Use of a static adjustable ankle-foot orthosis following tibial nerve block to reduce plantar-flexion contracture in an individual with brain injury. (Case Report).

Contractures are a common complication in people with central nervous system injuries. (1) The incidence of restricted ankle dorsiflexion (DF) range of motion (ROM) has been noted to be as high as 76% in people admitted for rehabilitation due to traumatic brain injuries. (1) Such a high percentage may be due to the fact that limb positioning and joint ROM may be neglected when the emphasis after acute brain injury is on life preservation. (1)

The term "contracture" refers to the restriction of "ROM about a joint to such a degree that it impedes activities of daily living." (1(p93)) Immobilization as a result of any condition can lead to the development of acontracture. (1,2) Although spasticity and paresis often contribute to contracture development, they are not the sole cause of contractures. Spasticity has been defined by Lance (3) as a velocity-dependent response of muscle to passive stretching. Paresis has been defined as muscle weakness in upper motoneuron lesions as a consequence of inadequate recruitment of lower motoneurons. (4) Morphological adaptations often accompany immobilization of a muscle in a shortened position in animals, including decreases in muscle (5-7) and tendon length (8) as well as decreases in number of sarcomeres in a series. (5-7) Other adaptations in animals include increases in the proportion of connective tissue to muscle fiber within the muscle, (6,9) decreases in extensibility of periarticular connective tissue, (10) and alterations in the orientation of intramuscular connective tissue. (9) Cellular muscle changes occur in animals after as little as 24 hours of disuse or bed rest. (7,11)

Contractures can affect a patient's functional outcomes. Adequate DF ROM (at least neutral DF to +10[degrees]12), for example, is necessary for typical performance of activities such as ambulation, (13) stair climbing, (14) and rising from a chair. (15) Gait pattern changes associated with inadequate DF ROM include decreased hip extension and knee hyperextension during the stance phase and poor foot clearance or excessive hip flexion during the swing phase. (16-18) In patients who are nonambulatory, maintenance of adequate DF can be important for safe transfers and appropriate wheelchair positioning. (12)

Rehabilitation clinicians must consider the physiological rationale behind each intervention when selecting the most appropriate method to reduce contractures. (19) Decision making becomes complicated as manifestations of spasticity, muscle stiffness, and contracture are combined with questions about how much motor control has been spared and how much recovery will occur. (20) Approaches to improve ROM include the use of biomechanical interventions such as serial casting or splinting, (16,21) pharmacological interventions such as botulinum toxin (22) or phenol (23,24) injections, and surgical interventions (25) in patients with long-term contracture.

Contractures resulting from adaptive shortening of muscle have traditionally been managed by a combination of interventions, including manual passive range of motion (PROM) and passive lengthening through prolonged positioning. (19) Warren et al, (26) using an animal model, evaluated the effects of load on tissue elongation. Low-load, long-duration tension produced greater elongation of tissues than heavier loads applied over shorter periods of time. Consequently, a low-load prolonged stretch is often effective for reducing contractures. (27-29) The duration of a passive stretch needed to cause a true length change continues to be debated. (30) Studies by Zito et al, (30) Bohannon, (31) and Light et al (27) that evaluated short-duration stretch and compared short--and long-duration stretching showed that manual (short-duration) stretching probably lacks efficacy. (32) Zito et al (30) evaluated the effects of one bout of two 15-second passive stretches on ankle dorsiflexion ROM in subjects without known pathology. No statistically significant length gains were found over the 24-hour measurement period. Bohannon (31) evaluated 8-minute stretches of the hamstring muscle over 3 consecutive days in young subjects without known pathology, also finding no significant change in ROM during straight leg raises. Additionally, the small increases in the angle of ROM were mostly lost after 24 hours. Light et al, (27) in treating knee extension contractures, compared low-load prolonged stretches (LLPSs) of 1 hour (twice daily, 5 times a week for 4 weeks) with the application of 3 high-load brief stretches (HLBSs) of 1 minute over the same time period and treatment frequency. These subjects were nonambulatory geriatric nursing home patients, with no specific diagnosis mentioned. After a total of 11 patients, the LLPS PROM measurements were greater than the HLBS PROM measurements (at a P<.05 significance level).

