Stretch for the treatment and prevention of contractures

Lisa A Harvey; Owen M Katalinic; Robert D Herbert; Anne M Moseley; Natasha A Lannin; Karl Schurr

doi:10.1002/14651858.CD007455.pub3

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Figure 1

Study flow diagram

^1. These numbers are approximate only

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Figure 2

Methodological quality summary: review authors' judgements about each methodological quality item for each included study

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Figure 3

Forest plot of comparison: Joint mobility ‐ short‐term effects following stretch ‐ neurological conditions (degrees)

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Figure 4

Forest plot of comparison: Joint mobility ‐ short‐term effects following stretch ‐ non‐neurological conditions (SMD)

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Figure 5

Forest plot of comparison: Joint mobility ‐ long‐term effects following stretch ‐ neurological conditions (degrees)

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Figure 6

Bubble plot of meta‐regression analysis: Joint mobility ‐ effects of total stretch time on joint mobility ‐ all conditions (degrees)

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Figure 7

Forest plot of comparison: Joint mobility ‐ subgroup analyses by type of stretch intervention ‐ neurological conditions (degrees)

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Figure 8

Funnel plot of comparison: 1 Joint mobility ‐ short‐term effects following stretch, outcome: 1.1 Neurological conditions (degrees)

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Figure 9

Funnel plot of comparison: 1 Joint mobility ‐ short‐term effects following stretch, outcome: 1.2 Non‐neurological conditions

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Analysis 1.1

Comparison 1 Joint mobility ‐ short‐term effects following stretch, Outcome 1 Neurological conditions.

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Analysis 1.2

Comparison 1 Joint mobility ‐ short‐term effects following stretch, Outcome 2 Non‐neurological conditions.

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Analysis 2.1

Comparison 2 Joint mobility ‐ long‐term effects following stretch, Outcome 1 Neurological conditions.

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Analysis 2.2

Comparison 2 Joint mobility ‐ long‐term effects following stretch, Outcome 2 Non‐neurological conditions.

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Analysis 3.1

Comparison 3 Quality of life ‐ short‐term effects following stretch, Outcome 1 Non‐neurological conditions.

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Analysis 4.1

Comparison 4 Pain ‐ short‐term effects following stretch, Outcome 1 Neurological conditions.

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Analysis 4.2

Comparison 4 Pain ‐ short‐term effects following stretch, Outcome 2 Non‐neurological conditions.

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Analysis 5.1

Comparison 5 Pain ‐ long‐term effects following stretch, Outcome 1 Neurological conditions.

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Analysis 5.2

Comparison 5 Pain ‐ long‐term effects following stretch, Outcome 2 Non‐neurological conditions.

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Analysis 6.1

Comparison 6 Activity limitations ‐ short‐term effects following stretch, Outcome 1 Neurological conditions.

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Analysis 6.2

Comparison 6 Activity limitations ‐ short‐term effects following stretch, Outcome 2 Non‐neurological conditions.

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Analysis 7.1

Comparison 7 Activity limitations ‐ long‐term effects following stretch, Outcome 1 Neurological conditions.

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Analysis 7.2

Comparison 7 Activity limitations ‐ long‐term effects following stretch, Outcome 2 Non‐neurological conditions.

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Analysis 8.1

Comparison 8 Participation restrictions ‐ short‐term effects following stretch, Outcome 1 Non‐neurological conditions.

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Analysis 9.1

Comparison 9 Participation restrictions ‐ long‐term effects following stretch, Outcome 1 Non‐neurological conditions.

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Analysis 10.1

Comparison 10 Spasticity ‐ short‐term effects following stretch, Outcome 1 Neurological conditions.

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Analysis 11.1

Comparison 11 Spasticity ‐ long‐term effects following stretch, Outcome 1 Neurological conditions.

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Analysis 12.1

Comparison 12 Joint mobility ‐ subgroup analyses, Outcome 1 Types of stretch intervention.

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Analysis 12.2

Comparison 12 Joint mobility ‐ subgroup analyses, Outcome 2 Large versus small joints.

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Analysis 12.3

Comparison 12 Joint mobility ‐ subgroup analyses, Outcome 3 Influence of discomfort.

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Analysis 12.4

Comparison 12 Joint mobility ‐ subgroup analyses, Outcome 4 Joint mobility measured less than one day versus more than one day.

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Summary of findings for the main comparison. Short‐term effects of stretch for the treatment and prevention of contractures in people with neurological conditions

