Low-load, prolonged stretch in treatment of elbow flexion contractures secondary to head trauma: a case report.

Low-load, Prolonged Stretch in Treatment of Elbow Flexion Contractures Secondary to Head Trauma: A Case Report Joint contractures are a common complication following head injuries. One study reported an 84% incidence of contractures in a population of patients with head trauma requiring inpatient rehabilitation. [1] The joints most commonly affected were the hips (81%), shoulders (76%), ankles (76%), and elbows (44%). [1]

One of the factors contributing to contracture formation is an imbalance in activity of antagonistic muscle groups acting across the joint. In patients with upper motoneuron lesions such as head trauma, this imbalance may be due to a combination of spasticity and paretic muscle weakness. Prolonged contraction of the spastic muscles (usually flexor muscles in the upper extremity and extensor muscles in the lower extremity) can result in fixed, abnormal posturing and subsequent joint contracture. Akeson and colleagues investigated the mechanism of contracture formation using immobilized rabbit knee joints. [2] They found the main structural change to be increased collagen cross-linking in the periarticular connective tissue.

Prevention of joint contracture is the ultimate therapeutic goal. It is well known that motion, either active or passive, acts in some way to prevent contracture formation, although the specific mechanism remains unclear. [3] Akeson et al postulated that motion stimulates the production of proteoglycans, which in turn lubricate the collagen fiber interface, thus preventing cross-linking and allowing joints to move freely. [4] Daily range-of-motion exercises have become a standard prophylactic measure in the management of patients with head trauma. Despite this intervention, however, contracture formation remains a major sequela of head injuries. [1] Furthermore, manual passive stretching, the principal physical therapy method of treating contractures, is of limited effectiveness. [5] Kottke et al reported that connective tissue has a high tensile resistance to tension applied for a short duration. [6] Prolonged, mild tension, however, does result in elongation, which has been attributed to the separation of the collagen cross-links. A comparison of stretching methods using rat tail tendor as the tissue model revealed that the low-force, long-duration procedure was more effective than short-term, vigorous stretching at producing residual elongation of the connective tissue. [7]

One method of providing low intensity, prolonged-duration force across a contracted joint is through the application of a dynamic splint known as the Dynasplint [TM]. (*1) This device consists of two adjustable cuffs with medial and lateral struts hinged at the joint axis. By varying the tension of the springs housed in each of the distal struts, the amount of force applied across the joint can be altered. Effective use of this splint has been reported in the treatment of elbow flexion contracture subsequent to a supracondylar fracture [8] and in the case of an elbow flexion burn contracture. [9] A recent article reviewed the use of the Dynasplint [TM] in a single case of a contracture secondary to a cerebrovascular accident and in 12 cases of contractures resulting from orthopedic conditions such as knee and elbow fractures. [10] Although the manufacturer's information refers to the use of the Dynasplint [TM] for joint contractures following head trauma, previous studies on such application have not been reported. The purpose of this case report is to describe the application of the Dynasplint [TM] in the treatment of a patient with elbow flexion contracture secondary to head trauma.

Patient History

A 22-year-old man with a left elbow flexion contracture was referred to our outpatient physical therapy clinic for follow-up examination and treatment. Thirteen months prior to this referral, the patient had been struck by a car and sustained severe head trauma. Investigations at the time of the injury revealed a subdural hematoma in the right parieto-occipital area and a compound fracture of the left clavicle. The patient had a Glasgow coma scale rating of

4 and remained in decorticate posturing for several weeks.

