ArticleLiterature Review

Review of the Use of Physical Restraints and Lap Belts With Wheelchair Users

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Abstract

Wheelchair-related physical restraints, lap belts, and other alternatives are intended to provide safe and adequate seating and mobility for individuals using wheelchairs. Physical restraints and lap belts are also helpful for positioning people in their wheelchairs to reduce the risk of injury during wheelchair tips and falls. However, when used improperly or in ways other than intended, injury or even death can result. Although widely prescribed, little evidence is available to direct professionals on the appropriate use of these restraints and lap belts and for whom these restraints are indicated. The purpose of this study was to conduct a review of available literature from 1966-2006 to identify the risks and benefits associated with lap belts while seated in wheelchairs. Twenty-five studies that met the inclusion criteria were reviewed. Nine studies reported the frequency of asphyxial deaths caused by physical restraints, nine studies reported the long-term complication and indirect adverse effects of physical restraints and lap-belt use, and seven studies reported the benefits of physical restraints and lap belts with individuals using wheelchairs. Despite the weak evidence, the results suggest a considerable number of deaths from asphyxia caused by the use of physical restraints occurred each year in the U.S. The majority of the deaths occurred in nursing homes, followed by hospitals, and then the home of the person. Most deaths occurred while persons were restrained in wheelchairs or beds. Based on that, caution needs to be exercised when using restraints or positioning belts. In addition, other seating and environment alternatives should be explored prior to using restraints or positioning belts, such as power wheelchair seating options. Positioning belts may reduce risk of falls from wheelchairs and should be given careful consideration, but caution should be exercised if the individual cannot open the latch independently. Also, the duration of use of the physical restraint should be limited. Therefore, several factors should be considered when devising a better quality of physical-restraint services provided by health care professionals. These efforts can lead to improved safety and quality of life for individuals who use wheelchairs.

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... When physical or chemical restraints of residents have been associated with PU development, it is thought to be likely correlated with the residents' inability to move to relieve pressure (Mott, Poole, and Kenrick 2005;Brower 1993). Residents may be restrained physically by belts, vests, and jackets in an effort to protect them from inflicting injury on themselves or others (Ben Natan et al. 2010;Chaves et al. 2007;Brower 1993) and to prevent residents from falling (Bellenger et al. 2017). Highly restrictive restraints have been associated with death from asphyxiation (Chaves et al. 2007), neck compression, and entrapment (Bellenger et al. 2017). ...
... Residents may be restrained physically by belts, vests, and jackets in an effort to protect them from inflicting injury on themselves or others (Ben Natan et al. 2010;Chaves et al. 2007;Brower 1993) and to prevent residents from falling (Bellenger et al. 2017). Highly restrictive restraints have been associated with death from asphyxiation (Chaves et al. 2007), neck compression, and entrapment (Bellenger et al. 2017). The development of PUs in restrained residents in RACFs increases the facility's exposure to legal action (Voss et al. 2005;Toolan et al. 2014;Brower 1993;Tsokos, Heinemann, and Puschel 2000). ...
... In 635 patients with hip fractures in six European countries, 10 per cent had a PU on arrival to hospital, while twice as many, 22 per cent, had a PU on discharge from hospital (Lindholm et al. 2008). Most commonly, PUs develop on the sacrum and heels in bed-bound residents (Rich, Margolis, and Shardell 2011;Exton-Smith and Sherwin 1961) and the ischial tuberosities in wheelchair-bound residents (Chaves et al. 2007;Anthony, Barnes, and Unsworth 1998). ...
Article
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For decades, aged care facility residents at risk of pressure ulcers (PUs) have been repositioned at two-hour intervals, twenty-four-hours-a-day, seven-days-a-week (24/7). Yet, PUs still develop. We used a cross-sectional survey of eighty randomly selected medical records of residents aged ≥ 65 years from eight Australian Residential Aged Care Facilities (RACFs) to determine the number of residents at risk of PUs, the use of two-hourly repositioning, and the presence of PUs in the last week of life. Despite 91 per cent (73/80) of residents identified as being at risk of PUs and repositioned two-hourly 24/7, 34 per cent (25/73) died with one or more PUs. Behaviours of concern were noted in 72 per cent (58/80) of residents of whom 38 per cent (22/58) were restrained. Dementia was diagnosed in 70 per cent (56/80) of residents. The prevalence of behaviours of concern displayed by residents with dementia was significantly greater than by residents without dementia (82 per cent v 50 per cent, p = 0.028). The rate of restraining residents with dementia was similar to the rate in residents without dementia. Two-hourly repositioning failed to prevent PUs in a third of at-risk residents and may breach the rights of all residents who were repositioned two-hourly. Repositioning and restraining may be unlawful. Rather than only repositioning residents two-hourly, we recommend every resident be provided with an alternating pressure air mattress.
... Unstable pelvis invariability limits the comfort and security of wheelchair elements that must be considered to increase safety and comfort. According to the literature (Chaves et al., 2007), the belt should be placed high across the thighs with a downward and slightly backward pull to prevent the pelvis from submarining. In this way, no belt pressure across the abdomen is created. ...
... These assessments were mainly observational or based on interviews and questionnaire with patients, parents or therapists. Furthermore, the assessments are limited to physical variables, EMG activity, number of pathological movements, and qualitative aspects of sitting posture (Chaves et al., 2007;Crane, Holm, Hobson, Cooper, & Reed, 2007;Hatta et al., 2007;Ivancic, Cholewicki, & Radebold, 2002;Lacoste et al., 2009;Reid et al., 1999;Rigby, Reid, Schoger, & Ryan, 2001;Ryan et al., 2005). ...
... Data demonstrated that the presence of the belt influenced the passive stability of the lumbar spine, but not the active stability. In a review study, Chaves et al. (2007) reported that the 4-point belt system seemed to be as effective as a seatbelt when a wheelchair goes straight into a curb or falls straight off a curb, using an instrumented dummy. On the other hand, a seatbelt was shown to be more effective than a 4-point belt when a wheelchair falls diagonally off a curb because of the produced lower extension forces at the upper neck and the moments at the lower neck bellow injury level. ...
Article
Maintenance of stability for children in a wheelchair, particularly for those with spasticity, can be achieved through external stabilization components, such as pelvic positioning belts. Different kinds of pelvic belts exist on the market and one of the main characteristics is the different number of attachment points between the seat and the belt. As literature on this topic is limited to qualitative assessments, this study compared quantitatively 4-point versus 2-point pelvic positioning belts for the trunk fixation in 20 young patients with spasticity. Our data showed that 70% of the children required the use of pelvic belts on wheelchairs for stability and a better stability was observed with the 4-point belts than compared to the 2-point. Data generally showed in fact a higher percent of variation in terms of trunk flexion angleand knee joint angle with the 2-point belt than the 4-point belt, indicating increased submarining with the 2-point belt during sitting maintenance if compared to the 4-point belt (p < 0.05). According to our results, the 4-point belts seem to be the most effective configuration for patient stabilization, suggesting that its use prevents the thigh from submarining.
... Six reviews evaluated devices for personal mobility (Table 5). Two reviews had minor [13,86] methodolog-ical limitations, three moderate [19,82,83], and one major [33]. ...
... Two reviews evaluated the harms and benefits associated with lap belts and other restraints for wheelchair users [19,33], and included observational studies of persons in hospitals or residential care using restraints or test dummies. The studies revealed a considerable number of deaths from asphyxia, a risk of prolonged hospitalization, loss of muscle strength causing weakness, and difficulty in standing or sitting. ...
... Evans et al. [33] recommends using only minimal restraint levels for minimal duration as a last resort with close monitoring. The benefit is that the restraints may be helpful in positioning people into their wheelchairs to reduce falls or injuries when designed as an integral part of the wheelchair safety system [19]. Thus we conclude that despite the low-quality of evidence, there are major risks associated with the use of restraints, and these risks may outweigh the possible benefits. ...
Article
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This overview summarizes the available evidence from systematic reviews of outcomes studies on various assistive technologies (AT) for persons with disabilities. Systematic reviews published between January 2000 and April 2010 were identified by comprehensive literature searches. Study selection, data extraction and methodological quality evaluation were done by two authors independently. The quality of evidence was summarized by explicit methods. Types of disabilities, settings, and AT interventions were recorded. Outcomes were mapped according to the Taxonomy of Assistive Technology Device Outcomes. Forty-four systematic reviews were included in this overview. High-quality evidence was found in single AT (positive effects of providing AT in connection with home assessment and hearing aids, no effects of hip protectors ) for limited populations (older people at home, people with hearing loss, and older people in institutional care, respectively). Low-quality or unclear evidence was found for the effectiveness of the other evaluated AT interventions. Current gaps in AT outcomes research were identified. Many frequently used devices have not been systematically reviewed. Well-designed outcomes research to inform clinical decision-making is urgently needed. The systematic review methodology seems to be feasible for summarising AT outcomes research, but methodological development for grading and for primary studies is warranted.
... However, the authors note that this was contradicted by the number of deaths reported in other studies included in their review as a result of physical RPs use. In a review of the risks and benefits of lap-belt use, Chaves et al. (2007) identified studies that reported adverse outcomes ranging from loss of muscle strength or death by asphyxiation. However, the authors cautioned that the quality of the evidence was weak. ...
... The data reported herein reflect the use of all RPs types in all registered disability RCFs in Ireland. Other reviews and studies have focussed on one type of RPs (Chaves et al., 2007;Deveau & McGill, 2009;Lundström et al., 2011) or on a specific region (Deveau & McGill, 2009;Webber et al., 2010) or on a particular disability type (Lundström et al., 2011). The regulatory framework in Ireland requires that service providers only use RPs after all alternatives have been considered and that the RPs used is the least restrictive and used for the shortest duration. ...
Article
Restrictive practices (RPs) are a contentious issue in health and social care services. While use may be warranted in some instances, there are risks and concerns around human rights infringements. There are limited data available on the types and incidences of RPs used in health and social care services internationally. The objective of this study is to describe the type of RPs and incidence of use in disability residential care facilities (RCFs) in Ireland. RP notifications from disability RCFs reported from November 2019 to October 2020 were extracted from the Database of Statutory Notifications from Social Care in Ireland. National frequency and incidence of use of categories and type of RPs were calculated. The number and percentage of disability RCFs reporting RP use, along with the mean annual incidence of use, were also calculated. A total of 48,877 uses of RPs were notified from 1387 disability RCFs (9487 beds) during the 12-month period. The national incidence of RPs use per 1000 beds was as follows: all categories: 5152.0, environmental: 2988.2, physical: 1403.0, other: 527.0 and chemical: 233.8. The most frequently used RPs for each category was as follows: environmental: door locks, physical: other physical, other: liberty and autonomy and chemical: anxiolytics. Most RCFs (81.7%) reported at least one RPs use. The median incidence of any RPs per 1000 beds in these RCFs was 4.75 (IQR: 2.00 to 51.66). Usage of RPs was generally low, although some RCFs reported relatively high usage. Nationally, on average, five RPs were applied per resident over 12 months; environmental contributing to more than half. These findings can be used to inform policy, measure progress in reducing RPs use and for cross-jurisdiction comparisons.
... A comprehensive literature review on safety restraint and securement systems for people using mobility devices on public transport has been conducted [18]. Although an updated review in this area is now timely, the topic of wheelchair tiedown and occupant restraint systems (WTORS) was beyond the scope of the current review. ...
... quality ratings for each study as described below. As transport access for people using mobility devices includes the whole journey, the studies were also reviewed to identify environmental and person-related access barriers for the four typical segments of a journey which were determined a-priori and consistent with literature in this field [12,18]: 1) travelling to or from a public transport stop (bus stop, train station, tram stop or taxi stand); 2) waiting at the stop; 3) boarding and alighting public transport; and 4) moving within a public transport conveyance to the allocated space. Table 2 was developed to summarise information from the studies that identified access barriers across these segments of a journey, and it was also identified that this would be a logical approach to organise the Discussion section of the review. ...
