A pilot randomized controlled trial of a daily muscle stretch regime to prevent contractures in the arm after stroke. Comparing botulinum toxin A with casting for treatment of dynamic equinus in children with cerebral palsy. The use of knee splints after total knee replacements. A programme of static positional stretches does not reduce hemiplegic shoulder pain or maintain shoulder range of motion--a randomized controlled trial. Mobilization regimens for the prevention of jaw hypomobility in the radiated patient: a comparison of three techniques. Low-load, prolonged stretch in the treatment of knee flexion contractures in nursing home residents. The effects of casting on upper extremity motor disorders after brain injury. Night splinting does not increase ankle range of motion in people with Charcot-Marie-Tooth disease: a randomised, cross-over trial. The effect of serial casting on gait in children with cerebral palsy: preliminary results from a crossover trial. A randomized comparative study of two methods for controlling Tendo Achilles contracture in Duchenne muscular dystrophy. Splinting the hand in the functional position after brain impairment: a randomized, controlled trial. Effects of splinting on wrist contracture after stroke: a randomized controlled trial. Four weeks of daily stretch has little or no effect on wrist contracture after stroke: a randomised controlled trial. The effect of casting combined with stretching on passive ankle dorsiflexion in adults with traumatic head injuries. Passive stretching does not enhance outcomes in patients with plantarflexion contracture after cast immobilization for ankle fracture: a randomized controlled trial. Is routine splintage following primary total knee replacement necessary? A prospective randomised trial. Thirty minutes of positioning reduces the development of shoulder external rotation contracture after stroke: a randomized controlled trial. Effectiveness of a bed positioning program for treating older adults with knee contractures who are institutionalized. Physiotherapeutic treatment improves oral opening in oral submucous fibrosis. Twelve weeks of nightly stretch does not reduce thumb web-space contractures in people with a neurological condition: a randomised controlled trial. Neutral functional realignment orthosis prevents hand pain in patients with subacute stroke: a randomized trial. Examination of shoulder positioning after stroke: A randomised controlled pilot trial. Randomised trial of the effects of four weeks of daily stretch on extensibility of hamstring muscles in people with spinal cord injuries. The role of passive stretching in the treatment of ankylosing spondylitis. The role of the rehabilitation brace in restoring knee extension after anterior cruciate ligament reconstruction: a prospective controlled study. Effects of splinting in the treatment of hand contractures in progressive systemic sclerosis. Neurodevelopmental therapy and upper-extremity inhibitive casting for children with cerebral palsy. Orthotic intervention for development of hand function with C-6 quadriplegia. 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. Pectoral stretching program for women undergoing radiotherapy for breast cancer. Does 12 weeks of regular standing prevent loss of ankle mobility and bone mineral density in people with recent spinal cord injuries? Contracture preventive positioning of the hemiplegic arm in subacute stroke patients: a pilot randomized controlled trial. Dynamic splinting after treatment with botulinum toxin type-A: a randomized controlled pilot study. A randomized trial assessing the effects of 4 weeks of daily stretching on ankle mobility in patients with spinal cord injuries.
To evaluate the feasibility and effects of daily stretch positioning for prevention of contractures in stroke patients without arm function.
                Randomized controlled pilot study.
                Stroke rehabilitation ward, U.K.
                Twenty-five subjects drawn from an initial pool of 126 presenting with loss of arm function, all within four weeks of stroke.
                In addition to usual care, subjects in the experimental group (n=13) were prescribed two 30-min stretches for wrist and finger flexors and two 30-min stretches targeting shoulder adductors and internal rotators, per day for up to 12 weeks post stroke. Stretches were carried out by therapists and nursing staff.
                Passive range of wrist extension and shoulder external rotation to standard force or to pain at four, eight and twelve weeks after stroke.
                Compliance was variable. Frequency of positioning was fair from four to eight weeks post stroke but declined after that. Mean (SD) frequency of stretch positions completed between four and eight weeks was 36.5 (13.0) for the wrist, 31.2 (14.1) for the shoulder, out of 56 prescribed. There were no significant effects of treatment. By eight weeks post stroke the mean range of wrist extension and shoulder external rotation lost on the affected side in both groups was approximately 30 degrees.
