Orthopedic vs. Restorative Products

Three types of Restorative Contractures:

There are two major types of contractures, Orthopedic and Restorative.

Orthopedic patients suffer lost range of motion after injuries or surgical intervention resulting in scar tissue and adhesions. The historical treatment is to “break through” these adhesions in order to restore lost range of motion.

Restorative Contractures typically have no adhesions – therefore if we use aggressive methods to attempt to quickly relengthen the range, we risk not only causing needless pain, but also of causing injury. Aggressive stretching can also kick in the Stretch Reflex which will cause the joint or body part to pull even farther into flexion. If your patient’s limb is very hard to range and if their degree of range of motion is shorter after your session than before you started, you may have unknowingly initiated this reflex.

Under the category of Restorative are three different types:

  1. ” Adaptive Tissue Shortening” which starts within about 3 days of “immobility” and occurs from the joint not being stretch to full extension enough to prevent shortening tissue shortening. The treatment for this injury is Prolonged Low Load Passive Stretch. Begin with about a 30 minute wearing schedule of a good high quality comfortable splint that applies low load stretch toward normal alignment, then gradually increase the wearing time up to no more than 6 hours per shift. This device must be adjustable to continue the joint or body part farther and farther toward and to normal alignment. If at home a similar pattern is ideal, but in any setting, one 6 hour period of continual stretch may be the best you can expect and should provide positive results.
  2. “Neurological Tone” with or without spasticity, resulting from an insult (injury, pressure or disease process) to the brain, spinal cord or other nerves. Specifically designed and manufactured orthotic devices must be applied to provide slight stretch, but allow the body to pull through with the tone then bring the limb or body part back to the preset range. Allowing this FLEX process to occur for 15 to 20 minutes will typically result in a muscle inhibition or relaxation. Only then can you determine if there is underlying shortened tissue.
  3. “Neurological Tone with Adaptive Tissue Shortening” is tone/spasticity with underlying tissue shortening. First the tone must be worked through, then Prolonged Low Load Passive Stretch applied to relengthen shortened tissue.

Restorative patients typically do not have adhesions to "break through" - they usually have either simple adaptive tissue shortening (from immobility), but much more common is neurological tone. This is typical with any neurological condition and is commonly mistaken as "fixed" joints.

Example: Knee joint. Once the knee has been gently stretched to passive resistance – do NOT overstretch - apply a high quality knee splint that will allow the joint to pull through with tone with slight tension, then as the episode of tone begins to diminish and the muscles begin to fatigue, it will take the joint back to the preset degree of extension. If applied with only about 10-15 degrees of stretch, the knee can "work through" the neurological tone to reach muscle inhibition. The device must also provide Prolonged Low Load Passive Stretch to achieve permanent relengthening over a period of time after the tone has been successfully diminished. At first the goal may only be to address the tone, then later to increase lost range.

Diagnoses like Parkinson’s disease, Cerebral Palsy, CVA (stroke), Multiple Sclerosis, Traumatic Brain Injury, Spinal Cord Injury, Huntington’s chorea, and end stage Alzheimer’s disease either present with this tone or very commonly develop neurological tone over a period of time. This development of tone can be of sudden onset – as with spinal cord damage – or it can be gradual, and many times insidious and not recognized.

Asking nursing assistants and family members:

  1. who is hard to dress because their shoulders and arms are held tightly to their body?
  2. whose fingernails are hard to trim because they hold their hand in a fist?
  3. whose hand smells so bad, and the odor gets on you when you are working with them?
  4. who is hard to transfer because they cannot put their feet flat on the floor or
  5. they are unable to straighten their knees?
  6. who seems to “fight” or “resist” when you try to pull their arms down, and the arms end up close to their chest in a stiff “protective position.”
  7. who is difficult to position in a chair (persons need to sit upright in a wheelchair and not reclined back in a geri-chair to achieve an improved health status) due to their “posture?”
  8. who is in danger of having a feeding tube surgically planted simply because they are unable to eat and swallow because of their “posture?”

If a patient has a history of falls from straightening their body into extension, and they require a restraint, they very likely need something to work through the tone in their spine and hips to allow them to set up and their spine be worked toward correction. Patients who lean forward or sideways must have something to support weakened muscles while moving their spine toward correct alignment and working through any flexor tone. These patients may be able to right their position upon verbal command, but do they have the strength to maintain that position?

Patients who are unable to eat and look around at their environment because their head is down may become disoriented simply due to lack of stimulation.

In summary, static and rigid devices are typically not recommended for Restorative Patients of any age. Static and rigid devices are designed for orthopedic conditions that require the joint or body part to be maintained in a certain plane to facilitate healing and function. It is not uncommon for one patient to have both conditions as seen in a person with Cerebral Palsy or Traumatic Brain Injury who may need a functional AFO or knee splint to enhance their ambulation, but upper extremity Restorative splinting to decrease the tone in their hands and elbows. If we fit appropriate splinting on these patients as soon as they start to develop neurological tone, we are more likely to prevent the injuries of lost range of motion. By our choices of treatment methods and orthotic devices, we may be determining the quality of life for these individuals for the rest of their lives.

Karen L Bonn, RN, COF, CFO
Restorative Medical