Contracture Management in Spinal Cord Injury
Original Editor - Vidya Acharya
The most common complication of spinal cord injury is contractures. It is a debilitating problem for patients with 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, 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%.
Mechanism of Contracture
Contractures are either neurally or non-neurally mediated.
- Neurally mediated contractures are due to spasticity (i.e., involuntary reflex contraction of muscles) and are common sequelae of upper motor neuron lesions. Spasticity is usually managed with medication. Stretching also induces functionally important and lasting reductions in spasticity, however, this is to be verified with good quality studies.
- Non-neurally mediated contractures are due to structural adaptations of soft tissues. Prolonged immobilization and habitual use of soft tissues in their shortened range are the leading cause of contractures. Muscle shortening is associated with a decrease in the number of sarcomeres, changes in intramuscular connective tissues' alignment, and a decrease in tendon resting length.
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 due to triceps paralysis, and as they are frequently sitting with their elbows in flexion on the armrests of wheelchairs and lie with their elbows flexed, the chances of developing elbow flexion contractures increases 
Knee flexion contractures develop in the patient using wheelchair and may lead to the development of hip flexion and abduction contractures. Upper extremities contracture may be seen at the shoulders, elbows, wrists, and fingers which limits the patient's ability to perform fine motor skills, ADLs. Ankle, wrist, and shoulder are most commonly affected.
Factors that predispose patients to contractures:
- Position: Position or postures in which the patient spends most of each day in bed or wheelchair increases the susceptibility to contracture.
- Pain: Pain increases the likelihood of contracture because it leads to an increased tendency to contract the non-paralyzed muscles, which increases the time soft tissues spend in shortened positions.
- Spasticity: The pattern and extent of spasticity directly influence the extensibility of muscles and also increases the time that muscles and surrounding soft tissues spend in shortened positions, indirectly contribute to contracture.
Assessment of range of motion for Spinal cord injury patient includes:
- Simple passive range of motion of all joints can be carried out by the therapist to assess the contractures. It is categorized on a 4-point ordinal scale:
- No Contracture: No loss in the range of motion.
- Mild Contracture: Loss of up to one-third range
- Moderate Contracture: Loss of one-third to two-thirds range.
- Severe Contracture: Loss greater than two-thirds range.
- Goniometer can be used to evaluate the passive ROM
- Another method used to assess contractures was measuring passive range of motion at standardized torque.
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.
Orthosis reduces contractures through the prolonged low-load stretch, maintaining joint length. Splints can be used for the prevention and reduction of contractures. Orthosis can be used to reduced contractures through a prolonged low-load stretch. Splinting can help both to prevent and manage length-associated changes in muscles and connective tissue. Splints can be combined with passive movements, positioning active tissue 'stretching' procedures, and/or weight-bearing exercises. Splints can be used overnight to apply sustained stretch for muscle lengthening. Dynamic splinting is another option to get a repeated stretch. A spring or elastic band provides tension to move the joint in the desired direction.
Casts are a workable approach for 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 the 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.
Proper positioning of the joints while lying in bed or sitting in a wheelchair also can prevent contractures by protecting the articulary structure and maintain the optimal muscle tone. A firm mattress can maintain normal alignment of the joints. Air circulation, water bed can be used. Pillows, sandbags, padded rolls, and hand and foot splints and braces can be used to maintain the shoulder, elbow, hand, ankle, and knee joints in fully extended positions. Plaster splints or orthosis like ankle-foot orthosis, knee-ankle-foot orthosis, or static ankle-foot orthosis can be used for positioning.
- Activating or strengthening the weak agonist opposing the tight muscle can help prevent contractures.
- Proprioceptive neuromuscular facilitation (PNF) techniques, such as contraction-relaxation or hold-relax may be used to inhibit the tight muscle.
- Standing using a tilt table, standing frame and\or knee extension splints should be carried out to stretch the muscles.
- Weight-bearing exercises of the upper extremities to stretch the elbow flexors and wrist extensors.
Contractures reduce joint mobility and interfere with motor tasks and limit the activities of persons with SCI. They reduce a person's independence. Information about contractures (patient education) and commitment to good care (proper positioning/passive movements) by patients and caregivers can help prevent contractures' development. Also, identifying the joints at a greater risk of developing contractures by the therapist is very important so that they can be targeted by intensive preventive rehabilitation intervention.
- Harvey LA, Glinsky JA, Katalinic OM, Ben M. Contracture management for people with spinal cord injuries. NeuroRehabilitation. 2011 Jan 1;28(1):17-20.
- SCI joint Contractures. Research and Training Center on Independent Living, University of Kansas. (1996). Contractures. Lawrence, KS. Available fromhttps://rtcil.drupal.ku.edu/sites/rtcil.drupal.ku.edu/files/images/galleries/SCI%20Joint%20Contractures.pdf Accessed on 16/12/20
- Diong J, Harvey LA, Kwah LK, Eyles J, Ling MJ, Ben M, Herbert RD. Incidence and predictors of contracture after spinal cord injury—a prospective cohort study. Spinal cord. 2012 Aug;50(8):579-84.
- Harvey LA, Herbert RD. Muscle stretching for treatment and prevention of contracture in people with spinal cord injury. Spinal cord. 2002 Jan;40(1):1-9.
- Dalyan M, Sherman A, Cardenas DD. Factors associated with contractures in acute spinal cord injury. Spinal Cord. 1998 Jun;36(6):405-8.
- Yarkony GM, Bass LM, Keenan V, Meyer PR. Contractures complicating spinal cord injury: incidence and comparison between spinal cord center and general hospital acute care. Spinal Cord. 1985 Oct;23(5):265-71.
- Salierno F, Rivas ME, Etchandy P, Jarmoluk V, Cozzo D, Mattei M, Buffetti E, Corrotea L, Tamashiro M. Physiotherapeutic procedures for the treatment of contractures in subjects with traumatic brain injury (TBI). Traumatic Brain Injury. InTechOpen. 2014 Feb 19:307-28.