Scholarly article on topic 'Stretch for the treatment and prevention of contracture: an abridged republication of a Cochrane Systematic Review'

Stretch for the treatment and prevention of contracture: an abridged republication of a Cochrane Systematic Review Academic research paper on "Health sciences"

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{Stretch / "Physical therapy" / Contracture / "Systematic review"}

Abstract of research paper on Health sciences, author of scientific article — Lisa A Harvey, Owen M Katalinic, Robert D Herbert, Anne M Moseley, Natasha A Lannin, et al.

Abstract Question Is stretch effective for the treatment and prevention of contractures in people with neurological and non-neurological conditions? Design A Cochrane Systematic Review with meta-analyses of randomised trials. Participants People with or at risk of contractures. Intervention Trials were considered for inclusion if they compared stretch to no stretch, or stretch plus co-intervention to co-intervention only. The stretch could be administered in any way. Outcome measures The outcome of interest was joint mobility. Two sets of meta-analyses were conducted with a random-effects model: one for people with neurological conditions and the other for people with non-neurological conditions. The quality of evidence supporting the results of the two sets of meta-analyses was assessed using GRADE. Results Eighteen studies involving 549 participants examined the effectiveness of stretch in people with neurological conditions, and provided useable data. The pooled mean difference was 2 deg (95% CI 0 to 3) favouring stretch. This was equivalent to a relative change of 2% (95% CI 0 to 3). Eighteen studies involving 865 participants examined the effectiveness of stretch in people with non-neurological conditions, and provided useable data. The pooled standardised mean difference was 0.2 SD (95% CI 0 to 0.3) favouring stretch. This translated to an absolute mean increase of 1 deg (95% CI 0 to 2) and a relative change of 1% (95% CI 0 to 2). The GRADE level of evidence was high for both sets of meta-analyses. Conclusion Stretch does not have clinically important effects on joint mobility. [Harvey LA, Katalinic OM, Herbert RD, Moseley AM, Lannin NA, Schurr K (2017) Stretch for the treatment and prevention of contracture: an abridged republication of a Cochrane Systematic Review. Journal of Physiotherapy 63: 67–75]

Academic research paper on topic "Stretch for the treatment and prevention of contracture: an abridged republication of a Cochrane Systematic Review"

ARTICLE IN PRESS

Journal of Physiotherapy xxx (2017) xxx-xxx

Journal of

PHYSIOTHERAPY

journal homepage www.elsevier.com/locate/jphys

Research

Stretch for the treatment and prevention of contracture: an abridged republication of a Cochrane Systematic Review$

Lisa A Harveya, Owen M Katalinica, Robert D Herbertb, Anne M Moseleyc, Natasha A Lannind, Karl Schurre

5 a John Walsh Centre for Rehabilitation Research, Northern Clinical School, Sydney School of Medicine, University of Sydney, Australia; b Neuroscience Research Australia, Australia;

6 c The George Institute for Global Health, Sydney Medical School, The University of Sydney, Sydney, Australia; d School of Allied Health, Department of Community and Clinical Allied

7 Health, Occupational Therapy, College of Science, Health and Engineering, La Trobe University, Melbourne, Australia;e Physiotherapy Consultant, Sydney, Australia

KEY WORDS

ABSTRACT

Stretch

Physical therapy Contracture Systematic review

Question: Is stretch effective for the treatment and prevention of contractures in people with neurological and non-neurological conditions? Design: A Cochrane Systematic Review with metaanalyses of randomised trials. Participants: People with or at risk of contractures. Intervention: Trials were considered for inclusion if they compared stretch to no stretch, or stretch plus co-intervention to co-intervention only. The stretch could be administered in any way. Outcome measures: The outcome of interest was joint mobility. Two sets of meta-analyses were conducted with a random-effects model: one for people with neurological conditions and the other for people with non-neurological conditions. The quality of evidence supporting the results of the two sets of meta-analyses was assessed using GRADE. Results: Eighteen studies involving 549 participants examined the effectiveness of stretch in people with neurological conditions, and provided useable data. The pooled mean difference was 2 deg (95% CI 0 to 3) favouring stretch. This was equivalent to a relative change of 2% (95% CI 0 to 3). Eighteen studies involving 865 participants examined the effectiveness of stretch in people with non-neurological conditions, and provided useable data. The pooled standardised mean difference was 0.2 SD (95% CI 0 to 0.3) favouring stretch. This translated to an absolute mean increase of 1 deg (95% CI 0 to 2) and a relative change of 1% (95% CI 0 to 2). The GRADE level of evidence was high for both sets of meta-analyses. Conclusion: Stretch does not have clinically important effects on joint mobility. [Harvey LA, Katalinic OM, Herbert RD, Moseley AM, Lannin NA, Schurr K (2017) Stretch for the treatment and prevention of contracture: an abridged republication of a Cochrane Systematic Review. Journal of Physiotherapy XX: XX-XX] © 2017 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction

9 10 11 12

Contractures are common for people with many types of injuries and disabilities. For example, they are common in people with neurological conditions such as brain injury, stroke or spinal cord injuries.1,2 They are also common in people with non-neurological conditions such as burns, fractures, shoulder capsu-litis and Dupuytren's Disease.3 Contractures are undesirable because they are unsightly and have deleterious implications on function and quality of life. For instance, ankle plantarflexion contractures in people with brain injuries impede gait, and finger flexion contractures in people with crush injuries interfere with hand function.

$ This article is based on a Cochrane Review published in the Cochrane Database of Systematic Reviews (CDSR) 2017, Issue 1. Art. No.: CD007455. DOI: 10.1002/ 14651858.CD007455.pub3. (see www.cochranelibrary.com for information). Cochrane Reviews are regularly updated as new evidence emerges and in response to feedback, and the CDSR should be consulted for the most recent version of the review.

Stretch is the main intervention used by physiotherapists for the treatment and prevention of contractures. Stretch is applied in many different ways, including plaster casts, splints or through the hands of therapists (see www.physiotherapyexercises.com for examples of stretches typically prescribed by physiotherapists). In addition, physiotherapists widely recommend that people with all types of injuries and disabilities routinely stretch at home in an effort to either treat or prevent contractures. For example, those with spinal cord injuries are often instructed to devote up to 1 hour per day for the rest of their lives to stretch, in an effort to treat and prevent contractures.

