F- CLINICAL ASPECTS OF SPINAL CORD INJURIES
539
and internal rotators—if the proper positioning of the patient has been neglected in
the early stages, but also later on, if the patient has given up standing exercises and sits
the whole day in his wheelchair. These contractures are often very painful on passive
or active movement, and the disfigurement may be grotesque, as was seen in a young
woman of 22 years, who contracted transverse myelitis and was admitted to Stoke
Mandeville 7J months after onset of the illness. The neurological signs were those of an
incomplete lesion below L3. However, these symptoms were overlaid by flexion contrac
tures of the knees and most severe flexion contractures of the hips, resulting in subluxa-
tion of the right hip and extreme lordosis, with backwards distortion of the pelvis, as the
result of prolonged, faulty positioning in bed (Fig. 2233 and b). The reduction of such
multiarticular contractures is difficult and demands great patience and endurance on the
part of both the patient and the physiotherapist. Correct positioning and passive move
ments alone are generally ineffective in reducing long-standing and excessive contractures,
and these procedures need to be supplemented by passive stretching for longer periods.
This can be carried out as follows:
1
Flexion contractures of the hips and knees are best reduced by stretching while the
patient is in supine position or by placing the patient into prone lying position, either in
bed or on a plinth, with the aid of pillows, well-padded slings and straps.
2 Adduction contractures of the legs are best treated in lying or half-lying position
for increasing periods on the plinth, with the legs maintained in abduction over each
side of the plinth by weights attached to well-padded slings around the knees. When such
patients sit in their wheelchairs, the knees should be kept well apart by placing firm pads
of increasing size between the knees.
3
For the reduction of extension contractures of the knees, the sitting position over the
end of the bed or plinth or in a wheelchair is preferable. Protective pillows are placed in
front of and behind the legs, below the knees, and a strap is then placed around the legs
and fixed to the legs of the plinth or bed or to the lower part of the wheelchair. The strap
is gradually tightened, thus increasing the degree of knee flexion.
4 For the reduction of fixed lordosis, with flexion contractures of the hips resulting in
backwards distortion of the pelvis, suspension of the patient in hanging position has
proved most effective (Fig. 223C and d). The patient is suspended in the hanging apparatus
by a corset fixed round his trunk. He may support himself in parallel bars, while being
pulled into suspension. At first, some patients may have difficulty in tolerating the hang
ing position and have to be closely supervised. The period of suspension is commenced
with 5 min and gradually increased to half an hour or longer. As a rule, the weight of the
body is sufficient to stretch the contracted muscles of the spine and hips, but in certain
cases, weights have to be fixed to the legs to increase the stretch.
The physiotherapist has to be warned to carry out all passive movements and stretch
ing procedures with great gentleness and care, in order to avoid fractures, especially of
the femur, as the development of osteoporosis has always to be borne in mind, in para
plegics.
Special attention is drawn to abduction contractures of the arms, due to over-action
of the normal deltoid, and, in particular, to flexion contractures of the forearms, due to
overaction of the biceps and brachioradialis muscles, occurring so often in cervical