                The stretch treatment was not well tolerated over many weeks. Statistical power was low due to the large degree of variability of range of motion and small sample size. The regime tested cannot be recommended as a workable treatment to prevent contractures. The purpose of this study was to compare the cumulative efficacy (three treatment sessions) of botulinum toxin A (BTX-A) alone, casting alone, and the combination of BTX-A and casting in the management of dynamic equinus in ambulatory children with spastic cerebral palsy (CP). Thirty-nine children with spastic CP (mean age 5y 10mo, range 3 to 9y) were enrolled in the study. A multicenter, randomized, double blind, placebo-controlled prospective study was used. Children were randomly assigned to one of three treatment groups: BTX-A only (B), placebo injection plus casting (C), or BTX-A plus casting (B+C). The dosage for the BTX-A injections was 4U/kg per extremity. Assessments were performed at baseline, 3, 6, 7.5, and 12 months with a total of three treatments administered after the evaluations at baseline, 3, and 6 months. Primary outcome measures were ankle kinematics, velocity, and stride length. Secondary outcome measures were ankle spasticity, strength, range of motion, and ankle kinetics. Group B made no significant change in any variable at any time. Groups C and B+C demonstrated significant improvements in ankle kinematics, spasticity, passive range of motion, and dorsiflexor strength. Results of this 1-year study indicate that BTX-A alone provided no improvement in the parameters measured in this study, while casting and BTX-A/casting were effective in the short- and long-term management of dynamic equinus in children with spastic CP. The aim of this randomised prospective study was to establish whether the use of knee splints following total knee replacement is necessary. The study included 81 patients undergoing total knee replacement who were randomised into a 'splint' and a 'no splint' group post-operatively. The following parameters were recorded: The range of movement pre-operatively, 5 days post-operatively and 6 weeks post-operatively; the length of time to straight leg raise; the blood drained from the wound; and the amount of post-operative analgesia required. We found that patients in the 'no splint' group achieved significantly greater flexion at 5 days and 6 weeks post-operatively but drained significantly more blood from the wound. Transfusion requirements were similar in the two groups. There was no other significant difference in the parameters measured between the two groups. In conclusion we found no evidence to advocate the use of knee splints following total knee arthroplasty.
                Copyright 2002 Elsevier Science B.V. To evaluate the effectiveness of a programme of static positional stretches and positioning of the stroke-affected shoulder for maintaining shoulder external rotation and decreasing hemiplegic shoulder pain.
                Randomized controlled trial with pretest and posttest design.
                Inpatient rehabilitation unit.
                Thirty-two participants (17 treatment, 15 comparison) with a first time stroke who were admitted for rehabilitation. Interventions: Treatment participants completed a programme of static positional stretches of the stroke-affected shoulder twice daily and positioned the stroke-affected upper limb in an armrest support at all other times when seated.
                The main outcome measures were pain-free range of motion into external rotation, pain in the stroke-affected shoulder at rest and with movement, motor recovery and functional independence.
                All participants demonstrated a significant loss of external rotation (P = 0.005) with no significant group differences. All participants demonstrated a significant improvement in motor recovery (P < 0.01) and functional independence (P < 0.01) with no significant group differences. There were no significant effects for pain. The comparison group recorded a decrease in mean pain reported with movement from admission to discharge, and the treatment group recorded an increase.
                Participation in the management programme did not result in improved outcomes. The results of this study do not support the application of the programme of static positional stretches to maintain range of motion in the shoulder. The effect of increasing pain for the treatment group requires further investigation. This study evaluated and compared the Therabite Jaw Motion Rehabilitation System (Therabite Corporation, Bryn Mawr, PA) to tongue blades as a technique for maintaining and/or improving mandibular range of motion in post-irradiated patients. Three groups of patients were evaluated and compared: 1) unassisted exercise, 2) mechanically assisted mandibular mobilization with stacked tongue depressors combined with unassisted exercise, and 3) the Therabite System combined with unassisted exercise. The initial average maximum incisal opening (MIO) for the study population was 21.6 mm, and did not vary significantly among the groups. Measurements were recorded at 2-week intervals for 10 weeks. At week 6 and thereafter, the net increase in MIO of group 3 (13.6 mm [+/- 1.6 mm]) was significantly greater than group 1 (6.0 mm [+/- 1.8 mm]) and group 2 (4.4 mm [+/- 2.1 mm]) (P < .05). The rate of improvement leveled after 4 week in group 1 and group 2. However, the rate of gain in MIO in the Therabite group (group 3) remained constant at 10 weeks. There was no statistical difference between groups 1 and 2. The purpose of this study was to do a pilot test of the effectiveness of prolonged stretch (use of splint) in reducing knee flexion contractures more than a traditional program of passive range of motion (PROM) in a group of nursing home residents.
                The subjects were 28 nursing home residents with 10 degrees or more of knee flexion contracture bilaterally. Eighteen subjects completed the study.
                Data were collected prior to the initiation of the intervention and at monthly intervals during the 6 months of treatment. Repeated measurements were made of hip, knee, and ankle range of motion (ROM); the torque required to maintain passive impairment. knee extension; knee pain; several indicators of function; and cognitive impairment. Both legs of each subject received PROM and manual stretching twice a week; in addition, one leg was given a prolonged stretch (use of a splint) five times a week.
                There were no differences in knee ROM between the side that received prolonged stretching and the side that received only PROM and manual stretching at the beginning of the study. No differences in ROM or torque measurements existed between the side that received prolonged stretching and the side that received only PROM and manual stretching at any interval, nor in ROM or torque over time for either side. Because of the low statistical power of the study, the results should be viewed with caution.
                Physical therapists need to question whether prolonged stretch for nursing home residents with knee flexion contractures greater than 10 degrees is of any greater benefit than PROM and manual stretching. Investigations of other treatment protocols and treatment doses are needed, including work in the area of prevention of knee flexion contractures. For the pilot group of nursing home residents studied, gains in knee extension did not occur with the use of prolonged stretch for 3 hours a day, 5 days per week. [Steffen TM, Mollinger LA. Low-load, prolonged stretch in the treatment of knee flexion contractures in nursing home residents. This study compares casting to traditional techniques, such as passive range of motion, static stretch, and splinting, in the treatment of the hypertonic upper extremity in individuals with severe brain injury.
