Vol. 48, No. 4, 442–452
Copyright 2008 by The Gerontological Society of America
Physical Restraint Initiation in Nursing Homes
and Subsequent Resident Health
John Engberg, PhD,1Nicholas G. Castle, PhD,2and
Daniel McCaffrey, PhD1
Purpose: It is widely believed that physical restraint
use causes mental and physical health decline in
nursing home residents. Yet few studies exist showing
an association between restraint initiation and health
decline. In this research, we examined whether
physical restraint initiation is associated with sub-
sequent lower physical or mental health.
and Methods: We used all nursing homes (N=740)
in Pennsylvania in 2001, with 12,820 residents. We
used the Minimum Data Set data; Online Survey,
Certification and Reporting data; and the Area
Resource File as data sources. We restricted our
sample to newly admitted nursing home residents
who were not restrained in the first two quarters of
their residency. We examined which facility and
individual characteristics during those first two
quarters were associated with restraint initiation
during the third quarter. We then examined the
association of third-quarter restraint initiation with
fourth-quarter health outcomes, using regressions that
controlled for first- and second-quarter health status as
well as other resident, facility, and market character-
istics. The physical health outcomes examined con-
sisted of falls, walking dependence, activities of daily
health outcomes examined consisted of cognitive
performance, depression, and behavior problems.
Results: The initiation of restraint use was associated
.01), and the absence of pressure ulcers (p , .10), as
well as a variety of facility characteristics. Subsequent
to restraint initiation, we found an association with
lower cognitive performance (p , .01), lower ADL
performance (p , .01), and higher walking depen-
dence (p , .01).
Implications: We found that an
association between restraint initiation and subse-
quent adverse health consequences exists and is
substantial. Moreover, these results would appear to
have practical as well as statistical significance.
Key Words: Physical restraint, Outcomes,
Health, Nursing homes
A physical restraint is ‘‘a device that is attached ...
and cannot be easily removed by the resident which
restricts freedom of movement and/or normal access
to his/her body’’ (State Operations Manual, 2002,
p. 23). Some believe that these restraints cause
negative health outcomes for nursing home residents.
But in actuality, many of the pernicious effects of
physical restraint use are not well investigated, and
questions exist as to whether adverse effects of re-
straint use exist. Thus, in this study we investigated
the nexus between the use of physical restraints and
the subsequent lower health status of residents.
Understanding whether physical restraints con-
tribute to health problems is important. As others
have pointed out, it is not good clinical practice, or
even ethical, to physically restrain nursing home
residents (Evans & Strumpf, 1989). Consumer
groups such as the National Citizens Coalition for
Nursing Home Reform have been particularly
successful in sensitizing policy makers, the public,
and practitioners about the indiscriminate use of
physical restraints in nursing homes. However, if
restraints are shown to cause physical or mental
health decline, a more powerful rationale for limiting
their use may develop, helping further reduce
restraint use and improving the health and satisfac-
tion of residents. With a concomitant reduction in
residents with health problems, nursing homes may
then better provide services to other impaired
Prior studies have shown that restraint use may be
associated with mental health problems, including
This study was supported in part by a grant from the Agency for
Healthcare Research and Quality, 1 R03 HS013983-01A1 (PI: Castle).
Address correspondence to Nicholas G. Castle, PhD, A610 Crabtree
Hall, 130 DeSoto Street, School of Public Health, University of
Pittsburgh, Pittsburgh, PA 15261. E-mail: CASTLEN@Pitt.edu
1RAND Corporation, Pittsburgh, PA.
2School of Public Health, University of Pittsburgh, PA.
by guest on December 31, 2015
increased social isolation and decreased cognitive
function. Restraint use can create social isolation, as
both other residents and staff avoid restrained resi-
healthof elders (Moret al., 1995). FolmarandWilson
are most likely to be restrained, which further
attenuates their social performance. In addition,
combative residents often become more combative
when restrained (Marks, 1992). Burton, German,
Rovner, and Brant (1992) suggested that restraints
may contribute to cognitive decline. Moseley (1997)
determined that physical restraint use was associated
with increased resident disorientation and walking
Residents are frequently restrained to prevent
them from falling (Capezuti, Evans, Strumpf, &
Maislin, 1996). However, restrained residents still
experience falls. For example, Werner, Cohen-
Mansfield, Braun, and Marx (1989) cited a resident
who fell four times, even though he was restrained
during three of these falls. In an empirical analysis,
Mion, Frengley, Jakoveic, and Marino (1989)
identified more frequent falls (p=.001) in restrained
patients. Tinetti, Wen-Liang, Marottoli, and Ginter
(1991) found serious fall-related injuries in 17% of
restrained residents as compared to 5% of those
who remained unrestrained (significant at p , .001).
