The Nature of Contractures
Justin Alexander, Ph.D. *
When orthotic devices are supplied to a patient, it is generally in the hope that function can be enhanced. If this expectation is to be realized, joint mobility or range of motion should be within normal limits. Unfortunately, there are many patients where a significant deficit in freedom of movement occurs. It is essential to realize that the causative factor for such limitation is varied, so that one may develop a reasonable treatment approach.
Impedence to free motion can result from injury or malfunction of the skin overlying a joint, muscles or tendons surrounding or crossing joints, the joint capsule, or the joint surfaces. In many instances joint disturbances can be avoided by timely intervention such as correct positioning; active, assistive or passive exercises; or stretching and joint mobilization. Unfortunately, even when meticulous care is provided, limitations of movement can occur. Once tightness has been allowed to develop, it becomes more difficult and painful to restore normal function. A variety of mechanical devices designed to minimize the danger of developing contractures, or to overcome them, have been described in the literature. Surgical intervention may be attempted in carefully selected instances as well.
A common sequela to prolonged inactivity is loss of flexibility, probably due to shortening of muscle fibers and connective tissue. In an otherwise healthy individual this does not cause a serious problem and one can expect that with resumption of normal activity, muscles will regain length and flexibility. If, however, a limb is immobilized because of injury or disease, tissue repair involves replacement of muscle fibers with scar tissue which consist of collagen. Early, persistent, and careful physical therapy usually produces satisfactory restoration of movement.
Delay in starting therapy or placing the responsibility for performing a prescribed regimen completely on the patient or family member, without assurance that the program is understood and that it will be performed, is prone to produce serious impedance to normal mobility. It is important to note that when a distal joint is immobilized, the more proximal joints are not utilized as much as under ordinary conditions and secondary joint limitation may develop. Some common examples are the concommitant tightness of hip flexors and knee flexors, or the limitation seen in the shoulder and elbow of the patient who has sustained a Colles fracture of the wrist.
Immobilizing a part in a resting position does not necessarily produce limitation of movement, provided there is physiological rest. On the other hand, if a part is immobilized and there is active muscle contraction to prevent the muscle from being elongated or the joint moved, muscle tightness can be invariably expected. When a person expects that motion might be painful, such as during the acute phase of Rheumatoid Arthritis or during severe and prolonged periods of ischemia, a "protective spasm" can be anticipated and frequently results in "irreversible contracture." The term "irreversible" must be used tentatively, since, if given enough time, the contracture may be relieved through ordinary activity. In most instances, therapy cannot be provided or justified for the long period required to ameliorate the situation. In several instances, we have observed changes occuring over two years or longer following initial insult.
Extravasation of fluid into tissue surrounding the joint, such as may be observed following repeated trauma as a result of stretching which is performed too enthusiastically, or after episodes of bleeding in an individual with hemophilia, will invariably result in deposition of collagen and may continue to permit calcification of the capsule and end in heterotopic bone formation.
Heterotopic ossification presents a difficult problem to manage. While there have been some reports of spontaneous remission over time, others have reported recurrence after surgical excision.
Repeated insults to the integrity of the joint itself can lead to complete blockage of the joint, either as ankylosis of the capsule or due to fusion of the joint surfaces. Depending on which joint is involved, total or partial joint replacements have been very successful in restoring function and almost completely eliminating pain.
The management of the patient with contractures is complicated and if it is to be successful, close collaboration between physician, therapist, orthotist, and the patient and family is imperative. In the presence of contracture, the application of an orthotic device can be wrought with danger. If too much tension is applied in order to gain motion when the patient is walking, protective spasms may counteract any stretching effect. It is also possible that excessive pressure can result in a fracture, especially if the patient has ben inactive for some time and if osteoporosis is present. The chances of successfully reducing joint limitations are increased when physical therapy and orthotic devices are combined in a comprehensive treatment program.
References:
- Harris, R. and Copp, E.P., "Immobilization of the Knee Joint in Rheumatoid Arthritis," Ann. Rheum. Dis., 21:353, 1962.
- Partridge, R.E.H. and Duthie, J. Jr., "Controlled Trial of the Effect of Complete Immobilization of the Joints in Rheumatoid Arthritis," Ann. Rheum. Dis., 22:91, 1963.
- Alexander, J., "Irreversible Contractures: An Impediment to Prosthetic Rehabilitation" Newsletter Prosthetics and Orthotics Clinic, 4:3, 1, 1980.
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