Transcript Clinical Pathways 2015

Clinical Pathways for
Successful Orthotic
Therapy Contracture
Management
John Kenney, BOCO
Clinical Pathway to Orthotic
Therapy Success
1.
2.
3.
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
RA, RSD, Severe OA = Static Therapy
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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
RA Hands
RA w/ Ulnar Drift – Wrist -35°; Thumb
Adduction – Support & Position
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.
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

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)
Muscle Fiber - Myofibril
Sarcomere
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
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
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)
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.

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

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

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)
Motor Control
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Alpha motor
system:
Volitional
movement
Gamma motor
system: Tone,
proprioception
and coordination
Muscle Spindle
Senses muscle
length
 Senses velocity
of change in
muscle length
 Initiates muscle
contraction
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Stretch Reflex

Contraction of a
muscle in an
attempt to resist
a change in
muscle length
Golgi Tendon Organ
Senses muscle
tension
 Initiates muscle
inhibition
 Gentle tension
initiated by a brace
can have an inhibiting
effect on the joint

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
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
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
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
Joint Assessment
Neurostretch
An Alternative Passive Range
of Motion & Joint Assessment
Technique
NeuroStretch as an Assessment Tool
 Palpation
the Joint
for Structural Changes in
 End
Feel Evaluation – Elasticity
Check
 Tonal
Assessment – determine
degree of abnormal tone or spasticity
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
NeuroStretchTM Technique
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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
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
NeuroStretch - Shoulder
Proximal to Distal
NeuroStretch - Elbow
NeuroStrech - Wrist / Hand
NeuroStretch - Post Stretch
Application of Orthotic
Two Hours Later - Post Orthotic
Therapy
NeuroStretch - Lower Extremity
NeuroStretch - Knee
Submaximal Stretch
Application of Orthotic
NeuroStretch Lab
End Feel & Tonal
Assessment
Orthotic Therapy Goals

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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
Orthotic Selection
 Joint
pathology and rehabilitation
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
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

