Mechanisms of Injury and Death Proximal
to Restraint Use
Wanda K. Mohr and Brian D. Mohr
Restraints have been subsumed under the rubric of “interventions” in the
nursing literature. However, alarming reports of lethal consequences proximal to their use raise the issue to a life and death matter that requires
immediate attention from professionals. Little is known about the mechanisms of death and other adverse consequences of restraint use. This
article describes these mechanisms and also considers some hypothesized
factors and adverse effects associated with their use.
Copyright © 2000 by W.B. Saunders Company

R

ESTRAINTS ARE among the most coercive
interventions available to psychiatric staff
members. The modern practice of this procedure
has a long history in psychiatric settings. Yet despite the remarkable progress in our understanding
of the brain and human behavior, historical studies
suggest that rates of restraint use in psychiatric
institutional settings remain unchanged during the
past centuries (Esther, 1997).
Physical restraint, as used in acute psychiatric
settings, is a security measure designed to protect
patients or staff. The term “restraint” refers to
physical restriction of movement and is most commonly used to restrain limbs on a bed (“four-point”
or “five-point” restraint). The term is also used to
refer to restricting patients to a chair or to limit the
movement of their arms or legs (“ambulatory restraint”).
Restraints are labeled “interventions” in the
nursing literature. However, the extent to which
restraints are therapeutic interventions is questionable. Their efficacy as therapeutic measures has not
been empirically shown in any outcome studies to
date (Singh, Singh, Davis, Latham, & Ayers,
1999). Alarming reports of lethal consequences
proximal to the use of restraints requires immediate attention from professionals.
The practice of restraints puts patients and staff
at great risk for injury and even death. Consequences related to the use of restraints can be both
traumatic and lethal. Moreover, even when they do
not result in injury and death, the practice of restraints and seclusion are not benign. Although the

incidence and prevalence of deaths and injury are
not collected (U.S. General Accounting Office,
September 1999), the 1998 Hartford Courant investigation suggested that within the past 10 years
142 reported deaths were connected to the use of
physical restraint in mental health settings (Weiss,
1998). Those who died were disproportionately
young children. The newspaper exposé, as well as
an exposé of conditions in some Charter facilities
conducted by the Columbia Broadcasting System,
prompted Congress to request an investigation by
the U.S. General Accounting Office (September
1999). This investigation confirmed the risks inherent in the use of mechanical restraints. There
has been little discussion regarding the sequelae
associated with restraints and seclusion. Mental
health professionals have not written or spoken up
about this important topic, which has led to questions regarding the extent of the professional
knowledge with respect to the restraints’ adverse
effects. This article describes some of what is
known about death in restraints and also considers
some hypothesized factors and adverse effects asFrom the Department of Psychiatric Mental Health
Nursing, Indiana University School of Nursing, Indianapolis, IN; and Private Practice, Permian Cardiology
Associates, Midland, TX.
Address reprint requests to Wanda K. Mohr, Ph.D.,
R.N., F.A.A.N., 6441 Greenridge Dr, Indianapolis, IN
46278.
Copyright 䊚 2000 by W.B. Saunders Company
0883-9417/00/1406-0004$10.00/0
doi:10.1053/apnu.2000.19091

Archives of Psychiatric Nursing, Vol. XIV, No. 6 (December), 2000: pp 285-295

285

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sociated with their use. Because the use of restraint
with adults has been widely discussed in the geriatric literature, children are the primary focus of
this discussion.
CHILDREN AT SPECIAL RISK FOR TRAUMA