                Fifteen subjects with brain injury were randomly assigned to one of two groups. One group received a month of casting followed by a month of traditional therapy; the second group received 1 month of traditional therapy followed by casting. The subjects' limbs were evaluated for range of motion, clinical indications of spasticity, and functional use of the extremity at three intervals--before intervention, after the first month of intervention, and after the second month of intervention. Two sample t-tests and paired t-tests were used in data analysis.
                All but one subject showed a greater improvement in range of motion with casting than with traditional treatment; 11 subjects showed a greater improvement in clinical measures of spasticity with casting. There was no apparent correlation between these measures and functional use of the extremity.
                These findings suggest that casting is more effective than traditional techniques in reducing contracture and in decreasing hypertonicity in some cases. The greater improvements in these motor indicators with casting did not translate into greater gains in functional use of the upper extremities. What is the effect of wearing splints at night to stretch the plantarflexors on dorsiflexion range of motion (ROM) in people with Charcot-Marie-Tooth disease?
                Randomised, assessor-blinded, cross-over trial.
                14 people (1 dropout) aged 7 to 30 years with Charcot-Marie-Tooth disease Type 1A and with < or = 15 degrees dorsiflexion range of motion (ROM).
                A splint holding the ankle in maximum dorsiflexion was worn nightly on one leg for 6 weeks followed by the opposite leg for the subsequent 6 weeks.
                The primary outcome was dorsiflexion ROM; secondary outcomes were eversion ROM, and dorsiflexion, eversion, and inversion strength, measured before and after splinting, and three months later.
                There was no significant difference between the experimental and the control intervention in terms of ROM or strength. Wearing the splint at night increased dorsiflexion ROM by 1 degree (95% CI -3 to 4; p = 0.72) and eversion ROM by 1 degree (95% CI -1 to 3; p = 0.28) compared to not wearing the splint. Wearing the splint increased dorsiflexion strength by 41 N (95% CI -53 to 135; p = 0.38), reduced eversion strength by 6 N (95% CI -112 to 101; p = 0.92) and reduced inversion strength by 8 N (95% CI -110 to 95; p = 0.88) compared to not wearing the splint.
                Wearing night splints does not increase ankle ROM or strength in people with Charcot-Marie-Tooth disease Type 1A. Serial casting aims to improve an equinus gait pattern in children with spastic cerebral palsy (SCP). We evaluated the effect of short-term stretch casting on gait in children with SCP, compared to the natural history. A crossover trial, consisting of a control phase and a casting phase, was conducted with children randomised into two groups. Both groups were assessed clinically, and using 3D gait analysis, at 0, 5 and 12 weeks. Subjects in one group had the 3 month casting phase first and in the other had the 3 month control period first. Casts were changed weekly and set at maximum available ankle dorsiflexion. The mean changes at 5 weeks and 12 weeks from baseline measurements in the casting phase were compared with the change within the same time interval in the control phase. Significant improvements in passive ankle dorsiflexion (knee flexed) were found at 5 and 12 weeks. Passive ankle dorsiflexion (knee extended), ankle dorsiflexion in single support, ankle dorsiflexion in swing and minimum hip flexion in stance improved significantly at 5 weeks but not at 12 weeks from baseline. Other kinematic parameters, the score on the Gillette Functional Assessment Questionnaire, and maximum reported walking distance were not changed by casting. Casting to improve range appears to improve passive and dynamic ankle dorsiflexion, but the changes are small, short lived and do not appear to affect function. A 30-month prospective randomized study of 27 Scandinavian boys with confirmed diagnosis of Duchenne muscular dystrophy was done to compare the effect of passive stretching combined with the use of night splints (group A) or passive stretching (group B) on the evolution of Tendo Achilles contractures. Assessments were based on the methodology of Scott et al. (Muscle Nerve 1982;5:291-301)Analysis of the pattern and mechanism of dropout was done to eliminate bias between the two groups. Logistic regression showed that Tendo Achilles contracture was the most important variable (P=0.0020) for dropout. Methods of statistical analysis for longitudinal data avoiding induced serial correlations were used in the analysis. The expected annual change in Tendo Achilles contracture was found to be 23% less in group A than in group B after equalization for total muscle strength (%MRC). To evaluate the effects of 4 weeks of hand splinting on the length of finger and wrist flexor muscles, hand function, and pain in people with acquired brain impairment.
                Randomized, assessor-blinded trial.
                Rehabilitation center in Australia.
                Twenty-eight adults with acquired brain impairment, all within 6 months of the first injury. There was 1 withdrawal.
                Subjects in both experimental (n=17) and control (n=11) groups participated in routine therapy-motor training for upper-limb use and upper-limb stretches-5 days a week. The experimental group also wore an immobilizing hand splint in the functional position (10 degrees -30 degrees wrist extension) for a maximum of 12 hours each night for the duration of the 4-week intervention period.
                The length of the wrist and extrinsic finger flexor muscles was evaluated by measuring the torque-controlled range of wrist extension with the fingers extended. Functional hand use was evaluated with the Motor Assessment Scale. Pain was evaluated with a visual analog scale.