There is animal evidence to indicate a reduction in the number of serial sarcomeres of muscles immobilised in a shortened position,4 while regular and prolonged stretch causes morphological changes with a resultant lasting increase in extensibility.4,5 These studies give credence to the belief that stretch is effective for the treatment and prevention of contractures. These beliefs are further supported by strong anecdotal evidence along with the promising results of case studies and uncontrolled trials. However, the effects observed in case studies and uncontrolled trials may reflect bias or the effects of natural recovery or other co-interventions. It is therefore imperative

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http://dx.doi.Org/10.1016/j.jphys.2017.02.014

1836-9553/© 2017 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons. org/licenses/by-nc-nd/4.0/).

ARTICLE IN PRESS

Harvey et al: Stretch for contractures

to focus on randomised, controlled trials if a reliable answer is to be found as to whether stretch is effective for the treatment and prevention of contractures. This question was examined in a Cochrane Systematic Review in 20106 and in an updated review in 2017.7 The present paper provides an abridged republication of the 2017 version of this Cochrane Systematic Review. It focuses on the short-term effects of stretch on joint mobility (effects present for < 1 weekafterthelaststretchintervention), but includes the two key meta-analyses involving people with neurological and non-neurological conditions. The full review includes other outcomes and examines the long-term effects (effects present > 1 week after the last stretch intervention) as well as various sub-group analyses.

Therefore, the main research question for this systematic review was:

Does stretching improve joint mobility in the short term in people with neurological or non-neurological conditions?

Methods

All databases were searched up until November 2015 (see Cochrane Systematic Review7 for full details) and potentially eligible trials screened for inclusion by two review authors. Disagreements between the two review authors were resolved by discussion and, when necessary, arbitrated by a third author. The following inclusion criteria were used to identify trials.

Participants: People of any age, including children, provided they either had or were deemed susceptible to contracture. This included conditions such as burns, arthritis, spinal cord injury, stroke and frailty.

Type of intervention: Any intervention that involved administering a stretch to maintain or increase the mobility of any synovial joint. The stretch needed to be administered on more than one occasion and for > 20 seconds. This included stretch administered through positioning programs, splints, serial casting or as part of manual therapy.

Comparisons: The stretch intervention needed to be compared to no stretch, placebo stretch or sham stretch. The stretch could also be compared to another intervention or usual care, provided the other intervention or usual care was also administered to the group receiving the stretch.

Outcomes: There were seven outcomes, including: joint mobility, quality of life, pain, activity limitation, participation restriction, adverse events and spasticity. However, for this publication we only report results for joint mobility. Joint mobility could be measured in many ways; the most common were: active range of motion (deg), passive range of motion (deg), passive joint stiffness (deg per unit torque) or linear distance between two points (eg, finger-tip to floor distance in mm).

Two review authors extracted joint mobility data for two time points: short term and long term. However, only the short-term effects are presented in this paper. This referred to effects present up to 1 week after the last stretch intervention. ANCOVA-adjusted

between-group means and standard deviations were extracted in preference to change scores. However, if neither were provided, post-intervention scores were used. Two meta-analyses were conducted by pooling studies involving people with neurological conditions and non-neurological conditions using a random-effects model. The data were only pooled if there was no evidence of clinical or statistical heterogeneity (I2 > 50%). In both meta-analyses the results were divided and also analysed by diagnosis. The pooled treatment effect was expressed as a mean difference if the outcomes in all the studies were the same and a standardized mean difference if they differed. Further sub-group analyses were conducted to explore the possibilities that the effectiveness of stretch depends on different factors, including the size of the joint or muscle that is stretched and whether stretch is administered for the treatment or prevention of contractures (see Cochrane Systematic Review for full details). Here we just report the results of the sub-group analyses exploring the possibility that the effectiveness of stretch depends on the dosage of stretch and the way in which the stretch is administered. All data were analysed using Review Manager 5.a

Trials were assessed for risk of bias using the Cochrane Risk of Bias Tool. Each trial was rated as high risk, unclear risk or low risk on the following eight domains: sequence generation, conceal allocation, blinding of participants and therapists, blinding of outcome assessors for objective outcomes, blinding of outcome assessors for subjective outcomes, incomplete outcome data, selective outcome reporting and other potential threats of bias. The GRADE approach was used to evaluate the quality of evidence in each meta-analysis as high, medium, low or very low. This approach takes into account: susceptibility to bias; directness of evidence; heterogeneity or inconsistencies in the results; imprecision; and probability of publication bias.

Results

A total of 5048 papers were screened for inclusion and 135 were potentially eligible. Ultimately, 49 studies involving 2135 participants met the inclusion criteria, with 28 studies involving 898 participants with neurological conditions and 21 studies involving 1237 participants with non-neurological conditions. All studies measured joint mobility, but some did not provide useable data and others did not measure joint mobility within 1 week of the last intervention.

The risk of bias in the 49 studies was variable (see Figure 1). Approximately half of the studies were rated as low risk of bias for each of the eight domains. No study blinded participants or therapists, as this is not possible in trials involving stretch. All studies compared stretch and a co-intervention to a co-intervention only. The co-interventions included usual care, botulinum toxin, passive stretches, exercise and therapy. Joint mobility was measured in degrees in all but four studies involving non-neurological conditions (see Table 1).

Random sequence generation (selection bias) Allocation concealment (selection bias) Blinding (performance bias and detection bias) Blinding of outcome assessors (detection bias) - objective outcomes Blinding of outcome assessors (detection bias) - self-reported outcomes Incomplete outcome data (attrition bias) Selective reporting (reporting bias)

High risk of bias Unclear risk of bias Low risk of bias

Other bias _

0 25 50 75

Trials categorised by risk of bias

Figure 1. Risk of bias of included trials.

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Table 1

Characteristics of the included trials (n=49). The shaded trials were excluded from the quantitative analyses.

