Contractures

1. Contractures edited by Edward Warren, MD, Chair Geriatrics, Carolinas Campus, February 2012

2. Contractures

3. Goals • Define what contractures are. • List types of contractures. • Discuss complications of contractures. • Discuss the treatment of contractures.

4. Contractures • Contractures are shortenings of muscle, connective tissue, tendons, ligaments, or skin. • A contracture develops when normally elastic connective tissues become replaced with inelastic fibrous tissues.

5. Contractures • The main symptom is loss of range of motion of a joint. • When a joint is painful, the body's natural reaction is to "splint" or immobilize the area. • A cycle of pain involving reduced movement, pain with movement, and further reduction of mobility to avoid pain ensues.

6. Contractures • Contractures produce restrictions on mobility and the performance of activities of daily living, ADL’s: Mobility, Toileting, Eating, and Dressing. • Adhesive capsulitis of the shoulder is one example of a contracture that results in reduced movement and function and a reduction in ADL’s.

7. Types of Contractures • Joint Contractures: • Cartilage damage(e.g., osteoarthritis), Synovial proliferation, effusion (e.g., rheumatoid arthritis), Capsular fibrosis (e.g., trauma) • Soft Tissue Contractures • Soft tissues surrounding the joint (e.g., immobilization), Skin, subcutaneous tissue (e.g., burns), Tendon and ligaments (e.g., tendinitis) • Muscle Contractures • Intrinsic (e.g., trauma, inflammation, atrophy, ischemia), Extrinsic (e.g., spasticity, paralysis) • Mixed Contractures

8. Types of Contractures • Upper extremity contractures of the elbow, wrist, and fingers impair the performance of all basic activities of daily living as well as advanced skills requiring fine motor coordination.

9. Types of Contractures • Hip flexion contractures alter gait pattern and increase the energy expenditure of walking. Hip and knee extension contractures can interfere with wheelchair mobility and car transfers.

10. Types of Contractures • Patients with multiple joint contractures are at risk for developing hygiene problems • Areas of skin breakdown (decubiti) are more likely to occur near the site of joint contracture

11. Differential Diagnosisof Contractures 1. Spasticity 2. Heterotopic ossification 3. Degenerative joint disease 4. Fracture 5. Dislocation 6. Loose body in a joint 7. Meniscal tears 8. Psychogenic

12. Physical Exam • Neuromuscular examination documenting active and passive range of motion is necessary. The most effective tool for joint measuring is a goniometer. • Observe for abnormalities of limb shape, size, and symmetry. Improper positioning of the joints as well as the presence of marked imbalance of muscle strength should be noted. • Check for abnormally brisk reflexes, sustained clonus, or increased muscle tone occur with spasticity. • If hypertonus is present, apply gentle, prolonged passive stretch to determine whether full range of motion can be achieved or whether there is a true contracture.

13. Diagnosis • The diagnosis of contracture is made clinically. • Radiographic evaluation with plain x-rays can be done if contributing conditions, such as bone spurs, heterotopic ossifications, or ankylosis, are suspected.

14. Treatment • The initial "treatment" for contractures is prevention. • Contractures are prevented by moving muscles and joints through their full range on a daily basis.

15. Treatment • Pain control is essential in the prevention and treatment of contractures. NSAIDs/ oral prednisone, non-narcotic and narcotic analgesics are used for treatment of acute painful conditions that, if left untreated, could result in contractures.

16. Treatment • Splints and therapeutic positioning can be important in the prevention of contractures. • These measures help to maintain the correct length of connective tissue

17. Rehabilitation – PT & OT • Once contractures have developed, rehabilitation includes range of motion exercises and sustained stretching. • Adequate treatment of pain is essential • Active range of motion accomplished by the patient is preferable, but in extreme cases of debility or obtundation/sedation, active assisted or passive range of motion may be necessary.

18. Rehabilitation – PT & OT • Along with therapeutic stretching exercises, massage may assist in improving contractures. Splints are also commonly prescribed, as they provide a gentle sustained stretch (e.g., night splints used to stretch the Achilles tendon).

19. Rehabilitation – PT & OT • Manual stretching exercises are the most effective therapy. With adequate pain control, patients should be encouraged to perform daily therapeutic exercises. • Small joints may be heated by the use of paraffin bath dips or fluidotherapy. • Some physicians use ultrasound therapeutically, but there is no evidence that it is more effective than placebo for most uses.

20. Rehabilitation - Procedures • When therapeutic heating and stretching are not effective, procedures to be considered include motor point or nerve blocks. • The use of these injection techniques can be diagnostic as well as therapeutic since they can help differentiate a true contracture from spasticity.

21. Rehabilitation - Procedures • Following anesthetic block, the affected area can be stretched to its maximal extent and a cast is applied. The cast is removed every 2 or 3 days. Stretching is repeated and the cast is re-applied. This process, known as "serial casting" • Serial casting should not be performed on patients with circulatory or sensory compromise

23. Rehabilitation - Surgical • Surgical treatments for contractures include tenotomy, tendon lengthening, and joint capsule release. • Reserved for patients in whom • less aggressive methods of treatment have failed • when the contracture persistance is felt to be affecting hygiene, skin care, or mobility

24. Treatment Complications • Analgesics, NSAIDs, and COX-2 inhibitors have well-known side effects that most commonly affect the gastric, hepatic, and renal systems. • Opioids may cause problems with bowels, but are often needed for pain relief to allow proper therapy.

25. Treatment Complications • Over-aggressive stretching can inadvertently result in muscle, ligament, or capsular tears. • Splinting and casting can result in ischemia or skin ulceration. • Complications from motor point and nerve blocks may include tendon rupture, nerve injury, infection, and or skin atrophy.

26. References • McPeak L: Physiatric history and examination. In Braddom RL (ed): Physical Medicine and Rehabilitation, 2nd ed. Philadelphia, W.B. Saunders, 2000, pp 3–45. • Halar EM, Bell KR: Contracture and other deleterious effects of immobility. In DeLisa JA (ed): Rehabilitation Medicine Principles and Practice. Philadelphia, J.B. Lippincott, 1988, pp 448–462. • Norkin CC, White DJ: Measurement of Joint Motion: A Guide to Goniometry, 2nd ed. Philadelphia, F.A. Davis, 1995. • Wilson CH: Exercise for arthritis. In Basmajian JV (ed): Therapeutic Exercise, 4th ed. Baltimore, Williams & Wilkins, 1984, pp 529–545. • Lennard TA (ed): Pain Procedures in Clinical Practice, 2nd ed. Philadelphia, Hanley & Belfus, 2000. • Robinson R: Fight Against Contractures. www.mdausa.org/publications/Quest/q34contrc.html. • Countering Contractures. www.adbiomech.com/o14-1.html • Garden Fae: Contractures.InFrontera:Essentials of Physical Medicine and Rehabilitation,1sted.Hanley and Belfus ,2002