                The effects of splinting were statistically nonsignificant and clinically unimportant. At follow-up, estimates of treatment effects slightly favored the control group: range of motion at the wrist favored controls by 2 degrees (95% confidence interval [CI], -7.2 degrees to 3.2 degrees ), function favored controls by 0.2 points (95% CI, -2.7 to 2.3), and pain favored the experimental group by 1cm (95% CI, -4.6 to 2.2).
                An overnight splint-wearing regimen with the affected hand in the functional position does not produce clinically beneficial effects in adults with acquired brain impairment. Splints are commonly applied to the wrist and hand to prevent and treat contracture after stroke. However, there have been few randomized trials of this intervention. We sought to determine whether wearing a hand splint, which positions the wrist in either a neutral or an extended position, reduces wrist contracture in adults with hemiplegia after stroke.
                Sixty-three adults who had experienced a stroke within the preceding 8 weeks participated. They were randomized to either a control group (routine therapy) or 1 of 2 intervention groups (routine therapy plus splint in either a neutral or an extended wrist position). Splints were worn overnight for, on average, between 9 and 12 hours, for 4 weeks. The primary outcome, measured by a blinded assessor, was extensibility of the wrist and long finger flexor muscles (angle of wrist extension at a standardized torque).
                Neither splint appreciably increased extensibility of the wrist and long finger flexor muscles. After 4 weeks, the effect of neutral wrist splinting was to increase wrist extensibility by a mean of 1.4 degrees (95% CI, -5.4 degrees to 8.2 degrees), and splinting the wrist in extension reduced wrist extensibility by a mean of 1.3 degrees (95% CI, -4.9 degrees to 2.4 degrees) compared with the control condition.
                Splinting the wrist in either the neutral or extended wrist position for 4 weeks did not reduce wrist contracture after stroke. These findings suggest that the practice of routine wrist splinting soon after stroke should be discontinued. In adults undergoing rehabilitation after stroke, does 30 minutes of daily stretch of the wrist and finger flexors for four weeks prevent or reverse contracture, decrease pain, or improve upper-limb activity? Are any gains maintained one week and five weeks after the cessation of stretching?
                Randomised controlled trial with concealed randomisation, assessor blinding, and intention-to-treat analysis.
                40 adults undergoing rehabilitation after stroke or stroke-like brain injury, who were unable to actively extend the affected wrist.
                Both groups received routine upper-limb retraining five days a week. In addition, the experimental group received 30 minutes daily stretch of the wrist and finger flexors five days a week for four weeks.
                The primary outcome was contracture, measured as torque-controlled passive wrist extension with the fingers extended. Secondary outcomes were pain at rest measured on a 10-cm visual analogue scale, and upper-limb activity measured using the Motor Assessment Scale. Outcomes were collected at baseline, post-intervention, and one and five weeks after cessation of intervention. Results: The mean effect on passive range of wrist extension was 3.8 [corrected] degrees (95% CI -2.5 to 10.1) [corrected] after 4 weeks of daily stretch, 4.1 degrees (95% CI -4.0 to 12.3) after a week of no stretch, and 3.5 degrees (95% CI -4.6 to 11.7) after a further four weeks.
                These data suggest that four weeks of regular stretching has little or no effect on wrist contracture after stroke. However the estimate of the size of this effect is not sufficiently precise to rule out the possibility of a marginally worthwhile effect. The stretch had no significant effect on upper-limb pain, and did not result in significantly improved upper-limb activity. Ankle plantar-flexion contractures are a common problem following traumatic head injury. Although serial casting is used to correct and prevent ankle plantar-flexion contractures, treatment efficacy has not been evaluated using an experimental design. The aim of this research was to establish the effect of a regimen of casting combined with stretching on passive ankle dorsiflexion motion.
                Nine people who had sustained traumatic closed head injuries and had limited dorsiflexion motion participated in the study.
                A crossover design was used in the study. Subjects were assigned to both experimental and control groups. Torque-controlled measurements of passive ankle dorsiflexion motion were obtained for all subjects before and after 1 week of casting combined with stretching, as well as before and after a 1-week control period. The order of the experimental and control conditions was randomized.
                Passive ankle dorsiflexion increased by a mean of 13.5 degrees (SD = 9.3) during the experimental condition, as compared with a mean decrease of 1.9 degrees (SD = 10.2) during the control condition. The difference between the experimental and control conditions was statistically significant.
                These findings suggest that casting combined with stretching is an effective method of correcting ankle plantar-flexion contractures in patients with traumatic head injuries. To compare the efficacy of short- and long-duration passive stretches with a control treatment for the management of plantarflexion contracture after cast immobilization for ankle fracture.
                Assessor-blinded, randomized controlled trial.
                Hospital physical therapy outpatient departments.
                Adults with plantarflexion contracture (N=150) after cast immobilization for ankle fracture. All subjects were weight bearing or partial weight bearing.
                Exercise only, exercise plus short-duration passive stretch, and exercise plus long-duration passive stretch. All subjects had a 4-week course of exercises. In addition, subjects in the short-duration stretch plus exercise group completed 6 minutes of stretching per day, and subjects in the long-duration stretch plus exercise group completed 30 minutes of stretching per day.
