Lower Extremity Interventions Post Acquired Brain Injury

Casting

Spasticity frequently results in musculoskeletal contractures (Mayer et al. 1997) and has been estimated in one study to have an incidence as high as 84% (Yarkony & Sahgal 1987). As with hand splinting, the theoretical premise for the effect of casting on hypertonia and joint mobility is neuro-physiologically and biomechanically based (Mortenson & Eng 2003). Spasticity may be reduced by the effect of prolonged stretch, or possibly the effects of neutral warmth or prolonged pressure which may in turn reduce the cutaneous sensory input to the spinal cord. From a biomechanical perspective, muscle and connective tissues are likely elongated when immobilized in a stretched position (Mortenson & Eng 2003). Casting may also be a reasonable adjunct to other therapies such as pharmacological interventions. 

Serial casting has been utilized by physiotherapists for more than 40 years and although there is consensus that this is a useful adjunct to other therapies for the management of spasticity and contracture there has been little empirical data to support it.

Individual Studies

Table: Effects of Serial Casting Techniques in Managing Spasticity

Discussion

Seven studies were identified that evaluated the effect of serial casting on change in range of motion of the casted joint.  Moseley et al. (2008) found that those patients receiving elbow serial casting showed a greater reduction in elbow contractures post intervention than individuals who receiving passive stretching; however, this improvement diminished quickly (mean reduction was 22°, then 11° one day later). Follow up assessments found no significant difference in improvements between the groups. Evidently, this intervention increases range of motion but the effects are unfortunately not maintained (Moseley et al. 2008). In a another study of casting, Hill (1994) reported that, compared with traditional therapies, casting was effective in improving range of motion and joint angle at which the stretch reflex was elicited in the upper extremity; however there was no difference between groups in performance on functional tasks or in rapid alternating motions. It should also be noted that this RCT received a poor methodological score; thus, the findings should be interpreted with caution.  

For lower extremity, Moseley (1997) used a randomized open cross-over design to compare one week of casting combined with stretching to a week of no therapy (control) for ankle plantar flexion contractures. The experimental group had a significantly improved range of passive ankle plantar flexion whereas the control condition tended to have overall deterioration of ankle range of motion (Moseley 1997). Verplancke et al. (2005) found that casting was more effective in improving range of motion than passive stretching. This study found that active prophylaxis of leg spasticity using casting is beneficial; however there was no difference comparing persons casted with or without Botulinum toxin (Verplancke et al. 2005). Future studies, with a larger sample size, are needed to examine this further. 

These studies are promising as greater ankle mobility has been shown to be associated with improved transfer independence (Singer et al. 2003).

In a retrospective case comparison study, Pohl et al. (2002) compared short, one to four days, of casting to a longer duration, five to seven days, for both upper and lower extremity joints.  Although improvements in range of motion were seen in each group immediately following the intervention and at a one month follow-up, there was no significant difference found between groups.  However, the discontinuation rate in the longer duration group due to complications was significantly higher than for the short casting interval group. From these studies, casting seems to be beneficial.

Table: Summary of the Effect of Serial Casting Techniques in Managing Spasticity

 

Authors/Year
 

 

n
 

 

Intervention
 

 

Result
 

Moseley et al. (2008)

26

Passive Stretching (control) vs serial casting (experimental)

Reduced contracture (+ post-intervention)

Reduced contracture (- follow-up)

Verplancke et al.(2005)

28 Standard physical therapy (control) vs lower leg casting + saline injections (experimental 1) vs lower leg casting + Botox injections (experimental 2)

Glasgow Outcome Scale (+ intervention groups)

Modified Ashworth Scale (+ intervention groups, - control group)

Singer et al. (2003) 16 Below knee plaster casts

Ankle Passive Range of Motion (+)

Transfer Assistance (+)

Singer et al. (2003) 9 Serial casting

Maximal Ankle Passive Range of Motion (+ post intervention and at 6 months)

Passive Resistance Torque Angle (+)

Pohl et al. (2002)

105

Conventional (5-7days) versus shorter (1-4 days) serial casting change intervals

Range of Motion (+ within groups; - between groups)

Moseley (1997)

9

No casting or stretching (control) versus casting combined with stretching (experimental)

Passive Ankle Dorsiflexion (+ short term)

Hill (1994)

15

Traditional therapy (control) versus serial casting combined (experimental)

Passive ROM (+)

Point of stretch reflex angle elicitation (+)

Performance on functional tasks (-)

(+) Indicates statistically significant differences between intervention groups
(-)  Indicates non-statistically significant differences between intervention groups

Conclusions

Based on a small RCT, there is Level 1b evidence that serial casting does induce increases in range of motion; however, these effects began to diminish one day post intervention.

There is Level 2 evidence that serial casting does reduce ankle plantar flexion contractures due to spasticity of cerebral origin.

There is Level 3 evidence that short duration (one to four days) serial casting has a significantly lower complication rate than longer duration (five to seven days) serial casting; however, there was no difference in range of motion outcome.

There is Level 2 evidence that casting alone is as effective as the combination of casting and Botulinum toxin injections for treating plantar flexion contractures due to spasticity of cerebral origin.

 

Serial casting reduces ankle plantar flexion contractures.

Serial casting appears to reduce elbow contractures; however, this effect was not sustained.

 

Adjustable Orthosis

Similar to casting, an adjustable pre-fabricated orthosis would potentially provide prolonged stretching of an ankle plantar flexion contracture.  Advantages of the orthosis include the ease of adjustability and the ability to remove it for short periods of time on a daily basis. A pre-post study by Grissom and Blanton (2001) examined six participants with mixed etiologies who received a 2% lidocaine block of the posterior tibial nerve and then wore an adjustable ankle-foot orthosis on the affected ankle for 23 hours per day for two weeks for plantarflexion contractures. Adjustments were attempted every two to three days to increase dorsiflexion passive range of motion. There was a significant mean gain in ankle dorsiflexion of 20.1° (p=0.0078). Of concern, there was a relatively high complication rate of skin breakdown and pain that occurred with splinting (44%). Further, the only individual with a TBI dropped out as the orthosis was thought to agitate the individual (Grissom & Blanton 2001). More research is needed with an ABI population before conclusions on adjustable orthoses can be made. 

 

A pre-fabricated adjustable ankle foot orthosis reduces ankle plantar flexion contractures; however, the individual should be monitored for skin breakdown and pain.