Passive movements for the treatment and prevention of contractures

Rama KR Prabhu; Narasimman Swaminathan; Lisa A Harvey

doi:10.1002/14651858.CD009331.pub2

Movimientos pasivos para el tratamiento y la prevención de contracturas

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References

References to studies included in this review

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excluded studies
additional references
other published versions

Harvey LA, Herbert RD, Glinsky J, Moseley AM, Bowden J. Effects of 6 months of regular passive movements on ankle joint mobility in people with spinal cord injury: a randomized controlled trial. Spinal Cord 2009;47(1):62‐6. [PUBMED: 18574489]

Hobbelen JH, Tan FE, Verhey FR, Koopmans RT, de Bie RA. Passive movement therapy in severe paratonia: a multicenter randomized clinical trial. International Psychogeriatrics / IPA 2012;24(5):834‐44. [PUBMED: 22185768]

References to studies excluded from this review

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included studies
additional references
other published versions

Bennell KL, Hinman RS, Metcalf BR, Buchbinder R, McConnell J, McColl G, et al. Efficacy of physiotherapy management of knee joint osteoarthritis: a randomised, double blind, placebo controlled trial. Annals of the Rheumatic Diseases 2005;64(6):906‐12. [PUBMED: 15897310]

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Carmeli E, Bartur G, Peleg S, Barchad S, Vatine JJ. Does passive leg activity influence oxygen saturation and activity in sedentary elderly adults?. The Scientific World Journal 2006;6:1075‐80. [PUBMED: 16951900]

Cheng H‐YK, Ju Y‐Y, Chen C‐L, Chang Y‐J, Wong AM‐K. Managing lower extremity muscle tone and function in children with cerebral palsy via eight‐week repetitive passive knee movement intervention. Research in Developmental Disabilities 2013;34(1):554‐61. [PUBMED: 23123868]

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Krause P, Szecsi J, Straube A. Changes in spastic muscle tone increase in patients with spinal cord injury using functional electrical stimulation and passive leg movements. Clinical Rehabilitation 2008;22(7):627‐34. [PUBMED: 18586814]

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Additional references

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other published versions

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References to other published versions of this review

Jump to:

included studies
excluded studies
additional references

Prabhu RKR, Swaminathan N, Harvey LA. Passive movements for the treatment and prevention of contractures. Cochrane Database of Systematic Reviews 2011, Issue 9. [DOI: 10.1002/14651858.CD009331]

Characteristics of studies

Characteristics of included studies [ordered by study ID]

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excluded studies

Harvey 2009

Methods	Design: within‐subject randomised controlled trial
Participants	Health condition: adults with spinal cord injury Sample size: experimental group: 20 ankles; control group: 20 ankles^a Setting: community, Australia Joint of interest: ankle Inclusion criteria: Participants were included if they: were wheelchair dependent; had mild to moderate ankle stiffness (less than 101 degrees dorsiflexion with a 12‐Nm torque applied to the ankle but an arc of at least 15 degrees of motion); had paralysis around both knees and ankles; and had care givers able to provide the intervention Exclusion criteria: not reported Median age (IQR) Both groups: 39 (34 to 44) Gender Both groups: 17 M, 3 F Study dates: not reported Other: Funding through the University of Sydney's Research and Development Grants Scheme. Conflict of interest not reported
Interventions	Groups included in this review: Experimental group: PMs to one randomly allocated ankle of each participant Experimental ankles of participants were passively moved by participants' care givers for 10 minutes in the morning and 10 minutes in the evening, five days a week for six months. Care givers were given written instructions and training on how to administer PMs Participants or care givers were required to record in a diary when and for how long PMs were administered Total time: 288 treatments × 10 minutes over a period of six months Control group: no PMs to the second ankle of the participant Control ankles did not receive PMs or stretches for the duration of the trial
Outcomes	Outcomes included in this review Passive ankle dorsiflexion range of motion (degrees) Ankle plantar flexor spasticity (Modified Ashworth Scale, points) Other outcomes Knee hamstring muscle spasticity (Modified Ashworth Scale, points) Outcomes testing period Tested at baseline and one day after the six‐month intervention period. No PMs were administered in the 24 hours before either assessment
Notes	^aBoth ankles of 20 participants were included (a total of 40 ankles). No dropouts from the study were reported
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Quote: "...a computer‐generated random number sequence was created by a person not involved in recruitment to determine allocation schedule" Comment: Authors have explained the procedure
Allocation concealment (selection bias)	Low risk	Quote: "...each participant's allocation was placed in a sealed, opaque, sequentially numbered envelope to ensure allocation" Comment: Authors have explained the procedure
Incomplete outcome data (attrition bias) All outcomes	Low risk	Comment: no dropouts
Selective reporting (reporting bias)	Low risk	Comment: all prestated outcomes reported
Other bias	Low risk	Comment: appears free of other bias
Blinding of participants and personnel (performance bias) All outcomes	Low risk	Comment: not possible to blind participants and personnel; however, this was unlikely to bias the results because participants had paralysis and limited ability to influence outcomes
Blinding of outcome assessment (detection bias) All outcomes	Low risk	Quote: "...all assessors were blinded to group allocation"

