Passive Range of Motion Exercises & the Prevention of Contractures

Using Muscles--or
 Losing Them--in
 Late-Stage Dementia 

 Evelyn Smith

MS in Library Science (2012) University of North Texas

 

When I came for an unscheduled visit at the nursing home last Thursday, Mother wasn’t wearing the gloves that she customarily wears to keep her from scratching herself.  A search of her bedside table and wardrobe didn’t turn up any of the five pairs of gloves that I had bought a month before, and her aide for the shift spoke up from across the room when I complained at the nurse’s station--the gloves were simply too small, making it difficult to put the gloves on her fingers. Indeed, as I later patiently eased the largest newly bought cotton gardening gloves I could find over her fingers, I noticed the rigidity of their joints.  All of which made me wonder what I could do to alleviate their newly-noticed curvature. 

Although some of the sources that I read made me realize that it might be too late to correct the flexibility of Mother’s finger joints, the research below motivated me to schedule an appointment with her nursing home’s physical therapist whereby I can receive instruction in giving Passive Range of Motion therapy as soon as possible.  Since the goal of hospice or palliative care for an Alzheimer’s patient is to make his or her remaining time as comfortable as possible, performing PROM exercises should limit further muscle shrinkage and atrophy as well as preventing bed sores. As of yet, I haven’t heard back from the physical therapist, but if she feels such exercises will prove helpful, I’ll try and perform them at least once daily.  I only hope I have caught this problem in time.

A little research, of course, soon reveals the reason for this rigidity: Because the end-stage patient can no longer walk and is confined to wheelchairs and beds for long periods of time, deformities, known as contractures, develop, whereby joints are frozen in place.   In this case, since Mother no longer dresses or feeds herself, the tissues in her finger joints are contracting.  Contractures result in difficult in dressing and moving the patient, pain in the joints, and bedsores; moreover, the lack of muscle movement so slows the circulation that it often results in strokes.  

Although research indicates that steroids may be effective in preventing contractures in an immobilized patient, it is also necessary to move the joints to keep the muscles from atrophying.   Unfortunately, by the time someone noticed this problem, the short window of time where PROM exercises are truly helpful may have already passed.  I only hope that the daily glass of glucosamine drink mix that eases Mother’s arthritis pain has bought us a little time. 

___________

P. S. --  (Friday, March 29, 2013) Mother has begun a PROM regime four days a week, and the physical therapist hopes that restorative therapy will be helpful in straightening her hands.  Part of the therapy applies warm heat to Mother's shoulders and arms.  She will eventually be supplied with stents to keep her hands straight.

(Sunday, December 13, 2015) -- Mother continued her passive exercises as long as they proved beneficial.  Mother didn't like some of the exercises the physical therapist performed. As evidence of this, even though Mother had stopped talking, she voiced more than one very definite "no" while the physical therapist was putting her through this regime.  Hence, when at last she entered hospice care in May 2013, her PROM therapy stopped completely. However, I would like to think that the physical therapy improved her quality of life for about a year.

____________





Definitions

Contracture

Vorvick, L. J. (2012, August 14).  Contracture deformity.  Retrieved from http://www.nlm.nih.gov/medlineplus/ency/article/003185.htm

A contracture develops when non-stretchy fiber-like tissue replaces elastic tissues, making it hard to stretch the area and preventing normal movement and causing pain.  Rigidity occurs when the individual doesn’t exercise the muscles, or else they are not exercised for the patient.

Don't wait until contractures are severe to begin physical therapy.

Active Assisted Range of Motion

 

Koehler, S. (2013).  Active assisted range of motion.  eHow.  Demand Media, Inc.  Retrieved from http://www.ehow.com/way_5420614_active-assisted-range-motion-exercises.html

Active-assisted Range of Motion helps an injured patient maintain joint flexibility and strength with a little assistance from a physical therapist or caregiver (Koehler, S. 2013, para. 1).

Passive Range of Motion

Chisholm, K. (2008).  Definition of passive range of motion. eHow.  Demand Media, Inc.  Retrieved from http://www.ehow.com/about_5070066_definition-passive-range-motion.html

Physical therapy uses Passive Range of Motion to manipulate body parts without activating muscles to perform the movement in an attempt to restore and/or maintain muscle mobility (Chisholm, 2008, para. 1, 2 & 7). Either trained individuals or a continuous Passive Motion Machine can perform this therapy (Chisholm, 2008, para. 8).

