Contracture Management pesentation by Dr. Jason Henderson DPT at Ergos Solutions Washington DC

1. Contracture Management Ergo Solutions Dr. Jason Henderson DPT

2. Muscle contractures can occur for many reasons, such as paralysis, muscular atrophy , and forms of muscular dystrophy. Fundamentally, the muscle and its tendons shorten, resulting in reduced flexibility. the loss of strength Loss of muscle control leading to an imbalance between the various muscle groups around specific joints. Muscle Contracture www.georgorrehab.com

3. Various interventions can slow, stop, or even reverse muscle contractures physical therapy surgery. Interventions www.georgorrehab.com

4. Contractures occur when the soft tissues cannot accommodate changes in bone length. To treat contractures effectively, one needs to identify the potential problem muscles. In tibial lengthening, for example, the problem muscles are the gastrocnemius and toe flexors. As a result, patients can develop knee flexion, ankle plantar flexion, and toe flexion contractures. In the femur, both rectus femoris and hamstring muscles resist lengthening.. Contractures- Lower Extremity www.georgorrehab.com

5. This can result in a fixed flexion deformity of the knee and a flexion range of motion deficit. Lengthening of the humerus involves the fewest problems. If problems do arise, they are the result of biceps and brachioradialis tightness. In the forearm, finger flexors tighten more quickly, causing proximal and distal interphalangeal flexion and hyperextension of the metacarpophalangeal joints. Upper Extremity www.georgorrehab.com

6. Positioning: Optimal maximal positions vary based on the body parts that are affected. For example, patients who are undergoing tibial lengthening should be positioned with the knee extended straight and the ankle flexed up. Knee extension along with hip abduction is a desirable position for patients who are undergoing femoral lengthening. Patients undergoing humeral lengthening need elbow extension. Patients undergoing forearm lengthening require elbow extension (elbow straight), wrist in slight dorsiflexion (bent upward and backward), and finger extension (straight). Therapy www.georgorrehab.com

7. Splints: Custom designed splints help to keep the soft tissues (muscles and tendons) stretched properly. Using a splint to place a muscle under tension for as many hours as possible helps prevent contractures by obtaining plastic response in the connective tissue Therapy www.georgorrehab.com

8. Dynamic splinting: In certain situations, we use special dynamic splints. These are different from static splints because they include a spring-like or elastic mechanism to produce elongation of the tissues through a low load prolonged duration stretch. Dynamic splints work most effectively in treating knee and elbow flexion contractures. Note that splints work only in optimal positions and that their tension should always be increased gradually. These types of splints are also often used for the fingers and toes. Therapy www.georgorrehab.com

9. Electrical stimulation: Electrical stimulation can be used as an adjunct to a strengthening program and to augment voluntary muscle contraction. To accomplish this, a muscle stimulator machine is applied to the surface of the limb (thigh, for example) and a low level electrical signal stimulates the underlying muscle to contract. Some children do not tolerate this well. Therapy www.georgorrehab.com

10. Hydrotherapy (water therapy): Hydrotherapy helps patients avoid significant muscle weakness, especially when both legs are being lengthened. It promotes active range of motion. The natural buoyancy allows simulated weight bearing. The higher the level of the water (chest deep versus waist deep, for example), the more "weightless" one feels. Hydrotherapy also helps in keeping pin sites clean. Therapy www.georgorrehab.com

11. Progressive weight bearing: Programs of progressive weight bearing are important during all phases of limb lengthening rehabilitation. During the lengthening phase, patients should be encouraged to perform weight bearing as prescribed. Some patients may experience pain from increased weight bearing, and the increased weight bearing can cause undue stress on the pins or wires. Weight bearing is even more critical during the consolidation phase. The patient should progress from two crutches to one and then to none. He or she should also perform closed chain exercises. (Closed chain exercises are defined as resistive exercises with which the load is applied through the feet; some examples of closed chain exercises are leg press, stair climber, and bicycle). Many patients can walk without assistive devices and have no limp during the latter part of the consolidation phase Therapy www.georgorrehab.com

12. Nerve injury occurs primarily in patients who are undergoing tibial lengthening. It happens when certain nerves do not stretch enough to accommodate the bone lengthening. Peroneal nerve symptoms during tibial lengthening are caused by referred pain in the dorsum of the foot. This pain may present initially as hyperesthesia (increased sensitivity) and then as hypoesthesia (reduced sensitivity). Weakness in the muscles that control toe and foot action are sometimes observed. Pain medications usually do not help. Referred pain in the top of the foot is increased with knee extension and is relieved by flexing the knee. When signs of peroneal nerve irritation occur, the use of a dynamic knee extension splint should be discontinued and knee extension exercises should be reduced. A patient who may be developing this condition should notify us as soon as possible. We monitor nerve function using a quantitative sensory testing device called a pressure specified sensory device (PSSD). This device measures tactile sensitivity (feeling ability) for one- and two-point touch. This device often allows us to identify nerve stretch problems even before they cause symptoms. This device does not work reliably in children younger than 6 years. In most cases, reducing the rate of lengthening reduces the symptoms of nerve irritation and the PSSD results return to normal. In cases in which patients do not respond to rate reduction, peroneal nerve decompression surgery is required. This is a small procedure that involves a small incision and, at most, an overnight hospital stay. When indicated, nerve decompression prevents permanent nerve injury and allows the nerve to recover. This, in turn, allows the lengthening to continue. Nerve Treatment www.georgorrehab.com

13. Joint Contracture Contracture around a joint can occur as a result of tissue trauma and subsequent scar formation, or joint immobilisation and resultant tissue adaptation, or as a combination of both. Connective and periarticular tissues which surround a joint heal in a clearly defined and predictable manner. Healing by mitosis (cell division) is not always possible due to either the nature/capacity of the specific tissue or size of insult. Most frequently lost cells and structure are replaced by with scar tissue, often complicating complete recovery of function. Timeframes and success of healing may vary with size, location and nature of wound (accidental or surgical), and initial management. Joint Contractures www.georgorrehab.com

14. Surgical wounds heal by first intention, healing rapidly with small degree of scarring and low risk of infection or complication (Knottenbelt, 2003). Degree of scarring is related to size and degree of the incision, and keyhole surgery is often preferred over open surgery as it limits tissue trauma, scarring and recovery time (apposition of edges). Open surgery to a joint is likely to result in some scarring as several structures are involved, and also contracture formation as postoperative ROM is likely to be restricted due to pain, functionally splinting the affected joint. Medical Treatment www.georgorrehab.com

15. As scar tissue cannot fully replicate the strength of the tissue it has replaced. Surgical incisions therefore tend to be performed longitudinally to tissues tension lines rather than transecting them, as the tissue can then has potential to regain more dynamic and tensile strength. Adhesions formed can be broken, but this induces further inflammation and can thus further scar tissue formation and this occurrence is therefore best prevented (Johnston, 1985). Medical Treatment www.georgorrehab.com

16. Joint contracture is mostly caused by immobilisation, either physical or physiological. Joint immobilisation is often used as a prescribed treatment following surgery or trauma, but can also occur as a result from any disease or situation which leads to limb disuse or recumbency. Contracture formation is therefore an adaptive reaction of affected tissues to diminished mechanical loading and altered joint position. Medical Treatment www.georgorrehab.com