Hobbelen 2012

Methods	Design: multi‐centre single‐blinded randomised controlled trial
Participants	Health condition: adults with dementia. Sample size: experimental group: 48^a; control group: 54 Setting: nursing home residents, Netherlands Inclusion criteria: Participants were included if they: met DSM‐IV‐TR criteria for dementia; were diagnosed with paratonia; and had moderate to severe paratonia defined as a score on the MAS of at least two in at least one limb Exclusion criteria: Participants were excluded if they: had been prescribed any antipsychotic medication; had received PMs less than four weeks before the start of the trial; had an unstable health problem or disease before admission or during the trial^b; or showed signs of challenging behaviour towards the therapist and or the intervention Median age (range) Experimental group: 84 (74 to 98) Control group: 83 (67 to 97) Gender Experimental group: 9 M, 38 F Control group: 9 M, 45 F Study dates: Data collection occurred between April 2007 and April 2009 Other: Funding through the Vitalis WoonZorg Groep Eindhoven, the Netherlands. The first author was a part‐time employee at the Vitalis WoonZorg Groep
Interventions	Groups included in this review: Experimental group: PMs to all limbs Participants were comfortably supine in bed when therapists started PMs with the left arm, moving the shoulder and subsequently the elbow. Next, the same movements were made in the right arm. Subsequently, the left leg and the right leg were moved, with the hip and knee in flexion, extension and abduction/external rotation, although with no spinal movements Total time: 12 sessions × 20 minutes over a period of four weeks Control group: no PMs to limbs Participants were comfortably supine in the bed while therapists sat silently alongside the bed for an equal duration of time as required to administer PMs to experimental participants
Outcomes	Outcomes included in this review Severity of paratonia in upper limbs (tallied Modified Ashworth Scale, points) Pain (Pain Assessment Checklist for Seniors With Limited Ability to Communicate Scale, points) Other outcomes Severity of paratonia in lower limbs (tallied Modified Ashworth Scale, points) Care giver burden (Clinical Global Impression of Change—change, points) Functional status of the participant (Modified Patient Specific Complaints, points) Outcomes testing period Tested at baseline (one day before commencement of treatment), after two weeks and after four weeks (one day after treatment 12)
Notes	^a102 participants were randomly assigned, but one dropout was reported. Therefore, data from only 101 participants were included in the analyses (Analysis 2.1 and Analysis 3.1) ^bIt is not clear how a health condition occurring "during the trial" (so after randomisation) could be part of the exclusion criteria
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Quote: "...computerized and concealed block randomisation (block size four)" Comment: Authors have explained the procedure
Allocation concealment (selection bias)	Low risk	Quote: "The randomisation code was only available to the assigned therapists and was kept secret from all other personnel involved, including the primary investigator" Comment: Authors have explained the procedure, although the fixed block size of four may have enabled those recruiting to guess some participants' allocation if they were aware of this
Incomplete outcome data (attrition bias) All outcomes	Low risk	Comment: one of 48 in the experimental group
Selective reporting (reporting bias)	Low risk	Comment: all prestated outcomes reported
Other bias	Low risk	Comment: appears free of other bias
Blinding of participants and personnel (performance bias) All outcomes	Low risk	Comment: not possible to blind participants and personnel; however, this was unlikely to bias the results because participants were in the advanced stages of dementia with limited ability to influence outcomes
Blinding of outcome assessment (detection bias) All outcomes	Low risk	Quote: "...all assessors were blinded to group allocation"

Characteristics of excluded studies [ordered by study ID]

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included studies

Study	Reason for exclusion
Bennell 2005	Not clear whether PMs were administered to experimental participants
Cadenhead 2002	Not a randomised controlled trial
Carmeli 2006	PMs administered through device
Cheng 2013	PMs administered through device
Ferrarello 2011	Systematic review of active interventions
Gebhard 1993	Animal study
Goldsmith 2002	Compared active, passive range of motion exercises versus control group; therefore cannot isolate the effects of PMs
Hoeksma 2004	No PMs administered
Jesudason 2002	No PMs administered
Krause 2008	PMs administered through device
Litmanovitz 2007	PMs not administered for treatment and prevention of contractures
Lorentzen 2012	Compared a neural tension technique versus PMs (PMs were "within a small range of motion" and were administered to have an effect similar to that of placebo)
Nilgun 2011	Not a randomised controlled trial
Shin 2012	Not a randomised controlled trial

Data and analyses

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Comparison 1. Joint mobility—short‐term effects

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Spinal cord injury Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected
Open in figure viewer Analysis 1.1 Comparison 1 Joint mobility—short‐term effects, Outcome 1 Spinal cord injury.

