Spinal Cord (2002) 40, 1±9 ã 2002 International Medical Society of Paraplegia All rights reserved 1362 ± 4393/02 $25.00 www.nature.com/sc

Scienti®c Review

Muscle stretching for treatment and prevention of contracture in people with spinal cord injury

LA Harvey*,1 and RD Herbert2 1Moorong Spinal Injuries Unit, Royal Rehabilitation Centre, Sydney, Australia; 2School of Physiotherapy, University of Sydney, Australia.

Contracture, or reduced joint mobility, is a common and disabling sequel of spinal cord injury. The primary intervention for the treatment and prevention of contracture is regular stretch to soft tissues. While the rationale for this intervention appears sound, the e€ectiveness of stretching has not been veri®ed with well designed clinical trials. One recent randomised trial suggests there is no clinically worthwhile e€ect from a typical stretch protocol applied to spinal cord injured patients. Despite the negative results of this ®rst trial, we argue that therapists should continue administering stretch for the treatment and prevention of contracture until the results of further studies emerge. To maximise the probability of attaining a clinically worthwhile e€ect, we suggest that therapists stretch soft tissues for long periods (at least 20 min, and perhaps for as long as 12 h a day). Practical suggestions are given on how to readily provide spinal cord injured patients with sustained stretch to key joints and muscle groups. Stretch is most likely to be e€ective if started before the onset of contracture. Soft tissues most at risk should be targeted, particularly if contracture is likely to impose functionally important limitations. Spinal Cord (2002) 40, 1 ± 9. DOI: 10.1038/sj/sc/3101241

Keywords: spinal cord injury; contracture; stretch

Introduction Contractures (reduced joint mobility) are due to loss of lesions.18 Spasticity is usuallymanagedwithmedication.18 extensibility in soft tissues spanning joints, and are a While some believe that stretching also induces function- common complication of spinal cord injury.1,2 One study ally important and lasting reductions in spasticity, this is found that spinal cord injured patients had, on average, yet to be veri®ed with good quality studies. seven contractures (SD=6.2) at between 6 and 7 weeks Non-neurally mediated contractures are due to after injury.1 Contractures are undesirable for many structural adaptations of soft tissues (for reviews see reasons but primarily because they prevent the perfor- Gossman et al,19 Akeson et al,20 and Herbert21,22). mance of motor tasks.1,3 ± 5 For example, elbow ¯exion Animal studies23 ± 25 indicate that such changes occur in contractures make it dicult for tetraplegics with response to prolonged immobilisation, particularly paralysis of triceps muscles to bear weight through the immobilisation of soft tissues in shortened positions. upper limbs, and hence attain independence with Ten days immobilisation of rabbit ankles in plantar- transfers.6±8 Contractures also create unsightly deformi- ¯exed position (the shortened position of the plantar- ties and are thought to predispose patients to spasticity, ¯exor muscles) results in approximately a 10% reduction pressure areas, sleep disturbances and pain.1,2,5,8 ± 12 in resting length of soleus muscle-tendon units,25 which is sucient to produce functionally signi®cant loss of ankle joint mobility. Muscle shortening is associated Mechanisms of contracture with a decrease in the number of sarcomeres, changes in Contractures are either neurally or non-neurally the alignment of intramuscular connective tissues and a mediated.13 Neurally mediated contractures are due to decrease in tendon resting length.23±34 spasticity (ie, involuntary re¯ex contraction of muscles) 13 ± 17 and are a common sequelae of upper motor neuron E€ects of muscle stretching Stretch has become a widely accepted means of treating *Correspondence: Dr Lisa Harvey, Department of Physiotherapy, and preventing contractures in people with spinal cord Moorong Spinal Injuries Unit, Royal Rehabilitation Centre, P.O. 35 ± 37 Box 6, Ryde, NSW 2112, Australia injuries. For instance, it is now accepted practice Contracture in spinal cord injury LA Harvey and RD Herbert 2

