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doi: 10.2522/ptj.20100265Originally published online December 2, 2010

2011; 91:11-24.PHYS THER.Owen M. Katalinic, Lisa A. Harvey and Robert D. HerbertNeurological Conditions: A Systematic ReviewPrevention of Contractures in People WithEffectiveness of Stretch for the Treatment and

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Effectiveness of Stretch for the

Treatment and Prevention ofContractures in People WithNeurological Conditions:A Systematic ReviewOwen M. Katalinic, Lisa A. Harvey, Robert D. Herbert

Background. Contractures are a disabling complication of neurological condi-tions that are commonly managed with stretch.

Objective. The purpose of this systematic review was to determine the effective-ness of stretch for the treatment and prevention of contractures. The review is partof a more-detailed Cochrane review. Only the results of the studies including patients

with neurological conditions are reported here.

Data Sources. Electronic searches were conducted in June 2010 in the followingcomputerized databases: Cochrane CENTRAL Register of Controlled Trials, Databaseof Abstracts of Reviews of Effects (DARE), Health Technology Assessment Database(HTA), MEDLINE, Cumulative Index to Nursing and Allied Health Literature(CINAHL), EMBASE, SCI-EXPANDED, and Physiotherapy Evidence Database (PEDro).

Study Eligibility Criteria. The review included randomized controlled trials

and controlled clinical trials of stretch applied for the purposes of treating orpreventing contractures in people with neurological conditions.

Study Appraisal and Synthesis Methods. Two reviewers independentlyselected studies, extracted data, and assessed risk of bias. The primary outcomemeasures were joint mobility (range of motion) and quality of life. Secondary out-come measures were pain, spasticity, activity limitation, and participation restriction.Meta-analyses were conducted using random-effects models.

Results. Twenty-five studies met the inclusion criteria. These studies providemoderate-quality evidence that stretch has a small immediate effect on joint mobility(mean difference3, 95% confidence interval [CI]0 to 5) and high-quality evi-

dence that stretch has little or no short-term or long-term effects on joint mobility(mean difference1 and 0, respectively, 95% CI0 to 3 and 2 to 2, respec-tively). There is little or no effect of stretch on pain, spasticity, and activity limitation.

Limitations. No studies were retrieved that investigated the effects of stretch forlonger than 6 months.

Conclusion. Regular stretch does not produce clinically important changes injoint mobility, pain, spasticity, or activity limitation in people with neurologicalconditions.

O.M. Katalinic, BAppSc(Physio-therapy), is Physiotherapist, Reha-bilitation Studies Unit, NorthernClinical School, Sydney Medical

School, University of Sydney, Syd-ney, New South Wales, Australia.This systematic review was donein partial fulfillment of the require-ments for Mr Katalinics Master ofPhilosophy (MPhil) degree, Syd-ney Medical School, University ofSydney.

L.A. Harvey, BAppSc(Physio-therapy), GradDipAppSc(ExSpSc),MAppSc(Physiotherapy), PhD, isAssociate Professor, RehabilitationStudies Unit, Northern ClinicalSchool, Sydney Medical School,University of Sydney, PO Box 6Ryde, New South Wales, 2112,Australia. Address all correspon-dence to Dr Harvey at: [email protected].

R.D. Herbert, BAppSc(Physio-therapy), MAppSc(ExSpSc), PhD,is Associate Professor, Musculo-skeletal Division, The George Insti-tute for Global Health, Sydney,New South Wales, Australia.

[Katalinic OM, Harvey LA, HerbertRD. Effectiveness of stretch for thetreatment and prevention of con-

tractures in people with neuro-logical conditions: a systematic re-view. Phys Ther. 2011;91:1124.]

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Contractures are a commoncomplication of neurologicalconditions such as stroke, spi-

nal cord injury, traumatic brain in-jury, and cerebral palsy.1 They are

characterized by a reduction in jointmobility and an increase in resis-tance to passive joint movement.1,2

Contractures are due to neural andnon-neural factors, including spastic-ity and structural changes in softtissues.3 Spasticity is characterized

by an increased resistance to passivejoint movement due to involuntarymuscle contraction. Contracturescan result in deformities, pain, andskin breakdown and may restrict ac-tivity and participation.2,47 For

these reasons, the treatment and pre-vention of contractures are impor-tant goals of therapy for people with

neurological conditions.

Stretch is widely used to treat andprevent contractures (as defined bythe International Classification of

Functioning, Disability and

Health8).*,913 Stretch can be self-administered, applied manually bytherapists, or administered with po-

sitioning programs, splints, or serialcasts. The duration of stretch variesdepending on how it is applied. Forexample, stretch administered man-ually is applied for a few minutes aday, whereas stretch administeredthrough serial casts is applied contin-uously for days or weeks at a time.

Any stretch induces a transient in-crease in tissue extensibility. This in-crease is due to viscous deformation

and quickly dissipates with the re-moval of the stretch.1418 Contrac-

ture management requires more-lasting changes in tissue extensibility.Evidence from animal studies sug-gests that contracture managementcan be achieved through repeated orsustained stretch (over days, weeks,or months). For example, 4 weeks of

sustained stretch in cat soleus mus-cles results in tissue remodeling andspecifically an increase in the num-ber of sarcomeres in series.19 Nostudy on humans has investigatedthe effect of stretch on sarcomere

numbers. However, many studies onhumans have investigated the effectsof stretch on joint mobility and range

of motion.

This systematic review is part of amore-detailed Cochrane review in-

vestigating the effectiveness ofstretch for the treatment and preven-tion of contractures in all types ofparticipants, including those withcontractures following trauma or dis-

ease processes.20

The results of thestudies including participants withneurological conditions are reportedhere. The purpose of this systematicreview, therefore, was to determinethe effectiveness of stretch for con-tracture management in people withneurological conditions. The pri-mary objective was to determine

whether stretch increases joint mo-bility or quality of life. The secondaryobjective was to determine the ef-fects of stretch on pain, spasticity,activity limitation, and participationrestriction.

