Contracture Management in Spinal Cord Injury

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Introduction

The most common complication of spinal cord injury is contractures. It is a debilitating problem for patients suffering from a spinal cord injury. Contractures result from a loss in the extensibility of the soft tissue structures-skin, ligaments, muscles, and joint capsules crossing joints, leading to restriction in joint mobility, causing joint stiffness, and later on the deformity. Contractures reduce joint mobility and restrict activities of daily living. They are also associated with pain, spasticity, sleep disturbances and skin breakdown. Most often contractures affect the joints important to daily living: hips, knees, ankles, wrists, and shoulder, causing problems with dressing, eating, transferring, sleeping comfortably, using a wheelchair, or doing any tasks that require full joint movement. Problems in any of these areas can reduce a person's independence.

According to a prospective cohort studying the incidence of contracture at one year after spinal cord injury showed that 66% of the patients developed at least one contracture in any joint at one year after acute spinal cord injury. The proportion of participants with paraplegia developing at least one contracture in any joint was 47%, while the proportion of participants with tetraplegia who got at least one contracture in any joint was 83%.

Causes of contracture

Contractures occur in patients with SCI as a result of paralysis combined with prolonged sitting and lying

• prolonged immobilization and
• habitual use of soft tissues in their shortened range.

Factors

Contractures are characterized by decreased range of motion and increased stiffness. An increased resistance to stretch caused by changes in the mechanical properties of tissues is due to both neurally and non-neurally mediated factors 

Non-neural factors

• changes in mechanical properties of tissue resulting from stress deprivation,
• secondary to orthopaedic injury, heterotopic ossification,
• pain,
• paralysis,
• severe spasticity or
• any disorder that restricts movement Contractures also produce structural changes within muscles; myofibril shortening and loss of sarcomeres are often observed, as well as relative increase in connective tissue causing loss of elasticity.

Neural factors

Are due to central origin and cause muscle overactivity. They cause spasticity, increase interdigitation between actin and myosin, thus reducing muscular concentric contraction range and producing rigidity, because of the absence of monosynaptic reflex inhibition.

Common contractures

Research findings suggest that patients with tetraplegia have a higher rate of contractures than those with paraplegia. Patients with motor complete C5 tetraplegia are prone to developing elbow flexion contractures as they commonly sit with their elbows positioned in flexion on the armrests of wheelchairs and lie with their elbows flexed in bed and triceps paralysis, and they retain voluntary control of the biceps muscles.

Patients with motor complete C5 tetraplegia are prone to developing elbow flexion contractures due to paralysis of the triceps. However, the biceps are spared and as they commonly sit with their elbows positioned in flexion on the armrests of wheelchairs and lie with their elbows flexed, these factors increase susceptibility to elbow flexion. contractures

Treatment

Stretching and Passive Movements

Stretching and passive movements were the primary treatment approaches for SCI. The passive movements and stretch would help in avoiding contractures resulting from the inability of individuals to move joints. Passive Movements can be administered using mechanical devices or manually by carers and therapists. Prolonged stretch can be administered through positioning programs, splints, standing frames, and orthoses. Heat combined with stretch followed by a maintenance of stretch during cooling with further facilitate the restoration of joint motion.

However, there are issues concerning the dosage and relative effectiveness of passive exercises and stretches administered differently. Literature suggests that five minutes, twenty minutes, or even one hour of any intervention (including stretch) does not attain a therapeutic effect. Instead, the research suggests exercises and functional activities carried out in a lengthened muscle position may have a positive outcome.

Generally, therapists recommended 20 to 30 minutes of sustained stretch per muscle a day for the prevention and treatment of contracture. However, clinical trials suggest that therapists should not expect to see a clinically meaningful change in joint mobility or muscle extensibility from stretches applied for less than 30 minutes a day over less than 3 months. A Cochrane systematic review investigating stretch interventions for the treatment and prevention of contracture due to neurological conditions including SCI concludes that stretch has no clinically important short-term or long-term effects on joint mobility in people with neurological conditions.

Splints

Orthosis reduces contractures through the prolonged low-load stretch, maintaining joint length.

Serial Casting

Casts are a feasible approach to treating contractures. These are non-removable external devices, made of plaster or casting tape, applied to change structural or functional characteristics of the neuromuscular system.

The affected joint is heated, using moist heat, and manually stretched to obtain a maximum range of motion. The cast is applied by therapist and left on for two to seven days depending on the treatment. It removed so the skin can be checked for pressure sores and then reapplied in a new position of greater stretch for several days more until the contracture eases enough to permit sufficient ROM.

During a serial casting, care must be taken to avoid pressure sores. Physical therapy must also be used to make sure the muscles not being stretched are strengthened after their period of disuse.

Exercises

Activating or strengthening the weak agonist opposing the tight muscle,  propioceptive neuromuscular facilitation techniques, such as contraction-relaxation or hold-relax may be used to inhibit the tight muscle selectively, so it will tolerate being stretched without immediate activation of the stretch reflex.

References

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