Article
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Purpose: Being able to access public transport is vital for mobility device users as this is an affordable way of maintaining community connections and participating in activities that promote quality of life. This systematic review investigated literature on public transport access for people using mobility devices, excluding transit restraint and securement literature. Materials and methods: A systematic review of the peer-reviewed literature in English from 1995 to 2019, with critical appraisal and narrative synthesis. Results: Twenty-six articles were identified, including 14 studies investigating user experiences, seven examining bus formats and floor layouts, and five focusing on bus ramp incidents and optimal design. Studies were generally observational and descriptive, with 12 including analysis of video data. Conclusion: This is the first systematic review of literature related to the accessibility of public transport for people using mobility devices. Topics such as ramp access have been relatively well-researched, as have the experiences of users. However, many gaps remain and there is a need for research to; address the barriers identified through user experiences, discern the best access to stations and stops, as well as floor formats for people to ingress, manoeuvre and egress from a variety of transport modes, and promote universal design principles in the transport sector. Rehabilitation professionals can use the findings of this review to advocate for, and support people using mobility devices to successfully negotiate public transport. • Implications for Rehabilitation • Accessible public transport is vital to enable people using mobility devices to remain connected in their communities. • Despite increased international awareness and adoption of accessibility features by the public transport sector to improve getting to a stop, ingress, manoeuvrability within and egress from conveyances, access for people using wheeled mobility devices cannot be assumed. • When prescribing new wheeled mobility devices with clients, rehabilitation professionals and users need to consider public transport access and the suitability of different devices for this purpose. • Rehabilitation professionals can undertake skills training with people using wheeled mobility devices to test out access prior to independent travel on public transport and develop strategies to overcome any barriers.
... Because these patients spend a considerable amount of time per day in a wheelchair, it is important that they are able to correctly sit on the wheelchair without adverse effects that may originate from a poor sitting posture. Typical adverse effects of improper sitting are sensation of discomfort, development of muscular pain, development of back or shoulder injuries and related pain, and pressure ulcers [7]. Additionally, in severe patients there is a risk of falling out of the wheelchair. ...
... -Manual re-positioning by nurses, based on observation of posture -Restraints, such as belts, mainly to prevent falling out of wheelchair -Specifically designed cushions and pillows, for example a 'pommel cushion', to correct sitting posture -Table mounted on wheelchair that supports the arms In some cases, specific high-end backward-tilting wheelchairs are being used [2] [7]. ...
Article
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Purpose: We present a novel wheelchair posture support device (WPSD) and its clinical validation. The device was developed in order to assure correct sitting posture and to reduce the time spent by caregivers for re-positioning of hospitalized, wheelchair-bound, post-acute stroke patients. Method: The device was validated with 16 subjects during a period of 5 days in which use of the device was compared with regular care practice. Results: The device was used for the five consecutive days in 69% of patients, while for 6% it was not suitable; 25% did not complete the 5 days for reasons unrelated to the device. Caregivers needed to re-position the patients that used the device for the full 5 days (n = 11) on an average 52% less often when using the device, as compared to regular practice. Furthermore, the device was rated as usable and functional by the caregivers while significantly reducing perception of trunk and shoulder pain in patients during its use. Conclusions: The newly designed WPSD is a valuable system for the improvement of medical assistance to wheelchair-bound post-stroke patients by reducing pain and number of re-positioning manoeuvres. The WPSD might be applicable to any group of patients who need posture control in either wheelchair or common chair with arms support. IMPLICATIONS FOR REHABILITATION Advanced supports and cushions that can be shaped to individual needs, may help assure correct sitting posture in wheelchair-bound post-acute stroke patients. Advanced supports and cushions that can be shaped to individual needs, may reduce the number of times a caregiver has to re-position a hospitalized wheelchair-bound post-acute stroke patient on overall average by 52%. Advanced personalized supports and cushions may improve sitting comfort and reduce pain complaints for post-acute hospitalized stroke patients using a wheelchair.
... This makes it more difficult to design a fall protection solution compared to a restrained passenger. While seat belts provide no observable downside for fall protection, there are usage barriers, complications from use, and stigmas on belt discomfort and appearance that prevent unanimous acceptance [30]. Belt use in wheelchair users can be fatal if the rider slips under the belt resulting in asphyxiation [31,32]. ...
... Importantly a seat belt used for safety can become a physical restraint for riders who are unable to open the latch independently. This can result in significant stress for patients and care providers and is considered unethical and potentially illegal [30,33]. Practical implementations of restraint systems need to address these issues so that the entire rider community benefits from the potential for reduced or avoided head trauma. ...
Article
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Background To reduce the occurrence of wheelchair falls and to develop effective protection systems, we aimed to quantify sideways tip and fall dynamics of electric power wheelchairs (EPWs). We hypothesized that driving speed, curb height and angle of approach would affect impact forces and head injury risk for wheelchair riders. We further expected that fall dynamics and head injury risk would be greater for unrestrained riders compared to restrained riders. Methods Sideways wheelchair tip and fall dynamics were reconstructed using a remotely operated rear wheel drive EPW and a Hybrid III test dummy driving at different approach angles (5 to 63°) over an adjustable height curb (0.30 to 0.41 m) at speeds of 0.6–1.5 m/s. Rigid body dynamics models (Madymo, TASS International, Livonia, MI) were developed in parallel with the experiments to systematically study and quantify the impact forces and the sideways tip or fall of an EPW user in different driving conditions. Results Shallower approach angles (25°) (p < 0.05) and higher curbs (0.4 m) (p < 0.05) were the most significant predictors of tipping for restrained passengers. Unrestrained passengers were most affected by higher curbs (0.4 m) (p < 0.005) and fell forward from the upright wheelchair when the approach angle was 60°. Head impact forces were greater in unrestrained users (6181 ± 2372 N) than restrained users (1336 ± 827 N) (p = 0.00053). Unrestrained users had significantly greater head impact severities than restrained users (HIC = 610 ± 634 vs HIC = 29 ± 38, p = 0.00013) and several tip events resulted in HICs > 1000 (severe head injury) in unrestrained users. Conclusions Sideways tips and forward falls from wheelchairs were most sensitive to curb height and approach angle but were not affected by driving speed. Sideways tips and falls resulted in impact forces that could result in concussions or traumatic brain injury and require injury prevention strategies. Seat belts eliminated the risk of falling from an upright chair and reduced head impact forces in sideways wheelchair tips in this study; however, their use must be considered within the ethical and legal definitions of restraints.
... Gran parte de los percances ocurrieron en personas que sufrían trastornos cognitivos, agitación y alteraciones del sueño [35][36][37][38][39] . A pesar de la elevada prevalencia de uso de restricciones en este colectivo, son numerosos los trabajos que previenen de sus riesgos 11,12,40 . ...
... Una alternativa son los cinturones con velcro, los cuales ayudan a posicionar al paciente al tiempo que pueden ser desabrochados con facilidad. La inclinación hacia atrás del respaldo de la silla también evita el deslizamiento de la persona y, por tanto, la necesidad de utilizar este tipo de restricción 37 . ...
Article
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The use of physical restraint devices on frail elderly could have significant negative consequences on their health. Apart from complications due to prolonged immobility, the use of this procedure is associated with other serious adverse effects which occur when a person is restricted in a position which carries a risk of asphyxiation. The devices most implicated in these incidents are bedrails, vests and restraining belts. Physical restraint could also be associated as much with the sudden death of patients, due to the stress that it causes, as with injuries from falling. This article presents the recommendations which experts, manufacturers and institutions dealing with the quality of health care have issued for the safest use of this procedure. It stresses the need for better training of professionals, as well as the importance of investigating the factors which can lead to accidents with the aim of preventing them.
... For some, keeping an upright posture is a challenging task, due to weakness of the core muscle groups in the body, and this usually results in them slouching forward when seated (Williams, 2005;Fonad, Wahlin, Winblad, Emami, & Sandmark, 2008b). To prevent wheelchair fall incidents, wheelchair accessories (footplates and side arms, lap belts, and detachable trays) and physical restraining measures have traditionally been implemented (Chaves, Cooper, Collins, Karmarkar, & Cooper, 2007;Fonad, Burnard, & Emami, 2008a). However, since the passage of the Care Standards Act of 2000 in the United Kingdom (Great Britain, 2000), attitudes toward their use have changed. ...
... Unfortunately, many NHs are unable to meet most individualized wheelchair needs of their residents due to lack of resources; as such they adopt a "one-size-fits-all" approach (often the standard sling-back and sling-seat wheelchair or geri-chair), with no major customization to improve comfort other than a seat cushion (Bourbonniere, Fawcett, Miller, Garden, & Mortenson, 2007). Secondly, arguments that the use of restraints on patients do not preserve their rights, dignity, and physical and emotional well-being have encouraged many facilities to implement "no restraining" care policies (Chaves et al., 2007;Paterson et al., 2003). Such policies tend to compromise safety by encouraging care staff to make decisions about safety based on traditional and/or personal experience rather than scientific evidence Downloaded by [Health & Safety Executive], [Olanrewaju O. Okunribido] at 07:40 01 February 2013 (Nelson & Baptiste, 2006); they also tend to discourage the use of wheelchair accessories (footplates and seat/lap belts), when residents are moved around in assistant propelled wheelchairs (APW) by care staff (Okunribido & Edgar, 2011). ...
Article
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This article is a report of a study of the effect of the seat cushion on risk of falling from a wheelchair. Two laboratory studies and simulated assistant propelled wheelchair transfers were conducted with four healthy female participants. For the laboratory studies there were three independent variables: trunk posture (upright/flexed forward), seat cushion (flat polyurethane/propad low profile), and feet condition (dangling/supported), and two dependent variables: occupied wheelchair (wheelchair) center of gravity (CG), and stability. For the simulated transfers there was one independent variable: seat cushion (flat polyurethane/propad low profile), and one dependent variable: perception of safety (risk of falling). Results showed that the wheelchair CG was closer to the front wheels, and stability lower for the propad low profile cushion compared to the polyurethane cushion, when the participants sat with their feet dangling. During the simulated transfers, sitting on the propad low profile cushion caused participants to feel more apprehensive (anxious or uneasy) compared to sitting on the polyurethane cushion. The findings can contribute to the assessment of risk and care planning of non-ambulatory wheelchair users.
... Gran parte de los percances ocurrieron en personas que sufrían trastornos cognitivos, agitación y alteraciones del sueño [35][36][37][38][39] . A pesar de la elevada prevalencia de uso de restricciones en este colectivo, son numerosos los trabajos que previenen de sus riesgos 11,12,40 . ...
... Una alternativa son los cinturones con velcro, los cuales ayudan a posicionar al paciente al tiempo que pueden ser desabrochados con facilidad. La inclinación hacia atrás del respaldo de la silla también evita el deslizamiento de la persona y, por tanto, la necesidad de utilizar este tipo de restricción 37 . ...
Article
Full-text available
The use of physical restraint devices on frail elderly could have significant negative consequences on their health. Apart from complications due to prolonged immobility, the use of this procedure is associated with other serious adverse effects which occur when a person is restricted in a position which carries a risk of asphyxiation. The devices most implicated in these incidents are bedrails, vests and restraining belts. Physical restraint could also be associated as much with the sudden death of patients, due to the stress that it causes, as with injuries from falling. This article presents the recommendations which experts, manufacturers and institutions dealing with the quality of health care have issued for the safest use of this procedure. It stresses the need for better training of professionals, as well as the importance of investigating the factors which can lead to accidents with the aim of preventing them. Copyright © 2010 SEGG. Published by Elsevier Espana. All rights reserved.
... To our knowledge, this is the first study examining the acceptance of LVAs in a Greek population with LV investigating also possible factors affecting the decision-making process to choose such an assistive device at baseline. There is a lack of awareness among eye care practitioners about LV rehabilitation [9,[47][48][49][50], and studies investigating the patients' perspectives using individualized approaches are few. Thus, it is important to investigate such parameters so that clinicians can develop strategies to improve compliance with the use of the LVAs. ...
