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Review
. 2017 Jan 9;1(1):CD007455.
doi: 10.1002/14651858.CD007455.pub3.

Stretch for the treatment and prevention of contractures

Lisa A Harvey  1 , Owen M Katalinic  2 , Robert D Herbert  3 , Anne M Moseley  4 , Natasha A Lannin  5 , Karl Schurr  6
Affiliations
Review

Stretch for the treatment and prevention of contractures

Lisa A Harvey et al. Cochrane Database Syst Rev. .

Abstract

Background: Contractures are a common complication of neurological and non-neurological conditions, and are characterised by a reduction in joint mobility. Stretch is widely used for the treatment and prevention of contractures. However, it is not clear whether stretch is effective. This review is an update of the original 2010 version of this review.

Objectives: The aim of this review was to determine the effects of stretch on contractures in people with, or at risk of developing, contractures.The outcomes of interest were joint mobility, quality of life, pain, activity limitations, participation restrictions, spasticity and adverse events.

Search methods: In November 2015 we searched CENTRAL, DARE, HTA; MEDLINE; Embase; CINAHL; SCI-EXPANDED; PEDro and trials registries.

Selection criteria: We included randomised controlled trials and controlled clinical trials of stretch applied for the purpose of treating or preventing contractures.

Data collection and analysis: Two review authors independently selected trials, extracted data, and assessed risk of bias. The outcomes of interest were joint mobility, quality of life, pain, activity limitations, participation restrictions and adverse events. We evaluated outcomes in the short term (up to one week after the last stretch) and in the long term (more than one week). We expressed effects as mean differences (MD) or standardised mean differences (SMD) with 95% confidence intervals (CI). We conducted meta-analyses with a random-effects model. We assessed the quality of the body of evidence for the main outcomes using GRADE.

Main results: Forty-nine studies with 2135 participants met the inclusion criteria. No study performed stretch for more than seven months. Just over half the studies (51%) were at low risk of selection bias; all studies were at risk of detection bias for self reported outcomes such as pain and at risk of performance bias due to difficulty of blinding the intervention. However, most studies were at low risk of detection bias for objective outcomes including range of motion, and the majority of studies were free from attrition and selective reporting biases. The effect of these biases were unlikely to be important, given that there was little benefit with treatment. There was high-quality evidence that stretch did not have clinically important short-term effects on joint mobility in people with neurological conditions (MD 2°; 95% CI 0° to 3°; 26 studies with 699 participants) or non-neurological conditions (SMD 0.2, 95% CI 0 to 0.3, 19 studies with 925 participants).In people with neurological conditions, it was uncertain whether stretch had clinically important short-term effects on pain (SMD 0.2; 95% CI -0.1 to 0.5; 5 studies with 174 participants) or activity limitations (SMD 0.2; 95% CI -0.1 to 0.5; 8 studies with 247 participants). No trials examined the short-term effects of stretch on quality of life or participation restrictions in people with neurological conditions. Five studies involving 145 participants reported eight adverse events including skin breakdown, bruising, blisters and pain but it was not possible to statistically analyse these data.In people with non-neurological conditions, there was high-quality evidence that stretch did not have clinically important short-term effects on pain (SMD -0.2, 95% CI -0.4 to 0.1; 7 studies with 422 participants) and moderate-quality evidence that stretch did not have clinically important short-term effects on quality of life (SMD 0.3, 95% CI -0.1 to 0.7; 2 studies with 97 participants). The short-term effect of stretch on activity limitations (SMD 0.1; 95% CI -0.2 to 0.3; 5 studies with 356 participants) and participation restrictions were uncertain (SMD -0.2; 95% CI -0.6 to 0.1; 2 studies with 192 participants). Nine studies involving 635 participants reported 41 adverse events including numbness, pain, Raynauds' phenomenon, venous thrombosis, need for manipulation under anaesthesia, wound infections, haematoma, flexion deficits and swelling but it was not possible to statistically analyse these data.