Author

Health condition

Sample size

Joint of interest

Neurological conditions Ackman 200535

Ada 2005

Children with spastic cerebral palsy

Adults with stroke

Exp: 13 Con: 12 Oth: 14 Exp: 18 Con: 18

Shoulder

Basaran 2012"

Adults with stroke

Exp: 13 Con: 13 Other: 13

Ben 2005" Bürge 200812 Copley 2013"

Adults with spinal cord injury

Adults with stroke

Adults with acquired brain injury

Exp: 20 legs Con: 20 legs Exp: 31 Con: 16 Exp: 6 Con: 4

Ankle Wrist

Wrist and fingers

Crowe 2000" Adults with spinal cord injury Exp: 18 Con: 21 Shoulder

De Jong 200615 Adults with stroke Exp: 10 Con: 9 Shoulder

Dean 200016 Adults with stroke Exp: 14 Con: 14 Shoulder

DiPasquale-Lehnerz 199417 Adults with spinal cord injury Exp: 7 Con: 6 Hand

Gustafsson 2006ls Adults with stroke Exp: 17 Con: 17 Shoulder

Harvey 200019 Adults with spinal cord injury Exp: 14 legs Con: 14 legs Ankle

Harvey 2003s Harvey 200620 Adults with spinal cord injury Adults with spinal cord injury, stroke or traumatic brain injury Exp: 16 legs Con: 16 legs Exp: 30 thumbs (spinal cord injury 19, stroke 7, traumatic brain injury 4) Con: 30 thumbs (spinal cord injury 20, stroke 7, traumatic brain injury 3) Hip Thumb carpometacarpal

Hill 199421 Adults with brain injury Exp: 8 Con: 7 Elbow and wrist

Horsley 2007" Adults with stroke or stroke-like brain injury Exp: 20 Con: 20 Wrist

Hyde 200023 Children with Duchenne muscular dystrophy Exp: 15 Con: 12 Ankle

Groups Dosage of stretch Outcome included in this review

Exp: Botulinum toxin plus cast Con: Botulinum toxin Oth: Placebo plus cast 24 hrs x 7 d x 9 wks = 1512 hrs over a 9-wk period Passive ankle dorsiflexion with the knee extended (deg)

Exp: Participants received two 30-min sessions of shoulder positioning Con: Participants received up to 10 min of shoulder exercises and routine upper-limb care Exp: Volar splint and home-based exercise program Con: Home-based exercise program only Other: Dorsal splint and home-based exercise program Exp: Weight-bearing and stretch Con: Non weight-bearing and non stretch 30 min x 5 d x 4 wks = 10 hrs for each position over a 4-wk period Maximum passive shoulder external rotation of the affected limb (deg)

10 hrs x 7 d x 5 wks = 350 hrs over a 5-wk period 30 min x 3 d x 12 wks = 18 hrs over a 12-wk period Passive wrist extension (deg) Passive ankle dorsiflexion (torque controlled; deg)

Exp: Orthosis plus conventional care Con: Conventional care Total stretch time not reported Wrist range of motion (Fugl-Meyer Assessment sub-scale)

Exp: Splint and standard practice occupational therapy program Con: Standard practice occupational therapy program only 10 hrs x 90 d = 900 hrs over a 13-wk period Wrist extension with the fingers extended (deg)

Exp: Positioning plus conventional care Con: Conventional care 45 mins x 5 d x (2 to 16 wks) = 7.5 hrs to 60 hrs over a 2 to Passive shoulder abduction (right arm; deg)

Exp: Positioning plus conventional care Con: Conventional care Exp: Shoulder positioning plus conventional care Con: Conventional care 16-wk period 30 mins x 2 sessions x 5 d x (5 to 10wks) = 25 to 50 hrs over a 5 to 10-wk period 3 sessions x 20 mins x 5 d x 6 wks = 30 hrs over a 6-wk period Passive shoulder abduction (deg) Passive shoulder external rotation (deg)

Exp: Positional orthosis plus conventional rehabilitation 8 hrs x 7 d x 12 wks = 672 hrs over a 12-wk period Passive metacarpophalangeal extension (deg)

Con: Conventional rehabilitation Exp: Shoulder positioning plus conventional care Con: Conventional care Exp: Stretch Con: Non-stretch Exp: Stretch Con: Non-stretch Exp: Thumb splint Con: No splint 24 hrs x 30 d = 720 hrs over a 4-wk period 30 mins x (5 to 7 d) x 4 wks = 10 to 14 hrs over a 4-wk period 30 mins x 5 d x 4 wks = 10 hrs over a 4-wk period 8 hrs x 7 d x 12 wks = 672 hrs over a 12-wk period Passive shoulder external rotation (deg) Ankle angle at 10 Nm torque with the knee extended (deg) Hip flexion at 30 Nm torque (deg) Palmar abduction of the thumb carpometacarpal joint (deg)

Exp: Serial casting Con: Therapy

Exp: Stretch plus usual care Con: Usual care

Exp: Night splint plus passive stretch Con: Passive stretch

24 hrs x 7 d x 4.33 wks = 728 hrs over a 4-wk period 30 mins x 5 d x 4 wks = 10 hrs over a 4-wk period

Total stretch time not reported

Unidirectional passive joint ROM (deg)

Passive wrist extension (deg) Tendo-achilles contracture

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Table 1 (Continued)

Author Health condition Sample size Joint of

interest

Krumlinde-Sundholm 201124 Children with cerebral palsy (12 children had 37 children (cross-over) Exp: not specified Wrist and thumb

Lai 200925 unilateral and 14 bilateral cerebral palsy) Adults with stroke Con: not specified Exp: 15 Con:15 Elbow

Lannin 200327 Lannin 200726 Adults with stroke or brain injury Adults with stroke Exp: 17 Con: 11 Exp: 21 Con: 21 Other: 21 Wrist (long finger flexors) Wrist (long finger flexors)

Law 199128 Children with spastic cerebral palsy Exp: 19 Con:18 Other 1: 17 Other 2: 18 Wrist (wrist flexors)

McNee 20 0734 Children with cerebral Exp: 5 Ankle

palsy Con: 4

Moseley 199729 Adults with traumatic Exp: 5 Ankle

brain injury Con: 5

Refshauge 200630 Children and young Exp: 14 legs Ankle

adults with Charcot- Con: 14 legs

Marie-Tooth disease

Rose 201031 Children and young Exp: 15 Ankle

adults with Charcot- Con:15

Marie-Tooth disease

restricted ankle

dorsiflexion range

Sheehan 200632 Adults with stroke Exp: 6 Wrist (finger

Con: 8 flexors)

Turton 200533 Adults with stroke Exp:14 Wrist and

Con:15 shoulder

Non-neurological conditions

Aoki 200936 Adults with knee Exp: 17 (33 knees) Knee

osteoarthritis Con: 19 (33 knees)

Buchbinder 199337 Adults post-radiation Exp: 9 Mandibular

therapy for the jaw Con: 5

Other: 7

Bulstrode 19873s Collis 201339

Cox 200940

Adults with ankylosing spondylitis Adults following surgical release for Dupuytren's contracture Adults with oral submucous fibrosis