Article
The aim of this study is to investigate the compliance with low-vision aids (LVAs) among patients with low vision (LV) in a Greek population. An explorative study was conducted in a sample of patients with LV attending our outpatient unit at the School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece. Patients' demographics and daily visual demands were recorded, and they were administered with the National Eye Institute Visual Function Questionnaire-25 (VFQ-25) at baseline. Participants were trained in the use of a wide range of LVAs before their prescription. Evaluation of the use of the LVAs was conducted at one year after the baseline using a structured phone survey. A total of 100 LV patients were included, with 68% of them being older than 65 years and 50 being males. The main cause of LV (57.0%) was age-related macular degeneration, and the mean VFQ-25 score at baseline was 49.2 (SD= 17.8). Overall, 75 patients had been prescribed LVAs, with 76.0% of these patients preferring an optical aid. The vast majority (98.7%) of these patients stated using the LVA one year after the baseline, and 62.1% of them reported using the aid often to very often. Significantly, 76% of these patients reported that their quality of life was positively affected by the use of the aid, and 97.3% would recommend the use of LVA to another individual with the same problem. Providing appropriate training before the prescription is of high significance to improve the rate of compliance with the use of LVAs. These results can be used to develop appropriate strategies in this field.
... However, physical restraint can be harmful if patients are vigorous and struggling, increasing falls, fracture rate and the possibility of death [7]. A literature review from reported that several cases of deaths occurred as a direct or indirect result of physical restraint, such as asphyxia [8]. Physical restraint can worsen a patient's incontinence due to immobility [9]. ...
Article
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Background In Taiwan, physical restraint is commonly used in institutions to protect residents from falling or injury. However, physical restraint should be used cautiously to avoid side effects, such as worse cognition, mobility, depression, and even death. Objectives To identify the rate of physical restraint and the associated risk factors in institutionalized residents in Taiwan. Methods A community-based epidemiological survey was conducted from July 2019 to February 2020 across 266 residential institutions. Among the estimated 6,549 residents being surveyed, a total of 5,752 finished the study. The questionnaires were completed by residents, his/her family or social workers. The cognition tests were conducted by specialists and a multilevel analysis approach was used to identify cognition/disability/medical history/special nursing care/BPSD risk factors for physical restraints. Results Of the 5,752 included institutionalized residents, 30.2% (1,737) had been previously restrained. Older age, lower education level, lower cognitive function, higher dependence, residents with cerebrovascular disease, pulmonary disease, dementia, and intractable epilepsy, all contributed to a higher physical restraint rate, while orthopedic disease and spinal cord injury were associated with a lower physical restraint rate. Furthermore, residents with special nursing care had a higher restraint rate. Residents with most of the behavior and psychological symptoms were also associated with an increased restraint rate. Conclusions We studied the rate of physical restraint and associated risk factors in institutionalized residents in Taiwan. The benefits and risks of physical restraint should be evaluated before application, and adjusted according to different clinical situations.
... 13,14 Open communication among members of the interdisciplinary care team, access to advanced care clinicians, and correct application and positioning and frequent monitoring of lap-belts would be imperative to ensure that the lap-belts are used as intended, thus minimizing or preventing physical harms such as asphyxiation, increased agitation, or discomfort. 15 If, at any point, the burden of the lap-belt outweighed its benefit, it could be discontinued. As patients with TBI would be engaging in activities that require supervision, such as moving around the hospital in a wheelchair or engaging in group activities, health care professionals would be readily available to identify if the lap-belt needs to be removed. ...
Article
Due to restraints' consequences for personal liberty and dignity, the threshold to apply restraints is understandably high and heavily regulated. However, there can be clinical scenarios in which restraint use can facilitate a patient's freedom. This article considers such a case and examines conditions under which using restraints offers therapeutic benefit for patients with traumatic brain injuries.
... The purpose of this study was to examine literature (see Bragança et al., 2020;Chaves et al., 2007;Schofield et al., 2013;Stinson et al., 2013) and explore wheelchair users' perceptions and usage of assistive technological features on their wheelchairs. The results suggest some implications that may improve the processes surrounding wheelchair prescription, fitting, and advice provided to users. ...
... The purpose of this study was to examine literature (see Bragança et al., 2020;Chaves et al., 2007;Schofield et al., 2013;Stinson et al., 2013) and explore wheelchair users' perceptions and usage of assistive technological features on their wheelchairs. The results suggest some implications that may improve the processes surrounding wheelchair prescription, fitting, and advice provided to users. ...
... 3 Seatbelts or straps can also secure the rider when sudden stops or impacts occur, however many users reject such restraints due to the difficulties of donning and doffing, the restrictions they place on stationary trunk movements, and their potential contribution to more severe complications including pressure ulcers, skin breakdowns, and asphyxiation. 9,10 Transitioning to a power wheelchair may help since they offer a wider availability of seating configurations, however doing so can limit accessibility, incur the social stigma of using a device that implies a more severe disability 11 and still may be susceptible to injurious falls in some situations. 12 A large percentage of manual wheelchair users consists of individuals with spinal cord injury (SCI). ...
Article
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Objective: Wheelchair safety is of great importance since falls from wheelchairs are prevalent and often have devastating consequences. We developed an automatic system to detect destabilizing events during wheelchair propulsion under real-world conditions and trigger neural stimulation to stiffen the trunk to maintain seated postures of users with paralysis. Design: Cross-over intervention Setting: Laboratory and community settings Participants: Three able-bodied subjects and three individuals with SCI with previously implanted neurostimulation systems Interventions: An algorithm to detect wheelchair sudden stops was developed. This was used to randomly trigger trunk extensor stimulation during sudden stops events Outcome Measures: Algorithm success and false positive rates were determined. SCI users rated each condition on a seven-point Usability Rating Scale to indicate safety. Results: The system detected sudden stops with a success rate of over 93% in community settings. When used to trigger trunk neurostimulation to ensure stability, the implant recipients consistently reported feeling safer (P<.05 for 2/3 subjects) with the system while encountering sudden stops as indicated by a 1–3 point change in safety rating. Conclusion: These preliminary results suggest that this system could monitor wheelchair activity and only apply stabilizing neurostimulation when appropriate to maintain posture. Larger scale, unsupervised and longer-term trials at home and in the community are indicated. This system could be generalized and applied to individuals without an implanted stimulation by utilizing surface stimulation, or by actuating a mechanical restraint when necessary, thus allowing unrestricted trunk movements and only restraining the user when necessary to ensure safety. Trial Registration: NCT01474148
... Although PR is used to ensure patient safety, there is limited evidence concerning its effectiveness [25]. Studies show that PR can endanger patient safety and cause different physical and mental complications. ...
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Background: Using physical restraint (PR) for hospitalized elderly people is a major nursing challenge. It is associated with different physical and mental complications and ethical dilemmas, though many nurses still use it to ensure patient safety. Nurses' perceptions are one of the most important factors affecting PR use. This study aimed to evaluate Iranian nurses' perceptions about PR use for hospitalized elderly people. Methods: This cross-sectional descriptive-correlational study was conducted from July to December 2019. Participants were 270 hospital nurses who were purposively recruited from intensive care units and medical and surgical wards of three teaching hospitals in Kermanshah, Iran. Data were collected using a demographic questionnaire and the Perceptions of Restraint Use Questionnaire (PRUQ). The SPSS software (v. 23.0) was used for data analysis through the independent-sample t test, the one-way analysis of variance, and the multiple regression analysis. Results: The total mean score of PRUQ was 4.08 ± 0.12 in the possible range of 1-5. The most important reasons for PR use were to prevent patients from falling out of bed and to prevent them from pulling out catheters. The total mean score of PRUQ had significant relationship with participants' age, work experience, and history of receiving PR-related educations (P < 0.05), but had no significant relationship with their gender, educational degree, and affiliated hospital ward (P > 0.05). Conclusion: This study suggests that nurses attach high importance to PR use for hospitalized elderly people. Healthcare policy-makers at national and hospital levels are recommended to provide nurses with PR-related educations in order to reduce the rate of PR-related complications.
... Along these lines, Overbury et al. [45] found that success with low vision aids was positively associated with present need for activities requiring vision. When the assistive technology was well integrated into the users' own life, device users felt grateful, and when they considered the device as a physical extension of themselves, the acceptance was described as internal [46]. Surprisingly, 23% of the general low vision aids prescribed were found useful at home [40]. ...
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Background: The decision process around the (non-)use of assistive technologies is multifactorial. Its determinants have previously been classified into personal, device-related, environmental and interventional categories. Whether these categories specifically apply to the use of magnifying low vision aids was explored here, using this classification. Methods: A scoping review (Embase, MedLine, Cochrane, ERIC ProQuest, CINAHL, NICE Evidence, Trip Database) was conducted to summarize the extent, range, and nature of research regarding the categories that are associated with low vision aid (non-)usage. A combination of key words and MeSH terms was used based upon the identified core concepts of the research question: low vision, assistive technology and adherence. Inter-rater reliability for the selection process was considered acceptable (kappa = 0.87). A combination of numerical and qualitative description of 21 studies were performed. Results: Studies report high variability rates of people possessing devices but not using them (range: 2.3–50%, M = 25%, SD = 14%). We were able to replicate the conceptual structure of the four categories that had previsouly been identified with other devices. Age, diagnosis and visual acuity demonstrated contradictory influence on optical low vision aids usage. Change in vision, appropriate environment, consistent training, patient’s motivation and awareness of low vision services, emerged as contributor factors of use. Conclusion: This review provides evidence that clinicians should not rely on traditionally available clinical factors to predict device use behavior. Worsening vision and low motivation appear as predictors of device nonuse and should be considered from the clinician's point of view. Education about potential facilitating factors and promotion of innovative care are strongly encouraged. • Implications for rehabilitation • Investigation of the factors predicting (non-)use of magnifying low vision aids is important. These findings can help clinicians to identify patients with a higher risk of non-use of low vision aids as well as provide evidence for interventions designed to improve use. • Knowledge of low vision services and types of magnifying low vision aids available to patients appears as fundamental in the process of device use and needs to be supported by more educational programs. • Psychological factors predicting (non-)use of low vision aids need to be considered in the choice of rehabilitation and follow-up strategies by a multidisciplinary team, focusing more in mechanisms of adaptation and patient’s motivation. • Training intensity should play a central role in the development of innovative intervention programs to reduce device abandonment.
... Current methods to maintain trunk stability for manual wheelchair users with SCI include seat belts to keep the trunk from falling forward, seat cushioning systems to decrease the exaggerated posterior pelvic tilt that results from paralysis of the hips and trunk, increased seat dump to take advantage of gravity in a backwards leaning posture, or supports to limit lateral motions of the trunk. These methods have many disadvantages, including reduced work volumes and impaired ability to reach and manipulate objects due to the external constraints, as well as pressure ulcers, skin tears, lowered self-esteem and even asphyxiation [11]. Non-compliance with such strategies is high since they also restrict desired motions and interfere with functional tasks while the wheelchair is not moving [12]. ...
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Background: The leading cause of injury for manual wheelchair users are tips and falls caused by unexpected destabilizing events encountered during everyday activities. The purpose of this study was to determine the feasibility of automatically restoring seated stability to manual wheelchair users with spinal cord injury (SCI) via a threshold-based system to activate the hip and trunk muscles with electrical stimulation during potentially destabilizing events. Methods: We detected and classified potentially destabilizing sudden stops and turns with a wheelchair-mounted wireless inertial measurement unit (IMU), and then applied neural stimulation to activate the appropriate muscles to resist trunk movement and restore seated stability. After modeling and preliminary testing to determine the appropriate inertial signatures to discriminate between events and reliably trigger stimulation, the system was implemented and evaluated in real-time on manual wheelchair users with SCI. Three participants completed simulated collision events and four participants completed simulated rapid turns. Data were analyzed as a series of individual case studies with subjects acting as their own controls with and without the system active. Results: The controller achieved 93% accuracy in detecting collisions and right turns, and 100% accuracy in left turn detection. Two of the three subjects who participated in collision testing with stimulation experienced significantly decreased maximum anterior-posterior trunk angles (p < 0.05). Similar results were obtained with implanted and surface stimulation systems. Conclusions: This study demonstrates the feasibility of a neural stimulation control system based on simple inertial measurements to improve trunk stability and overall safety of people with spinal cord injuries during manual wheelchair propulsion. Further studies are required to determine clinical utility in real world situations and generalizability to the broader SCI or other population of manual or powered wheelchair users. Trial registration: ClinicalTrials.gov Identifier NCT01474148 . Registered 11/08/2011 retrospectively registered.