Similarly, Halbertsma and colleagues (33) found that the acute short-term effect of repeated manual passive stretching of short hamstring muscles was negligible in subjects without known pathology. In this study, the hamstring muscles were stretched as far as the subject allowed and then immediately returned to the horizontal starting position of the leg. This stretch was repeated 5 times with 2-minute intervals between sessions. Although some studies (34,35) have indicated that a stretch of as short a duration as 15 seconds may be sufficient for increasing ROM, these results were based on subjects who did not have neurological problems or ROM limitations. Rothstein et al, (12) in a conference of physical therapists reviewing current approaches to intervention for plantar-flexion (PF) contractures, concluded that poor carryover usually occurs with stretching of a short duration. Tardieu et al (36) supported this conclusion by showing that 6 hours of "stretching" (elongation) is necessary to prevent contracture in the soleus muscle of children with cerebral palsy (CP). Furthermore, progressive contracture was noted in these children when the soleus muscle was elongated for less than 2 hours a day.

As an adjunct to intervention, serial casting has been used commonly and effectively for over 20 years to manage contractures in patients with brain injury. (21,37) An increase in ROM is gained by maintaining a prolonged passive stretch in the submaximal range. (37) Conine et al (38) found a mean increase of 20 degrees of PF using an average of 5 cast applications in patients with acute brain injury. Moseley (16) found similar improvements with patients with traumatic brain injuries. After 7 days of casting combined with stretching, the mean increase in ankle was 13.5 degrees. The ankle DF PROM of a control group of patients decreased when not treated with serial casting and stretching, suggesting that PF contractures do not tend to resolve spontaneously without intervention in these patients.

When using serial casting, casts usually are removed after several days to 1 week and are reapplied when the tissues that constrained the motion are lengthened. (37) The therapist should provide PROM at each cast change to maintain full mobility of all immobilized joints. (16) Serial casting does have limitations, which were not identified from specific systematic investigations of casting risk factors, but from various clinical observations. Limitations include lack of attention to active movement, (21) length of time for application, (12) skin breakdown, (39,40) and restricted use of the casted extremity. (39) Reports vary about the maintenance of gains in ROM after casting. Boothe et al reviewed the results from casting 42 patients with acquired brain injury and stated that, through their own clinical experience, "if no underlying motor control is unmasked and spasticity is not reduced after the casting procedure, the probability of maintaining improvement without bracing or splinting is poor." (21(p1960)) Generally, the cast is bivalved and converted into an anterior-posterior splint so that the patient can continue immediately with the regimen.

Studies evaluating the long-term affects of serial casting are limited, and most involve children. Brouwer et al (41) compared serial casting in children who were classified as idiopathic toe-walkers and children with spastic CP who toe-walked. Decreased resistance to passive stretch and increased DF ROM were seen in both groups, but were better maintained in the children who were idiopathic toe-walkers. The authors suggested that the decline in some of the children with CP 6 weeks after casting reflected the persistence of abnormal neural drive to the plantar-flexor muscles despite the immediate effects of serial casting. Cottalorda et al (42) also studied the effect of serial casts on toe-walking in children with CP. They found a mean increase in DF PROM from an initial angle of 3 degrees to 20 degrees immediately after removal of the casts. An average of approximately 3 years later, however, the mean DF PROM had decreased from 20 degrees to 9 degrees, indicating a persistent but limited carryover effect.