                Lower Extremity Functional Scale and passive dorsiflexion range of motion with the knee bent and straight at baseline, and at 4 weeks and 3 months postintervention.
                One hundred thirty-nine (93%) subjects completed the 4-week assessment and 134 (89%) subjects completed the 3-month assessment. There were no statistically significant or clinically important between-group differences for the primary outcomes.
                The addition of passive stretching confers no benefit over exercise alone for the treatment of plantarflexion contracture after cast immobilization for ankle fracture. It was hypothesised that routine splintage following primary total knee replacement has no affect on flexion deformity and offers no benefit over simple wool and crepe. Fifty-five patients undergoing primary total knee replacement were entered into a prospective study. The patients were randomly assigned to two groups: The first group was rehabilitated without a splint and the second received an adjustable semi-rigid extension splint (Richards splint) for the first 48 h after surgery. Range of motion measurements were recorded pre-operatively and at 2 days, 1 week and 3 months post-operation by a research nurse blinded to the allocation. No statistically significant difference in flexion deformity was found at any stage (P>0.5). No difference was found in general or wound complications, or requirement for blood transfusion, and the post-operative stay was equal in the two groups. We conclude that routine use of a semi-rigid splint following primary total knee replacement has no advantage over simple wound dressings.
                Copyright 2002 Elsevier Science B.V. To determine the efficacy of positioning the affected shoulder in flexion and external rotation to prevent contracture shortly after stroke.
                Prospective, parallel-group, randomized controlled trial.
                Four metropolitan mixed rehabilitation units.
                A volunteer sample of 36 subjects (minus 5 dropouts), whose mean age was 68 years and had had their first stroke within the past 20 days.
                The experimental group received two 30-minute sessions a day, 5 days a week, for 4 weeks, during which the affected upper limb was placed in maximum comfortable external rotation and 90 degrees of flexion. Both the experimental and control groups received up to 10 minutes of shoulder exercises and standard upper-limb care.
                Contracture was measured as the maximum passive shoulder external rotation and flexion of the affected side as compared with the intact side. Measures were taken at 2 and 6 weeks after stroke by an assessor blinded to group allocation.
                The 30-minute program of positioning the shoulder in maximum external rotation significantly reduced the development of contractures in the experimental group, compared with the control group ( P =.03). The 30-minute program of positioning the shoulder in 90 degrees of flexion did not prevent contractures in the experimental group as compared with the control group ( P =.88).
                At least 30 minutes a day of positioning the affected shoulder in external rotation should be started as soon as possible for stroke patients who have little activity in the upper arm. Although contractures in patients in long-term care institutions are an important issue, there have been only a few studies that have evaluated interventions for contractures. The purpose of this study was to determine the effectiveness of a bed positioning program (BPP) for the treatment of patients with knee flexion contractures.
                Sixteen patients with a high level of cognitive and functional impairment (mean age=82 years, SD=6.48, range=71-93) in a chronic care hospital participated in the study.
                The BPP consisted of stretching a patient's knee into extension and then securing and maintaining the position for a period of 40 minutes, 4 times per week. Participants were randomly assigned to 2 groups (n=8 in each group). One group received a BPP for 8 weeks, followed by 8 weeks of no intervention. The other group received the intervention in the reverse order. Once a week, participants were assessed for range of knee extension, knee pain, and skin integrity.
                Twelve participants completed the study. There was no improvement in participants' range of knee extension during the intervention period. Overall, there was no difference in mean range of knee extension between the intervention period and the no-intervention period.
                The results of this study do not support the use of a BPP for treating patients with knee flexion contractures. In oral submucous fibrosis (OSF) fibrous bands and burning mucosal pain restrict oral opening to limit speech and eating. The pathogenesis of OSF remains unclear, while surgical and pharmacological treatments have limited success, and are often inaccessible in communities using areca nut where OSF is prevalent. Improved outcomes are reported for surgical treatment when followed by physiotherapy. We tested the hypothesis that physiotherapy alone can modify tissue remodelling in OSF to increase oral opening.
                Fifty-four Nepali OSF patients were managed for 4 months in three randomly assigned groups receiving either: five times daily physiotherapy by inter-positioning tongue spatulas between teeth and adding a new spatula every 5-10 days; local injection of hyaluronidase with steroids; or no active treatment.
                More males presented with OSF than females (p < 0.05). All patients reported reduced opening and 47% had mucosal pain. Progressive mucosal involvement was always in the same order, starting with the soft palate, and then progressing to the fauces, unilateral buccal mucosa, bilateral buccal mucosa, floor of mouth and finally lip mucosa (p < 0.006). Physiotherapy improved oral opening (p < 0.0005), but not oral pain, while no clear improvement was seen in untreated patients as well as patients managed by injection.
                We conclude OSF in the Nepali population progresses in a predictable pattern, and that physiotherapy is effective for increasing the oral opening. We further suggest physiotherapy can be readily used to improve OSF in communities with otherwise limited health resources. What is the effectiveness of 12 weeks of nightly stretch in reducing thumb web-space contracture in people with neurological conditions?
                Assessor-blinded, randomised controlled trial.