MethodData SourcesComputerized databases were origi-nally searched in April 2009 for theCochrane review and then updatedin May and June 2010 for this publi-cation. The included databases were:Cochrane CENTRAL Register of Con-

trolled Trials, Database of Abstractsof Reviews of Effects (DARE), HealthTechnology Assessment Database

(HTA; Wiley Interscience; May2010), MEDLINE (OVID; 1950 to

May 2010), Cumulative Index toNursing and Allied Health Literature(CINAHL; EBSCOhost; 1982 to May2010), EMBASE (OVID; 1980 to May2010), SCI-EXPANDED (ISI Web ofKnowledge; 1900 to May 2010), andPhysiotherapy Evidence Database

(PEDro; www.pedro.org.au; June2010). The electronic searches werecomplemented with a search of clin-ical trial registers and of the refer-ence lists of included studies and rel-evant systematic reviews (for full

search strategies, see the Cochranereview20). Forward citation trackingof included studies also was used to

search for additional studies usingthe ISI Web of Knowledge. Authorsof included studies were contactedfor additional studies and unpub-lished data where necessary andpossible.

Study Eligibility CriteriaStudies were included if they were

published or unpublished random-ized controlled trials or controlledclinical trials that measured joint mo-bility (reported in any language).They could use parallel-group, within-subjects, or crossover designs. Par-ticipants could be of any age or ei-ther sex, provided they had existingcontractures or were at risk of devel-

oping contractures. Only studies in-cluding participants with neurologi-cal conditions were eligible for thisreview.

Studies were included if stretch wascompared with no stretch or withsham stretch. Studies with a cointer-

vention (eg, botulinum toxin) were

included if the cointervention wasthe same for the treatment and con-trol groups. Stretch interventionscould include sustained passivestretch, positioning, splinting, serialcasting, or any other manual stretch

* See www.physiotherapyexercises.com formore than 100 examples of stretches typicallyprescribed by physical therapists.

Available WithThis Article atptjournal.apta.org

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This article was published ahead ofprint on December 2, 2010, atptjournal.apta.org.

Stretch for Contracture in Neurological Conditions

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technique aimed at maintaining orincreasing the mobility of any syno-

vial joint. To be included, the stretch

needed to sustain the soft tissues ina lengthened position for at least 20

seconds on more than one occasion.Studies were excluded if the inter-vention involved oscillating a jointthrough range. For example, studiesof joint mobilization, joint manipula-tion, continuous passive motion, pas-sive movements, and active move-

ments were excluded. Studies wereexcluded where 2 types of stretch

were compared with each other orwhere stretch was compared withan active intervention.

Study Appraisal and SynthesisMethodsTwo authors independently ex-

tracted data and assessed the qualityof the evidence using precon-structed forms. The following data

were extracted: information aboutstudy design, inclusion and exclu-sion criteria, characteristics of theparticipants, details of the interven-tions, and results of the outcomemeasures. The risk of bias in each

study was assessed using CochraneRisk of Bias tables.21 Each study wasrated on 8 domains: sequence gener-ation; allocation concealment; blind-ing of participants, therapists, andoutcome assessors; incomplete data;selective outcome reporting; andother potential threats to validity. Inaddition, the pooled evidence about

the effectiveness of stretch on jointmobility was rated according toGRADE on a 4-point scale (high, me-dium, low, and very low).2225

GRADE uses set criteria that take intoaccount factors such as the consis-tency of results across studies, theprecision of estimates, and the sus-ceptibility to publication bias. Dis-

agreements in ratings were resolvedby discussion or, where necessary,arbitrated by the third author.

Measures of treatment effect wereextracted for primary and secondary

outcomes. The primary outcomemeasures were joint mobility (essen-tial for inclusion) and quality of life.

Torque-controlled measures of jointmobility were extracted in prefer-

ence to all other joint mobility mea-sures. If torque-controlled measureswere not reported, passive joint mo-bility measures were given the nextorder of preference. If passive jointmobility measures were not reported,active joint mobility measures were

extracted. The secondary outcomesof interest were pain (eg, visualanalog scale scores), spasticity (eg,Tardieu scale or modified Ashworthscale scores), activity limitation (eg,Functional Independence Measure

or Motor Assessment Scale scores),and participation restriction (eg, re-turn to work). Measures of treatment

effect were extracted for 3 timeframes: immediate (ie, effects presentless than 24 hours after the laststretch was ceased), short-term (ie,effects present between 24 hoursand 1 week after the last stretch wasceased), and long-term (ie, effectspresent more than 1 week after thelast stretch was ceased).

Analysis of covariance-adjustedbetween-group means and standarddeviations were extracted in prefer-

ence to between-group differencesin change scores, and between-

group differences in change scoreswere extracted in preference tobetween-group differences in finalscores. If studies reported data asmedians and interquartile ranges(IQRs), medians were used as a sur-rogate for means and standard devi-

ations were estimated as 80% ofthe IQR. Differences in the data ex-tracted by the 2 review authors wereresolved by discussion and, whennecessary, arbitrated by the third au-thor. Study authors were contacted

when there was incomplete report-ing of data.

Meta-analysis using a random-effectsmodel was considered when there

were at least 2 clinically homoge-nous studies (studies that investi-gated the effect of similar interven-tions on similar populations andreported similar outcomes). ReviewManager 526 was used for the pri-mary data analysis. Data were pooled

The Bottom Line

What do we already know about this topic?

It is widely believed that regular stretch is effective for the treatment and

prevention of contractures. Anecdotal evidence, single-case studies, case

reports, and nonrandomized trials support the ongoing use of stretch.

What new information does this study offer?

This review of randomized trials shows that programs of stretch, as

typically applied, have little or no effect on joint range of motion when

applied for less than 7 months. The effects of longer-duration programs of

stretch are not known.

If youre a patient, what might these findings meanfor you?

People with contractures or who are at risk for contractures are unlikely

to benefit from programs of stretch applied for less than 7 months.





