
10 points
Over 5 current
sources, of which at
least 3 are peer-
review journal
articles or scholarly
books. Sources
include both general
background sources
and specialized
sources. Special-
interest sources and
popular literature
and acknowledged
as such if they are
cited. All websites
utilized are
authoritative.
5 current sources,
of which at least 2
are peer-review
journal articles or
scholarly books. All
websites utilized
are authoritative.
Fewer than 5
current sources or
fewer than 2 of 5
are peer-reviewed
journal articles or
scholarly books. All
websites utilized
are credible.
Fewer than 5
current sources or
fewer than 2 of 5
are peer-reviewed
journal articles or
scholarly books.
Not all websites
utilized are credible,
and/or sources are
not current.
Citations
5 points
Fewer than 5
incomplete citations
and/or quotations,
and APA format
errors
5
More than 5 but
fewer than 10
incomplete
citations and/or
quotations, and
APA format errors.
4
More than 10
incomplete
citations and/or
quotations, or APA
format errors.
3
The citation style is
inconsistent or
incorrect. It does
not cite sources.
**## MSN_Capstone_Part1_Revised1.docx**
1
**Reducing Muscle Stiffness Through a Brief Stretching Intervention:** **A Capstone PICOT Proposal**
Alex De Cardenas
Florida National University
MSN Capstone Project-DAX-DL01
Dr. Carmen Lazo
May 21, 2026
**Abstract**
Mild muscle stiffness is a common musculoskeletal issue that is seen in primary care and community health settings and is associated with working-age and older adults, often related to physical inactivity, prolonged postures at work and sedentary lifestyles. Although these conditions are common and have significant health service utilization and cost (likely in the United States, over $200 billion per year for all musculoskeletal conditions), self-management interventions are underutilized in community and primary care settings. This culminating proposal is an evidence-based program to decrease self-reported muscle stiffness through education and implementation of a short five minute stretching routine daily and is nurse-led. The target population for this study is adults in Miami-Dade County, FL who visit primary care providers and/or community health services and are experiencing mild muscle stiffness. The intervention will be assessed with a numeric stiffness rating scale at baseline and week 8. This program is designed to increase the self-efficacy of patients, minimize need for analgesic medications, minimize avoidable use of healthcare resources and optimize functional quality of life for a socioeconomically diverse and vulnerable patient population based on Dorothea Orem's Self-Care Deficit Nursing Theory and the Iowa Model of Evidence Based Practice.
Keywords:
_muscle stiffness, stretching, self-care, nurse-led education, primary care, community health, Miami-Dade_
**Reducing Muscle Stiffness Through a Brief Stretching Intervention:** **A Capstone PICOT Proposal**
Muscle stiffness is an increasingly common but undertreated health problem in adults in community and primary care practices. Muscle stiffness is often linked to sedentary lifestyle and unhealthy occupational postures, as well as physical inactivity, and is not only a problem for mobility but also for comfort and functional status (Zvetkova et al., 2023). While it's not a serious health condition, ongoing stiffness can be a significant quality-of-life problem and can over time lead to increased use of healthcare and a loss of independence. Musculoskeletal conditions, such as muscle, tendon, and connective tissue related to stiffness, impact the lives of about 126.6 million Americans annually with over $213 billion in treatment expenses, lost wages and economic burden (United States Bone and Joint Initiative, 2021). These statistics emphasize the need for strategies that prevent and intervene early in the course of musculoskeletal issues to prevent them from becoming chronic and expensive.
Miami-Dade County is a uniquely burdened area for MS complaints at the local level. Florida is one of the highest states for musculoskeletal-related visits to the emergency department and primary care providers, and many of these visits are due to work-related musculoskeletal disorders among service-sector and manual labor employees (Florida Department of Health, 2022). These factors combine to decrease the chances residents have for timely, organized musculoskeletal care, with the Miami-Dade County uninsured rate estimated at about 19%, compared to the national average of 9.2% (U.S. Census Bureau, 2023). Uncontrolled muscle stiffness in this population comes with direct costs (such as increased consumption of pain medications) and indirect costs (such as unnecessary clinic visits, loss of working time, and exacerbated chronic pain problems). Minimally costly and specialized equipment-free nurse-led interventions, which are evidence-based and fiscally-sound, are strategies to reduce this burden.