                Forty-four (one dropout)community-dwelling patients with a neurological condition (14 stroke, 7 traumatic brain injury, 23 spinal cord injury) who had uni or bilateral thumb web-space contractures (60 thumbs).
                The experimental thumbs were splinted into a stretched,abducted position each night for 12 weeks. The control thumbs were not splinted.
                Thumb web-space was measured as the carpometacarpal angle during the application of a 0.9 Nm abduction torque before and after intervention.
                The mean increase in thumb web-space after 12 weeks was 1 deg (95% CI, -1 to 2).
                Intensive stretch administered regularly over three months does not reduce thumb web-space contractures in neurological conditions. To quantify the preventive effect of a neutral functional realignment orthosis on pain, mobility, and edema of the hand in subacute hemiparetic poststroke patients with severe motor deficits.
                Randomized trial.
                Rehabilitation center.
                Poststroke patients (N=30) with subacute hemiparesis and severe deficits of the upper limb were enrolled. Fifteen patients were randomized to a standard rehabilitation program without orthosis and 15 patients received an experimental orthosis in addition to their standard rehabilitation program.
                The orthosis group wore the neutral functional realignment orthosis for at least 6 hours daily.
                Hand pain at rest (visual analog scale), wrist range of motion (Fugl-Meyer Assessment subscale), and edema of hand and wrist (circumferences). Outcome measures were assessed at time of randomization and after 13 weeks between groups.
                At baseline, 2 patients in each group complained about a painful hand. After 13 weeks, 8 subjects in the control group and 1 subject in the orthosis group complained of hand pain (P=.004). Mobility and edema evolved similarly in both groups.
                Neutral functional realignment orthoses have a preventive effect on poststroke hand pain, but not on mobility and edema in the subacute phase of recovery. Shoulder pain and stiffness is a serious problem in patients following stroke. The purpose of this study was to investigate the effect of a shoulder positioning protocol on shoulder joint pain and range in the affected upper limb. Twenty-eight subjects were randomly assigned to the experimental or control groups and participated in a multidisciplinary rehabilitation program. In addition, the experimental group received prolonged positioning of the shoulder daily for six weeks. Resting pain, pain on dressing, pain-free active abduction and passive external rotation range were measured on entry to the study and after six weeks. Twenty-three subjects completed the study. The differences between the groups were not statistically significant (p < 0.05), however, because of low statistical power the results are inconclusive. The aim of this assessor-blind randomised controlled trial was to determine the effect of four weeks of 30 minute stretches each weekday on extensibility of the hamstring muscles in people with recent spinal cord injuries. A consecutive sample of 16 spinal cord-injured patients with no or minimal voluntary motor power in the lower limbs and insufficient hamstring muscle extensibility to enable optimal long sitting were recruited. Subjects' legs were randomly allocated to experimental and control conditions. The hamstring muscles of the experimental leg of each subject were stretched with a 30 Nm torque at the hip for 30 minutes each weekday for four weeks. The hamstring muscles of the contralateral leg were not stretched during this period. Extensibility of the hamstring muscles (hip flexion range of motion with knee extended, measured with a 48 Nm torque at the hip) of both legs was measured by a blinded assessor at the commencement of the study and one day after the completion of the four-week stretch period. Changes in hamstring muscle extensibility from initial to final measurements were calculated. The effect of stretching was expressed as the mean difference in these changes between stretched and non-stretched legs. The mean effect of stretching was 1 degree (95% CI -2 to 5 degrees). Four weeks of 30 minute stretches each weekday does not affect the extensibility of the hamstring muscle in people with spinal cord injuries. A controlled study of 39 consecutively-admitted patients with ankylosing spondylitis was conducted to assess the effects of daily passive stretching of the hip joints during a 3-week in-patient physiotherapy course. Measurements were performed by an independent assessor on admission, at discharge and six months after discharge. Results showed that passive stretching resulted in a significant increase in the range of all movements of the hip joints except flexion during the physiotherapy course. Follow-up at 6 months in seven patients suggested that this increase in range of movement could be maintained by patients who had been performing the stretching exercises regularly. We suggest that the inclusion of passive stretching of the hip joint in the treatment of patients with ankylosing spondylitis will increase the range of movement and thus improve function and influence posture. To evaluate the effects of a rehabilitation brace locked in extension for the first week on the recovery of full extension after ACL reconstruction we compared two groups of subjects who underwent ACL bone-patellar tendon-bone reconstruction. The brace was unlocked twice a day for assisted physiotherapy. In Group A, 18 male subjects wore a post-operative brace locked from 0 degrees to 90 degrees. In Group B, 18 male subjects wore the same post-op brace locked in full extension for the first week. In both groups the brace was unlocked (0 degrees -120 degrees ) at the beginning of the second postoperative week, and then removed at the beginning of the third week. All the subjects followed the same rigorous, accelerated rehabilitation protocol. Each subject was evaluated pre and post-operatively (at second, fourth and eighth week) with bubble-level heel height difference (HHD) measurements and KT 1000 arthrometric assessment at the fourth postoperative month. Preoperative bubble-level HHD measurements of the two groups were statistically similar (Group A 0.6 cm, Group B 1 cm; not significant, n.s.). At the fourth week (Group A 2.2 cm, Group B 0.6 cm) and eighth week (Group A 1.6 cm, Group B 0.1 cm) follow-ups, bubble-level HHD measurements showed that the extension of the operated knees of Group B was significantly greater than in Group A. KT 1000 arthrometric scores showed no difference between the two groups (Group A 1.8 mm, Group B 1.5; n.s.). One of the major factors in the decreasing functional ability of patients with progressive systemic sclerosis is involvement of the patient's hands with secondary immobility and contractures. In a 2-month study of 19 patients, we assessed whether dynamic splinting could decrease