Introduction[edit | edit source]The most common complication of spinal cord injury is contractures. It is a debilitating problem for patients with a spinal cord injury. Contractures result from a loss in the extensibility of the soft tissue structures-skin, ligaments, muscles, and joint capsules crossing joints, leading to restriction in joint mobility, causing joint stiffness, and later on the deformity.[1] Contractures reduce joint mobility and restrict activities of daily living. They are also associated with pain, spasticity, sleep disturbances, and skin breakdown. Most often contractures affect the joints important to daily living: hips, knees, ankles, wrists, and shoulder, causing problems with dressing, eating, transferring, sleeping comfortably, using a wheelchair, or doing any tasks that require full joint movement. Problems in any of these areas can reduce a person's independence[2]. Show
According to a prospective cohort studying the incidence of contracture at one year after spinal cord injury, 66% of the patients developed at least one contracture in any joint at one year after acute spinal cord injury. The proportion of participants with paraplegia developing at least one contracture in any joint was 47%, while the proportion of participants with tetraplegia who got at least one contracture in any joint was 83%.[3] Mechanism of Contracture[edit | edit source]Contractures are either neurally or non-neurally mediated.[4]
Common Contractures[edit | edit source]Research findings suggest that patients with tetraplegia have a higher rate of contractures than those with paraplegia.[5] Patients with motor complete C5 tetraplegia are prone to developing elbow flexion contractures due to triceps paralysis, and as they are frequently sitting with their elbows in flexion on the armrests of wheelchairs and lie with their elbows flexed, the chances of developing elbow flexion contractures increases [1] Knee flexion contractures develop in the patient using wheelchair and may lead to the development of hip flexion and abduction contractures. Upper extremities contracture may be seen at the shoulders, elbows, wrists, and fingers which limits the patient's ability to perform fine motor skills, ADLs. Ankle, wrist, and shoulder are most commonly affected.[3] Factors[edit | edit source]Factors that predispose patients to contractures[4]:
Measurement[edit | edit source]Assessment of range of motion for Spinal cord injury patient includes:
Treatment[edit | edit source]Stretching and Passive Movements[edit | edit source]Stretching and passive movements were the primary treatment approaches for SCI. The passive movements and stretch would help in avoiding contractures resulting from the inability of individuals to move joints. Passive Movements can be administered using mechanical devices or manually by carers and therapists. Prolonged stretch can be administered through positioning programs, splints, standing frames, and orthoses. Heat combined with stretch followed by a maintenance of stretch during cooling with further facilitate the restoration of joint motion.[6] However, there are issues concerning the dosage and relative effectiveness of passive exercises and stretches administered differently. Literature suggests that five minutes, twenty minutes, or even one hour of any intervention (including stretch) does not attain a therapeutic effect. Instead, the research suggests exercises and functional activities carried out in a lengthened muscle position may have a positive outcome[1]. Generally, therapists recommended 20 to 30 minutes of sustained stretch per muscle a day for the prevention and treatment of contracture. However, clinical trials suggest that therapists should not expect to see a clinically meaningful change in joint mobility or muscle extensibility from stretches applied for less than 30 minutes a day over less than 3 months[1]. A Cochrane systematic review investigating stretch interventions for the treatment and prevention of contracture due to neurological conditions including SCI concludes that stretch has no clinically important short-term or long-term effects on joint mobility in people with neurological conditions[1]. Splints[edit | edit source]Orthosis reduces contractures through the prolonged low-load stretch, maintaining joint length. Splints can be used for the prevention and reduction of contractures. Orthosis can be used to reduced contractures through a prolonged low-load stretch. Splinting can help both to prevent and manage length-associated changes in muscles and connective tissue. Splints can be combined with passive movements, positioning active tissue 'stretching' procedures, and/or weight-bearing exercises. Splints can be used overnight to apply sustained stretch for muscle lengthening[7]. Dynamic splinting is another option to get a repeated stretch. A spring or elastic band provides tension to move the joint in the desired direction.[2] Serial Casting[edit | edit source]Casts are a workable approach for treating contractures. These are non-removable external devices, made of plaster or casting tape, applied to change structural or functional characteristics of the neuromuscular system[7]. The affected joint is heated, using moist heat, and manually stretched to obtain a maximum range of motion. The cast is applied by the therapist and left on for two to seven days depending on the treatment. It removed so the skin can be checked for pressure sores and then reapplied in a new position of greater stretch for several days more until the contracture eases enough to permit sufficient ROM[2]. During a serial casting, care must be taken to avoid pressure sores. Physical therapy must also be used to make sure the muscles not being stretched are strengthened after their period of disuse[2]. Positioning[edit | edit source]Proper positioning of the joints while lying in bed or sitting in a wheelchair also can prevent contractures by protecting the articulary structure and maintain the optimal muscle tone. A firm mattress can maintain normal alignment of the joints. Air circulation, water bed can be used. Pillows, sandbags, padded rolls, and hand and foot splints and braces can be used to maintain the shoulder, elbow, hand, ankle, and knee joints in fully extended positions[2]. Plaster splints or orthosis like ankle-foot orthosis, knee-ankle-foot orthosis, or static ankle-foot orthosis can be used for positioning. Exercises[edit | edit source]
Conclusion[edit | edit source]Contractures reduce joint mobility and interfere with motor tasks and limit the activities of persons with SCI. They reduce a person's independence. Information about contractures (patient education) and commitment to good care (proper positioning/passive movements) by patients and caregivers can help prevent contractures' development. Also, identifying the joints at a greater risk of developing contractures by the therapist is very important so that they can be targeted by intensive preventive rehabilitation intervention.[2][3] References[edit | edit source]
Which positioning of the patient by the nurse will help prevent flexion contracture of the cervical? By turning the patient's head to one side and supporting it with a. small pillow in prone position, flexion or hyperextension of the cervical vertebrae can be prevented.
What positioning aid increases cervical flexion?Which positioning aid increases the cervical flexion? Rationale: When thick pillows are used under the patient's head, it increases cervical flexion.
Which aspect of positioning a patient in the supported Fowler's position?Fowler's Position
The patient's arms should be flexed and secured across the body, the buttocks should be padded, and the knees flexed 30 degrees. In Fowler's position, the patient is at an increased risk for air embolism, skin injury from shearing and sliding, and DVT forming in the patient's lower extremities.
What are the different types of patient positioning?In this guide for patient positioning, learn about the common bed positions such as Fowler's, dorsal recumbent, supine, prone, lateral, lithotomy, Sims', Trendelenburg's, and other surgical positions commonly used.
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