The aim of this proposed program is to determine if a nurse-led structured 5-minute daily stretching education program can significantly decrease muscle stiffness in adults over an 8 week period in a primary care or community health care setting. The expected results are clinically relevant decreases in stiffness scores (measured by patient-reported outcomes) at the end of the eight-week intervention period. The importance of this program is not just to reducing unnecessary clinic visits, but also less use of analgesic medicines and long-term functional health of a vulnerable adult population.
**PICOT**
In adults with mild muscle stiffness (P), does teaching a simple five-minute daily stretching routine (I), compared to usual care without structured stretching education (C), reduce self-reported muscle stiffness (O) over eight weeks (T)?
The population of this project is adults with mild muscle stiffness, who are commonly seen in primary and community health services. This population includes individuals who are working age who have sedentary work, those who are older who have lower levels of physical activity and those who have discomfort in their musculoskeletal system, which is in early stages. Chronic musculoskeletal pain or stiffness is reported by about 54 million adults in the United States, and prevalence is higher among older people and those who are sedentary in their occupations (Theis et al., 2021). Low access to physical therapy, low health literacy, and lack of guidance on self-management strategies (Çimen, 2023) make this population vulnerable.
Proposed intervention is a five-minute, standardized, nurse delivered stretching program done at the end of the visit with emphasis on major muscle groups that tend to become stiff when injured, such as the neck, shoulders, lower back and lower extremities. Systematic reviews provide evidence of the significant benefits of regular static and dynamic stretching programs, including decreases in musculoskeletal pain severity, range of motion, and perceived muscle stiffness in adults. (Behm et al., 2023) The briefness of the routine is deliberate because shorter structured exercise programs have been shown to have greater sustained patient adherence versus longer programs that utilize equipment or gym access.
The comparison intervention is usually care plus verbal advice or referring to physical therapy for self-management training, but not providing a formal self-management program. There is a consistent body of evidence of less enduring improvement in musculoskeletal symptoms associated with passive care approaches compared to active, patient-centerd approaches like structured exercise or stretching education (Behm et al. 2023). The project is expected to yield statistically and clinically meaningful improvement of self-reported muscle stiffness scores (measured by a validated Numeric Rating Scale) at the end of the 8 weeks when compared to the baseline score. The eight-week duration is long enough to establish a pattern of stretching and to demonstrate measurable changes in muscle physiology such as increased tissue extensibility and decreased resting muscle tension (Zvetkova et al., 2023).
**Vulnerable Population and Setting**
The target population for this project are adults (ages 18) who live in Miami-Dade County, Florida, and present to their primary care clinics or community health centers with complaints of mild muscle stiffness. Miami-Dade is a diverse urban area with a concentration of population where most residents have sedentary service jobs and earn low wages in manual jobs. The two occupations are related to high levels of musculoskeletal complaints from the static position and repetitive motion patterns (Çimen, 2023). The occupational dimension of musculoskeletal disorder occurrence in and susceptibility of workers is demonstrated by the fact that service and manual labor workers make up a disproportionate share of the estimated 544,900 reported cases of MSDs that result in days away from work annually in the United States (BLS, 2022).
The musculoskeletal burden of this population is heavily influenced by social determinants of health. Around 19% of Miami-Dade County residents do not have health insurance, which reduces their access to specialist musculoskeletal care, physical therapy referrals, and preventive health services (U.S. Census Bureau, 2023). Low income also makes it harder to join gyms, get ergonomic workstations, and access evidence-based self-care resources. Difficulty with language may impede seeking help and compliance to health guidelines in Spanish-speaking and Haitian Creole-speaking populations. In addition, long work hours and caregiving duties limit physical activity time which also contributes to stiffness and functional decline. Cultural and low barrier approaches to addressing social disadvantage are essential for these compounded social disadvantage groups (Zvetkova et al., 2023).