... Restraints may be considered with individuals who have poor judgment but should be avoided whenever possible and be regarded separately from seating postural needs. Restraint reduction efforts in long-term care facilities may be enhanced by use of appropriate and comfortable seating, and with risks associated with wheelchair seating restraints, planning for client's control of releasing belts and straps should considered (Chaves et al., 2007). ...
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After studying this chapter, the reader will be able to do the following: 1. Describe the factors that should be considered in wheelchair selection and explain how they interrelate. 2. Describe the three basic types of wheelchairs and reasons for each to be chosen. 3. Specify measurements typically taken to determine wheelchair and related seating system configurations for a particular individual. 4. Demonstrate knowledge of the components common to many wheelchairs, and describe why each merits consideration in wheelchair selection. 5. Discuss the roles and responsibilities of the occupational therapist in wheelchair selection. 6. Suggest how the occupational therapist can acknowledge user preferences and facilitate the user's participation in wheelchair selection. Wheelchair Selection Radomski_Chapter17.indd 498 7/11/13 2:39 AM
... human activities; patient positioning; personal autonomy; residential facilities; self concept; wheelchairs Most residents in long-term care depend on wheelchairs for mobility (Shields, 2004), but there are many issues with their use. In many facilities, residents are provided with facility chairs that are not set up to allow independent propulsion or are not fitted to the user's size (Chaves, Cooper, Collins, Karmarkar, & Cooper, 2007;Karmarkar et al., 2012). Users in these settings commonly experience poor posture, discomfort, and impaired mobility (Fuchs & Gromak, 2003;Shaw & Taylor, 1991). ...
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Tilt-in-space (TIS) wheelchairs are common in residential care, but little empirical evidence exists regarding how they are used by residents and staff in these settings. As part of a larger study exploring the use of wheeled mobility in these facilities, we conducted a substudy to examine how TIS wheelchairs are used in practice and to explore the experiences of the residents who use them. We conducted a series of three participant observations and interviews with 6 residents or their family members and interviewed 10 staff. Our analysis identified taking control as the main overarching theme, subsuming two subthemes: promoting comfort and mobilizing to participate. Findings suggest that power TIS wheelchairs enable user control, whereas manual TIS wheelchairs promote staff control. These findings illustrate how TIS wheelchairs may enable or inhibit occupational engagement and suggest that vigilance is necessary to prevent their use as a restraint. Copyright © 2015 by the American Occupational Therapy Association, Inc.
... The figures included deaths that occurred at home, with most deaths happening while people were restrained in wheelchairs or in bed. 14 Other adverse effects have also been reported, such as depression, aggression, and general feelings of discomfort, for instance, absence of privacy, freedom, and independence, 5 as well as deterioration in social behavior. 11,12 Even the use of side rails has not been proven to decrease fall occurrence. ...
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To gain more knowledge of the application of physical restraints to restrict, restrain, or prevent movement by elderly people living at home. Survey. Nursing staff in Dutch home care. One hundred fifty-seven nursing staff in home care (registered nurses and certified nursing assistants) from a randomly selected and nationally representative panel returned the questionnaire (response rate 72%). A structured questionnaire on the use of physical restraints. Four of every five nursing staff members have applied physical restraints. The use of bed rails, putting the client in a deep chair or using a chair with a table, and locking doors to prevent wandering were most frequently applied, often at the request of the client or his or her family. Protection of the client is the reason most frequently given for these actions. Almost all respondents (94%) know of no alternatives, nor does consensus exist on what is considered to be a physical restraint. Guidelines are necessary regarding the course of action to be taken when a client is in danger of hurting him- or herself. Further education on and due consideration of the use of physical restraints in home care are also required.
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Access to transport is key to people’s movement in cities, their social participation, and personal development. People with mobility disabilities (PMDs) face additional barriers when using public transport. The objective of this study is to identify the dilemmas that PMDs face in their daily mobility practices and their coping strategies, in particular the ways in which these dilemmas and strategies are influenced by both personal and environmental characteristics. We conducted ethnographic research, utilizing narrative interviews, life stories, focus groups, and participant observations. Our aim was to analyse multiple experiences of mobility in situations of disability in Quebec City, Canada. This study engages the following research question: how do PMDs navigate their social environment, considering the impact of personal, social, and physical landscape factors on their mobility strategies? Depending on the accessibility of fixed-route public buses and the availability of public paratransit services, what are the dilemmas that PMDs face and how do they shape their mobility strategies? Using the three-dimensional model of narrative analysis, we present a narrative ethnography of participants’ dilemmas and strategies about their experiences on public transport. Five dilemmas are examined. Through this methodology, we propose to extend the study of “constellations of mobility” by including the notion of strategies as an experiential outcome between personal and physical landscape factors, practices, and meanings of mobility. This offers new research perspectives both in disability and mobility studies and in the understanding of urban accessibility experiences in situations of disability.
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Purpose: To investigate abandonment rates of near-vision low vision devices (LVDs) and factors that influence abandonment among patients attending a tertiary low vision rehabilitation centre in South India. Methods: Two hundred and eighty-six adults with low vision completed the modified device abandonment survey 1 year following device prescription. The survey included six questions: possession of device, timing of last use, reasons for abandonment, tasks for which the device was used, payment type and change in quality of life (QoL) from device use. The primary outcome measure was abandonment. Multivariate logistic regression analysis was used to investigate factors for abandonment. Results: Three hundred and twelve near-vision devices were prescribed (mean, 1.09 device per patient.) Stand magnifiers (35%) followed by hand-held magnifiers (24%) were most frequently prescribed. Mean logMAR visual acuity (Snellen) in the better-seeing eye was 0.80 (6/38). Of the prescribed near-vision devices, 22% (95% CI, 17 to 27) were abandoned. Patients who abandoned the device were significantly older than those who did not (49.3 ± 17.2 vs. 43.5 ± 18.1 years; p = 0.03). In multivariable analysis, patients reporting no change in their QoL from device use had higher odds of abandoning the device (OR: 63.97; 95% CI, 23.77 to 172.12). Device-related (31%) and psychological (30%) factors were the most frequent reasons for abandonment. Among device-related issues, the most frequent reason was that patients felt the device was too complex to use (50%) followed by being too cumbersome to use (25%). Conclusion: The abandonment rate for near-vision LVDs in South India was comparable with that reported in high-income countries. Patients reporting no change in their QoL had a higher likelihood of abandoning the device compared with those who reported some change. Device-related and psychological factors were the most frequent reasons for abandonment. These results can be used to develop strategies to improve compliance with use of devices.
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As lethal events associated with wheelchair use are poorly reported in the literature, a search was undertaken of the Forensic Science South Australia (FSSA), Australia, autopsy database over a 20-year period for all cases where individuals who were wheelchair bound were found dead either in or beside their chairs. There were 16 cases, ranging in age from 30 to 92 years ( M = 58.6 years) and with a male-to-female ratio of 9:7. There were six accidents that involved burns, asphyxia, a fall and impact with a vehicle; three suicides that involved drowning and asphyxia; a single homicide involving drowning; a single undetermined case; and five cases due to medical conditions such as cerebral palsy with choking, ischaemic heart disease and pulmonary thromboembolism. Individuals who use wheelchairs may die from a wide variety of both unnatural and natural causes. Wheelchair users may be predisposed to specific types of accidents because of significant underlying physical impairment or serious diseases that may limit their ability either to move away from danger or to perform self-rescues. Morbidity and mortality associated with underlying medical conditions may be contributed to by the structure, stability and motility of wheelchairs.
Chapter
Wheelchair and seating systems allow individuals with mobility impairments to actively participate in all aspects of society. The quality of life of an individual is reflective of the overall effectiveness of the wheelchair and seating system when considering activities of daily living. Therefore, it is imperative that the multidisciplinary team of rehabilitation professionals considers the wheelchair not just within the clinic, but in the full context of an individual’s life. To do so, rehabilitation professionals must understand current technologies in assistive technology as well as best practices for service delivery, and execute a systematic approach to wheelchair assessment. Successful wheelchair outcomes occur when clinicians are well versed in available equipment, its intended application, and all seating and positioning parameters. Fitting, training, and follow-up are just as important as device selection and are essential to a successful match between patient and device.
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A restraint is a device or medication that is used to restrict a patient's voluntary movement. Reported prevalence of physical restraint varies from 7.4% to 17% use in acute care hospitals up to 37% in long term care in the United States. Prevalence of 34% psychotropic drug use in long term care facilities in the United States has been reported; but use is decreasing, probably due to regulation. Use of restraints often has an effect opposite of the intended purpose, which is to protect the patient. The risk of using a restraint must be weighed against the risk of not using one, and informed consent with proxy decision makers should occur. Comprehensive nursing assessment of problem behaviours, a physician order when instituting restraints, and documentation of failure of alternatives to restraint is required. Ignorance about the dangers of restraint use results in a sincere, but misguided, belief that one is acting in the patient's best interest.Steps can be taken to reduce restraints before the need for restraints arises, when the need for restraints finally does arise, and while the use of restraints is ongoing.
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In 2005, a lady fell from her wheelchair during transport by care staff and later died. Two experts discuss how correct wheelchair use may have helped prevent this tragic incident.
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The use of physical restraints in nursing homes among black and white residents was examined on the basis of data from the 2004 National Nursing Home Survey to determine if black residents were more susceptible to the use of physical restraints. Odds ratios acquired through logistic regression are provided with 95 percent confidence intervals. Findings revealed that black residents are more likely than white residents to be restrained with bed rails, side rails, and trunk restraints. Findings suggest that racial disparities exist in the use of physical restraints. Implications for practice, policy, and research are discussed.
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Physical restraint devices are frequently used in agitated patients, particularly those with cognitive impairment, for preventing self-injury. However, these procedures are not risk-free. We present two cases of fatal accidents in patients with dementia while lying in bed with restraining belts. Causal mechanisms of both accidents are discussed in order to make professionals and healthcare institutions more aware of the benefits and risks of the use of restraining belts, and to improve measures for preventing death. Forensic medicine is a valuable source of information for knowledge and prevention these deaths.
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Falling is a significant cause of injury and death in frail older adults. Residents in long-term care (LTC) facilities fall for a variety of reasons and are more likely to endure injuries after a fall than those in the community The American Medical Directors Association (AMDA) Clinical Practice Guideline is written to give LTC staff an understanding of risk factors for falls and provide guidance for a systematic approach to patient assessment and selection of appropriate interventions. It is intended to help facilities establish processes for evaluating, managing, and preventing falls. AMDA guidelines are written specifically for the elder in the LTC setting. Facility teams systematically address each individual's risk factors for falls and fall risks and the adverse consequences on the patient's functioning and quality of life. AMDA guidelines emphasize key care processes and are organized for ready incorporation into facility-specific policies and procedures to guide staff and practitioner practices and performance.
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Twenty elderly restrained patients and their primary nurses (N = 18) were studied to determine (a) the subjective impact of physical restraints on the patient and (b) the nurses' beliefs about use of restraints. Despite reported cognitive impairments, patients vividly described anger, discomfort, resistance, and fear in response to the experience of physical restraint. The decision to restrain posed a conflict between protection of the patient and beliefs about professional behavior for the nursing staff. Lack of interdisciplinary collaboration in decisions to use a physical restraint was also apparent. The findings suggest that the use of physical restraint is not a benign practice and support the need for developing alternatives more consistent with professional practice and quality care.