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only if the I2 statistic (a measure ofhomogeneity) was less than 50%. IfI2 was greater than 50%, possible

causes of heterogeneity were ex-plored in sensitivity analyses. Indi-

vidual studies were omitted one at atime, stratified by particular charac-teristics or, where appropriate, ana-

lyzed with meta-regression. The sen-sitivity analyses examined the effectsof randomization (adequate versus

inadequate sequence generation),concealed allocation (concealed ver-sus nonconcealed allocation), asses-sor blinding (blinding versus noblinding), and completeness of data

reporting (complete versus incom-plete reporting of outcome data).

ResultsStudy Selection andCharacteristicsThe searches identified 11,393 refer-ences, of which 3,876 were dupli-

Figure 1.

Flow of studies through the review process. CCTclinical controlled trial, RCTrandomized controlled trial.





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Table

1.

DetailsofIncludedStudiesa

Study

Participants

StudyDetails

n

Details

Groups

StretchDosage

Design

Outcom

es

b

Stroke

Adaetal,28

2005

Exp18

Con18

Adultswithstroke

1.Two30-minsessionsofshoulder

positioningu

pto10minof

shoulderexercisesandroutine

upper-limbcare

2.Upto10mino

fshoulder

exercisesandro

utineupper-limb

care

2

30min

5d4wk

Randomizedparallel

groupstudy

Maximum

passiveshoulderexternal

rotationoftheaffectedlimb()

Painexperienceddurin

gmaximal

externalrotation(ye

s/no)

Item

6MotorAssessmentScale

(limits:0worse;6

better)

Burgeetal,30

2008

Exp31

Con16

Adultswithstroke

1.Wristorthosis

conventional

care

2.Conventionalcare

Notspecified

Randomizedparallel

groupstudy

WristROM

(Fugl-Meye

rAssessment

subscale)

Pain(VAS)

ModifiedAshworthScale

deJongetal,32

2006

Exp10

Con9

Adultswithstroke

1.Upper-limbpos

itioning

conventionalca

re

2.Conventionalcare

2

30min

5d510wk

Randomizedparallel

groupstudy

Passiveshoulderabduction()

Pain(yes/no)

Spasticity(Ashworthscale)

Arm

motorperformance(Fugl-Meyer

Assessment)

Deanetal,33

2000

Exp14

Con14

Adultswithstroke

1.Three20-minsessionsof

shoulderpositio

ning

conventionalca

re

2.Conventionalcare

3

20min

5d6wk

Randomizedparallel

groupstudy

Passiveshoulderextern

alrotation()

Painatrest(VAS)

Gustafssonetal,35

2006

Exp17

Con17

Adultswithstroke

1.Two20-minsessionsofshoulder

positioningand

ashoulder

positioningprogram

conventionalca

re

2.Conventionalcare

2

20min

Remainderoftheday

inapositioning

program

foran

averageof30d

Randomizedparallel

groupstudy

Passiveshoulderextern

alrotation()

Hemiplegicshoulderp

ainatrestover

previous24h(VAS)

Functionalindependen

ce(Modified

BarthelIndex)

Horsleyetal,40

2007

Exp20

Con20

Adultswithstroke

orstroke-like

braininjury

1.Upper-limbstre

tch

usualcare

2.Usualcare

30min

5d4wk

Randomizedparallel

groupstudy

Passivewristextension

()

Painatrestatthetime

oftesting(VAS)

Upper-limbactivity(co

mpositeof3

itemsofMotorAssessmentScale)

Laietal,42

2009

Exp15c

Con15c

Adultswithstroke

1.Elbowextensionsplint

botulinum

toxin

andtherapy

2.Botulinum

toxin

andtherapy

68h

7d14wk

Randomizedparallel

groupstudy

MaximalactiveROM(

elbowextension)

ModifiedAshworthScale(extension

score)

Lanninetal,43

2003

Exp17

Con11

Adultswithstroke

orbraininjury

1.Palmarrestingmittsplint

stretch

2.Stretch

12h

7d4wk

Randomizedparallel

groupstudy


()

Upper-limbpain(VAS)

Upper-limbactivity(co

mpositeof3

itemsofMotorAssessmentScale)

Lanninetal,44

2007

Exp21

Group22

1

Con21

Adultswithstroke

1.Wristextension

splint

2.Nosplint

12h

7d4wk

Randomizedparallel

groupstudy


()

Pain(DASHpainsever

ityitem)

Spasticityangle(Tardieuscale)

DASH

(Continued)





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Table

1.

Continued S

tudy

Participants

StudyDetails

n

Details

Groups

StretchDosage

Design

Outcom

es

b

Sheehanetal,50

2006

Exp6

Con8

Adultswithstroke

1.Restingwristsp

lint2ndweekto

7thweek

2.Restingwristsp

lint3rdweekto

7thweek

8h7d1wk

Randomizedparallel

groupstudy

Resistance(N)at20o

fextension

TurtonandBritton,5

1

2005

Exp14

Con15

Adultswithstroke

1.Two30-minsessionsofupper-

limbpositioning

usualcare

2.Usualcare

2

30min

7d12wk

Randomizedparallel

groupstudy


oftheaffected

arm

()

Spinalcordinjury

Benetal,29

2005

Exp20leg

s

Con20legs

Adultswithspinal

cordinjury

1.Weight-bearing

andanklestretch

2.Nonweightbe

aringandnon-

stretch

30min

3d12wk

Randomizedwithin-

subjectsstudy

Passiveankledorsiflexionat

standardizedtorque

()

Croweetal,31

2000

Exp18

Con21

Adultswithspinal

cordinjury

1.Shoulderpositioning

conventionalca

re

2.Conventionalcare

45min

5d216wk

Randomizedparallel

groupstudy

Passiveshoulderabduction,rightarm

()

Painduringpreceding

24h,right

shoulder(VAS)

FunctionalIndependen

ceMeasure

DiPasquale-

Lehnerz,3

4

1994

Exp7

Con6

Adultswithspinal

cordinjury

1.Positionalortho

sis(hand)

rehabilitation

2.Rehabilitation

8h7d12wk

Randomizedparallel

groupstudy

Passivemetacarpophalangealjoint

extension

JebsenHandTestsubitem

simulated

feeding(s)