Short‐term effects of stretch for the treatment and prevention of contractures
Patient or population: people with neurological conditions¹ Settings: inpatients and outpatients Intervention: short‐term effects of stretch (< 1 week after the last stretch)
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of participants (studies)	Quality of the evidence (GRADE)	Comments, summary statistics, NNTB and absolute risk difference (ARD)
	Assumed risk	Corresponding risk
	Control	Short‐term effects of stretch
Joint mobility Range of motion Scale from 0°‐135° (higher number reflects better outcome)	Mean joint mobility in the control groups was 10°²	The mean joint mobility in the intervention groups was 2° higher (0° to 3° higher)		549 (18 studies)	⊕⊕⊕⊕ high³	Absolute change = 1% better (0% to 2% better) Relative change = 2% better (0% to 3% better) The results rule out a clinically important treatment effect equivalent to 5°
Quality of life	No studies measured quality of life		Not estimable	Not estimable	Not estimable	Not measured
Pain 10‐point VAS (lower score reflects better outcome)	The mean pain in the control group was 0.6 points on a 10‐point VAS⁴	This translates to an absolute mean increase of 0.2 higher (‐0.1 to 0.6) points compared with control group on a 10‐point scale.⁵		174 (5 studies)	⊕⊕⊝⊝ low^3,6	SMD = 0.2 higher (0.1 lower to 0.5 higher) Absolute change = 2% worse (1% better to 6% worse) Relative change = 55% worse (28% better to 138% worse)
Activity limitations 18‐point upper limb scale (higher score reflects better outcome)	The mean activity limitation in the control group was 0.9 points on an 18‐point upper limb scale⁷	This translates to an absolute mean increase of 0.1 (‐0.1 to 0.3) points compared with control group on an 18‐point scale⁸		237 (7 studies)	⊕⊕⊝⊝ low^3,9	SMD = 0.2 higher (0.1 lower to 0.5 higher) Absolute change = 1% better (0% to 2% better) Relative change = 38% better (26% worse to 104% better)
Participation restrictions	1 study measured participation restrictions but it did not provide useable data		Not estimable	Not estimable	Not estimable	Not estimable
Adverse events	Five studies involving 145 participants reported 8 adverse events that may have been related to the intervention. These included skin breakdown, bruising or blisters from plaster casts, and shoulder and wrist pain from stretches applied through positioning		Not estimable	Not estimable	Not estimable	Not estimable
The assumed risk* (e.g. the mean control group risk across studies) is based on one representative study chosen on the basis of its size and susceptibility to bias. The corresponding risk (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; NNTB: number needed to treat for an additional beneficial outcome; RR: risk ratio; SMD: standardised mean difference; VAS: visual analogue scale
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.
¹ All the studies included in this review and included in the 'Summary of findings' outcomes included people with the following neurological conditions: stroke, Charcot‐Marie‐Tooth disease, acquired brain injury, spinal cord injury and cerebral palsy. The treatment effects were consistent across all types of neurological conditions except acquired brain injury (see Discussion). ² Post data of the control group in Refshauge 2006 (the corresponding data in Analysis 1.1 is not raw data). ³ The quality of evidence was not downgraded due to risk of bias even though at least some of the included trials had selection, performance, detection, attrition and reporting bias. These types of bias would tend to exaggerate treatment effectiveness. Given this review did not demonstrate treatment effectiveness these forms of bias are probably not important. ⁴ Post data of the control group in Horsley 2007 (the corresponding data in Analysis 4.1 is not post data). ⁵ Calculations based on the control group baseline mean (SD) pain: 0.4 (1.1) points on a 0‐10 scale (from Horsley 2007). ⁶ The quality of the evidence was downgraded due to indirectness and imprecision. The downgrading for indirectness was because the results are only based on studies involving people with stroke and spinal cord injury thereby limiting their generalisability. The downgrading for imprecision was because the 95% CI is wide, particularly when the results are expressed as a relative % change (the 95% CI is narrow when the results are expressed as an absolute risk difference). ⁷ Post data of the control group in Horsley 2007 (the corresponding data in Analysis 6.1 is not post data). ⁸ Calculations based on the control group baseline mean (standard deviation) activity limitation: 0.3 (0.6) points on an 18‐point Upper Limb Activity scale (from Horsley 2007). ⁹ The quality of the evidence was downgraded due to indirectness and imprecision. The downgrading for indirectness was because the results are only based on studies involving people with stroke, cerebral palsy and Charcot‐Marie‐Tooth disease thereby limiting their generalisability. The downgrading for imprecision was because the 95% CI was wide particularly when the results are expressed as a relative % change (the 95% CI is narrow when the results are expressed as an absolute risk difference).

Summary of findings for the main comparison. Short‐term effects of stretch for the treatment and prevention of contractures in people with neurological conditions

Joint mobility ‐ neurological conditions	Pooled results	Randomisation (studies with adequate sequence generation)	Allocation (studies with concealed allocation)	Assessors (studies with blinded assessors)	Dropout rate (studies with ≤ 15% dropouts)
Short‐term effects following stretch	2 ° (0 to 3) n = 18	2 ° (0 to 3) n = 16	1 ° (0 to 3) n = 15	2 ° (0 to 3) n = 14	2 ° (0 to 3) n = 13
Long‐term effects following stretch	1 ° (‐1 to 3) n = 8	1 ° (‐3 to 4) n = 6	0 ° (‐2 to 2) n = 5	1 ° (‐2 to 3) n = 6	0 ° (‐2 to 2) n = 6
Results are presented in degrees; mean (95% CI). n = number of studies included in analysis