An alternative method to reduce contractures through a low-load prolonged stretch incorporates the use of an orthosis to maintain the joint in a position of stretch. (28) Static (stationary) adjustable orthoses have several advantages, including: (1) the device can be removed easily and quickly to permit hygiene and close observation for skin integrity; (2) small adjustments at frequent intervals can be made, allowing a slow, comfortable stretch of joints; (3) little time is required to make adjustments; (4) patients may perform functional activities with the orthosis in place; and (5) the orthosis can become a permanent part of the patient's home program to maintain or further increase ROM. (39) Several studies (28,29,43,44) have shown that orthotic splinting is an effective intervention for joint contractures. Nuismer and colleagues (28) found a significantly increased ROM for a sample of 17 patients with contractures due to neurologic or orthopedic pathologies in a retrospective study examining the use of low-load prolonged stretch orthoses in inpatient rehabilitation programs ([t.sub.(17)]=4.99, P<.001). The patients' functional abilities also improved.

Studies showing the effectiveness of adjustable orthoses appear to primarily address upper-extremity or knee contractures. A review of the literature failed to reveal documentation of the use of this type of adjustable orthosis for the ankle. Most of the research providing low-load sustained stretch for ankle contractures relates to serial casting.

When addressing contractures in patients with central nervous system injury or disease, an adjunct to therapy includes nerve blocks that can reduce spasticity and resistance to passive stretch. (45) Fast-acting analgesic blocks (ie, lidocaine or bupivacaine) often are used to differentiate between fixed and dynamic (not fixed) contractures. If the diagnostic block is effective in increasing joint ROM, suggesting that the limited ROM is primarily a result of spasticity, then a longer-lasting block (ie, phenol) often is used. Phenol nerve blocks have been shown to decrease spasticity. (23,24,46-49) They also have been shown to improve function of daily tasks (23,47) and to facilitate ambulation. (47-49) Moritz (48) reported that the average duration of the blocking effect is approximately 8 months. In patients with moderate to severe spasticity and fixed contractures, the combination of a nerve block with a stretching protocol may be an effective means of improving ROM and mobility, (50) although no clinical trial has specifically evaluated this treatment option. Once increased ROM has been achieved, the use of a splint is important to maintain the new ROM, because the change in ROM is unlikely to remain once external forces are removed. (51)

The patient for this case report was involved in a pilot study (52) evaluating the effects of a specific brand of static adjustable ankle-foot orthosis (AFO)--the Restorative Care of America Inc (RCAI) Phase II Multi-Podus adjustable splint * (Fig. 1)--in reducing plantar-flexion contractures. Unlike the other participants in that study, this patient exhibited severe spasticity in addition to an existing fixed contracture. Through the course of the patient's intervention, certain strengths and limitations of the AFO became clear, warranting further explanation in a separate case study. The purposes of this case report are (1) to illustrate the use of an adjustable AFO as an adjunct to a peripheral nerve block and physical therapy to decrease an ankle PF contracture and (2) to describe the use and limitations of this type of device.

[FIGURE 1 OMITTED]

Case Description

Examination

The patient ("PG") was a 44-year-old woman diagnosed with a right frontal arteriovenous malformation (AVM). Her preoperative embolization, a surgical technique to reduce AVM blood flow to assist resection of such lesions, (53) was complicated by an intracerebral hematoma and an episode of status epilepticus. She underwent a craniotomy for evacuation of the hematoma and resection of the AVM. PG's postoperative course was complicated by episodes of hydrocephalus. She began inpatient rehabilitation approximately 4 weeks after the initial event. At that time, she had no voluntary movement in either the left upper extremity or lower extremity (Brunnstrom (54) stage 1 throughout), and she had extensor spasticity in her left knee and ankle of a Modified Ashworth Scale (55) grade of 3. Through Observation of functional activities, sensation and proprioception also appeared to be impaired, although formal testing was not completed due to PG's impaired cognitive status (decreased attention span, confusion, lethargy). Mobility was measured with the Functional Independence Measure (FIM). (56) She needed maximum assistance in all areas of mobility, with FIM scores of 2 for transfers and 1 for ambulation and stairs. Her left ankle DF PROM measured -31 degrees from neutral DF by goniometric assessment when measured with the patient positioned supine with the knee extended.

