Progression and Direction of Contractures of Knee Joints Following Spinal Cord Injury in the Rat

Transcutaneous application of carbon dioxide improves contractures after immobilization of rat knee joint

OBJECTIVE

Joint contractures are a major complication following joint immobilization. However, no fully effective treatment has yet been found. Recently, carbon dioxide (CO₂) therapy was developed and verified this therapeutic application in various disorders. We aimed to verify the efficacy of transcutaneous CO₂ therapy for immobilization-induced joint contracture.

METHOD

Twenty-two Wistar rats were randomly assigned to three groups: caged control, those untreated after joint immobilization, and those treated after joint immobilization. The rats were treated with CO₂ for 20 min once a daily either during immobilization, (prevention) or during remobilization after immobilization (treatment). Knee extension motion was measured with a goniometer, and the muscular and articular factors responsible for contractures were calculated. We evaluated muscle fibrosis, fibrosis-related genes (collagen Type 1α1 and TGF-β1) in muscles, synovial intima's length, and fibrosis-related proteins (Type I collagen and TGF-β1) in the joint capsules.

RESULTS

CO₂ therapy for prevention and treatment improved the knee extension motion. Muscular and articular factors decreased in rats of the treatment group. The muscular fibrosis of treated rats decreased in the treatment group. Although CO₂ therapy did not repress the increased expression of collagen Type 1α1, the therapy decreased the expression of TGF-β1 in the treatment group. CO₂ therapy for treatment improved the shortening of the synovial membrane after immobilization and decreased the immunolabeling of TGF-β1 in the joint capsules.

CONCLUSIONS

CO₂ therapy may prevent and treat contractures after joint immobilization, and appears to be more effective as a treatment strategy for the deterioration of contractures during remobilization.

Transcutaneous Carbon Dioxide Improves Contractures After Spinal Cord Injury in Rats

BACKGROUND

Joint contractures are a major complication in patients with spinal cord injuries. Positioning, stretching, and physical therapy are advocated to prevent and treat contractures; however, many patients still develop them. Joint motion (exercise) is crucial to correct contractures. Transcutaneous carbon dioxide (CO2) therapy was developed recently, and its effect is similar to that of exercise. This therapy may be an alternative or complementary approach to exercise.

QUESTION/PURPOSES

Using an established model of spinal cord injury in rats with knee flexion contractures, we sought to clarify whether transcutaneous CO2 altered (1) contracture, as measured by ROM; (2) muscular and articular factors contributing to the loss of ROM; (3) fibrosis and fibrosis-related gene expression in muscle; and (4) the morphology of and fibrosis-related protein expression in the joint capsule.

METHODS

Thirty-six Wistar rats were divided into three equal groups: caged control, those untreated after spinal cord injury, and those treated with CO2 after spinal cord injury. The rats were treated with CO2 from either the first day (prevention) or 15th day (treatment) after spinal cord injury for 2 or 4 weeks. The hindlimbs of rats in the treated group were exposed to CO2 gas for 20 minutes once daily. Knee extension ROM was measured with a goniometer and was measured again after myotomy. We calculated the muscular and articular factors responsible for contractures by subtracting the post-myotomy ROM from that before myotomy. We also quantified histologic muscle fibrosis and evaluated fibrosis-related genes (collagen Type 1, α1 and transforming growth factor beta) in the biceps femoris muscle with real-time polymerase chain reaction. The synovial intima's length was measured, and the distribution of fibrosis-related proteins (Type I collagen and transforming growth factor beta) in the joint capsule was observed with immunohistochemistry. Knee flexion contractures developed in rats after spinal cord injuries at all timepoints.

RESULTS

CO2 therapy improved limited-extension ROM in the prevention group at 2 weeks (22° ± 2°) and 4 weeks (29° ± 1°) and in the treatment group at 2 weeks (31° ± 1°) compared with untreated rats after spinal cord injuries (35° ± 2°, mean difference, 13°; 39° ± 1°, mean difference, 9°; and 38° ± 1°, mean difference, 7°, respectively) (95% CI, 10.50-14.86, 8.10-10.19, and 4.73-9.01, respectively; all p < 0.001). Muscular factors decreased in treated rats in the prevention group at 2 weeks (8° ± 2°) and 4 weeks (14°± 1°) and in the treatment group at 2 weeks (14 ± 1°) compared with untreated rats (15° ± 1°, 4.85-9.42; 16° ± 1°, 1.24-3.86; and 17° ± 2°, 1.16-5.34, respectively; all p < 0.05). The therapy improved articular factors in the prevention group at 2 weeks (4° ± 1°) and 4 weeks (6° ± 1°) and in the treatment group at 2 weeks (8° ± 1°) compared with untreated rats (10° ± 1°, 4.05-7.05; 12° ± 1°, 5.18-8.02; and 11° ± 2°, 1.73-5.50, respectively; all p < 0.05). CO2 therapy decreased muscle fibrosis in the prevention group at 2 weeks (p < 0.001). The expression of collagen Type 1, α1 mRNA in the biceps femoris decreased in treated rats in the prevention group at 2 and 4 weeks compared with untreated rat (p = 0.002 and p = 0.008, respectively), although there was little difference in the expression of transforming growth factor beta (p > 0.05). CO2 therapy did not improve shortening of the synovial intima at all timepoints (all p > 0.05). CO2 therapy decreased transforming growth factor beta immunolabeling in joint capsules in the rats in the prevention group at 2 weeks. The staining intensity and Type I collagen pattern showed no differences among all groups at all timepoints.