Exp: 27 Con: 12 Exp: 26 Con: 30

Exp: 23 Con: 16 Other: 15

Hip Hand

Jaw/mouth

Groups Dosage of stretch Outcome included in this review

Exp: Hand splint and usual care 8 hrs x 7 d x 26 wks = 1456 hrs Passive wrist extension (deg)

Con: Usual care over a 26-wk period

Exp: Extension splint plus botulinum toxin 6 to 8 hrs x 7 d x 14 wks = 588 hrs Maximal active elbow extension

and therapy to 784 hrs over a 14-wk period (deg)

Con: Botulinum toxin and therapy

Exp: Splint plus routine therapy 12 hrs x 7 d x 4 wks = 336 hrs over Passive wrist extension (deg)

Con: Routine therapy a 4-wk period

Exp: Wrist extension splint and usual 12 hrs x 7 d x 4 wks = 336 hrs over Passive wrist extension (deg)

rehabilitation a 4-wk period

Con: No splint and usual rehabilitation

Other: Neutral wrist splint

Exp: Cast plus intensive neurodevelopmental 4 hrs x 7 d x 26 wks = 728 hrs over Wrist range of motion (scale not

therapy a 26-wk period reported)

Con: Intensive neurodevelopmental therapy

Other 1: Cast plus regular

neurodevelopmental therapy

Other 2: Regular neurodevelopmental

therapy

Exp: Cast 24 hrs x 7 d x (3 to 4 wks) = Passive ankle dorsiflexion with the

Con: No cast 504 to 672 hrs over a 3 knee extended (deg)

to 4-wk period

Exp: Cast 24 hrs x 7 d = 168 hrs over a Passive ankle dorsiflexion (deg)

Con: No cast 1-wk period

Exp: Night splint 4 to 9hrs x 7d x 6 wks = 78 to Passive ankle dorsiflexion (deg)

Con: No splint 168 hrs over a 6-wk period

Exp: Night cast for 4 wks followed by (6 to 10hrs x7dx4wks) + Ankle dorsiflexion during a lunge

stretches in standing for 4 wks (1 min x 6 times per day x test (deg)

Con: No intervention 7d x 4wks) = 170.8 to 282.2hours

over an 8-wk

period

Exp: Splint 8 hrs x 7 d x 1 wk = 56 hrs over Resistance at 20 deg extension (N)

Con: No splint a 1 -wk period

Exp: Stretch plus usual care 2 wrist stretches x 30 min x Passive wrist extension of the

Con: Usual care 7 d x 12 wks = 84 hrs over a affected arm (deg)

12-wk period

Exp: Home-based stretch 5 min x 7 d x 11.6 wks = 6.7 hrs Knee range of motion in supine

Con: Maintain usual physical activity over a 12-wk period (deg)

Exp: Therabite System plus unassisted 5 repetitions x 30 s x (6 to Maximal incisal opening (mm)

exercise 10 sessions) x 7 d x 10 wks =

Con: Unassisted exercise 17.5 to 29.2 hrs over a 10-wk

Other: Stacked tongue depressors plus period

unassisted exercise

Exp: Stretch plus conventional care Total stretch time not reported Hip extension with knee in

Con: Conventional care extension (deg)

Exp: Night extension orthosis plus hand 8 hrs x 7 d x 12 wks = 672 hrs over Active extension of the little finger

therapy a 12-wk period (sum of metacarpophalangeal.

Con: Hand therapy alone proximal interphalangeal and

distal interphalangeal joints; deg)

Exp: Physiotherapy (stacked tongue 5 min x 5 sessions x 7 d x Maximal inter-incisal opening

depressors) plus conventional care 17 wks = 49.6 hrs over a (mm)

Con: Conventional care 17-wk period

Other: Hyaluronidase and steroid injections

plus conventional care

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Table 1 (Continued )

Author

Health condition

Sample size

Joint of interest

Groups

Dosage of stretch

Outcome included in this review

Fox 2000

Horton 200242 Hussein 201543

Jang 201544

Jerosch-Herold 201145

John 201146

Jongs 201247 Kemler 201248 Kolmus 201249

Lee 200750 Melegati 200355 Moseley 200551 Paul 201452 Seeger 198753 Steffen 199554

Zenios 200256

Elderly nursing-home residents

Adults following total knee replacement Adults with shoulder adhesive capsulitis

Adults with recent (< 30 d) burns around the shoulder joint Adults following surgical release for Dupuytren's contracture

Adults with hallux limitus in the first metatarsophalangeal joint following surgery Adults with contracture following distal radial fracture Adults with Dupuytren's disease

Adults with an axillary burn (anterior chest involving the axillary fold, anterior, lateral or posterior shoulder and the axillary region) Adult women following radiotherapy for breast cancer

Adults with primary anterior cruciate ligament reconstruction Adults with ankle fracture

Adults with adhesive capsulitis (frozen shoulder)

Adults with systemic sclerosis (scleroderma)

Elderly people with bilateral knee contractures

Adults following total knee replacement

Exp: 9 Con: 9

Exp: 27 Con: 28 Exp: 30 Con: 30

Exp: H Con:13

Exp: 77 Con: 77

Exp: 25 Con: 25

Exp: 19 Con: 21

Exp: 28 Con: 26

Exp: 27 Con: 25

Exp: 31 Con: 30

Exp: 18 Con:18

Exp: 51 Con: 50 Other: 49 Exp: 50 Con: 50

Exp: 19 hands Con: 19 hands

Exp: 14 Con:14

Exp: 42 Con: 39

Knee Shoulder

Shoulder

Metatarsophalangeal joint of great toe

Proximal interphalangeal

Shoulder

Shoulder

Shoulder

Proximal interphalangeal

Exp: Bed positioning program (low-load

prolonged knee stretch)

Con: No intervention

Exp: Splint

Con: No splint

Exp: Static progressive stretch device plus traditional therapy Con: Traditional therapy Exp: Shoulder splint and usual care Con: Usual care