To evaluate PG's PROM at the ankle, measurements were taken with a goniometer of talocrual DF and PF, using the left fibular head and lateral border of the plantar surface of the foot for landmarks. (52,57,58) Measurements were obtained by placing the long stationary arm of the goniometer ([dagger]) over a line between the fibular head and the lateral malleolus and the movable arm over a line formed by the lateral plantar surface of the foot below the fifth metatarsal. The bony landmark of the fibular head was marked to increase the reliability of goniometric measurement. The patient's primary (nonblinded) therapist took all measurements while the patient was positioned supine with her knee extended, with attempts at applying the same maximal DF force with each measurement. Three measurements were taken, and the average of those 3 measurements was recorded. Intrarater reliability was determined for the therapist conducting the measurements using another patient with an upper motor neuron lesion and PF contractures, using procedures described by Grissom and Blanton. (52) Grissom and Blanton stated:

   With the blinded side of the goniometer toward the therapist, a maximal
   dorsiflexion force was applied while the long arm of the goniometer was
   placed over the line between the fibular head and the lateral malleolus.
   The other moving arm was positioned over a line formed by the lateral
   plantar surface of the foot below the fifth metatarsal. The goniometer was
   then read and the number of degrees was recorded from the nonblinded side.
   This was repeated 3 times, with attempts at applying the same maximal
   dorsiflexion force for each measurement. The patient's foot and ankle was
   then passively circumducted and the patient was repositioned supine with
   the knee extended. The therapist then repeated the measurements as
   previously described, which were again read and recorded. The intraclass
   coefficient (ICC) was calculated by using the means of the first set of 3
   measurements and the second set of 3 measurements. (52(p271))

The intraclass correlation coefficient (ICC [3,3]) for intrarater reliability of goniometric measurements was .95.

Evaluation

The patient's healthy and active premorbid lifestyle, in conjunction with a supportive network of friends and family, were good prognostic indicators for PG's ultimate discharge back to her home. (59) The primary factors limiting PG's mobility were her dense left hemiplegia and marked hypertonicity. Immediately on admission, PG's attending physiatrist was concerned with her severe PF contracture and decided to enroll her in an ongoing pilot study evaluating the effectiveness of a static adjustable orthosis. This course of action was chosen as an alternative to serial casting. This device, the RCAI Phase II Multi-Podus adjustable splint (Fig. 1), had previously been used in this rehabilitation center to improve ROM with patients with neurological impairments as well as to provide protection from skin breakdown by suspension of the heel from the splint bottom. This orthosis is made of flexible plastic stabilized by adjustable metal rods on either side. A rotating dial on the positioning bars can be adjusted to increase or decrease the angle of the orthosis, with a clockwise rotation being approximately 1 degree of movement. This measurement of joint angle represents position of the orthosis, not goniometric measurement of ankle ROM.

Intervention

Inpatient intervention. Following the pilot study protocol, PG was given a diagnostic 2% lidocaine nerve block to the left tibial nerve as described by Arendzen and colleagues. (45) Prior to the block, her ankle PROM measured -31 degrees from neutral DF. After the block, ankle PROM measured -25 degrees. This initial nerve block was given to confirm the presence of a soft tissue contracture versus ROM limitations due to spasticity.

The orthosis was applied within a few hours of the nerve block, with the metal measurement bars placed at 30 degrees from neutral DF. PG wore the brace at all times, except for approximately 1 to 2 hours per day for hygiene and stretching in physical therapy. Usually only the primary therapist (taking the measurements and supervising the physical therapy treatments) or physiatrist replaced the brace. Nursing staff were instructed to notify the therapist or physician when the brace was removed for hygiene. Only 2 or 3 occasions occurred when another therapist or nurse replaced the brace.

