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Incidence and Predictors of Early Ankle Contracture in Adults with Acquired Brain Injury

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Neurology Asia 2015; 20(1) : 49 – 58 Incidence and predictors of early ankle contracture in adults with acquired brain injury 1Norhamizan Hamzah MBChB MRehabMed, 2Muhammad Aizuddin Bahari Dip PT, 3Saini Jeffery Freddy Abdullah MBBS MRehabMed, 1Mazlina Mazlan MBBS MRehabMed 1Department of Rehabilitation Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur; 2Department of Rehabilitation Medicine, University Malaya Medical Center, Kuala Lumpur; 3Tawakkal Specialist Hospital, Kuala Lumpur, Malaysia Abstract Objective: To determine the incidence and predictors of early ankle contracture in adults with acquired brain injury. Methods: A prospective cohort study of patients admitted to Neurosurgical Intensive Care Unit (NICU), University Malaya Medical Centre and referred for rehabilitation within a period of 12 months. Adult patients with newly diagnosed acquired brain injury with no prior deformity to lower limbs, Glasgow Coma Scale ≤ 12, no concomitant spinal or lower limb injuries, medical stability at inclusion into the study and agreed to participate for the total duration of assessment (3 months) were recruited. We conducted weekly review of ankle muscle tone and measurement of ankle maximum passive dorsiflexion motion. The end point is reached if ankle contracture developed or completed 3 months post injury assessment. Results: The cohort included 70 patients, of which only 46 patients completed the study. Twenty-eight patients suffered from severe brain injury whilst 18 from moderate brain injury. Out of the 46 patients, 13 (28%) developed ankle contracture at the end of the study period. Abnormal motor pattern was significantly associated with incidence of ankle contracture, which included spasticity (p<0.001), spastic dystonia (p=0.001) and clonus (p=0.015). Using univariate analysis, the predictors for ankle contracture were spasticity (OR 51.67, CI 7.53-354.52, p<0.001), spastic dystonia (OR 27.43 CI 2.84-265.35, p=0.004) and clonus (OR 4.18 CI 1.33-13.19, p =0.015). Conclusion: Abnormal motor patterns are strongly associated with early incidence of ankle contracture amongst adult with new diagnosis of moderate to severe acquired brain injury despite a regular standard therapy program. This is an important clinical finding towards early prevention of ankle contracture. INTRODUCTION tissues to muscle fibres of the limbs, which leads Ankle contracture is a common musculoskeletal to the first mechanism of muscle contracture.5,6 The complication of moderate to severe acquired second mechanism that participates in contracture brain injury (ABI) in adult, particularly related formation is muscle over activity, which results to traumatic or spontaneous diffuse subarachnoid from loss of the central motor system’s ability to or intracerebral haemorrhage.1,2 It has been synchronize and generate force from a muscle and described to range from abnormal posturing to relax the muscle at rest.5,6 In short, sustained of the foot and ankle with plantarflexor and/or abnormal posturing with associated muscle invertor muscle overactivity during movement, imbalance combined with muscle over activity to fixed joint contracture.3 Thus, the term ankle can cause irreversible joint malalignment that contracture and equinovarus deformity has been leads to joint contracture.5 used interchangeably in the literature as the The pathological changes described above presentations tend to co-exist.3-5 tend to occur rapidly following brain injury, as The mechanisms that cause joint contracture early as six hours of immobilization and progress following brain injury have been discussed in throughout the following weeks.5 Therefore, joint the literature. During immobility, muscles are contractures were reported early following acute in a shortened position, which causes muscle hospitalization in previous studies, as early as unloading. This is followed by muscle atrophy, between one and 16 weeks after brain injury.3 muscle shortening and accumulation of connective Clavet et al.7 published a study looking at the Address correspondence to: Dr Norhamizan Hamzah, Department of Rehabilitation Medicine, Faculty of Medicine, 12th Floor, Menara Selatan, University Malaya Medical Centre, 50603 Kuala Lumpur, Malaysia. Tel: +6012- 3068790, Fax: +603-79674766, 49 Neurology Asia March 2015 incidence of joint contractures in Intensive Care Neurosurgical Intensive Care Set-up Unit (ICU) setting, and reported that 39% of the The NICU has 18 beds with 11 mechanical patients developed joint contractures within their ventilators. Within the unit, there are two sections stay of at least 2 weeks in the ICU. From all dividing the mechanically ventilated and non- the joint contractures noted, 