Permanent knee contracture?

[antiquity]

Is there anyway besides surgery, to stretch shortened tendons in the backs of the knees?

I'm a C7/8 quad with a 35 degree contracture in both of my knees for 10 years. Exercise and ultrasound didn't help.

[antiquity]

I found this site while researching, I wonder if this technique can be applied to SCI induced atrophy?

http://www.congo-pages.org/ipvrc/muscle.htm

[SCI-Nurse]

Seneca - I am assuming that you were in the described program in a rehab setting whose personnel were familiar with SCI. Were you evaluated by a physiatrist (doctor of Physical Medicine) whose background/expertise is in SCI?

I have looked at the link listed and would suggest that such an approach should be discussed with a physiatrist who does have SCI experience. The use of casting in SCI can be a source of further problems due to the risk of pressure points and skin breakdown under the cast.

The development of contractures unfortunately is a preventable complication. It is so very important that one's daily routine include range of motion of the joints of the paralyzed limbs and stretching of those muscles. CRF

[antiquity]

I received therapy in 1978. When I was sent home, I don't think anyone told my mother to make sure my legs spent a couple of hours straightened instead of in the bent position they were always in while sleeping on my side and sitting in my wc. By the time I was 9/10, my knees had significant contracture and no one's recommended anything worthwhile, outside of surgery, since.

[SCI-Nurse]

Seneca - I am sure your Mother probably was not given this kind of instruction. I think so little was known and/or identified at that point in time re: management of the spinal cord injured person. The development of the Clinical Practice Guidelines has only occurred in the recent years. Have you been evaluated for the contractures by a doctor with expertise in SCI? If not, I would encourage you to do so. I will do some more searching re: this issue. CRF

[SCI-Nurse]

Seneca - With some discussion with another member of the SCI-Nurse team, we offer this additional information. Surgery for the SCI patient with contractures is at best a risky choice as there may be bony involvement as well as tendon involvement with a contracture that has existed for a long time. One may not necessarily regain range of motion (ROM) with surgery but rather end up with the leg in a fixed extended position. As with any surgery, but particularly a risk in this kind of surgery, is the concern about infection and hematoma formation.

A word of caution to all with SCI should include education about the importance of daily ROM, proper positioning, standing (where possible) and periods of time daily during which one lies in a prone (face down) position. This latter activity will stretch the tendons and muscles of the lower extremeties. CRF

[Jeremy]

Seneca: Here's some site for range of motion exercises

http://www.rohcg.on.ca/mobile/rom/index.html

http://calder.med.miami.edu/pointis/range.html

"If the wind could blow my troubles away,
I'd stand in front of a hurricane."

[SCI-Nurse]

Jeremy - Thanks for posting these sites; both are most helpful. CRF

[Curt Leatherbee]

I started getting the same thing too and found it helpful to do leg stretches while sitting in a hottub. I push down on my knees with an even pressure (no bouncing) and slowly the legs go into the extended position. I found that in doing this everyday for about a month, my legs now go into a straight out position fairly easily. Things were getting so bad for a while that I could not even get on my long leg braces, now its no problem.

"Life is about how you
respond to not only the
challenges you're dealt but
the challenges you seek...If
you have no goals, no
mountains to climb, your
soul dies".~Liz Fordred

[antiquity]

Thank you everyone for your responses.

ROM is good for preventing contracture but it's ineffective for reversing contracture. All my other joints are fairly lithe and limber.

SCI-Nurse, since surgery is so risky, are you saying that at this point, there's really nothing that can be done.

This might be a good time to talk to a SCI doctor about maybe using Botox to release the contractures of the muscles. That and stretching or serial casting might help to the point you could begin a standing program. The Easy Stand is made in a way that you could slowly go to complete extension overtime by just not pumping the hydrolics completely up. Serial casting is tough as the nurse saaid though. You have to be real careful of sores. I tried this on a contracted hand and although it didn't help much I also was able to stop before I had anything but a few surface sores that healed easily.

[antiquity]

Thanks DTX, I had wondered about botox and other drugs used to relax stiff joints and muscles.

