Transferring Patients with Contractures

It is a common occurrence for clinicians to assess dependent older people for contractures in community and residential settings.¹ Contractures contribute to increased disability by limiting joint range of movement, reduced ability to engage in functional tasks, such as dressing or feeding, and can cause pain and discomfort.¹

What are contractures?

When joint, muscle, or soft tissue limitations interfere with passive range of motion, it is known as a limb contracture.¹ The most common cause leading to the development of fixed limb contractures is static positioning for prolonged periods of time. Positioning a dependent patient with joints in flexion for a prolonged period of time, places the patient at risk for developing contractures.

Muscle cell density in each given muscle is determined by the joint's statically positioned position. Muscle cell loss due to muscle length reduction could reach 40%.⁴ When a muscle in a statically positioned limb undergoes fibrotic alterations, contracture formation occurs in the immobilized position.⁴ Research has found that paratonia is present in virtually all patients with dementia, which can lead to fixed postures and contractures.² Many Patients experience a rapid onset of contractures after switching to a wheelchair.²

Some principles to help manage contractures

Early identification and implementation of physical medicine techniques like passive ROM exercises and splinting using mobilisation orthosis tools, before contractures are apparent or while contractures are minor, are necessary for contracture prevention.

• Some patients with neuromuscular disease will always develop contractures.

• Surgical intervention may be necessary for advanced contractures that do not respond to conservative interventions such as stretching or splinting programs.

• Contractures of lower limbs should be controlled to minimize their adverse effects on independent ambulation, but the primary cause of wheelchair use among people with neuromuscular disease is most commonly weakness, not contractures.

• It is important to note that both upper and lower limbs can develop contractures due to static positioning.

• Function may not be affected by mild contractures.⁴

In addition to orthopaedic surgical procedures, aggressive rehabilitation techniques like stretching, positioning, and splinting may reduce the degree of dysfunction brought on by contractures in neuromuscular disease.³

Early intervention is key in identifying development and preventing the worsening of contractures. Clinicians should implement 24-hour postural support for the patient at risk of contractures. This includes providing postural support in bed and in sitting. Unless these patients receive adequate postural care, they will adopt preferred positions as a result of gravity, muscle tone, and muscular imbalance, called destructive positions. If left unmanaged, these positions can often lead to the development and the worsening of muscle contractures, joint subluxations, and spinal curvatures.⁴

Seating considerations:

• A through assessment is essential in assessing joint range of movement and establishing if contractures are fixed or flexible.
• Provide adequate postural supports to accommodate or correct deviant postures.
• Back angle recline accommodates the patient’s hip angle.
• Ensuring the correct chair set up and chair dimensions.
• The patient’s body should be fully loaded in the chair with no tension at the joints.
• To accommodate knee flexion in the event of severe fixed leg contractures, it is advised to:
• open the back angle of the chair.
• reduce the seat depth.
• adjust the leg rests into negative angle. Footrests are positioned under the chair behind the knees.

Full hoist transfer technique for the patient with severe leg contractures

By supporting and enclosing the patient with cushions, one can affect muscle tone. Therefore, if a patient is supported and relaxed, muscle tone reduces and maximal extension of joints may be achieved.⁵ In order to attempt to achieve a good sitting position, Seating Matters recommends clinicians conduct a full seating assessment and if the patient is suitable, to trial this technique for full hoist transfers into a Sorrento or Milano chair;

• Open the back angle of the chair.
• Assess the patient’s range of comfortable hip flexion when in seated position and reduce the seat depth accordingly.
• Adjust the leg rests into negative angle. Footrests are positioned under the chair behind the knees.
• Assess suitability of the sling. Assess hip adduction to ensure sling can be positioned without discomfort between the legs. If patient experiences distress or discomfort, assess suitability of a cradle sling.
• First hoist the patient from the bed and slowly lower into the chair. Focus on position of the legs. The patient is unlikely to reach hips to the back of the chair at this stage.
• Supervise and reassure the patient while they are sitting. Allow the patient to sit and rest for 5-10 minutes.
• Observe for reducing muscle tone in lower legs.
• Secondly, hoist the patient up slowly, and this time lower the patient into the chair, this time focusing on positioning the patient’s hips as far back into the chair as possible, without causing discomfort.
• Assess for any tension at back of legs. If pressure occurs, adjust the leg angle into a more negative position.

How Seating Matters can help

Seating Matters have a range of chairs that are designed to meet the changing needs of patients. To accommodate leg contractures, chairs would have features such as, back angle reline, adjustable seat width and depth, and negative leg angle. Our Sorrento, Phoenix and Milano chairs have features which meets the needs of most patients with leg contractures, and the chair you choose depends on the levels of support required. All 3 chairs are fully adjustable, hoist compatible, and have negative leg angle, to facilitate transfers and meets the changing needs of the patient.

References

1. Dehail, P., Gaudreault, N., Zhou, H., Cressot, V., Martineau, A., Kirouac-Laplante, J., Trudel, G. (2019) ‘Joint contractures and acquired deforming hypertonia in older people: which determinants?’, Ann. Phys. Rehabil. Med., 62 (6), pp. 435-441, 10.1016/j.rehab.2018.10.005

2. Drenth, Hans, Zuidemac , S., Bautmansd, I., Marinellie, L., Kleinerg, G. and Hobbelena, H. (2020) ‘Paratonia in Dementia: A Systematic Review’, Journal of Alzheimer’s Disease, 78, 1615-1637. Doi: 10.3233/JAD-200691

3. Osborne LJ, Gowran RJ, Casey J. (2023) ‘Evidence for 24-hour posture management: A scoping review’, British Journal of Occupational Therapy, 86(3):176-187. doi:10.1177/03080226221148414

4. Skalsky AJ, McDonald CM. (2012) ‘Prevention and management of limb contractures in neuromuscular diseases’, Phys Med Rehabil Clin N Am, (3):675-87. doi: 10.1016/j.pmr.2012.06.009. PMID: 22938881; PMCID: PMC3482407

5. Van Deun, B., Van den Noortgate, N., Cinthia, S., Van Bladel, A. and Dirk, C. (2018) ‘Paratonia in Flemish Nursing Homes, American Journal of Alzheimer’s Disease & Other Dementias, 33(4):205-214. doi:10.1177/1533317518760594