Would physical therapy or occupational therapy (OT) be indicated for a 64-year-old male with post-stroke paraplegia who has injured his paralyzed hand, without fractures, to prevent contracture formation during the healing process?

From the Guidelines

Physical therapy (PT) or occupational therapy (OT) is essential for this 64-year-old male stroke survivor with paraplegia who injured his paralyzed hand to prevent contractures during healing. The patient's condition, with hemiparesis and sensory changes, places him at high risk for joint and muscle contractures and skin breakdown, as noted in the guidelines for adult stroke rehabilitation and recovery from the American Heart Association/American Stroke Association 1. Key aspects of the treatment plan should include:

• Regular assessment of skin and the use of objective scales of risk such as the Braden scale to prevent skin injury
• Daily stretching of the hemiplegic limbs to avoid contractures, with patients and families taught proper stretching techniques to avoid injury and maximize effectiveness 1
• Consideration of resting hand splints, although their effectiveness is not well established, and potentially combining their use with other treatments like early botulinum toxin injection to wrist and finger flexors 1
• Positioning of the hemiplegic shoulder in maximum external rotation for 30 minutes each day to prevent shoulder contracture 1
• Potential application of serial casting or static adjustable splints to prevent elbow or wrist contractures, despite conflicting data 1 A rehabilitation specialist should evaluate the patient as soon as possible to develop a personalized treatment plan, which would typically include passive range of motion exercises performed 3-5 times daily, with 10-15 repetitions for each joint in the affected hand. The therapist might suggest specific adaptive equipment to support hand function during recovery, and these interventions are crucial because immobilization combined with pre-existing neurological deficits significantly increases contracture risk, as contractures develop when muscles and tendons shorten due to lack of movement, which can permanently limit function 1. Early intervention through PT/OT helps maintain joint mobility, prevent tissue shortening, reduce pain, and potentially improve functional outcomes, and the therapy should continue throughout the healing process with regular reassessment to adjust the treatment plan as needed.

From the Research

Physical Therapy and Occupational Therapy for Preventing Contractures

• The use of passive range of motion exercises to prevent contractures in adults with cerebral palsy was studied in 2, which found that the exercise protocol did not have an effect on lower-extremity goniometric measurements.
• A systematic review 3 investigated the effects of passive movements on joint mobility and found that the evidence for their effectiveness in treating and preventing contractures is very low.
• While these studies do not directly address the specific case of a 64-year-old male post-stroke with paraplegia, they suggest that physical therapy and occupational therapy may be beneficial in preventing contractures.

Timing of Physical Therapy Initiation

• A systematic review 4 found that early initiation of physical therapy for musculoskeletal conditions may decrease health costs and improve outcomes, although the quality of evidence was limited.
• This study did not specifically address the prevention of contractures, but it suggests that early physical therapy intervention may be beneficial in general.

Clinical Guidance for Physical Therapist Practice

• A clinical practice guideline 5 provides guidance for physical therapy clinicians when evaluating, treating, and managing individuals who experience limitations in the ability to participate in work following injury or illness, but it does not specifically address the prevention of contractures.
• Another study 6 found that patients referred to physical therapy for musculoskeletal conditions have certain expectations, including a desire to understand their symptoms and how they can improve them, which may be relevant to the case of a patient with paraplegia.

Prevention of Contractures in Paraplegia

• While there is limited direct evidence on the use of physical therapy and occupational therapy to prevent contractures in patients with paraplegia, the available studies suggest that these interventions may be beneficial in maintaining joint mobility and preventing contractures.
• Therefore, physical therapy and occupational therapy may be considered as part of a comprehensive treatment plan to prevent contractures in a 64-year-old male post-stroke with paraplegia, as cited in 2, 3, 4.