2.6 Contractures Post ABI

While on rehabilitation, the patient developed significant spasticity on the left side and to a lesser extent involving the right lower extremity.  There is concern that she is beginning to develop a number of contractures in the affected limbs.

2.6.1  Defining Contractures

Define contractures and their pathophysiology.

  1.  “Contractures are defined as a fixed loss of passive joint range of movement secondary to pathology of connective tissue, tendons, ligaments, muscles, joint capsules and cartilage.”2.
     
  2. Trauma, inflammation, ischemia, infection can produce a collagen proliferation. Initially, these collagen fibers may be deposited in a disorganized mannerbut the collagen can be organized in a linear fashion if the joint is taken through full actively or passively functional range.
     
  3. “Alternatively, if the joint is immobilized, the collagen matrix will organize in a tightly packed manner, and a contracture will result” 2.

2.6.2  Locations of Contractures

What are common locations for the development of contractures?

  1.  In the lower extremities, ankle plantarflexion, hip flexion, and knee flexion contractures are common. 
     
  2.  In the upper extremities, elbow flexion and supination contractures are also seen as are adduction and internal rotation contractures of the shoulder. 
     
  3.  Muscles that cross multiple joints, such as the biceps, hamstrings, tensor fascia lata, and gastrocnemius, are predisposed to contracture formation 2.

2.6.3  Prevention of Contractures

Discuss the prevention of contractures.

Contractures can be prevented with: 

  •  Early mobilization
     
  •  Range of motion exercises
     
  • Proper positioning
     
  • Orthotic devices          

   Other important measures include:

  •  Antispasticity medication

2.6.4  Treatment of Contractures

While on rehabilitation, the patient went on to develop a left hip flexion contracture, a left knee flexion contracture, a left plantarflexor contracture and a right plantarflexion contracture.

Discuss the treatment of contractures.

Once a contracture has developed, a variety of interventions are available:

  1. Factors that contribute to contracture formation should be treated, i.e. pain,   spasticity, inflammation and improper positioning;
     
  2. Physical interventions include therapeutic heat (i.e. ultrasound) prior to a stretching    program;
     
  3. Manual stretching: terminal sustained stretch is essential;
     
  4.  Serial casting;
     
  5. Dynamic splinting;
     
  6. Phenol nerve blocks;
     
  7.  Botulinum toxin injections;
     
  8.  Intrathecal baclofen administration;
     
  9. Orthopedic surgical procedures, such as joint manipulation, tendon release and tendon lengthening.
  • Treatment of contractures depends on their severity 10.
     
  • Pharmacological treatmentsaddress abnormal muscle tone and may help with reducing spasticity.
     
  •  However, the more general pharmacological treatments may have adverse effects on attention and cognition 10;11.
     
  •  Focal pharmacological treatment is effective in reducing localized tone without suffering the possible systemic side effects seen with more general treatments.
     
  • Non- pharmacological intervention is effective in tone reduction in a specific muscle groups such as lower limb adductors or plantar flexors.
     
  • Potential treatments and the evidence supporting their use are listed in the table below. 

What evidence is there supporting the various treatments of contractures post ABI?

Treatment of Contractures

Level of Evidence

 

Discussion

Electrical stimulation

Level 4

May be helpful in reducing lower extremity spasticity for up to 24 hours.

Serial Casting

 

 

Can be addressed to prevent and treat contractures 10

Level 2

May reduce ankle plantar flexion contractures due to spasticity.

Level 3

Short duration (1 to 4 days) has a significantly lower complication rate than longer duration (5 to 7 days)

Dynamic Splinting

Level 1

According to Marshall et al.12hand splintingis uses to prevent contractures and release spasticity after acquired brain injury.

Phenol Neural Blocks

Level 4

May temporarily reduce contractures and spasticity at the elbow, wrist and finger flexors for up to 5 months post injection.

Botulinum Neurotoxin Injections

Level 4

Effective for the treatment of localized spasticity and can be managed if oral treatments are associated with significant adverse effects                                                                                            

Intrathecal baclofen

 

 

Serves to reduce the side effects of oral baclofen treatment for patients who have arousal, attention and cognitive problems.  It can also help control hypertension in ABI. The intrathecal route requires much smaller doses of oral baclofen.  However, overdose of intrathecal baclofen can lead to coma and respiratory depression 11.

Level 1

Reduce upper and lower extremity spasticity over the short-term (up to 6 hours).

Level 4

Prolonged treatment results in long-term (3 months, and 1 year) reductions in spasticity of the upper and lower extremities.

Surgical intervention

 

Contractures may assist with skin care and hygiene, avert the development and advance the healing of pressure sores, decrease pain and advance transfers and ambulation. The procedures are generally regarded as last resort to be used in extreme cases to increase function and tend to be limited to more chronic patients 10.

What is the rationale behind serial casting for contractures post ABI

  1. Musculoskeletal contractures are often associated with spasticity.
     
  2. Spasticity may be reduced by the effect of prolonged stretch or the effects of neutral warmth and prolonged pressure reducing cutaneous sensory input to the spinal cord.
     
  3. Muscles and connective tissues are elongated when immobilized in a stretched position.
  •  Musculoskeletal contractures often are associated with spasticity 14.
     
  • 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 position15.
     
  • There is also the potential that casting may be a reasonable adjunct to other therapies such as pharmacological interventions.

 

For a more detailed discussion on contracture post ABI please see ERABI/Motor and Sensory Impairments Remediation Post Acquired Brain Injury.

What is the evidence that serial casting is effective?

  1. There is Level 2 evidence, based on a single RCT, that serial casting reduces ankle plantar flexion contractures due to spasticity of cerebral origin.
     
  2. These is Level 3 evidence, based on a single RCT, that casting alone is as effective as casting and Botulinum toxin injections for treating plantar flexion contractures due to spasticity of cerebral origin.
     
  3. There is Level 2 evidence, based on a single RCT, that casting alone is as effective as casting and Botulinum injections for treating plantar flexion contractures due to spasticity of cerebral origin.
  • 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. 
     
  • Based on multiple studies reviewed, overall it was found that serial casting did help to reduce plantar flexion contractures.

     

For a more detailed discussion of serial casting post ABI please see ERABI/ Motor and Sensory Impairments Remediation Post Acquired Brain Injury.

2.6.4.2  Adjustable Orthoses for Contractures Post ABI

What is the rationale for use of adjustable orthosis to treat contractures and what are the advantages over serial casting?

  1.  Similar to casting, an adjustable pre-fabricated orthosis would potentially provide prolonged stretching of an ankle plantar flexion contracture. 
  2. 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.

What evidence is there for the use of adjustable orthoses in the management of contractures post ABI?

  1. There is Level 4 evidence that a pre-fabricated ankle foot orthosis does reduce ankle plantar flexion contractures due to spasticity of cerebral origin.
  • A single group (n=5) comparison study by Grissom and Blanton16found intervention with a fabricated ankle orthosis resulted in a significant improvement in ankle dorsiflexion after 2 weeks; mean gain in dorsiflexion of 20.1 degrees (range: 6-36) (p=0.0078). 
     
  •  A significant concern was the relatively high complication rate of skin breakdown that occurred with splinting. 

     

For a more detailed discussion on adjustable orthoses post ABI please see ERABI/Motor and Sensory Impairments Remediation Post Acquired Brain Injury.