Clinical Pathways to Orthotic Success –
Non-Orthopedic
Joint Pathology / Rehab Objective
stretch not indicated / desired
stretch therapeutic
Support & Position Joint(s)
Restore LROM
Good = Progress. Extension
Better = Air Bladder Stretch
Best = Dynamic LLPS
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
Full Contact End Range Static Fit
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
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Restorative Orthotic Therapy
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1.
2.
3.
Fair to good end feel indicates that there is
the potential to restore ROM with treatment
Progressive Extension static orthotic therapy
provides the most conservative restorative
therapy; frequent modification of the device is
required. GOOD
Air Bladder Low Load Prolonged Stretch
provides adjustable gentle stretch which is very
appropriate for adaptive tissue shortening
contractures, especially is LROM is severe.
BETTER
Dynamic Low Load Prolonged Stretch
provides the best option for restored LROM by
providing more clinically effective stretch; brace
usually requires significantly less frequent
modification compared to progressive extension
braces (dynamic or static/dynamic orthotic
technology). BEST
Elastic Stretch
 Force
is applied to the tissue, then
released
 When the force is removed, the
tissue returns to its original length
Plastic Deformation
 Elongation
of tissue produced under
loading that will remain after the
removal of a load.
 Tissue undergoing plastic
deformation will remain stretched,
yielding a permanent increase in
length
Stress – Relaxation Phenomena
 When
a gentle tension or stress
is applied to a muscle that does
not risk injury to the muscle, the
muscle will adapt, and “relax” or
elongate as opposed to opposing
the gentle stress or stretch. This
phenomena (relaxed elongation)
will usually occur within several
minutes of applying the gentle
stress.
Progressive Extension Fitting
 Set
angle of static brace progressively
ahead of end range by 5° to 10°
 Elongation of tissue after the stress –
relax phenomena can be 5° to 8°
 Use adjustable elastic leverage strap to
initiate gentle tension into joint,
applying a therapeutic stretch
 Progressive Extension orthotic therapy;
conservative stretch therapy.
Clinical Pathways to Success
LROM Rehabilitation
Restore LROM w/
Therapeutic Stretch
(no - mild
stasticity)
Maintain Stretch
from Therapy
Good
Low Load
Prolonged Stretch
Better
Low Load
Prolonged Stretch
Best
Low Load
Prolonged Stretch
Best
Progressive
Extension
Air Bladder
Static / Dynamic
Spring loaded
dynamic braces
SoftPro™
AirPro™
DynaPro™
Low Load Prolonged Stretch (LLPS)
A low load tension is delivered
by a brace to a joint that
when maintained for a
prolonged period results in
permanent elongation of the
affected tissue.
LLPS Brace Fitting
 The
brace initiates a therapeutic
stretch to the shortened tissue to
permanently elongate or lengthen the
tissue.
 After the stress-relaxation release of
tissue, the brace maintains stretch
 Prolonged Stretch = 3 to 6 hours / day
 Low Load Prolonged Stretch therapy is
the optimal therapy to reverse tissue
shortening
Low Load Prolonged Stretch
Bracing Options
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Air Technology: usually most gentle stretch,
ideal for severe contracture of 90° or more.
Static–Flex: bio-engineered dynamic stretch;
very effective for tissue shortening or neuro
contractures. Must be modified every 4 – 6 weeks
for best results.
Dynamic: best for post surgical tissue
shortening; constant linear tension can be
effectively used for neuro contractures. Very little
modifications required. DME, so not allowed in
nursing homes.
AirPro Orthotics
 Use
of pneumatic air bladders to
provide a gentle Low Load Prolonged
Stretch to the shortened tissue
 Appropriate
for spasticity treatment
as air “gives” during episode of tone
 Recommended
90° or more
for contractures of
Static – Dynamic Braces
 DynaPro™
braces are static but
flexible braces that have dynamic
properties.
 Tension is adjusted by setting the
brace “ahead” of end range (15°)
 The brace flexes into the contracture
to provide dynamic Low Load
Prolonged Stretch
Static/Neuro-Dynamic Orthotics
Static braces fabricated from flexible
materials (no springs) with dynamic LLPS
properties
 Brace is set to “flex” into the LROM to
provide a dynamic stretch (+15°)
 Dynamic tension initiates inhibition
 Bio-engineered to “give” or reduce stretch
force on the joint w/ involuntary muscle
contraction; ideal for spasticity

DynaPro™ Orthotics
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

Brace will flex or “give”
w/ dynamic stretch
reflex to accommodate
spasticity
Bioengineered to
reduce tension or flex
force with a dynamic
muscle contraction
Best option for severe
spasticity due to
negative tension
dynamics
Case Study:
Lateral Neck Flexion Contracture
Immediately Post Fit
10 Minutes Post Fit
30 Minutes Post Fit
CP Severe WHF Spasticity
Post DynaPro Fit
Palpation Method of
Orthotic Fitting
Evaluation of Stress –
Relaxation Release
Palpate Stretched Tissue to Assess Fit
 IMMEDIATELY
post fit, palpate the
stretched tissue to assess the stretch
 Stretched
 Patient
tendons should be taut
should feel “stretch”, but no
discomfort or pain
Re-Palpate 5 to 10 Minutes Post Fit

Fitter must re-palpate stretched joint 5 to 10
minutes post fit at crease in elbow (bicep tendon)
to confirm stress-relax phenomena indicating
brace is holding relaxed tissue at optimal resting
length

Tendons should demonstrate significant softening
or improved pliability

Adjust fit as necessary

Device should be worn 3 to 6 hours per day for
best results
Design Selection Criteria
Brace must deliver three point leverage
stretch to each affected joint.
 Middle “lever” should have elastic
properties.
 Strapping should align with the apex of
each affected joint (i.e., wrist, MCP’s of
fingers & thumb).
 Optional finger straps may be necessary
to optimize WHFO therapy.