CONCLUSION

CO2 therapy may be useful for preventing and treating contractures after spinal cord injuries. CO2 therapy particularly appears to be more effective as a prevention and treatment strategy in early-stage contractures before irreversible degeneration occurs, as shown in a rat model.

CLINICAL RELEVANCE

Our findings support the idea that CO2 therapy may be able to improve the loss of ROM after spinal cord injury.

Effects of hypertonia on contracture development in rat spinal cord injury

STUDY DESIGN

Experimental animal study.

OBJECTIVES

Spastic hypertonia is originally believed to cause contractures from clinical observations. Botulinum toxin is effective for the treatment of spasticity and is widely used in patients who have joints with contractures. Using an established rat model with knee contractures after spinal cord injuries, we aimed to verify whether hypertonia contributes to contracture development, and the botulinum toxin improves structural changes in muscles and joint components responsible for contractures.

SETTING

University laboratory in Japan.

METHODS

To evaluate the effect of hypertonia on contracture development, the rats received botulinum toxin injections after spinal cord injuries. Knee extension motion was measured with a goniometer applying a standardized torque under anesthesia, and the contribution by muscle or non-muscle structures to contractures were calculated by measuring joint motion before and after the myotomies. We quantitatively measured the muscle atrophy, muscle fibrosis, and synovial intima length.

RESULTS

Botulinum toxin injections significantly improved contractures, whereas did not completely prevent contracture development. Botulinum toxin was effective in improving the muscular factor, but little difference in the articular factor. Spinal cord injuries induced muscle atrophy, and botulinum toxin significantly accelerated muscle atrophy and fibrosis. The synovial intima length decreased significantly after spinal cord injuries, and botulinum toxin did not improve this shortening.

CONCLUSIONS

This animal study provides new evidence that hypertonia is not the sole cause rather is the partial contributor of contractures after spinal cord injuries. Furthermore, botulinum toxin has adverse effects in the muscle.

Mechanical Stress by Spasticity Accelerates Fracture Healing After Spinal Cord Injury

Accelerated fracture healing in patients with spinal cord injuries (SCI) is often encountered in clinical practice. However, there is no distinct evidence in the accelerated fracture healing, and the mechanisms of accelerated fracture healing in SCI are poorly understood. We aimed to determine whether SCI accelerated fracture healing in morphology and strength, to characterize the healing process with SCI, and to clarify the factors responsible for accelerated fracture healing. In total, 39 male Wistar rats were randomly divided into healthy control without intervention, SCI only, fracture with SCI, botulinum toxin (BTX) A-treated fracture with SCI, and propranolol-treated fracture with SCI groups. These rats were assessed with computed microtomography, histological, histomorphological, immunohistological, and biomechanical analyses. Both computed microtomography and histological analyses revealed the acceleration of a bony union in animals with SCI. The strength of the healed fractures after SCI recovered to the same level as that of intact bones after SCI, while the healed bones were weaker than the intact bones. Immunohistology revealed that SCI fracture healing was characterized by formation of callus with predominant intramembranous ossification and promoting endochondral ossification. The accelerated fracture healing after SCI was attenuated by BTX injection, but did not change by propranolol. We demonstrated that SCI accelerate fracture healing in both morphology and strength. The accelerated fracture healing with SCI may be due to predominant intramembranous ossification and promoting endochondral ossification. In addition, our results also suggest that muscle contraction by spasticity accelerates fracture healing after SCI.

Stretching After Heat But Not After Cold Decreases Contractures After Spinal Cord Injury in Rats

BACKGROUND

Contractures are a prevalent and potentially severe complication in patients with neurologic disorders. Although heat, cold, and stretching are commonly used for treatment of contractures and/or spasticity (the cause of many contractures), the sequential effects of these modalities remain unclear.

