Contractures

Definition Adaptive shortening of skin, fascia, muscle, or a joint capsule that prevents normal mobility or flexibility of that structure A contracture deformity is the result of a stiffness or constriction in your muscles, joints, tendons, ligaments, or skin that restricts normal movement. It develops when your normally pliable connective tissues become less flexible

Contractures Factors contributing towards tendency towards contractures: Muscles becoming less elastic due to limited use/positioning Muscles out of balance around the joint Maintaining good range of movement and symmetry is important Maintains best possible function Prevents development of fixed deformities Prevents pressure problems with the skin

Mechanism of contracture Contractures are either neurally or non-neurally mediated. Neurally mediated contractures are due to spasticity (ie, involuntary reflex contraction of muscles) and are a common sequelae of upper motor neuron lesions. Non-neurally mediated contractures are due to structural adaptations of soft tissues. Animal studies indicate that such changes occur in response to prolonged immobilisation, particularly immobilisation of soft tissues in shortened positions. Muscle shortening is associated with a decrease in the number of sarcomeres, changes in the alignment of intramuscular connective tissues and a decrease in tendon resting length

Causes Inactivity and scarring from an injury or burn. People who have other conditions that keep them from moving around are at high risk for tightening of their muscles and joints. For example, joint contractures are common in patients discharged from intensive care units or after long hospital stays. Muscular dystrophy Cerebral palsy Central nervous system diseases like polio also cause this condition rheumatoid arthritis

Sites In the lower extremities, ankle plantarflexion, hip flexion, and knee flexion contractures are common.    In the upper extremities, elbow flexion and supination contractures are also seen as are adduction and internal rotation contractures of the shoulder.    Muscles that cross multiple joints, such as the biceps, hamstrings, tensor fascia lata, and gastrocnemius, are predisposed to contracture formation

Management of muscle extensibility and joint contractures Physiotherapist: key contact for contracture management Ideally input from local PT supported by a specialist PT every 4 months Stretching should be performed at least 4-6 times a week as part of family’s daily routine Effective stretching may require a range of techniques including stretching, splinting, and standing devices

Stretches Regular ankle, knee and hip stretching is important Later, regular stretching at the arms becomes necessary – especially fingers, wrist, elbow and shoulder Additional areas requiring stretching may be identified on individual examination Standing programes (in a standing frame, or power chair with stander) are recommended after walking becomes impossible Resting hand splints are appropriate for individuals with tight long-finger flexors

Splints Night splints (ankle-foot orthoses/AFOs) can help control ankle contractures Should be custom-made, not “off the shelf” After loss of ambulation, daytime splints may be preferred Daytime splints not recommended for ambulant boys Long-leg splints (knee-ankle-foot-orthoses) may be useful at stage when walking is becoming very difficult or impossible Can help control joint tightness, prolong ambulation, and delay the onset of scoliosis

Wheelchairs, seating and assistive equipment Early ambulatory phase Stroller, or wheelchair may be used for long distances to conserve strength Posture is important: customisation of chair normally necessary With increased difficulty walking, provision of powered wheelchair is recommended This should be adapted/customised for comfort, posture and symmetry

Wheelchairs, seating and assistive equipment (2) Arm strength becomes an issue over time PTs/OTs can recommend assistive devices to maintain independence (e.g. alternative computer/environmental control access) Proactive consideration of equipment allows timely provision Additional adaptations in late ambulatory and non-ambulatory stages may be needed to help with getting upstairs, transferring, eating/drinking, turning in bed, and bathing

Recommendations for exercise High-resistance strength training and eccentric exercise are inappropriate across the lifespan Concerns about contraction-induced muscle-fibre injury To avoid disuse atrophy and other secondary complications of inactivity, all ambulatory and early non-ambulatory boys should participate in regular submaximal (gentle) functional strengthening/activity, including a combination of swimming-pool exercises and recreation-based exercises in the community

Recommendations for exercise (2) Swimming may benefit aerobic conditioning and respiratory exercise: highly recommended from early ambulatory to early non-ambulatory phases (can be continued as long as medically safe) Additional benefits may be provided by low-resistance strength training and optimisation of upper body function Significant muscle pain in 24h period after a specific activity is a sign of overexertion and-induced injury. If this occurs, the activity should be modified