4.3 Contractures

4.3.1  Definition of Contractures

Define contractures and 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” 31.
     
  2. Trauma, inflammation, ischemia, infection can produce a collagen proliferation. Initially, these collagen fibers may be deposited in a disorganized manner but 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”  31.

4.3.2  Common 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 31.

4.3.3  Prevention of Contractures

List important interventions in the prevention of contractures.

Contractures can be prevented with: 

1.    Early mobilization

2.    Range of motion exercises

3.    Proper positioning

4.    Orthotic devices                                     

Other important measures include:  Antispasticity medications

4.3.4      Treatment of Contractures

List the interventions available for 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 the severity (p. 295)32.

Non- pharmacological interventionsare effective in tone reduction in a specific muscle groups such as lower limb adductors or plantar flexors.  Physical management interventions such as range of motion, positioning, hygiene, etc. should be considered in rehabilitation for patients with disorders of consciousness33Occupational Therapy and Physiotherapy programs have been developed to assist with Range of Motion (ROM) and positioning programs.      

Pharmacological treatments address abnormal muscle tone and may help with reducing spasticity.  However they may have adverse effects on attention and cognition ((p. 294-5)32 and (p.634)34).  Focal pharmacological treatment is effective in reducing localized tone.  Pain needs to be managed as it can increase spasticity and reduce range of motion exercises. 

 

Meythaler 35 recommends the following treatment protocol when dealing with the spastic limb prone to contractures:

  1. Splinting and ROM
     
  2. Modalities and/or casting 
     
  3. Medications:
  • Dantrolene sodium
  • Baclofen
  • Tizanidine
  • Neurolytics (Botulinum toxin, Phenol)
  • It is recommended that one proceed to the first three options before moving to the neurolytics.

Table 2: Evidence for Treatment of Contractures Post ABI

Treatment of Contractures

Level of Evidence

(ERABI 2008)

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 (p295)32

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. 36hand splinting is 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 (p.635)7

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 procedure are generally regarded as last resort to be used in extreme cases to increase function and tends to be limited to more chronic patients (p.295)32.

4.3.5    Serial Casting for Contractures

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 spasticity7. In a study conducted by Yarkony and Sahgal 37the incidence of spasticity was has high as 87%. The theoretical premises for the effect of casting on hypertonia and joint mobility are neurophysiologically and biomechanically based 38. 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 position38. There is also the potential that casting may be a reasonable adjunct to other therapies such as pharmacological interventions.

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. Overall it was found that serial casting did help to reduce plantar flexion contractures. Results from the seven studies reviewed indicate the following (see Table 3) 39.

Table 3: Summary of the Effect of Serial Casting Techniques in Managing Spasticity

Authors/

Year

n

Intervention

Result

Pohl et al. 40

 

105

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

Rangeof Motion

(+ improvement post treatment and at 1 month follow-up in both groups)

(- differences between groups)

Moseley 41

 

9

Short term effects of no casting or stretching (control) vs casting combined with stretching (experimental) using crossover design.

Passive Ankle Dorsiflexion

(+ short term)

Kent et al. 42

 

18

Effect of unilateral lower extremity serial plaster casting on ambulatory function during post-acute phase of rehabilitation

Holden Scale

(- ambulatory improvement between treatment group and matched retrospective controls)

Singer et al. 43

 

16

Below knee plaster casts re-applied weekly to increase joint range and muscle extensibility

AnklePassive Rangeof Motion (+)

Transfer Assistance (+)

Rancho Los Amigos Scale

(- before compared to 3 months post intervention)

Singer et al. 44

 

9

Serial casting to correct spastic ankle equinovarus deformity

MaximalAnkle Passive Rangeof Motion (+ post intervention and at 6 months)

Passive Resistance Torque Angle

(+ over casting period)

Verplancke et al. 45

 

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.

MaximalAnkle Passive Rangeof Motion(- control vs saline)

(+ control vs Botox)

(- saline vs Botox)

GlasgowOutcome Scale

(+ treatment groups)

Modified Ashworth Scale

(+ treatment groups, - control group)

Conine et al. 46

10

Serial Casting within 14 days of injury for prevention or correction of equinus

DorsiflexionRangeof Motion (+)

Hill 47

15

Effects of traditional therapy (control) vs. serial casting combined (experimental) using crossover design.

Passive ROM (+)

Point of stretch reflex angle elicitation (+)

Rapid alternating motions (-)

Performance on functional tasks (-)

(+) Indicates statistically significant differences between treatment groups; (-)  Indicates non-statistically significant differences between treatment groups. For further details on spasticity and casting post ABI please see Marshall et al.,39

4.3.6  Adjutable 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.

In a single group comparison study conducted by Grissom and Blanton48they found intervention with a fabricated ankle orthosis demonstrated a significant improvement in ankle dorsiflexion after 2 weeks; mean gain in dorsiflexion of 20.1 degrees (range: 6-36) (p=0.0078). One significant concern was the relatively high complication rate of skin breakdown that occurred with splinting. Another concern is the very small sample (n=5) of individuals with an ABI who participated in the study.