While caring for adult patients can be trying at
times, children in psychiatric facilities are exceedingly vexing and difficult. They are wounded and
mistrustful, and their main mode of coping is to
lash out in attack. This can be frightening to inadequately prepared staff, and they can construe a
verbal assault by a child in a personal way, especially if staff members do not have a ready arsenal
of understanding, verbal skills, and self-awareness.
These staff can lose all boundaries between their
issues and the child’s issues. This is the essence of
negative countertransference reactions, and its effects
result in fear and paralysis in staff members who then
tend to resort to survival and control tactics. This
begins the aggression coercion cycle described by
Goren, Singh, and Best (1993) in which staff members and patients provoke each other in a game of
one-upmanship. Staff members who seek to control a
frightening or uncertain situation engage in a power
play. This places the child in a “no-win situation” and
the potential for a take-down, restraint, and possible
abuse and injury escalate.
Yet it is extremely important to understand the
effects of restraints on children who are still in the
process of development. Placing a child in restraints by way of a temporary therapeutic hold or
in leather 5-point restraints strapped to a bed for
hours is indisputably a highly aversive experience.
It is also not a rational option given what we know
about children who exhibit aggressive tendencies
and disruptive behavior disorders.
Children who are placed in restraints most often
suffer from some type of disruptive behavior disorder. Disruptive behavior disorders refer to a core
set of behaviors and symptoms represented by the
Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1994)
categories that include attention deficit hyperactivity disorder, oppositional defiant disorder, and conduct disorder (CD). CD is a sufficiently disruptive
condition that it accounts for up to 50% of consultations in psychiatric clinics (Fergusson, Horwood,
& Lynskey, 1994; Steiner, 1997). CD is typified
by a “repetitive and persistent pattern of behavior in which the basic rights of others and major

MOHR AND MOHR

age appropriate societal norms or rules are violated” (American Psychiatric Association, 1994, p.
85). Although debate as to the genesis of CD
continues, scholars have found that children with
this disorder share remarkably similar risk factors
(Kazdin, 1993). One of these is a history of trauma
or physical abuse or neglect, another is low verbal
intelligence quotient and difficulties with receptive
language (Moffitt, 1993; Ontnow-Lewis, 1992;
Richters & Cicchetti, 1993; Wolff, Waber, Bauermeister, Cohen, & Ferber, 1982).
The interaction of traumatic exposure (abuse) to
single or recurring violence within an environment
of chronic danger is a relatively recent field of
study (Cicchetti, 1989; Garbarino, Kostelny, &
Dubrow, 1991). However, scholars have developed
some remarkable hypotheses and have conducted
compelling research about what happens to children who experience chronic abuse, and those exposed to violence.
Researchers in this area (Perry & Pollard, 1998;
Perry, Pollard, Blakley, Baker, & Vigilante, 1995;
van der Kolk & Greenberg, 1987) posit that a
child’s acute responses to threat can develop in a
pattern based on their individual traumatic experiences. This response can be one of hyperarousal or
dissociation. The hyperarousal response is an
alarm reaction that begins to activate the sympathetic nervous system, resulting in stimulation of
the hypothalamic pituitary axis. The dissociative
response involves a variety of mechanisms in
which the child disengages from the world attending to stimuli in their own internal world—a kind
of defeat reaction from an unavoidable and painful
situation. The mechanism behind this latter response is not well understood but it seems to begin
with central nervous system activation, yet what
follows is a marked increase in vagal tone with
lowering of blood pressure and heart rate, despite
increasing levels of circulating epinephrine. This
response seems to be mediated by naturally occurring opioids (van der Kolk & Greenberg, 1987;
Pynoos, 1993). Females and younger children are
more apt to react along the dissociative continuum
to severe stress than males and older children
(Perry & Pollard, 1998).
Increasing evidence suggests that in children
who experience chronic abuse, the adrenal system
goes awry, causing an imbalance of the steroids in
the brain (Perry, 1997; Perry & Pollard, 1998;
Schwartz & Perry, 1994). Researchers believe that

