Education

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Restorative Support Systems Co.
CONTRACTURE MANAGEMENT SOLUTIONS

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

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STATISTICS

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.