management of tone range and contracture

Question 1

role of physio in contracture

Answer 1

minimise contracture + development of deformity
reduce pain
reduce burden of care
improve QOL

Question 2

key principles of contracture mgmt

Answer 2

understand pathology 
understand normal anatomy and physiology 
Ax
mgmt plans 
education 
reevaluation
collar with MDT team members

Question 3

acute or delayed

Answer 3

acute -->paresis --> immobilisation in short position 
soft tissue plastic rearrangement 
contracture 
muscle overactivity - 
spasticity (dystonia) (cocontraction)

delayed goes to CNS plastic rearrangement - supra spinal spinal before paresis

Question 4

understand pathology of neurology and biomechanical changes

Answer 4

neuro Spasms  Dystonia
Co-contraction
Weakness
Overactive stretch reflexes
All lead to inappropriate posturing or
alignment
“Dynamic tightness”
Muscle tone (reversible)

biomechanical 
loss of length 
contracture 
soft tissue tightness 
muscle structure

Question 5

neurological or biomechanical

Answer 5

history Time since injury
Severity of injury
Activity level and abilities
Clinical assessment
Resting position
Resting tone
Range on slow stretch (fixed tightness)
Range on fast stretch (fast catch, spasticity)
Power and active movement
Limb hygiene

Functional assessment:
Bed mobility Transfers Gait

Analysis of findings Identification of problems Discussion with MDT SMARTER goals

Question 6

understand consideration in treatment planning

Answer 6

nature of condition 
static or deteriorating 
motor and functional capacity 
functional performance independence and social interaction 
secondary associated complications

Question 7

consider positive factors
ability

and negative factors
complications for each person

Answer 7

abilities
posture ability quality ROM
functional independence

challenges/ complications 
contracture / deformity 
tissue damage / pressure ulcers 
infections 
pain/ discomfort 
positive features in UMN syndrome

Question 8

Assessment : outcome measures

Answer 8

ROM: goniometer
electrogoniometer

muscle tone
modified ashworth scale
tardieu scale
VAS - how much is it bothering you right now

functional activity limitation
arm activity measure
LEG activity measure

Question 9

plan: treatment options for people who may lose / losing / lost already range

Answer 9

WB - passive
active

mvmt - PROM active assisted
antagonist activation

positioning and splinting
24 hr approach
removable springs
serial casting

Question 10

movement

Answer 10

Options: Passive / active-assisted / active (antagonist)

Passive movements* not adequate on their own
30 mins daily movement necessary in mice
4w of 30 mins daily stretching of ankle muscles in SCI did not significantly** change ROM
6 hours in children with CP

8w bed positioning programme in frail elderly with knee contractures – no effect

Question 11

positioning rationale

Answer 11

1. align and stabilise body segments relative to each other and to supporting surface
2. control forces actin on the body to avoid sustained localised high forces
3. provide a functional posture
4. facilitate comfort.

Question 12

why do we position

Answer 12

Muscle benefits
Modulation of tone
Prevention of damage to affected limbs
Support / stabilisation of body segments
Prevention of contracture
Comfort

Functional benefits
Ease burden of care
Optimise level of alertness
Promote interaction
Promote optimum muscle activity
Promote carryover from therapy

Question 13

considerations in positioning

Answer 13

1. task to be performed
2. level of mobility
3. symmetry of alignment
4. WB distribution through supporting structure
5. safety
6. 24 hr plan: rest and sleep positions
7. patient preference
8. family staff and carer preferences

Question 14

principles of support

Answer 14

The pelvis is the keystone of the body structure
Gravity is used to secure postural stability (rather than working against gravity)
Identify the direction of the bending and axial rotations occurring within and between body segments
Asymmetry = flexible = corrected
Asymmetry = established = accommodated
Function takes precedence over posture

Question 15

stable posture

1. sitting
2. supine

Answer 15

sitting 
The pelvis
The thighs
Lower legs
The feet
The thorax and shoulder girdle
The upper limbs
The head
Tilt and recline

supine 
24 hour postural management  system essential where there is:  inability to change position, postural  asymmetry, positive features of UMN  syndrome
Consider rest and sleep positions
Start with the pelvis
Support with equipment

Question 16

precautions for positioning

Answer 16

Local and national restraint policies

Fractures

Skin condition

Cardiovascular compromise

Question 17

splinting

Answer 17

Splinting is defined as the ‘process of applying a prolonged stretch through the application of a range of devices’ (ACPIN, 2015)
Splints may be removable or non-removable
Important to distinguish if the goal is contracture prevention or contracture management
Possibilities: Splints Casts Orthoses

Question 18

Contraindications for splinting

Answer 18

if there is not identified benefit
if it causes pain / discomfort
if there is no clear plan for application, removal or monitoring of the splint
if other treatment strategies are working
if there is poor patient compliance
if there is a lack of follow up
if contracture has become established resulting in fixed joint deformity

Question 19

precautions for splinting

Answer 19

if pt has vascular disorder
if pt has concomitant fracture or severe STI
if pt is medically unstable
if pt is incontinent
if pt is diagnosed with hereotopic ossification
if pt has acute inflammation
if pt can’t communicate
if pt has cognitive problems
if uncontrolled ICP
if there is poor skin integrity
if there is oedema
if there is sensory loss or hypersensitivity
If there is fluctuation or severe tone or spasms
if there is a history of DVT

Question 20

casting vs splinting

Answer 20

casting Individually fabricated
Stretch can be progressed with serial
casting
More short-term
Need education in donning / doffing

Off-the-shelf or custom
Less opportunity to progress stretch
More long-term use
Needs education in donning / doffing

Question 21

serial casting

Answer 21

Fabrication of custom-made plaster casts at low-level stretch to increase range
Low-force, long duration stretch used: a) for comfort; b) to encourage connective tissue “creep”

lasts 1-4 days
number of casts needed to achieve 10 deg or greater of passive DF with knee extended = 3 to 4

Consider impact on mobility

Question 22

ACPIN guidelines for splinting

Answer 22

Considers evidence for casts, splints (custom) and non-custom-made splints for contracture prevention and correction

Strongest evidence for casting (level 2) at end of range for preventing and improving range at the ankle and knee, and improving range at the elbow

Recommended in conjunction with Botox for clinically significant spasticity

Ankle splint can prevent loss of range positioning at plantargrade

Shorter duration casting has a lower potential complication rate

Question 23

educate
re-evaluate
collaboration

Answer 23

Educate those who will be implementing treatment
Positioning: who, how and when?
Splinting: donning and doffing, skin care

Re-evaluate after a set time according to SMART goals
Outcome measures

Collaborate with MDT, patient and family: agree goals and responsibilities