 RESTRAINTS

excess cortisol leads to damage in the hippocampus, causing memory lapses, anxiety, and an inability to control emotional outbursts. Cortisol can
also alter brain centers that regulate attention and
affect a child’s capacity to attend to meaningful
stimuli.
Abused children show a variety of disturbances
in physiology, thinking, and behavior. Similar to
children who have experienced any other traumatic
stress, many have elevated resting heart rates, temperature, and blood pressure (Ontnow-Lewis,
1992; Pynoos, 1993). If they respond along the
dissociative continuum, they may have lower heart
rates and blood pressures (Perry & Pollard, 1998;
Perry et al., 1995). Verbal deficits are one of the
neuro-psychologic sources of abused children’s
difficult behavior. In addition, several studies indicate that this misbehavior may be associated with
deficiencies in the brain’s self-control functions,
commonly referred to as “executive functions”
(Moffitt, 1993; Moffitt & Henry, 1991; Newman,
1987). These functions include sustaining attention
and concentration; abstract reasoning and concept
formation; formulating goals; anticipating and
planning; programming and initiating purposive
sequences of behavior; self-monitoring and selfawareness; inhibiting unsuccessful, inappropriate,
or impulsive behaviors; and interrupting ongoing
behavior patterns to shift to a more adaptive alternative behavior.
After repeated exposure to trauma, the same
systems initially activated in the brain by the original trauma will be reactivated when the child is
merely exposed to reminders of the traumatic
event. For example, these children may react physiologically to a playful scream heard on a playground in the same way they may have reacted to
a scream heard during a violent altercation at
home. These systems may also be reactivated in
response to a child’s thoughts or dreams about the
traumatic event. They may even begin reactivation
when they are warned by an adult: “If you don’t do
this, I will. . .”(Perry & Pollard, 1998, p. 8). Such
stimulus reminders may generalize to other situations and lead to the repeated activation of the
stress-response apparatus, although the child may
be temporally and geographically distanced from
any apparent threat. The helpless and frightened
child begins to view the world through a filter (or
template) of the original trauma and will respond
accordingly (Cicchetti, 1995; Perry et al., 1995).

287

This template or filter is a result of the high
levels of adrenergic and cortisone derivative substances that remain after the original trauma and
are responsible for permanently altering the neurosynaptic junctions in a way that fixates memories
and impulse response. Perry and colleagues (1995)
refer to this event as an acute state that eventually
becomes a permanent trait. In essence, without
intervention, the children develop a disarming of
the down-regulating circuit that would return them
to more normal function.
HYPOTHOSIZED CUMULATIVE AND
ADDITIVE TRAUMA

Although the study of life events is not as advanced in child psychiatry as in adult psychiatry,
research has shown that noxious life events have a
cumulative or additive effect on children. The effects of these events may be delayed, resulting in a
lag of approximately 4 months (Goodyer, Kolvin,
& Gatzanis, 1987).
As mentioned previously, research shows that
traumatized children may suffer from language
deficits, both receptive and expressive, and cognitive impairments that include distorting the intent
of others. These contribute to a “present-oriented”
cognitive style and limit their responses in threatening or ambiguous social situations. Because of
their cognitive handicaps, these children are at a
significant disadvantage in high stress situations in
which demands are put on them to make “appropriate” decisions and remain rational (Dodge,
Price, Bachorowski, & Newman, 1990).
These children may become aggressive and
threatening and are subject to being “taken down”
by staff and placed in restraints. A “take down” is
a highly emotional and volatile situation that is
highly stressful to both staff members and patients.
Although it is not designed to be a punishment, it
is often perceived this way by the children who
experience it (Mohr, Mahon, & Noone, 1998).
When a child exhibits threatening behavior, a team
of staff members converge on the child intending
to subdue and restrain him and/or administer medication. It follows that in such a situation the predominate emotions would be an escalation of galvanizing anger or paralyzing fear. Faced with the
threat of being taken down by 5 or more persons
larger than him or her, the child’s body will initiate
a cascade of physiologic reactions. He or she experiences a dramatic increase in the brain regions

