Treatment and Management of Muscle Contractures

Introduction to Muscle Contracture Management

• The British Journal of Sports Medicine recommends a multimodal approach for the first-line treatment of cervical muscle contracture, including therapeutic exercise combined with manual therapy, as well as medications for pain control and muscle relaxation as needed 1
• The management of muscle contractures involves a comprehensive approach, including pharmacological management, physical therapy, and the use of orthoses and assistive devices, as recommended by various medical societies, including the American Academy of Sleep Medicine, the American Geriatrics Society, and the American Physical Therapy Association 2, 3, 4

Diagnosis and Evaluation

• It is essential to evaluate the presence of "red flags" that may indicate underlying severe pathology, and to assess psychosocial factors that may contribute to pain and dysfunction, and to rule out cervical dystonia, characterized by painful spasms of the cervical muscles 5
• The British Journal of Sports Medicine suggests that routine imaging studies should not be requested unless severe pathology is suspected, there is an unexplained progression of symptoms, or the information may change the management 1

Postural Training and Prevention

• The American Thoracic Society recommends addressing common problems such as thoracic kyphosis, shoulder elevation, and protraction, and correcting postural alignment during rest and functional activities to prevent prolonged positioning of joints in extreme ranges 6
• Encourage optimal postural alignment at rest and during functional activities to prevent worsening of contractures, and support the affected limb when at rest using pillows or furniture to take weight off the limb, ensuring even distribution of weight in sitting, transfers, standing, and walking to normalize movement patterns, as recommended by the Journal of Neurology, Neurosurgery and Psychiatry 7
• Avoid postures that promote prolonged positioning of joints at end range, such as full hip, knee or ankle flexion while sitting, to prevent contractures, as suggested by the Journal of Neurology, Neurosurgery and Psychiatry 7

Exercise and Maintenance

• Regular exercises of stretching and strengthening should be continued, and flexibility exercises should be performed 2-3 days a week 6
• Daily exercises, including stretching, are recommended by the American Geriatrics Society when pain and stiffness are minimal, such as before bedtime, preceded by a warm shower or application of moist heat, and followed by relaxation before starting stretching exercises, moving slowly and extending the range of motion to a comfortable point of slight resistance, holding the stretch for 10-30 seconds, and modifying exercises to avoid pain when the joint is inflamed 3
• Exercise sessions should have three essential phases: warm-up (5-10 minutes) with low-intensity repetitive exercises, training with overload stimulus to increase joint range of motion, muscle strength, or aerobic capacity, and cool-down (5 minutes) typically involving static stretching of muscles, as recommended by the American Physical Therapy Association 3
• Dynamic training, including isotonic contractions with variable joint speed against constant resistance, is more useful for individuals with contractures and closely resembles daily activities, making it the recommended form of dynamic training, as suggested by the American Physical Therapy Association 3

Pharmacological Management

• Gabapentin or pregabalin are recommended for reducing spasticity, starting with gabapentin at 300mg daily or pregabalin at 75mg twice daily, with strong evidence for efficacy, as recommended by the American Academy of Sleep Medicine 2
• Cyclobenzaprine is indicated as an adjunct to rest and physical therapy for relief of muscle spasm associated with acute and painful musculoskeletal conditions, but should be used for short periods only (up to two or three weeks) 3
• Oral analgesics, particularly NSAIDs, should be considered for limited duration to relieve symptoms, with caution due to GI risks and consideration of gastroprotective agents, as recommended by the American College of Rheumatology 8, 9
• Tizanidine is particularly effective for chronic spasticity with improvements in pain without loss of motor strength in patients with spastic paraparesis, and is a first-line medication for spasticity-related contractures, along with oral baclofen and dantrolene 10

Orthoses and Assistive Devices

• The use of hand orthoses for contractures of the carpometacarpal joint (CMC) and patellofemoral knee orthoses for knee contractures may be considered, with the latter being conditionally recommended, as suggested by the American Academy of Orthopaedic Surgeons 4, 11
• Resting hand/wrist splints may be considered for patients without active hand movement, as recommended by the American Academy of Orthopaedic Surgeons 4
• Hand orthoses are strongly recommended for first CMC joint osteoarthritis, and patellofemoral braces are conditionally recommended for knee contractures, as recommended by the American Academy of Orthopaedic Surgeons 11
• Tibiofemoral knee braces are strongly recommended when knee contractures affect ambulation and joint stability, as recommended by the American Academy of Orthopaedic Surgeons 11
• Kinesiotaping is conditionally recommended for knee and first CMC joint contractures, as suggested by the American Academy of Orthopaedic Surgeons 11

Skin and Wound Care

• Regular skin assessments using objective risk scales like the Braden scale, minimizing friction and pressure on the skin, providing adequate support surfaces, regular position changes, good skin hygiene, and the use of specialized mattresses can help prevent skin lesions, as recommended by the American Heart Association 4
• Education of patients, staff, and caregivers on preventing skin injuries is crucial, as recommended by the American Heart Association 4

Nutrition and Fall Prevention

• Comprehensive fall prevention strategies and regular assessment of nutritional status are important to prevent malnutrition and falls, which can worsen muscle weakness and contracture risk, as recommended by the American Heart Association 12, 13
• Proper positioning to counteract deforming forces is essential, using supportive devices and implementing regular position changes every 2 hours, as recommended by the American Academy of Orthopaedic Surgeons 11
• Power mobility features, such as tilt, recline, and elevating leg rests, can allow position changes and weight shifting, reducing the risk of contractures, as recommended by the American Academy of Orthopaedic Surgeons 14

Surgical Interventions

• Surgical release of the brachialis, brachioradialis, and biceps muscles may be considered for substantial elbow contractures when other treatments have not been sufficiently effective, as suggested by the American Academy of Orthopaedic Surgeons 4
• Surgery should be considered when other treatments have not been sufficiently effective (Level 5 evidence, Grade D recommendation), as recommended by the American Academy of Orthopaedic Surgeons 9

Alternative Therapies

• Botulinum toxin injections are the first-line therapy for focal hand dystonia and can be beneficial for managing spasticity-related contractures, as reported by the American Academy of Neurology 9
• A comprehensive approach including orthoses, exercises, topical treatments, and botulinum toxin injections is recommended for managing contractures in the hands, as per the American College of Rheumatology 9
• Neuromuscular electrical stimulation (NMES) may provide short-term increases in motor strength and control, and helps prevent fiber atrophy and disuse muscle atrophy, with a low strength of evidence, according to the American Physical Therapy Association 15, 6
• Continuous passive motion (CPM) and neuromuscular electrical stimulation (NMES) can help prevent fiber atrophy, protein loss, and disuse muscle atrophy in immobile individuals, as recommended by the American Physical Therapy Association 6

Education and Follow-up

• Education and training in ergonomic principles, activity pacing, and use of assistive devices (Level 1b evidence, Grade A recommendation) are essential, as suggested by the American Occupational Therapy Association 9
• Regular follow-up adapted to individual patient needs (Level 5 evidence, Grade D recommendation) is crucial, as recommended by the American Academy of Physical Medicine and Rehabilitation 9