Contractures are the chronic loss of joint motion due to structural changes in non-bony tissue. These non-bony tissues include muscles, ligaments, and tendons.
Description
Contractures can occur at any joint of the body. This joint dysfunction may be a result of immobilization from injury or disease; nerve injury, such as spinal cord damage and stroke; or muscle, tendon, or ligament disease.
Causes and symptoms
There are a number of pathologies and diseases that can lead to joint contractures. The primary causes resulting in a joint contraction are muscle imbalance, pain, prolonged bed rest, and immobilization. Because of the frequency of fractures and surgery, immobilization is the most frequent cause of joint contractures. Symptoms include a significant loss of motion to any specific joint that results in immobility. If the contracture is of a significant degree, pain can result even without any voluntary joint movement.
Diagnosis
Manual testing of joint mobility by a healthcare professional skilled in joint mobilization techniques (e.g. a physical therapist) will identify indications of restricted structures within the joint. Measuring the motion of the joint with a device termed a "goniometer" can be useful if the decrease of motion can be shown to be a proven result of a joint contracture. X rays can be of some benefit in the diagnosis of contractures, because a visible decrease in joint space may indicate a tight, contracted joint. Most physicians will make the diagnosis after a thorough physical examination involving physical and manual testing of the joint motion.
Manual techniques
Joint mobilization and stretching of soft tissues is a common technique used to increase joint elasticity. Structures are stretched in similar directions to those which take place upon normal joint motion. Some healthcare professionals may use some form of heat prior to the stretching and mobilization. If appropriate, exercise may follow manual techniques to help maintain the additional motion achieved.
Mechanical techniques
Devices known as continuous passive motion machines are very popular, especially following surgery of joints. Continuous passive motion machines (CPM) are specifically adjusted to each individual's need. This method is administered within the first 24–72 hours after the injury or surgery. The joint is mechanically moved through the patient's tolerable motion. CPM machines have been proved to accelerate the return motion process, allowing patients more function in less time.
Casting or splinting
Casting or splinting techniques are used to provide a constant stretch to the soft tissues surrounding a joint. It is most effective when used to increase motion of a joint from prolonged immobilization. It is also popular for treating contractures resulting from an increase in muscle tone from nerve injury. After an initial holding cast is applied for seven to 10 days, a series of positional casts are applied at weekly intervals. Before the application of each new cast, the joint is moved as much as can be tolerated by the patient, and measured by a goniometer. When as much motion as possible is obtained after stretching, another final cast is applied to maintain the newly acquired motion.
Surgery
In some cases the contracture may be severe and not respond to conservative treatment. In this event, manipulation of the joint under a general anesthesia may be necessary.
Alternative treatment
In some areas of the body, chiropractic techniques have been found to be useful to improve motion. Massage therapy can be beneficial by promoting additional circulation to joint structures, causing better elasticity. Yoga can help prevent as well as rehabilitate a contracture and can facilitate the return of joint mobility.
Prognosis
Prognosis of contractures will depend upon the cause of the contracture. In general, the earlier the treatment for the contracture begins, the better the prognosis.
Prevention
Prevention of contractures and deformities from spinal cord injury, fracture, and immobilization is achieved through a program of positioning, splinting if appropriate, and range-of-motion exercises either manually or mechanically aided. These activities should be started as early as possible for optimal results.
BOOKS
Umphred, Darcy A. "Traumatic Spinal Cord Injury." In Neurological Rehabilitation. St. Louis: C. V. Mosby Co., 1990.
PERIODICALS
Ito, Caryn S. "Conservative Management of Joint Deformities and Dynamic Posturing." Orthopaedic Physical Therapy Clinics of North America 2, no. 1 (Mar. 1993): 25-38.
