CHHS18/025 Canberra Hospital and Health Services Clinical Guideline Muscle Length - Management in Adult Patients with Neurological Conditions Contents Contents..................................................... 1 Guideline Statement..........................................2 Scope........................................................ 2 Section 1 – Assessment.......................................2 Section 2 – Measurement......................................3 Section 3 – Intervention.....................................3 Section 4 – Documentation....................................4 Implementation............................................... 4 Related Policies, Procedures, Guidelines and Legislation.....4 References................................................... 5 Definition of Terms..........................................5 Search Terms................................................. 5 Attachments.................................................. 5 Attachment 1: Tardieu scale.................................7 Doc Number Version Issued Review Date Area Responsible Page CHHS18/025 1 19/01/2018 01/02/2022 RACC 1 of 10 Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register
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CHHS18/025
Canberra Hospital and Health ServicesClinical Guideline Muscle Length - Management in Adult Patients with Neurological Conditions Contents
Doc Number Version Issued Review Date Area Responsible PageCHHS18/025 1 19/01/2018 01/02/2022 RACC 1 of 7Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register
CHHS18/025
Guideline Statement
BackgroundThis document has been developed in response to the recognised risk of secondary complications due to decreased muscle length in patients with neurological impairments.
Key ObjectiveThis document will support the development of physiotherapy management programs so that they are implemented effectively, safely, and in accordance with evidence based practice, to ensure optimal functional outcomes for patients.
Alerts Patients who have neurological weakness and/or paralysis and/or spasticity have a high risk of developing contractures. It is easier to prevent a muscle contracture than try to reverse the effects of muscle shortening once it has occurred.
All physiotherapists should conduct a clinical risk assessment to determine appropriate manual handling requirements as per the ACT Health Manual Handling Policy.
Consider safe handling and force applied to muscles of the affected upper and lower limbs to prevent musculoskeletal injury.
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Scope
This document provides clinical practice guidelines to physiotherapists working with adult patients who have neurological weakness and/or paralysis and/or spasticity to reduce the risk of contracture in these populations. This clinical guideline is consistent with other relevant documents and evidence based practice, e.g. National Stroke Foundation Clinical Guidelines for Stroke Management (2017).
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Section 1 – Assessment
Obtain informed consent from the patient, or Enduring Power of Attorney (EPA) as indicated, and document in the patient’s clinical record.
Assess joint range of motion (to determine muscle length) of areas that may be contributing to the patients’ difficulty performing a given task. Always consider shoulder abduction and external rotation, elbow supination, wrist extension, hand web space, hip extension and external ‐rotation and ankle dorsiflexion.
Assess strength and spasticity with particular attention to muscle groups at greater risk of contracture, and those which will seriously impact on function if contracture occurs, including
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shoulder adductors and internal rotators, elbow pronators, wrist and finger flexors, web space, ‐hip flexors and internal rotators and ankle plantarflexors.
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Section 2 – Measurement
Valid and reliable outcome measures should be used to quantify the main assessment findings.
Outcome measures should be implemented at a clinically indicated timeframe.
Measure using the Tardieu scale to differentiate between the presence of contracture and spasticity (Attachment 1).
Ensure that joint range of motion, strength and spasticity is regularly monitored throughout the person’s rehabilitation.
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Section 3 – Intervention
For stroke survivors at risk of developing contracture or who have developed contracture, the following interventions should be provided: Participation in an active rehabilitation program Functional task practice through normal range of motion for every activity Active movement through range of motion (as strength allows) Electrical Stimulation to elicit muscle activity through passive range of motion Positioning throughout the day in an optimal position (e.g. in chair/wheelchair or in bed with
equipment to maintain an optimal position if indicated).
For stroke survivors at risk of developing contracture who are participating in an active rehabilitation program, routine use of splints or prolonged positioning of upper or lower limb muscles in a lengthened position (stretch) is not recommended.
If spasticity or pain is present consider liaison with the medical team for consideration of pharmacological management as an adjunct to physiotherapy interventions.