Some heel slippage out of proper position in the orthosis was noted on days 2 to 4 (Fig. 2), as was some redness on the plantar surface of the fifth metatarsal head. The lateral metal bars of the orthosis were lengthened to -40 degrees from neutral on day 3 to help relieve these problems. Minimal improvement (less than 2[degrees]) was noted in DF PROM. The orthosis was removed on day 5 due to increased redness of the entire plantar surface of the foot. The orthosis was reapplied the following day. Reducing the angle of the orthosis to -30 degrees was attempted again. Maintaining the ankle in proper position within the orthosis continued to be a problem. Consequently, the manufacturer representative was notified on day 8. He noted that the orthosis was too large and provided a smaller one, in which the ankle remained in proper position for 2 days, when more redness developed along the fifth metatarsal head. The patient did not wear the orthosis from day 10 until the primary physiatrist could be notified on day 12. At that time, the therapist suggested that the patient would benefit from a longer-lasting phenol block because her spasticity was too severe (Modified Ashworth Scale (55) grade 3) to safely use the orthosis without risking skin breakdown. The interrater reliability of Modified Ashworth Scale scores in the lower extremities of people with stroke is poor (Kendall tau-b correlation of .062 [P=.461]). (60) However, intrarater reliability is better, with a Kendall tau-b correlation of .567 (P<.001). (60)

[FIGURE 2 OMITTED]

A phenol nerve block was administered to the left tibial nerve on day 13, and the orthosis was reapplied. No immediate change in DF PROM was noted immediately after the nerve block. From that time on, no skin redness was observed and the ankle did not slip out of position in the orthosis. The patient's PROM improved from -16 degrees from neutral to + 10 degrees of DF from day 13 to day 27. The orthosis was changed to accommodate the increase in PROM, approximately 5 degrees (as grossly measured by the lateral rods on the orthosis) on days 13, 14, 15, and 17 and 10 degrees on day 19 (a total change from -30 to 0 degrees of the lateral rod measurements in 6 days).

The total intervention period of full-time use of the orthosis was 27 days, with the patient wearing the orthosis 23 days and receiving physical therapy for 23 days. From day 28 to PG's discharge from inpatient rehabilitation at day 35, she wore the orthosis at night and wore a custom-made plastic ankle-foot orthosis (PAFO) during the day to assist with safety during transfers and gait. PG received an average of 90 minutes physical therapy daily during the week and 45 minutes over the weekend. PG received physical therapy twice daily, Monday through Friday, and once on Saturday. During each visit, the therapist removed the orthosis to evaluate skin integrity and joint ROM. The orthosis usually remained off during intervention to facilitate stretching and general lower-extremity strengthening exercises. Bed mobility, transfers, and sitting balance also were addressed daily. Without the orthosis, stretching of the gastrocnemius and soleus muscles was performed daily in a weight-bearing standing position. Initially, a tilt table was used due to the patient's limited ability to stand. Stretching on a wedge board while strapped to the tilt table was done for 10 to 20 minutes on 9 of the initial treatment days. From day 15 to day 27, standing activities were performed in the parallel bars daily after DF PROM was -4 degrees. Pre-gait activities and progressive gait training began at this stage, as she was able to more closely approximate a neutral ankle position and not exhibit excessive overcompensation of hip flexion or knee extension in stance. Pre-gait activities included trunk stabilization exercises, weight bearing on the hemiplegic leg with abduction/adduction of the contralateral hip, repetitive practice of a single-swing or stance-phase cycle on the hemiplegic side, and sit-to-stand repetitions and standing balance exercises. Progressive gait training activities included facilitated gait in parallel bars, progressing to gait training with a large-based quad cane, with focus on step length, cadence, pelvis and trunk control, and dynamic balance. After each physical therapy session, the orthosis was reapplied. The importance of allowing only the primary physical therapist or physiatrist to replace the orthosis (after treatments and hygiene) was emphasized to all staff to ensure proper positioning of the foot to protect skin and joint integrity as well as to apply the device consistently.

