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Contracture Management

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Dear DQ,

I cannot tell you what a relief it was to find your website. My mother has had Alzheimer’s for years, and no one has presented the practical information in any way HALF as cogently and helpfully as you have. I only wish I had discovered you years ago.

Here’s my question. My mother is in late stage Alzheimer’s, and is relatively healthy. But she began developing contractures (which we never knew were called that) about 6 months ago in one hand, and now the other. My Dad took her to doctors. They never MENTIONED this, only said, She doesn’t have arthritis. They gave him no guidance. So, not knowing what to do, he left it alone.

She does not appear to be in pain, but the twists are getting worse, and for all the reasons you mention.

 If the contractures have already begun, will physical therapy of the type you mention be helpful, or is it too late?

– Donna

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We need to talk more about this topic.

There is some interesting dialogue in the physical/occupational therapy world about the effectiveness of splinting and stretching interventions for contracture management in neurologically impaired individuals (1, 2).  The results of this systematic literature review raised some eyebrows… the conclusion being   “Regular stretch does not produce clinically important changes in joint mobility…in people with neurological conditions.”(1).

But let’s drill down to the neurological condition that is discussed routinely on this site- Alzheimer’s disease.  I would even include Parkinson’s disease in this discussion due to the increased rigidity and tonal changes seen in that population.  Contractures in these diseases are generally caused by disuse.  The reason for the disuse is neurological, relating to apraxia, initiation deficits, and the re-emergence of primitive movement patterns.  In a stroke patient, by contrast, you usually have a direct blow to the sensory-motor cortex, causing changes in tone that can be severe and difficult to inhibit.

In progressive neurological disorders, contractures don’t usually present with a dramatic, sudden onset.  Joints usually contract over time, as purposeful use of the extremities decline.  Sustaining active range of motion through the use of reflexive behavior (If I toss this balloon to you, you will probably try to deflect it with an open hand), will keep joints moving longer.  Once active elicitation of purposeful movement is impossible, passive range of motion, stretching, and splinting can maintain joints in a position that PREVENTS further contracture.  Full range of motion for some folks may not be realistic, but a healthy range where the joint is able to extend far enough that the skin on the inner surface of the joint can stay dry and open to air is a reasonable goal.  Moist skin hosts bacteria.  Bacteria leads to odor, skin breakdown, pain, and infection.  Contracture management strategies should address those possibilities.

There is no denying the lack of objective evidence supporting the improvement of joint mobility through regular range of motion exercises and splinting for someone with a neurological condition.  But there is a case to be made for contracture prevention and pain management through regular stretching and splinting for the progressive neurological diseases.  The hand is less painful the more it is moved.  The act of putting the splint on and off mobilizes the joints.  The hand is easier to clean and keep dry if it’s easy to open.  Mobilizing and stretching tight fingers and wrists may not have the support of research for “clinically important changes in joint mobility”, but if you want to slow the journey toward frozen, painful, and deformed joints, my experience says to keep them moving and stretched.

Common positioning devices for contractures:

Comfy Hand Thumb Orthosis

 

Comfy Elbow and Knee Orthosis

 

 

1.  Katalinic OM, Harvey LA, Herbert RD. Effectiveness of stretch for the treatment and prevention of contractures in people with neurological conditions: a systematic review. Phys Ther. 2011;91:11–24. Abstract/FREE Full Text

2.  Lannin NA, Ada L.. Neurorehabilitation splinting: theory and principles of clinical use.  (1):21-8. doi: 10.3233/NRE-2011-0628.

 

 

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16 comments

  1. Can you give some suggestions for helping to unclench the hand that we can pass along to caregivers?

  2. My husband’s hand contracture has progressed to the point that I believe he is developing infections on his hands. He has advanced Parkinson’s Disease with dementia. The doctor has ordered hand splints, but the OT staff at the nursing home has been unable to open his hands. Can anything be done to clear up & prevent further infection?

    • This is tough. Fungus loves a dark, damp environment. Sometimes even getting a rolled up washcloth into that space will help keep the fingernails out of the palm and the skin relatively dry. He may need something for pain before anyone pulls on those fingers. Sometimes rolling out the thumb first helps relax the other fingers. Good contracture management requires diligent and consistent attention, which is hard to get in some settings. Good luck.