Review of the patient's medical records indicated that physical therapy was initiated while the patient was in the intensive care unit (ICU). Intervention included daily ROM exercise of the extremities and a program of sensorimotor stimulation. The patient spent 1.5 months in the ICU, 3.5 months on the neurosurgical ward, and 4.5 months in a rehabilitation center. Limitation in ROM of the left elbow was first documented in the patient's medical records at 2.5 months posttrauma (-74 [degrees] of passive extension) (Figure) and was attributed to hypertonicity of the elbow flexion musculature. An inhibitive cast was applied across the elbow, but the development of a pressure sore over the lateral epicondyle necessitated its removal 4 days later. Passive stretching of the elbow flexor muscles was performed twice daily. At the time of transfer to the rehabilitation center 5 months posttrauma, the patient's elbow flexion contracture had increased to 80 degrees. No restriction in the active and passive ROM of the right elbow was noted.

Treatment of the contracture at the rehabilitation center involved twice-daily manual stretching after a 15-minute application of ice packs. Although cognitive function improved, progress in functional mobility was restricted, in part, by the persistent elbow flexion contracture. The deformity resulted in a change in handedness from left to right and precluded the use of the quadruped position during matwork and the use of rollators, walkers, and parallel bars during gait retraining. Consequently, the patient remained wheelchair dependent. Maneuvering of the wheelchair was made difficult by the lack of elbow extension. At the time of discharge to home 9.5 months posttrauma, the patient was reported to have an elbow flexion contracture of 70 degrees.

Physical Examination

Examination at the initiation of outpatient therapy 13 months posttrauma revealed a moderate increase in the patient's resistance to passive movement (tone) of the flexor muscles of the left upper extremity and a mild increase in the flexor muscles of the right upper extremity and extensor muscles of the lower extremities. Standard manual goniometric measurement of the left elbow with the forearm in midposition demonstrated full flexion and a lack of 67 degrees of passive and active extension of the left elbow. Functional movement of the left upper extremity was restricted mainly by the limited ROM of the elbow. Although ROM was not restricted in the right upper extremity, isolated movement was impaired by an intention tremor and ataxia. The patient could sit independently but required one-person support in standing and two-person support for short-distance ambulation. In terms of cognitive function, the patient was able to carry out daily routines with minimal confusion, demonstrated poor carry-over for new learning, and had superficial insight into his disabilities.

Treatment

One of the main problems impeding improvement in this patient's function was the left elbow flexion contracture. In his past management, passive stretching to gain ROM into extension had proven ineffective. I decided, therefore, to initiate a six-month trial of the Dynasplint [TM] and prescribed the neurological elbow extension low-load, prolonged-stretch (LPS) unit. This particular Dynasplint [TM] device is indicated to reduce contractures greater than 40 degrees and allows bidirectional active movement between 40 degrees and 130 degrees of elbow flexion. Initially, the splint was applied for 30 minutes at a tension setting of 2. After removal, the skin was checked for pressure areas. The patient had no complaints of discomfort. The same protocol was used for the next two visits. The patient's family were then instructed in the proper application of the splint and were requested to apply it for one hour each morning and one hour each evening for the next week. In addition, the family were provided with a forn on which to record, on a daily basis, the hours of wear, duration of discomfort, and any relevant comments. At weekly intervals, the patient returned to the clinic to have the ROM of the elbow documented and to have the wearing time and tension of the splint adjusted.

Wearing time progressed rapidly. After one month of use, the patient could tolerate the splint for 10 hours per night and 2 hours per day. As the tension setting was adjusted beyond the setting of 7, however, the patient began to complain of interrupted sleep because of splint discomfort. Also, the family noted an increase in agitated behavior. For these reasons, I decided to restrict the use of the splint to daytime. Wearing time ranged between 8 and 12 hours daily for the remainder of the trial with a decrease in agitation and no further complaints of splint discomfort.

The tension setting of the splint was gradually increased with maximum tolerable force achieved by 2.5 months (tension setting of 10). During this period of time, the patient gained 27 degrees of passive and active extension (-40[degrees]). The splint was replaced with the elbow extension LPS Dynasplint [TM] which permits bidirectional active movement between 65 degrees of elbow flexion and neutral extension.