Authors' conclusions: There was high-quality evidence that stretch did not have clinically important effects on joint mobility in people with or without neurological conditions if performed for less than seven months. Sensitivity analyses indicate results were robust in studies at risk of selection and detection biases in comparison to studies at low risk of bias. Sub-group analyses also suggest the effect of stretch is consistent in people with different types of neurological or non-neurological conditions. The effects of stretch performed for periods longer than seven months have not been investigated. There was moderate- and high-quality evidence that stretch did not have clinically important short-term effects on quality of life or pain in people with non-neurological conditions, respectively. The short-term effects of stretch on quality of life and pain in people with neurological conditions, and the short-term effects of stretch on activity limitations and participation restrictions for people with and without neurological conditions are uncertain.

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Conflict of interest statement

Lisa A Harvey: no financial interest in this intervention but has authored trials reported in this review. Owen M Katalinic: no financial interest in this intervention and has not authored trials reported in this review Robert D Herbert: no financial interest in this intervention but has authored trials reported in this review. Anne M Moseley: no financial interest in this intervention but has authored trials reported in this review. Natasha A Lannin: no financial interest in this intervention but has authored trials reported in this review. Karl Schurr: no financial interest in this intervention and has not authored trials reported in this review.

Figures

1
1
Study flow diagram 1. These numbers are approximate only
2
2
Methodological quality summary: review authors' judgements about each methodological quality item for each included study
3
3
Forest plot of comparison: Joint mobility ‐ short‐term effects following stretch ‐ neurological conditions (degrees)
4
4
Forest plot of comparison: Joint mobility ‐ short‐term effects following stretch ‐ non‐neurological conditions (SMD)
5
5
Forest plot of comparison: Joint mobility ‐ long‐term effects following stretch ‐ neurological conditions (degrees)
6
6
Bubble plot of meta‐regression analysis: Joint mobility ‐ effects of total stretch time on joint mobility ‐ all conditions (degrees)
7
7
Forest plot of comparison: Joint mobility ‐ subgroup analyses by type of stretch intervention ‐ neurological conditions (degrees)
8
8
Funnel plot of comparison: 1 Joint mobility ‐ short‐term effects following stretch, outcome: 1.1 Neurological conditions (degrees)
9
9
Funnel plot of comparison: 1 Joint mobility ‐ short‐term effects following stretch, outcome: 1.2 Non‐neurological conditions
1.1
1.1. Analysis
Comparison 1 Joint mobility ‐ short‐term effects following stretch, Outcome 1 Neurological conditions.
1.2
1.2. Analysis
Comparison 1 Joint mobility ‐ short‐term effects following stretch, Outcome 2 Non‐neurological conditions.
2.1
2.1. Analysis
Comparison 2 Joint mobility ‐ long‐term effects following stretch, Outcome 1 Neurological conditions.
2.2
2.2. Analysis
Comparison 2 Joint mobility ‐ long‐term effects following stretch, Outcome 2 Non‐neurological conditions.
3.1
3.1. Analysis
Comparison 3 Quality of life ‐ short‐term effects following stretch, Outcome 1 Non‐neurological conditions.
4.1
4.1. Analysis
Comparison 4 Pain ‐ short‐term effects following stretch, Outcome 1 Neurological conditions.
4.2
4.2. Analysis
Comparison 4 Pain ‐ short‐term effects following stretch, Outcome 2 Non‐neurological conditions.
5.1
5.1. Analysis
Comparison 5 Pain ‐ long‐term effects following stretch, Outcome 1 Neurological conditions.
5.2
5.2. Analysis
Comparison 5 Pain ‐ long‐term effects following stretch, Outcome 2 Non‐neurological conditions.
6.1
6.1. Analysis
Comparison 6 Activity limitations ‐ short‐term effects following stretch, Outcome 1 Neurological conditions.
6.2
6.2. Analysis
Comparison 6 Activity limitations ‐ short‐term effects following stretch, Outcome 2 Non‐neurological conditions.
7.1
7.1. Analysis
Comparison 7 Activity limitations ‐ long‐term effects following stretch, Outcome 1 Neurological conditions.
7.2
7.2. Analysis
Comparison 7 Activity limitations ‐ long‐term effects following stretch, Outcome 2 Non‐neurological conditions.
8.1
8.1. Analysis
Comparison 8 Participation restrictions ‐ short‐term effects following stretch, Outcome 1 Non‐neurological conditions.
9.1
9.1. Analysis
Comparison 9 Participation restrictions ‐ long‐term effects following stretch, Outcome 1 Non‐neurological conditions.
10.1
10.1. Analysis
Comparison 10 Spasticity ‐ short‐term effects following stretch, Outcome 1 Neurological conditions.
11.1
11.1. Analysis
Comparison 11 Spasticity ‐ long‐term effects following stretch, Outcome 1 Neurological conditions.
12.1
12.1. Analysis
Comparison 12 Joint mobility ‐ subgroup analyses, Outcome 1 Types of stretch intervention.
12.2
12.2. Analysis
Comparison 12 Joint mobility ‐ subgroup analyses, Outcome 2 Large versus small joints.
12.3
12.3. Analysis
Comparison 12 Joint mobility ‐ subgroup analyses, Outcome 3 Influence of discomfort.
12.4
12.4. Analysis
Comparison 12 Joint mobility ‐ subgroup analyses, Outcome 4 Joint mobility measured less than one day versus more than one day.
See this image and copyright information in PMC

