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

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

3. 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

4. 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)

5. 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.

6. Most frequent contractures:
Foot
Knee
Hip
Back (Scoliosis)

7. 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.

8. 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

9. 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

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

11. 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.

12. 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.

13. 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.

14. 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.

15. 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.

16. 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.

17. 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