Outpatient intervention. After discharge, PG received physical therapy 3 times a week for 4 weeks in this center's rehabilitation day program. During that period, she wore the static adjustable orthosis only at night, and she wore her PAFO with her shoe during the daytime. The PAFO helped to improve PG's quality of and safety with transfers and walking as well as maintaining her DF ROM. Insurance benefits were limited, so she received further outpatient physical therapy only on an intermittent basis. The patient's husband stated that PG wore the static adjustable orthosis every other night for the next 2 months and then once or twice a week for another month. This wear schedule was decided by the patient's family based on the patient's preference (the outpatient physical therapist did not suggest a long-term wear schedule for the orthosis). During the initial 3 months after inpatient rehabilitation discharge, the patient continued to consistently wear the custom-made PAFO during the day. At the fifth month, she quit using the PAFO on the recommendation of her outpatient therapist. By the sixth month, her husband stated she had decided to quit wearing the static adjustable orthosis as well.

Outcomes

Dorsiflexion PROM increased from the first orthosis application to the second orthosis application by 15 degrees, and from the second orthosis application to the end of the treatment period by 26 degrees (Table). A 15-degree change was noted from the initial (lidocaine) nerve block to the second (phenol) nerve block. Another 26-degree change was observed from the second block to the end of treatment. The total DF PROM change was 41 degrees. PG was discharged 8 days after the orthosis was discontinued from full-time use. At that time, her PROM remained unchanged at +10 degrees. Daily PROM changes during full-time use of the orthosis are charted in Figure 2.

PG's functional status improved slowly but steadily during her rehabilitation stay. Her bed mobility improved from requiring maximum assistance (patient performed 25%-49% of task) on day 1 to moderate assistance (patient performed 50%-74% of task) on day 15 to minimum assistance (patient performed 75% or more of task) on day 27. Her ability to transfer improved from a dependent (performing less than 25% of task) sliding board transfer on day 1 to a modified stand-pivot transfer with maximum assistance of one person and minimum assistance of another person on day 6. At that point, she had gained 8 degrees of DF PROM (day 6 DF PROM=-23[degrees]). At day 18, her transfers had improved to moderate assistance of one person and her DF PROM had increased to 0 degrees. From day 18 to day 27, she gained 10 more degrees DF PROM=+10[degrees]) and improved to a minimum/moderate assisted transfer (patient performed 60%-80% of task). Ambulation was not attempted until day 16, when DF PROM lacked 4 degrees from neutral. At that point, she required maximum assistance (performing 25%-49% of task) in the parallel bars and was able to don a metal AFO to assist with ambulation.

On day 27, with +10 degrees of DF PROM, she required moderate assistance and was able to don the metal AFO with greater ease, but still required use of the parallel bars to walk. At discharge from the rehabilitation center, on day 35 of her inpatient stay, PG required minimum assistance with bed mobility and stand-pivot transfers, and moderate assistance to walk with a large-base quad cane for a distance of 12.2 m (40 ft), using a custom-made PAFO with a nonarticulating ankle joint. Her FIM scores changed from 1 upon admission to 4 at discharge for transfers and from 1 to 2 for gait/stairs. Brunnstrom evaluation of the lower extremity was at stage 3.

After discharge, during the first 4 weeks of therapy in the rehabilitation day program, PG's functional status improved to requiring supervision for bed mobility and transfers, contact guard for walking 22.9 m (75 ft) with a large-based quad cane and PAFO, and walking up and down 4 stairs with a railing and contact guard. Although the outpatient therapist did not note any loss of ROM, goniometric measurements were not taken at that time. By the third month, she had achieved independence with transfers and household ambulation with a narrow-base quad cane (FIM score of 6) and by the fifth month had discontinued using the PAFO. During the sixth month, she returned for an evaluation and her DF PROM was +6 degrees, as measured by her inpatient therapist.