    • Hello I am an OT who regularly splints people following a stroke we are receiving more and more referrals for people with dementia and we are goi g to have to turn these down. I don’t know who will splint them which worries me a lot.
      Susan regarding your husband – ask the gp to prescribe kendels amd foam pads. They are anti fungal and anti bacterial. If the ot is unable to get a splint in they should be able to get these in. Good hand care is important too – try soaking his hand in a bowl of warm water to loosen the joints – but the hand must be thoroughly dried afterwards. Hope this helps.

  3. I am also an OT. If you are having difficulty getting the hand to open, first try dropping the wrist down into full flexion, allowing the fingers to relax, then gently pull the fingers apart, beginning with the thumb and working into the rest of the fingers, continually keeping the wrist bent. It may be best to try this when he is sleeping, or in a relaxed state, to allow you to clean and dry the palm, or do range of motion, or even to apply a splint. Hope you find this helpful.

  4. I’m working as a fysiotherapist with a dynamic bed orthesis called the V!GO D!NA Sleep, so we can position people with dementia in different positions when they are bedridden.

    By using this we are stabilizing the person with dementia how is confrontated with flexion contractures in the lower limbs. In this way we are stopping the negative evolution of the flexion contractures and we can prevent total stiffening in the fetal position.

    We also give them in this way a lot of extra tactile and proprioceptive input, so they are better aware of their own body scheme and they can relax!

    Do you know sush a positioning system?
    If so what is your experience with it?
    If not would you be interested in getting to know it?

    I’m looking forward to an answer.

  5. My mother has Parkinson dementia. Her two hands have contractures. She was was forever having infections. Always having antibiotics. The only thing that helps now is Botox administered in both elbows.
    You also have to look out for fingers having a tendency to stick together, ie sweat rigidity.always having to make sure fingers are thoroughly cleaned & dry.

  6. I take care of my mother full time. She has vascular dementia and left side contracture from stroke and brain tumors. She just received Botox injections for the first time a week ago, which has already caused the fingers to relax a bit. I worked with a therapist to keep range of motion and do stretches, and used a “carrot” splint and washcloths as long as I could. Eventually, she couldn’t stand those for very long at all and her hand and wrist tightened up quite a lot. That’s when Botox was recommended. The injection treatment was not that bad at all, she only made one little squeak. I keep her nails filed back and carefully soak her hand in warm water with essential oils that have antiseptic / antibacterial / anti fungal properties. She likes lemongrass. We also tried clove, oregano, lemon. About 10 drops into a pitcher full of warm water. Then I used a washcloth and pile of q-tips to swab every little crack, between fingers and down into the center of the palm to dig out any dry skin or yeast that is starting up. Finally, I fully dry her hand with towel and more q-tips and then to be sure it’s not damp, I douse the hand with anti-fungal powder and work it in to all cracks. This method has worked amazingly well and doesn’t cause much pain to my sensitive mother. I also keep a soft pillow between her contracted arm and torso at all times, which keeps range of motion, she doesn’t tighten up much. Before I started that, her whole arm and fist would be extremely tight up against her, causing severe pain. And she takes over-the-counter pain medication, per doctor’s order. I am thankful she never punctured her skin with her strong nails and she rarely has any odor, which I’ve heard can be quite bad with some. Q-tips and essential oils in warm water!!! It’s the best, and benefits the caregiver as well, with a relaxing fragrance. May you be blessed as you care for your loved one.

    • Amazing! Thank you so much for sharing.

    • My mother is 80 & in late stage 7 Alzheimer’s. She was diagnosed in 2007. She is at home with me & has been the past 10 years. In the last year she developed severe contractures in her arms & hands. Tightly presses them against her body. Truly heart breaking. The last 3 months it has advanced greatly. With her crossing so tight & rigid, I don’t see the splints as an option. Is there any topical or oral med to gain some relief for relaxing contractures? God bless those that are taking care of their loved ones with this vicious disease. It has been a long
      hard journey.

      • Spasticity and contractures are difficult to manage. As far as pharmaceutical relief, I would ask her doctor. Sometimes botox injections right into the muscle or drugs like Baclofen can provide a little relief, but there are side effects and logistical issues with both. Positioning her extremities with soft pillows, in the nook of her armpits, elbows, and knees, might be the best you can do. Can you get a therapist out there to assess her?

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