QUESTIONS/PURPOSES

Using an established rat model with spinal cord injury with knee flexion contracture, we sought to determine what combination of heat or cold before stretching is the most effective for treatment of contractures derived from spastic paralyses and investigated which treatment leads to the best (1) improvement in the loss of ROM; (2) restoration of deterioration in the muscular and articular factors responsible for contractures; and (3) amelioration of histopathologic features such as muscular fibrosis in biceps femoris and shortening of the joint capsule.

METHODS

Forty-two adolescent male Wistar rats were used. After spasticity developed at 2 weeks postinjury, each animal with spinal cord injury underwent the treatment protocol daily for 1 week. Knee extension ROM was measured with a goniometer by two examiners blinded to each other's scores. The muscular and articular factors contributing to contractures were calculated by measuring ROM before and after the myotomies. We quantitatively measured the muscular fibrosis and the synovial intima length, and observed the distribution of collagen of skeletal muscle. The results were confirmed by a blinded observer.

RESULTS

The ROM of heat alone (34° ± 1°) and cold alone (34° ± 2°) rats were not different with the numbers available from that of rats with spinal cord injury (35° ± 2°) (p = 0.92 and 0.89, respectively). Stretching after heat (24° ± 1°) was more effective than stretching alone (27° ± 3°) at increasing ROM (p < 0.001). Contrastingly, there was no difference between stretching after cold (25° ± 1°) and stretching alone (p = 0.352). Stretching after heat was the most effective for percentage improvement of muscular (29%) and articular (50%) factors of contractures. Although quantification of muscular fibrosis in the rats with spinal cord injury (11% ± 1%) was higher than that of controls (9% ± 0.4%) (p = 0.01), no difference was found between spinal cord injury and each treatment protocol. The total synovial intima length of rats with spinal cord injury (5.9 ± 0.2 mm) became shorter than those of the controls (7.6 ± 0.2 mm) (p < 0.001), and those of stretching alone (6.9 ± 0.4 mm), stretching after heat (7.1 ± 0.3 mm), and stretching after cold (6.7 ± 0.4 mm) increased compared with rats with spinal cord injury (p = 0.01, p = 0.001, and p = 0.04, respectively). The staining intensity and pattern of collagen showed no difference among the treatment protocols.

CONCLUSIONS

This animal study implies that heat or cold alone is ineffective, and that stretching is helpful for the correction of contractures after spinal cord injury. In addition, we provide evidence that heat is more beneficial than cold to increase the effectiveness of stretching.

CLINICAL RELEVANCE

Our findings tend to support the idea that stretching after heat can improve the loss of ROM and histopathologic features of joint tissues. However, further studies are warranted to determine if our findings are clinically applicable.

Combined Effects of Neurotrophin Secreting Transplants, Exercise, and Serotonergic Drug Challenge Improve Function in Spinal Rats

Objectives. To determine the effects of neurotrophin-secreting transplants combined with exercise and serotonergic drug challenges on recovery of hindlimb function in rats with midthoracic spinal cord transection injuries. Methods. Spinalized animals received transplants of fibroblasts genetically modified to express brain-derived neurotrophic factor and neurotrophin-3 and daily cycling exercise. Hindlimb movement in an open-field test (BBB) was scored weekly. Serotonin agonists were used monthly to further stimulate motor function. Axonal growth was quantified in the transplant and at L5 using immunocytochemical markers. Weights of hindlimb muscles were used to assess muscle atrophy. Results. Neurotrophin-secreting transplants stimulated axonal growth, and cycling prevented muscle atrophy, but individual treatments did not improve motor scores. Combined treatments resulted in improvements in motor function. Serotonergic agonists further improved function in all groups, and transplant groups with exercise achieved weight-supporting levels following drug treatment. Conclusion. Combined treatments, but not individual treatments, improved hindlimb function.

Remobilization causes site-specific cyst formation in immobilization-induced knee cartilage degeneration in an immobilized rat model