Discussion

The purpose of the case report was to illustrate the use of a static adjustable AFO as an adjunct to a nerve block and physical therapy for treatment of a PF contracture. When treating an individual with brain injury, clinicians often are faced with a complex set of impairments contributing to functional limitations, Determining the appropriate plan of care to improve mobility requires evaluation of the direct, indirect, and composite impairments that result from the original pathology. (61)

The complications that occurred during treatment of PG's contracture helped to elucidate the strengths and limitations of this type of static adjustable orthosis. The limited effectiveness of both the initial nerve block and the initial incorrectly sized orthosis helped to clarify the role of soft tissue structures and neurological mechanisms involved in limiting PROM. The initial lidocaine block was used diagnostically to distinguish between the presence of a fixed contracture versus ROM limitations due to spasticity. The initial change in PROM, from -31 to -25 degrees, led the therapist to believe that soft tissue structures were the primary limitation to movement. Results supporting this notion include those of Becher and colleagues, (62) who noted that after blocking the tibial nerve, electromyographic data for abnormal muscle activation decreased, whereas electromyographic data (from analysis of torque angle diagrams) for muscle stiffness remained unchanged. Glazer and Mooney (25) also noted that intrathecal phenol had no effect on fixed contractures in patients with multiple sclerosis.

Consequently, the adjustable orthosis was applied to provide a low-load prolonged stretch to the ankle to address the apparent soft tissue shortening, and the phenol nerve block was administered to address the PROM limitations due to spasticity. At this rehabilitation center, the RCAI Phase II orthosis had been used effectively for patients with moderate to low tone (Modified Ashworth Scale (55) grades 1-2) but had not been used in patients with severe tone (Modified Ashworth Scale grades 3-4). Serial casting had traditionally been used in the later cases. Work by Gossman and colleagues, (63,64) however, indicates that the reduced resistance to passive movement following casting may be due to anatomical changes in the muscle rather than actual neurological changes in the activity of the involved motoneurons. The loss of muscle tissue due to immobilization-induced atrophy may actually be the primary factor contributing to the reduced tension-producing capabilities of the muscle. Whether or not this explanation of the effectiveness of serial casting is accurate, PG's outcomes suggest that the application of a static adjustable orthosis to achieve a low-load prolonged stretch in combination with a nerve block may be an appropriate treatment alternative.

De Deyne (65) provided some evidence as to why stretch-based rehabilitation methods might be effective. He cited myofibrillogenesis (more sarcomeres in a series) as one biomechanical explanation for how a stretched muscle fiber ultimately becomes a longer muscle, thus allowing for more movement around a joint. If this hypothesis is correct, it would tend to lend even more support for a therapeutic approach of a prolonged mechanical stretch accompanied by pharmacological intervention.

The confounding and limiting factors of this case report need to be addressed. Goniometric measurement of DF at the ankle can be quite difficult and often unreliable between therapists. (12,66) Elveru et al, (66) however, found that measurements became moderately reliable if taken by the same therapist over a short period of time. Intraclass correlation coefficients for intratester reliability of the ankle and subtalar joints in patients with neurologic and orthopedic disorders ranged from .74 to .94. For this report, only one therapist was involved in the measurements; however, she was not blinded and was the primary physical therapist for the patient. Attempts were made to take all measurements at the same time of day; however, some measurements deviated from the designated afternoon time. Choice of landmarks on the foot for measurement can also be a source of error. Bohannon and colleagues (57) found that although using different landmarks (heel, fifth metatarsal, and lateral border of the plantar surface) may provide different measurements, these measurements correlate strongly (r=.72-.90) with one another and tend to be reliable (ICC=.80-.93). In this report, the same landmarks of fibular head and lateral border of plantar surface were used consistently. Actual amount of force applied to achieve maximum DF PROM available also may be a source of error; however, having one physical therapist take all measurements without assistance may have minimized this error. (66)

This case report is typical of the many factors that may be related to improvement of DF PROM. Distinguishing the roles of traditional physical therapy (bed mobility, transfer and gait training, balance activities, tilt table, and trunk/lower-extremity strengthening exercises) and spontaneous recovery from the effects of the static adjustable orthosis in combination with the nerve block is obviously not possible. Research has shown that the use of a tilt table-wedge board regimen can increase DF PROM from 3 to 17 degrees, at a rate of 0.11 to 1.0 degree per day, in patients with neurologic disorders. (58)