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Seated posture and trunk control are important factors affecting upper extremity (UE) function of wheelchair users. A stable pelvis and trunk are required to provide a base from which UE movement occurs, but, conversely, the ability to move one's trunk and pelvis can increase functional ranges of motion. For wheelchair users, balancing sufficient trunk support with adequate trunk mobility has important functional and medical consequences. To determine the effect of cushion and backrest height on posture and reach and to determine the relationship between posture and UE reach using a randomized 2 x 3 repeated-measures factorial design. Twenty-two subjects with spinal cord injury were tested in 6 configurations, including 3 types of cushions (segmented air, contoured viscous fluid/foam, and air/foam) and 2 of 3 backrest heights (referenced to T12, inferior scapular angle, and scapular spine) while performing unilateral and bilateral reaching tasks. Seated posture (pelvic tilt and torso angle) and American Spinal Injury Association (ASIA) score were also measured. Pelvic tilt and ASIA score were significant predictors of reach. No evidence was found indicating cushion type or backrest height affected reach or posture. No consistent patterns of posture were found across cushion types or backrest heights. The posture adopted by wheelchair users is a more important influence on UE reach than are the cushion or backrest height used. Sitting with increased posterior pelvic tilt enhanced stability and permitted greater reach. Because individuals adopt different postures when using different cushions and backrest heights, clinicians should monitor posture while assessing seating and function of wheelchair users.
Article
Objective.— This article reviews the current status of the utilization of physical restraints in the practice of medicine. Based on current data from the reference sources, appropriate guidelines for the utilization of physical restraints in the practice of medicine are presented. Data Sources.— A review of the current literature as referenced in the article. Only English-language references were used. Study Design.— Articles were selected based on a review of articles from Index Medicus, English-language only. Articles were reviewed by the author for validity and appropriateness. Data Extraction.— The guidelines of data quality, validity, and appropriateness were applied to all articles by the author. Data Synthesis.— Restraints are frequently used in the practice of medicine. As many as 85% of nursing home patients will be restrained at some time and up to 17% of hospitalized medical patients will be restrained. This treatment is not always appropriate but there are no current guidelines available for the practicing physician to assist him or her in these decisions. The current use of physical restraints is discussed. The risks of restraints are reviewed and the reasons for restraint use are cited. The question regarding the efficacy of restraints is directly addressed for each of the situations in which restraints are most commonly used. The ethical and legal considerations concerning the use of restraints are reviewed, current concepts are summarized, and guidelines for improved usage of restraints are suggested. Conclusions.— Despite their extensive use, there is virtually no evidence to support the efficacy of restraints. The risks of using mechanical restraints are numerous and well documented. The detrimental psychologic impact of restraints needs to be emphasized. Restraints are inappropriately used if employed because of fear of liability should a patient fall. The proper approach to the patient at risk of falling is to address the contributing factors that place the patient at risk and, where possible, correct them.Restraints are overused in medicine. Guidelines are given to help improve the employment of this potentially harmful practice.(Arch Intern Med. 1992;152:2203-2206)
Article
Pelvic-positioning straps are usually used to maintain the client/seating system interface. This article discusses the proper use of these straps. Proper selection and use of a pelvic-positioning strap will affect the success of the entire seating system, so careful attention must be paid to the size of the strap(s) and components and the placement of the strap as it crosses over the client's thigh/lower pelvic area. The direction of pull as the fastening system is closed and tightened may affect pelvic position as well. The author suggests the use of belts mounted to cross the upper thigh at a 90° angle to the seating surface. Placing the pelvic positioning strap at this angle leaves the pelvis free for active anterior movement during weight shift and functional reaching. Adjustable mounting hardware is recommended as a method of providing a pelvic-positioning system that is flexible enough to achieve proper alignment.
Article
Proper positioning affects many areas of life for the older adult. This article reviews some of the key points in a seating evaluation and gives suggestions on interventions to address seating problems that are special to the older population. Evaluation of skin, posture, mobility pattern, and environment are essential before making seating recommendations. The fixed or flexible nature of kyphosis often determines the intervention given. Proper positioning can significantly reduce the need for restraints.
Article
This article addresses the problems associated with standard sling-type wheelchairs used by many older people and the need for individualized wheelchair seating based on assessments by physical and/or occupational therapists. Standard sling-type wheelchairs have many detrimental effects on the physical and social functioning of older people. They also often lead to the use of physical restraints because the older person is unable to maintain a sitting posture in such chairs. Wheelchairs that fit the individual and support postural abnormalities usually eliminate the need for restraints. The steps in an individualized assessment are described. The goal of individualized seating is to provide stability without compromising comfort and function. The older person's body contours, curvatures, joint range of motion, and measurements are documented and used to order wheelchair components to fit that person. Guidelines and suggestions for obtaining reimbursement for wheelchairs are presented.
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Many aspects of the management of acutely disturbed behaviour have only relatively recently come under systematic scrutiny. Perhaps regrettably one of the last amongst the range of strategies that may be employed to be subjected to rigorous examination has been physical restraint. Considerable debate has recently taken place around what represents good practice in this sensitive and controversial area but the continuing dearth of research in some aspects of this area of practice has meant that this discussion has arguably been over reliant on ‘expert’ opinion. Questions continue regarding some fundamental issues of restraint, including the relative risks involved in alternative approaches, and anxieties have been expressed about the potential for injuries and death to result from restraint. This article outlines the results of a survey that sought to explore the incidence of deaths associated with restraint in health and social care settings in the UK. The outcome of an initial analysis of the cases identified is then discussed, with reference to the literature on restraint-related deaths, in order to identify the implications for practice.
Article
This article reviews the current status of the utilization of physical restraints in the practice of medicine. Based on current data from the reference sources, appropriate guidelines for the utilization of physical restraints in the practice of medicine are presented. A review of the current literature as referenced in the article. Only English-language references were used. Articles were selected based on a review of articles from Index Medicus, English-language only. Articles were reviewed by the author for validity and appropriateness. The guidelines of data quality, validity, and appropriateness were applied to all articles by the author. Restraints are frequently used in the practice of medicine. As many as 85% of nursing home patients will be restrained at some time and up to 17% of hospitalized medical patients will be restrained. This treatment is not always appropriate but there are no current guidelines available for the practicing physician to assist him or her in these decisions. The current use of physical restraints is discussed. The risks of restraints are reviewed and the reasons for restraint use are cited. The question regarding the efficacy of restraints is directly addressed for each of the situations in which restraints are most commonly used. The ethical and legal considerations concerning the use of restraints are reviewed, current concepts are summarized, and guidelines for improved usage of restraints are suggested. Despite their extensive use, there is virtually no evidence to support the efficacy of restraints. The risks of using mechanical restraints are numerous and well documented. The detrimental psychologic impact of restraints needs to be emphasized. Restraints are inappropriately used if employed because of fear of liability should a patient fall. The proper approach to the patient at risk of falling is to address the contributing factors that place the patient at risk and, where possible, correct them. Restraints are overused in medicine. Guidelines are given to help improve the employment of this potentially harmful practice.
Article
A retrospective analysis of 122 deaths caused by vest and strap restraints found that most victims were women (78%) and a median age of 81. Victims were found suspended from chairs (42%) or beds (58%); 83% were in nursing homes. Detailed analysis of 19 cases showed that all were demented, 13 had impulsive or involuntary movements, and 14 had recently tried to escape from a restraint or been found in a dangerous position while restrained. Restraints are an underrecognized, underreported, avoidable, and proximate cause of at least 1 of every 1,000 nursing home deaths.
Article
To evaluate the association between mechanical restraint use and the occurrence of injurious falls among persons residing in skilled nursing facilities. Prospective observational cohort study. Twelve skilled nursing facilities in southern Connecticut. The 397 persons who were mobile and unrestrained at baseline. Restraint use was defined both as the number of days restrained and as "never," "intermittently," or "continually" restrained. The primary outcome measure was the occurrence of a serious fall-related injury. Analyses were done on the entire cohort as well as on a subgroup hypothesized as having a high risk for falls. During one year of follow-up, 122 subjects (31%) became restrained, 83 intermittently and 39 continually. A serious fall-related injury was experienced by 5% (15 of 275) of unrestrained, compared with 17% (21 of 122) of restrained, subjects (chi-square = 12.478; P less than 0.001). Restraint use remained independently associated with serious injury after adjusting for other factors, both in the entire cohort (adjusted odds ratio, 10.2; 95% CI, 2.8 to 36.9) and in the high-risk subgroup (adjusted odds ratio, 6.2; CI, 1.7 to 22.2). Among the 305 subjects who experienced two or fewer falls, the proportion having a serious injury was 15% for restrained subjects compared with 4% for unrestrained subjects (difference in proportions 11%, CI, 4% to 17%), whereas the comparable proportions for the 92 subjects who experienced more than two falls were 20% and 16%, respectively. Results were similar in the high-risk subgroup. Mechanical restraints were associated with continued, and perhaps increased, occurrence of serious fall-related injuries after controlling for other injury risk factors. Study results suggest the need to consider whether restraints provide adequate, if any, protection.
Article
The patterns of and risk factors for mechanical restraint use were determined in 12 skilled nursing facilities. Restraints were being used for 59% of residents at the beginning of the study; 31% of remaining residents were restrained during the follow-up year. No facility characteristic was associated with restraint use. The resident characteristics independently associated with initiation of restraints were older age, disorientation, dependence in dressing, greater participation in social activities, and nonuse of antidepressants. Unsteadiness (72%), disruptive behavior such as agitation (41%), and wandering (20%) were the most frequently cited reasons for initiation of restraints. (JAMA. 1991;265:468-471)
Article
Of the 3.3 of every 1000 persons in the United States who use a wheelchair, an estimated 3.3% per year have a serious wheelchair-related accident. Yet, only isolated case reports of fatal accidents have appeared. To obtain a better estimate of the incidence and nature of fatal accidents, a search was carried out of the death certificate database (1973-1987) of the National Information Clearinghouse of the Consumer Product Safety Commission; 770 wheelchair-related deaths were identified. The majority, 596 persons (77.4%), experienced a fall from their chairs or tipped over. Of 85 deaths (11%) caused by environmental factors, stairs were implicated in 51 (60.0%). Of 48 fatal burns (6.2%), 27 (57.3%) were related to smoking. Asphyxia owing to restraints occurred in 44 persons (5.7%) of all ages and caused 10 of the 17 deaths (58.8%) among persons 1-20 yr old. Wheelchair-related accidental death is uncommon (about 0.2% of serious accidents per year), but some types of accidents appear to be preventable.
Article
An observational study was performed to determine whether the use of physical restraints in agitated nursing home residents leads to decreased or increased agitation. Results indicate that restraint use does not decrease agitation in nursing home residents. Residents exhibited either the same amount or more agitated behaviors when they were restrained than when they were not restrained, suggesting that the act of restraining may itself contribute to manifestations of agitation. The implications of the use of restraints in agitated nursing home residents are discussed, with particular reference to the prevention of falls.
Article
This paper addresses the question: Are physical restraints related to decreased social behavior among nursing home residents? Data collected from 112 nursing home residents suggest that low social performance puts a resident at risk of being restrained, but more frequently the use of a restraint hampers a resident's performance of social behavior.
Article
Little information exists on the use of mechanical restraints among nonpsychiatric inpatients. This prospective study evaluates their use among consecutive medical and surgical admissions to an acute care hospital. Daily direct observation of patients and hospital record review provided data on potential predictors of restraint, reasons for their application, complications, and outcome. Cox regression analysis was used to calculate relative risk of restraint while adjusting for duration of hospitalization as well as other variables. Restraints were applied to 37 (17%) of the 222 study patients. Restrained patients were eight times more likely to die during hospitalization (24% v 3%; P < 0.01). Abnormal mental status exam, diagnosis of dementia, surgery, and presence of monitoring and support devices (eg, intravenous lines) were statistically significant independent predictors of restraint. Mechanical restraint is a common occurrence among nonpsychiatric inpatients particularly those with impaired mentation, requirement for surgery, or intensive medical intervention. Identification of medical and surgical patients at risk for restraint may reduce the use of these devices by concentrating surveillance and prevention on this group.