An understanding of the articular cartilage degenerative process is necessary for the prevention and treatment of joint disease. The present study aimed to examine how long‐term immobilization‐induced cartilage degeneration is aggravated by remobilization. Sixty 8‐week‐old male Wistar rats were used in this study. The unilateral knee joint was immobilized using an external fixator for 8 weeks. The rats were killed at 0 and 3 days, and at 1, 2, 4 and 8 weeks after removing the fixator. After the rats were killed, the maximum knee extension angles were measured. Histological sections at the medial mid‐condylar region (non‐contact, transitional and contact regions of the femur and tibia) were prepared and scored. The cartilage thickness and number of chondrocytes were measured, and CD44 and Col2‐3/4c expression levels were assessed immunohistochemically. The histological assessment revealed progressive aggravation of cartilage degeneration in the transitional region, with a decreased number of chondrocytes and CD44‐positive chondrocytes as well as poor scoring over time, particularly in the tibia. Cyst formation was confirmed in the transitional region of the tibia at 8 weeks post‐remobilization. The cartilage thickness in the transitional region was thicker than that in the contact region, particularly in the tibia. Col2‐3/4c expression was observed in the non‐contact and transitional regions, and the knee extension angle was recovered. In conclusion, immobilization‐induced cartilage degeneration was aggravated by remobilization over time in the transitional region, followed by observations of a decreased number of chondrocytes and morphological disparity between different cartilage regions.

Amount of torque and duration of stretching affects correction of knee contracture in a rat model of spinal cord injury

BACKGROUND

Joint contractures are a common complication of many neurologic conditions, and stretching often is advocated to prevent and treat these contractures. However, the magnitude and duration of the stretching done in practice usually are guided by subjective clinical impressions.

QUESTIONS/PURPOSES

Using an established T8 spinal cord injury rat model of knee contracture, we sought to determine what combination of static or intermittent stretching, varied by magnitude (high or low) and duration (long or short), leads to the best (1) improvement in the limitation in ROM; (2) restoration of the muscular and articular factors leading to contractures; and (3) prevention and treatment of contracture-associated histologic alterations of joint capsule and articular cartilage.

METHODS

Using a rat animal model, the spinal cord was transected completely at the level of T8. The rats were randomly assigned to seven treatment groups (n = 4 per group), which were composed of static or intermittent stretching in combination with different amounts of applied torque magnitude and duration. We assessed the effect of stretching by measuring the ROM and evaluating the histologic alteration of the capsule and cartilage.

RESULTS

Contractures improved in all treated groups except for the low-torque and short-duration static stretching conditions. High-torque stretching was effective against shortening of the synovial membrane and adhesions in the posterosuperior regions. Collagen Type II and VEGF in the cartilage were increased by stretching.

CONCLUSIONS

High-torque and long-duration static stretching led to greater restoration of ROM than the other torque and duration treatment groups. Stretching was more effective in improving articular components of contractures compared with the muscular components. Stretching in this rat model prevented shortening and adhesion of the joint capsule, and affected biochemical composition, but did not change morphologic features of the cartilage.

CLINICAL RELEVANCE

This animal study tends to support the ideas that static stretching can influence joint ROM and histologic qualities of joint tissues, and that the way stretching is performed influences its efficacy. However, further studies are warranted to determine if our findings are clinically applicable.

Impairment of postural control in rabbits with extensive spinal lesions

Our previous studies on rabbits demonstrated that the ventral spinal pathways are of primary importance for postural control in the hindquarters. After ventral hemisection, postural control did not recover, whereas after dorsal or lateral hemisection it did. The aim of this study was to examine postural capacity of rabbits after more extensive lesion (3/4 section of the spinal cord at T(12) level), that is, with only one ventral quadrant spared (VQ animals). They were tested before (control) and after lesion on the platform periodically tilted in the frontal plane. In control animals, tilts of the platform regularly elicited coordinated electromyographic (EMG) responses in the hindlimbs, which resulted in generation of postural corrections and in maintenance of balance. In VQ rabbits, the EMG responses appeared only in a part of tilt cycles, and they could be either correctly or incorrectly phased in relation to tilts. Because of a reduced value and incorrect phasing of EMG responses on both sides, this muscle activity did not cause postural corrective movements in the majority of rabbits, and the body swayed together with the platform. In these rabbits, the ability to perform postural corrections did not recover during the whole period of observation (< or =30 days). Low probability of correct EMG responses to tilts in most rabbits as well as an appearance of incorrect responses to tilts suggest that the spinal reflex chains, necessary for postural control, have not been specifically selected by a reduced supraspinal drive transmitted via a single ventral quadrant.

Contrasting alteration patterns of different cartilage plates in knee articular cartilage after spinal cord injury in rats

STUDY DESIGN

Experimental, controlled trial, animal study.

OBJECTIVE

To assess morphologic changes in different cartilage plates after spinal cord injury and identify the localization of these alterations.

SETTING

Saitama, Japan.

METHODS

A total of 16 Wistar rats were used. Eight rats underwent a spinal cord injury and eight rats had no intervention as control. The cartilage alterations of the knee joint were evaluated with radiography and histomorphometric analysis. To quantify cartilage alterations, we selected the histologic characteristics: thickness of the articular cartilage, number of chondrocytes, matrix staining to toluidine blue as a reflection of proteoglycan content and surface irregularity.