Unless stiffness is treated early, it's likely to become a chronic pain problem, to result in reduced range of motion, and to be a fall risk, especially for older individuals in this group. In Miami-Dade, chronic musculoskeletal pain has been linked to emergency department visits that have an average cost of $1,389 per visit, while a structured nurse-led primary care intervention has average costs of about $120 per visit, indicating the cost-effectiveness of early preventive programming (Florida Department of Health, 2022). The differences highlight the need for proactive nursing interventions based in the community as a clinical priority and also a cost-effective approach to the healthcare system in Miami Dade.
**Proposal**
The proposed intervention is a nurse-led patient education program that will be delivered in a primary care or community health clinic in Miami-Dade County. If adults are identified on a regular basis in clinics for having mild muscle stiffness, a trained registered nurse or advanced practice registered nurse will provide a structured 15-minute educational session where the patient will be taught a standardized 5-minute stretching exercise. The routine concentrates on the cervical spine, shoulders, thoracic back, lumbar spine, hip flexors and hamstrings, each stretch being bilaterally performed for 30-60 seconds. A laminated take home reference card with illustrated instructions will be provided for patients to use independently each day. The evidence supports this educational approach, as Galmarini et al., (2024) showed that self-directed stretching programs that are supplemented with visual instructional materials are more likely to lead to improved patient adherence and musculoskeletal outcomes than verbal instruction alone.
The resources needed for implementation are the printed patient education materials, an area in the clinical setting for demonstration and nurse time of 20 minutes per patient encounter. The estimated cost of the intervention is $15-$25, per patient, which is very practical in resource-limited community settings (Theis et al., 2021). Multilingual patient materials in English, Spanish and Haitian Creole will be developed to meet the language needs of Miami-Dade's diverse population and ensure equitable access to the intervention. Furthermore, the short duration of the routine and its ease of implementation will contribute to patient compliance.In addition, the routine is brief and straightforward, making it easier to implement.
The program will take a total of 10 weeks: 2 weeks of staff training and program preparation, 8 weeks of open enrolment of patients and delivery of the intervention, and 8 weeks concurrently for outcome assessments, with a standardized numeric stiffness rating scale used at baseline and week 8. Advanced practice nurse overseeing program will review outcome data at 4 weeks to determine the progress that has been made and to discuss any challenges to adherence as needed (Behm et al., 2023). If the 8-week outcome data show statistical difference in stiffness scores, presentation will be made to clinic leadership for further consideration of wider program implementation.
**Theoretical Framework**
This Capstone project is designed and implemented through a pair of complementary frameworks: Dorothea Orem's Self-Care Deficit Nursing Theory and the Iowa Model of Evidence-Based Practice. These frameworks offer a clear and comprehensive basis for patient-centered education and for integrating evidence in clinical practice.
In accordance with Orem's Self-Care Deficit Nursing Theory, patients have a natural ability for self-care and nursing can support, educate, and empower patients when their self-care ability falls short of their therapeutic needs (Tanaka, 2022). The five-minute stretching exercise is a self-care behavior and this theory can be directly applied to the proposed intervention. There is a lack of structured knowledge among adults in case of mild muscle stiffness, which can be compensated by nursing education and leads to a lack of self-care. The role of the nurse in this project is an educative-supportive role as the nurse provides patients with the knowledge, skill, and motivation to perform the daily stretches alone. The preventive focus of the intervention is also understood through Orem's framework; in doing so, the skills needed to successfully implement self-care behavior are introduced, thereby decreasing reliance on healthcare services and decreasing the accumulation of health deficits over time.
The Iowa Model of Evidence-Based Practice offers a systematic approach to moving from evidence to practice. Based on the Iowa Model, Cullen et al. (2022) offer practitioners guidance for problem identification, evidence appraisal, pilot implementation, and outcome evaluation. Muscle Stiffness is determined as a clinically relevant trigger of practice change in this Capstone project. Systematic reviews and RCTs published and supporting stretching interventions are appraised and included in intervention design. A standardised 5 minute routine is rehearsed in the clinic and the patient's outcome is formally assessed at 8 weeks. When outcomes data show positive results, the model can be used to share the results and to consider the broader implementation at the healthcare organization level. This is a well-structured intervention that is theory driven, operationally astute, and can produce transferable clinical knowledge.