In this treatment, patients stood on a wedge board while they were strapped to a tilt table at 70 degrees for 30 minutes. Increases in ROM obtained from PROM stretching, however, tend to be lost unless maintained by supportive devices or active motion. (21) Consequently, even if the prolonged low-load stretch provided by the static adjustable orthosis was not responsible for the ankle ROM gained, the immediate application of the device after the nerve block and stretching may have helped to maintain that ROM.

The amount and duration of the patient's physical therapy intervention also may have affected her ROM. At this rehabilitation center, 30-to 45-minute sessions usually are given twice daily for inpatients with neurological problems. PG consistently received at least 90 minutes of treatment a day, in part due to the complexity of her case.

The major limiting factor with this orthosis was illustrated by the few degrees of DF PROM gained following the initial block. Unless severe spasticity is addressed by a nerve block or similar pharmacological intervention, this type of orthosis probably is at best marginally effective and can cause skin irritation. This point is important to consider when determining an appropriate intervention. Although other types of static adjustable orthoses are available, other designs may not yield similar results. Studies specific to each type of splint need to be conducted.

Conclusion

Management of contractures is important in the treatment of patients with brain injuries. Clinicians must determine the primary causes and specific structures involved before effective intervention can take place. This case report illustrated the use of a static adjustable orthosis after administration of a phenol nerve block in conjunction with stretching, strengthening, and functional mobility training for management of a patient with a DF contracture.

The next step in evaluating this intervention would be a crossover research design study to help determine structural (soft tissue) versus reflex-based (neurological) change in PROM, with the role of physical therapy differentiated from the change occurring due to the orthosis. An important part of the study would be to address the longitudinal effects of motion and the longitudinal effects of the consequences of motion on function, caregiving, and safety. The study also should compare the use of a static adjustable orthosis coupled with a peripheral nerve block and the use of serial casting for both cost-effectiveness and side effects.

Table.
Changes in Ankle Passive Range of Motion (PROM) (in Degrees) (a)

                                       PROM
Time Frame                             ([degrees])

NB1-NB2                                15
NB2-day 27                             26
L1-L2                                  15
L2-day 27                              26
Total degree changes day 1-day 27=41

(a) NB1 = first nerve block, NB2 = second nerve block, L1 = first
fitting of orthosis (large), L2 = second fitting of orthosis (medium).

* Restorative Care of America Inc, 11236 47th St N, Clearwater, FL 33762.

([dagger]) Fred Sammons Inc, a Bissell Healthcare company, Box 32, Brookfield, IL 60513-0032.

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S Blanton, PT, MPT, NCS, is Project Coordinator, EXCITE National Clinical Trial, Emory Center for Rehabilitation Medicine, Room 206, 1441 Clifton Rd, Atlanta, GA 30322 (USA) ([e-mail]).

SP Grissom, MD, is Staff Physician, Virginia Mason Medical Center Physical Medicine and Rehabilitation, Seattle, Wash.

L Riolo, PT, PhD, NCS, is Associate Professor, Department of Rehabilitation Science, and Adjunct Professor, Department of Geriatric Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Okla.

Dr Grissom provided concept/project design, subjects, project management, and fund procurement. Ms Blanton provided writing, data collection, institutional liaisons, and clerical support. Ms Blanton and Dr Grissom provided data analysis. Dr Riolo provided consultation (including review of manuscript before submission). The authors thank Tim Norton, TRS, and Restorative Care of America Inc for their generous support in the completion of this work. They also thank Donna Logan, PT, for her assistance with the preliminary aspects of the project as well as the patient and her ever supportive family for their support and cooperation during the application of the brace.

This work was supported, in part, by Restorative Care of America Inc.

This article was submitted May 18, 2001, and was accepted May 26, 2002.