[antiquity]

It seems like botox injections are commonly used to treat dynamic muscle contracture in CP patients and neurogenic pain, spasticity and voiding dysfunctions in people with SCI. It's also used to improve gait in people with incomplete SCI.

http://www.kennedykrieger.org/whatsnew/newevents/abstracts.htm


Has botulinum toxin type A a place in the treatment of spasticity in spinal cord injury patients?

Al-Khodairy AT, Gobelet C, Rossier AB.

Department of Physical Medicine and Rehabilitation, Hopital de Gravelone, CH-1950 Sion, Switzerland.

OBJECTIVE: To present and discuss treatment of severe spasms related to spinal cord injury with botulinum toxin type A. DESIGN: A 2-year follow-up study of an incomplete T12 paraplegic patient, who was reluctant to undergo intrathecal baclofen therapy, presenting severe painful spasms in his lower limbs treated with intramuscular injections of botulinum toxin type A. SETTING: Department of Physical Medicine and Rehabilitation, Hopital de Gravelone, Sion, Switzerland. SUBJECT: Single patient case report. MAIN OUTCOME MEASURE: Spasticity, spasms and pain measured with the modified Ashworth scale, spasm frequency score and visual analogue scale. RESULTS: Treatment of spasticity with selective intramuscular injections of botulinum toxin type A resulted in subjective and objective improvement. CONCLUSION: Botulinum toxin type A has its place in the treatment of spasticity in spinal cord injury patients. This treatment is expensive and its effect is reversible. It can complement intrathecal baclofen in treating upper limb spasticity in tetraplegic patients. Tolerance does occur to the toxin. Although high doses of the product are well tolerated, the quantity should be tailored to the patient's need. The minimal amount necessary to reach clinical effects should be adhered to and booster doses at short period intervals should be avoided.


Muscle Nerve Suppl 1997;6:S14-20 Related Articles, Books, LinkOut


A clinical overview of treatment decisions in the management of spasticity.

Gormley ME Jr, O'Brien CF, Yablon SA.

Gillette Children's Hospital, St. Paul, MN, Colorado, USA.

Spasticity from an upper motor neuron syndrome may cause a variety of symptoms that interfere with function. Decisions regarding spasticity treatment are influenced by the chronicity, severity, and distribution of the spasticity; the locus of injury; the presence and severity of co-morbidities; the availability of support; and the goals of treatment. Not all spasticity can or even should be treated; tone reduction is indicated only if spasticity interferes with some level of function, positioning, care, or comfort. Treatment goals should be well outlined before treatment begins. Botulinum toxin may be used to treat focal spasticity as part of an overall treatment plan.

Muscle Nerve Suppl 1997;6:S169-75
Clinical trials of botulinum toxin in the treatment of spasticity.

Simpson DM.

Department of Neurology, Mount Sinai Medical Center, New York, NY 20019, USA.

Botulinum toxin has been tested as a treatment for spasticity resulting from cerebral palsy, multiple sclerosis, traumatic brain injury, spinal cord injury, and stroke. The results of 18 studies are reviewed in this article. In both open label and double-blind, placebo-controlled trials, botulinum toxin has proven to be an effective measure for reduction of focal spasticity. Improvements have been documented in tone reduction, range of motion, hygiene, autonomic dysreflexia, gait pattern, positioning, and other criteria, though not all criteria tested showed improvement in all studies. In none of the studies were there significant adverse effects. Future trials may be improved by refinement of several design parameters, including patient selection, treatment timing, and selection of dose and injection site.

[SCI-Nurse]

Thanks all for the plethora of information. (SAH)

[antiquity]

Oops, meant to say neuropathic (not neurogenic)pain.

[Carl R]

I was looking for something else and ran across these. Not sure if they work or not. I tried something similar for my arms with no luck, but mainly due to the pressure sores could not continue wearing them for a extended period of time. They are expensive as well.

http://www.dynasplint.com/

[rtr]

I tried these on my elbows. I wore them at night for several weeks. They were uncomfortable/almost painful and didn't accomplish much. It was expensive, but insurance covered it. My therapists weren't really familiar with how to use them. I think it's possible to get better results.