Article
Evidence has been accumulating that injuries related to wheelchair use are common and sometimes serious. The object of this study was to evaluate the databases of the Food and Drug Administration (FDA) for insights to the nature and causes of such problems. We analyzed 651 records that were received by the FDA between 1975 and 1993. There were 368 injuries, 21 of which were fatal, affecting 334 wheelchair users. Fractures were the most common (45.5%), with lacerations (22.3%) and contusions/abrasions (20.1%) accounting for most of the remainder. The proportion of incidents related to the use of scooters, powered wheelchairs, and manual wheelchairs were 52.8%, 24.6%, and 22.6%, respectively. Four broad classes of contributing factors, often acting in combination, were implicated: engineering (60.5%), environmental (25.4%), occupant (9.6%), and system (4.6%). Of the tips and falls, those in the forward direction were most common in incidents affecting manual or powered wheelchairs, but the sideways direction was most common in scooters. The FDA database provides a unique perspective on wheelchair safety, with implications for clinicians, users, manufacturers, and regulatory bodies.
Article
The purpose of this study was to document what proportion of noninstitutionalized users of manually propelled wheelchairs are affected by wheelchair-related accidents caused by tips and falls, determine the nature and severity of the resulting injuries, and, by comparison with an unaffected group, identify factors associated with the risk of such accidents. We administered a postal questionnaire to as many as possible of the estimated 2055 members of the target population in the province of Nova Scotia. Among the 577 appropriate respondents, 57.4% reported they had completely tipped over or fallen from their wheelchairs at least once, and 66.0% reported having partially tipped. Of the falls and tips that were reported, 46.3% were forward in direction, 29.5% backward and 24.2% sideways. Many of the accidents occurred outdoors or on ramps. A total of 292 injuries were reported by 272 (47.1%) respondents. Most of the injuries (84.3%) were minor (e.g., abrasions, contusions, lacerations and sprains). Of the 15.8% of injuries that were serious, the most common were fractures (10.6%) and concussions (2.7%). Factors that appear to be associated with an increased risk of accidents and injuries included younger age, male gender, paraplegia or spina bifida as the reason for wheelchair use, having had a wheelchair prescribed, some wheelchair features (lightweight, camber, adjustable rear-axle positions, a knapsack), daily use of a wheelchair, propelling the chair with both hands, use of the wheelchair for recreation, use of a sideways transfer (without a transfer board) and doing repairs themselves or having them done by the dealer. Factors associated with a decreased risk include multiple sclerosis, stroke or arthritis as the reason for wheelchair use, attendant propulsion and the use of a one-person assist for transfers. The results of this study, that wheelchair-related accidents caused by tips and falls are very common, that serious injuries are not unusual and that there is a pattern of risk factors, should be useful to wheelchair users, clinicians, manufacturers and regulatory bodies.
Article
To examine changes in the rate of falling of an experimental group of restrained subjects who underwent restraint reduction, and to compare their rate of falling with a group of subjects who did not have restraint orders during the study period. A quasi-experimental, multiple time-series study utilizing the principles of single-subject design. Each subject was followed for 25 weeks before and 25 weeks after initiation of the intervention. Seven nursing homes. Formal programs aimed at reducing all bed and chair restraints were initiated in all sites after staff received education and training. Multidisciplinary teams implemented the restraint reduction process on a case-by-case basis, beginning with 1 unit/floor at a time in each site. Most experimental subjects reached their optimum restraint-elimination/reduced status within 2 weeks of intervention initiation. The implementation periods ranged from 4 months to more than a year. Subjects with chart orders for restraints at the start of the study comprised the experimental group and participated in the restraint reduction program (184 subjects). Subjects with no orders for restraints during the study period comprised the nonequivalent control group (111 subjects) and, therefore, did not undergo the intervention. Incident reports documenting all falls during the study period were examined. Falls, the dependent variable, were classified as serious or nonserious. The independent variable (intervention) was the restraint reduction program offered to experimental subjects. Based on the principles of single subject design, the impact of the intervention on falls was calculated before and after the date the restraint reduction process was initiated for an individual (experimental group) subject. For the control group, the pre- and posttest period was calculated from the start date of the restraint reduction program on the unit on which each subject resided. Serious falls did not increase, but nonserious falls increased significantly after restraints were removed or reduced in experimental subjects. The total mean weekly fall rate for this group increased from 1.87% of residents falling per week during preintervention to 3.01% during postintervention. The mean weekly fall rate of the control group was 3.18% at pretest and did not change statistically over time. The increase in nonserious falls among the experimental group may be attributed to restraint reduction. The mean weekly fall rate in the experimental group postintervention (25 weeks) became comparable to the mean weekly fall rate for the control group during the entire study period (50 weeks). In light of such findings, policy makers have to confront the ethical choice between tying some frail, elderly subjects to beds and chairs versus exposing them to the risks of freedom in their old age.
Article
To assess the common factors and the pattern of deaths related to the use of physical restraints. Case series. The chief death investigators of 37 large jurisdictions were sent questionnaires for all cases of restraint-related deaths. Sixty-three questionnaires from 23 jurisdictions were returned. The questionnaires allowed us to determine the restraint type used, the age and sex of the deceased, the furniture type with which restraints were used, the type of facility where the deceased was restrained, and whether the application of restraints was incorrect. We report 63 cases of asphyxial deaths from the use of physical restraints. Ages of decedents ranged from 26 weeks to 98 years. The greatest number of deaths occurred in the 80- to 89-year-old patients. There is a higher frequency for females of all ages, but the distribution for males and females is roughly the same for all age groups. Deaths occurred while the patient was restrained in a chair (wheelchair or geriatric recliner) or a bed. Most chair-related deaths (six of 19) and bed-related deaths (16 of 42) involved the use of vest restraints. Thirteen of the 42 bed-related deaths involved bedrails. The majority of deaths (61%) occurred in nursing homes and 57 of these 63 cases occurred while restraints were properly applied. Our report of 63 cases is an underrepresentation of the true number of restraint deaths. Our finding that the vast majority of restraint deaths occurred while restraints were correctly applied implies an inherent danger in the use of physical restraints. The safety of restraining patients and the efficacy of physical restraint needs to be examined and alternate means of assuring the safety of patients need to be developed.
Article
To examine the relationship between restraint use and falls while controlling for the effect of psychoactive drug use among nursing home residents, including subgroups of nursing home residents with high rates of restraint use and/or falls. Secondary analysis of data from a longitudinal clinical trial designed to reduce restraint use. Three nursing homes. Subjects (n = 322) were either restrained (n = 119) or never restrained (n = 203) at each observation point during a 9.5-month data collection period that preceded the intervention phase of the clinical trial. We evaluated restraint status (independent variable) three times during the data collection period by direct observation over a 72-hour period. Incident reports documenting falls and fall-related injuries (dependent variables) were reviewed. Cognitive status was measured using the Folstein Mini-Mental State Exam and functional status (including ambulation status) by the Psychogeriatric Dependency Rating Scale. Psychoactive drug use profile was obtained through record review. Using multiple logistic regression, we compared the effect of restraint use on fall risk between a confused ambulatory subgroup and the remaining sample and found a significant difference in the odds ratio for falls and recurrent falls (P = .02; chi-square = 5.24, df = 1; P = .003, chi-square = 9.12, df = 1). In the confused ambulatory subgroup, restraint use was associated with increased falls (odds ratio: 1.65, 95% CI: 0.69, 3.98) as well as recurrent fall risk (odds ratio: 2.46, 95% CI: 1.03, 5.88). Increased falls and recurrent fall risk was not observed in the remaining sample (falls odds ratio: 0.49, 95% CI: 0.28, 0.87; recurrent falls odds ratio: 0.42, 95% CI: 0.20, 0.91). One subgroup, the nonconfused ambulatory residents, were never restrained; after removing this subgroup, the confused ambulatory continued to be associated, though not significantly, with a higher risk of falls and injuries. Only nonconfused nonambulatory restraints were associated with a lower risk of all three outcomes: falls (odds ratio: 0.28, 95% CI: 0.05, 1.58), recurrent falls (odds ratio: 0.48, 95% CI: 0.05, 4.72), and injurious falls (odds ratio:0.42, 95% CI: 0.04, 4.01); these results, however, were not statistically significant. There was no evidence that the effect of restraint use on fall risk depended upon the use of psychoactive drugs (chi square = 4.43; df = 2, P = .11). Restraints were not associated with a significantly lower risk of falls or injuries in subgroups of residents likely to be restrained. These findings support individualized assessment of fall risk rather than routine use of physical restraints for fall prevention. Researchers and clinicians should continue to focus efforts on developing a variety of approaches that reduce risk of falls and injuries and promote mobility rather than immobility.
Article
Although the use of physical restraint has declined in nursing homes, the practice remains widespread in hospitals. The use of physical restraint in hospitals was reviewed to identify the current clinical, legal, and ethical issues and the implications for policy and further research. Clinicians use physical restraints to prevent patient falls, to forestall disruption of therapy, or to control disruptive behavior, but they vary in how they determine to institute these restraints. The evidence to support the reasons for their determinations is not compelling. Fear of litigation remains a powerful motivator. The ethical dilemma of autonomy versus beneficence has not been resolved satisfactorily for patients in this setting. The lack of large-scale studies in any of these areas makes it difficult for policy makers to determine whether it is necessary to address hospital physical restraint practices through additional regulation.
Article
To investigate the relative effects of two experimental interventions on the use of physical restraints. Prospective 12-month clinical trial in which three nursing homes were randomly assigned to restraint education (RE), restraint education-with-consultation (REC), or control (C). Three voluntary nursing homes in the Philadelphia area providing both skilled and intermediate care. A total of 643 nursing home residents over the age of 60 were enrolled at baseline, and 463 remained to completion (1 year). Both RE and REC homes received intensive education by a masters-prepared gerontologic nurse to increase staff awareness of restraint hazards and knowledge about assessing and managing resident behaviors likely to lead to use of restraints. In addition, the REC home received 12 hours per week of unit-based nursing consultation to facilitate restraint reduction in residents with more complex conditions. Restraint status was observed systematically at baseline, immediately after the 6-month intervention, and again at 9 and 12 months. Staff levels, psychoactive drug use, and injuries were also determined. Compared with baseline, the REC home had a statistically significant reduction in restraint prevalence, whereas RE and C homes did not. At 9 months (3 months post-intervention), absolute decline in the percents restrained were 7% RE, 7% C, and 20% REC; at 12 months (6 months post-intervention) declines were 4% RE, 6% C, and 18% REC. However, relative to baseline, these declines represent an average reduction in restraint use of 23% RE, 11% C, and 56% REC. The differences in changes over time were consistently significant (P = .01), whether considering survivors or those present at each time point, and also when controlling for differences between groups at baseline. Further, given any change in restraint use, REC-residents were between 25% and 40% more likely than either RE or C residents to experience decreased restraint use. Results were achieved without increased staff, psychoactive drugs, or serious fall-related injuries. A 6-month-long educational program combined with unit-based, resident-centered consultation can reduce use of physical restraints in nursing homes effectively and safely. Whether extending the intervention will achieve greater reduction is not known from these results.
