How are contractures managed in patients with Parkinson's disease?

Management of Contractures in Parkinson's Disease

Contractures in Parkinson's disease should be treated with a stepwise approach beginning with non-invasive therapies such as antispastic positioning, range of motion exercises, and stretching, progressing to more invasive interventions only when necessary. 1

Assessment and Early Intervention

• Patients with Parkinson's disease are at high risk for developing contractures due to:

  • Rigidity
  • Bradykinesia
  • Prolonged immobility
  • Abnormal posturing

• Early identification is crucial as contractures can:

  • Impede rehabilitation efforts
  • Limit potential for recovery
  • Cause significant pain
  • Reduce functional independence
  • Decrease quality of life

First-Line Treatment Options

1. Non-pharmacological approaches:

   • Antispastic positioning (maintaining limbs in neutral positions)
   • Range of motion exercises (performed several times daily)
   • Stretching (both passive and active)
   • Physical therapy with focus on maintaining joint mobility

2. Exercise therapy:

   • Structured exercise programs tailored for Parkinson's patients
   • Task-oriented interventions with or without multisensory components
   • Balance training to prevent falls and maintain mobility 1
   • Tai Chi and aquatic therapy may be beneficial for maintaining range of motion

Second-Line Treatment Options

When first-line treatments are insufficient, consider:

1. Splinting and orthotics:

   • Serial casting for progressive correction
   • Custom-made splints to maintain joint position
   • Night splints to prevent contracture progression

2. Pharmacological management:

   • Muscle relaxants:
     • Tizanidine (particularly effective for chronic patients)
     • Oral baclofen (may cause sedation but can reduce spasticity)
     • Dantrolene (benefits include minimal cognitive side effects)
   • Avoid benzodiazepines due to potential deleterious effects on recovery and sedation 1

Advanced Interventions

For severe or refractory contractures:

1. Focal treatments:

   • Botulinum toxin injections for disabling or painful spasticity
   • Phenol/alcohol injections for selected patients with focal spasticity

2. Surgical options:

   • Intrathecal baclofen for chronic patients with pain or poor function
   • Neurosurgical procedures (selective dorsal rhizotomy or dorsal root entry zone lesion)
   • Surgical correction of fixed contractures when conservative measures fail

Special Considerations in Parkinson's Disease

• Medication timing: Schedule physical therapy and exercise during "on" periods when dopaminergic medications are most effective 1

• Protein redistribution: For patients experiencing motor fluctuations, consider protein redistribution dietary regimens to maximize levodopa absorption and efficacy 1

• Nutritional monitoring: Regular assessment of nutritional status is important as malnutrition can worsen muscle weakness and contracture risk 1

• Fall prevention: Implement comprehensive fall prevention strategies as contractures can increase fall risk 1

Pitfalls and Caveats

• Contractures can develop rapidly in Parkinson's patients, particularly during periods of reduced mobility or hospitalization
• Delayed intervention often leads to irreversible contractures requiring surgical correction
• Focusing solely on pharmacological management of Parkinson's symptoms without addressing physical mobility can lead to preventable contractures
• Benzodiazepines should be avoided despite their muscle relaxant properties due to potential negative effects on recovery and increased fall risk
• Inadequate treatment intensity is a common cause of treatment failure 2

Early, consistent, and multidisciplinary management of contractures in Parkinson's disease is essential to maintain function and quality of life throughout disease progression.