Range of Motion

Little, M. A. (2010, July 13).  Define range of motion. Livestrong.com. Retrieved from http://www.livestrong.com/article/173550-define-range-of-motion/

Range of Motion is a measure of the amount of movement that occurs when moving a joint from its starting to ending position (Little, 2010, para. 1).  Active Range of Motion is the measurement of how much a limb [or other body part like a wrist or finger] can move without help while an examiner determines Resistant Range of Motion by applying opposing pressure. 

____________

Online Range of Motion Exercise Guides

The following Online guides for passive range of motion exercises should only serve as examples of possible exercises caregivers and family members can include in a personalized passive movement program.  Since different guides give slightly different instructions, family members shouldn’t attempt PROM exercises on an Alzheimer’s patient without professional instruction since they might injure swollen joints. 

Passive and assistive range of motion exercises. (2004, February 19).   ALS.org. Retrieved from http://www.alsworldwide.org/pdfs/rom_exercises.pdf

Therapists can equip caregivers with a personalized exercise program that is active or passive depending on the strength of a patient’s muscles groups (ALS.org, 2004, para. 1).  Beginning slowly, repetitions should gradually increase as joints are moved to the point of resistance and held for 30 seconds (ALS.org, 2004, para. 2).

Passive range of motion exercises. (2013). Drugs.com. Retrieved from

http://www.drugs.com/cg/passive-range-of-motion-exercises.html

Drugs.com recommends learning Passive Range of Motion exercises from a qualified caregiver [or therapist], practicing these exercises, so an experienced individual can critique technique (Drugs.com, 2013, para. 1 & 3).  The patient should be comfortable before  the caregiver moves the limbs smoothly and gently, stopping if the patient is in pain (Drugs.com, 2013, para. 2-8). The exercises should become a part of the patient’s daily routine during which time the individual moving the patient’s limbs should periodically check back with the therapist (Drugs.com, 2013, para. 9).

____________

General References on Contractures

Caring for a person with Alzheimer’s disease.  Coping with late-stage AD.  (n. d.). Alzheimer’s Disease Education and Reference Center.  National Institute on Aging.  National Institutes of Health.  Retrieved from http://www.nia.nih.gov/alzheimers/publication/coping-last-stages-ad/coping-late-stage-ad

The Alzheimer’s Disease Education and Referral Center recommends that the caregiver ask a physical therapist for instruction on how to move joints restricted by contractures several times a day since the physical movement of these joints prevents stiffness as well as bedsores (Alzheimer’s Disease Education, n. d., para. 2).

Fabian, F. (2011, March 15). Final stages of dementia. Livestrong.com.  Retrieved from  http://www.livestrong.com/article/103819-final-stages-dementia/

Fabian notes that final stages of dementia include a continuous physical and biological breakdown known as lability, physical rigidity, and contracture (Fabian, 2011, para. 3).

The 5 most preventable problems in late stage Alzheimer’s disease. (2012, January 31). 

The Dementia Queen.  (2012, January).  Retrieved from http://thedementiaqueen.com/2012/01/the-5-most-preventable-problems-in-late-stage-alzheimers-disease/

The Dementia Queen defines a contracture as “a chronic loss of joint motion caused by the shortening of a muscle or tendon” and then goes on to explain that contractures form not only from lack of movement, but also from neurological changes in muscle tone when an individual sits in one place with legs and elbows bent.  Thus, the blog recommends passive exercise as a way to prevent contractures (Dementia Queen, 2011, para. 7-9).

Contractures and aging. (2009).  Rasansky Law Firm.  Retrieved from

http://www.texasinjuryattorney.com/nursing-home-abuse/signs-of-abuse/contractures#top

After defining contractures as “painful, disfiguring deformities of the joints” (Rasansky, 2009, para. 1), this elder law firm’s Web page, which cites contractures as evidence of possible elder abuse, sets out to delineate the progression and causes of contractures as well as their prevention and the range of motion exercises necessary to prevent them.  Although contractures develop in four different stages, unfortunately nursing home staff often don’t recognize their occurrence until the third stage—two or three weeks after they start to develop within the small window of time wherein they may be delayed or prevented.  Moreover, since nursing home residents don’t ordinarily exercise all their joints daily without intervention, they eventually atrophy (Rasansky, 2009, para. 3).  

