Why Treat A Contracture?
Conditions common in a patient that is bedfast for even a short period of time, or is allowed to suffer immobility from lost range of motion. Possible events follow the symptoms in parenthesis:
increased blood sugar (adult onset diabetes),
increased cardiac output and cardiac stroke volume ( myocardial infarction, increased B/P, stroke),
increased heart rate (myocardial infarction)
bone demineralization (fractures, pain, osteoporis, increased nursing hours)
coagulation of blood in circulatory system (blood clots, strokes),
decreased blood flow to extremities (blood clots, bed sores, venous stasis ulcers, amputations and other surgeries, increased nursing hours),
tidal volume shift of the lungs (decreased oxygen/carbon dioxide exchange across the alveoli/capillary permeable membrane)
decreased respiratory movement (pneumonia = increased antibiotic usage, further increase in immobility due to shortness of breath, increased inhaler usage and respiratory treatments, pain, depression/fear, loss of cognition from lack of oxygen to brain, tissue destruction from lack of oxygen to cells, increased hospitalization, increased stress on the heart, congestive heart failure, pulmonary edema, death)
decreased movement of secretions (same as above)
disturbed oxygen-carbon dioxide balance
pressure areas (bed sores, surgery, infections, increased antibiotic usage, death and increased nursing hours),
urinary stasis = infection and incontinence (increase usage of antibiotics and catheters, and nursing hours),
gastrointestinal hyper – or hypo motility/constipation and impactions (results in hospitalizations and increased nursing hours),
muscle wasting/atrophy/protein catabolism (increased ammonia in blood = kidney disease),
supine position reduces the production of adrenocortical hormones
fluid and electrolyte imbalance (including essential electrolytes: sodium, potassium and chloride)
metabolic rate falls/decreased appetite (malnutrition = decreased tissue healing and cell destruction, require being fed with special diet or the surgery to place a feeding tube with life long tubing, pumps and enteral food, increased nursing hours)
psychosocial changes = depression (increased psychotropic drug usage, increased nursing hours)
The more immobile a patient is allowed to become – whether one joint or multiple joints, the more they cost the system, not even considering their pain and suffering. These are real life situations that are the norm – not the exception. This situation is prevalent with all institutionalized human beings, not just those in a skilled level nursing facility. The acuity level of all residents has increased drastically in the last decade and will increase even more rapidly with the aging of the Baby Boomers.
If we learn to begin at the acute care level in hospitals, educate staff beginning with the emergency room and continuing through the discharge planners, to create a plan of care for each person designed to keep them as active as possible and in as upright a position as possible, we will have a healthier and less expensive patient population. If we allow patients to lie in bed through out their hospital stay, we are doing them an injustice by not planning a healthy future for them. When these people are already compromised in some way and this is allowed to happen, they may not bounce back.
In a nursing facility, it is also vital that people be kept as upright and active as possible in good body alignment. The typical scenario in a nursing home sees people in chairs with their feet dangling, which results in plantar flexion contractures. People sit in wheel chairs with seats that are sagging, which results in hip adduction contractures. People sit with their spine in a twisted position, which results in rotation of the spine and spinal contractures and amazing pain.
If we allow them to loose even the smallest amount of range of motion, we are setting them up for a “domino effect” of continually decreasing health status as shown by the bullet points above.
Anyone of any age who has a neurological diagnosis like Parkinson’s Disease, Cerebral Palsy, CVA (stroke), Multiple Sclerosis, closed head injury, spinal cord injury, Traumatic Brain Syndrome, Huntington’s Chorea, and end stage Alzheimer’s Disease has the compounded problem of neurological tone. This tone is many times misdiagnosed as a permanent deformity and if untreated will also result in shortened adaptive tissue. The tone must be managed before shortened adaptive tissue can be corrected or prevented.
The answer is not more regulations on caregivers. In fact, the answer is reducing inappropriate regulations which take too much of the caregivers’ time away from direct patient care. Appropriate care can be measured by outcomes. Look at the patient. Train the caregivers with current Contracture Management knowledge. Allow them access to the appropriate devices needed to care for their patients, and the time to do the hands-on care necessary to accomplish that care with the minimal record keeping necessary.
Karen L Bonn, RN
Bibliography: Hazards of Immobility, The American Journal of Nursing. April 1967, Vol. 67, No 4
National Institute on Aging has released revealing statistics about the elderly beyond the age of 75:
40 percent cannot walk two blocks
32 percent cannot climb ten steps
50 percent who fracture hips never walk independently again
♦ PREVENTION OF IMMOBILITY AND ITS COMPLICATIONS ARE ESSENTIAL ACTIONS THAT SHOULD BE CONSIDERED IN EVERY RESIDENT’S CARE PLAN.
TIME TABLE OF A CONTRACTURE: After four (4) days of immobility, contractures are noticeable. At the end of ten (10) days, contractures are significant. At the end of fourteen (14) days gross contractures or near crippling deformities are present. For EVERY day after the fourth (4) day, it will take ten (10) days of treatment to restore the extremity to a functional state, NOT FULL RANGE OF MOTION. Thus, fourteen (14) days of contracture will require one hundred (100) days for recovery. The degree of recovery will depend upon individual condition and health. Immobility and poor bed positioning are two of the major causes of contracture in the long-term care patient. When a patient is confined to bed for long periods of time, joints stiffen even more, and it becomes easy to assume the same “comfortable” position hour after hour. Because moving these stiff joints creates some discomfort or pain initially, the patient may be reluctant to use them, increasing the loss of movement by their inactivity. If the joints remain inactive, a permanent shortening of the connective tissue fibers will occur.
