Factors Associated with Development of New Joint Contractures in Long-Term Care Residents

Aerobic Training and Ointment Effect on range of motion, von Willebrand factor, vascular endothelial factor and Femoral Artery Hemodynamics in Joint Contracture: A Rat Model

OBJECTIVE

Using a rat model, we investigated the effect of multidisciplinary rehabilitation, including aerobic training and ointment, on the ROM, vWF, VEGF content, and femoral artery hemodynamics in rats with joint contracture.

METHODS

A total of 44 Wistar rats were divided into the normal control group (NC, eight rats) and the experimental group (EG). A joint contracture model was established for the rats in the EG group by an external fixator. After fixator removal, 32 rats are further divided into the MC, SC, RE, and SR groups (n = 8). Before and after the 42 day intervention, the ROM, vWF, VEGF, PS, ED, and RI were measured using X-ray imaging, ELISA, and color Doppler ultrasound, respectively.

RESULTS

After fixator removal, ROM for EG group was lower than that of the NC group (p < .01). After the intervention, ROM for the SR, RE, and SC groups was improved. The ROM for the SR group reached a similar value for NC group. vWF and VEGF levels in SR group were lower than in the MC, SC, and RE groups (p < .05), and had a similar value to the NC groups. PS value for SR and RE groups was higher than the MC and SC groups. The RI value for SR group was higher than that of NC and MC groups.

CONCLUSION

Multidisciplinary rehabilitation used in this study can treat joint contracture synergistically. It improves the ROM of the joint, reduces the content of vWF and VEGF, and improves the femoral artery hemodynamics.

Development and evaluation of a quality improvement educational video on joint contractures for care home staff

BACKGROUND

Contractures are a debilitating problem for individuals living in long-term care settings. However, there is a lack of education and training among the care staff regarding the identification of risk factors related to contractures and the preventive strategies that can decrease their development or progression. Addressing this knowledge gap has the potential to improve the quality of care provided to residents in care homes.The objective of this quality improvement (QI) project was to investigate the impact of a newly developed educational video on the awareness, knowledge and understanding of contractures among the care staff.

METHODS

This QI project involved two sequential Plan-Do-Study-Act cycles and employed a pre and post-test design to evaluate the impact of the contracture educational video. Primary outcomes were assessed using paper surveys to capture prevideo and postvideo levels of knowledge and understanding of contractures. Furthermore, both verbal and written feedback from participants were gathered to identify areas of strengths and improvement.

RESULTS

Baseline data revealed that about 56% of the care staff lacked knowledge and understanding of contractures with another 33% reporting possessing only basic knowledge. Following the video intervention, percentage of care staff who reported good knowledge and understanding increased to 67% while 22% reported basic knowledge and understanding of contractures. The care staff suggested changes to the video to improve accessibility of the information, this was incorporated in the refilming of the video.

CONCLUSION

This QI project demonstrated that the introduction of a contracture educational video is a feasible and positively received method of enhancing awareness, knowledge and understanding of contractures among care staff. Educating care staff about the risk factors and prevention strategies for contractures will potentially improve their ability to identify the risk of contractures and help prevent their occurrence, ultimately enhancing the quality of care of the residents.

Process evaluation of an individually tailored complex intervention to improve activities and participation of older nursing home residents with joint contractures (JointConEval): a mixed-methods study

BACKGROUND

Older people with joint contractures in nursing homes often experience severe restrictions in their activities and participation. The effectiveness of an individually tailored complex intervention to improve residents' activities and participation by incorporating the biopsychosocial perspective into nursing care using a structured facilitator approach could not be established in the JointConEval cluster-randomised controlled trial. This process evaluation aimed to systematically identify factors influencing implementation and effectiveness.

METHODS

The mixed-methods process evaluation analysed recruitment, implementation, mechanisms of impact, and context. Qualitative data was generated in semi-structured focus groups and in individual interviews with facilitators, nursing and social care staff, residents, relatives and guardians. Quantitative data was recorded with facilitators and 20% of nursing and social care staff using standardised documentation forms and questionnaires. Qualitative data was analysed using qualitative thematic content analysis, while the quantitative data was analysed descriptively. An interpretation was performed by combining and comparing the qualitative and quantitative results after the separate analyses.

RESULTS

The implementation was realised as planned, but the intervention did not always reach the nursing home staff, which hindered the planned change in attitude and behaviour. The attitude of the facilitators was mainly in line with the intervention. However, the intervention reached only half the residents. We identified various key influencing factors related to the context, setting and implementation agents. Nursing homes lacking facilitator support from staff or management or experiencing staff shortages and facing organisational weaknesses had difficulties in achieving the desired behavioural changes and positive primary outcomes.

CONCLUSIONS

The complex intervention was delivered as planned with several factors affecting the implementation. A key influencing factor was the organisational structure and leadership of the nursing homes, which had an impact on the behaviour and motivation of the implementation agents. The findings highlight challenges in achieving behavioural changes among nursing staff in the context of long-term care in Germany. We recommend a systematic organisational context analysis for similar complex interventions in long-term care, involving stakeholders and improving leadership participation for more effective implementation.

TRIAL REGISTRATION

DRKS (German Clinical Trials Register), number DRKS00015185. Registered on 1 August 2018, https://drks.de/search/en/trial/DRKS00015185 . Universal Trial Number U1111-1218-1555.