Harveyetal,36

2000

Exp14leg

s

Con14legs

Adultswithspinal

cordinjury

1.Anklestretch

2.Noanklestretch

30min

57d

4wk

Randomizedwithin-

subjectsstudy

Ankleangleat10Nm

oftorquewith

thekneeextended(

)

Harveyetal,37

2003

Exp16leg

s

Con16legs

Adultswithspinal

cordinjury

1.Hamstringmusclestretch

2.Nohamstringm

usclestretch

30min

5d4wk

Randomizedwithin-

subjectsstudy

Hipflexionat30Nm

oftorque()

Braininjury

Hill,39

1994

Exp8c

Con7c

Adultswithbrain

injury

1.Serialcastingoftheelbowor

wristfollowedb

ytherapy

2.Therapyfollowe

dbyserial

castingofthee

lboworwrist

24h

7d4.3wk

Randomizedcross-

overstudy

UnidirectionaljointpassiveROM

()

Jointangleatwhichst

retchreflex

elicited()

Observationofperform

anceof

functionaltasks

Moseley,4

7

1997

Exp5

Con5

Adultswith

traumaticbrain

injury

1.Short-legcastd

2.Nocastd

24h

7d

Randomizedcross-

overstudy

Passiveankledorsiflexion()

Mixed

Harveyetal,38

2006

Exp30

thumbs

Con30

thumbs

Adultswith

stroke,spinal

cordinjury,or

traumaticbrain

injury

1.Thumbsplint

2.Nosplint

8h7d12wk

Randomizedwithin-

subjectsand

parallelgroup

study

Palmarabductionofth

ethumb

carpometacarpaljoint()

Effectofthesplintingregimenonself-

selectedgoals(Cana

dianOutcome

PerformanceMeasure)

(Continued)





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Table

1.

Continued S

tudy

Participants

StudyDetails

n

Details

Groups

StretchDosage

Design

Outcom

es

b

Cerebralpalsy

Ackmanetal,27

2005

Exp13

Con12

Childrenwith

cerebralpalsy

1.Botulinum

toxin

cast

2.Botulinum

toxin

24h

7d9wk

Randomizedparallel

groupstudy

Passiveankledorsiflexionwithknee

extended()

Tricepssuraemusclespasticity

(Ashworthscale)

Lawetal,45

1991

Exp19c

Con18c

Childrenwith

cerebralpalsy

1.IntensiveNDT

short-arm

cast

2.IntensiveNDT

4h7d26wk

Randomizedparallel

groupstudy

WristROM

(scalenotreported)

PeabodyFineMotorScale

McNeeetal,46

2007

Exp5

Con4

Childrenwith

cerebralpalsy

1.Short-legcastd

2.Nocastd

24h

7d34wk

Randomizedcross-

overstudy

Passiveankledorsiflexionwithknee

extended()

NormalcyIndexforwalking

Charcot-Marie-Tooth

disease

Refshaugeetal,48

2006

Exp14leg

s

Con14legs

Children

young

adultswith

Charcot-Marie-

Toothdisease

1.Nightsplint(an

kle)d

2.Nonightsplintd

49h

7d6wk

Randomizedwithin-

subjectscross-

overstudy

Passiveankledorsiflexion()

Roseetal,49

2010

Exp15

Con15

Children

young

adultswith

Charcot-Marie-

Toothdisease

1.Below-kneenightcast

ankle

stretch

2.Nointervention

Weeks14:

8h7d4wk

Weeks58

3

2min

7d4wk

Randomizedparallel

groupstudy

Ankledorsiflexion()(lungetest)

Preferredwalkingspee

d(m/s)

Duchennemuscular

dystrophy

Hydeetal,41

2000

Exp15

Con12

Childrenwith

Duchenne

muscular

dystrophy

1.Below-kneenightsplint

passivestretch

2.Passivestretch

Nightsplinttimenot

reported

Randomizedparallel

groupstudy

Achillestendoncontracture

MotorAbilityScale

a

Expexperimentalgroup,Concontrol

group,ROMrangeofmotion,VASvisualana

logscale,DASHDisabilitiesoftheArm,Should

er,andHandOutcomeMeasure,NDTneurod

evelopmental

therapy.

b

Outcomeslistedinthetablearethesubsetofstudyoutcomesthatwerewithinthescopeofthisreview.

c

Numberofparticipantsanalyzedbythe

studyauthors(thesenumbersdonotincludedropouts).Authorsdidnotreportthesizeofthe

groupallocationsatbaseline.

d

Detailsofthefirstcross-overperiodonly

.





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cates (Fig. 1). After screening titlesand abstracts, 102 studies were iden-tified as potentially eligible. Afterinspecting the full reports, 36 studies

were included and 66 were ex-cluded. Twenty-five studies with atotal of 812 participants investigated

the effects of stretch in people withneurological conditions (Tab. 1).2751

An additional 11 studies investigat-ing the effects of stretch in people

with non-neurological conditions arereported in the full Cochrane re-

view.20 The updated search in Mayand June 2010 identified one addi-tional study not included in the orig-inal Cochrane review.49 The additionof this study explains the very smalldiscrepancies between the resultsof the Cochrane review and this

publication.

The 25 studies of people with neu-rological conditions investigated theuse of stretch in people with stroke,spinal cord injury, Duchenne muscu-

lar dystrophy, traumatic brain injury,cerebral palsy, and Charcot-Marie-Tooth disease. Stretch was pro-

vided passively (self-administered,therapist-administered, and device-administered) and included position-ing, splinting, and serial casting. The

stretch dosage was variable, rangingfrom 30 minutes to 24 hours per day(median390 minutes, IQR41720) for between 7 days and 6months (median 30days, IQR2260). The total cumulative time that

Table 2.Methodological Quality Summary (Risk of Bias)a

Study

Adequate

Sequence

Generation?

Allocation

Concealment?

Blinding

(Participants)?

Blinding

(Therapists)?

Blinding

(Assessors)?

Incomplete

Outcome

Data

Addressed?

Free of

Selective

Reporting?

Free

of

Other

Bias?

