management of tone range and contracture Flashcards
role of physio in contracture
minimise contracture + development of deformity
reduce pain
reduce burden of care
improve QOL
key principles of contracture mgmt
understand pathology understand normal anatomy and physiology Ax mgmt plans education reevaluation collar with MDT team members
acute or delayed
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
understand pathology of neurology and biomechanical changes
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
neurological or biomechanical
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
understand consideration in treatment planning
nature of condition static or deteriorating motor and functional capacity functional performance independence and social interaction secondary associated complications
consider positive factors
ability
and negative factors
complications for each person
abilities
posture ability quality ROM
functional independence
challenges/ complications contracture / deformity tissue damage / pressure ulcers infections pain/ discomfort positive features in UMN syndrome
Assessment : outcome measures
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
plan: treatment options for people who may lose / losing / lost already range
WB - passive
active
mvmt - PROM active assisted
antagonist activation
positioning and splinting
24 hr approach
removable springs
serial casting
movement
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
positioning rationale
- align and stabilise body segments relative to each other and to supporting surface
- control forces actin on the body to avoid sustained localised high forces
- provide a functional posture
- facilitate comfort.
why do we position
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
considerations in positioning
- task to be performed
- level of mobility
- symmetry of alignment
- WB distribution through supporting structure
- safety
- 24 hr plan: rest and sleep positions
- patient preference
- family staff and carer preferences
principles of support
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
stable posture
- sitting
- supine
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
precautions for positioning
Local and national restraint policies
Fractures
Skin condition
Cardiovascular compromise
splinting
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
Contraindications for splinting
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
precautions for splinting
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
casting vs splinting
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
serial casting
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
ACPIN guidelines for splinting
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
educate
re-evaluate
collaboration
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