**References**
Behm, D. G., Alizadeh, S., Daneshjoo, A., Anvar, S. H., Graham, A., Zahiri, A., & Konrad, A. (2023). Acute effects of various stretching techniques on range of motion: A systematic review with meta-analysis.
_Sports Medicine-Open, 9_(1), 107. https://doi.org/10.1186/s40798-023-00652-x
Bureau of Labor Statistics. (2022).
_Employer-reported workplace injuries and illnesses — 2021._ U.S. Department of Labor. https://www.bls.gov/news.release/osh.nr0.htm
Çimen, O. (2023). The efficiency of ergonomics, active break and stretching exercise program in office workers with chronic neck and back pain.
_Deneysel ve Klinik Tıp Dergisi, 40_(2), 329–332. https://dergipark.org.tr/en/pub/omujecm/issue/79274/1282408
Cullen, L., Hanrahan, K., Farrington, M., Tucker, S., & Edmonds, S. (2022).
_Evidence-based practice in action: Comprehensive strategies, tools, and tips from University of Iowa Hospitals & Clinics._ Sigma Theta Tau.
Florida Department of Health. (2022).
_Florida musculoskeletal health data and statistics._ https://www.floridahealth.gov
Theis, K. A., Murphy, L. B., Guglielmo, D., Boring, M. A., Okoro, C. A., Duca, L. M., & Barbour, K. E. (2021). Prevalence of arthritis and arthritis-attributable activity limitation — United States, 2016–2018.
_Morbidity and Mortality Weekly Report, 70_(40), 1401–1407.
[https://doi.org/10.15585/mmwr.mm7040a2](https://doi.org/10.15585/mmwr.mm7040a2)
Galmarini, E., Marciano, L., & Schulz, P. J. (2024). The effectiveness of visual-based interventions on health literacy in health care: A systematic review and meta-analysis.
_BMC Health Services Research_,
_24_(1), 1–10. https://doi.org/10.1186/s12913-024-11138-1
Tanaka, M. (2022). Orem's nursing self-care deficit theory: A theoretical analysis focusing on its philosophical and sociological foundation.
_Nursing Forum, 57_(3), 480–485. https://doi.org/10.1111/nuf.12696
U.S. Census Bureau. (2023).
_American Community Survey: Health insurance coverage in the United States._ https://www.census.gov/topics/health/health-insurance.html
United States Bone and Joint Initiative. (2021).
_The burden of musculoskeletal diseases in the United States: Prevalence, societal and economic cost (4th ed.)._ https://www.bmus-ors.org/
Zvetkova, E., Koytchev, E., Ivanov, I., Ranchev, S., & Antonov, A. (2023). Biomechanical, healing and therapeutic effects of stretching: A comprehensive review.
_Applied Sciences, 13_(15), 8596. https://doi.org/10.3390/app13158596
**## Attemptfeedback2.docx**
Attempt feedback
You are on the right track and did well overall. Choose one clinic setting within Miami-Dade to make it realistic. Missing Conclusion paragraph as per APA.
**## CapstonePartIIintrucctions.docx**
Capstone Part II: Review of Literature
**CAPSTONE: PART II due 10/4/2025 by 11:59pm**
1. Review of Literature:
– Review and discuss literature: Synthesize at least 10 primary research studies and/or systematic reviews; do not include summary articles. This section is all about the scientific evidence rather than someone else's opinion of the evidence. Do not use secondary sources; you need to get the article, read it, and make your own decision about quality and applicability to your question even if you did find out about the study in a review of the literature. This is a synthesis rather than a study-by-study review. Address the similarities, differences, and controversies in the body of evidence.
2. Analyze and apply knowledge directly to your PICOT- The studies that you cite in this section must relate directly to your PICOT question.
3. Provide precise body of evidence for your Practice Change- Include Nurses as leaders in this project, statistics, cost, impact on healthcare.
4. Discuss objectives for your practice change, Why is change necessary?
5. Discuss where the problem exists, why it exists, what is the preposition for change. Include information from your PICOT.
6. Apply all that is relevant to the problem. For example: Pros vs Cons, current state of problem
NOTE: It should not reflect your opinion, but rather Evidence Based Practice should be applied
-After completing a literature search on interventions addressing your chosen health problem, write a review that evaluates the strengths and weaknesses of all the sources you have found, compare anc constrast.
