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Contractures After Brain Injury: Causes and Prevention

physical therapist stretching man with brain injury contractures

Contractures are a common result of brain injury. They limit joint movement and can interfere with activities of daily living.

Today you will learn the causes of contractures after brain injury and some of the best techniques used to prevent them.

Causes of Contractures After Brain Injury

Contractures occur when muscle fibers shorten, causing a fixed tightening across the associated body part. This causes a decrease in range of motion and a restriction of function.

The most common areas that contractures affect include:

  • Hips
  • Shoulders
  • Ankles
  • Elbows
  • Knees
  • Wrist
  • Hand

It is common for patients to develop contractures across multiple joints, which places importance on early intervention and appropriate treatment.

Contractures can have both neurological and non-neurological causes. For example, a person whose arm is in a cast for months is at risk of contractures because, without movement, their muscles will tighten.

Following a TBI, the most common cause of contractures is spasticity.

Spasticity and Contractures

3d hologram of brain to illustrate how the brain affects spasticity

Spasticity is a condition in which the muscles are continuously contracted, causing tightness and muscle shortening. It is caused by damage to the part of the brain that controls voluntary movement. This damage leads to an imbalance of signals between the brain and the muscles.

Normally, your brain sends messages through the spinal cord to tell your muscles when to contract or relax. This helps your body maintain a comfortable balance between contracting and relaxing, and allows for proper muscle tone.

However, after a brain injury, this message flow can be interrupted, and your muscles no longer know whether they are supposed to tighten or relax.

As a result, the muscles stay in a constant state of contraction, also known as spasticity.

The longer the muscle stays contracted (causing this body part to be flexed), the shorter the muscle becomes, until eventually a contracture (the fixed stiffening of the muscle fibers) sets in, if not treated beforehand. A true contracture is irreversible.

Therefore, to prevent contractures after brain injury, you will need to address spasticity first.

Preventing Contractures After Brain Injury

While you may not be able to prevent all contractures after brain injury, you can prevent them from getting so severe that they are irreversible or you require surgery.

The best way to do so is through regular exercise and activity. Even if your contractures stop you from moving correctly, it’s important to move just a little every day. If you don’t, the contractures will worsen and bone damage can occur.

Here are the best treatment methods for preventing contractures after brain injury:

1. Therapist Evaluation

The first step to preventing contractures after brain injury is to have a physical or occupational therapist evaluate you (depending on what body part is being assessed).  

The therapist can assess you to see if there is any spasticity present in the muscles. If there is severe spasticity, they might recommend you try Botox injections first.

2. Botox Injections

Botox is a nerve-blocking agent that prevents the release of acetylcholine, a neurotransmitter that causes your muscles to contract.

It can help your muscles relax and stop painful spasms, which makes it a popular treatment option for spasticity. However, the effects will wear off in a few months.

During that period, you can work on extending your muscles to minimize your spasticity. The following methods offer some helpful ways to do that.

3. Passive Lengthening

therapist stretching contractures in brain injury patients knees

Passive lengthening involves a therapist slowly increasing your range of motion by stretching the affected limb. This must be done gradually to avoid injury.

There are two main techniques therapists use to accomplish this:

  • Manual stretching. The therapist stretches the muscle to its maximum length and holds for a few seconds. This can only be done for a short amount of time every day, otherwise, the muscles can become damaged.
  • Prolonged holding. This involves holding the joint in a moderate stretch for a prolonged period. It usually requires the use of a splint.

Typically the best approach is a combination of these options.

4. Activating Antagonist Muscles

Another way to treat spasticity to minimize your chances of contractures is to activate or strengthen the muscle opposite the one contracted (the antagonist muscle).

For example, if your bicep has spasticity, your therapist might have you strengthen your triceps.

The idea is, if the antagonist muscle can become stronger, it can counter the tightening of the agonist muscle and pull the joint through the full range.

This technique works best for patients who still can activate their opposing muscles.

5. Contract/Relax

man lifting weights with arm to improve contractures after brain injury

Another helpful way to treat spasticity and prevent contractures is to inhibit the stretch reflex.

The stretch reflex is a muscle contraction that occurs in response to stretching within the muscle. When a muscle lengthens, the muscle spindles are stretched and alpha motor neuron activity increases. This causes muscle fibers to contract.

This reflex normally protects the muscles from injury and tears, but it also makes them more difficult to stretch. To get around this, therapists recommend taking advantage of reciprocal inhibition. This occurs when the one muscle group activates and the brain inhibits the stretch reflex of the opposing muscle.

Therefore, to stretch your spastic muscle, you must activate the opposite muscle. For example, if your calf muscles are tight, activate your shin muscles. Then, after a few seconds, you will relax that muscle and start stretching the spastic muscle.

This approach is effective but can be dangerous if not done correctly, so only try it under the supervision of your therapist.  

6. Surgery

Finally, in some cases, surgery may be needed to correct otherwise irreversible contracture deformities. Contractures not only shorten muscles, but they also can damage bones and ligaments.

Surgery, therefore, can help lengthen muscles and repair some damage that has occurred. If the bones have become twisted by the contracture, the surgeon will most likely need to straighten them.

Some of these surgeries have long and painful recoveries, so it’s best to take early action to prevent the need for surgery.

Brain Injury Contractures: Conclusion

Contractures after brain injury can occur for a number of reasons. The most common causes of contractures are inactivity and prolonged spasticity.

Preventing contractures will require regular stretching. This can help elongate the muscle fibers and prevent spasticity from developing into contractures, or prevent contractures from getting worse.

Finally, stay as active as possible. The more you keep your muscles and joints moving, the more flexible they can become.


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