Exp: Static night splint plus hand therapy Con: Hand therapy

Exp: Dynamic splint and usual care Con: Usual care

Exp: Splint and routine care Con: Routine care

Exp: Hand splint and usual therapy Con: Usual therapy

Exp: Shoulder splint and usual care Con: Usual care

Exp: Stretch plus usual care Con: Usual care

Exp: Knee extension brace Con: Range of motion brace

Exp: Long-duration stretch plus exercise Con: Exercise

Other: Short-duration stretch plus exercise

Exp: Stretch with countertraction device and

usual care

Con: Usual care

Exp: Splint

Con: No splint

Exp: Knee splint (prolonged stretch) plus

passive range of motion exercises and

manually administered stretches

Con: Passive range of motion exercises and

manually administered stretches

Exp: Splint

Con: No splint

40min x 4d x 8 wks = 21.3hrs over an 8-wk period

24 hrs x 2 d = 48 hrs over 2-d period

(30min x 7d x 1 wk) + (60min x 7d x 2wks)+ (90min x 7d x 1 wk) = 28 hrs over a 4-wk period 24 hrs x 7d x 4 wks = 672 hrs over a 4-wk period

8 hrs x 182 d = 1456 hrs over a 26-wk period

3 hrs x 7d x 8 wks = 168 hrs over an 8-wk period

6 hrs x 7d x 8 wks = 336 hrs over an 8-wk period

(24hrs x28d)+ (8hrs x 7dx

7 wks) = 1064 hrs over an

11-wk period

(24hrs x 7dx 6wks)+ (8hrs x 7d x 6wks) = 1344hrs over a

12-wk period

10min x 2 muscles x 2 sessions x 7d x 30.33 wks = 141.5 hrs over a 30-wk period 23 hrs x 7 d = 161 hrs over a 1-wk period

30 min x 7d x 4 wks = 14 hrs over a 4-wk period

10min x 5d x 2wks = 1.7hrs over a 2-wk period

8 hrs x 7d x 8 wks = 448 hrs over an 8-wk period

3 hrs x 5d x 26 wks = 390 hrs over a 26-wk period

23 hours x 3 days = 69 hours over a 3-day period

Passive knee extension (deg)

Knee fixed-flexion deformity (deg) Active shoulder abduction (deg)

Active shoulder abduction (deg)

Active extension of the metacarpophalangeal, proximal interphalangeal and distal interphalangeal joint of the operated fingers (deg) Active dorsiflexion at the first metatarsal joint of the hallux (great toe; deg)

Passive wrist extension (deg)

Passive extension of proximal interphalangeal joint (deg)

Shoulder range of abduction (deg)

Passive shoulder horizontal extension of the affected arm (deg)

Passive knee extension (heel height difference in cm)

Ankle dorsiflexion angle at peak baseline torque with knee straight (deg)

Shoulder flexion (deg)

Combined proximal interphalangeal passive extension (deg)

Passive knee extension (deg)

Knee fixed flexion (passive knee extension; deg)

ARTICLE IN PRESS

Harvey et al: Stretch for contractures

159 160 161 162

The effects of stretch in people with neurological conditions

Twenty-six studies with a total of 699 participants investigated the short-term effects on joint mobility following stretch in people with neurological conditions.8-33 Two additional studies only measured the long-term effects of stretch and are not included here.34,35 Eighteen studies with a total of 549 participants provided sufficient data, and all studies measured joint mobility.8-n,i3,i5,i6,i8-2o,22,25-27,29-3i,33 The participants included people with stroke, Charcot-Marie Tooth disease, acquired brain injury and spinal cord injury. The mean difference was 2 deg (95% CI 0 to 3, I2 = 37%, p = 0.009) (see Figure 2, see Figure 3 on the eAddenda for a detailed forest plot). This is equivalent to a relative change of 2% (95% CI 0 to 3). The GRADE quality of evidence for this result was high.

The effects of stretch in people with non-neurological conditions

Nineteen studies with a total of 925 participants investigated the short-term effects on joint mobility following stretch in people with non-neurological conditions.36-54 Two additional studies only measured the long-term effects of stretch and are not

Subgroup Study

MD (95% CI) Random

Stroke Ada9

Basaran10 De Jong15 Dean16 Gustafsson18 Harvey20 Horsley22 Lai25 Lannin27 Lannin26 Turton33 Subtotal

Charcot-Marie-Tooth disease Refshauge30 Rose31 Subtotal

Acquired brain injury Copley13 Harvey20 Moseley29 Subtotal

Spinal cord injury Ben11 Harvey19 Harvey8 Harvey20 Subtotal

Total +

-20 -10 0 10 20 Favours con (deg) Favours exp

Figure 2. Mean difference (95% CI) in immediate effect of stretch versus control on joint mobility in people with neurological conditions. Subtotals are presented for each clinical condition.

included here.55,56 All 19 studies provided sufficient data and all but two studies measured joint mobility in degrees.37,40 There was substantial statistical heterogeneity between studies (I2 = 67%) and the standardised mean difference was 0.3 SD (95% CI 0.1 to 0.6). The main reason for this heterogeneity was one study,43 in which the results for two of the three outcomes were between 5 and 30 times greater than the results for any other study. There was no obvious explanation for this but the extreme results all favouring the experimental condition seemed implausible. Therefore, 18 studies with a total of 865 participants were included in the present analyses.36-42,44-54 The participants included frail elderly and people with ankle fracture, anklylosing spondylitis, oral submu-cous fibrosis, post radiation therapy to the breast, post-radiation therapy to the jaw, progressive systemic sclerosis, total knee replacement, arthritis, Dupuytren's contractures, shoulder adhesive capsulitis/frozen shoulder, hallux limitus, wrist fracture and burns. The standardised mean difference was 0.2 SD (95% CI 0.0 to 0.3, I2 = 27%, p = 0.06) (see Figure 4, see Figure 5 on the eAddenda for a detailed forest plot). This translates to an absolute mean increase of 1 deg (95% CI 0 to 2) when the results are back converted using the largest, least biased and most representative study of those included in the analysis.51 This is equivalent to a relative change of 1% (95% CI 0 to 2). The GRADE quality of evidence for this result was high.

Sub-group analyses

The dosage of stretch

Thirty seven studies with a total of 1519 participants measured joint mobility in degrees, and provided sufficient data to estimate the effect of mean total stretch time on joint mobility.8-11,13,15,16,18-20,22,25-27,29,30,33-36,38,39,41-54,56 As mean time data were skewed,

they were transformed by taking the natural logarithm of time. Total stretch time was adjusted for the length of time between randomisation and measurement, as well as the length of time between the last stretch and measurement using multiple metaregression. The mean difference was 0 deg for each log hour increase in total stretch time (95% CI -1 to 1, I2 = 31%, p = 0.119).