-Use appropriate APA 7th Ed. Scholarly, peer-reviewed, and research articles cited should be within the last five years.
-This section should be minimum 4-6 pages long (not including the title and reference page).
-Use proper in-text citations with a properly formatted reference list.
-All papers must be written APA in the 3rd person.
**Rubric Capstone II.docx**
**Submission**
Text Editor
_Word count: 0_
**Drag files here**
Maximum size: 512 MB
**or**
**Details & Information**
CRITERIA OUTSTANDING VERY GOOD GOOD UNACCEPTABLE
Integration of
Knowledge
25 points
Thoroughly selected
and present an
appropriate
Evidence Based
Practice for the
health problem and
change.
25
Briefly selected and
present an
appropriate
Evidence Based
Practice for the
health problem and
change.
20
Vaguely selected
and present an
appropriate
Evidence Based
Practice for the
health problem and
change.
15
Did not select and
present an
appropriate
Evidence Based
Practice for the
health problem and
change.
0
Topic Focus
25 points
The health problem
is focused narrowly
enough for the
scope of this
assignment. A topic
statement provides
direction for the
paper. The topic is
consistently well
thought out,
thorough offers
insight into the topic,
and includes cited
evidence to support
the topic.
25
The health problem
is focused but
lacks direction. The
paper is about a
specific topic, but
the writer has not
established a
position. The topic
is somewhat well
thought out, offers
limited insight into
the topic, but does
not include cited
evidence to support
the topic.
20
The health problem
is too broad for the
scope of this
assignment.
15
The health problem
is unclear or
unrelated to the
discussion topic
with little or no
supporting
evidence.
0
Depth of
Discussion and
Cohesiveness
25 points
In-depth discussion
and elaboration in all
sections of the
paper.
Ties together
information from all
sources. Paper flows
from one issue to
the next with no
headings. The
author’s writing
demonstrates an
understanding of the
relationship among
material obtained
from all sources
Mostly, it ties
together information
from all sources.
In-depth discussion
and elaboration in
most sections of
the paper.
Mostly, it ties
together
information from all
sources. Paper
flows with only
some
disjointedness. The
author’s writing
demonstrates an
understanding of
the relationship
among material
obtained from all
sources.
The writer has
omitted content.
Quotations from
others outweigh the
writer’s own ideas
excessively.
Sometimes ties
together
information from all
sources. The paper
does not flow.
Disjointedness is
apparent. The
author’s writing
does not
demonstrate an
understanding of
the relationship
between material
obtained from all
sources.
Cursory discussion
in all the sections
of the paper or brief
discussion in only a
few sections.
It does not tie
together
information. Paper
does not flow and
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**## MSN_Capstone_Part1_Revised1.docx**
1
**Reducing Muscle Stiffness Through a Brief Stretching Intervention:** **A Capstone PICOT Proposal**
Alex De Cardenas
Florida National University
MSN Capstone Project-DAX-DL01
Dr. Carmen Lazo
May 21, 2026
**Abstract**
Mild muscle stiffness is a common musculoskeletal issue that is seen in primary care and community health settings and is associated with working-age and older adults, often related to physical inactivity, prolonged postures at work and sedentary lifestyles. Although these conditions are common and have significant health service utilization and cost (likely in the United States, over $200 billion per year for all musculoskeletal conditions), self-management interventions are underutilized in community and primary care settings. This culminating proposal is an evidence-based program to decrease self-reported muscle stiffness through education and implementation of a short five minute stretching routine daily and is nurse-led. The target population for this study is adults in Miami-Dade County, FL who visit primary care providers and/or community health services and are experiencing mild muscle stiffness. The intervention will be assessed with a numeric stiffness rating scale at baseline and week 8. This program is designed to increase the self-efficacy of patients, minimize need for analgesic medications, minimize avoidable use of healthcare resources and optimize functional quality of life for a socioeconomically diverse and vulnerable patient population based on Dorothea Orem's Self-Care Deficit Nursing Theory and the Iowa Model of Evidence Based Practice.
