Contractures

1. Contractures Edward Via College of Osteopathic Medicine Department of Geriatric Medicine Edward Warren, MD, Chair Geriatrics, Carolinas Campus, February 2012

2. History of Present Illness 65 year old black female is admitted to your nursing home approximately 1 month after a ”stroke”. You are informed that she has been getting home physical therapy and is doing pretty well but she continues to have difficulty with walking and carrying out her ADLs.

3. Past Medical History • HTN( hypertension) • CVA( cerebrovascular accident) • DM( diabetes mellitus) • GERD

4. Past Surgical History • T&A (tonsillectomy & adenoidectomy) as child • Nissan Fundoplication (pinches of stomach wrapped around the esophagus to form a valve to prevent reflux)

5. Medications • Omeprazole 20mg-1 tab po qam • ASA 81mg-1 tab po qd • HCTZ 25mg-1 tab po qd • KCl 10 mEq -1 tab po qd • Acetaminophen 500mg- 1 tab po QID prn pain

6. Social History • Widowed • Lived alone prior to CVA • No ETOH • No Tobacco

7. Review of Systems Patient complains of ankle, knee, and foot pain on the right side. Complains of increased constipation (has not had a BM in 4 days). Complains of some continued reflux symptoms. All other review of systems is unremarkable.

8. Physical Examination • HEENT - Unremarkable • Neck - Supple, no JVD/Bruit/Lymphadenopathy • Heart - RRR without murmur, no S3/S4 • Lungs – clear to auscultation and percussion • Abdomen - BS decreased but present in all quadrants, no organomegaly, no fullness, but some tenderness in LLQ (no distinct mass) • Extremities - trace pitting edema on right lower extremity, decreased dorsiflexion of right foot as well as decreased extension at knee. Decreased external/internal rotation of right hip. • Neuropsych - flat affect and tearful. R lower extremity with 4+ muscle strength, DTR 3+ and brisker at R achilles and patella

9. Clinical Case 1 On starting physical therapy for this patient, the therapist relates to you that the patient is complaining of a great deal of pain. If you are trying to decide on what “pill” to help with her pain, which of the following would be most appropriate for this patient? Why or why not? • acetaminophen • NSAID (non-steroidal anti-inflammatory drug) • Opioid analgesic • Prednisone • Muscle relaxer

10. Clinical Case 2 When this patient was initially admitted to your nursing home she had labs, including a BUN/creatinine. After 2 weeks the patient’s lab shows up in the patients chart and you note that she has a creatinine of 2.5. The patient states that she was told in the past that her kidneys were a “little off”. She also relates that the naproxen 400 mg you are giving her doesn't seem to help. She relates that in the hospital she used to take 600mg BID and this did help her pain. At this point what should she be treated with? Why or why not? • Increase the dose of naproxen • Acetaminophen • Muscle relaxer • Opioid analgesic • Prednisone

11. Clinical Case 3 In a patient with contractures, which of the following treatments should be tried before scheduling a patient for a tendonotomy? • Massage • Physical Therapy • Fluidotherapy or Ultrasound • OMT with or without injection therapy • All of the above

12. Clinical Case 4 4.Prevention is the best treatment for contractures. • True • False

13. Clinical Case 5 An elderly patient complaining of decreased ROM in her shoulder (but no pain) is seen by a third year osteopathic student during his geriatric rotation. Using his goniometer he sees that this patient has an adhesive capsulitis and can abduct to only 70 degrees. The student decides that this patient should be treated with the Seven Stages of Spencer to help the shoulder problem. The student notes that the ROM is up to 90 degrees after the treatment and considers it a great result. The student doesn’t see this patient after that and soon goes to his next rotation. A year later the student , now an MS4, is back on geriatrics and sees the same resident. He notes that the resident has almost complete loss of abduction. The patient states that it has been this way since his treatment. What of the following could explain this result. • Treatment resulted in a muscle strain • Treatment resulted in a muscle tear • Joint inflammation due to overly vigorous treatment • Neither the student nor attending physician re-evaluated the shoulder so it is hard to know exactly what happened to it. • Any of the above could be true

14. Clinical Case 1: Discussion The word “pill” is in quotes to remind us that there are nonpharmacologic approaches to pain. Acetaminophen (APAP) is the best choice. When given regularly it relieves most pain. We do not use prn pain medications alone because they fail to work that way. Hypertension is treated with regular doses of effective medications, and pain is treated likewise. The total daily dose should be less than 4 gm acutely and 3 gm chronically to prevent destruction of the liver by oxidation. NSAID’s (non-steroidal anti-inflammatory drug) are poor choices in most people, but especially in the elderly. They work by interfering with prostaglandins. This results in less inflammation in the joints, but it also disables the kidneys from being able to augment their blood flow. This leads to renal insufficiency. Opioid analgesics would be a good choice if the APAP failed. Start with very low doses and increase as needed. Give regular doses (hydrocodone/APAP 2.5/325 qid) with or without a prn for breakthrough pain (i po q4h prn breakthrough pain). Watch the total APAP dose! Prednisone can be used for pain from many inflammatory conditions such as COPD with asthma, gout, rheumatoid arthritis, etc, but it is not an analgesic. There is not necessarily any inflammation in this case. When it is used, the risk of Cushinoid symptoms must be balanced against the benefits. Muscle relaxants will not help a contracture. Most of them are really tranquilizers and cause confusion in the elderly. Baclofen may be the only real muscle relaxant. Still tense muscles are not the problem and relaxing them will not help the pain.

15. Clinical Case 2: Discussion This question presumes the wrong choice from question 1. The discussion is the same. Increasing the NSAID (naproxen) would make the harmful effects even more likely. The correct answer is to use regular doses of acetaminophen.

16. Clinical Case 3: Discussion Obviously the answer is “e”. Some of these actions will improve range of motion. The ultrasound is unlikely to do much, but it may feel good. Carefully selected injection of a corticosteroid may help. It can be combined with OMT, massage, or PT.

17. Clinical Case 4: Discussion Prevention is the best treatment for contractures. There is not much more to say than this. Contractures rarely get better. When they do, they recur unless maintenance therapy continues indefinitely. Preventing them is easy, but it requires a vigilant physician who thinks about prevention whenever a person or limb is going to be left at rest for any length of time.

18. Clinical Case 5: Discussion The answer is “d”. The Seven Stages of Spencer is a manipulation procedure that involves gently stretching the shoulder into extension, flexion, compression circumduction, traction circumduction, adduction with external rotation, abduction, internal rotation, and traction with inferior glide. It is done in a way that would not normally cause injury. It should be repeated and would be a part of a comprehensive treatment and maintenance program.