Ackman et al,27 2005 ? ? N N Y Y Y N

Ada et al,28 2005 Y Y N N Y Y Y Y

Ben et al,29 2005 Y Y N N Y Y Y Y

Burge et al,30 2008 Y Y N N Y Y N Y

Crowe et al,31 2000 Y Y N N Y ? N N

de Jong et al,32 2006 Y Y N N Y N N N

Dean et al,33 2000 Y Y N N Y N Y Y

DiPasquale-Lehnerz,34

1994

? ? N N ? N N Y

Gustafsson et al,35

2006

Y Y N N N Y Y ?

Harvey et al,36 2000 Y Y N N Y Y Y Y

Harvey et al,37 2003 Y Y N N Y Y Y Y

Harvey et al,38 2006 Y Y N N Y Y ? Y

Hill,39 1994 N N N N Y N N Y

Horsley et al,40 2007 Y Y N N Y Y Y Y

Hyde et al,41 2000 Y ? N N Y N N Y

Lai et al,42 2009 ? ? N N ? N Y ?

Lannin et al,43 2003 Y Y N N Y Y Y Y

Lannin et al,44 2007 Y Y N N Y Y Y Y

Law et al,45 1991 ? ? N N Y Y N N

McNee et al,46 2007 ? ? N N ? ? ? N

Moseley,47 1997 ? ? N N N Y Y Y

Refshauge et al,48

2006

Y N N N Y Y Y Y

Rose et al,49 2010 Y Y N N Y Y Y Y

Sheehan et al,50 2006 Y Y N N Y Y Y Y

Turton and Britton,51

2005

Y Y N N Y N N N

aYyes (low risk of bias), Nno (high risk of bias), ?unclear (either lack of information or uncertainty over the potential for bias).





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stretch was administered rangedfrom 8 to 1,512 hours (median227

hours, IQR22672). Joint mobilitywas reported in all included studies,but quality of life was reported innone. Pain was reported in 9 stud-ies,28,3033,35,40,43,44 spasticity was re-ported in 6 studies,27,30,32,39,42,44 ac-tivity limitation was reported in 13studies,28,31,32,34,35,39 41,4346,49 andparticipation restriction was re-

ported in 1 study.38

Quality of the EvidenceThe risk of bias in the 25 studies ofpeople with neurological conditions

was variable (Tab. 2). There was riskof bias associated with failure to use

adequate methods to generate therandomization sequence (28% ofstudies), failure to conceal allocation(36% of studies), failure to blind as-sessors (20% of studies), and inade-quate follow-up (36% of studies). Re-sults from all studies were includedin the main analyses regardless ofquality. When lower-quality studies

were excluded in the sensitivity anal-yses, there was no or little change inthe estimates of the effect of stretch.

Effect of Stretch on Joint MobilityThe immediate, short-term, and

long-term effects of stretch on jointmobility each were investigatedby pooling the data from 10studies,28,32,33,35,4244,4749 6 stud-ies,29,3638,40,51 and 7 stud-ies,27,35,36,40,43,44,46 respectively. Thereis moderate-quality evidence (ac-cording to the GRADE criteria) thatstretch has a small immediate effect

on joint mobility (Fig. 2; mean differ-ence3, 95% CI0 to 5; I241%;

P.04). There is high-quality evi-dence (according to the GRADE cri-teria) that stretch has little or no

Figure 2.Forest plot of mean difference with 95% confidence interval (CI) for immediate effects of stretch on joint mobility.IVinverse variance.





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short-term or long-term effect onjoint mobility (Figs. 3 and 4; meandifference1, 95% CI0 to 3;I235%; P.12 and mean differ-ence0, 95% CI2 to 2; I20%;

P.73, respectively).

Effects of Stretch on PainThe immediate effects of stretch on

pain were investigated by poolingdata from 4 studies.31,35,43,44 Thestandardized mean difference was0.2 standard deviation (95% CI0.1 to 0.6; I214%; P.23). Only

one study provided sufficient datato investigate the short-term effectsof stretch on pain (ie, pain present1 week after the cessation ofstretch).40 The mean difference was0.2 cm on a 10-cm visual analog scale(95% CI1.0 to 1.4; P.73). Thelong-term effects of stretch on pain

were investigated by pooling the

data from 4 studies.35,40,43,44 Thestandardized mean difference was0.0 standard deviation (95% CI0.4 to 0.5; I238%; P.90).

Effects of Stretch on SpasticityThe immediate effects of stretch on

spasticity were investigated by pool-ing the data from 4 studies.30,32,42,44

The standardized mean differencewas 0.1 standard deviation (95%CI0.3 to 0.5; I20%; P.69). The

long-term effects of stretch on spas-ticity were investigated by poolingthe data from 2 studies.27,44 The stan-dardized mean difference was 0.3standard deviation (95% CI0.9to 0.4; I228%; P.41). No study

Figure 3.Forest plot of mean difference with 95% confidence interval (CI) for short-term effects of stretch on joint mobility.IVinverse variance.





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measured the short-term effects ofstretch on spasticity.

Effects of Stretch on ActivityLimitation and ParticipationRestrictionThe immediate effects of stretch onactivity limitation were investigatedby pooling the data from 6 stud-ies.28,35,4345,49 The standardized meandifference was 0.1 standard devia-tion (95% CI0.2 to 0.5; I242%;

P.48). Only 1 study provided suffi-

cient data to investigate the short-term effects of stretch on activitylimitation.40 The mean difference

was 2 points on an 18-point scale(95% CI0 to 4; P.11). The long-

term effects of stretch were investi-gated by pooling the data from 6studies.35,40,4346 The standardizedmean difference was 0.2 standard

deviation (95% CI0.1 to 0.6;I225%; P.19). The effects ofstretch on participation could not bedetermined in any study.

Discussion and ConclusionsThe aim of this systematic review

was to determine the effects ofstretch in people with neurological

conditions. The primary outcomemeasures were joint mobility andquality of life. Secondary outcomemeasures were pain, spasticity, activ-ity limitation, and participation re-

striction. The results of this reviewindicate that stretch does not haveclinically important effects on jointmobility in people with or at risk of

contractures. There is little or no ef-fect of stretch on pain, spasticity,or activity limitation in people

with neurological conditions. Con-clusions could not be made aboutthe effects of stretch on quality of lifeor participation restriction.