Keywords:
_muscle stiffness, stretching, self-care, nurse-led education, primary care, community health, Miami-Dade_
**Reducing Muscle Stiffness Through a Brief Stretching Intervention:** **A Capstone PICOT Proposal**
Muscle stiffness is an increasingly common but undertreated health problem in adults in community and primary care practices. Muscle stiffness is often linked to sedentary lifestyle and unhealthy occupational postures, as well as physical inactivity, and is not only a problem for mobility but also for comfort and functional status (Zvetkova et al., 2023). While it's not a serious health condition, ongoing stiffness can be a significant quality-of-life problem and can over time lead to increased use of healthcare and a loss of independence. Musculoskeletal conditions, such as muscle, tendon, and connective tissue related to stiffness, impact the lives of about 126.6 million Americans annually with over $213 billion in treatment expenses, lost wages and economic burden (United States Bone and Joint Initiative, 2021). These statistics emphasize the need for strategies that prevent and intervene early in the course of musculoskeletal issues to prevent them from becoming chronic and expensive.
Miami-Dade County is a uniquely burdened area for MS complaints at the local level. Florida is one of the highest states for musculoskeletal-related visits to the emergency department and primary care providers, and many of these visits are due to work-related musculoskeletal disorders among service-sector and manual labor employees (Florida Department of Health, 2022). These factors combine to decrease the chances residents have for timely, organized musculoskeletal care, with the Miami-Dade County uninsured rate estimated at about 19%, compared to the national average of 9.2% (U.S. Census Bureau, 2023). Uncontrolled muscle stiffness in this population comes with direct costs (such as increased consumption of pain medications) and indirect costs (such as unnecessary clinic visits, loss of working time, and exacerbated chronic pain problems). Minimally costly and specialized equipment-free nurse-led interventions, which are evidence-based and fiscally-sound, are strategies to reduce this burden.
The aim of this proposed program is to determine if a nurse-led structured 5-minute daily stretching education program can significantly decrease muscle stiffness in adults over an 8 week period in a primary care or community health care setting. The expected results are clinically relevant decreases in stiffness scores (measured by patient-reported outcomes) at the end of the eight-week intervention period. The importance of this program is not just to reducing unnecessary clinic visits, but also less use of analgesic medicines and long-term functional health of a vulnerable adult population.
**PICOT**
In adults with mild muscle stiffness (P), does teaching a simple five-minute daily stretching routine (I), compared to usual care without structured stretching education (C), reduce self-reported muscle stiffness (O) over eight weeks (T)?
The population of this project is adults with mild muscle stiffness, who are commonly seen in primary and community health services. This population includes individuals who are working age who have sedentary work, those who are older who have lower levels of physical activity and those who have discomfort in their musculoskeletal system, which is in early stages. Chronic musculoskeletal pain or stiffness is reported by about 54 million adults in the United States, and prevalence is higher among older people and those who are sedentary in their occupations (Theis et al., 2021). Low access to physical therapy, low health literacy, and lack of guidance on self-management strategies (Çimen, 2023) make this population vulnerable.
Proposed intervention is a five-minute, standardized, nurse delivered stretching program done at the end of the visit with emphasis on major muscle groups that tend to become stiff when injured, such as the neck, shoulders, lower back and lower extremities. Systematic reviews provide evidence of the significant benefits of regular static and dynamic stretching programs, including decreases in musculoskeletal pain severity, range of motion, and perceived muscle stiffness in adults. (Behm et al., 2023) The briefness of the routine is deliberate because shorter structured exercise programs have been shown to have greater sustained patient adherence versus longer programs that utilize equipment or gym access.
The comparison intervention is usually care plus verbal advice or referring to physical therapy for self-management training, but not providing a formal self-management program. There is a consistent body of evidence of less enduring improvement in musculoskeletal symptoms associated with passive care approaches compared to active, patient-centerd approaches like structured exercise or stretching education (Behm et al. 2023). The project is expected to yield statistically and clinically meaningful improvement of self-reported muscle stiffness scores (measured by a validated Numeric Rating Scale) at the end of the 8 weeks when compared to the baseline score. The eight-week duration is long enough to establish a pattern of stretching and to demonstrate measurable changes in muscle physiology such as increased tissue extensibility and decreased resting muscle tension (Zvetkova et al., 2023).
