A contracture is a fixed tightening or shortening of muscles, tendons, or ligaments that hinders movement. Most commonly, contractures affect the joints in the hands and feet. They can develop in response to brain and spinal cord injury from stroke or TBI or a neurological disorder.
PT and OT treatments can be used to help prevent contractures or treat them when they develop. However, if a contracture has been present for a long time, it can be difficult to reverse.
Causes
Contractures are fixed tightenings or shortenings of muscles, tendons or ligaments that hinder movement. They often result from a period of time where a body part is not used, such as after a stroke or spinal cord injury (SCI). Inactivity causes the muscles and joints to loosen and then tighten, restricting the range of motion (ROM) of the area. People who have a chronic health condition such as Cerebral Palsy, Multiple Sclerosis or Dupuytren’s Contracture are more at risk of contractures.
Normally, the surfaces of bones that make up a joint are smooth and move against each other easily. But an injury or disease can cause the surfaces to degenerate, causing inflammation and resulting in structures that stick together. This results in a restriction of the movement of the joints and can also result in the formation of deformities.
Muscle contractures are common in patients with central motor lesions, but the underlying cause is not fully understood. It is generally assumed that decreased neural drive to the muscles is the primary cause of the development of muscle contractures. However, a number of other mechanisms such as an increase in pain, spasticity or protracted placement of the joint with the muscle in a short position have been proposed.
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In some cases, the underlying reason for contractions is myofascial trigger points (TrPs), which are bundles of tight muscle fibers that are unable to relax without intervention. TrPs are characterized by reduced extensibility, disrupted muscle fiber architecture and a lack of electrical activity. The development of TrPs has been linked to reduced functional recovery following a stroke or brain injury.
A physical therapist can identify a contracture by examining the affected area and testing its range of motion, or how far the joint can move in different directions. Your healthcare provider may also order X-rays to find the underlying cause. Treatment aims to restore the full range of motion and improve the function of the affected area. This includes exercises to improve the muscles’ strength and flexibility. Treatment strategies can also include repositioning devices that will help you change your position throughout the day, as well as the use of heat or cold.
Diagnosis
Contractures are characterized by a fixed tightening of muscles, tendons and ligaments that affect the movement of a body part. They usually develop from the nonuse of a muscle due to weakness, spasticity, or loss of ROM caused by brain and spinal cord injury, stroke, TBI, or congenital neuromuscular disorders.
Physical and occupational therapy (PT/OT) utilizing passive range of motion (ROM) exercises is the usual first-line treatment for these problems. Depending on how long the contractures have been present, they may require a more comprehensive approach such as splinting or orthopedic bracing.
To make a diagnosis of a contracture, your healthcare provider will ask about the symptoms you have and how they began. Your provider may also ask questions about your pain and whether the symptoms have gotten worse or better over time. Your provider will feel the affected areas to see if they are thickened. They may also perform a “table top test,” which involves placing your hand, palm down, on a table to see if the fingers straighten.
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When a contracture is not treated, it can get worse and lead to irreversible symptoms that interfere with everyday activities such as dressing, eating, and performing basic hygiene. It can also increase the risk of a fall or a tripping accident that could cause injury to other people.
Some types of contractures, such as Dupuytren contracture, do not have any triggers and simply progress slowly over time as nodules develop into cords that might affect your ability to straighten the affected finger. If you are experiencing these symptoms, you may want to discuss treatment options with your healthcare provider, which might include a steroid injection.
A rehabilitation team should evaluate the patient to ensure that their goals are being met. Typically, a comprehensive PT/OT evaluation includes gathering history and observing the person ambulating, transferring, performing ADLs, and engaging in activities of daily living. This should be done in the setting where the contractures are present to assess their effect on the person’s function and quality of life. This can be a valuable tool in providing an accurate treatment plan that will meet the person’s needs.
Treatment
A contracture is a fixed tightening or shortening of muscles, tendons, and ligaments that affects joint mobility. Contractures typically develop when a person’s ability to move a body part is compromised, usually due to injury or disease. They can result in a limited range of motion and, if severe, may produce deformities. They can also lead to pressure injuries, pain, and decreased self-care and quality of life.
The underlying health condition that causes the contracture and how long it has been present determines treatment options. In many cases, physical therapy and occupational therapy (PT/OT) utilizing passive ROM exercises will help loosen and stretch the contracted muscle or skin.
Muscle contractures are common in people who have had a stroke or TBI, or have a congenital neurological disorder such as cerebral palsy or multiple sclerosis. They are also common in people who have rheumatic conditions that cause inflammation of joints and soft tissue, such as RA or osteoarthritis.
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A person can also experience a muscle contracture because of spasticity (stiff, tight muscles that limit movement). In this situation, a diagnosis of a contracture should be made, but the therapist must be careful to differentiate between spasticity and a true contracture. Performing PROM at different speeds and with heat modalities can help to distinguish these differences.
Surgical procedures are used to treat a variety of contractures, depending on the underlying cause and severity of the contracture. A contracture of the skin may be treated by opening and removing the tight nodule or cord, which is known as a fasciotomy. In severe cases, a surgeon may need to cut the tight cords in the hand and carefully remove diseased skin, which is known as a fasciectomy.
Getting treatment for a contracture early on can help reduce the risk of pressure injuries and other complications, such as infections and loss of skin integrity. It can also improve the perception of personal independence and help people maintain flexibility in other non-affected areas of their bodies. It is also important to preserve ROM in affected muscles so that it can be used for movement and daily activities as functional recovery progresses.
Prevention
Despite their infrequent occurrence, contractures significantly impact quality of life. They restrict limb movement, impair repositioning and can cause pain, sleep disturbances, pressure ulcers and edema. Consequently, considerable time and resources are devoted to their prevention.
Physiotherapists generally concentrate on stretching as an effective strategy for contracture prevention and many research studies have included this in treatment. However, it is important to remember that the effectiveness of stretch may be influenced by the condition for which a person is treated. This is because some contractures (e.g., supination contractures of the forearm in tetraplegic patients with C5 lesions) are caused by positioning of soft tissues in stretched positions over prolonged periods.
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It is thought that both neurally mediated factors, such as spasticity, and non-neurally mediated factors, including changes to muscle-tendon units, play a role in the development of contractures (Lieber 2004). Neurally mediated factors are present only in people with neurological conditions while the others can occur in people with all types of injuries or illnesses.
To prevent contractures, it is recommended that you stretch your limbs daily. If you have paralysis that limits your ability to self-perform stretches, a physical or occupational therapist can perform these on your behalf. You should also keep your joints as flexible as possible and try to avoid putting pressure on affected areas. In addition, a healthy diet and regular exercise are also important. Your healthcare team can offer you information on the best nutrition for your condition and will be able to recommend the most appropriate exercises for your needs. They can also prescribe or provide devices to help you move your muscles and joints. These can include passive range-of-motion exercises, splinting and mechanical devices for active motion.
