Joint Contractures in Children with CP

By Drew Dillard

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Joint contracture is the abnormal and essentially permanent shortening of a muscle resulting in the loss of normal joint movement. It is an especially prevalent condition in patients suffering from spastic cerebral palsy. Learn how to recognize joint contracture in your child and what treatment and therapy options are available to help alleviate the condition.

Definition

Normal muscles work in pairs. When one contracts, the other relaxes. This allows for conventional movement in the desired direction. In children with spastic CP, because brain-to-muscle communication is compromised, muscles have a tendency to work against each other, thus inhibiting effective movement. Over time, the pathological result of this muscular conflict (hypertonic spasticity) is a tightening or shortening of the joint. When muscle fibers are shortened (dystonia), the nearby joint can remain fixed in one position.  This, in part, is what causes the abnormal gait and postures seen in some spastic CP patients.

Hands, wrists, elbows, shoulders hips, feet, the back and even the jaw can be affected. Sometimes it affects only one or two joints, but in more extreme cases it can affect nearly every joint in the body. Untreated, it can lead to extreme pain and frequent bone fractures. Although spastic CP is not thought to be a progressive disorder, as brain damage does not get worse over time, spasticity in muscles can increase over time.

Symptoms and Diagnosis

In children with spastic CP, the process of growth often acts against them, making contractures more problematic. Symptoms may include a loss of motion in one or more extremity, joint inflammation, abnormal movements, disrupted growth (especially longitudinal growth) or an inability to stretch.  Discomfort is another symptom, as pain can result even without voluntary joint movement.

A healthcare professional skilled in joint mobilization will be able to test your child for indications of restricted structures within the joint. They might use a goniometer to measure the motion capabilities of a particular joint or use X-rays to reveal visible decreases in joint space, which could be an indication of a tight, contracted joint.

Prevention

As with anything, early detection is key. The best way to increase and maintain joint elasticity and prevent joint contracture is through joint mobilization and stretching. This can best be done with the guidance of a qualified physical or occupational therapist. Your child’s treatment regimen will depend on the severity of the condition and the child’s prior physical development. The sooner physical therapy is introduced into the child’s routine the better, because once joint contracture has taken place, it cannot be stretched or exercised away.

All physical therapy for cerebral palsy patients should include activities and education aimed at improving flexibility, strength, mobility and function. Cerebral palsy patients suffer from increased muscle tone (in the correct use of the term, muscle tone is an unconscious, low-level muscle contraction while the body is supposedly at rest). Tight muscles are the enemy of CP patients.

A physical therapist can also work with a client on “positioning” (placing the body in a specific position to attain long stretches) or suggest or provide adaptive equipment. A good physical therapist will teach the care-giver how to continue exercising, stretching and positioning at home.

Newer techniques, such as aquatic-based rehabilitation, have achieved impressive results in recent years. In addition to its restorative and detoxifying properties, water provides buoyancy that makes aerobic and anaerobic exercises easier and, in many cases, safer. Some of the documented benefits include improved neuromuscular responses, better muscle synchrony and improved range of motion in joints.

Treatment

If joint contraction has taken place, physical therapy and therapeutic massage will remain major parts of the treatment. Anything that increases mobility, joint elasticity and muscle strength can prevent the contraction from worsening, prevent additional contractions and provide pain relief.

Other treatments that may get introduced include: casts or splints, medication, nerve blocks and electrical stimulation and/or surgery.

• Casts or Splints. Casts or splints can hold a body part in place in an effort to stretch the soft tissues surrounding an affected joint and keep it in a more functional position. They need to be examined and changed regularly to reassess joint position and avoid skin breakdown.
• Medications. Baclofen infusion, a relatively new procedure, involves inserting a pump into the abdomen that distributes baclofen (a muscle relaxant) to muscles, thus temporarily reducing spasticity. Another relatively new treatment involves botox (a muscle paralyzer) injections into overly tightened muscles. In successful cases, the botox was able to weaken the group of muscles and reduce spasticity for periods of up to 4 months.
• Nerve Blocks and Electrical Stimulation. Because the root problem in spasticity is muscles not working in tandem as they should, in some cases, opposing muscles can be alternately blocked (anesthetically numbed) while others are electrically stimulated. This treatment is usually combined with casting.
• Surgery. When a contracture is unresponsive to other treatments, it may become necessary for an orthopedic surgeon to surgically lengthen or release certain tendons or muscles to improve range of motion.

The treatment for spastic cerebral palsy can vary greatly depending on the condition and prior development of your child. Assembling and consulting with a treatment team, including physical therapist, pediatrician, physiatrist, neurologist and orthopedic surgeon will aid in the decision making process. Started early, a well-managed and determined therapy regimen can prevent joint contracture from ever occurring.

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