What is the treatment for joint contraction pain in nonverbal patients?

Treatment of Joint Contracture Pain in Nonverbal Patients

A comprehensive approach including daily passive stretching exercises, proper positioning, pharmacological pain management, and assistive devices is strongly recommended for managing joint contracture pain in nonverbal patients.

Assessment of Pain in Nonverbal Patients

Pain assessment in nonverbal patients requires careful observation of:

• Facial expressions (grimacing, frowning)
• Vocalizations (moaning, crying)
• Body movements (guarding, resistance to movement)
• Changes in behavior (agitation, withdrawal)
• Physiological indicators (increased heart rate, blood pressure)

Non-Pharmacological Interventions

Positioning and Exercise

• Perform passive stretching exercises multiple times daily to maintain joint mobility and prevent worsening of contractures 1
• Proper positioning to counteract deforming forces is essential 1
  • Use supportive devices (pillows, wedges, foam supports)
  • Implement regular position changes every 2 hours
• Range of motion exercises help maintain joint mobility 2

Orthoses and Splinting

• Hand orthoses are strongly recommended for first CMC joint osteoarthritis 2
• Resting hand/wrist splints may be considered for patients lacking active hand movement 1
• Patellofemoral braces are conditionally recommended for knee contractures 2
• Tibiofemoral knee braces are strongly recommended when knee contractures affect ambulation and joint stability 2

Physical Modalities

• Kinesiotaping is conditionally recommended for knee and first CMC joint contractures 2
• Functional electrical stimulation (FES) may provide short-term increases in motor strength and control 2, 1
  • Note: Evidence shows FES increases motor strength but not necessarily function 2
• Continuous passive motion devices may help with severe knee flexion contractures 3

Pharmacological Management

First-Line Medications

• Topical NSAIDs are the first pharmacological treatment of choice for contracture pain due to osteoarthritis 1
• Oral analgesics, particularly NSAIDs, should be considered for limited duration to relieve symptoms 1
  • Use with caution due to GI risks; consider gastroprotective agents 2
• For spasticity-related contractures, consider:
  • Tizanidine (particularly effective for chronic spasticity) 2, 1
  • Oral baclofen (effective but may cause sedation) 1
  • Dantrolene (for patients who need spasticity management without cognitive side effects) 1

Advanced Interventions

• Botulinum toxin injections for focal spasticity that is disabling or painful 1
• Intra-articular glucocorticoid injections for painful joints 1
• Intrathecal baclofen for severe spasticity not responding to oral medications 1

Monitoring and Follow-up

• Regular assessment of pain response to interventions
• Monitor for adverse events including:
  • Skin breakdown
  • Bruising or blisters
  • Increased pain or discomfort
  • Changes in spasticity
• Adjust interventions based on response

Special Considerations

• Early intervention is crucial as 60% of stroke patients develop joint contractures on the affected side within the first year 1
• Recent evidence suggests passive movements alone may not be sufficient to prevent joint stiffness in long-term immobile patients 4
• The effectiveness of stretching may be greater in muscle groups with limited extensibility 5
• Coordinate use of positioning, splinting, and standing devices with medical specialists due to potential contraindications 1

Caution

• Recent evidence from a 2023 study suggests passive movements alone may not prevent or reduce joint stiffness in medium to long-stay ICU patients 4
• Benzodiazepines should be avoided due to potential negative effects on recovery 1
• Monitor for adverse effects of medications, particularly sedation from muscle relaxants

By implementing this comprehensive approach to contracture pain management in nonverbal patients, clinicians can effectively reduce pain, maintain joint mobility, and improve quality of life.