Clinical Pathways for Successful Orthotic Therapy Contracture Management

1. Clinical Pathways for Successful Orthotic Therapy Contracture Management John Kenney, BOCO

2. Clinical Pathway to Orthotic Therapy Success • Comprehensive assessment of joint pathology & rehab potential • Setting realistic therapy goals based upon in depth assessment • Selecting the most appropriate orthotic therapy to achieve rehabilitation objectives

3. RA, RSD, Severe OA = Static Therapy • Where disease significantly limits use, support, protect, and correctly position the joint(s) to relieve pain, reduce inflammation, and prevent further joint deformity. • Where therapeutic stretch is contraindicated for any reason. • Must be light, comfortable, and able to be easily modified as the “position of comfort” may need to be changed frequently. • Bend to fit in all planes (i.e., ulnar) • Use SoftPro™ “Bend to Fit” Orthotics

4. RA Hands

5. RA w/ Ulnar Drift – Wrist -35°; Thumb Adduction – Support & Position

6. Static Bracing Static orthotics are most appropriate for support, protection, and positioning of the joint(s) Orthotic type of choice where therapeutic stretch is contraindicated for any reason Brace of choice for optimizing limb positioning; provides positioning therapy.

7. Adaptive Tissue Shortening • Connective tissue, tendons, and muscles adapt to immobility by shortening and thickening • Bio-mechanical changes in tissue occur over time with a significant loss of tissue elasticity • Shortening and loss of elasticity can be reversed if the contracture is not “fixed” or ankylosed • 10˚ of joint movement indicates joint is likely not ankylosed

8. Strategy for Treatment Tissue shortening: create demand to lengthen connective tissue, tendons and muscle Muscle length will adapt to daily demands for muscle length Use manual techniques, modalities, and appropriate bracing to create muscle lengthening. Brace should initiate gentle stretch to tissue (AirPro. DynaPro)

9. Muscle Fiber - Myofibril

10. Sarcomere

11. Muscle Shortening • Sarcomeres at either end of the myofibrils fall off if not needed • Muscle length depends on demands placed on the muscle • Muscle length is constantly adapting depending on need • Rehabilitation should include strategies to re-lengthen muscle

12. Muscle Elasticity Loss of glycogen in muscle: addition of lactic acid = reduced ability to work and sore limbs Decreased ATP reduces elasticity efficiency Approximately 7% of water content is lost in 30 days of immobility Muscle becomes relatively inelastic

13. Treatment Strategy Improve elasticity of tissue by significantly increasing cellular metabolism (biological activity) Use manual techniques (activity), modalities, and therapeutic bracing to rehabilitate tissue (therapeutic tension)

14. Muscle Growth / Elongation • Muscle protein is continuously recycled with a half life of 7 to 15 days. • Muscle can easily adapt to a change in conditions due to new demands or a lack of demand. • The rate of protein synthesis in muscles can be increased by stimulating muscle growth or exercise. • Therapeutic stretch is one very important factor is reversing tissue shortening • Stretch must be held for 1 hour or more to have a “carry over” effect.

15. Treatment Expectations Need a minimum of 15 treatments over 30 days to see significant improvement Expect 5 to 8° improvement in 30 days w/ Low Load prolonged Stretch bracing alone. Double expected outcome w routine modality use (10 to 16°) Do “elasticity” test and goniometer measurements weekly to chart progress

16. Treatment Focus • Stimulate biological activity to the affected tissue to improve elasticity • Incrementally improve cellular equilibrium – increase water content; increase glycogen in tissue • Add sarcomeres to increase muscle length w/ positioning & prolonged stretch w/ brace • Increase protein synthesis to recycle poor muscle with healthier muscle tissue • Improve tissue elasticity • Lay down new healthy collagen

17. Neurological Contracture • Usually related to upper motor neuron (brain) dysfunction or injury • Results in disruption of inhibitory pathway from the brain • Limb becomes movement sensitive (rate & degree of stretch) • Hypertonicity and frequent occurrence of episodes of tone can significantly limit functional use of the affected limb(s)

18. Motor Control • Alpha motor system: Volitional movement • Gamma motor system: Tone, proprioception and coordination

19. Muscle Spindle • Senses muscle length • Senses velocity of change in muscle length • Initiates muscle contraction

20. Stretch Reflex • Contraction of a muscle in an attempt to resist a change in muscle length

21. Golgi Tendon Organ • Senses muscle tension • Initiates muscle inhibition • Gentle tension initiated by a brace can have an inhibiting effect on the joint

