4.2 Lower Extremity Interventions Post Acquired Brain Injury
4.2.1 Casting
As mentioned earlier, spasticity frequently results in musculoskeletal contractures (Mayer 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 premises for the effect of casting on hypertonia and joint mobility are neurophysiologically 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, it is likely that muscle and connective tissues are elongated when immobilized in a stretched position (Mortenson & Eng, 2003) There is also the potential that casting may 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.
Seven studies evaluating serial casting techniques to manage spasticity-induced contractures post ABI were identified.
Individual Studies
Table 4.4 The Effect of Serial Casting Techniques in Managing Spasticity
|
Author/Year/ Country/ Study design/ PEDro/D&B Score |
Methods |
Outcome |
|
Moseley et al., (2008) |
N=26 Individuals with ABI were randomly assigned to one of two groups: Serial casting (n=14) or Passive Stretch (n=12). Those in the serial casting group all had long arm synthetic casts applied for 2 weeks with the elbow in a stretched position. Casts were changed to progress the stretch. Changes in the arm (blood circulation etc) were monitored. At the end of the 2 weeks the cast was removed and the participants underwent passive stretching 1hr/week for 4 weeks. The other group were subjected to passive stretch which was applied to the elbow flexor muscles for 1 hour/day 5x week. The elbow was stretched until the subject reported feeling the stretch or until the physiotherapist felt the arm had been significantly stretched. Torque controlled passive elbow extension was measured at baseline, post-intervention and at follow-up. |
All participants completed the study. Those in the serial casting group had a greater reduction in contracture in the short term: serial casting reduced contracture by approximately 22º (p<0.001) when compared to the positioning group, although this difference was not noted one day later. At follow up assessment, there was no differences between the groups (p=0.782). When looking at spasticity, pain, or maximum reach there was not significant differences between baseline measures and those reported at post intervention, or follow-up. |
|
Verplancke et al., (2005) |
N=28 Severely brain injured individuals (aged 17-60, GCS <= 6) unable to achieve 3 degree passive ankle dorsiflexion at 65 newtons of force were randomized into control, serial casting and serial casting with Botox groups to measure effect on calf contracture after ABI. |
88% of patients developed spasticity within 14 days of injury. Mean range of ankle PROM (degrees) improvement was 4.59 in controls, 11.69 in cast (saline) and 13.59 in cast (Botox). Casting vs. controls significantly different (p=0.07), but not saline vs. Botox (p=0.11). |
|
Moseley (1997) |
N=9 TBI adults with plantar-flexion contractures completed a casting combined with stretching intervention to improve passive ankle dorsiflexion movement (PAD). |
PAD movement increased (mean: 13.5 degrees) during treatment compared to a decrease (mean: 1.9 degrees) for control condition (significant). |
|
Hill (1994) |
N=15 Severe brain injury subjects who had suffered a brain injury no more than 2 years before and who experienced unilateral or bilateral hypertonicity and contractures in their upper extremities that interfered with function were randomly assigned to receive either serial casting or traditional therapy for 1 month. In a cross over fashion, patients received the other treatment (casting or traditional) during the second month. Casts were left in place for 5-7 days and then replaced incorporating any gain in rage of motion (ROM). Traditional therapy included: passive and active ROM, prolonged stretch, splinting, neurophysiological and relaxation techniques. |
Goniometric measurements of ROM, performance on a variety of functional tasks, goniometric measurements of joint angle at which stretch reflex was elicited and observation of rapid alternating motions were assessed after each treatment condition. Gains made in passive ROM during the month of casting were greater than those made during traditional therapy (p=0.014). Significantly greater improvements in point of stretch reflex angle elicitation with casting (p=0.001). No significant changes in rapid alternating motions or performance on functional tasks after casting, although these values showed improvements over traditional therapy. |
|
Kent et al., (1990) |
N=36 (cases=18, control=18) Adults with open or closed TBI (mean age: 28 yrs) treated by unilateral lower extremity serial plaster casting during post-acute rehabilitation phase were retrospectively matched by age, gender and admission ambulatory score (Holden Scale) to noncasted control group from same centre and compared by ambulatory status as measured by the Holden Scale. |
