Contractures, or reduced joint mobility, are a common problem associated with spinal cord injury. Depending on the level of injury, we can often anticipate the muscle, tissues and joints at risk and ideally focus on prevention. From experience, prevention is always better than trying to manage these problems once a contracture is established.

I was with a client in the community recently who had developed a significant plantar flexion deformity at the foot and ankle. This was sufficient to cause a number of practical problems for her. She was finding it difficult to don footwear and even keep her foot in position on her wheelchair footplate thereby increasing the risk of accidental injury.

At present, she has been provided with bilateral “of the shelf” orthoses with adjustable, but fixed, ankle joints that are accomodating her deformity with the intention to help prevent progression. However, these were heavy and not really ideal for use in bed so I suspect were not being worn as directed. Her visits to the prescribing orthotist were infrequent and adjustments to her orthoses had not been made.

Surgical treatment was now being offered but she had little enthusiasm for this. The question arises, could an orthosis that would provide a persistent dynamic stretch to the soft tissues be resonably expected to produce results?

Lack of research

Despite the frequency with which they are seen in physical medicine, contractures and the effwctiveness of conservative management have not been the subject of extensive research. The small amount of research that has been conducted would suggest that stretching is not going to be effective. However, we need to look in more detail at the limitations of research so far. This is one of those situations that the “dose” of the intervention is likely to be sigificant - 30 minutes of passive stretching once per week is not, for example, likely to be effective.

Joint contracture situations are either neurally or non-neurally mediated. Neurally influenced contractures are due to the effects of spasticity (ie, involuntary reflex contraction of muscles) and are a common consequence of upper motor neuron lesions. Spasticity is often managed with medication to damp down the elevated muscle tone and resulting imbalance of force across a joint. Whilst some clinicians believe that stretching can induce functionally important and lasting reductions in spasticity, again, this is yet to be verified with good quality studies.

Non-neurally influenced contractures are due to structural adaptations of muscle and other soft tissues that will take place over time. Animal studies suggest that changes can occur in response to prolonged immobilisation; particularly immobilisation of soft tissues with joints in shortened positions. Ten days immobilisation of rabbit ankles in plantarflexed position (the shortened position of the plantarflexor muscles) results in approximately a 10% reduction in resting length of soleus muscle-tendon units,which is sufficient to produce a functionally significant loss of ankle joint mobility. Muscle shortening is associated with changes to the structure of the muscle. A decrease in the number of sarcomeres, changes in the alignment of intramuscular connective tissues and a decrease in tendon and soft tissue resting length are all influenced.

The primary conservative intervention for the treatment and prevention of contracture is “regular” stretch to soft tissues. What is meant by regular stretch though? Prevention is certainly better than trying to treat established contractures. One recent randomised trial suggests there is no clinically worthwhile effect from a "typical" stretch protocol applied to spinal cord injured patients.

Despite the negative results of this first trial, some authors suggest that therapists should continue administering stretch for the treatment and prevention of contracture until the results of further studies emerge.

To maximise the probability of attaining a clinically worthwhile effect, the authors suggest that therapists stretch soft tissues for long periods (at least 20 min, and perhaps for as long as 12 hours a day). In support of prevention, stretch is most likely to be effective if started before the onset of contracture. The idea is that soft tissues most at risk should be targeted, particularly if contracture is likely to impose functionally important limitations.

One randomised study has investigated lasting effects of stretch on contracture in people with spinal cord injury. This study examined the effect of 4 weeks of 30 min daily stretches (7.5 N.m applied corrective moment) to the ankles of recently injured paraplegics and tetraplegics. Ankle mobility was measured at 24 h and again 1 week after the removal of stretch. No treatment effect was found. The authors suggest this may have been because co-interventions (such as routine positioning of ankles at 90 degrees in wheelchairs) were sufficient to reverse or prevent plantarflexion contractures, and muscle stretching provided no additional benefit. Alternatively, it may have been that the stretch protocol was just of insufficient intensity or duration.

It's obvious that if stretches are to be applied for more than a few minutes a day, therapists will need to move away from the labour-intensive tradition of manually applying stretches with their hands. Instead, limbs should be positioned with at-risk soft tissues in stretched positions, and where possible positioning programs should be incorporated into patients' rehabilitation programs and daily lives.

**654SKG DDA**

This version of the PRAFO ankle foot orthosis is hinged at the heel to allow dorsiflexion and plantar flexion whist providing the usual heel pressure relief. However the two adjustable straps can be used to apply a constant stretch for plantar flexion contracture reduction. Medial or lateral deviation can be managed by varying the tension in these two straps. Care must be taken to ensure full contact between the plantar surface of the foot and the orthosis.

Often only relatively simple equipment or suitable orthoses are required for this purpose. The advantage of using an orthosis is that some designs can provide a dynamic stretch. The muscle stretch can be sustained overnight or for prolonged periods.

The 654SKG DDA (Dynamic dorsi assist) orthosis was designed to dynamically stretch the gastrocnemius muscle and posterior structures to offset equinus contractures. The use of a series of posterior articulations allows for a virtually unrestricted range of plantar or dorsiflexion. The DDA Orthosis also provides nearly unlimited inversion or eversion of the ankle/foot complex by adjusting the tension on the medial or lateral straps. This orthosis is also available in a smaller paediatric configuration - 554SKG

Like all of our AFO designs, any pressure to the heel and the medial/lateral aspects of the malleoli are eliminated. The device is suitable for left and right feet and adjusts to various foot and lower limb sizes. The liner can be cleaned regularly, and/or replaced to refresh the orthosis. It is important to ensure that the plantar surface of the foot is in intimate contact with the footbed of the orthosis to minimise localised pressures.

Spinal cord injury contracture correction

Lack of research

Further reading

Anatomical Concepts.
Every Body Better.

Spinal cord injury contracture correction

Lack of research

Further reading

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Anatomical Concepts.Every Body Better.

Anatomical Concepts.
Every Body Better.