22. Neuro-Rehabilitation Strategy • Re-Activate GTO’s • NeuroStretch PROM • Non Thermal Ultasound over GTO’s • Nerve block e-stim • Electro-acupuncture • Static Flex Orthotics, Air Orthotics Stimulate GTO / Muscle Spindle Communication • Movement therapy • PENS • Static Flex Orthotics, Air Orthotics

23. Neuro Contractures • Neuro contractures may be “mixed”, meaning that there is neurological opposition to stretch and adaptive tissue shortening • End range post stretch is less than full range indicating tissue shortening • Must treat neurological dysfunction first; tissue shortening after spasticity is managed

24. Stretch Reflex Implications • Traditional ROM techniques may be ineffective and painful • Normal passive ROM may facilitate muscular contraction via the stretch reflex • Passive ROM is best obtained by encouraging muscle inhibition and avoiding the stretch reflex when applying device

25. New Neuro-Rehab Paradigm Constraint Induced Therapy (Taub) Modified Constraint Induced Therapy (Levine) Robot Assisted Therapy (MIT) Massed practice leads to functional recovery years after CVA or TBI

26. Joint Assessment

27. NeurostretchAn Alternative Passive Range of Motion & Joint Assessment Technique

28. NeuroStretch as an Assessment Tool • Palpation for Structural Changes in the Joint • End Feel Evaluation – Elasticity Check • Tonal Assessment – determine degree of abnormal tone or spasticity

29. PROM Objective for Neuro- Contractures • Avoid Stretch Reflex during PROM • PROM is completed comfortably for patient • Manipulated joint is relaxed and remains extended post PROM • Improved joint positioning post PROM

30. NeuroStretchTM Technique • Begin with the joint in a relaxed position • Give 90 seconds of manual joint stimulation at the acupressure point • Slowly move joint to point of resistance • Hold joint at sub maximal stretch until release

31. End Feel Assessment • Check “play” at relaxed end range post NeuroStretch • May need to continue stimulating NS point(s) while assessing end feel • Compare to unaffected side if possible; evaluate relative to unaffected side • List as poor, fair, good, or excellent and measure w/ goniometer

32. NeuroStretch - Shoulder

33. Proximal to Distal

34. NeuroStretch - Elbow

35. NeuroStrech - Wrist / Hand

36. NeuroStretch - Post Stretch

37. Application of Orthotic

38. Two Hours Later - Post Orthotic Therapy

39. NeuroStretch - Lower Extremity

40. NeuroStretch - Knee

41. Submaximal Stretch

42. Application of Orthotic

43. NeuroStretch Lab End Feel & Tonal Assessment

44. Orthotic Therapy Goals • Support & protect: stop further declines in LROM; support and protect the joint from further injury/deformity; reduce pain & discomfort; reduce the risk of more serious problems (pressure sores) • Restoration of LROM: achieve incremental permanent lengthening of the connective tissue, tendons, and muscles to restore joint range of motion; provide neuro-rehabilitation by managing spasticity

45. Orthotic Selection • Joint pathologyandrehabilitation goals drive orthotic brace selection • Orthotic braces are designed to provide specific types of therapy • Matching the type of therapy provided by the brace to joint pathology and the rehabilitation objectives results in the optimal patient outcome

46. Types of Orthotic Braces & Therapy Provided by Brace Type • Static: protect, support, and position joint or provide progressive extension stretching • ROM: 2 stop hinge for controlled range of motion therapy in the brace; controlled movement and support in brace for ambulation support (orthopedic indications) • Air Bladder: gentle Low Load Prolonged Stretch • Dynamic: spring loaded Low Load Prolonged Stretch (LLPS); creep therapy • Static/Neuro-Dynamic: flexible static brace w/ dynamic LLPS and neuro-inhibiting properties

47. Joint Pathology / Rehab Objective stretch not indicated / desired stretch therapeutic Support & Position Joint(s) RestoreLROM Good = Progress. Extension Better = Air Bladder Stretch Best = Dynamic LLPS Clinical Pathways to Orthotic Success – Non-Orthopedic

48. Benefits of Static Orthotic Therapy • Pain & discomfort due to contracture can be significantly reduced • Improved joint alignment w/o brace use • Joint is protected from further injury and additional LROM w/ daily use • Skin integrity issues can be managed more effectively • Improved quality of life

49. Full Contact End Range Static Fit

50. Rehab Therapy Bracing • Most important time to use a therapeutic brace is immediately after therapy treatment • Joint mobilization therapy; heat, and use of modalities significantly improve joint elasticity • Treatment improvement is significantly improved w/”carry over” when post treatment lengthening is held for 1 hour or more w/ a brace