Joint contracture following prolonged stay in the intensive care unit

Abstract

Background: Prolonged immobility during a critical illness may predispose patients to the development of joint contracture. We sought to document the incidence of, the risk factors for and the reversibility of joint contractures among patients who stayed in a tertiary intensive care unit (ICU) for 2 weeks or longer.

Methods: We conducted a chart review to collect data on the presence of and risk factors for joint contractures in the shoulders, elbows, hips, knees and ankles among patients admitted to the ICU between January 2003 and March 2005.

Results: At the time of transfer out of the ICU, at least 1 joint contracture was recorded in 61 (39%) of 155 patients; 52 (34%) of the patients had joint contractures of an extent documented to impair function. Time spent in the ICU was a significant risk factor for contracture: a stay of 8 weeks or longer was associated with a significantly greater risk of any joint contracture than a stay of 2 to 3 weeks (adjusted odds ratio [OR] 7.09, 95% confidence interval (CI) 1.29-38.9; p = 0.02). Among the variables tested, only the use of steroids conferred a protective effect against joint contractures (adjusted OR 0.35, 95% CI 0.14-0.83; p = 0.02). At the time of discharge to home, which occurred a median of 6.6 weeks after transfer out of intensive care, 50 (34%) of the 147 patients not lost to follow-up still had 1 or more joint contractures, and 34 (23%) of the patients had at least 1 functionally significant joint contracture.

Interpretation: Following a prolonged stay in the ICU, a functionally significant contracture of a major joint occurred in more than one-third of patients, and most of these contractures persisted until the time of discharge to home.

Figure 1: Flow diagram for patient recruitment. Discharge home means discharge to the patient's home, a nursing home or a regional hospital.

Figure 2: Adjusted odds of experiencing any joint contracture. The results are based on a single multivariable model simultaneously including the demographic variables age and sex, presence of diabetes mellitus as a comorbidity, admission diagnosis, Acute Physiology and Chronic Health Evaluation (APACHE II) severity score, length of stay in the intensive care unit, duration of invasive mechanical ventilation, co-interventions (specifically neuromuscular blockade and steroids) and length of stay in the hospital. For definitions of variables see Table 2. Note: ref = reference group.

Figure 3: Adjusted odds of experiencing a functionally significant joint contracture. The results are based on a single multivariable model simultaneously including the demographic variables age and sex, presence of diabetes mellitus as a comorbidity, admission diagnosis, Acute Physiology and Chronic Health Evaluation (APACHE II) severity score, length of stay in the intensive care unit, duration of invasive mechanical ventilation, co-interventions (specifically neuromuscular blockade and steroids) and length of stay in hospital. For definitions of variables see Table 2. Note: ref = reference group.