Abstract
BackgroundContractures are a syndrome associated with reduced range of motion [ROM] around a joint. They are commonly observed in care home settings due to the high levels of immobility and conditions associated with contracture development. Contractures can negatively impact comfort, functionality, and quality of life for those living with them and can also be challenging to prevent and manage. There is limited clarity in the literature across the spectrum of understanding, ranging from uncertainty in the definition of contracture, unclear data on contracture prevalence, ill-defined methods for identification and assessment and lack of evidence of effect in interventional studies. The uncertainties in definition, prevalence, identification, and assessment need addressing before robust studies to evaluate the effectiveness of contracture prevention interventions can be designed. Interventions aimed at the care home setting require an understanding not only in the context of the resident, but also that of the health and social care professionals that will support implementation of effective interventions.
Aim
The aim of this thesis was to explore the impact of contractures in care homes; to better understand their prevalence, how they are perceived and managed by health and social care staff working in care homes and the optimal methods for identification and assessment.
Objectives
1. Determine the prevalence of contractures in older people living in care home settings by systematically reviewing the literature, to better understand the scale of the problem.
2. Understand how contractures are experienced by Health and Social Care Professionals [HSCP] working in care homes and to explore the impact of contractures on HSCP.
3. Identify the rigour with which contractures are defined and the variability in definitions used as well as to ascertain the range of assessments used to identify the presence of contracture in research.
Methods
This research followed a multi-phase mixed method approach, wherein a quantitative systematic review of contracture prevalence in care home residents was undertaken. This led onto a qualitative focus group and semi-structured interview study with the aim of understanding HSCP perceptions of contractures, how that related to the existing literature and the implication for future prevention and management interventions. This then led to a subsequent narrative review which aimed to explore how contractures are defined and measured published literature.
During the systematic review, electronic databases were searched for studies reporting on contracture in care home settings; due to regional variations in terminology, studies were included if they described a place of residence for older people providing 24 hour supervised assistance with healthcare and activities of daily living [ADL]. Included studies were appraised for quality using the Joanna Briggs Institute [JBI] checklist for prevalence studies. Subgroup analysis and narrative synthesis were conducted to explore the heterogeneity and associated factors.
The transcribed focus groups and interviews were analysed via the Braun and Clarke six step thematic analysis framework, with bottom-up inductive coding allowing theory and theme to be generated from the raw data. The perceptions of were explored through a social constructivism paradigm, asserting that individuals make sense of their experiences through both their own understanding and their social interaction with others.
The narrative review was conducted through a rapid review protocol, as the aim was to explore what is already known about a policy or practice. Electronic databases were searched to identify studies that reported on a measurement of specified limb contractures in adult humans. Narrative synthesis analysis was used to evaluate the current understanding of contracture measurement and definition.
Results
The systematic review identified 14 studies on the prevalence of contractures published between 1988-2022. The analysed studies included 281,066 participants with a mean age ranging from 80.5 to 88.9 years. Contracture prevalence ranged from 1.6% to 87.5%, with significant clinical and methodological heterogeneity. Pooling the data resulted in an overall prevalence of 30.1%. Subgroup analysis demonstrated that contracture as a primary outcome was associated with an increased contracture prevalence. There was no relationship identified between prevalence data and institution type, joint, or definition of contracture, though the high heterogeneity weakens these results.
Thirty-two individuals participated in the 4 focus groups and 15 semi-structured interviews. Three themes were identified: 1) comprehension of contractures, 2) ‘challenges of doing the right thing’, and 3) the role of culture, policy, and practice. These themes were linked by the overarching central theme of delivering tailored care. The qualitative study identified that HSCP face negative emotional and physical burden as a result of caring for people living with contractures. It elucidated the complexity of contracture comprehension, with differences depending on roles, highlighting the importance of good communication between multi-disciplinary teams in order to best provide effective, tailored care.
Among the 28 studies that were included in the narrative review, 18 presented both a definition of contracture and a description of measurement, 8 studies presented only a method of assessment, and 1 study provided only a definition. A final study implied a method of assessment but did not provide a detailed methodology. Of the 19 studies that provided a definition, the most common definition (n=7) indicated a specified reduction in ROM, where authors indicated an explicit point of measurement at which contracture could be classified, although the exact specificity was inconsistent between studies. The narrative review established that there is considerable variation in the definition and assessment of contractures in the studies reviewed. It identified the necessity of a standardised definition to be used in research and clinical practice.
Conclusion
The three studies highlighted a lack of clarity regarding the understanding of contractures and demonstrated both the necessity of a standardised definition of contracture and the challenges in doing so. It suggests that a contracture should be defined as any reduction in passive ROM due to loss of tissue extensibility, and that a severe contracture should be defined in the same manner with the addition of a secondary complication such as a limitation on functionality, difficulties in providing basic care, observable discomfort during movement, or a physical health complication i.e. pressure ulcer or infection.
In order to prevent contracture, further research and understanding of the modifiable risk factors is necessary. This would require validation of the proposed definition of contracture, followed by epidemiological studies to identify prevalence, incidence, and risk factors.
Date of Award | 1 Oct 2023 |
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Original language | English |
Awarding Institution |
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Supervisor | Julie Whitney (Supervisor), Salma Ayis (Supervisor) & Lindsay Bearne (Supervisor) |