Contractures and Positioning “limbs that no longer straighten” Handicap International Henk Willemsen

Goals of Presentation Contractures, provide you with knowledge about : What are contractures? How they develop What can we do? Good positions to prevent contractures

What are contractures? Limbs that no longer straighten; fixed shortening of muscles / skin / tendons / joints (capsule) In children: that lay in bed or sit a lot, and don`t move very much amputations spastic painful joint juvenile rheumatoid arthritis

Contractures: Can often be prevented through exercise and positioning Make rehabilitation difficult Correction is costly, uncomfortable, slow, painful Have to be corrected in an early stadium Active and varied moving is one of the better ways to prevent contractures. Contractures limit the possibilities for walking & bracing, ADL, transfers etc. Early contractures can be easily corrected with exercise and positioning, but advanced , old contractures are more difficult to correct (need plaster casting, surgery)

Causes of Contractures 1 Develop if a joint is not moved regularly through its full Range Of Motion due to: Muscle imbalance (paralysis, amputations, spasticy) Inactivity (painful joints, sickness) Muscle imbalance: a muscle that pulls the limb in one direction is much stronger than the one that pulls in the other direction.

Most frequent contractures: Foot Knee Hip Back (Scoliosis)

Causes of contractures 2 Children with cerebral palsy often spend a lot of time in the same positions, this be avoided as much as possible or the child can be Deformed.

Different Contractures Difference between: spasticy (resistance that slowly yields under pressure) contracture( resistance that does not yield) Decreased movement due to shortening of the muscle: springy resistance. Decreased movement due to contracted / shortened tendon/ capsule; stiff continuous resistance. Decreased movement due to bony problem: movement is blocked

Example 1: Hamstring Contracture Muscle contracture: knee straightens more when hip is straight than when hip is bent. Joint capsule contracture: No difference between bent or straight hip. Hamstring runs all the way from the hip bone to the lower leg

Example 2: Ankle Joint Difference between knee straight and knee bent: muscle contracture. No difference; joint capsule contracture

What to do? Contractures of muscles & cords: Range Of Motion-exercises and stretching / ortheses & night splints Positioning ! Joint capsule involved: difficult to correct, surgery may be needed Motivation child & parents Prevention of scoliosis: custom-made sitting orthotics and ortheses for sleeping at night (prone or supine) Motivation: can the child sleep with splints, can the child handle 3 – 6 weeks of plaster casting After surgery exercises and bracing are often still needed to prevent the contractures from coming back.

Why Seating and Positioning ? Prevention of: Pressure sores Deformities Contractures Abnormal movements Improvement of: Respiration Digestion Functional skills New view of the environment Prevention of: Pressure sores, orthopaedic deformities, muscle contractures. Improvement of: respiration, digestion, functional skills that the child may otherwise be unable to do. (Pesperin). Miedaner: improved speech and vocalization, head control, self feeding and drinking. Positioning is often static, no stimulus for learning new movements, transitions or exploration, important goals of normal motor development.

Positioning Try to position in such a way that the affected joints are stretched A child that spends most of the day sitting should spent part of the day lying or standing. Make it interesting; play, talk, give her interesting things to do Start as early as possible Daily Prone positioning? Guidelines! Look for ways to to stretch during day-to-day activities (lying, carrying, sitting, playing, studying etc.) Guidelines for prone positioning during the daytime periods when the child`s breathing status can be monitored. There are few, if any, clear scientific, objective guidelines on which to base a decision about positioning. It is still rather an art than a science.

Positioning Look for ways to help the child stay in contracture-preventing positions. Children with cp whose legs press together or cross: look for a way to sit with the legs separated.

Standing frame Stimulates standing. Pay special attention to: Symmetrical standing Prevent hyperextension of the neck, high-guard position of the arms. Use a tray to encourage forward position of the arms Benefits for CP children: Helps to develop normal acetabulum Stretching of hip and knee flexors, ankle plantar flexors Stimulates antigravity muscles Weight bearing New visual perspective of the environment, social and perceptual opportunities. In general 1 hour each day.

Positioning Side-lyers are particular useful for young children or large people of low developmental function. Alternative to sitting or lying on the floor. Allows for easy manipulations of toys and objects. The position is not optimal for perceptual development: I.e. toys are rotated 90 °with respect to the visual field. Criteria: Trunk should be as symmetric as possible Head should be supported in alignment, neutral to the trunk. Try to stimulate the child to lay on both sides.

Exercise Daily Full Range of Motion & stretching The child should do as much as she can by herself (active is better than passive!) Strengthening of weak muscles Promote (sport) activities Exercising should be fun Make instruction sheets for the parents Stretching: After relaxing the muscles (warmth), slowly but steady until the end of the motion, should not be painful: increase muscle tone. Duration: small muscle groups 10 – 40 sec , big muscle groups some minutes (Ferrrari & Cioni) Collagen contractures: difficult to stretch; at least 6 – 8 hours a day. Splints for the night and ortheses work better than stretching Active exercising helps better than passive; ortheses work better than night splints