After five months of wearing the splint, the patient had -25 degrees of passive elbow extension. The reduction in the flexion contracture was accompanied by a decrease in tone of the elbow flexion musculature detectable by a gradual lessening in resistance to passive movement. The family reported increased use of bilateral arm movement in activities of daily living, and ambulation with a walker was now possible for short distances. At about the same time, the lateral cam of the splint split. The breakdown was attributed to increased use of the left arm while wearing the splint as well as to the prolonged application of the splint at a high tension setting. To prevent further breakdown, the splint was equipped with longer metal struts, and the patient was advised to avoid wearing the splint during activities involving excessive use of the left arm, such as ambulation with the walker.

By the end of the six-month trial, -20 degrees of passive and active elbow extension were available. Although the patient was becoming impatient with wearing the splint, he agreed to extend the trial an additional six weeks. Another 5 degrees of elbow extension were achieved during this time period. Despite increased unilateral function of the left upper extremity and persistent ataxia and tremor of the right upper extremity, the right upper extremity remained the dominant extremity in

I was concerned that after discontinuing the use of the splint, the gains in ROM could be lost without ongoing external support. At the reassessments performed two months and six months after termination, however, both active and passive ROM in elbow extension remained at -15 degrees.

Discussion

Joint contractures can impose severe limitations to the functional recovery of the patient with head trauma. My patient's elbow flexion contracture not only restricted the use of his left upper extremity but also limited the use of ambulatory aids. Furthermore, it necessitated a change in hand dominance from left to right, despite the presence of ataxia and tremor in his right upper extremity.

Without reducing the contracture, improvement in this patient's functional status could not be achieved. Yet, the conventional approach of daily passive stretching had proven ineffective in his past management. Plaster casting, also referred to as serial or inhibitive casting, has been used in the prevention and treatment of spasticity-induced contractures. [11-14] King applied serial casting across the elbow of a patient who has sustained a subarachnoid hemorrhage 1.5 months previously. [1] Within five days, the passive ROM into elbow extension increased 70 degrees (-90[degrees] to -20[degrees]), the gains being attributed to a reduction in flexor spasticity. Casting has also been reported to be useful in preventing an increase in the progressive elbow flexion contracture of a 5.5-year-old girl with spastic quadriplegia. [12] In a review of 42 patients with head trauma with lower extremity serial casting. Booth and colleagues concluded that the intervention was most effective when initiated within the first six months after injury and with patients demonstrating ongoing neurological recovery. [13] In my patient, casting had been attempted 2.5 months posttrauma but failed because of the development of a pressure sore on the lateral epicondyle.

By the time the patient was referred to our outpatient department (13 months posttrauma), the contracture was longstanding, and a trial of the Dynasplint [TM], rather than plaster casting, was chosen as the means of intervention. The Dynasplint [tm] device had been used successfully in our facility for soft tissue shortening resulting from orthopedic conditions such as ligamentous repairs. We had never used it, however, with patients with central nervous system (CNS) lesions. The knowledge that contracture formation in patients with CNS lesions is often secondary to spasticity appears to discourage clinicians from trying techniques commonly used with orthopedic patients. This case report demonstrated that the Dynasplint [TM] could be applied effectively without aggravating the underlying hypertonicity. The tone of the spastic flexor muscles gradually diminished over the course of the 7.5-month trial. Gains in ROM were maintained after discontinuing the use of the splint, possibly as a result of the decreased tone and enhanced functional use of the left upper extremity.

The major difficulties encountered during the trial of the splint were episodes of splint discomfort and splint breakdown. Both of these problems were of short duration and easily remedied. The possibility of similar but more persistent complaints, however, must be born in mind when prescribing the splint. Although the use of the Dynasplint [TM] reduces the therapist-patient contact time, it does require the ongoing attention of the patient or, when necessary, his family. The attentive and responsive nature of my patient's family members was instrumental in minimizing complications and achieving success.