For stroke survivors, serial casting may be trialled to reduce severe, persistent contracture when conventional therapy has failed.
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Section 4 – Documentation
Refer to: ACT Health Clinical Records Policy.
Complete documentation in medical records either daily, or after every contact with a patient if the patient is not being treated daily.
Include functional goals in documentation linked to a clinically indicated timeframe.
Outcome measures should be documented as completed.
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Implementation
Physiotherapists involved in the management of patients with neurological conditions will be prompted to read and become familiar with this clinical guideline.
Physiotherapists involved in management of patients with neurological conditions will attend regular (at least fortnightly) relevant education sessions and professional development.
Physiotherapists involved in the management of patients with neurological conditions will be supported clinically by their senior colleagues, peers and clinical educator through regular formal and informal supervision, in the identification and management of patients at risk of developing muscle contracture.
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Related Policies, Procedures, Guidelines and Legislation
Policies ACT Health Administrative Records Management Policy ACT Health Clinical Records Policy Manual Handling Policy
Standards Australian Standards for Physiotherapy 2006 Physiotherapy Board of Australia, codes and guidelines Australian Physiotherapy Association Code of Conduct 2008 Clinical Guidelines for Stroke Management 2017 Standards of Practice for Allied Health Professionals ACT
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References
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1. Hill K, Denisenko S, Miller K, Clements T, Batchelor F (2005) Clinical Outcome Measurement in Adult Neurological Physiotherapy 3rd Edition; Australian Physiotherapy Association National Neurology Group.
2. Harvey LA, Katalinic OM, Herbert RD, Moseley AM, Lannin NA, Schurr K. Stretch for the treatment and prevention of contractures. Cochrane Database of Systematic Reviews 2017, Issue 1. Art. No.: CD007455. DOI: 10.1002/14651858.CD007455.pub3.
3. Clinical Guidelines for Stroke Management (2017) https://informme.org.au/Guidelines/Clinical-Guidelines-for-Stroke-Management-2017
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Definition of Terms
Spasticity A motor disorder characterised by a velocity-dependent increase in tonic stretch reflexes (muscle tone) with exaggerated tendon jerks resulting from hyperexcitability of the stretch reflex as one component of upper motor neuron syndrome.
Muscle contracture Contractures are characterised by a reduction in joint range of motion or an increase in resistance to passive joint movement, both limiting joint mobility.
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Disclaimer: This document has been developed by ACT Health, Canberra Hospital and Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.
Policy Team ONLY to complete the following:Date Amended Section Amended Divisional Approval Final Approval 10/01/2018 Complete Review ED RACC CHHS Policy Committee
This document supersedes the following: Document Number Document Name10/10 Electrical Stimulation10/41 Management of Muscle Length in Patients with Neurological Conditions
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Attachment 1: Tardieu scale
Measurement: Strength: Muscle strength can be measured using manual muscle testing and grading for upper limb and lower limb muscle groups.
0 - no contraction palpated.1 - muscle flicker. 2 - complete range of motion with gravity eliminated.3 - complete range of motion against gravity.4 - complete range of motion against gravity with some (moderate) resistance.5 - complete range of motion against gravity with maximal resistance.
A dynamometer can also be used to quantify strength.
Differentiation between contracture and spasticity: Must be measured using the Tardieu scale.Assess at two velocities: V1 – as slow as possible. V3 – as fast as possible (faster than the rate of the natural drop of the limb segment under gravity)
Measure: The angle of muscle reaction (Y). The quality of the muscle reaction (X):
0 - no resistance throughout the course of the passive movement.1 - slight resistance throughout the course of the passive movement, with no clear catch at a precise angle.2 - clear catch at a precise angle, interrupting the passive movement, followed by release. 3 - fatigable clonus (< 10 seconds when maintaining pressure). 4 - non fatigable clonus (> 10 seconds when maintaining pressure). ‐
Measurement of range of motion: Use a goniometer with standardised positioning. Consider use of a dynamometer to standardise force.
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