More than one-third of patients who stayed for 2 weeks or longer in the ICU had a functionally significant joint contracture. On average, these patients each had more than 2 functionally significant joint contractures. The duration of the ICU stay was associated with the presence of any joint contractures at the time of transfer out of intensive care. At 2 weeks, these patients were already experiencing functionally significant joint contractures. Thereafter, relative to patients who stayed in the ICU for just 2 to 3 weeks, the adjusted OR was greater among those who stayed for 5 to 8 weeks and was even higher among those who stayed for 8 weeks or more. Neither sex nor age played a role in the occurrence of any joint contractures in this population. The rate of joint contracture among patients who were admitted to intensive care for a neurologic or vascular disease and among those who received neuromuscular blockade was similar to that of other patients. Conversely, receiving steroids protected against any joint contractures.
One of the most important findings was the potential persistence of joint contractures until the time of discharge home. Our data indicate that joint contractures did not resolve spontaneously before discharge. About one-quarter of the patients were discharged to home with, on average, 2 joint contractures severe enough to interfere with daily activities.8,17,19,21–26
Several previous reports have mentioned persistent functional deficits after immobility.2,5,8,15,16,28,29
Joint contractures have been identified as a potentially important cause of such deficits, but their prevalence and risk factors have not been quantified.13,16
The severity in the restriction of range of motion and the location of a joint contracture determine the patient's functional limitations. Upper limb contractures impair tasks such as showering, dressing, feeding, hand to occiput and hand to perineum;15,26
lower limb contractures affect ambulation5,8,10,28,30
and increase the risk of falls.30
Of the 39% of patients in our study who had any contractures, most (85%) had 1 or more contractures with severity that was considered functionally important. For patients with physical occupations and for athletes in virtually all sports, a loss of even a few degrees of the full range of motion may be detrimental to performance.–25
Contracture at a single joint may induce compensatory strategies. Contractures of multiple joints compound the patient's difficulties in performing activities of daily living and leisure pastimes and impose a burden on health care providers and on family members.5,8
Contractures of normal joints subjected to immobility are theoretically preventable. In this tertiary care ICU, 1.25 full-time physiotherapists and a 0.75 full-time occupational therapist (with assistance from nurses for positioning) were responsible for 24 intensive care beds. However, our data suggest that these usual monitoring and preventive activities were insufficient to prevent the joint contractures.
These data concur with findings of alterations of fibrosis,7
and decreased synoviocyte proliferation32
in the joint capsule of rats, measured as early as 2 weeks after immobilization of a normal joint and continuing for the next 30 weeks. The dose–response relation between exposure to intensive care and development of joint contracture supports immobility as a key pathophysiologic risk factor for joint contractures, without a supplemental contribution from affected neurologic systems. Given that multiple contractures were present, immobility related to multiple local causes (e.g. arterial or venous catheters, restraints, pressure sores) or generalized immobility can be incriminated. Our results are consistent with experimental literature showing that exogenous or endogenous steroid hormones improve the elasticity of periarticular soft tissues.33–35
Our study had limitations. Our range-of-motion data relied on the chart entries of health care professionals with different measuring and charting patterns. We analyzed only quantitative entries; cases with non-numeric, qualitative reporting of contractures and cases with no report of contracture (where contracture might have been present but went unrecorded) were defined as no contracture. This limitation would lead to underestimation of the true incidence of joint contractures. Baseline range of motion was unavailable, so some patients might have had one or more joint contractures before admission to the ICU, which would lead to overestimation of the incidence of contractures. Furthermore, not all directions or all joints were assessed for all patients. Data were not extracted for extension, external rotation, internal rotation or adduction of the shoulder; pronation–supination of the elbow; abduction, adduction, internal rotation or external rotation of the hip; or flexion or inversion–eversion of the ankle. Small joints such as the wrist, temporomandibular joint, and the joints of the hands, fingers, feet, toes and neck were not included in our study. The limited number of range-of-motion directions and the limited number of joints studied would lead to underestimation of the incidence of joint contractures. Finally, the retrospective design did not allow us to question patients to confirm the limitations associated with joint contracture we defined as functionally significant. Rather, we based our definition on authoritative literature involving measurement of functional limitations based on the range of motion of individual joints.
Our findings imply that patients requiring a lengthy stay in the ICU should be monitored and treated to prevent the appearance of joint contractures that could persist long after the patient is sent home. The lack of complete reversibility at discharge to home that we observed suggests that the natural evolution of joint contractures is not benign and that an expectation of spontaneous recovery could lead to increases in disability in this patient population. These data also underscore the difficulty of treating established joint contractures. Usual hospital care and rehabilitation in a large Canadian academic urban centre were insufficient to reverse the contracture process.
Our study suggests that prevention of joint contractures should be considered a central issue for critical care patients, akin to prevention of thromboembolic events and stress ulcers. As a rule, patients are admitted to the ICU because of major organ failure, not as a result of joint problems. However, prolonged immobility of normal joints predisposes critically ill patients to the development of contractures. In our study, many patients who were saved from life-threatening illnesses left the hospital with contractures severe enough to cause functional impairment. Joint contractures acquired in the ICU may lead to substantial costs associated with increased length of stay in hospital; increased need for rehabilitation treatments, outpatient treatments and use of devices for activities of daily living or gait; increased need for personal care at home; and loss of productivity due to inability to return to work.