date: 2004 Mar 18;26(6):335-45.
author: Singer B.
publication: Disabil Rehabil
BACKGROUND AND PURPOSE:
The purpose of this study was to document the outcome of non-surgical management of equinovarus ankle contracture in a cohort of patients with acquired brain injury admitted to a specialist Neurosurgical Rehabilitation Unit.
This prospective descriptive study examined all patients with a new diagnosis of moderate to severe acquired brain injury (Glasgow Coma Scale score </=12) admitted for rehabilitation over a 1 year period. Ankle dorsiflexion range and plantarflexor/invertor muscle activity were evaluated weekly during the period of hospitalization. Contracture was defined as maximal passive range of motion </= 0 degrees dorsiflexion, with the knee extended, on a minimum of two measurement occasions. Patients were retrospectively allocated to one of four treatment outcome categories according to ankle dorsiflexion range, type of intervention required and response to treatment.
Ankle contracture was identified in 40 of the 105 patients studied. Contracture resolved with a standard physiotherapy treatment programme, including prolonged weight-bearing stretches and motor re-education, in 23 patients. Contracture persisted or worsened in 17 of 40 cases, all of whom exhibited dystonic muscle overactivity producing sustained equinovarus posturing. Ten of 17 cases required serial plaster casting (+/- injection of botulinum toxin type A) in order to achieve a functional range of ankle motion. Remediation of ankle contracture was not considered a priority in the remaining seven patients due to the severity of their overall disability.
The incidence of ankle contracture identified in this population was considerably less than previously reported. Reduced dorsiflexion range was remediated with standard physiotherapy treatment in over half of the cases. Additional treatment with serial casting +/- botulinum toxin type-A injection was required to correct persistent or worsening contracture in one quarter of cases. Dystonic extensor muscle overactivity was a major contributor to persistent or progressive ankle contracture.
Does 12 weeks of regular standing prevent loss of ankle mobility and bone mineral density in people with recent spinal cord injuries?
author: Ben M.
publication: Aust J Physiother.
The purpose of this study was to determine the effects of a 12-week standing program on ankle mobility and femur bone mineral density in patients with lower limb paralysis following recent spinal cord injury. An assessor-blinded within-subject randomised controlled trial was undertaken. Twenty patients with lower limb paralysis following a recent spinal cord injury were recruited. Subjects stood weight-bearing through one leg on a tilt-table for 30 minutes, three times each week for 12 weeks. By standing on one leg a large dorsiflexion stretch was applied to the ankle and an axial load was applied to the bones of the weight-bearing leg. Ankle mobility and femur bone mineral density of both legs were measured at the beginning and end of the study. Ankle mobility (range of motion) was measured with the application of a 17 Nm dorsiflexion torque. Femur bone mineral density was measured using dual energy X-ray absorptiometry (DEXA). The effect of standing was estimated from the difference between legs in mean change of ankle mobility and femur bone mineral density. The results indicated a mean treatment effect on ankle mobility of 4 degrees (95% CI 2 to 6 degrees) and on femur bone mineral density of 0.005 g/cm(2) (95% CI -0.015 to 0.025 g/cm(2)). Tilt-table standing for 30 minutes, three times per week for 12 weeks has a small effect on ankle mobility, and little or no effect on femur bone mineral density. It is unclear whether clinicians and patients would consider such effects to be clinically worthwhile.
To investigate the prevalence of joint contracture (limited passive range of joint motion) and muscle weakness in a population with multiple sclerosis (MS). A secondary aim was to establish normative data of functional tests of mobility and balance of people with MS who are still ambulant.
People with MS living in metropolitan Sydney, Australia.
330 people with MS living in metropolitan Sydney, Australia were randomly sampled on 23 July 2009 from the MS Australia register and invited to participate.
MAIN OUTCOME MEASURES:
Passive range of motion of large joints of the limbs and muscle strength. Tests of walking and balance were also conducted.
156 people (109 females, 47 males; mean age 54.2 years; mean time since diagnosis 14.9 years) agreed to participate and were assessed. Fifty-six per cent (56%) of participants had contracture in at least one major joint of upper or lower limb. The most common site of contracture was the ankle (43.9%). Seventy per cent (70%) of participants had muscle weakness in one or more muscle groups. As muscle weakness, joint contractures were present at early stage of MS and the prevalence was associated with the progression of the disease.
These data show that in addition to muscle weakness joint contractures are highly prevalent among people with MS, especially in the ankle joint. This implicates that prevention of contracture is crucial in providing rehabilitation to people with MS.
Passive ankle dorsiflexion increases in patients after a regimen of tilt table-wedge board standing. A clinical report.
We monitored the result of a tilt table-wedge board routine on the passive ankle dorsiflexion of 20 patients consecutively to determine the effectiveness of the treatment. The calculated frequency of the treatment, which was applied for 30 minutes on each of 5 to 22 treatment days, ranged from 2.3 to 6.4 treatments a week. All patients demonstrated increased passive ankle dorsiflexion. The increases ranged from 3 to 17 degrees and occurred at a calculated rate of 0.11 to 1.0 degrees a day. We believe the treatment is an effective clinical method for increasing passive ankle dorsiflexion in neurologically involved patients.