The way the stretch is administered

Thirty seven studies with a total of 1530 participants measured joint mobility in degrees, and provided sufficient data to estimate the effect of different stretch interventions on joint mobility. 811,13,15,16,18-20,22,25-27,29,30,33-36,38,39,41-54,56 The overall effect of

administering stretch in five different ways was examined. This included stretch administered with serial casting, positioning, splinting, self-administration and other ways. The effect of stretch on joint mobility was not influenced by the way stretch was administered (test for subgroup differences; p = 0.33), although these results need to be interpreted with caution because some subgroups only included two studies.

Discussion

There is high-quality evidence that stretch does not have clinically important effects on joint mobility. The pooled mean treatment effect for neurological and non-neurological conditions is 2 deg and 1 deg, respectively. These estimates are very precise, with the upper end of the 95% CI spanning to 3 deg and 2 deg, respectively. So unless readers consider a maximal possible treatment effect of 3 deg to be clinically worthwhile, these results conclusively indicate that stretch does not change joint mobility. These findings are robust in most sensitivity and sub-group analyses, and are based on the results of 36 studies involving 1414 participants. The participants included people with a range of different diagnoses, including spinal cord injury, acquired brain injury, stroke, ankylosing spondylitis, oral submucous fibrosis, systemic sclerosis, ankle fracture and arthritis. The studies were categorised and analysed on the basis of whether the underlying

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Subgroup Study

SMD (95% CI) Random

Frail elderly Fox41 Steffen54 Subtotal

Ankle fracture Moseley51

Ankylosing spondylitis Bulstrode38

Oral submucous fibrosis Cox40

Radiotherapy to breast Lee50

Radiotherapy to jaw Buchbinder37

Systemic sclerosis Seeger53

Total knee replacement Horton42

Arthritis Aoki36

Dupuytren's contracture Collis39

Jerosch-Herold45 Kemler48 Subtotal

Frozen shoulder Paul52

Hallux limitus John46

Wrist fracture Jongs47

Burns Jang44 Kolmus49 Subtotal

-2-10 1 2 Favours con Favours exp

Figure 4. Standardised mean difference (95% CI) in immediate effect of stretch versus control on joint mobility in people with non-neurological conditions. Subtotals are presented only where multiple trials examined the same clinical condition.

condition was neurological or non-neurological, to guard against the possibility that the effectiveness of stretch differs depending on the involvement of the nervous system. However, there was no indication that this was the case. Nor was there any evidence that the effects of stretch differed between different types of neurological or non-neurological conditions. The only exception was acquired brain injury. The point estimates for people with acquired brain injury was very imprecise, failing to rule in or rule out a clinically important treatment effect. These results therefore need to be interpreted with caution.

There are two important caveats to our findings. Firstly, no study administered stretch for > 7 months, with most studies applying stretch for between 4 and 12 weeks. It is possible that the effects of stretch accumulate over time. If this is the case, regular stretching applied for many years as part of a home maintenance program for people with spinal cord injury, stroke and other similar conditions, may ultimately yield clinically important effects on joint mobility. It is unfortunate that studies looking at the effects of stretch administered for such periods of time are unlikely to ever be conducted. For this reason, uncertainty will remain about the worth of these sorts of stretching programs. The second important caveat is that no study compared stretch, as typically incorporated into routine nursing care, with nursing care that did not incorporate stretch. The results of our review are therefore potentially harmful if people extrapolate the findings to mean that it is acceptable for semi-comatosed or paralysed patients to lie flexed in bed with no attention to the position of their limbs. We do not advocate this and do not believe that this is a valid interpretation of our results.

This republication of the updated 2017 Cochrane Systematic Review7 does not include the results of the other outcomes that were investigated. These include quality of life, pain, activity limitation, participation restriction, adverse events and spasticity. However, in the updated 2017 Cochrane Systematic Review7 it was concluded that it is uncertain whether stretch has clinically important short-term effects on pain (standardised mean difference 0.2, 95% CI -0.1 to 0.5, five studies with 174 participants) or activity limitations (standardised mean difference 0.2, 95% CI -0.1 to 0.5, eight studies with 247 participants) in people with neurological conditions, and the effects of stretch on quality of life or participation restrictions are unknown. The effects of stretch in people with non-neurological conditions are somewhat clearer. For example, there is high-quality evidence that stretch does not have clinically important effects on pain (standardised mean difference -0.2, 95% CI -0.4 to 0.1, seven studies with 422 participants) and moderate quality evidence that stretch does not have clinically important effects on quality of life (standardised mean difference 0.3, 95% CI -0.1 to 0.7, two studies with 97 participants). However, the effects of stretch on activity limitations and participation restrictions in people with non-neurological conditions are also uncertain. The long-term effects are either more ambiguous or have not been investigated. There are some reports of adverse events predominantly from studies that applied stretch through splints or plaster casts. The adverse events included numbness, pain, swelling, skin breakdown, bruising and blisters.

It is unlikely that further studies will change the results of this review. There may, however, be value in examining the effects of stretch administered with other interventions. For example, stretch administered with motor training or botulinum toxin in people with neurological conditions. There may also be worth in specifically investigating the effectiveness of stretch administered for extended periods of time (eg, years). In addition, there may be value in further exploring the effectiveness of stretch for the prevention of contracture, particularly in those at very high risk of developing severe contracture (eg, people with traumatic brain injury). For example, there is no way of knowing whether the studies included in this review that claimed to include people at risk of contracture included people who subsequently went on to develop contracture. If those who are likely to develop severe contracture could accurately be predicted, these individuals could be selectively recruited to studies. However, it is proving more difficult than commonly assumed to accurately predict those likely to develop severe contractures.1,2

The results of this Cochrane Systematic Review are challenging for the physiotherapy profession because they contradict a fundamental assumption that physiotherapists have made for a long time. Namely, that stretch is effective for the treatment and prevention of contracture. However, the evidence is now compelling that stretch does not have clinically meaningful effects on joint mobility and that these results are robust to many different sub-

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8 Harvey et al: Stretch for contractures

group analyses. However, caution is recommended before extrapolating these results to stretch applied regularly for many months or years. The effectiveness of stretch administered for such extended periods of time is unknown.

Footnotes: aReview Manager 5, The Cochrane Collaboration, Copenhagen, Denmark.

eAddenda: Figures 3 and 5, Appendix 1 can be found online at http://dx.doi.org/10.1016/jjphys.2017.02.014.

Ethics approval: Not required.

Competing interests: The authors declare no conflict of interest.

Sources of support: Nil.

Acknowledgements: Nil.

Provenance: Not invited. Peer reviewed.