in spinal cord injury units for therapists to routinely found. The authors speculated that this may have been administer between 2 and 5 min of stretch a day to because co-interventions (such as routine positioning each major group of soft tissues, particularly when of ankles at 90 degrees in wheelchairs) were sucient patients are con®ned to bed immediately after injury. to reverse or prevent plantar¯exion contractures, and Consequently, it is not unusual for therapists to spend muscle stretching provided no additional bene®t. between 30 and 60 min a day with each patient, Alternatively, it may have been that the stretch administering stretches. Despite the time, e€ort and protocol was of insucient intensity or duration. resources devoted to administering stretches in this These ®ndings di€er from those of two well-designed way, few rigorously designed studies have examined the randomised trials on other populations, both of which e€ectiveness of this intervention.38 found a therapeutic e€ect with 4 ± 24 h stretch a day in The use of stretch to treat and prevent contractures head-injured4 and elderly bedridden patients.48 How- is usually justi®ed by animal studies23,39 that indicate ever, the results of both these studies may re¯ect the deleterious structural and morphological changes viscous deformation rather than lasting increases in associated with immobilisation in shortened positions tissue extensibility. Clearly, therefore, more rando- can be prevented25 or reversed23 by prolonged im- mised clinical trials are needed to determine if stretch mobilisation in lengthened positions (ie, continuous is e€ective for the treatment and prevention of stretch). Continuous stretch of this kind appears to contractures, and if so, to clarify the optimal dosage trigger remodelling of soft tissues. However, while of stretch. animal studies show that continuous stretch can reverse deleterious length adaptations in muscles, the e€ect of shorter periods of stretch is less clear. Only two Clinical implications studies29,40 have investigated the e€ects of short periods of daily stretch on soft tissue extensibility. These studies Optimal stretch protocol The challenge for therapists found that when the soleus muscles of mice were is to use the available evidence to make reasonable immobilised at short lengths, deleterious length adapta- decisions about clinical practice. It is disconcerting that tions such as decreases in sarcomere number and the ®rst randomised clinical trial on stretching in spinal muscle resting length could be partly prevented by cord injured patients found no clinically worthwhile interrupting the immobilisation with as little as 15 min e€ect, despite the application of daily stretches well in of stretch each day. Thirty minutes of stretch was excess of those typically used in clinical practice (ie, enough to completely prevent these changes. No study despite the application of 30 min of stretch per day). has yet examined the e€ect of less than 15 min daily However, the rationale supporting the use of stretch is stretch in an animal model, though stretches of this strong. Given the serious consequences of contractures, duration are typically applied in the clinic. we do not recommend that therapists discontinue A large number of human studies have examined stretching on the basis of one negative randomised the e€ects of stretch on the extensibility of soft tissues. trial. Instead it is probably appropriate that therapists However, the majority of these studies have only continue to provide stretches to spinal cord injured examined the e€ects of stretch on joint mobility and patients, at least until further randomised trials range of motion within minutes of the cessation of the indicate otherwise. In the meantime, it may be prudent stretch intervention. Increases in joint mobility ob- to apply stretches for as long as is practically possible served soon after the cessation of stretching are (ie, for at least 20 min, and perhaps for as long as 12 h primarily due to viscous deformation,41 ± 47 and need a day) in order to maximise the likelihood of attaining not re¯ect the structural adaptations of soft tissues a therapeutically worthwhile e€ect. required for lasting increases in extensibility.22 For this If stretches are to be applied for more than a few reason, studies which only report measurements taken minutes a day, therapists need to move away from the within minutes of the removal of stretch cannot labour-intensive tradition of manually applying provide evidence about the e€ectiveness of particular stretches with their hands. Instead, limbs should be types of muscle stretching for the treatment and positioned with at-risk soft tissues in stretched prevention of contracture. Only studies that measure positions, and where possible positioning programs joint mobility many hours or days after the removal of should be incorporated into patients' rehabilitation stretch, when the transient e€ects of viscous deforma- programs and daily lives. Often only relatively simple tion have subsided, can be validly used for this equipment is required for this purpose. For example, purpose. the hamstring muscles of patients con®ned to bed can To our knowledge only one randomised study38 has be readily stretched for sustained periods of time with investigated lasting e€ects of stretch on contracture in a splint and pulley device attached to the bed (Figure people with spinal cord injury. This study examined 1). The extrinsic ®nger ¯exor muscles of the hand can the e€ect of 4 weeks of 30 min daily stretches be stretched with a simple wooden device (Figure 2), (7.5 N.m) to the ankles of recently injured paraplegics and the shoulder extensor muscles of seated tetra- and tetraplegics. Ankle mobility was measured 24 h plegics can be stretched by positioning the arms on and again 1 week after the removal of stretch. Despite high tables (Figure 3). Hand splints are also an excellent statistical power, no treatment e€ect was e€ective way of positioning soft tissues in lengthened