RESULTS

No differences in knee joints were found between the groups by radiography. In the medial knee joint, cartilage thickness of spinal-cord-injured knees increased at the anterior femoral region and decreased at the tibial and posterior femoral regions; however, in the lateral knee, that of spinal cord injuries did not change compared with control knees. Spinal cord injuries decreased the number of chondrocytes, especially at the anterior femoral regions. Matrix staining increased partially at the tibial regions. Surface irregularity of spinal-cord-injured knees was comparable to that of control knees in all cartilage plates.

CONCLUSION

The present findings exhibit characteristics of the cartilage after spinal cord injury. These alterations were different in nature between the medial and lateral regions. Future studies should assess separately different cartilage plates, to overestimate these severities when the changes at the medial knee were examined and to underestimate when the changes at the lateral knee were examined.

Alteration in articular cartilage of rat knee joints after spinal cord injury

OBJECTIVE

Mechanical forces are crucial for the maintenance of the morphologic and functional integrity of articular cartilage. The alteration of the articular cartilage after spinal cord injury (SCI) has been described in relation to a suppression of mechanical forces, since the joint is unloaded and restricted in movement. However, the morphological and biochemical characteristics of the cartilage after SCI are still poorly understood. We identified the localization of cartilage alterations after SCI and verified the influence of mechanical forces on the articular cartilage.

METHOD

A total of 32 Wistar rats were used. Sixteen animals underwent an SCI and 16 animals served as control. The articular cartilage of the knee joint was assessed, respectively, at 4, 8, 10, and 12 weeks after intervention by histochemical, histomorphometric, immunohistochemical, and biochemical analyses.

RESULTS

Cartilage thickness of spinal cord-injured knees decreased at the tibial and posterior femoral (FP) regions and increased at the anterior femoral (FA) region. Spinal cord injuries decreased the number of chondrocytes at the anterior regions and decreased the cartilage matrix staining only at the tibial regions. Immunolabeling to collagen type II was noted comparably in the superficial layer but noted weakly from the middle to deep layer. Collagen type I existed excessively at the cartilage surface and the pericellular regions.

CONCLUSION

Cartilage alterations after SCI would not be explained by only a suppression of mechanical forces by unloading and immobilization, but there may be influences on the cartilage in addition to the change in mechanical forces.

Alteration of knee joint connective tissues during contracture formation in spastic rats after an experimentally induced spinal cord injury

This study was made to elucidate the changes in the periarticular connective tissue that can underlie the contracture after spasticity development. Sixteen Wistar rats underwent a spinal cord injury and 16 rats were either sham- or nonoperated. The periarticular connective tissue of the knee joint was assessed with histological, histomorphometric, immunohistochemical, and biochemical analyses. Histological results showed a smaller synovial intima, a dense subintimal and posterior joint capsule without fibrosis, and a disarranged posterior capsule in the spinal cord-injured knees with the flexion contracture. The synovial intima length was shortened only at the posterior capsule. Neither the distribution nor expression of type I and III collagen was affected. Contractures after spinal cord injuries are characterized by synovial intima adhesions. A dense and disarranged capsule may lead to joint stiffness. The alteration of periarticular connective tissues exhibits properties characteristic of the contracture after spasticity development.

Comparison of muscular and articular factors in the progression of contractures after spinal cord injury in rats

STUDY DESIGN

Experimental, controlled trial.

OBJECTIVES

To identify the relationship between the muscular and articular factors in the progression of contractures after spinal cord injury (SCI).

SETTING

Hiroshima University, Hiroshima, Japan.

METHODS

In total, 48 female Wistar rats were used. The 24 experimental rats that underwent a spinal cord transection and the other 24 control rats that underwent a sham-operation were assessed at 2, 4, 8, 12, 16, or 24 weeks postsurgery. Knee joint motion was measured for flexion and extension. Myotomy of the transarticular muscles was then performed and range of motion was measured again. The degree of contractures was assessed by goniometry measuring the femorotibial angle before and after the myotomies.

RESULTS

The spinal cord-injured rats demonstrated flaccid paralysis during the first few days postsurgery and thereafter spastic paralysis. Intra- and inter-rater reliabilities for all measurements were >0.814. Knee flexion contractures developed in the all experimental rats, and progressed for the first 12 weeks and plateaued thereafter. Both the muscular (48+/-5%) and articular (52+/-5%) factors contributed almost equally to the overall progression of the contracture.

CONCLUSION

The present findings may shed light on the underlying pathophysiology of contractures and should help guide research towards finding the elucidation of contracture development after SCI.