Pediatric Contractures

Posted by Nurse Linda in Life After Paralysis on September 29, 2020 # Health

Our bodies are fascinating in so many ways. However, all our bodies require maintenance. As individuals, both adults and children, we need to supply our physical bodies with many things but included are fluids and foods as well as movement.

For bodies to function well, they need fluid to keep hydrated. The body functions at its best when it has enough fluid to work. Food is needed for energy. Both keeping hydrated and eating a healthy diet can be a challenge for children with spinal cord injury. Fluid and foods should be in line with the child's chronological age, development stage, and needs with spinal cord injury. Some children have difficulty in meeting their body's needs, while others take in too much. Working with a dietician will help establish the proper amount of fluids and food for your child's needs. Frequent updates are needed as your child grows and progresses.children posing

Movement is needed to do functional activities but, even more importantly, to stimulate the nerves and circulation in the body. Even though a child has a spinal cord injury, their body still works below the level of the injury. Messages to move and sensation messages travel back and forth from the body to the brain. The spinal cord injury interrupts this communication. The body is still capable of moving; it is just not getting the message from the brain to do so. Therefore, to maintain health, the body needs to be moved manually.

Muscles are attached to the bones by tendons. Nerves control muscle movement. Joints allow the bones of the body to produce movement. Usually, the muscles stretch to allow the body to move at the joints. If the muscles are not activated by the nerve by a message from the brain, they tend to become tight, eventually replacing that elasticity of the muscle with hard, fibrous tissue. This can mostly be avoided by the movement of the muscles either by the individual or by someone on their behalf.

When a muscle loses its stretch, it becomes tight and less able to stretch as far as it originally did. This process happens over time, with a little loss every day or may happen even more quickly, depending on other conditions. The phenomenon of a tight muscle from lack of movement is a contracture. Contractures can involve the muscle, tendons, ligaments (usually all three) but also might be formed on the skin and tissue under the skin from a burn or as the result of a secondary complication of SCI, a pressure injury.

Individuals most susceptible to contractures are those with neurological injuries, such as spinal cord injury or cerebral palsy. Some inherited issues can lead to contractures such as muscular dystrophy. Other causes of contracture are nerve damage, severe muscle, or bone injury, scaring, or lack of use for any reason.

Muscles are typically found in pairs in the body. One set is for extending (pushing). The complimentary muscle is for flexing (pulling). Usually, the flexing muscles are a bit stronger than the extending muscles. Therefore, contractures of the muscles usually cause the muscles to flex a limb toward the body. The neck typically will contract toward the chest but may also pull to one side. The back can become contracted to pull to one side, curling around the chest or pulling the spine into an 'S' shape as in scoliosis. The arms draw into the torso, the elbows toward the upper arm, the wrist toward the forearm, and the fingers to curl down. In the legs, the thigh folds up to the torso, the calf toward the thigh, the feet to fold up to the shin, and the toes to curl down.

If a contracture of the muscular system develops, pain is a key issue. Your child might not feel pain in the traditional way due to sensation decreases in the body. However, the body will still feel pain. That message will be sent to the brain but might not reach that destination due to the interruption by the spinal cord injury. Pain may be signaled by spasms, referred to a part of the body where it might be felt like the shoulder or jaw (just as cardiac pain is a referred pain). Or pain may be demonstrated through Autonomic Dysreflexia (AD).

A forming muscular contracture may be seen visually, through lack of use of the full range of motion of the joint or through functional loss. Or the contracture may be felt when the range of motion is gently provided; the person performing the motion to the child's body will notice less and less able to move the joint through the full motion.

There are several ways to avoid contractures. This can be done by performing a range of motion exercises to the entire body at a minimum of two times per day. If you can, when doing a position change, add a range series to the legs or before eating, add a range series of the arms, work in the neck, and back as you do something else throughout the day. The range of motion should be performed very gently to avoid damage to the joints or soft tissues and to reduce the stimulation of spasms. Be careful not to push the joint beyond its normal movement.

Treat spasticity. The range of motion will help control spasticity as it fatigues the muscles. There are times when spasticity becomes so strong that medication must be used. Oral medications are often provided with success, but they also can produce brain fog. Many individuals have opted for Botox injections to reduce the number of nerve fibers firing at one time. These must be repeated regularly. For very intense spasticity, a baclofen pump can be implanted in the abdomen with a catheter that is threaded under the skin to deliver the medication directly into the spinal canal. This bathes the entire spinal cord in medication. Pain medication can be delivered through the pump as well. All treatments for spasticity have risks and benefits. Carefully determine which you think would be best for your child.

Braces and splints are often used to keep a child's limbs, trunk, or body in alignment. This relates to last month's discussion about proper body alignment. Braces or splints are used to keep the muscles extended or in a functional position. Serial casting or braces are sometimes used to stretch a muscle over time. The braces or splints can be prefabricated, made individually for your child, or made from casting material.

Some individuals will be taught to use paraffin over a sock (not directly on the skin) on the area to help warm and relax the muscles, which makes a range of motion a bit easier. Do not attempt this prior to getting a healthcare professional's approval and education from a therapist.

There are surgical interventions that can also be used in extreme cases of contracture. It is important to notice the development of a contracture, so less invasive treatments can be attempted first. Sometimes, in children, muscle contraction happens quickly regardless of your prevention techniques. Surgery might be the direct treatment. Surgical interventions might include 'feathering' the muscle, so the contraction is not as strong. Splinting and extensive physical therapy follows.

The contracture of the skin is a bit different. After spinal cord injury, the skin might contract due to pressure injury. The skin is very elastic. It stretches over joints body areas to allow movement. It snaps back into place when the position is changed. Scars do not have this elasticity. A scar is formed when an open pressure injury area heals. Monitoring for pressure injury prevention is key for preventing contracted skin. A scar area on the skin is more fragile than regular skin tissue.

As a parent or caregiver, there are many activities to keep in mind and perform to maintain the health of a child. It can become overwhelming at times. Sticking with good practices of proper positioning and performing a range of motion exercises is a great place to start to avoid contractures. Try not to get lost in the weeds. If you stay with the basics of good positioning, you have accomplished the first step in the goal of maintaining the child's skin and avoiding contractures. Having knowledge allows you to be the best care provider for your child. Nurse Linda

Linda Schultz, Ph.D., CRRN, a leader and provider of rehabilitation nursing for over 30 years, and a friend of the Christopher & Dana Reeve Foundation for close to two decades. Within our online community, she writes about and answers your SCI-related healthcare questions in our Heath & Wellness discussion.