Thus, a nursing home patient who can still move independently should exercise frequently while physical therapists, and/or trained aides [and family members] should either help the immobile patent perform Active Assistive Range of Motion exercises or else perform passive-range-of-motion exercises on an individual who can’t otherwise move the limbs (Rasansky, 2009, para. 5-7).  Here the therapist or caregiver should make sure to align the body properly, respect the patient’s dignity, and encourage relaxation while exercising each joint a prescribed number of times each passive-exercise session (Rasansky, 2009, para. 7). 

Reisberg, B. (n. d.).  An Atlas of Alzheimer’s Disease.  Pearl River, New York: Parthenon.  Retrieved from http://www.alzinfo.org/clinical-stages-of-alzheimers

Physical rigidity becomes evident in the seventh and final stage of Alzheimer’s disease in 95 percent of all Alzheimer’s patients.  Such rigidity appears before physical deformities known as contractures appear that prevent the passive movement of the joints, making the patient more difficult to move and clothe without producing severe pain.  Neurological grasping, sucking, and Babinski plantar extension reflex often accompany increasing physical rigidity as part of the physical changes the patient in the last stage of Alzheimer’s undergoes (Reisberg, n. d., para. 37). 

Stern, D. (2013).  Methods of contracture management in nursing homes.  eHow.  Demand Media, Inc. Retrieved from http://www.ehow.com/way_5509890_methods-contracture-management-nursing-homes.html

Methods that prevent contracture include positioning, splinting, and passive exercise.  Positioning means adding extra cushions, pillows, and head rests to prop the patient up in wheel chairs and geri chairs (Stern, 2013, para. 1).  Splinting places special boats, wrist cushions, and pads, knee and elbow parts on at risk body parts to prevent contractures (Stern, 2013, para. 2).  Nursing and physical therapy staff should be aware of contractures that can develop in less than a week so a patient’s caregiver needs to gently rotate the joints clockwise and counter-clockwise several times a day else the joints risk permanent deformation (Stern, 2013, para. 3).

___________

Medical References on Contractures 

Clavet, H. Hébert, C. & Fergusson, D. et al. (2008, March 11).  Joint contracture following prolonged stay in the intensive care unit.  CMAJ. 178, 6.  doi: 10.1503/cmaj.071056 Retrieved from http://www.canadianmedicaljournal.ca/content/178/6/691.full

 

Canadian researchers determined that a stay of two weeks in intensive care proves to be a significant factor in the development of contractures while a patient immobilized eight weeks or longer has an even greater risk for developing these deformities in the shoulders, elbows, hips, knees, and ankles (Clavet, 2008, para. 1, 2 & 9).   However, the study revealed that taking steroids in ICU lessened the chance of developing contractures (Clavet, 2008, para. 10). 

Fergusson, D., Hutton, B., & Drodge, A. et al. (2007, March).  The epidemiology of major joint contractures:  A systematic review of literature.  Current Orthopaedic Practice.  456, 22-29.  doi: 10.1097/BLO.0b013e3180308456

After surveying Medline epidemiology studies from 1966 to March 2005, the authors admit that medical science has limited knowledge of the causes of joint contractures, although immobility is a common factor in at risk populations.

Fox, P., Richardson, J., & McInnes B., et al.  (2000, April). Effectiveness of a bed positioning program for treating older adults with knee contractures who are institutionalized.  Physical Therapy. 80 (4), 363-372.  Retrieved from http://www.physther.org/content/80/4/363.full.pdf+html

Physical therapy that stretches the patient’s limbs into extension and then maintains it in that position for 40 minutes four times a week does little to improve range of movement, knee pain, or skin integrity (Fox, 2000, p. 363).  The small size of the survey group, however, limits this report’s viability since it needed a sampling size of 14 patients to determine its effect, but only 12 patients completed the study (Fox, 2000, p. 369).  Additionally, the researchers could only determine if a patient was in pain if he or she cried or moaned, made a face, or withdrew from touch (Fox, 2000, p. 367).