In contrast, Ejaz, Folmar, Kaufmann, Rose, and
Goldman (1994) identified a significant increase in
falls after the implementation of a restraint reduction
program. However, a more recent study by Capezuti
and associates (1996) found restraint use to neither
increase nor decrease falls among nursing home
residents. Levine, Marchello, and Totolos (1995) did
not observe any increase in the number of falls (or
injuries) over a 3-year period, even though they
reduced restraint use from 39% to 4%. It is inter-
esting to note that falls are probably the most
researched health consequence associated with phys-
ical restraint use, yet the findings of these studies are
It is also worth noting that federal regulations
mandate that to prevent the damaging side effects of
immobility due to restraint, restrained residents
should be released, exercised, and repositioned every
2 hours (Schnelle, Simmons, & Ory, 1992). How-
ever, Schnelle and colleagues (1992) determined that
facilities often do not follow this mandate. Rather,
they found that facilities with restrained residents
also have poor restraint management practices. Two
other well-known consequences of immobility are
pressure ulcers and contractures. Pressure ulcers
affect both the comfort and the medical outcomes
of nursing home residents with impaired mobility.
Contractures are an abnormal shortening and
stiffening of muscle tissue that can decrease the
range of motion at a joint. This can produce a change
in gait and a decrease in walking velocity—both of
which are major risk factors for falls—and may also
limit mobility in daily life.
Based on these prior studies, we hypothesized that
the initiation of physical restraints would be asso-
ciated with lower subsequent mental and physical
health outcomes. Following these prior studies, we
examined the following mental health outcomes:
cognitive performance, depression, and behavior
issues. Also following these prior studies, we exam-
ined the following physical health outcomes: falls,
activities of daily living (ADLs), pressure ulcers,
contractures, and walking dependence.
These previous studies were mostly observational
and used small sample sizes. The most comprehen-
sive empirical examination in this area comes from
Castle (2006), who, using 2,000 nursing home resi-
dents, found that restraint use was associated with
lower cognitive performance, depression, and social
engagement. However, this study only examined
mental health outcomes (Castle, 2006). In addition,
this study, and all others in this area, used limited
statistical tests that could not account for potential
biases such as the fact that residents who have
already become impaired may be most likely to be
restrained. Some of these studies were done at the
facility level and aggregated nonrepresentative sam-
ples of residents. Other studies did not account for
different sources of resident and facility variation.
Thus, in this analysis we used a large sample size and
took into consideration statistical variation at the
market, facility, and individual level in a regression
model of outcomes. Most important, we used the
longitudinal information on a sample of unrestrained
new residents and investigated the factors that are
associated with restraint initiation and the sub-
sequent health outcomes of individuals who are and
are not restrained.
Three sources of information constituted the pri-
mary project database: Minimum Data Set (MDS)
data; Online Survey, Certification and Reporting
(OSCAR) system data; and the Area Resource File.
The MDS is a summary assessment of nursing
home residents. It was created to measure residents’
functional status, health conditions, services re-
ceived, demographics, and payer source and has
nearly 400 data elements, including cognitive func-
tion, communication/hearing problems, physical
functioning, continence, psychosocial well-being,
mood state, activity and recreation, disease diag-
noses, health conditions, skin conditions, special
treatments, and medication use. All Medicare- and
Medicaid-certified nursing facilities are required to
use the MDS on at least three occasions: (a) on
admission, (b) at least annually, and (c) if the
resident shows ‘‘significant change.’’ In addition, all
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Received May 22, 2007
Accepted September 21, 2007
Decision Editor: William J. McAuley, PhD
452 The Gerontologist
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