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Comparison 2. Spasticity—short‐term effects

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Paratonia Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 2.1 Comparison 2 Spasticity—short‐term effects, Outcome 1 Paratonia.

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Comparison 3. Pain—short‐term effects

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Paratonia Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 3.1 Comparison 3 Pain—short‐term effects, Outcome 1 Paratonia.

Figure 1

Study flow diagram.

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Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies. Two studies are included in this review.

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Figure 3

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Analysis 1.1

Comparison 1 Joint mobility—short‐term effects, Outcome 1 Spinal cord injury.

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Analysis 2.1

Comparison 2 Spasticity—short‐term effects, Outcome 1 Paratonia.

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Analysis 3.1

Comparison 3 Pain—short‐term effects, Outcome 1 Paratonia.

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Summary of findings for the main comparison. Short‐term effects on spasticity, pain and joint mobility

Short‐term effects on spasticity, pain and joint mobility
Patient or population: patients with or at risk of contractures Settings: nursing home or community Intervention: PMs versus no PMs
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No. of participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	Control	PMs versus no PMs
Spasticity Tallied Modified Ashworth Scale Follow‐up: mean 1 day	Data were not pooled	Data were not pooled	Not estimable	121 (two studies)	⊕⊝⊝⊝ very low^1,2,3
Pain Pain Assessment Checklist for Seniors With Limited Ability to Communicate Scale from: 0 to 24 Follow‐up: mean 1 day	Mean pain in control groups was 3.8 points	Mean pain in intervention groups was 0.4 higher (0.56 lower to 1.36 higher)	Not estimable	101 (one study)	⊕⊝⊝⊝ very low^1,2,3
Joint mobility Ankle dorsiflexion range of motion. Scale from 0 to 120 Follow‐up: mean 1 day	Mean joint mobility in control groups was 12 degrees	Mean joint mobility in intervention groups was 4.05 higher (1.65 to 6.46 higher)	Not estimable	40 (one study)	⊕⊝⊝⊝ very low^1,2,3
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval.
GRADE Working Group grades of evidence. High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
¹Consistency had been downgraded by one point because only one trial is included, and therefore the results cannot be consistent across different trials. ²Indirectness had been downgraded by one point because only one trial is included, and therefore the results cannot be generalised. ³Imprecision has been downgraded by one point because only one trial is included, and therefore the precision of the estimate from this one trial cannot be confirmed.

Summary of findings for the main comparison. Short‐term effects on spasticity, pain and joint mobility

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Comparison 1. Joint mobility—short‐term effects

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Spinal cord injury Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

Comparison 1. Joint mobility—short‐term effects

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Comparison 2. Spasticity—short‐term effects

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Paratonia Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

Comparison 2. Spasticity—short‐term effects

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Comparison 3. Pain—short‐term effects

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Paratonia Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

Comparison 3. Pain—short‐term effects

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References

References to studies included in this review

Harvey 2009 {published data only}

Hobbelen 2012 {published data only}

References to studies excluded from this review

Bennell 2005 {published data only}

Cadenhead 2002 {published data only}

Carmeli 2006 {published data only}

Cheng 2013 {published data only}

Ferrarello 2011 {published data only}

Gebhard 1993 {published data only}

Goldsmith 2002 {published data only}

Hoeksma 2004 {published data only}

Jesudason 2002 {published data only}

Krause 2008 {published data only}

Litmanovitz 2007 {published data only}

Lorentzen 2012 {published data only}

Nilgun 2011 {published data only}

Shin 2012 {published data only}

Additional references

Bennett 1946

Bohannon 1987

Diong 2012

Downie 1978

Eriks‐Hoogland 2009

Farmer 2001

Fergusson 2007

Fox 2000

GRADE Working Group 2004

GRADEpro 2008 [Computer program]

Halar 1988

Harrington 2006

Harvey 2001

Harvey 2001a

Harvey 2002

Harvey 2008

Harvey 2010

Higgins 2011

Hobbelen 2007

Huskisson 1974

Jamshed 2010

Katalinic 2010

Keith 1987

Krause 2000

Kwah 2012

Mahoney 1965

Mollinger 1993

Review Manager [Computer program]

Sackley 2008

Scott 1981

Singer 2004

Somers 2001

Souren 1995

Stockley 2010

Tardieu 1954

Treanor 1950

Wagner 2010

Ware 1992

Wiles 2010

Williams 1984

Yarkony 1985

References to other published versions of this review

Prabhu 2011

Characteristics of studies

Characteristics of included studies [ordered by study ID]

Characteristics of excluded studies [ordered by study ID]

Data and analyses

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