Treating Contractures in the Elderly By Purnananda Kar
Contracture is one of the most common problems I have experienced through my clinical practice in the last few years.
Contractures occur in different age groups and in people with different medical problems. Lots of money is spent every year, directly or indirectly, due to the effect of contractures that are overlooked by practitioners, family and caregivers. The problem is not completely ignored, but there is room to do a better job.
As an OT, I believe this is one of the very significant areas where we can take charge. We can make patients' lives better and save some dollars.
What I have found after years of practice is that the contractures in the elderly occur for two basic reasons:
* as a result of surgical problems--traumatic, neurological, orthopedic, miscellaneous
* from inadequate intervention--therapeutic approach, surgical approach
The most common causes are neurologic or orthopedic-related problems.
In orthopedics, the problem might rest in bone, cartilage, muscles, tendons, ligaments, or soft tissue. The most common neurological conditions which result in contractures are CVA, MS, Parkinsonism, paraplegia, UMN and PPRP. However, most of the conditions stem from combination of both, coupled with poor management of the specific problem.
We know that this problem does not develop overnight.
Without going into the physiology and pathomechanics of contractures, I would like to touch upon the best possible remedies for contractures in geriatric patients, from my perspective.
The common sites of contractures in the elderly, from most frequent to least, are hands and digits, shoulder, knee, elbow, foot, wrist, hip and spine. Is there any reason why the hand is the most often afflicted area? It is one of the most used parts of the body. It also performs the most fine-motor movements, which require the involvement of many small muscles. And there are other biomechanical principles that apply.
When it comes to contracture management, whether hand or knee, the OT should take charge, because either directly or indirectly, the contracture hinders functional activity. This is absolutely within the domain of occupational therapy.
In the elderly, conservative methods of treatment are the best choice, although sometimes surgical treatment is recommended. Medical treatment is required when the contracture is acute onset, or to reduce pain, spasms, spasticity or muscle guarding. It also may be needed to facilitate physical treatment
Physical treatment includes physical-agent modalities including electrical stimulation, pulsed short-wave diathermy, ultrasound, paraffin bath, whirlpool, hot and cold pack, etc; therapeutic intervention (exercises, stretching, mobilization, manipulation, etc.); and orthotic management (design, fabrication of splints, orthosis, and support devices).
Often, OT clinicians have problems in identifying a particular patient who is having a contracture or has a risk of it. Bed positioning can eventually lead to contractures. The team, which can include many other professionals who do not necessarily have the expertise that OTs have in diagnosing contractures, may not observe them closely.
Some OT clinicians may not have expertise in using orthoses. After all, you can't have expertise in everything. And an expert clinician's skill is wasted if he or she does not have supplies for a particular orthosis. Sometimes, clinicians face problems in reimbursement for contracture management, which creates a barrier to providing appropriate service in time.
Clinicians who do use contracture management techniques can experience problems when there is a lack of feedback from other team members or follow-up from nursing. The family may not want to give consent because they do not understand why treatment is necessary.
So let's talk about some easy, cost-effective solutions to the above-mentioned problems.
Identifying the appropriate case for splinting is not difficult if you target the patient's decline in function. Trace it to either the upper or lower body, then isolate the individual component of each limb and the trunk. Find the underlying cause, and identify the contracture risk as immediate, intermediate or long-term. Find out what kind of support the patient needs, and then you will be able to recommend the appropriate splint. Make sure, however, that you always consider function, so that the patient can keep as much function as possible without damaging joint and skin integrity.
Lack of team approach in this particular area is very common in most cases. The problem seems small in the beginning. It becomes serious in later stages, however, and it is the OT's duty to educate the other professionals periodically. You also may want to develop a questionnaire for contracture assessment, possibly facility-specific.
Check with the other professionals periodically, get their feedback, and make the necessary changes.
Lack of funding will not be an issue if the OT clinician can find a low-cost method of treatment and show other professionals and the patient's family. In my experience, this approach works most of the time.
If you are not adequately competent in splinting for contractures, take the initiative to learn more through continuing education courses and from other experienced professionals. Keep your knowledge updated.
In many places, clinicians do not get enough materials to take care of splinting. I encourage you to go through your catalogs.
Find the lowest-cost materials that will be effective, and make sure it is convenient and can be fitted easily.
Feedback is a big issue. If follow-through after the splint is fitted is not carried out properly, the problem can get worse and/or the patient loses the splint. This results in more frustration, and also makes it difficult to charge the same patient again and again for other splints. This problem can be solved by working closely together. Take your problems to the team and work out a plan.
Educate the patient and family about contracture risk, cause and cost, and about the long-term benefits of treatment.
Purnananda Kar, OTR/L, is employed by Sundance Rehab at Four Seasons N.C. in Durant, OK.