51% were of ankle mechanically ventilated patients but nonetheless joints. requiring close medical monitoring. Once patients The type of lower limb motor pattern, severity are deemed medically stable, they are transferred of injury, length of hospital stay as well as to a general surgical ward for further management. duration of mechanical ventilation are among The admission criteria to the NICU are best the factors predicting the development of ankle illustrated in Figure 1. contracture.1,3,8 One study found that dystonic Most of the patients are referred for muscle overactivity correlates closely with ankle rehabilitation while they are still in the NICU. contracture and severity of brain injury has a The main aspect of rehabilitation care at this point weak association with the development of ankle involves physiotherapy, mainly to maintain muscle contracture.3 Yarkony and Sahgal on the other tone and muscle strength, joint protection care, hand, found that the incidence of multiple joint pressure ulcer prevention and chest physiotherapy. contractures amongst craniocerebral trauma The physiotherapist in charge would perform daily patients was highest with duration of coma of review and bedside interventions followed by more than three weeks.1 Childers et al.8 found that once or twice weekly review by the rehabilitation low Glasgow Coma Scale (GCS) on admission physician. The regime varies slightly among to the rehabilitation ward, muscle weakness, the patients based on their clinical conditions hyperreflexia and pelvic fractures as significant but in general, the standard practice in NICU predictors for joint contractures in traumatic brain at our centre included: i) a one to one session injured patients, whereas Clavet et al.7 found between therapist and patient, ii) daily one- that ICU stay of more than eight weeks was a hour bedside therapy session that consists of significant risk factor for contracture. positioning, passive range of motion, stretching Studies related to ankle contracture after brain and strengthening exercises of all the limbs, iii) injuries were mostly carried during the subacute ambulation therapy, iv) chest physiotherapy and stage and patients were recruited in a rehabilitation v) education sessions to caregiver when necessary unit.3,8,9,10 Presence of ankle contracture at this especially in more medically stable patients. stage might delay patient’s ability to achieve Orthosis prescription is not a standard treatment independent ambulation and shifted the therapy option for prevention of equinovarus in our focus to various interventions to correct ankle centre, but rather a management option depending contracture instead, such as the use of Botulinum on case-to-case basis after the evaluation by a toxin.11 The aim of our study is to determine the rehabilitation physician. The type of orthosis incidence of early ankle contracture in adults with prescribed for the lower limb included Plaster moderate to severe acquired brain injury despite of Paris (POP) cast and ankle-foot orthosis early standardized physiotherapy and to determine (AFO). Other spasticity management such as the predictors of the deformity. Understanding oral medication and Botulinum toxin-A injection the factors predicting early ankle contracture are not part of a standard treatment in NICU but after brain injury is useful to plan appropriate provided depending on case-to-case basis after preventive measures during the acute care. the evaluation by a rehab physician. METHODS Patient Recruitment and Methods This is a prospective cohort study over a 12-month All patients who were referred with a first episode period from August 2010 until August 2011, at of moderate to severe brain injury were included in the Neurosurgical Intensive Care Unit (NICU), the study. Severity of brain injury was determined University Malaya Medical Centre (UMMC). by the post-resuscitation GCS, and those with Patients with ABI; comprised of traumatic brain GCS of less than 12 were included. Haemorrhagic injury (TBI) and haemorrhagic stroke admitted to stroke patients were also selected according to the NICU and referred for neurorehabilitation were same GCS scoring method. Other inclusion criteria selected for our study. included patients who were 18 years and older, having the ability to give consent or eligibility of 50 All trauma cases with isolated head injury requiring intensive mechanical ventilation A nationwide referral via Emergency Department of all patients with acute neurological All forms of illness or trauma spontaneous intracranial haemorrhages All patients undergoing radiological endovascular Patients with space procedures occupying lesion causing depressed conscious levels Admission criteria Neurology patients requiring to NICU mechanical ventilatory support Central nervous system infection
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