**Vulnerable Population and Setting**
The target population for this project are adults (ages 18) who live in Miami-Dade County, Florida, and present to their primary care clinics or community health centers with complaints of mild muscle stiffness. Miami-Dade is a diverse urban area with a concentration of population where most residents have sedentary service jobs and earn low wages in manual jobs. The two occupations are related to high levels of musculoskeletal complaints from the static position and repetitive motion patterns (Çimen, 2023). The occupational dimension of musculoskeletal disorder occurrence in and susceptibility of workers is demonstrated by the fact that service and manual labor workers make up a disproportionate share of the estimated 544,900 reported cases of MSDs that result in days away from work annually in the United States (BLS, 2022).
The musculoskeletal burden of this population is heavily influenced by social determinants of health. Around 19% of Miami-Dade County residents do not have health insurance, which reduces their access to specialist musculoskeletal care, physical therapy referrals, and preventive health services (U.S. Census Bureau, 2023). Low income also makes it harder to join gyms, get ergonomic workstations, and access evidence-based self-care resources. Difficulty with language may impede seeking help and compliance to health guidelines in Spanish-speaking and Haitian Creole-speaking populations. In addition, long work hours and caregiving duties limit physical activity time which also contributes to stiffness and functional decline. Cultural and low barrier approaches to addressing social disadvantage are essential for these compounded social disadvantage groups (Zvetkova et al., 2023).
Unless stiffness is treated early, it's likely to become a chronic pain problem, to result in reduced range of motion, and to be a fall risk, especially for older individuals in this group. In Miami-Dade, chronic musculoskeletal pain has been linked to emergency department visits that have an average cost of $1,389 per visit, while a structured nurse-led primary care intervention has average costs of about $120 per visit, indicating the cost-effectiveness of early preventive programming (Florida Department of Health, 2022). The differences highlight the need for proactive nursing interventions based in the community as a clinical priority and also a cost-effective approach to the healthcare system in Miami Dade.
**Proposal**
The proposed intervention is a nurse-led patient education program that will be delivered in a primary care or community health clinic in Miami-Dade County. If adults are identified on a regular basis in clinics for having mild muscle stiffness, a trained registered nurse or advanced practice registered nurse will provide a structured 15-minute educational session where the patient will be taught a standardized 5-minute stretching exercise. The routine concentrates on the cervical spine, shoulders, thoracic back, lumbar spine, hip flexors and hamstrings, each stretch being bilaterally performed for 30-60 seconds. A laminated take home reference card with illustrated instructions will be provided for patients to use independently each day. The evidence supports this educational approach, as Galmarini et al., (2024) showed that self-directed stretching programs that are supplemented with visual instructional materials are more likely to lead to improved patient adherence and musculoskeletal outcomes than verbal instruction alone.
The resources needed for implementation are the printed patient education materials, an area in the clinical setting for demonstration and nurse time of 20 minutes per patient encounter. The estimated cost of the intervention is $15-$25, per patient, which is very practical in resource-limited community settings (Theis et al., 2021). Multilingual patient materials in English, Spanish and Haitian Creole will be developed to meet the language needs of Miami-Dade's diverse population and ensure equitable access to the intervention. Furthermore, the short duration of the routine and its ease of implementation will contribute to patient compliance.In addition, the routine is brief and straightforward, making it easier to implement.
The program will take a total of 10 weeks: 2 weeks of staff training and program preparation, 8 weeks of open enrolment of patients and delivery of the intervention, and 8 weeks concurrently for outcome assessments, with a standardized numeric stiffness rating scale used at baseline and week 8. Advanced practice nurse overseeing program will review outcome data at 4 weeks to determine the progress that has been made and to discuss any challenges to adherence as needed (Behm et al., 2023). If the 8-week outcome data show statistical difference in stiffness scores, presentation will be made to clinic leadership for further consideration of wider program implementation.
**Theoretical Framework**
This Capstone project is designed and implemented through a pair of complementary frameworks: Dorothea Orem's Self-Care Deficit Nursing Theory and the Iowa Model of Evidence-Based Practice. These frameworks offer a clear and comprehensive basis for patient-centered education and for integrating evidence in clinical practice.
