The equinus posturing at the ankle is a compensation to keep the weight line and ground reaction force line anterior to the knee. For example, individuals with NMD resulting in proximal hip and knee extension weakness will exhibit lumbar lordosis, diminished stance phase knee flexion, and equinus posturing at the ankle during stance and gait. Compensatory strategies used to biomechanically stabilize joints to accommodate for muscle paresis result in reduced active ROM. 9 The static nature of wheelchair mobility in comparison to the dynamic movement associated with gait contributes to the development of limb contractures. Contractures rapidly develop in many NMD after transitioning to a wheelchair. 1 A statically positioned limb developing fibrotic changes within the muscle will develop contracture formation in the position of immobilization. A shortened muscle length may result in up to a 40% loss of sarcomeres. The position in which a joint is statically positioned influences the number of sarcomeres present in any given muscle. For example, less than antigravity knee extension strength places an individual at risk for knee flexion contractures, particularly if the patient no longer ambulates and spends the majority of their time seated with the knee joint positioned in flexion. Weakness and inability to achieve active joint mobilization throughout the full normal range is the single most frequent factor contributing to the occurrence of fixed contractures. 6 Bracing, stretching programs, and surgery have all been utilized in the prophylaxis and treatment of limb contractures. The rate of neuromuscular disease progression is also related to the frequency and severity of contractures with more rapidly progressive conditions resulting in earlier and more severe contracture formation. Myopathic conditions are associated with more severe limb contractures in comparison to neuropathic disorders. 10– 14 Lower limb contractures are much more prevalent than upper limb contractures. 2– 9 Contracture prophylaxis is important to maintain function, range of motion (ROM), and skin integrity. 1 Intrinsic factors include fibrotic changes to the muscle resulting in reduced extensibility. Known contributing extrinsic factors include decreased ability to actively move a limb through its full range of motion, static positioning for prolonged periods of time, and agonist antagonist muscle imbalance. The pathogenesis of contractures is multifactorial. They contribute to increased disability due to decreased motor performance, mobility limitations, reduced functional range of motion, loss of function for activities of daily living (ADL), and increased pain. Then swing the stick to the other side, feel the stretch, and hold for 5 seconds.Limb contractures are a common impairment in neuromuscular diseases (NMD). Keep your arms straight and swing the stick to one side, feel the stretch, and hold for 5 seconds. Place your arms straight out in front of you at shoulder level. Horizontal Abduction and Adduction: Stand upright and hold a stick in both hands.While keeping your elbows straight, use your good arm to push your injured arm out to the side and up as high as possible. Shoulder Abduction and Adduction: Stand upright and hold a stick with both hands, palms down.Hold the bent position for 5 seconds and then return to the starting position. Move the stick up and down your back by bending your elbows. Place the hand on your uninjured side behind your head grasping the stick, and the hand on your injured side behind your back at your waist. Internal Rotation: Stand upright holding a stick with both hands behind your back it should be perpendicular to the floor, in line with the body.Using your good arm, push your injured arm out away from your body while keeping the elbow of the injured arm at your side. Your upper arms should be resting on the floor, your elbows at your sides and bent 90 degrees. External Rotation: Lie on your back and hold a stick in both hands, palms up.Relax and return to the starting position. Extension: Stand upright and hold a stick in both hands behind your back.Hold for 5 seconds and return to the starting position. Stretch your arms by lifting them over your head, keeping your elbows straight. Flexion: Stand upright and hold a stick in both hands, palms down.
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