Is stretch effective for treating and preventing joint deformities?

Review question: we reviewed the evidence about the effect of stretch in people who had or were vulnerable to joint deformities.

Background: we wanted to know whether stretch interventions are effective for the treatment and prevention of joint deformities (also known as contractures) in people with neurological and non-neurological conditions. Some of the conditions contained in this review included people with fracture, stroke, brain injury, arthritis or burns.

Stretch can be administered with splints and positioning programmes, or with casts, which are changed at regular intervals (serial casts). Alternatively, stretch can be self-administered or applied manually by therapists.

Study characteristics: this Cochrane review is current to November 2015. It includes the results of 49 randomised controlled trials involving 2135 participants. The participants had a variety of neurological and non-neurological conditions including stroke, acquired brain injury and spinal cord injury, arthritis, wrist fracture and burns.

Studies compared stretch to no stretch, often delivered with standard care for the disorder or another co-intervention such as exercise or botulinum toxin injection in the case of spasticity.

The stretch was administered in a variety of different ways including through passive stretching (self-administered, therapist-administered and device-administered), positioning, splinting and serial casting.

The stretch dosage was highly variable, ranging from five minutes to 24 hours per day (median 420 minutes, IQR 38 to 600) for between two days and seven months (median 35 days, IQR 23 to 84). The total cumulative time that stretch was administered ranged from 23 minutes to 1456 hours (median 168 hours, IQR 24 to 672).

The outcomes of interest were joint range of motion, spasticity, pain, ability to move, ability to participate in life, quality of life and adverse events. The short-term (less than one week) and long-term (more than one week) effects were investigated separately.

Study funding sources: no study was funded by a drug manufacturer or by an agency with a commercial interest in the results of the studies.

Key results: we found the following short-term effects up to one week after the last stretch intervention in studies that compared stretch with no stretch:

Joint Mobility (high score is better outcome)

Neurological conditions: stretch improves joint mobility by 1% (0% to 2% better) or 2° (0° to 3°)

Non-neurological conditions: stretch improves joint mobility by 1% (0% to 3% better)

Quality of life (high score is better outcome)

Neurological conditions: no studies

Non-neurological conditions: stretch improves quality of life by 1% (0% to 3% better)

Pain (low score is better outcome)

Neurological conditions: stretch increases pain by 2% (1% worse to 6% worse)

Non-neurological conditions: stretch decreases pain by 1% (3% better to 1% worse)

Activity limitation (high score is better outcome)

Neurological conditions: stretch improves the ability to move by 1% (0% to 2% better)

Non-neurological conditions: stretch improves the ability to move by 1% (2% worse to 4% better)

Participation (high score is better outcome)

Neurological conditions: no studies

Non-neurological conditions: stretch decreases engagement in participation with life by 12% (31% worse to 6% better)

Adverse events

Neurological and non-neurological conditions: 49 adverse events were reported, including skin breakdown, pain, numbness, venous thrombosis, wound infections, haematoma, flexion deficits and swelling. We could not calculate the risk of such events with stretch as adverse events were not reported in all studies, or not reported for both the treatment and control groups.

Quality of the evidence: there was high-quality evidence that stretch does not have clinically important short-term effects on joint mobility in people with neurological or non-neurological conditions. There was high quality evidence that stretch does not have clinically important short-term effects on pain, and moderate-quality evidence that stretch does not have clinically important short-term effects on quality of life in people with non-neurological conditions.

Conclusion: stretch is not effective for the treatment and prevention of contractures and does not have short-term effects on quality of life and pain in people with non-neurological conditions. The short-term and long-term effects of stretch on other outcomes in people with neurological and non-neurological conditions are not known.

Authors' conclusions: 

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

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Background: 

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

Objectives: 

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

Search strategy: 

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

Selection criteria: 

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

Data collection and analysis: 

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

Main results: 

Forty-nine studies with 2135 participants met the inclusion criteria. No study performed stretch for more than seven months. Just over half the studies (51%) were at low risk of selection bias; all studies were at risk of detection bias for self reported outcomes such as pain and at risk of performance bias due to difficulty of blinding the intervention. However, most studies were at low risk of detection bias for objective outcomes including range of motion, and the majority of studies were free from attrition and selective reporting biases. The effect of these biases were unlikely to be important, given that there was little benefit with treatment. There was high-quality evidence that stretch did not have clinically important short-term effects on joint mobility in people with neurological conditions (MD 2°; 95% CI 0° to 3°; 26 studies with 699 participants) or non-neurological conditions (SMD 0.2, 95% CI 0 to 0.3, 19 studies with 925 participants).

In people with neurological conditions, it was uncertain whether stretch had clinically important short-term effects on pain (SMD 0.2; 95% CI -0.1 to 0.5; 5 studies with 174 participants) or activity limitations (SMD 0.2; 95% CI -0.1 to 0.5; 8 studies with 247 participants). No trials examined the short-term effects of stretch on quality of life or participation restrictions in people with neurological conditions. Five studies involving 145 participants reported eight adverse events including skin breakdown, bruising, blisters and pain but it was not possible to statistically analyse these data.

In people with non-neurological conditions, there was high-quality evidence that stretch did not have clinically important short-term effects on pain (SMD -0.2, 95% CI -0.4 to 0.1; 7 studies with 422 participants) and moderate-quality evidence that stretch did not have clinically important short-term effects on quality of life (SMD 0.3, 95% CI -0.1 to 0.7; 2 studies with 97 participants). The short-term effect of stretch on activity limitations (SMD 0.1; 95% CI -0.2 to 0.3; 5 studies with 356 participants) and participation restrictions were uncertain (SMD -0.2; 95% CI -0.6 to 0.1; 2 studies with 192 participants). Nine studies involving 635 participants reported 41 adverse events including numbness, pain, Raynauds’ phenomenon, venous thrombosis, need for manipulation under anaesthesia, wound infections, haematoma, flexion deficits and swelling but it was not possible to statistically analyse these data.

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