At discharge, 1 of the 18 cast subjects had reached level 5 of the Holden Scale (ambulatory independent) and 12 were rated at level 4 (independent at level surface), whereas none of the control group had scored at level 5, but 10 had advanced to level 4 (no significant statistical difference between groups). |
|
Pohl et al., (2002) |
N=105 A stepwise reduction of fixed, flexed joint contracture via serial casting attempted TBI, hypoxic and sub-arachnoid hemorrhage patients. Conventional casting of 5-7 day (control) and 1-4 day (treatment) intervals to maximum possible extension (<10% of extension deficit) or when extension deficit fails to reduce after two cast changes. Maximum deficits of different joints (elbow, wrist, knee, ankles), Range of Motion (ROM) defined the percentage of maximal passive ROM. Maximal ROM to neutral position defined as 140º (elbow), 150º (knee), 50º (wrist) and 50º (ankle). ROM was documented before casting, after each change, and 1 month after treatment. FIM completed before casting |
6.9 day median change interval for 92 joints of 56 control group patients. 2.7 day median change interval for 80 joints of 49 patients. Range of motion (ROM) post treatment and at follow-up (p<0.001) and percentage of maximum ROM (treated joints; p=0.03.) improved significantly in both groups. Casting complications (p=0.001), and discontinuation rate increased (p=0.03) in control. |
|
Singer et al., (2003) |
N=16 Subjects (aged 17-52, chronicity 2-10 months) with ABI, and equinovarus deformity of 1 or both ankles received below knee plaster casts re-applied weekly to increase joint range and muscle extensibility. |
There were significant improvements in ankle range (with knee extended and flexed: p<0.0001). 13 subjects reduced their need for transfer assistance (p<0.0015). |
|
Singer et al., (2003) |
N=9 ABI subjects admitted to a neurosurgical rehabilitation unit and unable to achieve a plantigrade position on one or both ankles when maximal passive stretch applied received a serial casting procedure addressing extensibility, passive resistance torque and stretch reflex response. Casts applied weekly, and continued until objective achieved, or no measurable gain recorded. |
Muscle extensibility and passive torque improved significantly over time (p<0.0001). Functional range maintained in 8 subjects at 6-month follow-up. |
|
Conine et al., (1990) |
N=10 Adult head injury patients (mean age: 28, admission GCS range 3-8) with passive ankle dorsiflexion of 0 degrees or less on admission or presence of spasticity received serial casting treatment within 14 days of injury for the prevention or correction of equinus. |
18 limbs were cast for an average of 5 casts over a duration of one month. There was a significant increase in dorsiflexion ROM after casting intervention (p<0.05). |
PEDro = Physiotherapy Evidence Database rating scale score (Moseley et al. 2002).
D&B = Downs and Black (1998) quality assessment scale score.
Discussion
Nine studies (Table 4.4) were identified which evaluated the effect of serial casting on change in range of motion of the casted joint. Moseley et al. (2008) found that those patients randomly assigned to the elbow serial casting group showed a greater reduction in elbow contractures post treatment; however, this improvement was only sustained for one day. Follow up assessments of patients found no improvements between the groups. Improvements noted immediately post intervention were not seen during the follow-up phase.
Moseley (1997) used a randomized open cross-over design to compare 1 week of casting combined with stretching compared to 1 week of a control condition 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.
In another RCT of casting, Verplancke et al (2005) found that casting compared to a control population was effective for improving range of motion; however there was no difference comparing persons casted with or without Botulinum toxin.
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; 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 (PEDro = 3), thus weakening the strength of its conclusions.
In a retrospective controlled trial, Pohl et al. (2002) compared short (1 to 4 days) duration casting to longer duration (5 to 7 days) casting for both upper and lower extremity joints. Although improvements in range of motion were seen in each group, there was no significant difference in this outcome after 1 month of casting. However, the discontinuation rate in the longer duration group due to complications was significantly higher than for the short casting interval group.
Using single group interventions designs, Singer (2003) and a study by Conine (1990) suggested that serial casting is effective for improving range of motion.