Estimates from high-quality studies

indicate there were little or no short-term or long-term effects of stretchon joint mobility (mean differ-ence1 and 0, respectively, 95%CI0 to 3 and 2 to 2, respec-

Figure 4.Forest plot of mean difference with 95% confidence interval (CI) for long-term effects of stretch on joint mobility.IVinverse variance.





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tively). The precision around bothestimates indicates that any possibletreatment effect is not greater than

3 degrees. Few authors considered atreatment effect as small as 3 degrees

to be clinically important.33,35,48,49

Estimates from moderate-qualitystudies indicate that stretch has asmall immediate effect on joint mo-bility (mean difference3, 95%CI0 to 5, P.04). Although thiseffect is statistically significant, the

immediate effects of stretch areprobably due to viscous deformationand, therefore, are likely to be tran-sient.5,52 Transient effects of stretchare not intrinsically useful for thetreatment and prevention of

contractures.

It is possible that the effectiveness of

stretch is dependent on the dosageof stretch and how stretch is admin-istered. This possibility was exam-ined in a number of meta-regressionanalyses not reported in this articlebut performed as part of the Co-chrane systematic review. They indi-cated that increasing the dosage ofstretch did not increase joint mobil-

ity and that there was no evidenceany particular type of stretch in-tervention was superior to others.The results of these meta-regressionsshould be interpreted with cautionfor 2 reasons. First, they combine theresults of neurological and non-neurological populations. Second,they are based on nonrandomized

between-study comparisons ratherthan randomized within-studycomparisons.

A common source of bias in system-atic reviews is the failure to identifyall relevant studies (ie, retrieval bias).Despite our best efforts, potentiallyeligible studies may have been

missed. Nonetheless, the main find-ings of this review probably are ro-bust because retrieval bias typicallyincreases estimates of effects53,54 andmost estimates of effects in this re-

view are very small. Another source

of bias in this systematic review mayhave been introduced because someof the authors of this systematic re-

view were authors of randomizedcontrolled trials included in the re-

view. To address this issue, reviewauthors did not extract data or assessrisk of bias on studies in which theyhad been involved.

The findings of this systematic re-view are broadly consistent with the

findings of other systematic reviews,once methodological issues are takeninto account. Two systematic re-

views reported immediate effects ofstretch on joint mobility.55,56 Theseeffects most likely reflect viscous de-

formation of soft tissues. Not sur-prisingly, systematic reviews thatincluded nonrandomized studies

tended to report more positive re-sults and concluded that stretch waseffective in increasing joint mobili-ty.5759 In addition, these systematicreviews did not distinguish betweenimmediate and lasting effects ofstretch. The most plausible reasonsfor the discrepancies between ourresults and those reviews could be

viscous deformation of soft tissuesand bias from inclusion of nonran-domized studies. A number of sys-tematic reviews examined the long-term effects of stretch, and allconcluded either that there is insuf-ficient evidence or that the exist-ing evidence is inconclusive.913,55,60

One recent systematic review used

meta-analysis to estimate the effectsof stretch for improving joint mobil-ity after stroke.61 Although that re-

view did not distinguish between theimmediate and lasting effects ofstretch, the authors concluded thatstretch did not improve joint mobil-ity or upper-limb function. Thesefindings are in agreement with the

findings of our review.

The studies included in this reviewcompared a stretch intervention withno intervention. However, in allstudies, participants in both groups

continued to receive usual care withor without other cointerventions(eg, botulinum toxin). Usual care

was rarely defined but may have in-volved the application of regular

stretch as part of participants activeand daily routines. For example, itmay have involved careful position-ing of feet in a wheelchair or bed. Itcannot be concluded, therefore, thatstretch applied as part of daily rou-tines or as part of other aspects of

rehabilitation has no therapeutic ef-fect, nor can it be ruled out thatstretch administered over very ex-tended periods of time (ie, years) isineffective for the treatment or pre-

vention of contracture, as no study

examined the effect of stretch ad-ministered for more than 6 months.Nonetheless, it is disconcerting that

the results of this systematic reviewindicate no added benefit fromstretch as typically applied by thera-pists. These results challenge long-held beliefs about contracture man-agement and stretch. They indicatethat stretch as typically administeredby therapists may not be a suffi-ciently potent stimulus to trigger tis-

sue remodeling. Interestingly, the re-sults from populations withoutneurological conditions are remark-ably similar.20 These findings indi-cate a pressing need for reappraisalof effective contracture manage-ment and current clinical practiceguidelines.

All authors provided concept/idea/researchdesign, writing, and data collection andanalysis. Mr Katalinic and Associate ProfessorHarvey provided project management andconsultation (including review of manuscriptbefore submission). Associate Professor Har-vey provided facilities/equipment and insti-tutional liaisons. The authors acknowledgethe contributions of Anne Moseley, NatashaLannin, and Karl Schurr as coauthors of theCochrane review. They also acknowledgethe assistance of Joanne Glinsky in preparingthe manuscript.

This is a version of a Cochrane review, whichis available in The Cochrane Library, 2010,issue 9 (see www.thecochranelibrary.com





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for information). A more-detailed review ispublished and updated in the CochraneDatabase of Systematic Reviews.19 The re-sults of a Cochrane reviewcan be interpreteddifferently, depending on peoples perspec-tives and circumstances. Please considerthe conclusions presented carefully. Theyare the opinions of review authors andare not necessarily shared by The CochraneCollaboration.

An oral presentation of this research wasgiven at the Australian Physiotherapy Asso-ciation Conference; October 15, 2009; Syd-ney, New South Wales, Australia.

This article was submitted August 13, 2010,and was accepted September 26, 2010.

DOI: 10.2522/ptj.20100265

References1 Fergusson D, Hutton B, Drodge A. The

epidemiology of major joint contractures:a systematic review of the literature. ClinOrthop Relat Res. 2007;456:2229.

2 Fox P, Richardson J, McInnes B, et al. Ef-fectiveness of a bed positioning programfortreating older adults with knee contrac-tures who are institutionalized. Phy Ther.2000;80:363372.

