Treatment of Contractures
The treatment of contractures should follow a stepwise approach beginning with non-invasive therapies such as antispastic positioning, range of motion exercises, stretching, splinting, and orthotic intervention, progressing to more invasive interventions only when necessary. 1
Non-Pharmacological Approaches (First-Line)
Prevention Strategies
- Daily stretching: Should be performed several times daily in persons with spasticity 2
- Proper positioning: Counteract deforming forces through correct positioning 2
- Range of motion exercises: Essential for maintaining joint mobility 2
- Splinting and orthotic intervention:
- Ankle foot orthoses (AFOs) to prevent plantar flexion contractures
- Thigh binders to prevent iliotibial band contractures
- Knee splints to prevent knee flexion contractures
- Resting wrist/hand/finger splints to prevent flexor contractures 2
Supportive Equipment
- Seating systems: Include solid seat and back, hip guides, lateral trunk supports, knee adductors, and head support as needed 2
- Supported standing: Using supine, prone, vertical and hydraulic standers or power standing capabilities on motorized wheelchairs 2
- Power mobility features: Tilt, recline, and elevating leg rests to allow position changes and weight shifting 2
Pharmacological Management (Second-Line)
For spasticity-related contractures that cause pain, poor skin hygiene, or decreased function:
First-line medications:
- Tizanidine (especially for chronic patients)
- Oral baclofen
- Dantrolene 2
Avoid benzodiazepines (including diazepam) due to potential deleterious effects on recovery and sedation side effects 2
Localized injections for selected patients with disabling or painful spasticity:
- Botulinum toxin
- Phenol/alcohol injections 2
Advanced Interventions (Third-Line)
For severe, refractory cases:
- Intrathecal baclofen: Consider for chronic patients with spasticity causing pain, poor skin hygiene, or decreased function 2
- Serial casting: For progressive correction of fixed contractures 2
- Surgical options:
Special Considerations
For Critically Ill Patients
- Continuous passive motion (CPM): 3 hours three times daily is more effective than passive stretching for 5 minutes twice daily in preventing fiber atrophy and protein loss 2
- Positioning: Upright positioning (well supported) and rotation when recumbent to prevent cardiorespiratory dysfunction and skin breakdown 2
- Neuromuscular electrical stimulation (NMES): Can help prevent disuse muscle atrophy in immobile individuals 2
Treatment Duration and Intensity
- Sustained stretch: For maximum effectiveness, stretch should be applied for long periods (at least 20 minutes) 3
- Treatment consistency: Recent evidence suggests that inadequate treatment intensity is a common cause of treatment failure, highlighting the need for early, consistent management 1
- Treatment timing: For patients with conditions like Parkinson's disease, scheduling physical therapy during "on" periods when medications are most effective can improve outcomes 1
Important Caveats
Limited evidence for effectiveness: Recent clinical trials question the effectiveness of traditional stretching interventions, particularly when applied for less than 30 minutes daily over less than 3 months 4
Risk assessment: The use of positioning, splinting, and standing devices should be coordinated with medical specialists due to potential contraindications such as:
- Cardiac or pulmonary compromise
- Osteoporosis and fracture risk
- Hip subluxation or dislocation
- Prohibitive existing contractures 2
Early intervention: Treatment is most effective when started before the onset of contracture, targeting soft tissues most at risk 3
Monitoring for adverse events: Watch for potential complications including skin breakdown, bruising, blisters, pain, numbness, and swelling 5