 288

that are involved in the hyperarousal response induced by the threat (locus coeruleus and ventral
tegmental nucleus activity). These regions play a
critical role in regulating the stress response,
arousal, vigilance, affect, attention, sleep, and the
startle response. In addition, a corresponding increase in the release of catecholamines occurs in
response to the threat. Catecholamines surge, causing tachycardia and hypertension while readying
the muscles for action. At the same time corticosteroids are released in response to the perceived
danger. The perceptual field narrows and the ability to process information decreases. This is especially critical in a child who already has difficulties
in verbal receptive skills.
This situation repeats the abuse cycle. The act of
restraint may constitute an event that appears to the
child much like an instance of abuse. Given the
child’s diminished judgement, caused by their
mental illness and as a result of the high intensity
stress of the “take down” situation, and given their
impaired verbal competence, actions that lead to
restraint could be as damaging to the child from a
physiologic standpoint as any other noxious life
event. It becomes one more layer of trauma.
Hypothosized Adverse Health Effects From Stress
Studies
Patients report that being placed in restraints is a
traumatic and stressful experience even when that
stress is purely “psychologic” and does not involve
physical injury (Gallop, McCay, Guha, & Khan,
1999; Mohr et al., 1998; Norris & Kennedy, 1992).
In recent years researchers have produced an impressive amount of literature showing the effect of
psychologic stress on the down-regulation of various aspects of the immune system. The mechanism for this is caused by the disruption of the
communication pathways that link the nervous,
endocrine, and immune systems under psychologic
stress (Ader, Cohen, & Felten, 1995; Glaser,
Rabin, Chesney, Cohen, & Natelson, 1999). Studies have shown that persons reporting high levels
of psychologic stress also have a higher incidence
and greater severity of illness (Cohen, Doyle, &
Skoner, 1999).
Because of the obvious ethical constraints of
studying the effects of experimentally induced immobilization stress, studies are conducted with animals. Scientists worldwide have been conducting
research on the effects of immobilization on the

MOHR AND MOHR

physiologic functioning of rats. Researchers in Japan sought a link between the immune response
and immobilization stress and found that neutrophil functioning was negatively affected as a result
of the immobilization. Moreover, they found that
immobilization affected blood cells and serum elements and damaged the host’s defense and physiologic functioning (Kuriyama, Oishi, Kakazu, &
Machida, 1998).
Furthermore, scientists in France showed the
effects of immobilization stress on sleep rebound
in rats (Marinesco, Bonnet, & Cespuglio, 1999).
Levels of reparative sleep following episodes of
stress were significantly more impaired after
longer periods of immobilization. Some of these
changes are caused by endocrine systems. It is
well-known that aldosterone and cortisol suppress
the immune system, whereas melatonin appears to
enhance it. Melatonin, a product of the pineal
gland, helps to regulate the circadian rhythm and
sleep-wake cycle. Although little is known about
the specific functions of sleep, the literature suggests that it is important for the proper functioning
of the host defense system (Benca & Quintas,
1997). As a result, researchers suggest that the
deleterious effect on sleep precipitated by stress
events could be responsible for the development of
pathologies in humans.
Studies in this area are in their infancy and
caution should be used when extrapolating from
animal studies. However, these studies suggest that
being placed in restraints and immobilized is not
benign, and that restraints may not only be subjectively noxious but also physically harmful.
RESTRAINTS AND THEIR HYPOTHOSIZED
ROLE IN DEATH

There is little consensus in the scientific literature concerning the causes of death proximal to the
use of restraints. The psychiatric literature pays
scant attention to this issue. The forensic and emergency research contain a number of studies on the
subject, and the Joint Commission on the Accreditation of Health Care Organizations (JCAHO) has
studied reports of restraint-related deaths. JCAHO
officials reviewed 20 restraint-related deaths voluntarily reported under their sentinel event reporting procedure. In 40% of the cases the cause of
death was asphyxiation, while strangulation, cardiac arrest, or fire caused the remainder (JCAHO,
1998). JCAHO determined that asphyxiation was