Article
To characterize changes in key aspects of process quality received by nursing home residents before and after the implementation of the national nursing home Resident Assessment Instrument (RAI) and other aspects of the Omnibus Budget Reconciliation Act (OBRA) nursing home reforms. A quasi-experimental study using a complex, multistage probability-based sample design, with data collected before (1990) and after (1993) implementation of the RAI and other OBRA provisions. Two independent cohorts (n > 2000) of residents in a random sample of 254 nursing facilities located in metropolitan statistical areas in 10 states. OBRA-87 enhanced the regulation of nursing homes and included new requirements on quality of care, resident assessment, care planning, and the use of neuroleptic drugs and physical restraints. One of the key provisions, used to help implement the OBRA requirements in daily nursing home practice, was the mandatory use of a standardized, comprehensive system, known as the RAI, to assist in assessment and care planning. OBRA provisions went into effect in federal law on October 1, 1990, although delays issuing the regulations led to actual implementation of the RAI during the Spring of 1991. MEASUREMENTS AND ANALYSES: Research nurses spent an average of 4 days per facility in each data collection round, assessing a sample of residents, collecting data through interviews with and observations of residents, interviews with multiple shifts of direct staff caregivers for the sampled residents, and review of medical records, including physician's orders, treatment and care plans, nursing progress notes, and medication records. The RNs collected data on the characteristics of the sampled residents, on the care they received, and on facility practices. The effect of being a member of the 1990 pre-OBRA or the 1993 post-OBRA cohort was assessed on the accuracy of information in the residents' medical records, the comprehensiveness of care plans, and on other key aspects of process quality while controlling for any changes in resident case-mix. The data were analyzed using contingency tables and logistic regression and a special statistical software (SUDAAN) to assure proper variance estimation. Overall, the process of care in nursing homes improved in several important areas. The accuracy of information in residents' medical records increased substantially, as did the comprehensiveness of care plans. In addition, several problematic care practices declined during this period, including use of physical restraints (37.4 to 28.1% (P < .001)) and indwelling urinary catheters (9.8 to 7% (P < .001)). There were also increases in good care practices, such as the presence of advanced directives, participation in activities, and use of toileting programs for residents with bowel incontinence. These results were sustained after controlling for differences in the resident characteristics between 1990 and 1993. Other practices, such as use of antipsychotic drugs, behavior management programs, preventive skin care, and provision of therapies were unaffected, or the differences were not statistically significant, after adjusting for changes in resident case-mix. The OBRA reforms and introduction of the RAI constituted an unprecedented implementation of comprehensive geriatric assessment in Medicare- and Medicaid-certified nursing homes. The evaluation of the effects of these interventions demonstrates significant improvements in the quality of care provided to residents. At the same time, these findings suggest that more needs to be done to improve process quality. The results suggest the RAI is one tool that facility staff, therapists, pharmacy consultants, and physicians can use to support their continuing efforts to provide high quality of care and life to the nation's 1.7 million nursing home residents.
Article
To determine the magnitude and distribution of the forces, moments, and accelerations acting on an individual sitting in a wheelchair during three possible accidents occurring while negotiating a sidewalk curb, experimental trials were performed in a bioengineering laboratory using a 50th percentile Hybrid III dummy seated in a standard wheelchair. A ramp was designed with an adjustable incline to allow the wheelchair to reach the edge of a sidewalk height platform at the desired forward speed of 2.5 miles per hour (comfortable walking speed). The wheelchair velocity was monitored via an optical pickup. Three types of accidents were simulated: (1) a wheelchair hitting straight into a curb; (2) a wheelchair falling forward straight off a curb; (3) a wheelchair falling diagonally off a curb. Each experiment was repeated three times. Each run was photographed using high-speed cameras and videotaped from three perspectives: frontal, lateral, and overhead. The results were averaged and compared with published injury Assessment Values (IAV) and Head Injury Criteria (HIC). Of significance were the following results. In the straight into a curb experiments, the wheelchair remained upright and the dummy seated. Low magnitude forces (23-73 N), moments (1-12 Nm), and accelerations (0.2-1 G) were recorded at the neck and head. The HIC was low at 0.3. These results were of no clinical significance. In the straight off a curb experiments, properly attached footrests prevented the wheelchair from toppling over but did not prevent the dummy from falling off the wheelchair. Forces (187-4,176 N), moments (3-178 Nm), and accelerations (131-206 G) of great magnitude were recorded at the head and neck when the dummy fell off the wheelchair. These values were above IAV. The HIC was 960. In the diagonally off a curb experiments, both the wheelchair and the dummy fell sideways. High-magnitude forces (274-2,313 N), moments (4-110 Nm), and acceleration (140-236 G) were recorded in the head and neck regions. The HIC was 975. These values were close to IAV and may signify potential serious injuries.
Article
The objective of this study was to determine the effect of two types of restraining belts (lap belt and a four-point belt) on an instrumented dummy during three situations: wheelchair hitting straight into curb (SIC); wheelchair falling straight off a curb (SOC); wheelchair falling diagonally off a curb (DOC). A fully instrumented (50th percentile Hybrid III) dummy was seated in a standard wheelchair and restrained with one of the belts. The wheelchair rolled down a ramp reaching a platform at 2.4 miles per hour (comfortable walking speed). Three types of experiments were performed: SIC, SOC, DOC. Each experiment was repeated at least three times. Forces, moments, and acceleration were monitored and recorded via 48 sensors placed at the head, spine, and limbs. All experiments were videotaped and photographed. The data were averaged and compared with standards that have been previously established in car crash testing and with data recently obtained in a similar study using a nonrestrained dummy. Our results showed that in the SIC experiments, low magnitude forces, moments, and acceleration of no clinical significance were recorded with both types of belts. The wheelchair remained upright and the dummy safely seated. In the SOC experiments, the two belts prevented the dummy's ejection from the chair and, thus, have been effective in lowering the forces, moments, and acceleration and preventing significant injuries to the head and neck regions. In the DOC experiments, the lap belt proved to be somewhat more effective than the four-point belt in lowering the extension forces at the upper neck and the moments at the lower neck below injury levels. It also kept the head injury criteria well below injury level. We postulate that the four-point belt was less effective because of its more extensive body fixation, which leads to concentration of moments and forces at the head and lower neck regions. The results of this study show that restraining systems can enhance the safety of wheelchair occupants in certain incidents. It has been demonstrated that the lap belt is as effective as the four-point belt system in SIC and SOC incidents. In DOC falls, neither belt could prevent falls and trauma to the head and neck region. The lap belt, however, was somewhat superior. We recommend that wheelchairs be equipped with a lap belt and patients be encouraged to buckle-up while using the wheelchair outdoors.
Article
To determine whether the "hobble" or "hog-tie" restraint position results in clinically relevant respiratory dysfunction. This was an experimental, crossover, controlled trial at a university-based pulmonary function laboratory involving 15 healthy men ages 18 through 40 years. Subjects were excluded for a positive urine toxicology screen, body mass index (BMI) greater than 30 kg/m2, or abnormal screening pulmonary function testing (PFT). Forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), and maximal voluntary ventilation (MVV) were obtained with subjects in the sitting, supine, prone, and restraint positions. After a 4-minute exercise period, subjects rested in the sitting position while pulse, oxygen saturation, and arterial blood gases were monitored. The subjects repeated the exercise, then were placed in the restraint position with similar monitoring. There was a small, statistically significant decline in the mean FVC (from 5.31 +/- 1.01 L [101% +/- 10.5% of predicted] to 4.60 +/- .84 L [88% +/- 8.8% of predicted]), mean FEV1 (from 4.31 +/- .53 L [103% +/- 8.4%] to 3.70 +/- .45 L [89% +/- 7.7%]), and mean MVV (from 165.5 +/- 24.5 L/minute [111% +/- 17.3%] to 131.1 +/- 20.7 L/minute [88% +/- 16.6%]), comparing sitting with restraint position (all, P < .001). There was no evidence of hypoxia (mean oxygen tension [PO2] less than 95 mm Hg or co-oximetry less than 96%) in either position. The mean carbon dioxide tension (PCO2) for both groups was not different after 15 minutes of rest in the sitting versus the restraint position. There was no significant difference in heart rate recovery or oxygen saturation as measured by co-oximetry and pulse oximetry. In our study population of healthy subjects, the restraint position resulted in a restrictive pulmonary function pattern but did not result in clinically relevant changes in oxygenation or ventilation.
Article
To examine the influence of three electric-powered wheelchair braking conditions and four wheelchair seating conditions on electric-powered wheelchair motion and Hybrid II test dummy motion. This study provides quantitative information related to assessing the safety of electric-powered wheelchair driving. Rehabilitation engineering comparison and ANSI/ RESNA standards testing. Convenience sample of eight different electric-powered wheelchairs. Within-chair comparisons were conducted. Electric-powered wheelchairs were compared under three braking scenarios (joystick release, joystick reverse, power-off) and four seating conditions (seatbelt and legrests, seatbelt and no legrests, no seatbelt but legrests, no seatbelt and no legrests). A rehabilitation engineering center. The braking distance, braking time, and braking accelerations for electric-powered wheelchairs during three braking scenarios; trunk motion, head motion, and trunk angular acceleration during three braking scenarios and four seating conditions; and number of falls from the wheelchairs for three braking scenarios and four seating conditions. Significant differences (p < .05) were found in braking distance, braking time, and braking acceleration when comparing the joystick release and joystick reverse scenarios with the power-off scenario. The mean braking distance was shortest with the power-off braking scenario (.89m), whereas it was longest when the joystick was released (1.66m). Significant differences (p < .05) in head displacement and trunk angular displacement were observed among braking conditions and between seating conditions. There were also significant differences (p = .0011) among braking conditions for maximum trunk angular acceleration. The Hybrid II test dummy fell from the wheelchairs with highest frequency when there were no legrests and no seatbelt used. The results of this study indicate that use of a seatbelt when driving an electric-powered wheelchair reduces the risk of falling from a wheelchair. Furthermore, the use of legrests can reduce the risk of injury to the wheelchair driver. This study shows that the most abrupt braking occurs when deactivating the power switch.
Article
To examine predictors of continued restraint use in nursing home residents following efforts aimed at restraint reduction. Secondary analysis of data from a clinical trial using a one-group, pre-test post-test design. Three nonprofit, religion-affiliated nursing homes in a metropolitan area. The sample consisted of 201 physically restrained nursing home residents. Following restraint reduction efforts, 135 of the sample were still restrained. Mean age of participants was 83.9 years. Physical restraint use was measured by observation and included any chest/vest, wrist, mitt, belt, crotch, suit, or harness restraint plus any sheet used as restraint or a geriatric chair with fixed tray table. Nursing home residents were subjected to any one of three conditions aimed at restraint reduction, including adherence to the mandate of the Omnibus Budget Reconciliation Act of 1987 (OBRA '87), staff education, and education with consultation from a gerontological clinical nurse specialist. Resident characteristics including dependency, health status, mental status, depression, behavior, fall risk; presence of treatment devices and institutional factors were determined. Physical dependency, lower cognitive status, behavior, presence of treatment devices, presence of psychiatric disorders, fall risk, and fall risk as staff rationale for restraint were associated (P < .10) with continued restraint use. Nursing hours, staff mix, prevalence of restraint use by unit, and site were also associated (P < .10) with continued use of physical restraints. Following bivariate analysis, associated resident characteristics were subjected to logistic regression. Lower cognitive status (OR = 2.4 (for every 7-point decrease in MMSE), 95% CI, 1.7, 3.3) and fall risk as staff rationale for restraint (OR = 3.5, 95% CI., 1.5, 8.0) were predictive of continued restraint use. Adding nursing hours, staff mix, and prevalence of restraint use by unit to the logistic regression model was not statistically significant (partial chi-square = 2.79, df = 6, P = .834). Nursing home site was added to the model without changing the significance (P < .05) of cognitive status or fall risk as a staff rationale for restraint use. Continued restraint use in nursing home residents in this study most often occurred with severe cognitive impairment and/or when fall risk was considered by staff as a rationale for restraint. Efforts to reduce or eliminate physical restraint use with these groups will require greater efforts to educate staff in the assessment and analysis of fall risk, along with targeted interventions, particularly when cognition is also impaired.
Article
This study attempted to define and quantify the need for appropriate seating for elderly nursing home residents. A questionnaire was administered to 200 randomly selected nonambulatory elderly residents living in six Memphis area nursing homes. The study results supported previous findings that many nursing home residents have seating and mobility problems. Of the 139 wheelchair users analyzed, 112 (80%) experienced at least one problem related to discomfort, hindered mobility, or poor posture. Thirty-four percent of the residents had at least one problem considered to be severe. In most cases our respondents' seating and mobility problems could have been solved by the tailored application of presently available technologies.
