Physiotherapy management of contractures after acquired brain injury

154 Pages·2014·4.94 MB·English

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Physiotherapy management of contractures after
acquired brain injury

Joan Wai-King Leung

Thesis submitted in fulfilment of the requirements for the
Degree of Doctor of Philosophy
in
Sydney School of Medicine
University of Sydney

September 2014
Table of contents
Page
Statement of Authentication iv
Candidate’s Statement v
Supervisors’ Statement vi
Acknowledgements vii
Publications and Presentations ix
Preface xi
Abstract xiii
CHAPTER 1: Introduction 1

1.1 Background 1
1.2 References 5
CHAPTER 2: Literature review 9

2.1 Acquired brain injury 9
2.1.1 Overview 9
2.1.2 Impairments after acquired brain injury 10

2.2 Physiology and measurement of contractures 11
2.3 Epidemiology of Contractures after acquired brain injury 15
2.4 Contributors to contractures 16
2.4.1 Muscle weakness and associated loss of motor function 16
2.4.2 Spasticity 17
2.4.3 Combined factors 18

2.5 Passive stretch as treatment for contractures 21
2.5.1 Rationale for clinical application of passive stretch 21
2.5.2 Clinical application of passive stretch 21
2.5.3 Effectiveness of stretch interventions 25

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2.5 Electrical stimulation 27
2.6.1 Electrical stimulation and muscle strength 27
2.6.2 Electrical stimulation and spasticity 28
2.6.3 Electrical stimulation and contracture management 28

2.7 Impact of contractures on gait 29
2.8 Summary 31
2.9 Aims of the thesis 33
2.10 References 34
CHAPTER 3: An intensive programme of passive stretch and 48
motor training to manage severe knee contractures after
traumatic brain injury: a case report
CHAPTER 4: Electrical stimulation and splinting were not 56
clearly more effective than splinting alone for contracture
management after acquired brain injury: a randomised trial
CHAPTER 5: Standing, electrical stimulation and splinting is no 67
better than standing alone for ankle contractures in people with
brain injury: a randomised controlled trial
CHAPTER 6: The impact of ankle plantarflexion contractures 95
on the knee joint during stance phase of gait: a within-subject
study
CHAPTER 7: Discussion 104

7.1 Physiotherapy for contractures 104
7.1.1 Overview 104
7.1.2 Principal findings 104
7.1.3 Implications and suggestions for further investigations 106

7.2 The impact of ankle contractures on gait 109
7.2.1 Overview 109
7.2.2 Principal findings 109
7.2.3 Implications and suggestions for further investigations 110

7.3 Summary 112
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7.4 References 113

APPENDICES: The procedure manuals for the two randomised 117
controlled trials

Appendix 1 The procedure manual for chapter four 118
Appendix 2 The procedure manual for chapter five 128

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Statement of Authentication

This thesis is submitted to the University of Sydney in fulfilment of the requirement for the
Degree of Doctor of Philosophy.

The work presented in this thesis is, to the best of my knowledge and belief, original except
as acknowledged in the text. I, Joan Leung, hereby declare that I have not submitted this
material, either in full or in part, for a degree at this or any other institution.

Joan Leung
15/05/2014
Signature: ................................ Date: .................................

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Candidate’s statement

I, Joan Leung, hereby declare that this submission is my own work and that it contains no
material previously written by another person except where acknowledged in the text. Nor
does it contain material that has been accepted for the award of another degree.
I, Joan Leung, understand that if I am awarded a higher degree for my thesis titled ‘Clinical
management of contractures after acquired brain injury’ being lodged herewith for
examination, the thesis will be lodged in the University Library and be available immediately
for use. I agree that the University Librarian (or in the case of a department, the Head of
Department) may supply a photocopy, electronic copy or microform of the thesis to an
individual for research or study or to a library.

Joan Leung
15/05/2014
Signature: ……………………………….. Date: …………………......

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Supervisors’ statement

As supervisors of Joan Leung’s doctoral work, we certify that her thesis ‘Physiotherapy
management of contractures after acquired brain injury’ is sufficiently well prepared to be
examined for the Degree of Doctor of Philosophy. To the best of my knowledge, no editorial
assistance has been sought in the writing of the thesis.

Associate Professor Lisa A Harvey Signed ………………………………..
Sydney School of Medicine,
University of Sydney Date ……27/8/2014.................

Dr Anne M Moseley Signed ………………………………..
The George Institute for Global Health,
Australia
Sydney School of Medicine Date ……27 Aug 2014…..................
University of Sydney

Professor Richard Smith, Signed
Faculty of Health Sciences,
University of Sydney Date ………27 Aug 2014.................

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Acknowledgements

This thesis was undertaken with the knowledge that contractures are difficult to treat, and
studies involving patients with traumatic brain injury (one of the targeted clinical
populations for this thesis) are challenging to conduct. Thus, it was a huge relief when the
thesis was finally completed. All the work relating to this thesis could not be accomplished
without the joint effort and great support of a large number of people.
I have been very lucky to have Associate Professor Lisa Harvey as my primary supervisor
who has a strong passion and vast knowledge on contractures, an area that this thesis
centres on. As expected, there were ups and downs throughout the years during the
candidature. I was able to go through all the emotional turmoils and take on all the
challenges only because of the incessant support, guidance and encouragement given by
Lisa. I am particularly grateful to her extreme patience with me. Her extensive knowledge in
research and writing skills have been a great help to me.
I have been blessed with having Professor Richard Smith and Dr Anne Moseley as my
associate supervisors. Their expertise in research has made things much easier for me. I
have learnt a lot from both of them, especially knowledge and skills in areas where I had not
been exposed to, such as gait analysis. I particularly appreciate the time and effort that
Richard gave me for the biomechanical study. Richard has made me, a novice in gait
analysis, feel not too intimidated in a domain that was totally foreign to me. A special thank
to Dr Moseley for all the skills she has taught me about conducting clinical trials and writing
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up manuscripts. Her attention to detail and ability to critically appraise articles are
admirable.
Conducting clinical studies is full of challenges and frustrating moments. For instance, the
two randomised controlled studies took much longer than expected to complete. Just for
subject recruitment alone, one study took 3 years and another more than 5 years to
complete. These two randomised controlled trials could not have been accomplished
without the invaluable assistance of and wonderful input from all the investigators,
assessors, co-authors and colleagues, in particular, Charis Tse, Davide de Sousa, Erin Doyle,
Victoria Podmore, Lakshmi Arunachalam, Jane Liu and Clare Goodman. I am very grateful for
all the help they offered me. I would also like to express my sincere thanks to James
Puttock, Dumas Morales, Peter Zhu and Jo Diong for manufacturing the measuring devices
used in the randomised controlled studies. Most important of all, I would like to thank all
the participants of the studies and their carers. Without them, none of the studies in this
thesis could be done. I appreciate their time, involvement, dedication and patience. I am
especially grateful to the participants for their involvements at the time when they were
going through a very tough time in their lives. They are truly remarkable people and the key
contributors to the studies.
I would also like to thank the Royal Rehab (The Rehabilitation and Disability Support
Network), the Motor Accidents Authority (NSW) and the University of Sydney for providing
funding for the studies. Last but not least, a special thank to the managers of the Royal
Rehab for their invaluable support for research activities.

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