Limb contractures in progressive neuromuscular disease and the role of stretching, orthotics, and surgery
Contractures are exceedingly common impairments in selected progressive NMD conditions, particularly those with excessive fibrosis and fatty infiltration into muscle (i.e., dystrophic myopathies) and more severe NMD conditions, resulting in significant weakness and wheel-chair reliance, such as SMA. Less than antigravity strength produces an inability to achieve full active range of motion. Static positioning of limbs (generally in flexion) and lack of weight bearing results in fixed contractures. This article has reviewed the prevalence and distribution of contractures in specific NMD conditions. Aggressive rehabilitation strategies, including stretching, positioning, splinting, upright weight bearing, and orthopaedic surgical management may help minimize the degree of disability in NMD patients with contractures.
Effects of the standing program with hip abduction on hip acetabular development in children with spastic diplegia cerebral palsy.
Early identification and intervention with conservative measures is important to help manage hip dysplasia in children with a high adductor and iliopsoas tone and delay in weight bearing. The effect of a daily standing program with hip abduction on hip acetabular development in ambulatory children with cerebral palsy was studied.
The participants were 26 children with spastic diplegia cerebral palsy (CP), classified at Level III according to the Gross Motor Function Classification System (GMFCS). Thirteen children stood with hip abduction at least 1 h daily from 12 to 14 months of age to 5 years with an individually fabricated standing frame with hip abduction.
At the age of 5 years, radiologic results of the study group were compared with a comparison group of 13 children with spastic diplegia CP who had not taken part in a standing program. The migration percentage in all children who stood with abduction remained within stable limits (13-23%) at 5 years of age, in comparison to children who did not stand in abduction (12-47%) (p < 0.01).
The results indicate that a daily standing program with hip abduction in the first 5 years may enhance acetabular development in ambulatory children with spastic diplegia CP. Implications for Rehabilitation Abnormal acetabular development is a problem related to mobility problems and spasticity muscles around the hip. The literature suggests that postural management and standing programs could reduce levels of hip subluxation and increase function in children with cerebral palsy. A standing program with hip abduction can be a beneficial to develop more stable hips in children with spastic diplegic GMFCS level III.
Effect of weight-bearing in abduction and extension on hip stability in children with cerebral palsy.
: To study the effect of 1 year of daily, straddled weight-bearing on hip migration percentage (MP) and muscle length in children with cerebral palsy who were nonambulatory.
: Participants stood upright in maximum tolerated hip abduction and hip and knee extension ½ to 1½ hours per day for 1 year. Controls, matched for age, motor ability, and surgery, were derived from a national cerebral palsy follow-up program.
: Participants using straddled weight-bearing after surgery had the largest decrease in MP (n = 3, 20 controls; P = .026). Children using straddled weight-bearing at least 1 hour per day for prevention also improved (n = 8, 63 controls; P = .029). Hip and knee contractures were found only in controls.
: Straddled weight-bearing, 1 hour per day, may reduce the MP after adductor-iliopsoas-tenotomies or prevent an MP increase and preserve muscle length in children with cerebral palsy who did not need surgery. Larger studies are needed to confirm the results.
The objective of this study was to determine whether static weight-bearing in a standing frame affected hamstring length and ease of activities of daily living (ADLs) in nonambulant children with cerebral palsy (CP). A convenient sample of nonambulant children with CP was recruited for this one-group quasi-experimental study. Participants stood in a standing frame for 1 h, 5 days per week, for 6 weeks, followed by 6 weeks of not using a standing frame; each phase was repeated. Popliteal angle measurements were made at baseline and weekly throughout the study period. Carers provided written feedback regarding ease of ADLs at the end of each standing and nonstanding phase. Five children were recruited (age range 6-9 years, mean age 7 years 2 months, SD 1 year 4 months). High compliance with the standing regime was achieved (85% of intended sessions completed). Repeated-measures analysis of variance and t-tests showed hamstrings significantly lengthened during standing phases (mean improvement 18.1 degrees , SD 5.5, P<0.01 for first standing phase; mean improvement 12.1 degrees , SD 7.7, P=0.03 for second standing phase). A trend for hamstrings to shorten during nonstanding phases was observed (mean change -14.0 degrees , SD 4.2, P=0.02 for first nonstanding phase; mean change -7.3 degrees , SD 6.5, P=0.20 for second nonstanding phase). Feedback from carers suggested that transfers and ADLs became slightly easier after phases of standing frame use. Preliminary evidence that 6 weeks of standing frame use leads to significant improvements in hamstring length in nonambulant children with CP, and may increase ease of performance of ADLs was found.
Use of a device to support standing during a physical activity program to improve function of individuals with disabilities who reside in a nursing home.
To demonstrate the feasibility of an innovative program of physical activity using a standing–support device targeted towards adult residents of a nursing home who are unable to transfer or stand independently.
Thirteen residents, age 82 +/- 11 years, at the Beit Bayer Nursing Home, Jerusalem, Israel, who were unable to transfer or stand independently.
Eight-week observational period followed by 12-week physical activity performed while standing in a Standing–Support Device.
Manual Muscle Testing, joint range of motion, forward and lateral reach, time to stand independently, distance walked with a walker, Functional Independence Measure.
Compared to the observational period, significant post-intervention improvements were noted particularly in lower extremity muscle strength. Improvements in the Functional Independence Measure were noted in sphincter control, locomotion, mobility, motor score, and total score. Over 60% of those previously requiring assistance in standing became able to stand for an average of 1 min unassisted and walk an average of 14 m with a walker.
A pilot program of physical activity using a Standing–Support Device is feasible in selected stance-disabled older adult nursing home residents. Participants showed evidence of muscle strength and functional improvement. Future studies of the device with a concurrent examination of healthcare costs, functional improvement, and staff burden, are recommended.