Article
In order to define the state of adaptive transportation equipment, wheelchair users with spinal cord injury (SCI) and equipment vendors were surveyed about equipment, funding, maintenance, and repair. SCI registries from two states, Virginia and Arkansas, were used to create the sample pool of users and 225 responses were received. A list of equipment vendors and vehicle modifiers was compiled from several national resources, and 123 responses were received from 36 states. User respondents were generally satisfied with their adaptive equipment, which typically required only minor inexpensive (< $100) repairs, if any. Personal or family money was used by over 90% of the respondents for equipment funding. Vendors reported that a substantial amount of custom modification or fabrication of equipment is required to meet the needs of their clients. Lifts, external controls, and six-way power seats were cited by vendors as the equipment requiring the most frequent repair. The survey results provide an examination of the opinions and experiences of users and vendors of adaptive transportation equipment, which should prove useful to those involved in evaluating equipment, equipment availability, and the need for industry-wide standards.
Article
Occupational therapists are often involved in assessing the seating needs of clients who have quadriplegia. One component of this process involves determining the appropriate use of wheelchair cushions and pressure relieving techniques in the prevention of pressure sores. The purpose of this study was to assess the effect of tilt and recline positioning and various wheelchair cushions on interface pressures at the ischial tuberosities and the sacrum of two subjects with C5 quadriplegia. In addition, interface pressures under bony prominences were assessed in the personal driving position (when the subject enters), neutral, 35 degree tilt, 45 degree tilt, and maximum recline (150 degrees). The results of this study indicate that for the two subjects evaluated, higher average interface pressures at the ischial tuberosities were obtained when using one of the three cushions under scrutiny. Futhermore, the general trend observed with both subjects is a reduction of pressure readings at the ischial tuberosities with tilt and recline positioning (especially with 45 degree tilt and 150 degree recline). The findings of this study are in keeping with previous studies which identified that individual and ongoing assessment is essential in providing the best cushion and pressure relief techniques for individuals.
Article
To describe how removing physical restraints affected injuries in nursing home settings. A 2-year prospective study of an educational intervention for physical restraint reduction. Sixteen diverse nursing homes with 2075 beds in California, Michigan, New York, and North Carolina. Study A: 859 residents who were physically restrained at the onset of the intervention on October 1, 1991. Study B: all residents who occupied the 2075 beds in the 16 facilities 3 months before the intervention and 3 months after its completion. Educational program for nursing home staff followed by quarterly site consultations to participating nursing homes. Rate of physical restraint use and injuries. Study A: Serious injuries declined significantly among the 859 residents restrained initially when restraint orders were discontinued (X2 = 6.2, P = .013). Study B: During the intervention period, physical restraint use among the 2075 residents decreased from 41% to 4%, a 90% reduction. The decrease in the percentage of injuries of moderate to serious severity was significant (i.e., 7.5% vs 4.4%, P2-tail = .0004) as was the rate of moderate and serious injuries combined (Rate Ratio = 1.580, P2-tail = .0033). A substantial decrease in restraint use occurred without an increase in serious injuries. Although minor injuries and falls increased, restraint-free care is safe when a comprehensive assessment is done and restraint alternatives are used.
Article
A 73-year-old man who had suffered from old myocardial and cerebral infarction for 4 years had been secured in wheelchair due to left hemiplegia and aphasia and also been received a home care of his wife. One day, his wife tied a cloth belt around his head and secured it to the wheelchair to prevent the flexion of his neck. One hour later, he was found dead by his wife. He also had slipped down in his wheelchair. The autopsy performed 24 hours after death revealed a ligature marks on the front of the neck. Petechial hemorrhages, visceral congestion and fluid blood, compatible with asphyxial death, were also found. Although severe cerebral cortical atrophy, old myocardial infarction, moderate to severe atherosclerosis and decubitus of the back were also found, they were not considered primary cause of death. No other anatomical or toxicological cause of death was present. Therefore, we concluded that the man died of accidental hanging. Recently, the home care of aged or handicapped patient is a social problem in Japan due to the increase in the number of elderly people. The death was caused by the inappropriate restraints used by his wife. This case suggests the importance of proper advice to non-professional caretakers from care professionals.
Article
Many aspects of the management of acutely disturbed behaviour have only relatively recently come under systematic scrutiny. Perhaps regrettably one of the last amongst the range of strategies that may be employed to be subjected to rigorous examination has been physical restraint. Considerable debate has recently taken place around what represents good practice in this sensitive and controversial area but the continuing dearth of research in some aspects of this area of practice has meant that this discussion has arguably been over reliant on 'expert' opinion. Questions continue regarding some fundamental issues of restraint, including the relative risks involved in alternative approaches, and anxieties have been expressed about the potential for injuries and death to result from restraint. This article outlines the results of a survey that sought to explore the incidence of deaths associated with restraint in health and social care settings in the UK. The outcome of an initial analysis of the cases identified is then discussed, with reference to the literature on restraint-related deaths, in order to identify the implications for practice.
Article
To investigate physical restraint-related injuries. Areas of interest were the prevalence of injury, types of injuries, risk of sustaining an injury and specific restraint devices associated with injury. Injury in the context of this review was considered to be either direct injury, such as lacerations and strangulation, or indirect injury considered to be an adverse outcome such as increased mortality rates or duration of hospitalization. A comprehensive search was undertaken that involved all major databases and the reference list of all relevant papers. To be included in the review studies had to involve people in acute or residential care settings and report data related to injury caused by restraint devices. A number of different types of research designs were included in the review. The findings of studies were pooled using odds ratio and narrative discussion. The search identified 11 papers reporting the findings of 12 observational studies. These studies were supplemented with the findings of a number of other types of studies that reported restraint-related data. The review highlights the potential danger of using physical restraint in acute and residential health care facilities. Observational studies suggest that physical restraint may increase the risk of death, falls, serious injury and increased duration of hospitalization. However, there is little information to enable the magnitude of the problem to be determined. Many of the findings highlight the urgent need for further investigation into the use of physical restraint in health care facilities. Further research should investigate the magnitude of the problem and specific restraint devices associated with injury. However, given the limited nature of the evidence, this association should be investigated further using rigorous research methods.
Article
Restraint use is not monitored in the US, and only institutions that choose to do so collect statistics. In 1999, investigative journalists reported lethal consequences proximal to restraint use, making it a life-and-death matter that demands attention from professionals. This paper reviews the literature concerning actual and potential causes of deaths proximal to the use of physical restraint. Searching the electronic databases Medline, Cinahl, and PsycINFO, we reviewed the areas of forensics and pathology, nursing, cardiology, immunology, psychology, neurosciences, psychiatry, emergency medicine, and sports medicine. Research is needed to provide clinicians with data on the risk factors and adverse effects associated with restraint use, as well as data on procedures that will lead to reduced use. Research is needed to determine what individual risk factors and combinations thereof contribute to injury and death.
Article
To examine the effect of organizational characteristics on physical restraint use for hospitalized nursing home residents. Secondary analysis of data obtained between 1994 to 1997 in a prospective phase lag design experiment using an advanced practice nurse (APN) intervention aimed at reducing physical restraint for a group of hospitalized nursing home residents. Eleven medical and surgical units in one 600-bed teaching hospital. One hundred seventy-four nursing home residents aged 61 to 100, hospitalized for a total of 1,085 days. Physical restraint use, APN intervention, age, perceived fall risk, behavioral phenomena, perceived treatment interference, mental state, severity of illness, day of week, patient-registered nurse (RN) ratio, patient-total nursing staff ratio, and skill mix. Controlling for the APN intervention, age, and patient behavioral characteristics (all of which increased the likelihood of restraint use), weekend days as an organizational characteristic significantly increased the odds of restraint (weekend day and patient-RN ratio on physical restraint use: odds ratio (OR) = 1.92, 95% confidence interval (CI) = 1.38-2.68, P <.001; weekend day and patient-total staff ratio on physical restraint use: OR = 1.91, 95% CI = 1.37-2.66, P <.001; weekend day and skill mix on physical restraint use: OR = 1.91, 95% CI = 1.37-2.67, P <.001). Key findings suggest that organization of hospital care on weekends and patient characteristics that affect communication ability, such as severely impaired mental state, English as a second language, sedation, and sensory-perceptual losses, may be overlooked variables in restraint use.
Article
To measure the response of a test dummy while traversing common obstacles encountered by users of electric-powered wheelchairs (EPWs) to determine whether optimal wheelchair fit, use of seatbelts, and driving speed affect the frequency and severity of EPW tips and falls. Repeated-measures comparison study. Constructed environment both in and around a Veterans Affairs medical center. A 50th percentile Hybrid II anthropometric test dummy (ATD) was used to simulate a person driving an EPW. The ATD was driven in 4 different EPWs over commonly encountered obstacles at speeds of 1 and 2m/s, with and without the use of a seatbelt, and at varying legrest heights. The response and motion of the ATD were observed and recorded as no fall, loss of control (the ATD falls forward or sideways but remains in the EPW), the ATD falls out of the EPW, or the EPW tips completely. A total of 97 adverse events out of 1700 trials were recorded: 88 were losses of control (instability) and 9 were ATD falls. No complete tips of any EPW occurred. Univariate statistical analysis indicated a significant relationship between the adverse events and the use of seatbelts, legrest condition, and test obstacles (P<.05). A mixed-model analysis confirmed the significant relationships between the adverse events and the use of seatbelts, legrest condition, and test obstacles (P<.05). However, the mixed model indicated that (1) there was no significant relationship between the adverse events and driving speed and (2) no one obstacle was designated to be the most problematic. Persons who use EPWs should use seatbelts and legrests while driving their EPWs, and clinicians should include common driving tasks when assessing the proper set-up of EPWs.
Article
Five cases of accidental death occurring in connection with physical restraints in long-term care facilities are reported. The position in which the deceased were found, autopsy findings, police investigations as well as the evaluation of each case under criminal law are described. The investigations by the prosecution as well as the attention of the public media have meanwhile contributed to an improvement of the technical standards and a reduction of the risk in applying such restraints under the Law on Medical Devices.
Article
To analyse the effect of patient and ward characteristics on the use of constraints in nursing homes. Primary carers in 222 wards in Norwegian nursing homes were asked about use of constraints towards 1926 patients during seven days. Constraints were grouped as mechanical restraints, non-mechanical restraints, electronic surveillance, force or pressure in medical examination or treatment, and force or pressure in ADL. The patients' mental capacity (CDR score), activity in daily living (ADL) and behaviour (BARS score) were rated. Type and size of ward, staffing level and educational level of the staff was recorded. In all 758 of the patients were subjected to any constraint. Degree of dementia, aggressive behaviour and loss of function in ADL had significant impact on all types of constraint except for electronical surveillance. The strongest associations were found between degree of dementia and mechanical restraint (OR 5.14), impaired ADL and mechanical restraint (OR 9.23) and aggression and force or pressure in ADL (OR 3.75). Mechanical restraint was less used towards patients in special care units for persons with dementia (SCU) (OR 0.38) compared to patients in regular units (RU), whereas non-mechanical restraint was more frequent used in SCUs (OR 2.28). Type of ward had no significant impact on use of other types of constraints. Staff level and education level of the staff had no significant impact on the use of constraint. Constraint is frequently used in nursing homes, and most frequent toward patients with severe dementia, aggressive behaviour or low ADL function.
Conditions for Coverage (CfCs) & Conditions of Participations (CoPs) Baltimore, MD: Centers for Medicare and Medicaid Services
  • Medicare Centers
  • Medicaid Services
Centers for Medicare and Medicaid Services. (2006), Conditions for Coverage (CfCs) & Conditions of Participations (CoPs). Baltimore, MD: Centers for Medicare and Medicaid Services. Retrieved May 14, 2007, from bttp:// wTA-w.cms.hhs.gov/CFCsAndCoPs/
Potential hazards of wheelchair lap-belts
  • P W Axelson
  • D A Chesney
Axelson, P. W., & Chesney, D. A. (1995). Potential hazards of wheelchair lap-belts. Proceedings of the 18th RESNA Conference (pp. 9-14). Vancouver, British Columhia, Canada;