Kent et al. (1990), compared discharge ambulation scale scores of patients who were casted to control patients who were not casted. The investigators did not find any significant differences in ambulation outcome between the groups. Actual ranges of motion of the joints that were casted were not recorded.
Table 4.5 Summary of the Effect of Serial Casting Techniques in Managing Spasticity
|
Authors/ Year |
n |
Intervention |
Result |
|
Moseley et al., (2008) |
26 |
Serial casting or positioning for 2 weeks. |
Serial casting |
|
Pohl et al., |
105 |
Conventional (5-7days) vs shorter (1-4 days) serial casting change intervals |
Range of Motion |
|
Moseley (1997) |
9 |
Short term effects of no casting or stretching (control) vs casting combined with stretching (experimental) using crossover design. |
Passive Ankle Dorsiflexion |
|
Hill (1994) |
15 |
Effects of traditional therapy (control) vs. serial casting combined (experimental) using crossover design. |
Passive ROM (+) |
|
Kent et al., |
18 |
Effect of unilateral lower extremity serial plaster casting on ambulatory function during post-acute phase of rehabilitation |
Holden Scale |
|
Singer et al., (2003) |
16 |
Below knee plaster casts re-applied weekly to increase joint range and muscle extensibility |
Ankle Passive Range of Motion (+) |
|
Singer et al., (2003) |
9 |
Serial casting to correct spastic ankle equinovarus deformity |
Maximal Ankle Passive Range of Motion (+ post intervention and at 6 months) |
|
Verplancke et al., |
28 |
Effects of Standard physical therapy (control) compared to lower leg casting plus saline injections (treatment group 1) and lower leg casting plus Botox injections (treatment group 2) on the development of calf contracture. |
Maximal Ankle Passive Range of Motion(- control vs saline) |
|
Conine et al., (1990) |
10 |
Serial Casting within 14 days of injury for prevention or correction of equinus |
Dorsiflexion Range of Motion (+) |
(+) Indicates statistically significant differences between treatment groups
(-) Indicates non-statistically significant differences between treatment groups
Conclusions
There is Level 1 evidence based on one small RCT that serial casting does induce transient increases in range of motion; however, these effects were noted for only one day post treatment.
There is Level 2 evidence based on a single RCT that serial casting does reduce ankle plantar flexion contractures due to spasticity of cerebral origin.
There is Level 3 evidence that short duration (1 to 4 days) serial casting has a significantly lower complication rate than longer duration (5 to 7 days) serial casting; however, there was no difference in range of motion outcome.
Based on a single RCT there is Level 2 evidence that casting alone is as effective as casting and Botulinum toxin injections for treating plantar flexion contractures due to spasticity of cerebral origin.
|
Serial casting reduces ankle plantar flexion contractures.
|
4.2.2 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 could include the ease of adjustability and the ability to remove it for short periods of time on a daily basis.
Individual Studies
Table 4.6 Treatment of Ankle Plantar Flexion Contractures with Adjustable Orthosis
| Author/Year/ Country/ Study design/ PEDro/D&B Score |
Methods |
Outcome |
|
Grissom and Blanton |
N=5 ABI subjects with passive ankle dorsiflexion of 0 degrees or less received an adjustable orthosis if there was less than a 5 degree change in passive range of motion (PROM) after receiving a 2% lidocaine block of the tibial nerve. Device worn 23 hrs/day with adjustments (0 – 4.5 degrees) every 48-72 hours for 14 days. |
There was a significant mean gain in dorsiflexion of 20.1 degrees (range: 6-36) (p=0.0078). Skin and pain complications occurred in 44% of treated ankles. |
D&B = Downs and Black (1998) quality assessment scale score.
Discussion
In this single group intervention comparison study Grissom and Blanton (2001), the pre-fabricated ankle orthosis demonstrated a significant improvement in ankle dorsiflexion after 2 weeks. One significant concern, however, was the relatively high complication rate of skin breakdown that occurred with splinting.
Conclusions
There is Level 4 evidence that a pre-fabricated, adjustable ankle foot orthosis does reduce ankle plantar flexion contractures due to spasticity of cerebral origin.
|
A pre-fabricated adjustable ankle foot orthosis reduces ankle plantar flexion contractures.
|