The use of physical restraints on nursing home patients declined nearly 40 percent nationally in recent years as the federal government, states and the nursing home industry placed greater emphasis on eliminating what once was a common practice. 

Overall, about 5.9 percent of 1.5 million long-term patients were physically restrained repeatedly in 2006. That's a drop from 9.7 percent in 2002.

Physical restraints, such as bed rails or wheelchair belts, were once regarded as necessary to improve safety, to keep patients from falling or wandering off, but that mind-set has changed during the past two decades.

States where physical restraints for nursing home patients were most frequently used in 2006 were: California, 13.4 percent; Arkansas, 13.2 percent; and Oklahoma, 11.5 percent.

States where restraints were least frequently used were Nebraska, 1.3 percent; and Iowa, Kansas and Maine, 2 percent. The nursing home data was part of an Agency for Healthcare Research and Quality report that compares states on numerous health issues.

Mary Jean Koren, assistant vice president at The Commonwealth Fund, a research group, said that changes to federal law in 1987 made it illegal for nursing homes to use restraints to discipline residents or as a matter of convenience. The restraints can only be used for medical reasons, such as to prevent a resident from tearing out an IV. Until the change in law, restraints were standard procedure in many homes.

"We didn't know better," Koren said. "We didn't understand what it did to people both physically and psychologically."

Those effects typically include depression, pressure sores and dehydration, she said. Research has also shown that restraints even increased the likelihood of injury as the restrained residents lost strength due to inactivity, making it harder for them to walk once they were allowed to move around.

Heather Thompson, director of nursing at Oakview Terrace, a nursing home in Freeman, S.D., said that about 21 percent of the home's residents were physically restrained in the fourth quarter of 2003. However, since May 2006, the home's policy has been that no restraints can be used on residents.

"It was kind of a scary deal for staff and for family," Thompson said. "In the past, restraints were always seen as something that was keeping the person safe. We thought that by restraining the frail, elderly person, they wouldn't fall and that we were helping them."

Family members have even reported the nursing home to South Dakota authorities because staff refused to allow any restraints, Thompson said.

"It's gotten to be quite heated at times," she said.

Thompson said that technology and greater anticipation of a patient's needs are good substitutes for restraints. For example, the unit for patients with Alzheimer's disease has doors that require a code before they will open. That way patients can't wander away. Beds can be lowered all the way to the ground, eliminating the need for rails for those patients susceptible to rolling out of bed.

Thompson said the nursing home also emphasizes increasing the patients' physical activities to improve their strength. Most importantly, she said, staff members are trained to work exclusively with certain patients.

"They have to have the same staff working with the same group of residents, to get to know their habits, their routines, their behavior," she said.

She said that nursing home workers that used restraints on patients had good intentions.

"The people working in nursing homes weren't bad people. They were just looking at it differently," she said.

Nursing homes, consumer groups and other organizations have pooled their resources through a program called Advancing Excellence in America's Nursing Homes. The organization's goal is to reduce by 30,000 the number of nursing home patients who are physically restrained. The timeline for that goal is September. 

"We're seeing this very rapid decline because all the interested parties are coming together around this issue," Koren said. "Everyone is putting their best thinking to it to see how we can reduce the use of these restraints."