 RESTRAINTS

related to putting excessive weight on the back of
the patient in a prone position, placing a towel or
sheet over the patient’s head to protect against
spitting or biting, or obstructing the airway when
pulling the patient’s arms across the neck area.
Among the deaths reported by the Hartford Courant as cases in which restraint or seclusion was a
factor, the causes included asphyxia, cardiac complications, drug overdoses or interactions, blunt
trauma, strangulation or choking, fire/smoke inhalation, and aspiration (Weiss, 1998).
Restraint Asphyxia
The most common cause of death, asphyxiation,
is termed “restraint asphyxia” (Milliken, 1998;
Reay, 1998). To date, studies conducted on this
issue have varied as to population, but the most
common reports concern adults who often have
been in police custody and frequently involve the
victim’s use of alcohol or some other illegal substance (Pollanen, Chiasson, Cairns, & Young,
1998). Admittedly the aforementioned presents
a confounding factor in applying this research to
the field of psychiatry. However, it could be posited that many patients receiving psychiatric care
are under the influence of psychotropic medications, some which depress central nervous system
activity.
Investigating the mechanism of unexpected
deaths of otherwise healthy persons in restraint,
Reay, Howard, Fligner, and Ward (1988) found
that 9 of 10 subjects in their study experienced a
prolonged recovery phase from exercise when they
were restrained in a prone position. The mechanism for this might include restriction of thoracic
respiratory movements, airway compromise, or the
release of catecholamines during the physical exertion. Interestingly, Reay (1998) stated that the
findings to support a diagnosis of restraint asphyxia can be meager to nonexistent, with no typical pathologic findings on autopsy. The only
sources for a determination of restraint asphyxia
are the historical events surrounding the physical
struggle.
Positional Asphyxia
Positional asphyxia occurs when the body’s position interferes with respiration. Respiration in
humans depends on the exchange of gases in the
lungs, the patency of the airway, and the pump
action of the muscles and bony thorax that are

289

responsible for ventilating the lungs. This coordinated activity is mediated by the nervous system.
In the forensic literature, death from positional
asphyxia was found to occur when individuals
were placed in a position that did not allow adequate breathing, most often a prone position. This
may have involved a restrictive or confining position, a simple flexion of the head onto the chest, a
partial or complete external airway obstruction, or
neck compression. Persons who later died were not
able to disengage themselves from the physical or
mechanical restraint causing the fatal position
(Bell, Rao, Wetli, & Rodriguez, 1992; Howard &
Reay, 1997; O’Halloran & Lewman, 1994).
Reay, Fligner, Stilwell, and Arnold (1992) reported that positional asphyxia occurred in 3 cases
of individuals who were in transport by law enforcement personnel. These individuals were being
transported in a prone position, and on autopsy
they were found to have died as a result of respiratory compromise. All 3 persons investigated by
Reay’s Los Angeles Medical Examiners Unit died
as a result mechanical interference with respirations. Although fatal positional asphyxia has been
documented in adults, it has not been in children.
However, it could be argued that a child’s small
size alone would be a significant factor in their
increased susceptibility to death from this mechanism.
Death by Aspiration
The JCAHO (1998) posits that while restraining
patients in the prone position may predispose them
to suffocation, restraining patients in a supine position may predispose them to aspiration. Aspiration occurs when persons have decreased levels of
consciousness, either as a result of their illness or
secondary to medications. Patients may aspirate
either through vomiting or regurgitation of gastric
contents. Supine positions, during which patients
are rendered immobile in conjunction with decreased or altered levels of consciousness, interfere
with their ability to protect their airway. Death
occurs as a result of asphyxia, acute pulmonary
edema, or pneumonitis (Plantadosi, 1996).
Asphyxia Secondary to Neck Compression
Deaths resulting from neck compressions were
investigated by Reay and Holloway (1982). Neck
holds are a commonly used law enforcement technique taught to some law enforcement personnel as