	Neurological conditions		Non‐neurological conditions
	Short‐term	Long‐term	Short‐term	Long‐term
Joint ROM	Ineffective¹ – HIGH (95% CI; 0 to 3°)	Ineffective¹ (95% CI; ‐1 to 3°)	Ineffective¹ – HIGH (95% CI; 0 to 0.3 SD)	Ineffective¹ (95% CI; ‐0.4 to 0.2 SD)
QOL	Not measured	Not measured	Ineffective² – MOD (95%CI; ‐0.1 to 0.7 SD)	Not measured
Pain*	Uncertain ‐ LOW (95% CI; ‐0.1 to 0.5 SD)	Uncertain (95% CI; ‐0.4 to 0.5 SD)	Ineffective³ – HIGH (95% CI; ‐0.4 to 0.1 SD)	Uncertain No meta‐analysis performed⁴
Spasticity*	Uncertain (95% CI; ‐0.3 to 0.3 SD)	Uncertain (95% CI; ‐0.8 to 0.1 SD)	Not relevant for people with non‐neurological conditions	Not relevant or people with non‐neurological conditions
Activity limitations	Uncertain – LOW (95% CI; ‐0.1 to 0.5 SD)	Uncertain (95% CI; ‐0.1 to 0.6 SD)	Uncertain ‐ HIGH (95% CI; ‐0.2 to 0.3 SD)	Uncertain (95% CI; ‐0.3 to 0.2 SD)
Participation restrictions	Not measured	Not measured	Uncertain ‐ LOW (95% CI; ‐0.1 to 0.7 SD)	Uncertain 95% CI; (‐0.6 to 0.3 SD)
* Negative value favours stretch Ineffective = the results rule out a clinically important treatment effect. The quality of the evidence for the short‐term effects was rated using GRADE and is indicated by high, moderate (mod) or low. GRADE was not used to rate the quality of evidence for the long‐term effects. ¹ The results rule out a clinically important treatment effect of 5°. Results expressed as SMD were back converted to degrees (see summary of findings Table for the main comparison). ² The results rule out a clinically important treatment effect equivalent to 10 points on a 160‐point scale, and an absolute change and relative change of 5% (see summary of findings Table 2). ³ The results rule out a clinically important treatment effect equivalent to 2 points on a 10‐point pain scale, and an absolute change and relative change of 5% (see summary of findings Table 2). ⁴ A meta‐analysis was not performed on the two studies because of clinical heterogeneity between studies (see Results).

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Neurological conditions Show forest plot	18	549	Mean Difference (IV, Random, 95% CI)	1.81 [0.45, 3.17]

1.1 Stroke	11	295	Mean Difference (IV, Random, 95% CI)	0.56 [‐1.56, 2.68]
1.2 Charcot‐Marie‐Tooth disease	2	82	Mean Difference (IV, Random, 95% CI)	2.27 [0.16, 4.38]
1.3 Acquired brain injury	3	35	Mean Difference (IV, Random, 95% CI)	8.48 [0.60, 16.36]
1.4 Spinal cord injury	4	137	Mean Difference (IV, Random, 95% CI)	1.42 [‐0.54, 3.37]
2 Non‐neurological conditions Show forest plot	18	865	Std. Mean Difference (IV, Random, 95% CI)	0.16 [‐0.00, 0.33]

2.1 Frail elderly	2	60	Std. Mean Difference (IV, Random, 95% CI)	0.23 [‐0.28, 0.74]
2.2 Ankle fracture	1	93	Std. Mean Difference (IV, Random, 95% CI)	‐0.05 [‐0.46, 0.35]
2.3 Anklylosing spondylitis	1	39	Std. Mean Difference (IV, Random, 95% CI)	0.63 [‐0.07, 1.32]
2.4 Oral submucous fibrosis	1	24	Std. Mean Difference (IV, Random, 95% CI)	0.83 [‐0.05, 1.72]
2.5 Post‐radiation therapy to breast	1	56	Std. Mean Difference (IV, Random, 95% CI)	0.05 [‐0.47, 0.58]
2.6 Post‐radiation therapy to jaw	1	14	Std. Mean Difference (IV, Random, 95% CI)	1.54 [0.25, 2.82]
2.7 Progressive systemic sclerosis	1	14	Std. Mean Difference (IV, Random, 95% CI)	0.78 [‐0.32, 1.88]
2.8 Total knee replacement	1	55	Std. Mean Difference (IV, Random, 95% CI)	‐0.19 [‐0.72, 0.34]
2.9 Arthritis	1	36	Std. Mean Difference (IV, Random, 95% CI)	0.41 [‐0.25, 1.07]
2.10 Dupuytren's contractures	3	226	Std. Mean Difference (IV, Random, 95% CI)	0.09 [‐0.27, 0.45]
2.11 Shoulder adhesive capsulitis/frozen shoulder	1	100	Std. Mean Difference (IV, Random, 95% CI)	‐0.28 [‐0.67, 0.11]
2.12 Hallux limitus	1	48	Std. Mean Difference (IV, Random, 95% CI)	0.43 [‐0.14, 1.01]
2.13 Wrist fracture	1	36	Std. Mean Difference (IV, Random, 95% CI)	0.24 [‐0.41, 0.90]
2.14 Burns	2	64	Std. Mean Difference (IV, Random, 95% CI)	0.14 [‐0.35, 0.63]

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