It was anticipated that with reduction in the contracture, the patient would revert to using his left hand as his dominant hand. The fact that he elected to continue to use his right hand despite poorer control on that side was attributed by his family to habitual behavior. This may not have been the outcome had the Dynasplint [TM] been introduced earlier in his rehabilitation.

Conclusion

This case report illustrates that low-load, prolonged stretch provided through the use of the Dynasplint [TM] can be used to treat elbow flexion contractures of neurologic etiology. Prior to the trial of the splint, the contracture measured -67 degrees of extension and was refractory to manual stretching techniques. Over the 7.5-month trial of the splint, the contracture decreased 52 degrees to -15 degrees of extension. A concomitant improvement in the patient's functional status was observed. At follow-up evaluations two and six months after terminating use of the splint, gains in ROM were found to be maintained. Although the Dynasplint [TM] has not been used extensively for contracture reduction in patients with head trauma, it should be considered as an alternative to traditional strategies in selected patients. A controlled study comparing the effectiveness of the Dynasplint [TM] to other forms of contracture-reduction therapy such as plaster casting is warranted.

(1) * Dynasplint Systems, Inc, 6655 Amberton Dr, Ste A, Baltimore, MD 21227

References

[1] Yarkony GM, Sahgal V: Contractures: A major complication of craniocerebal trauma. Clin Orthop 219:93-96, 1987

[2] Akeson WH, Amiel D, Mechanic GL: Collagen cross-linking alterations in joint contractures. Connect Tissue Res 5:15-19, 1977

[3] Frank C, Akeson WH, Woo SL-Y, et al: Physiology and therapeutic value of passive joint motion. Clin Orthop 185:113-125, 1984

[4] Akeson WH, Woo SL-Y, Amiel d, et al: Biomechanical and biochemical changes in the periarticular connective tissue during contracture development in the immobilized rabbit knee. Connect Tissue Res 2:315-323, 1974

[5] Krusen FH, Kottke FJ, Ellwood PM: Handbook of Physical Medicine and Rehabilitation, ed 2. Philadelphia, PA, W B Saunders Co, 1971, pp 398-399

[6] Kottke FJ, Pauley DL, Ptak RA: The rationale for prolonged stretching for correction of shortening of connective tissue. Arch Phys Med Rehabil 47:345-352, 1966

[7] Warren CG, Lehmann JF, Koblanski JN: Heat and stretch procedures: An evaluation using rat tail tendon. Arch Phys Med Rehabil 57:122-126, 1976

[8] Hepburn GR, Crivelli KJ: Use of elbow dynasplint for reduction of elbow flexion contractures: A case study. Journal of Orthopaedic and Sports Physical Therapy 5:269-274, 1984

[9] Richard RL: Use of the Dynasplint [TM] to correct elbow flexion burn contracture: A case report. J Burn Care Rehabil 7:151-152, 1986

[10] Hepburn GR: Case studies: Contracture and stiff joint management with Dynasplint [TM]. Journal of Orthopaedic and Sports Physical Therapy 8: 498-504, 1987

[11] King TI: Plaster splinting as a means of reducing elbow flexor spasticity: A case study. Am J Occup Ther 36:671-673, 1982

[12] Smith LH, Harris SR: Upper extremity inhibitive casting for a child with cerebral palsy Physical and Occupational Therapy in Pediatrics 5(1):71-79, 1985

[13] Booth BJ, Doyle M, Montgomery J: Serial casting for the management of spasticity in the head-injured adult. Phys Ther 63:196-1966, 1983

[14] Barnard P, Dill H, Eldredge P, et al: Reduction of hypertonicity by early casting in a comatose head-injured individual. Phys Ther 64 1540-1542, 1984

M MacKay-Lyons, MSc, PT, is Clinical Research Associate, Physiotherapy Department, Victoria General Hospital, Halifax, Nova Scotia, Canada B3H 2Y9.

This article was submitted May 3, 1988; was with the author for revision for five weeks; and was accepted October 12, 1988.