proximal interphalangeal (PIP) flexion contractures. Of the eight patients who completed the study, one experienced a statistically significant improvement in PIP range of motion as a result of the splinting. There was no evidence that the use of the splints served to maintain PIP extension when compared with the control hand. The purpose of this research was to study the effect of intensive neurodevelopmental therapy (NDT) and upper-extremity inhibitive casting, separately or in combination, on hand function, quality of upper-extremity movement and range of motion of 73 children with spastic cerebral palsy aged 18 months to eight years. There was no significant difference between intensive or regular therapy and casting or no casting for hand function, between intensive and regular NDT, or between intensive NDT plus casting and the other groups for quality of movement and range of motion. Casting led to increased quality of movement and wrist extension after six months. Casting with NDT improved the quality of upper-extremity movement and range of motion. There appear to be no immediate benefits from intensive therapy alone. Much has been written about the use of static orthoses to maintain proper position and prevent deformity, but there are few empirical data to determine whether static orthoses improve function, maintain range of motion, or prevent deformity in the hand.
                This study measured gains in hand function during a 3-month rehabilitation period in 13 persons with sixth cervical (C-6) level complete quadriplegia, 7 of whom wore a static orthosis at night (experimental group) and 6 who did not wear the orthosis (control group). Hand function, range of motion and strength were measured in all subjects 4 weeks and 8 weeks after the study commenced, and again after 12 weeks in only 69% of the subjects.
                No significant differences were found in hand function between control and experimental groups; hand function had improved significantly in all 13 subjects.
                As the effects of deformity have been clinically observed, future studies should examine the effects of static orthoses with increased daily wear or wear over a longer period of time. To obtain the best estimate of the size of the effect of a thermoplastic resting splint on spasticity in the stroke-affected upper limb.
                A randomized controlled intervention involving 14 adults affected by stroke,allocated to two groups.
                Inpatient and outpatient rehabilitation departments.
                Following one week of baseline when neither group wore a splint, group 1 continued without a splint for week 2 and then wore a splint during week 3. Group 2 wore a splint during weeks 2 and 3. Both groups then wore a splint through weeks 4-7.
                A computerized torque apparatus was used to measure resistance at the wrist in newtons at every one-degree angle through the range of extension. Amount and rate of change in resistance was compared between the groups to obtain the best estimate of the size of the effect of splinting.
                Effect sizes were small and failed to reach the suggested smallest clinically worthwhile effect size for amount and rate of change in resistance in the short term. However, the average estimated size of the effect for rate of change with longer term splinting exceeded the smallest clinically worthwhile effect.
                These findings and the fact that confidence intervals overlapped the smallest clinically worthwhile size of the effect for amount and rate of change in both short and long term suggest that a study with a larger sample is warranted. Surgery and radiotherapy commonly cause adverse musculoskeletal problems, particularly loss of strength and range of motion, in the upper quadrant of breast cancer patients. Few well-designed studies have investigated whether these impairments can be prevented. Stretching is an effective technique for increasing range of motion, hence the aim of this study was to investigate whether a stretching program reduced acute musculoskeletal impairments in patients undergoing radiotherapy for breast cancer. Sixty-four women were recruited prior to commencement of radiotherapy following breast cancer surgery. Participants were randomised to either a control or stretch group. Participants in both groups were reviewed by the physical therapist on a weekly basis for approximately 6 weeks, and were given general information about skin care and lymphedema. The control group received no advice about exercise. The stretch group received instruction on low-load, prolonged pectoral stretches, which were to be performed daily and were checked at weekly visits. Shoulder range of motion, strength, arm circumference, and quality of life measurements were taken prior to, and at completion of radiotherapy, and at 7 months after radiotherapy. There was no difference in any outcome between groups. Breast symptoms increased for both groups during radiotherapy, without loss of strength or range of movement. The incidence of lymphedema during the study was low for both groups and did not differ between groups. The pectoral stretching program did not influence the outcomes measured because the symptoms reported by patients were not a consequence of contracture. The purpose of this study was to determine the effects of a 12-week standing program on ankle mobility and femur bone mineral density in patients with lower limb paralysis following recent spinal cord injury. An assessor-blinded within-subject randomised controlled trial was undertaken. Twenty patients with lower limb paralysis following a recent spinal cord injury were recruited. Subjects stood weight-bearing through one leg on a tilt-table for 30 minutes, three times each week for 12 weeks. By standing on one leg a large dorsiflexion stretch was applied to the ankle and an axial load was applied to the bones of the weight-bearing leg. Ankle mobility and femur bone mineral density of both legs were measured at the beginning and end of the study. Ankle mobility (range of motion) was measured with the application of a 17 Nm dorsiflexion torque. Femur bone mineral density was measured using dual energy X-ray absorptiometry (DEXA). The effect of standing was estimated from the difference between legs in mean change of ankle mobility and femur bone mineral density. The results indicated a mean treatment effect on ankle mobility of 4 degrees (95% CI 2 to 6 degrees) and on femur bone mineral density of 0.005 g/cm(2) (95% CI -0.015 to 0.025 g/cm(2)). Tilt-table standing for 30 minutes, three times per week for 12 weeks has a small effect on ankle mobility, and little or no effect on femur bone mineral density. It is unclear whether clinicians and patients would consider such effects to be clinically worthwhile. To investigate the effectiveness of a contracture preventive positioning procedure for the hemiplegic arm in subacute stroke patients in addition to conventional physio- and occupational therapy.
