Neuro posturing vs. contractures

[anon456, BSN, RN]

I am an RN at a children's hospital and I work on a floor that specializes in trach/vent kids. We get a lot of total care kiddos with stable brain injuries. I see kids who have horrible, severe contractions and hip subluxations, scoliosis so severe it impacts their lung expansion, and they are hard to position and change and care for because they are so stuck. Their limbs are usually folded up and in towards their bodies and their joints are hard to extend out. I always assumed this was because they had not received proper therapy with braces, stretching and other interventions to prevent this from happening. I say this because we have other kids who come in and they are hypotonic, not contracted at all, are so floppy we have to be very careful when flipping and turning them for diaper changes and positioning that the top leg won't drop agains the bottom leg and cause injury, and they also are months to years post injury.

Recently we've had a few patients who are stuck in the decorticate or decerebrate posturing and it's different than contractures. My patient last night was so bad, I could not even visualize the armpits during the bath or barely put my finger in that space to bathe them, the arms were stuck straight at their sides and could not be moved in any direction. We had a hard time getting the shirt off from when they were admitted. The legs were also stiff and straight with foot drop and not able to bend at the hips or knees, feet rotated out and thighs turned out also. This patient had an anoxic brain injury years earlier. I also had an infant just 2 months post TBI who had similar posturing and they did not have time to develop that stiffness from lack of braces/stretches. It was clearly neuro causing them to be so stiff. I could turn this patient on their side and they would remain stiff as a board. No blink reflex or anything either.

Can someone explain what causes some patients to be hypotonic, hypertonic, or the stiff positioning of the last patients I described? Are patients who have the neuro posturing just stuck in that position, or can they be improved with time, meds, or therapy??

Thanks