TBI - Management of Muscle Length Flashcards
Why are TBI patients at high risk of contracture?
Due to loss of strength & spasticity
How significant is spasticity in TBI compared to other neurological conditions?
- Greater problem in TBI than in other neurological conditions such as stroke
- 88% patients developed spasticity within 14 days post TBI (ver Planke et al, 2005)
Which muscles should be assessed for strength in TBI?
- Muscles that may be contributing to difficulty performing a task, esp:
- Shoulder abductors/ER
- Elbow supinators
- Wrist extensors
- Hand web-space, thumb flexors/abductors
- Hip extensors/ER
- Ankle DFs
Which muscles should be assessed for length & spasticity in TBI?
- Muscles at greater risk of contracture & that will significantly affect function if contracture occurs, esp:
- shoulder adductors/IR
- elbow pronators
- wrist/finger flexors
- thumb flexors/abductors
- hip flexors/IR
- ankle PFs
What are the important components of measurement in TBI?
- Valid & reliable outcome measures should be used to quantify findings
- Consider frequent measurement to monitor
effects of intervention on muscle length (as evidence regarding duration of intervention required to prevent or reverse contracture is unclear)
What does the current evidence regarding management of muscle length state?
- Evidence currently unclear about optimal duration of prolonged stretch for a clinically worthwhile effect
- CIs: Measure, implement, re-measure
What did Moseley et al 2008 find regarding serial casting?
- TBI patients with elbow flexor contractures
- Experimental group did 2 weeks serial casting
- Control group did 2 weeks prolonged positioning
- Both groups had up to one hour positioning for 4 weeks following intervention phase
- Serial casting reduced contracture by an average of 22 degrees
- Effect decreased to 11 degrees after 1 day & almost disappeared after 4 weeks
- CIs: Serial casting induces transient increases in range of motion, that are not maintained
What did Ver Plancke et al 2005 find regarding serial casting?
- Patients within 14 days of TBI
- 88% developed spasticity, some early development of contracture
- Compared ankle serial casting + botox with ankle serial casting + saline for 12 weeks
- 11.5deg increase in DF ROM with serial casting (plus saline)
- 13.6deg increase in DF ROM with serial casting + botox
- CIs: Botox not really worthwhile
What did Mortenson & Eng 2003 find regarding serial casting?
- Systematic review of casting in acute & sub- acute neurological conditions (TBI & CVA)
- Casting to ankle PF, elbow flexors, wrist flexors & knee flexors
- Improvements in PROM in 9 studies
- Average increase in ankle range of 10.4-26deg
- No follow-up measures
What are the principles of managing muscle length?
- Assess accurately to allow appropriate interventions
- Aim for prevention rather than reversal
- Target muscles susceptible to shortening & consider position, requirements during activity, pain & spasticity
What are the strategies to maintain length of muscles at risk of shortening?
- AROM
- Activity through normal range of motion
- AAROM
- Electrical stimulation
- Optimal positioning throughout the day
- Resting splints
- Prolonged positioning at end of range for at least 30 mins at least daily
- Serial casting
What are the strategies to increase length of shortened muscle groups?
- Serial casting
• Prolonged positioning at end of range for at least 30 mins at least daily
• If spasticity or pain is present consider liaison with the medical team
What does serial casting involve?
- Applying a cast to a limb so a target muscle group and/or joint is held at its maximum length or excursion
- Cast remains in situ for 3-5 days
- Cast is then removed, & if clinically indicated another cast can be applied in a new position
What should be considered in the implementation of serial casting?
- All patients who have a significant loss of muscle length or joint range of motion that is contributing to activity limitations
- Using serial casting as an intervention to prevent loss of muscle length in the presence of spasticity or immobility due to loss of strength or immobilisation (e.g. in ICU)
- Ensure patients/carers are educated in management of serial casting
What can serial casting be used in conjunction with?
- Rehab program including impairment & activity training
- Post-serial casting rehab program to improve strength, activities & maintain/increase muscle length