Correspondence: Lisa Harvey, John Walsh Centre for Rehabilitation Research, Kolling Institute, C/O Royal North Shore Hospital, St Leonards, Australia. Email: l.harvey@usyd.edu.au.

Appendix A. Supplementary data

Supplementary data associated with this article can be found, in the online version, at http://dx.doi.org/10.1016/jjphys.2017.02.014.

References

1. Diong J, Harvey LA, Kwah LK, Eyles J, Ling MJ, Ben M, et al. Incidence and predictors of contracture after spinal cord injury-a prospective cohort study. Spinal Cord. 2012;50:579-584.

2. Kwah L, Harvey L, Diong J, Herbert R Half of those who present to hospital with stroke develop at least one contracture within six months: a prospective cohort study. J Physiother. 2012;58:41-47.

3. Offenbacher M, Sauer S, Riess J, Muller M, Grill E, Daubner A, et al. Contractures with special reference in elderly: definition and risk factors - a systematic review with practical implications. Disabil Rehabil. 2014;36:529-538.

4. Williams PE. Use of intermittent stretch in the prevention of serial sarcomere loss in immobilised muscle. Ann Rheum Dis. 1990;49:316-317.

5. Williams PE, Catanese T, Lucey EG, Goldspink G. The importance of stretch and contractile activity in the prevention of connective tissue accumulation in muscle. J Anat. 1988;158:109-114.

6. Katalinic OM, Harvey LA, Herbert RD, Moseley AN, Lannin NA, Schurr K. Stretch for the treatment and prevention of contractures. Cochrane Database Syst Rev. 2010. CD007455.

7. Harvey LA, Katalinic OM, Herbert RD, Moseley AM, Lannin NA, Schurr K. Stretch for the treatment and prevention of contractures. Cochrane Database Syst Rev. 2017. CD 007455.

8. Harvey LA, Byak AJ, Ostrovskaya M, Glinsky J, Katte L, Herbert RD. Randomised trial of the effects of four weeks of daily stretch on extensibility of hamstring muscles in people with spinal cord injuries. Aust J Physiother. 2003;49:176-181.

9. Ada L, Goddard E, McCully J, Stavrinos T, Bampton J. Thirty minutes of positioning reduces the development of shoulder external rotation contractures after stroke: a randomized controlled trial. Arch Phys Med Rehabil. 2005;86:230-234.

10. Basaran A, Emre U, Karadavut KI, Balbaloglu O, Bulmus N. Hand splinting for poststroke spasticity: a randomized controlled trial. Top Stroke Rehabil. 2012;19: 329-337.

11. Ben M, Harvey L, Denis S, Glinsky J, Goehl G, Chee S, et al. Does 12 weeks of regular standing prevent loss of ankle mobility and bone mineral density in people with recent spinal cord injuries? Aust J Physiother. 2005;51:251-256.

12. Bürge E, Kupper D, Finckh A, Ryerson S, Schnider A, Leemann B. Neutral Functional Realignment Orthosis Prevents Hand Pain in Patients With Subacute Stroke: A Randomized Trial. Arch Phys Med Rehabil. 2008;89:1857-1862.

13. Copley J, Kuipers K, Fleming J, Rassafiani M. Individualised resting hand splints for adults with acquired brain injury: a randomized, single blinded, single case design. NeuroRehabilitation. 2013;32:885-898.

14. Crowe J, MacKay-Lyons M, Morris H. A multi-centre, randomized controlled trial of the effectiveness of positioning on quadriplegic shoulder pain. Physiother Can. 2000;52:266-273.

15. de Jong LD, Nieuwboer A, Aufdemkampe G. Contracture preventive positioning of the hemiplegic arm in subacute stroke patients: a pilot randomized controlled trial. Clin Rehabil. 2006;20:656-667.

16. Dean CM, Mackey FH, Katrak P. Examination of shoulder positioning after stroke: A randomised controlled pilot trial. Aust J Physiother. 2000;46:35-40.

17. DiPasquale-Lehnerz P. Orthotic intervention for development of hand function with C-6 quadriplegia. Am J Occup Ther. 1994;48:138-144.

18. Gustafsson L, McKenna K. A program of static positional stretches does not reduce hemiplegic shoulder pain or maintain shoulder range of motion — a randomized controlled trial. Clin Rehabil. 2006;20:277-286.

19. Harvey LA, Batty J, Crosbie J, Poulter S, Herbert RD. A randomized trial assessing the effects of 4 weeks of daily stretching on ankle mobility in patients with spinal cord injuries. Arch Phys Med Rehabil. 2000;81:1340-1347.

20. Harvey LA, de Jong I, Geohl G, Marwedel S. Twelve weeks of nightly stretch does not reduce thumb web-space contractures in people with a neurological condition: a randomised controlled trial. Aust J Physiother 2006;52:251-258.

21. Hill J. The effects of casting on upper extremity motor disorders after brain injury. Am J Occup Ther 1994;48:219-224.

22. Horsley S, Herbert R, Ada L. Four weeks of daily stretch has little or no effect on wrist contracture after stroke: a randomised controlled trial. Aust J Physiother. 2007;53:239-245.

23. Hyde SA, Fl0ytrup I, Glent S, Kroksmark AK, Salling B, Steffensen BF, et al. A randomized comparative study of two methods for controlling Tendo Achilles contracture in Duchenne muscular dystrophy. Neuromuscul Disord. 2000;10:257-263.

24. Krumlinde-Sundholm L. Hand splints in children with cerebral palsy: Effects of maintained or disrupted use. Dev Med Child Neurol. 2011;53:27.

25. Lai JM, Francisco GE, Willis FB. Dynamic splinting after treatment with botulinum toxin type-A: A randomized controlled pilot study. Adv Ther 2009;26:241-248.

26. Lannin Na, Cusick A, McCluskey A, Herbert R Effects of splinting on wrist contractures following stroke: a randomized controlled trial. Stroke. 2007;38:111-116.

27. Lannin NA, Herbert RD. Is hand splinting effective for adults following stroke? A systematic review and methodological critique of published research. Clin Rehabil. 2003;17:.

28. Law M, Cadman D, Rosenbaum P, Walter S, Russell D, DeMatteo C. Neurodevelop-mental therapy and upper-extremity inhibitive casting for children with cerebral palsy. Dev Med Child Neurol. 1991;33:379-387.

29. Moseley AM. The effect of casting combined with stretching on passive ankle dorsiflexion in adults with traumatic head injuries. Phys Ther 1997;77:240-247.