Update of

References

References to studies included in this review

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Hill 1994 {published data only}
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Hussein 2015 {published data only}
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John 2011 {published data only}
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Jongs 2012 {published data only}
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Moseley 1997 {published data only}
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Moseley 2005 {published data only}
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Adams 2008 {published data only}
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De Jong 2013 {published data only}
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Duerden 2009 {unpublished data only}
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Flett 1999 {published data only}
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Gajdosik 2005 {published data only}
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Gillmore 1995 {published data only}
    1. Gillmore A, Baer GD. The effect of different durations of static stretch on hamstring muscle flexibility. 12th International Congress of the World Confederation for Physical Therapy. 1995:962.
Glasgow 2003 {published data only}
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Gonzalez‐Rave 2012 {published data only}
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Hogan 2001 {published data only}
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Jones 2002 {published data only}
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Jung 2011 {published data only}
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Kanellopoulos 2009 {published data only}
    1. Kanellopoulos AD, Mavrogenis AF, Mitsiokapa EA, Panagopoulos D, Skouteli H, Vrettos SG, et al. Long lasting benefits following the combination of static night upper extremity splinting with botulinum toxin A injections in cerebral palsy children. European Journal of Physical & Rehabilitation Medicine 2009;45:501‐6. - PubMed
Kappetijn 2014 {published data only}
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Kerem 2001 {published data only}
    1. Kerem M, Livanelioglu A, Topcu M. Effects of Johnstone pressure splints combined with neurodevelopmental therapy on spasticity and cutaneous sensory inputs in spastic cerebral palsy. Developmental Medicine and Child Neurology 2001;43(5):307‐13. - PubMed
Kilbreath 2006 {published data only}
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    1. Kilgour RD, Jones DH, Keyserlingk JR. Effectiveness of a self‐administered, home‐based exercise rehabilitation program for women following a modified radical mastectomy and axillary node dissection: a preliminary study. Breast Cancer Research and Treatment 2008;109(2):285‐95. - PubMed
Kilmartin 1994 {published data only}
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Kim 2013 {published data only}
    1. Kim EH, Jang MC, Seo JP, Jang SH, Song JC, Jo HM. The effect of a hand‐stretching device during the management of spasticity in chronic hemiparetic stroke patients. Annals of Rehabilitation Medicine 2013;37:235‐40. - PMC - PubMed
Lauridsen 2005 {published data only}
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Law 1997 {published data only}
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Li‐Tsang 2002 {published data only}
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Maloney Backstrom 1995 {published data only}
    1. Maloney Backstrom K, Forsyth C, Walden B. Comparison of two methods of stretching the gastrocnemius and their effects on ankle range of motion. 12th International Congress of the World Confederation for Physical Therapy. 1995:330.
Marschall 1999 {published data only}
    1. Marschall F. Effects of different stretch‐intensity on the acute change of range of motion. Deutsche Zeitschrift fur Sportmedizin 1999;50(1):5‐9.
McPherson 1985 {published data only}
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Morris 1991 {published data only}
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    1. Park ES, Rha D‐W, Yoo JK, Kim SM, Chang WH, Song SH. Short‐term effects of combined serial casting and botulinum toxin injection for spastic equinus in ambulatory children with cerebral palsy. Yonsei Medical Journal 2010;51:579‐84. - PMC - PubMed
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Robinson 2008 {published data only}
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    1. Thibaut A, Deltombe T, Wannez S, Gosseries O, Ziegler E, Dieni C, et al. Impact of soft splints on upper limb spasticity in chronic patients with disorders of consciousness: a randomized, single‐blind, controlled trial. Brain injury 2015;29:830‐6. - PubMed
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References to studies awaiting assessment

