Karen Bonn

Anyone who is familiar with my work knows I am not only dedicated to maintaining and restoring human bodies to normal range of motion and function — including to the most upright posture — I work diligently to encourage clinicians to use holistic thinking for all patient care, patient care planning and prevention.

The side effects of the COVID-19 pandemic have created an entirely new challenge for not just the sick but also for those who did not contract the virus but have had forced immobility during quarantine.  We have to remind ourselves that COVID-19 is not the only thing that threatens our residents’ health and welfare — they have other conditions that must also be addressed on an ongoing basis.

Before the quarantine, our goals were to always keep residents out of bed and out of their rooms for mobility and socialization. With this virus, residents have been kept in their rooms and have spent more time in bed and sitting in chairs.  This was for their protection from the virus, but at what cost? Our task when the quarantine is relaxed is to rebuild their mobility and improve their socialization while protecting them from potential infection.

In this population, how much time away from other human beings and normal activity before we begin to see signs of decreased cognitive functioning and depression? We all need the stimulation of our environment to remain oriented and this is even more pronounced by the age and comorbidities of residents in long-term care. We hear and read about all ages — even young and healthy persons — beginning to have anxiety, mood changes and even signs of depression from the forced isolation of the COVID-19 pandemic. 

https://www.usnews.com/news/health-news/articles/2020-04-27/isolation-during-coronavirus-pandemic-a-trigger-for-depression links to a study published April 22 in JAMA Psychiatry.  The study “assessed how people regulate their mood through their choice of everyday activities and found that this ability (mood homeostasis) is impaired in people with low mood and may be absent in people with a history of depression. One in 5 people will develop major depression in their lifetime, and pandemic lockdown measures could result in even more cases of depression, according to the researchers.”

With this “forced” mobility, our long- term care population not only can develop mood changes and depression, but also lost range of motion to joints. A large number of people who reside in skilled nursing facilities already have one or multiple joints that have what is commonly referred to as “contractures.”  This is a condition defined by not being able to fully extend a joint or body part — including spine/head/neck posture — to its full extension or flexion. This can occur with a person sitting or lying in the same position for long enough periods of time that their muscles shorten to the length they are being held. If they do not continually drink enough liquids to remain well hydrated, this can add to the problem.

We especially see lost range of motion in persons who suffer from some type of neurological implications including after a stroke, torticollis, spinal cord injury, traumatic brain injury, multiple sclerosis, Lou Gehrig’s disease (ALS), cerebral palsy, dementia and end stage Alzheimer’s disease.  Damage to nerves of the central nervous system can result in increased muscle tone and spasticity.  This “tone” holds the muscle in a shortened length either intermittently, over extended periods of time, or continuously thereby encouraging the adapting of the muscle to that length.

If this shortening occurs in the spine, head and neck, and the person is unable to hold their head in an upright position to view and receive stimulation from their environment, they may suffer a decline in orientation. It is easy to extrapolate that this posture might also have a negative effect on eating, digestion, swallowing, and breathing.

If swallowing is not corrected, they may receive a feeding tube and therefore be unable to chew and swallow normal food in a dining room setting with their peers. They may not be able to pull in enough oxygen and release carbon dioxide from their lungs to sustain health and orientation.  What effect might this have on current co-morbidities like heart, renal and lung diseases?

Also, with contracted joints, circulation of blood to the extremities is very likely compromised. This blood flow carries oxygen and nutrients to cells and carries “garbage” away from the cells.  Persons who have contractures may be prone to pressure areas from compromised body alignment, and the lack of blood flow with enriching oxygen to these areas further puts them at risk for skin breakdown and also makes the healing of these wounds much more difficult.

With the recent pandemic, we have been forced to value infection control with more seriousness than ever before. What personal items, like splints, belong to each person who has had or has come into close contact with someone who has had the COVID-19 virus? What items can confidently be safely cleaned and what items should be disposed of as a practical means of protecting the residents and caregivers? As part of the initial wave of 1135 waivers and flexibilities, Medicare included replacement of equipment effected by COVID-19 in some way without requiring some of the standard documentation. This is wording from Medicare:

When DMEPOS is lost, destroyed, irreparably damaged, or otherwise rendered unusable, CMS is allowing DME Medicare Administrative Contractors (MACs) to have the flexibility to waive replacements requirements such that the face-to-face requirement, a new physician’s order, and new medical necessity documentation are not required. Suppliers must still include a narrative description on the claim explaining the reason why the equipment must be replaced and are reminded to maintain documentation indicating that the DMEPOS was lost, destroyed, irreparably damaged, or otherwise rendered unusable or unavailable as a result of the emergency

It is vital to the health and welfare — including the mental welfare — of residents to look at their needs holistically. During this time of COVID-19, we must not simply look at the virus itself, but also all of the unintended consequences. 

Can these residents be out around other carefully selected residents who have either developed antibodies from already having recovered from the virus, have been tested and shown to not have it, or have been symptom free for more than 14 days without high risk of potential exposure? What are other creative ways we can help them to be “social” without risk? What can we do to keep them mobile and not suffer from sitting or lying in bed for prolonged periods? What do we need to do to address joints and body parts that have already sustained lost range of motion “contractures”?

Since the OBRA Legislation of 1987, therapy has played a vital role in nursing facilities — and certainly will in the future — to treat lost range of motion and apply appropriate splinting.  But it is nursing that is with these fragile human beings every minute of every day and knows who is at risk or who has actual lost range of motion and must relay that information to therapy. They know who is at risk for decreased nutrition and must relay that to dietary.

They know who is at risk for sadness and depression and should relay that to the social worker. And they know who is at risk for pressure areas that have to immediately and continuously be addressed. We must do a good job of training all staff to look for and recognize these at-risk persons. It is the nursing staff that is the day to day “family” who loves and cares for their residents’ every need when family cannot be present.  

Karen Bonn, RN, COF, is a clinical specialist at Restorative Medical.