In Multiple Sclerosis

1
Contracture Management

• In Multiple Sclerosis

2
What is Joint Contracture

• Muscle and connective tissue around a joint
  shortens and gets stiffer
• Leads to increased resistance to passive stretch
• Decreased range of movement

• Common in conditions leading to
  immobility/reduced use of joints
• Can occur as a result of weakness, paralysis,
  spasticity
• Leads to pain, deformity, reduced
  function/independence

3
Incidence of Contracture

• Common in conditions resulting in immobility
• Common complication of damage to CNS
• 84 brain injured patients had contracture 1 year
  post injury (Yarkony and Sahgal, 1987)
• More than 50 subjects with CVA had contracture 1
  year post stroke (ODwyer et al, 1996)
• Prevalence in MS not known (NICE, 2004)

4
Causes of Contracture Immobility

• Reduction in number of sarcomeres (atrophy)
• Decrease in overall length of sarcomeres (muscle
  becomes shorter)
• Relative increase in proportion of connective
  tissue (becomes stiffer)
• Shortened position leads to loss of sarcomeres,
  (shortened in length)

• Lengthened position leads effects reversed,
  more sarcomeres, increase in length
• Weight bearing muscles more severely affected.
• (Ahtikoski et al, 2001 Williams and Goldspink,
  1990 Gossman et al, 1982)

5
Spasticity definition

• Spasticity is a motor disorder
  characterised by a velocity-dependent increase in
  tonic stretch reflexes with exaggerated tendon
  jerks, resulting from hyperexcitability of the
  stretch reflex
• (Lance, 1980)

6
Causes of Contracture Spasticity

• Spasticity can lead to deformed posture (Farmer
  and James, 2001)
• Spastic muscle has increased resistance to
  passive stretch
• This may be due to changes in muscle structure,
  not necessarily hyperexcitable reflexes (Dietz et
  al, 1981)

• 13 out of 24 CVA subjects had contracture in
  their upper limbs, only 6 had hyperexcitable
  reflexes (ODwyer et al. 1996)
• Spasticity may not cause contracture
• Tissue changes due to immobilisation in shortened
  positions do!

7
Management of Contracture

• Multi-disciplinary Team involvement
• Long term management
• Medical
• reduce pain,
• spasticity,
• deformity

• Appropriate analgesia
• Antispasticity medication
• Local treatment phenol, botulinum
• Intrathecal baclofen
• surgery

8
Physiotherapy Treatment

• Serial casting increases ROM (Mortenson and Eng,
  2003)
• Few studies relate increased ROM to improved
  function (Moseley, 1997)
• Casting requires staff time and skill (Sullivan,
  1988)
• Stretch lost on tissue adaptation through creep
  (Farmer and James, 2003)

• People with MS can be at risk of
  complications/find casting difficult to tolerate
• Dynamic splints provide continual stretch and
  have been related to improved function (Gelinas
  et al, 2000, Karas et al, 2001)

9
Physiotherapy Treatment

• Stretching normal muscle leads to mechanical
  deformation (Gelinas et al, 2000)
• Holding the stretch for long enough, repeatedly,
  leads to permanent lengthening of muscle
• Optimum time inconclusive - 30 mins to 6 hours
  per day (Tardieu et al, 1988 Williams, 1999)

10
Audit Contracture Management PDRU

• 13 patients, 12 MS
• 21 contracted knee joints in total
• All had element of spasticity
• Stretched and splinted for around 2 hours per day
  for average of 3-4 weeks
• Used adjustable splint, ROM increased as required

• 12 out of 13 had significant increase in ROM, and
  achieved functional goals set
• Functional gains included Seated in wheelchair,
  improved position, increased seating tolerance
• Able to weight bear, improved independent
  mobility, independent gait

11
Research Study Rationale

• Little evidence on incidence of contracture in MS
• No optimum time for stretching
• We have seen clinical and functional improvements
  with the current regime in PDRU

12
Research Proposal questions

• Does splinting in a stretched position for 2
  hours, daily for 3 weeks, increase range of
  movement in subjects with knee joint contracture
  and MS?
• Is the increase in ROM related to alteration in
  muscle tone, pain or improvement in function?

13
Research Proposal preliminary study

• Aim to recruit 12 subjects, with MS and knee
  joint contracture
• Community based study to minimise impact of
  concurrent treatments
• Measures Range of Movement
• Modified Ashworth Scale
• Pain
• Function
• EDSS