 290

a means of subduing suspects resisting arrest or to
control combative or difficult to manage prisoners.
One kind of neck hold is intended to impede the
flow of blood in the carotid arteries. Although there
is compensating collateral circulation from vertebral arteries through the Circle of Willis, occlusion
of the blood flow in carotids can produce brain
ischemia or carotid sinus stimulation, which causes
bradycardia and hypotension. In extreme cases it
can result in cardiac arrest (Reay & Eisele, 1982;
Reay & Holloway, 1982).
In the second type of neck hold the intent is the
occlusion of the airway itself by forearm compression. This kind of hold can collapse the trachea
and, given enough pressure, can cause tracheal
fractures. Given that the combative individual is
trying to free himself, his struggle strengthens the
force around his neck. The individual then becomes aware that they cannot breathe, which leads
to further agitation and increasing demand for oxygen and intensifying the force even further. Death
can result from cardiac arrest secondary to hypoxia
(Reay & Eisele, 1982; Reay & Holloway, 1982).
Blunt Trauma to the Chest
Blunt trauma to the chest may occur during the
restraint process. Myocardial concussion (commotio cordis) resulting from this trauma has been
reported to cause sudden death, presumably by
cardiac arrhythmia secondary to myocardial injury.
Although rare, deaths have been primarily reported
in children, probably because of thinness of their
chest wall. Again the diagnosis is not made by
autopsy, in that no morphologic changes are seen
in the myocardium, but rather by history of the
event surrounding the trauma (Boglioli, Taff, &
Harleman, 1998).
Catecholamine Rush
In situations where children become increasingly agitated, followed by intense struggle with
staff members, taken down to the ground, carried
to a quiet room, and secured with restraints a
massive release of adrenal catecholamines occurs.
This response, mediated by the adrenal medulla,
induces an output of epinephrine and norepinephrine that sensitizes the heart and produces rhythm
disturbances (Lown, DeSilva, & Lenson, 1977).
Neural and psychologic factors have been implicated as risk factors for ventricular arrhythmias
and sudden death. For example, behavioral arousal

MOHR AND MOHR

and psychologic stress have been shown to induce
malignant cardiac rhythm disturbances (Johnson,
Pinto, Kirby, & Lown, 1992; Kirby, Pinto, Hottinger, Johnson, & Lown, 1991).
Neural integration of body functions takes place
through a complex system of feedback loops when
information from inside and outside the organism
is catalogued by the brain. These pathways play a
major role in causing sudden death in persons who
find themselves in perilous situations. Moreover,
the situations need not be perilous to precipitate
cardiac arrhythmias. Events that do not compare in
anxiety intensity to being restrained, such as making a speech in public, have been found to have
profound effects on cardiac vagal control (Coumel,
Rosengarten, Leclercq, & Attuel, 1982; Grossman,
Watkins, Wilhelm, Manolakis, & Lown, 1996).
More than 2 decades ago Lown and colleagues
(Lown et al., 1977) identified psychic stress as a
mediating factor for advanced cardiac arrhythmias,
and emotional extremes have been suggested in the
literature as a triggering mechanism for sudden
cardiac death (Engel, 1978). In a classic study
Lown and colleagues (1977) systematically explored the relationship between psychologic stress
that consisted of mental arithmetic, reading from
colored cards, and recounting emotionally charged
experiences. Such testing induced a significant increase in ventricular premature beat frequency in
11 of the total 19 patients. One patient experienced
paroxysms of ventricular tachycardia.
Psychotropic Medications, Muscarinic Receptor
Antagonists, and Hyperpyrexia
Sudden cardiac death caused by an abrupt
change in clinical status of the patient is frequently
caused by the onset of a lethal cardiac arrhythmia
(Braunwald, 1997). A syndrome that has been
linked to psychotropic medication is prolonged
Q-T interval, which is a functional abnormality
thought to be associated with neurogenic influences that cause lethal arrhythmias (Schwartz,
Periti, & Malliani, 1975.) The prolonged Q-T syndrome may be hereditary or acquired (Braunwald,
1997). Hereditary forms appear to be related to
sympathetic nervous system imbalance (Schwartz
et al., 1975). Among the many causes of the acquired form is the presence of a psychotropic drug
idiosyncracies. Lithium carbonate may prolong the
Q-T interval and has been reported to be associated
with an increased incidence of sudden death (Ly-