                A single-blind pilot randomized controlled trial.
                Inpatient neurological units from three rehabilitation centres in the Netherlands.
                Nineteen subacute stroke patients (minus two drop-outs) with a severe motor deficit of the arm.
                All subjects underwent conventional rehabilitation care. Nine subjects additionally received a positioning procedure for two 30-min sessions a day, five days a week, for five weeks.
                Passive range of motion of five arm movements using a hydrogoniometer and resistance to passive movement at the elbow using the Ashworth Scale. Secondary outcome measures were pain at the end range of passive motions, the arm section of the Fugl-Meyer Assessment and Barthel Index scores for ADL-independence. Outcome measures were taken after five weeks and additional measurements after 10 weeks by two assessors blinded to group allocation.
                Comparison of the experimental (n = 9) with the control subjects (n = 8) after five weeks showed that additional positioning significantly slowed down development of shoulder abduction contracture (P = 0.042, -5.3 degrees versus -23 degrees). No other differences were found between the groups.
                Applying a contracture preventive positioning procedure for the hemiplegic arm slowed down the development of shoulder abduction contracture. Positioning did not show significant additional value on other outcome measures. Since the sample size was small, results of this study need future verification. Over 1.5 million Americans are diagnosed with a stroke each year, and excessive flexion or extension (hypertonia) of upper extremity joints are common secondary conditions. The purpose of this study was to compare the efficacy of botulinum toxin type-A and manual therapy, with the adjunct treatment of dynamic splinting on range of motion, spasticity, and elbow flexor hypertonia, in a randomized trial.
                Thirty-six subjects were recruited for this pilot study and all exhibited hypertonia in elbow flexion. Six patients were excluded due to noncompliance. Testing was done with pre/post active range of motion in elbow extension, and the Modified Ashworth Scale (extension) for spasticity. All patients received the current standard of care: botulinum toxin type-A injections and manual therapy. Experimental patients were randomly assigned adjunct treatment with Elbow Extension Dynasplint.
                Thirty patients completed the study (mean age [SD] 52+/-17 years). The percentage of change in active range of motion in elbow extension was greater for the experimental than for control subjects (33.5% vs. 18.7%). The Modified Ashworth Scale (extension) scores showed comparable changes of a mean 9.3% improvement for experimental versus 8.6% for the control subjects.
                This study confirmed the efficacy of botulinum toxin type-A in tone management and occupational therapy in contracture reduction. It also showed the value of dynamic splinting in maintaining gains in range of motion. To determine the effect of 4 weeks of 30 minutes of daily stretching on ankle mobility in patients with recent spinal cord injuries (SCIs).
                Assessor-blinded randomized controlled trial.
                Two spinal injury units in Sydney, Australia.
                Consecutive sample of 14 recently injured patients with paraplegia and quadriplegia.
                Treated ankles were stretched continuously into dorsiflexion with a torque of 7.5 N x m for 30 minutes each weekday for 4 weeks. Contralateral ankles received no stretches.
                Passive torque-angle curves for both ankles were obtained at study commencement, then at weeks 2, 4, and 5 (ie, during, at the end of, and 1 week after the stretching program). Torque-angle measurements were obtained with the knee extended and flexed. Mean values for parameters (baseline angle, angle at 10 N x m, slope) describing the characteristics of the torque-angle curves were derived for each knee position. Changes from pretest to each subsequent test were calculated, as well as 95% confidence intervals (CIs) for differences in these changes between stretched and controlled ankles.
                The stretching intervention did not significantly change any of the 3 parameters describing the torque-angle curves of the ankle in either knee position. At the beginning of the study, the mean (+/-SD) angles obtained with the application of a standardized torque with the knee extended for the control and stretch ankles were 105 degrees (+/- 10.4 degrees) and 106 degrees (+/- 9.8 degrees), respectively. After 4 weeks, these values were 106 degrees (+/- 10.6 degrees) and 107 degrees (+/- 10.6 degrees) (mean difference in change of angle = 0 degrees; 95% CI, -3.3 degrees to 3.3 degrees).
                Thirty minutes of daily stretching for 4 weeks does not significantly change ankle mobility in recently injured patients with SCIs.
Stretch does not have clinically important effects on joint mobility in people with, or at risk of, contractures if performed for less than seven months. The effects of stretch performed for periods longer than seven months have not been investigated.