3 Point Leverage Stretch
to Correct Wrist Flexion
 Upwards
leverage point on forearm
 Upwards leverage point in palm of
hand
 Downwards adjustable elastic
leverage point at apex of wrist
 3 point leverage = adjustable stretch
at wrist w/ 5° to 10° of stretch
Setting the Wrist Strap
Secure the forearm strap first to position
the wrist/hand/finger brace
 Secure the hand / finger strap w/ the
thumb properly aligned to hold the hand /
fingers in place
 Pull the wrist strap “up” at the wrist,
stretching the wrist strap.
 Wrap the wrist strap around the wrist and
secure.
 Wrist strap should provide a gentle
downwards force on the wrist

Wrist Palpation – Flexion Contracture
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Brace is set straighter
than wrist at all
affected joints
Finger should easily fit
under wrist and over
brace if fit correctly
Wrist strap adjusts
stretch tension
MCP strap adjusts
MCP tension
Optional Ulnar Drift
Strap may be needed
for PIP stretch
Wrist Palpation – Flexion Contracture


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Palpate tendons at
crease in the wrist
joint
Initially, tendons
should be taut
5 to 10 minutes post
fit, tendons are
slightly softer and
more pliable
Adjust brace as
necessary
Finger Palpation
Fingers will initially
oppose shape of
brace set “ahead”
of comfortable end
range
 10 mins. post fit,
fingers should be
relaxed, often
move beyond end
stretch

Elbow 3 Point Leverage
 Downwards
leverage point on bicep
 Downwards leverage point on
forearm
 Upwards adjustable leverage point at
elbow cap
 3 point leverage = adjustable stretch
at elbow w/ 5° to 10° of stretch
Elbow 3 Point Leverage



Adjustable gel/foam
elbow cap brings the
elbow up into the
brace when tightened
Bicep cuff, forearm
cuff and elbow cap
provide a 3 pt.
leverage stretch of the
elbow
Center elbow cap;
snug up all 4 straps to
bring elbow up into
brace
Elbow Palpation - Flexion Contracture


Palpate biceps
tendon at crease in
the joint
immediately post
fit to check applied
stretch
Initially, bicep
tendon should be
taut
Elbow Palpation – 10 Mins.Post Fit


5 to 10 minutes
post fit
tendon and
surrounding tissue
is significantly
softer and more
pliable
Hip Abduction

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
Anatomical exception to
3 pt. leverage rule
Minimizing pressure thru
= distribution key in
static or pro ex fit
Thigh cuffs must rotate
or have gel to
accommodate changes in
abduction setting
Ease of application and
adjustment important
Hip Palpation
Palpate hip
adductors on both
legs immediately
post fit
 Muscle stretch
should be apparent
 Re-palpate after 10
mins.; muscles
should be more
pliable

Knee 3 Point Leverage
 Upwards
leverage point on back of
thigh
 Upwards leverage point on calf
 Downwards adjustable leverage point
at knee cap; center knee cap, then
snug up all straps
 3 point leverage = adjustable stretch
at knee w/ 5° to 10° of stretch
Knee Palpation - Flexion Contracture



Palpate medial
hamstring on the
medial crease in the
joint immediately post
fit
Initially, tendon should
be taut
5 to 10 minutes post fit,
medial hamstring and
surrounding tissue is
softer and more pliable
Ankle / Foot 3 Point Leverage
 Upwards
leverage point on bottom of
foot
 Upwards leverage point on calf
 Downwards adjustable leverage point
at anterior bend in the ankle
 3 point leverage = adjustable stretch
at knee w/ 5° to 10° of stretch
Ankle / Foot 3 Point Leverage
Ankle/Foot Palpation - Plantarflexion
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
Palpate tissue
between malleolus
and Achilles tendon
on both sides of
the ankle (soft spot
unstretched)
Initially, tissue
should feel
stretched or taut
Re-Palpate 5 to 10 Minutes Post Fit
 Fitter
must re-palpate stretched joint
5 to 10 minutes post fit
 Tissue should demonstrate
significant softening or improved
pliability
 Adjust fit as necessary
Questions