Treatment of Acquired Deforming Hypertonia with Botulinum Toxin in Older Population: A Retrospective Study

Acquired deforming hypertonia (ADH) affects the daily care of numerous nursing home residents. The aim of this study was to analyze the practice, aims, and effectiveness of botulinum toxin injections (BTxis) in the treatment of older patients with contractures, an indication for which BTxis are still underused. Data were extracted retrospectively from medical records regarding population, contractures, and injections. A prospective analysis was conducted to evaluate treatment goals set by goal attainment scaling (GAS) at T0 and at T1, to evaluate the therapeutic effects. We also recorded the occurrence of side effects, using a telephone questionnaire. This study included 41 patients older than 70 years who had received one or more BTxis for the first time between January 2018 and December 2021. Most of the older people we included lived in an institution (66%), manifested severe dependence, and presented significant morbi-mortality (37% of the patients died in the year after the last injection). The main objectives of these injections were purely comfort, without any functional goals. The GAS scores suggested effectiveness for comfort GAS scores. No complications were recorded. This study highlights the BTxis potential to address the needs of a larger number of older patients with ADH.

Effectiveness of an individually tailored complex intervention to improve activities and participation in nursing home residents with joint contractures (JointConEval): a multicentre pragmatic cluster-randomised controlled trial

OBJECTIVE

This study aims to examine the effects of the individually tailored complex intervention Participation Enabling Care in Nursing (PECAN) on activities and participation of residents with joint contractures.

DESIGN

Multicentre pragmatic cluster-randomised controlled trial.

SETTING

35 nursing homes in Germany (August 2018-February 2020).

PARTICIPANTS

562 nursing home residents aged ≥65 years with ≥1 major joint contracture (303 intervention group, 259 control group).

INTERVENTIONS

Nursing homes were randomised to PECAN (18 clusters) or optimised standard care (17 clusters) with researcher-concealed cluster allocation by facsimile. The intervention targeted impairments in activities and participation. Implementation included training and support for selected staff. Control group clusters received brief information.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary endpoint PaArticular Scales combined residents' activities and participation at 12 months. The secondary outcome comprised quality of life. Safety measures were falls, fall-related consequences and physical restraints. Residents, staff and researchers were unblinded. Data collection, data entry and statistical analysis were blinded. Primary analyses were intention-to-treat at cluster level and individual level using a generalised mixed-effect regression model and imputation of missing data.

RESULTS

Primary outcome analyses included 301 intervention group residents and 259 control group residents. The mean change on the Activities Scale was -1.47 points (SD 12.2) in the intervention group and 0.196 points (SD 12.5) in the control group and -3.87 points (SD 19.7) vs -3.18 points (SD 20.8) on the Participation Scale. The mean differences of changes between the groups were not statistically significant: Activities Scale: -1.72 (97.5% CI -6.05 to 2.61); Participation Scale: -1.24 (97.5% CI -7.02 to 4.45). We found no significant difference in the secondary outcome and no effects on safety measures.

CONCLUSION

The complex intervention did not improve the activities and participation of nursing home residents on the PaArticular Scales at 12 months. Current nursing conditions in Germany may hamper implementation.

TRIAL REGISTRATION NUMBER

DRKS00015185.

The Relationship Between Physical Activity and Limited Range of Motion in the Older Bedridden Patients

Background

The purpose of this study is to examine the association between physical activity and contracture in older patients confined to bed in long-term care (LTC) facilities.

Methods

Patients wore ActiGraph GT3X+ for 8 hours on their wrists, and vector magnitude (VM) counts were obtained as the amount of activity. The passive range of motion (ROM) of joints was measured. The severity of ROM restriction classified, as the tertile value of the reference ROM of each joint, was scored 1-3 points. Spearman's rank correlation coefficients (Rs) were used to measure the association between the VM counts per day and ROM restrictions.

Results

The sample comprised 128 patients with a mean (SD) age of 84.8 (8.8) years. The mean (SD) of VM was 84574.6 (115195.2) per day. ROM restriction was observed in most joints and movement directions. ROMs in all joints and movement directions, except wrist flexion and hip abduction, were significantly correlated with VM. Furthermore, the VM and ROM severity scores showed a significant negative correlation (Rs = -0.582, p < .0001).

Conclusions

A significant correlation between the physical activity and ROM restrictions indicates that a decrease in the amount of physical activity could be one of the causes of contracture.

Factors associated with joint contractures in adults: a systematic review with narrative synthesis

PURPOSE

The primary objective of the review was to collate the available evidence on factors associated with joint contractures in adults.

METHODS

A systematic literature search was conducted on MEDLINE, CINAHL, AMED, and EMBASE. Studies that involved participants aged ≥18 and assessed joint contracture as a primary or secondary outcome were included. Two independent reviewers screened studies against the eligibility criteria, performed data extraction, and assessed the quality of evidence. A narrative synthesis by domain and sub-domain was undertaken. The protocol was registered on PROSPERO: CRD42019145079.

RESULTS

Forty-seven studies were included in the review. Identified factors were broadly classified into three major domains: sociodemographic factors, physical factors, and proxies for bed confinement. Sociodemographic factors were not associated with joint contractures. Functional ability, pain, muscle weakness, physical mobility, and bed confinement provided the most consistent evidence of association with joint contractures. The evidence regarding the relationship between spasticity and joint contractures remains unclear. Other factors might be important, but there was insufficient evidence to make inferences.

CONCLUSIONS

The review identified and collated evidence on factors associated with joint contractures, which can be utilised to develop effective prevention and management strategies. Implications for rehabilitationClinical interventions based on the timely identification of risks related to joint contractures in vulnerable adults have the potential to prevent or ameliorate their development or progression.Quality and consistency of care for vulnerable adults would be enhanced by developing effective joint contracture prevention and rehabilitation strategies based on the evidence presented in this review.As many vulnerable adults are located in the community or non-acute care settings, strategies should target these loci of care.Structured risk assessments that can support non-physiotherapy staff working in these loci of care to identify risks related to joint contractures would provide an important resource for risk management.