Should a patient with ballism be physically restrained?

Management of Patients with Ballism: Physical Restraint Considerations

Physical restraint should only be used as a last resort for patients with ballism when there is imminent risk of injury to self or others, and should be implemented with proper medical supervision and safety protocols to prevent respiratory compromise.

Understanding Ballism and Its Implications

Ballism is characterized by continuous, coarse, flinging involuntary movements involving the limbs. These movements are:

• Vigorous, rapidly executed, and poorly patterned involuntary movements 1
• Most commonly presenting as hemiballism (affecting one side of the body) 2
• Usually caused by lesions in the subthalamic nucleus or other basal ganglia structures 2

Primary Treatment Approach

The primary approach should focus on treating the underlying cause and providing pharmacological management rather than physical restraint:

• First-line pharmacological treatments include:
  • Dopamine receptor blockers (haloperidol, chlorpromazine) 1, 3
  • Tetrabenazine 2
  • For older patients, sulpiride may be preferred due to fewer side effects 1
  • Sertraline may offer an alternative with better adverse effect profile than dopamine receptor blockers 4

Physical Restraint: When Necessary

If pharmacological management is insufficient and the patient is at immediate risk of harm, physical restraint may be considered with the following guidelines:

Safety Considerations

• Contraindications for physical restraint include:
  • Medical conditions that render restraint dangerous via potential airway or diaphragm restriction (e.g., obesity, drug intoxication) 5
  • Patients who are medically unstable 5

Implementation Protocol

When restraint is deemed necessary:

1. Staffing requirements:

   • Minimum of two trained staff members per patient 5
   • Adequate staffing must remain to care for other patients 5

2. Restraint technique:

   • Avoid restraints that cause airway obstruction, such as choke-holds 5
   • With supine restraints, ensure the patient's head can rotate freely 5
   • With prone restraints, ensure the airway remains unobstructed and lungs are not restricted by excessive pressure 5
   • Avoid prone wrap-up positions as these have been associated with injuries and deaths 5

3. Monitoring and reassessment:

   • When physical restraint exceeds 15 minutes, reassessment by nursing staff and attending psychiatrist is clinically indicated 5
   • Physical restraint episodes of 1 hour or longer require review by the medical director 5
   • Patients must be monitored continuously in person for the first hour 5

4. Environment:

   • Patients should be restrained in a quiet environment away from other patients 5
   • Continue restraint only until the patient is able to regain self-control 5

Mechanical Restraint Considerations

In some cases, mechanical restraint may be considered:

• Mechanical restraint may be recommended to prevent injury to self and others, particularly for aggressive behavior related to organic psychosis 5
• The patient should be placed on a bed that is either bolted to the floor or sufficiently stable 5
• Each limb should be wrapped with a protective collar and fastened by a strap 5
• Staff must be trained in safe restraint techniques 5

Important Cautions and Alternatives

• Physical or mechanical restraint may inhibit physiological compensation mechanisms during states of emotional hyperarousal, potentially resulting in airway obstruction, arrhythmias, or other fatal cardiovascular complications 5
• Consider 1:1 supervision as an alternative to restraint for medically unstable patients 5
• All types of restraints should be reviewed at least yearly by the organization's medical staff, with annual retraining for staff 5

Prognosis and Follow-up

• Contrary to older literature, hemiballism generally has a relatively good prognosis 2
• Many patients experience spontaneous improvements or remissions depending on the underlying cause 2
• For vascular causes, hemiballism typically shows gradual disappearance within days or weeks 1
• However, death from exhaustion has been reported in some patients within four to six weeks after onset, emphasizing the need for proper management 1

Remember that the goal is to use the least restrictive intervention necessary to ensure patient safety while effectively treating the underlying condition causing the ballism.