Short Term Therapy Needs for Long Term Residents: Contracture Management - Jason M., Occupational Therapist

Working in a Skilled Nursing Facility (SNF) with both short-term rehabilitation residents and long-term care residents, I have learned that it is especially important to not overlook the therapeutic needs that the residents living in the facility may have, which are often over-shadowed by the acute, fast-track therapy programs that provided to the short-term patients. Despite how long they have resided at the facility, there is typically always something that they could improve on or be more independent with after the time and attention of a therapist. Not to mention, from a program development and business stand point, building and maintaining a caseload with long-term residents is a productive and financial must.

For long term residents, particularly those that have limited mobility, are bed bound, or have long standing neurological disorders, management and preventing increased tone and contractures is a hallmark of quality of care. We all know that the human body is made to be up and moving around. As a patient’s age and medical status limit their daily activities, muscle atrophy and joint rigidity set in. Left unchecked or treated, this rigidity increases to form contractures in joints. With skilled interventions from therapists, these contractures can be better managed.

Identifying Contracture Management Needs:

A simple screen to assess a patient’s current range of motion (ROM), either active or passive, will allow you to easily identify joints and muscle groups with limited mobility. Sometimes, further hands-on assessment and joint manipulation will be needed to identify if the patient has any potential to decrease the tone, increase the ROM, or benefit from splinting/orthotics. In this case, an evaluation beyond the initial screen may be merited. Also consider that nursing, especially MDS nurses, do quarterly assessments that address a patient’s ROM throughout their extremities. This may provide that additional supportive documentation for therapy services.

Treatment Considerations for Contracture Management:

For contracture management, the focus should be where you will make improvements by applying skilled therapy interventions. If a person suffers from many years of untreated contractures, has joint deformity, intolerable pain with stretching, etc. then consequences/cost of therapy may outweigh the benefits that are achievable. If you feel the patient does demonstrate therapeutic potential for contracture management treatments, consider these points when developing your plan of care:

• Focus on skills that are unique to therapy services: joint manipulation, deep tissue massage, stretching, and other manual techniques.
• Don’t underestimate the power of stretching. If done properly and frequently enough, simple stretching within tolerated passive and active ROM’s can effectively treat tone.
• Even a few degrees are better than nothing. Set your goals at short intervals to illustrate progress. Remember that “full ROM” doesn’t always equal “functional ROM”.
• Supplement the treatment with modalities: electrical stimulation (particularly interferential), ultrasound, infrared, etc. Also consider the modalities as a way to treatment and limit post treatment pain/discomfort as not to discourage the patient from further treatment.
• Consider positioning devices for long-term use. Custom made splints or pre-fabricated can ensure prolonged contracture management and limit further tone development once therapy has been discharged.
• Finalize on carry-over and long-term management. Caregivers, family member, and nursing staff (think NMP and restorative therapy) should be educated and encouraged to provide almost daily ROM, stretching, or some form of treatment to continue with contracture management beyond therapy services.

Goals and Outcomes with Contracture Management:

Once the treatment course has reached a point that nursing or the patient themselves can manage the tone, ensure discharge. If successful:

• ROM is improved and maintained; decreasing skin breakdown, decreasing joint pain, and increasing performance with ADL’s.
• The facility does not need to supply skin/wound treatments; decreasing their pharmacy expenses.
• The facility does not need to supply medicine for joint pain; decreasing their pharmacy expenses.
• The nurse provides less treatment; decreasing their overall work-load.
• The caregiver/nursing staff provides less assistance with ADL’s; decreasing their overall work-load.
• Most importantly, the patient has decreased contractures and overall better quality of life.

Long-term benefits from short-term therapy to long-term residents.