 RESTRAINTS

man, Williams, Dinwoodie, & Schocken, 1984).
Because certain psychotropic medications can
cause Q-T prolongation, the stress of being placed
in restraints in conjunction with the effects of these
medications may be deadly.
Another example of potential complications
caused by psychopharmacotherapeutics is the use
of psychotropic agents with anticholinergic properties. Compounds with anticholinergic properties
act by inhibiting the action of acetylcholine at
autonomic effector sites innervated by postganglionic cholinergic nerves, and at presynaptic and
postsynaptic receptors of neurons (Hyman & Nestler, 1993). Antihistamine agents, phenothiazines,
tricyclic antidepressants, and some anti-Parkinsonian medications also possess this muscarinic receptor blocking activity (Hyman, Arana, & Rosenbaum, 1995). Children are more susceptible to the
adverse effects of anticholinergic drugs. These
range from dryness of skin and mucous membranes, mild tachycardia, constipation, urinary hesitancy to more severe signs, such as urinary retention, agitation, motor restlessness, confusion,
myoclonus, delirium, fever, and seizures (Watemberg, Roth, Alehan, & Epstein, 1999).
One of the systemic effects of these medications
is the attenuation of normal body cooling mechanisms. Children with extreme agitation who are
struggling with staff and against restraint have
decreased ability to discharge or release the heat
generated by this increased activity. Body temperature may increase and a serious and potentially
life-threatening hyperpyrexia may result.
The Possible Role of Rhabdomyolysis
There is no specific evidence that rhabdomyolysis occurs in situations of restraint, but this possibility has not been investigated either. However,
a review of the literature yields data that might lead
to future investigations. Rhabdomyolysis is a disorder that occurs both as a primary condition secondary to hereditary metabolic or structural abnormalities of the skeletal muscle cell, or as a
complication of various disease states. However,
the majority of the cases occur in otherwise healthy
persons as a result of strenuous exertion, infections, intoxications, deficiency states, prolonged
stasis, or trauma (Knochel, 1993; Manchip &
Hurel, 1995). Rhabdomyolysis (lysis of skeletal
muscle cells) is a potentially lethal condition that
has a broad spectrum of clinical and biochemical

291

findings. Current evidence suggests that some noxious factor injures the plasma membrane of the
cell, which interferes with its metabolism and disrupts the integrity of the skeletal muscle cells.
Common features of this condition are myalgia,
pigmenturia, and increased serum creatinine kinase. Rhabdomyosis is also associated with severe
metabolic disturbances and involvement of other
organ systems. Major complications are acute renal
failure and death (Poels & Gabrels, 1993).
Some reports and studies on rhabdomyosis
might shed light on some of the unexplained deaths
that have been associated with the use of restraints.
Manchip and Hurel (1995) reported a case of rhabdomyosis in a man medicated with lorazepam
who was suffering from an acute manic episode,
which they attributed to excessive exertion and
dehydration. Physicians in Germany reported a
case of rhabdomyosis in a 19-year-old healthy man
following his completion a 15-km march. This
young man developed acute respiratory failure,
renal failure, and consumption coagulopathy. He
required 8 days of intensive care treatment (Derstappen, Mathias, & Losse, 1995). Likewise the
condition was reported in 5 otherwise healthy sailors and marines who had begun a vigorous exercise program 1 to 3 days before the development of
symptoms (Brown, Elliott, & Sray, 1994). Rhabdomyosis was also reported in a 21-year-old man
who performed more than 100 deep knee bends
(Frucht, 1994).
Hyponatremia and benzodyazepines, the use of
chlorpromazine, and full-sheet restraint were reported as contributing factors in the development
of rhabdomyosis (Fernandez-Real, Ricard-Engel,
Camafort-Babkowski, 1994; Jermain & Crismon,
1992). Finally, Mercieca and Brown (1984) reported a case of rhabdomyosis in an otherwise
healthy patient who was experiencing a psychotic
reaction secondary to the use of a hallucinogen and
had been restrained in a straitjacket.
NURSING IMPLICATIONS

Clearly further research must be conducted on
this important issue. But the information that we
gleaned from the literature suggests that nurses are
obliged to recognize that restraining patients is not
a benign event from a physiologic standpoint. It
suggests that well-educated psychiatric nurses
need to take back psychiatric nursing practice. By
this the authors mean that a prerequisite of caring