3 Lieber RL, Steinman S, Barash IA, Cham-bers H. Structural and functional changesin spastic skeletal muscle. Muscle Nerve.2004;29:615627.

4 Harvey L, Herbert R, Crosbie J. Doesstretching induce lasting increases in jointROM: a systematic review. Physiother Res

Int. 2002;7:113.5 Mollinger LA, Steffen TM. Knee flexion

contractures in institutionalized elderly:prevalence, severity, stability, and related

variables. Phys Ther. 1993;73:437444.

6 Scott JA, Donovan WH. The prevention ofshoulder pain and contracture in the acutetetraplegia patient. Paraplegia. 1981;19:313319.

7 Yarkony GM, Bass LM, Keenan V III, MeyerPR Jr. Contractures complicating spinalcord injury: incidence and comparisonbetween spinal cord centre and generalhospital acute care. Paraplegia. 1985;23:265271.

8 International Classification of Function-ing, Disability and Health: ICF. Geneva,

Switzerland: World Health Organization;2001.

9 Blackmore AM, Boettcher-Hunt E, JordanM, Chan MD. A systematic review of theeffects of casting on equinus in children

with cerebral palsy: an evidence report ofthe AACPDM. Dev Med Child Neurol.2007;49:781790.

10 BovendEerdt TJ, Newman M, Barker K,et al. The effects of stretching in spasticity:a systematic review. Arch Phys Med Reha-bil. 2008;89:13951406.

11 Lannin NA, Herbert RD. Is hand splintingeffective for adults following stroke: a sys-tematic review and methodologic critiqueof published research. Clin Rehabil. 2003;17:807816.

12 Lannin NA, Novak I, Cusick A. A system-atic review of upper extremity casting forchildren and adults with central nervoussystem motor disorders. Clin Rehabil.2007;21:963976.

13 Pin T, Dyke P, Chan M. The effectivenessof passive stretching in children with ce-rebral palsy. Dev Med Child Neurol. 2006;48:855862.

14 Bohannon RW. Effect of repeated eight-minute muscle loading on the angleof straight-leg raising. Phys Ther. 1984;64:491497.

15 Duong B, Low M, Moseley AM, et al. Timecourse of stress relaxation and recoveryin human ankles. Clin Biomech (Bristol,Avon). 2001;16:601607.

16 Magnusson SP, Simonsen EB, Aagaard P,et al. Viscoelastic response to repeated

static stretching in the human hamstringmuscle. Scand J Med Sci Sports. 1995;5:342347.

17 Magnusson SP, Simonsen EB, Aagaard P,Kjaer M. Biomechanical responses to re-peated stretches in human hamstring mus-cle in vivo. Am J Sports Med. 1996;24:622628.

18 Magnusson SP, Simonsen EB, Dyhre-Poulsen P, et al. Viscoelastic stress relax-ation during static stretch in human skel-etal muscle in the absence of EMG activity.Scand J Med Sci Sports. 1996;6:323328.

19 Tabary JC, Tabary C, Tardieu C, et al. Phys-iological and structural changes in thecats soleus muscle due to immobilizationat different lengths by plaster casts.

J Physiol. 1972;224:231244.20 Katalinic OM, Harvey LA, Herbert RD,

et al. Stretch for the treatment and preven-tion of contractures. Cochrane DatabaseSyst Rev. 2010;9:CD007455.

21 Higgins JP, Altman DG. Assessing risk ofbias in included studies. In: Higgins JP,Green S, eds. Cochrane Handbook forSystematic Reviews of Interventions. Vol5.0.2. The Cochrane Collaboration; 2009:

Available at: www.cochrane-handbook.org. Updated September 2009. AccessedOctober 14, 2010.

22 Atkins D, Best D, Briss PA, et al. Gradingquality of evidence and strength of recom-mendations. BMJ. 2004;328:1490.

23 Guyatt GH, Oxman AD, Kunz R, et al.What is quality of evidence and why isit important to clinicians? BMJ. 2008;336:995998.

24 Guyatt GH, Oxman AD, Vist G, et al.GRADE: an emerging consensus on ratingquality of evidence and strength of recom-mendations. BMJ. 2008;336:924926.

25 Schunemann HJ, Jaeschke R, Cook DJ,et al. An official ATS statement: gradingthe quality of evidence and strength ofrecommendations in ATS guidelines andrecommendations. Am J Respir Crit CareMed. 2006;174:605614.

26 Review Manager (RevMan) [computerprogram]. Copenhagen, Denmark: TheNordic Cochrane Centre, The CochraneCollaboration; 2008.

27 Ackman JD, Russman BS, Thomas SS, et al.Comparing botulinum toxin A with cast-ing for treatment of dynamic equinus inchildren with cerebral palsy. Dev MedChild Neurol. 2005;47:620 627.

28 Ada L, Goddard E, McCully J, et al. Thirtyminutes of positioning reduces the devel-opment of shoulder external rotation con-tracture after stroke: a randomized con-trolled trial. Arch Phys Med Rehabil. 2005;86:230234.

29 Ben M, Harvey L, Denis S, et al. Does 12weeks of regular standing prevent loss ofankle mobility and bone mineral density inpeople with recent spinal cord injuries?Aust J Physiother. 2005;51:251256.

30 Burge E, Kupper D, Finckh A, et al. Neu-tral functional realignment orthosis pre-

vents hand pain in patients with subacutestroke: a randomized trial. Arch Phys MedRehabil. 2008;89:18571862.

31 Crowe J, MacKay-Lyons M, Morris H. Amulti-centre, randomized controlled trialof the effectiveness of positioning onquadriplegic shoulder pain. PhysiotherCan. 2000;52:266273.

32 de Jong LD, Nieuwboer A, AufdemkampeG. Contracture preventive positioning ofthe hemiplegic arm in subacute stroke pa-tients: a pilot randomized controlled trial.Clin Rehabil. 2006;20:656667. Erratumin Clin Rehabil. 2010;24:767.

