Question

1. Your patient has bilateral transtibial amputations. He has tight hip flexors and therefore when he is supine his residual limbs are not resting on the mat.

1. Does he have hip flexion or hip extension contractures?
2. Will you need to stretch his hip flexors or extensors?
3. How can you achieve a mechanical passive stretch?

Answer 1

a. Contractures are the permanent or semi-permanent restriction of movement of soft tissues due to shortening and/or structural changes in the connective tissues of the body. An above-knee (AK) amputee will have trouble with a hip flexion contracture.

b. Prevention is certainly the best approach to dealing with contractures because they are extremely difficult to stretch out once they develop.Lying in a hospital bed with the head of the bed up and the knees bent up or pillows under the knees is a sure way to induce contractures at the hips and knees. Stretching can certainly help, but activity and exercise are even more important for maintaining joint range of motion, especially when someone is limited to bed activity or wheelchair activity. At least 5 to 6 hours of activity per day is required to maintain normal joint motion, regardless of time spent stretching every day.

c. Stretching out contractures can be very difficult to impossible. How tissues elongate and what mechanisms can facilitate this are not well-understood. Therapists can manually stretch contracted joints, amputees can self-stretch and static splints and springloaded dynamic splints have been used. Even a process called serial casting has been used to stretch out contracted joints. A series of casts is applied to the contracted joint (serial casting), each one stretching out the joint more than the last one over time. This works much more easily with distal joints such as ankles, knees, wrists and elbows, but not so easily for hips and shoulders. The process is lengthy, uncomfortable and even more restrictive, as the cast itself is heavy and bulky.

Orthoses and static and dynamic splints can help limit contractures at the ankles, knees or elbows when a person is confined to a bed or chair for a long time. These devices can also help stretch out already contracted joints, but the emphasis is on “help stretch,” since it takes active exercise in addition to splints or orthoses to increase the motion in a restricted joint.

Joint Active Systems are splints applied across a joint to gain range of motion passively. Stretching exercises can be done passively using this device to apply a low amplitude force across a joint over a long period of time. Passive stretches done in this way can create "creep" in viscoelastic tissues - a long term lengthening of the soft tissues around a joint.

Deep heat, including ultrasound, can be used in conjunction with a stretching program. The elasticity of collagen increases as tissues are heated, hence a greater stretch can be achieved while the tissue is warmed.