What is the first line treatment for a patient with upper extremity contracture, considering their overall health and potential comorbidities such as neurological disorders?

First-Line Treatment for Upper Extremity Contracture

The first-line treatment for upper extremity contracture is physical and occupational therapy focused on task-specific training, stretching, and promoting normal movement patterns, with splinting reserved only as a last resort due to risks of worsening contractures and functional decline. 1

Initial Conservative Management Approach

Physical and Occupational Therapy (Primary Treatment)

Task-specific training with graded functional activities should be implemented immediately, as this represents the highest level of evidence for improving upper extremity function and preventing contracture progression. 1

• Engage patients in functional tasks that promote normal movement patterns, optimal postural alignment, and even weight-bearing throughout daily activities including transfers, sit-to-stand exercises, and using the affected hand to stabilize objects during kitchen or personal care tasks. 1

• Grade activities progressively to increase the time the affected limb is used with normal movement techniques, avoiding postures that promote prolonged positioning of joints at end-range (such as full flexion while sitting). 1

• Manual therapy approaches including stretching, passive exercise, and mobilization are routine practice for severely affected upper extremities to prevent contracture progression and manage spasticity, though evidence for sustained benefit is limited. 1, 2

Specific Therapeutic Strategies by Underlying Cause

For spasticity-related contractures:

• Botulinum toxin injection can serve both as therapeutic treatment for relieving spasticity and as a diagnostic tool to determine if the contracture is due to spasticity versus fixed myostatic changes. 3
• Muscle relaxation strategies, supporting the affected limb at rest using pillows or furniture, and addressing associated pain and hypersensitivity. 1

For neurological conditions (stroke, functional neurological disorder):

• Discourage "nursing" of the affected limb, which promotes learned non-use and worsening contractures. 1
• Demonstrate and promote therapeutic resting postures rather than allowing the limb to remain in contracted positions. 1

Adjunctive Modalities (Secondary Options)

Neuromuscular electrical stimulation (NMES) is reasonable to consider for individuals with minimal volitional movement within the first few months after stroke or for those with shoulder subluxation, though it should be combined with task-specific training. 1

Strengthening exercises are reasonable as an adjunct to functional task practice, not as standalone treatment. 1

Critical Pitfall: Avoid Early Splinting

Splinting should be avoided in the acute phase and only considered after conservative measures have failed, as it carries significant risks:

• Increases attention and focus to the affected area, potentially exacerbating symptoms 1
• Promotes increased accessory muscle use and compensatory movement strategies 1
• Causes immobilization leading to muscle deconditioning and learned non-use 1
• Serial casting for fixed functional dystonia has been associated with worsening symptoms and onset of complex regional pain syndrome 1
• Can increase joint pain (such as shoulder pain from walking with crutches) and muscle deconditioning 1

If splinting becomes necessary (for example, to enable safe hospital discharge), it should be: (1) considered a short-term solution only, (2) issued with a minimalist approach, and (3) accompanied by a specific plan to progress away from its use with regular follow-up monitoring. 1

When Conservative Management Fails

For mild contractures that persist despite therapy:

• Continue comprehensive rehabilitation program to increase range of motion and strength 4
• Consider infarct excision or tendon lengthening procedures 4

For moderate-to-severe contractures:

• Surgical options include release of secondary nerve compression, tendon lengthening or recession, and tendon or free-tissue transfers to restore lost function 4
• Postoperative splinting becomes important to maintain improved range of motion and protect tendon lengthening or transfers 3

Evidence Quality Considerations

The American Heart Association/American Stroke Association guidelines provide Class I, Level A evidence that functional task-specific training should be practiced with tasks graded to challenge individual capabilities, practiced repeatedly, and progressed frequently. 1 This represents the strongest available evidence for contracture prevention and management. The 2020 consensus recommendations on functional neurological disorders provide additional support for avoiding splinting and promoting normal movement patterns. 1