33 Dean CM, Mackey FH, Katrak P. Examina-tion of shoulder positioning after stroke: arandomised controlled pilot trial. Aust JPhysiother. 2000;46:3540.

34 DiPasquale-Lehnerz P. Orthotic interven-

tion for development of hand functionwith C-6 quadriplegia. Am J Occup Ther.1994;48:138 144.

35 Gustafsson L, McKenna K. A programmeof static positional stretches does not re-duce hemiplegic shoulder pain or main-tain shoulder range of motion: a random-ized controlled trial. Clin Rehabil. 2006;20:277286.

36 Harvey LA, Batty J, Crosbie J, et al. A ran-domized trial assessing the effects of 4

weeks of daily stretching on ankle mobilityin patients with spinal cord injuries. ArchPhys Med Rehabil. 2000;81:13401347.

37 Harvey LA, Byak AJ, Ostrovskaya M, et al.Randomised trial of the effects of four

weeks of daily stretch on extensibility of

hamstring muscles in people with spinalcord injuries. Aust J Physiother. 2003;49:176181.

38 Harvey L, de Jong I, Goehl G, MardwedelS. Twelve weeks of nightly stretch doesnot reduce thumb web-space contracturesin people with a neurological condition: arandomised controlled trial. Aust J Phys-iother. 2006;52:251258.

39 Hill J. The effects of casting on upper ex-tremity motor disorders after brain injury.Am J Occup Ther. 1994;48:219224.





15/16

40 Horsley SA, Herbert RD, Ada L. Fourweeks of daily stretch has little or no effecton wrist contracture after stroke: a ran-domised controlled trial [erratum in Aust

J Physiother. 2008;54:38]. Aust J Phys-iother. 2007;53:239245.

41 Hyde SA, FlLytrup I, Glent S, et al. A ran-domized comparative study of two meth-ods for controlling Tendo Achilles con-tracture in Duchenne muscular dystrophy.Neuromuscul Disord. 2000;10:257263.

42 Lai JM, Francisco GE, Willis FB. Dynamicsplinting after treatment with botulinumtoxin type-A: a randomized controlled pi-lot study. Adv Ther. 2009;26:241248.

43 Lannin NA, Horsley SA, Herbert R, et al.Splinting the hand in the functional posi-tion after brain impairment: a randomizedcontrolled trial. Arch Phys Med Rehabil.2003;84:297302.

44 Lannin NA, Cusick A, McCluskey A, Her-bert RD. Effects of splinting on wrist con-tracture after stroke: a randomized con-trolled trial. Stroke. 2007;38:111116.

45 Law M, Cadman D, Rosenbaum P, et al.Neurodevelopmental therapy and upper-extremity inhibitive casting for children

with cerebral palsy. Dev Med Child Neu-rol. 1991;33:379387.

46 McNee AE, Will E, Lin JP, et al. The effectof serial casting on gait in children withcerebral palsy: preliminary results froma crossover trial. Gait Posture. 2007;25:463468.

47 Moseley AM. The effect of casting com-bined with stretching on passive ankledorsiflexion in adults with traumatic headinjuries. Phys Ther. 1997;77:240247.

48 Refshauge KM, Raymond J, Nicholson G,van den Dolder PA. Night splinting doesnot increase ankle range of motion inpeople with Charcot-Marie-Tooth disease:a randomised cross-over trial. Aust J Phys-iother. 2006;52:193199.

49 Rose K, Raymond J, Refshauge K, et al.Serial night casting increases ankle dorsi-flexion range in children and young adults

with Charcot-Marie-Tooth disease: a ran-domised trial. J Physiother. 2010;56:113119.

50 Sheehan JL, Winzeler-Mercay U, MudieMH. A randomized controlled pilot studyto obtain the best estimate of the sizeof the effect of a thermoplastic restingsplint on spasticity in the stroke-affected

wrist and fingers. Clin Rehabil. 2006;20:10321037.

51 Turton AJ, Britton E. A pilot randomizedcontrolled trial of a daily muscle stretchregime to prevent contractures in the armafter stroke [erratum in Clin Rehabil. 2006;20:91]. Clin Rehabil. 2005;19:600 612.

52 Weppler CH, Magnusson SP. Increasingmuscle extensibility: a matter of increas-ing length or modifying sensation? PhysTher. 2010;90:438 449.

53 Dickersin K, Min YI. NIH clinical trials andpublication bias. Online J Curr Clin Tri-als. 1993;Doc No 50.

54 Egger M, Smith GD. Bias in location andselection of studies. BMJ. 1998;316(7124):6166.

55 Hellweg S, Johannes S. Physiotherapy aftertraumatic brain injury: a systematic re-

view of the literature. Brain Inj. 2008;22:365373.

56 Autti-Ramo I, Suoranta J, Anttila H, et al.Effectiveness of upper and lower limbcasting and orthoses in children with ce-rebral palsy: an overview of review arti-cles. Am J Phys Med Rehabil. 2006;85:89103.

57 Michlovitz SL, Harris BA, Watkins MP.Therapy interventions for improving jointrange of motion: a systematic review.

J Hand Ther. 2004;17:118131.

58 Mortenson PA, Eng JJ. The use of casts inthe management of joint mobility and hy-pertonia following brain injury in adults:a systematic review. Phys Ther. 2003;83:648658.

59 Teplicky R, Law M, Russell D. The effec-tiveness of casts, orthoses, and splints forchildren with neurological disorders. In-

fants Young Child. 2002;15:4250.

60 Van Peppen RP, Kwakkel G, Wood-Dauphinee S, et al. The impact of physicaltherapy on functional outcomes afterstroke: whats the evidence? Clin Rehabil.2004;18:833862.

61 Borisova Y, Bohannon RW. Positioningto prevent or reduce shoulder range ofmotion impairments after stroke: a meta-analysis. Clin Rehabil. 2009;23:681686.





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doi: 10.2522/ptj.20100265Originally published online December 2, 2010

2011; 91:11-24.PHYS THER.Owen M. Katalinic, Lisa A. Harvey and Robert D. HerbertNeurological Conditions: A Systematic ReviewPrevention of Contractures in People WithEffectiveness of Stretch for the Treatment and

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