Essential: Range of motion; Proper Positioning and Proper Alignment.
Orthopedic vs. Restorative Products
Three types of Restorative Contractures:
There are two major types of contractures, Orthopedic and Restorative.
Orthopedic patients suffer lost range of motion after injuries or surgical intervention resulting in scar tissue and adhesions. The historical treatment is to “break through” these adhesions in order to restore lost range of motion.
Restorative Contractures typically have no adhesions – therefore if we use aggressive methods to attempt to quickly relengthen the range, we risk not only causing needless pain, but also of causing injury. Aggressive stretching can also kick in the Stretch Reflex which will cause the joint or body part to pull even farther into flexion. If your patient’s limb is very hard to range and if their degree of range of motion is shorter after your session than before you started, you may have unknowingly initiated this reflex.
Under the category of Restorative are three different types:
” Adaptive Tissue Shortening” which starts within about 3 days of “immobility” and occurs from the joint not being stretch to full extension enough to prevent shortening tissue shortening. The treatment for this injury is Prolonged Low Load Passive Stretch. Begin with about a 30 minute wearing schedule of a good high quality comfortable splint that applies low load stretch toward normal alignment, then gradually increase the wearing time up to no more than 6 hours per shift. This device must be adjustable to continue the joint or body part farther and farther toward and to normal alignment. If at home a similar pattern is ideal, but in any setting, one 6 hour period of continual stretch may be the best you can expect and should provide positive results.
“Neurological Tone” with or without spasticity, resulting from an insult (injury, pressure or disease process) to the brain, spinal cord or other nerves. Specifically designed and manufactured orthotic devices must be applied to provide slight stretch, but allow the body to pull through with the tone then bring the limb or body part back to the preset range. Allowing this FLEX process to occur for 15 to 20 minutes will typically result in a muscle inhibition or relaxation. Only then can you determine if there is underlying shortened tissue.
“Neurological Tone with Adaptive Tissue Shortening” is tone/spasticity with underlying tissue shortening. First the tone must be worked through, then Prolonged Low Load Passive Stretch applied to relengthen shortened tissue.
Restorative patients typically do not have adhesions to "break through" - they usually have either simple adaptive tissue shortening (from immobility), but much more common is neurological tone. This is typical with any neurological condition and is commonly mistaken as "fixed" joints.
Example: Knee joint. Once the knee has been gently stretched to passive resistance – do NOT overstretch - apply a high quality knee splint that will allow the joint to pull through with tone with slight tension, then as the episode of tone begins to diminish and the muscles begin to fatigue, it will take the joint back to the preset degree of extension. If applied with only about 10-15 degrees of stretch, the knee can "work through" the neurological tone to reach muscle inhibition. The device must also provide Prolonged Low Load Passive Stretch to achieve permanent relengthening over a period of time after the tone has been successfully diminished. At first the goal may only be to address the tone, then later to increase lost range.
Diagnoses like Parkinson’s disease, Cerebral Palsy, CVA (stroke), Multiple Sclerosis, Traumatic Brain Injury, Spinal Cord Injury, Huntington’s chorea, and end stage Alzheimer’s disease either present with this tone or very commonly develop neurological tone over a period of time. This development of tone can be of sudden onset – as with spinal cord damage – or it can be gradual, and many times insidious and not recognized.
Asking nursing assistants and family members:
who is hard to dress because their shoulders and arms are held tightly to their body?
whose fingernails are hard to trim because they hold their hand in a fist?
whose hand smells so bad, and the odor gets on you when you are working with them?
who is hard to transfer because they cannot put their feet flat on the floor or
they are unable to straighten their knees?
who seems to “fight” or “resist” when you try to pull their arms down, and the arms end up close to their chest in a stiff “protective position.”
who is difficult to position in a chair (persons need to sit upright in a wheelchair and not reclined back in a geri-chair to achieve an improved health status) due to their “posture?”
who is in danger of having a feeding tube surgically planted simply because they are unable to eat and swallow because of their “posture?”
If a patient has a history of falls from straightening their body into extension, and they require a restraint, they very likely need something to work through the tone in their spine and hips to allow them to set up and their spine be worked toward correction. Patients who lean forward or sideways must have something to support weakened muscles while moving their spine toward correct alignment and working through any flexor tone. These patients may be able to right their position upon verbal command, but do they have the strength to maintain that position?
Patients who are unable to eat and look around at their environment because their head is down may become disoriented simply due to lack of stimulation.
In summary, static and rigid devices are typically not recommended for Restorative Patients of any age. Static and rigid devices are designed for orthopedic conditions that require the joint or body part to be maintained in a certain plane to facilitate healing and function. It is not uncommon for one patient to have both conditions as seen in a person with Cerebral Palsy or Traumatic Brain Injury who may need a functional AFO or knee splint to enhance their ambulation, but upper extremity Restorative splinting to decrease the tone in their hands and elbows. If we fit appropriate splinting on these patients as soon as they start to develop neurological tone, we are more likely to prevent the injuries of lost range of motion. By our choices of treatment methods and orthotic devices, we may be determining the quality of life for these individuals for the rest of their lives.
Karen L Bonn, RN, COF, CFO
Restorative Medical, Inc.