30. Refshauge KM, Raymond J, Nicholson G, van den Dolder PA. Night splinting does not increase ankle range of motion in people with Charcot-Marie-Tooth disease: A randomised cross-over trial. Aust J Physiother 2006;52:193-199.

31. Rose KJ, Raymond J, Refshauge K, North KN, Burns J. Serial night casting increases ankle dorsiflexion range in children and young adults with Charcot-Marie-Tooth disease: A randomised trial. J Physiother 2010;56:113-119.

32. Sheehan JL, Winzeler-Mer^ay U, Mudie MH. A randomized controlled pilot study to obtain the best estimate of the size of the effect of a thermoplastic resting splint on spasticity in the stroke-affected wrist and fingers. Clin Rehabil. 2006;20: 1032-1037.

33. Turton AJ, Britton E. A pilot randomized controlled trial of a daily muscle stretch regime to prevent contractures in the arm after stroke. Clin Rehabil. 2005;19:600-612.

34. McNee AE, Will E, Lin JP, Eve LC, Gough M, Morrissey MC, et al. The effect of serial casting on gait in children with cerebral palsy: preliminary results from a crossover trial. Gait & Posture. 2007;25:463-468.

35. Ackman JD, Russman BS, Thomas SS, Buckon CE, Sussman MD, Masso P, et al. Comparing botulinum toxin A with casting for treatment of dynamic equinus in children with cerebral palsy. Dev Med Child Neurol. 2005;47:620-627.

36. Aoki O, Tsumura N, Kimura A, Okuyama S, Takikawa S, Hirata S. Home stretching exercise is effective for improving knee range of motion and gait in patients with knee osteoarthritis. J Phys TherSci. 2009;21:113-119.

37. Buchbinder D, Currivan RB, Kaplan AJ, Urken ML. Mobilization regimens for the prevention of jaw hypomobility in the radiated patient: A comparison of three techniques. J Oral Maxillofac Surg. 1993;51:863-867.

38. Bulstrode SJ, Barefoot J, Harrison RA, Clarke AK. The role of passive stretching in the treatment of ankylosing spondylitis. Br J Rheumatol. 1987;26:40-42.

39. Collis J, Collocott S, Hing W, Kelly E. The effect of night extension orthoses following surgical release of Dupuytren contracture: A single-center, randomized, controlled trial. J Hand Surg. 2013;38:1285-1294e1282.

40. Cox S, Zoellner H. Physiotherapeutic treatment improves oral opening in oral submucous fibrosis. J Oral Pathol Med. 2009;38:220-226.

41. Fox P, Richardson J, McInnes B, Tait D, Bedard M. Effectiveness of a bed positioning program for treating older adults with knee contractures who are institutionalized. Phys Ther. 2000;80:363-372.

42. Horton TC, Jackson R, Mohan N, Hambidge JE. Is routine splintage following primary total knee replacement necessary? A prospective randomised trial. Knee. 2002;9:229-231.

43. Hussein AZ, Ibrahim MI, Hellman MA, Donatelli R. Static progressive stretch is effective in treating shoulder adhesive capsulitis: Prospective, randomized, controlled study with a two-year follow-up. Eur J Physiother. 2015;17:138-147.

44. Jang KU, Choi JS, Mun JH, Jeon JH, Seo CH, Kim JH. Multi-axis shoulder abduction splint in acute burn rehabilitation: a randomized controlled pilot trial. Clin Rehabil. 2015;29:439-446.

45. Jerosch-Herold C, Shepstone L, Chojnowski AJ, Larson D, Barrett E, Vaughan SP. Night-time splinting after fasciectomy or dermo-fasciectomy for Dupuytren's contracture: a pragmatic, multi-centre, randomised controlled trial. BMC Muscu-loskelet Disord. 2011;12:136.

46. John MM, Kalish S, Perns SV, Willis FB. Dynamic splinting for postoperative hallux limitus: a randomized, controlled trial. J Am Podiatr Med Assoc 2011;101:285-288.

47. Jongs RA, Harvey LA, Gwinn T, Lucas BR. Dynamic splints do not reduce contracture following distal radial fracture: a randomised controlled trial. J Physiother. 2012; 58:173-180.

48. Kemler MA, Houpt P, van der Horst CM. A pilot study assessing the effectiveness of postoperative splinting after limited fasciectomy for Dupuytren's disease. J Hand Surg Eur Vol. 2012;37:733-737.

What is already known on this topic: Contractures can occur with many types of injuries and disabilities. Stretch is commonly used by physiotherapists for the treatment and prevention of contractures.

What this study adds: High-quality evidence indicates that stretch does not have clinically worthwhile short-term effects on joint mobility. The effectiveness of stretch administered for many months or years is unknown.

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49. Kolmus AM, Holland AE, Byrne MJ, Cleland HJ. The effects of splinting on shoulder function in adult burns. Burns. 2012;38:638-644.

50. Lee T, Kilbreath S, Refshauge K, Pendlebury S, Beith J, Lee M. Pectoral stretching program for women undergoing radiotherapy for breast cancer. Breast Cancer Res Treat. 2007;102:313-321.

51. Moseley A, Herbert R, Nightingale E, Taylor D, Evans T, Robertson G, et al. Passive stretching does not enhance outcomes in patients with plantarflexion contracture after cast immobilization for ankle fracture: a randomized controlled trial. Arch Phys Med Rehabil. 2005;86:1118-1126.

52. Paul A, Rajkumar JS, Peter S, Lambert L. Effectiveness of sustained stretching of the inferior capsule in the management of a frozen shoulder. Clin Orthop Rel Res. 2014;472:2262-2268.

53. Seeger MW, Furst DE. Effects of splinting in the treatment of hand contractures in progressive systemic sclerosis. Am J Occup Ther. 1987;41:118-121.

54. Steffen TM, Mollinger LA. Low-load, prolonged stretch in the treatment of knee flexion contractures in nursing home residents. Phys Ther. 1995;75:886-895.

55. Melegati G, Tornese D, Bandi M, Volpi P, Schonhuber H, Denti M. The role of the rehabilitation brace in restoring knee extension after anterior cruciate ligament reconstruction: a prospective controlled study. Knee SurgSports Traumatol Arthrosc. 2003;11:322-326.

56. Zenios M, Wykes P, Johnson DS, Clayson AD, Kay P. The use of knee splints after total knee replacements. Knee. 2002;9:225-228.