 292

for vulnerable patients under psychiatric care is to
be with those patients. Patients deserve knowledgeable caretakers with the ability to recognize a
potentially escalating situation, intervene in that
situation, and monitor patients for adverse effects
related to the situation and the intervention.
Yet as far back as 1973, Rosenhan found that
mental health aides spent an average of 11.3% of
their time outside of the nursing station and that
nurses and physicians spent even less time interacting with patients. In a more recent study Aragon
and Holmes (1990) observed that conversations
between adult psychiatric patients and staff occurred most often when patients stood immediately
outside of the nursing station. They also found that
staff members were engaged in direct care and
engagement with patients an average of 27.55%
and in indirect care, such as charting, an average of
72.45%. These 2 studies suggest that staff members may have insufficient contact with patients to
make a meaningful assessment or even to observe
the initial signs of impending violent behavior.
They also suggest that the least educated staff
members have the most patient contact.
The review of the literature also suggests that
while waiting for further research on this issue, the
psychiatric nursing community is obliged to identify a common approach on which to base practice
with potentially violent patients. The National Association of State Hospital Program Directors
(NASHPD, October 1999) has developed such an
approach that is based on a public health model.
Although an in-depth discussion is beyond the
scope of this article, in short, such a model addresses (1) primary prevention (preventing and reducing the need for seclusion and restraint); (2)
secondary prevention (early intervention, using the
least restrictive methods possible); and (3) tertiary
prevention (intervention to reverse or prevent negative consequences). The model also suggests that
feedback from each stage should be used to inform
and improve subsequent actions, and will always
lead to the selection and use of the least possible
restriction consistent with the purpose of the intervention.
Based on suggestions in the literature, nurses
practicing in settings with high seclusion and restraint use would also benefit their patients, their
fellow staff members, and themselves by obtaining
mandatory consultation with a behavior modification specialist. Donat (1998) found that such con-

MOHR AND MOHR

sultation could help reduce seclusion and restraint
use by more than 60%.
Finally, moving beyond the subject of restraints
per se, this review of the literature points out that
“mental states” have their representation in brain
neuronal functions. It also underscores the remarkable plasticity of the brain and other parts of the
nervous system at all levels of organization. It
points out that each environmental influence results in brain changes and that the days of the
“mind” as something disconnected from body are
long gone. Advances in the understanding of the
brain-body connection and the effects of the environment on the brain are exciting new knowledge.
This knowledge comes with a responsibility and
mandate for psychiatric nursing to learn and incorporate it into both education and practice.
The psychiatric nursing community is encouraged to base their practice, their textbooks, and
their educational programs on these current and
relevant research findings. McCabe (2000) called
on the specialty to identify their core content and
divest itself of outdated and empirically unsupported practices. As she points out, nursing textbooks that still contain theories and unsupported
practices in empirical study do not enhance the
credibility or the future of the specialty.
CONCLUSION

The purpose of this article was to bring together
an extensive literature review to present an overview of some hypothesized and established complications of restraint use. These range from injury
to immune systems and patient trauma to death.
These authors conclude that given the lack of discussion of this issue in nursing texts and journals,
the extant literature concerning the use of restraints
and seclusion does not currently represent a body
of knowledge on which clinicians can continue to
use this security measure uncritically. Clearly research is needed that will provide clinicians with
data that will effect a reduction in these coercive
measures.
Finally, to the extent that caring for human beings and protecting them from harm is part of the
ethical codes of many health care professionals,
there are ethical and moral elements to the issues
of restraints. Consistent with the principle of beneficence and the obligation to do no harm, professionals are obliged to minimize any unintended
adverse consequences of any intervention. In view

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293

of evidence of restraints’ deleterious effects, their
continued use in circumstances where less restrictive or intrusive alternatives are reasonably available to accomplish the legitimate goal of child
safety or the safety of others violates the principles
of beneficence and nonmaleficence (Moss & La
Puma, 1991; Strumpf & Evans, 1991).
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