Amirsalari 2011 {published data only}
    1. Amirsalari S, Dalvand H, Dehghan L, Feizy A, Hosseini SA, Shamsodini A. The efficacy of botulinum toxin type A injection in the hamstring and calf muscles with and without serial foot casting in gait improvement in children with cerebral palsy. Tehran University Medical Journal 2011;69:509‐17.
Dalvand 2012 {published data only}
    1. Dalvand H, Dehghan L, Feizi A, Amirsalari S, Hosseini SA, Shamsoddini A. The effect of foot serial casting along with botulinum toxin type‐A injection on spasticity in children with cerebral palsy. Journal of Kerman University of Medical Sciences 2012;19:562‐73.
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Javanshir 2010 {published data only}
    1. Javanshir MA, Tutunchi E. Effects of adjustable wrist hand splint on spasticity and active range of motion on post stroke patients. Journal of Gorgan University of Medical Sciences 2010;13(1):23‐8. [IRCT138903193754N2]
Lagalla 1997 {published data only}
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    1. Lagalla G, Danni M, Reiter F, Severini S, Fiorani C, Ceravalo MG, et al. [Approccio multimodale al controllo della spasticita dell arto superiore]. Atti Della Accademia a Medico ‐ Chirurgica del Piceno 1997;1(12):86‐90.
Tutunchi 2011 {published data only (unpublished sought but not used)}
    1. Tutunchi E, Javanshir MA, Akbar‐Fahimi M, Kamali M. Effect of adjustable wrist hand splint on upper limb spasticity in post stroke patients. Journal of Gorgan University of Medical Sciences 2011;13(1):23‐8.

References to ongoing studies

ACTRN12613000690752 {unpublished data only}
    1. ACTRN12613000690752. Effectiveness of functional splinting combined with motor training to improve upper limb function in children with cerebral palsy and brain injury: A randomised controlled trial. https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=347475 (first received 16 June 2013).
ACTRN12616000230459 {unpublished data only}
    1. ACTRN12616000230459. The effectiveness of a stretching intervention in lowering plantar pressures related to reduced ankle range of motion in people with diabetes. https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=370079 (first received 11 Feb 2016).
Maas 2012 {published data only}
    1. Maas JC, Dallmeijer AJ, Huijing PA, Brunstrom‐Hernandez JE, Kampen PJ, Jaspers RT, et al. Splint: the efficacy of orthotic management in rest to prevent equinus in children with cerebral palsy, a randomised controlled trial. BMC Pediatrics 2012:10. [DOI: 10.1186/1471-2431-12-38] - DOI - PMC - PubMed
NCT02638480 {unpublished data only}
    1. NCT02638480. Effectiveness of KneeMD on Flexion Contracture in Total Knee Arthroplasty Patients (KneeMD) [Effectiveness of KneeMD on Flexion Contracture in Total Knee Arthroplasty Patients (KneeMD)]. https://clinicaltrials.gov/ct2/show/NCT02638480 (first received 18 Dec 2015).

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