Jamieson, N. (1989, September 10).  Hand contractures in mental illness.  Physiotherapy. 75(9), 46-500. doi:  10.1016/S0031-9406(10)62296-1

A Northern Ireland survey of patients in a psychiatric hospital found no organic causes of contractures, but it did note that the regular Passive Range of Movement stretching of finger joints reduced the severity of contractures in the hand.

Souren, L. E., Franssen, E. & Reisberg B. (1995, June).  Contractures and loss of function in patients with Alzheimer’s disease.  Journal of the American Geriatrics Society, 43(6), 650-655.  Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/7775724

Rigidity correlates with a high degree of functional impairment since 75 percent of their sample of 161 elderly patients diagnosed with Alzheimer’s had lost their ability to walk and thus suffered from contractures in the leg while fewer than 11 percent of the still walking Alzheimer’s patients had contractures in the legs.

Wagner, L. M., Capezuti, E., Brush, B. L., et al. (2008, July-August).  Contractures in frail nursing home patients [Abstract].  Geriatric Nursing. 29(4), 259-266. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/18694701

Wagner and associates classify contractures as “a common but preventable consequence of prolonged physical immobility”, reducing mobility and increasing the chance of pressure ulcers.

Conclusion 

Since contractures affect the quality of life for the late-stage Alzheimer’s patient, caregivers and family members should be alert to when they first occur, so they can begin Passive Range of Motion exercises to keep the muscles in the limbs and hands from further atrophying as long as possible.  However, there come a point when Passive Range of Motion exercises no longer delay contractures. 
.

____________

Exercise Blogs

Did you know that not only can taking a brisk walk daily prevent or delay the onset of Alzheimer's and MCI, but aerobic exercise also helps the executive function skills of patients still in the early stages of Alzheimer's, so they are better able to complete their activities for daily living skills?

For additional Web page blogs extolling the benefits of exercise in adults of all ages as well as for school children, click on the following URL links:

Smith, Evelyn E. (2013, November 14). Exercising tips: Exercise for better health. McGregor Memorial Public Library Books and Friends. Retrieved from http://evelynelainesmith.blogspot.com/2013/11/exercising-tips.html

------.  Exercise improves cognitive function in older adults: Delaying or preventing dementia. (2014, March 1). STEM Library Science Blog. Retrieved from http://evelynsmithsstemscienceblog.blogspot.com/2015/03/exercise-improves-cognitive-function-in.html

------. (2013, March 31). How to relieve arthritis: A summary of popular websites: Easing arthritis by weight loss, diet, & exercise. STEM Library Science Blog. Retrieved from http://evelynsmithsstemscienceblog.blogspot.com/2013/03/how-to-relieve-arthritis-summary-of.html

------. (2014, July 27). Lifestyle choices determine the risk of Alzheimer's & Mild Cognitive Impairment: Exercising the mind & body prevents Alzheimer's & MCI. STEM Library Science Blog. Retrieved from http://evelynsmithsstemscienceblog.blogspot.com/2014/07/lifestyle-choices-determine-risk-of.html

------. (2015, March 11). Lifestyle factors influence mortality rates: Lessening the risks of heart disease, stroke, cancer, type 2 diabetes, & Alzheimer's simultaneously through diet and exercise. STEM Library Science Blog. Retrieved from http://evelynsmithsstemscienceblog.blogspot.com/

------. (2013, November 14). Suggestions for living a long healthy life: May you live 100 years. McGregor, Texas, McGinley Memorial Public Library Books and Friends. Retrieved from http://evelynelainesmith.blogspot.com/2013/11/suggestions-for-living-long-healthy-life.html

------. (2014, March 8). Ways to improve your child's grades (3 of 10): Make sure your child participates in aerobic exercise daily: Students who regularly exercise make better grades. McGregor, Texas, McGinley Memorial Public Library Books and Friends. Retrieved from http://evelynelainesmith.blogspot.com/2014/03/ways-to-improve-your-childs-grades-3-of.html

The medical links furnished on this Web page represent the opinions of their authors, so they complement—not substitute—for a physician’s advice.