Adrian Suratos, PT, DPT, MS, GCS - Addressing Knee Flexion Contracture

Contracture Management / ROM Maintenance

We use PROM / stretching or splinting to maintain available ROM among patients in long term care facilities (LTCF's). Although there is evidence for the use of those interventions for acute conditions, evidence that either one is able to increase ROM over time in chronic conditions is lacking. (1,2) Both interventions have some pitfalls. With PROM / stretching, there is guarding against movement due to pain and discomfort especially among patients who are moderately or severely cognitively impaired. The selection and application of splints have their own challenges - especially when done by most nursing staff. There is a learning curve to splint application even among experienced clinicians. Using GAME READY (ice machine) is an effective alternative to manual stretching / PROM or splinting when managing contractures / ROM limitations.

CASE 1

The patient is an 87 yo male who has Parkinson's disease and was evaluated by PT for participation in a functional maintenance program (with the goal of maintaining his ability to ambulate). The patient's lower extremities are ace-wrapped to mitigate orthostatic hypotension which he experiences every time he stands up. When he ambulates, both knees are in slight flexion throughout the gait cycle. As distance increases, the degree of knee flexion increases. This increasing knee flexion "pushes" his COG posteriorly and puts the quads in a mechanically-disadvantaged position. Over time, the quadriceps approaches a threshold of knee flexion where it will fail to hold the body in the standing position, potentially resulting in a fall.

Hamstring tightness is ubiquitous even among fully active adults. Among older adults, this tightness can manifest as a posteriorly tilted pelvis, and later as a slightly flexed knee during ambulation.

INITIAL

TUG: 51 secs

SESSION 1

SESSION 2

TUG: 23 secs

CASE 2

The patient is a 70 yo female who has a remote history of CVA in 2020. According to medical records, she did not have residual weakness and was able to ambulate normally. More recently (2022), she had a fall at home which necessitated hospitalization, and was discharged to a SNF. On admission, she presented with "fisting" of the hemiplegic left hand, and was non-ambulatory. OT was originally managing the left hand, and it took 3 people to open her hand - one to hold the right hand, another to hold the right leg (because she kicks), and another therapist to open the left hand for application of a resting hand splint. The first time her hand was positioned in the splint, she had long nails which were all "broken." And, once opened, it had a strong, pungent odor. The odor continues to persist with application of the carrot.

It is important to address fisting because it puts the patient at risk for skin breakdown potentially leading to infection of broken skin. It also prevents hand hygiene.

After being discharged from OT, PT decided to keep the patient for a Maintenance Program to maintain ROM of the left hand and the left knee. PT decided to discontinue using the splint (because it took 3 people to apply it), and instead use the carrot. The patient still gets physically combative with use of the carrot, but significantly less intense, requiring only 1 therapist for its application. In image #3, you can see the difference in the color of the carrot which has and has not gone through the palm of her left hand. Discoloration of the nails is also apparent due to the pressure against the palm of her hand.

Note that the carrot has lines to indicate progression of hand-opening. It took 30 minutes of Game Ready application to get the carrot to its position in image #3.

Image #1

Image #2

Image #3

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