In accordance with Orem's Self-Care Deficit Nursing Theory, patients have a natural ability for self-care and nursing can support, educate, and empower patients when their self-care ability falls short of their therapeutic needs (Tanaka, 2022). The five-minute stretching exercise is a self-care behavior and this theory can be directly applied to the proposed intervention. There is a lack of structured knowledge among adults in case of mild muscle stiffness, which can be compensated by nursing education and leads to a lack of self-care. The role of the nurse in this project is an educative-supportive role as the nurse provides patients with the knowledge, skill, and motivation to perform the daily stretches alone. The preventive focus of the intervention is also understood through Orem's framework; in doing so, the skills needed to successfully implement self-care behavior are introduced, thereby decreasing reliance on healthcare services and decreasing the accumulation of health deficits over time.
The Iowa Model of Evidence-Based Practice offers a systematic approach to moving from evidence to practice. Based on the Iowa Model, Cullen et al. (2022) offer practitioners guidance for problem identification, evidence appraisal, pilot implementation, and outcome evaluation. Muscle Stiffness is determined as a clinically relevant trigger of practice change in this Capstone project. Systematic reviews and RCTs published and supporting stretching interventions are appraised and included in intervention design. A standardised 5 minute routine is rehearsed in the clinic and the patient's outcome is formally assessed at 8 weeks. When outcomes data show positive results, the model can be used to share the results and to consider the broader implementation at the healthcare organization level. This is a well-structured intervention that is theory driven, operationally astute, and can produce transferable clinical knowledge.
**References**
Behm, D. G., Alizadeh, S., Daneshjoo, A., Anvar, S. H., Graham, A., Zahiri, A., & Konrad, A. (2023). Acute effects of various stretching techniques on range of motion: A systematic review with meta-analysis.
_Sports Medicine-Open, 9_(1), 107. https://doi.org/10.1186/s40798-023-00652-x
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_Employer-reported workplace injuries and illnesses — 2021._ U.S. Department of Labor. https://www.bls.gov/news.release/osh.nr0.htm
Çimen, O. (2023). The efficiency of ergonomics, active break and stretching exercise program in office workers with chronic neck and back pain.
_Deneysel ve Klinik Tıp Dergisi, 40_(2), 329–332. https://dergipark.org.tr/en/pub/omujecm/issue/79274/1282408
Cullen, L., Hanrahan, K., Farrington, M., Tucker, S., & Edmonds, S. (2022).
_Evidence-based practice in action: Comprehensive strategies, tools, and tips from University of Iowa Hospitals & Clinics._ Sigma Theta Tau.
Florida Department of Health. (2022).
_Florida musculoskeletal health data and statistics._ https://www.floridahealth.gov
Theis, K. A., Murphy, L. B., Guglielmo, D., Boring, M. A., Okoro, C. A., Duca, L. M., & Barbour, K. E. (2021). Prevalence of arthritis and arthritis-attributable activity limitation — United States, 2016–2018.
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Galmarini, E., Marciano, L., & Schulz, P. J. (2024). The effectiveness of visual-based interventions on health literacy in health care: A systematic review and meta-analysis.
_BMC Health Services Research_,
_24_(1), 1–10. https://doi.org/10.1186/s12913-024-11138-1
Tanaka, M. (2022). Orem's nursing self-care deficit theory: A theoretical analysis focusing on its philosophical and sociological foundation.
_Nursing Forum, 57_(3), 480–485. https://doi.org/10.1111/nuf.12696
U.S. Census Bureau. (2023).
_American Community Survey: Health insurance coverage in the United States._ https://www.census.gov/topics/health/health-insurance.html
United States Bone and Joint Initiative. (2021).
_The burden of musculoskeletal diseases in the United States: Prevalence, societal and economic cost (4th ed.)._ https://www.bmus-ors.org/
Zvetkova, E., Koytchev, E., Ivanov, I., Ranchev, S., & Antonov, A. (2023). Biomechanical, healing and therapeutic effects of stretching: A comprehensive review.
_Applied Sciences, 13_(15), 8596. https://doi.org/10.3390/app13158596