Spinal Cord Contracture in spinal cord injury LA Harvey and RD Herbert 3

Figure 3 Method of administering a prolonged stretch to the shoulder extensor muscles. The arm is positioned on a high Figure 1 Method of positioning the hamstring muscles in a table with the shoulder in ¯exion stretched position for patients con®ned to bed. The knee is maintained in extension with a knee extension splint while the hip is maintained in ¯exion with slings and pulleys attached Preventing and anticipating contractures It is widely overhead believed that contractures can be more readily prevented than treated and that less stretch is required to maintain than increase the extensibility of soft tissues. Though the validity of these beliefs has not yet been substantiated, therapists are well advised to concentrate e€orts on preventing contractures. For example, supination contractures of the forearm (a common contracture of tetraplegics with C5 lesions) may be prevented by ensuring patients spend equal lengths of time each day sitting with forearms pronated and supinated. Minor modi®cations to the arm rests of wheelchairs may be required, but otherwise this is a relatively simple positioning protocol to implement. In contrast, once supination contractures are established it is dicult to e€ectively stretch the forearm, and often cumbersome splints are required.50 In the same way, Figure 2 Device to administer a prolonged stretch to the hip and shoulder adductor contractures may be extrinsic ®nger ¯exor muscles. The hand and forearm is prevented in patients con®ned to bed by simply strapped into a simple wooden device that hinges at the wrist. positioning patients for at least some of each day with Stretch is applied to the extrinsic ®nger ¯exor muscles by shoulders2 and legs abducted rather than adducted. positioning the wrist in extension while the metacarpopha- langeal and interphalangeal joints are maintained in exten- sion. This type of stretch may be indicated in incomplete Factors that predispose patients to contractures The tetraplegics with voluntary control of the ®nger ¯exor skill of preventing contractures largely lies in accurately 51 muscles but paralysis of the ®nger extensor muscles or in predicting them. At-risk soft tissues are those C5 and above tetraplegics. This type of stretch is habitually held in shortened positions. Fortunately, it inappropriate if attempting to promote a tenodesis grip is possible to predict soft tissues likely to be held at short lengths by looking at factors such as the pattern of innervation, pain, oedema, independence with positions. A splint that immobilises the metacarpo- various activities of daily living (ADL), and the phalangeal (MCP) joints in ¯exion and interphalangeal position in which the patient spends the majority of (IP) joints in extension may help prevent MCP each day (ie, in bed or in a wheelchair; see Table 1). hyperextension and IP ¯exion contractures49 (both of For example, patients with complete C5 and C6 which are common in tetraplegics with lesions at or tetraplegia are susceptible to elbow ¯exion contrac- above C5, particularly if oedema is also present). tures. These patients have paralysis of the triceps but Stretches applied in any of these ways can be readily not biceps muscles. Consequently, they tend to sit and sustained and easily administered by therapists and lie with their elbows ¯exed. The problem is particularly carers. Of course care needs to be taken to ensure that apparent in patients nursed in a supine position for strategies instigated to prevent contractures in one extended periods of time. From this position it is group of soft tissues does not promote contractures in dicult for patients with paralysis of the triceps the antagonistic group of soft tissues. muscles to passively extend their elbows once ¯exed.

Spinal Cord 4 pnlCord Spinal

Table 1 A guide to the types and causes of contractures that tetraplegics and paraplegics are susceptible to developing. Levels of Voluntary control of Activities limited by contractures Type of lesions agonist and antagonist Postures that increase Postures that help prevent and activities that help prevent contracture susceptible muscles susceptibility to contractures contractures contractures Loss of C5 and . ¯exors ± weak (C5) or . sitting or lying with arms beside . sitting with shoulders ¯exed and . lifting hand to mouth/face (C5) shoulder above absent (C4 and above) body supported on high table . dressing upper limbs (independent ¯exion . extensors ± weak (C5) . sidelying with shoulders in ¯exion or dependent) or absent (C4 and above) Loss of C5 and . abductors ± present . sitting or lying with arms beside . sitting with shoulders abducted . lifting hand to mouth/face (C5) shoulder above (C5) or absent (C4 and body and supported on high table . dressing upper limbs (independent abduction above) . lying in supine position with arms or dependent) . adductors ± weak (C5) supported on abduction boards injury cord spinal in Contracture or absent (C4 and above) Loss of C5 and . external rotators ± . sitting with hands against chest . sitting with hands away from . dressing upper limbs (independent Herbert RD and Harvey LA shoulder above weak (C5) or absent on lapboard chest or dependent) external (C4 and above) . lying in supine position or . lying in supine position with rotation . internal rotators ± sidelying with hands across or on hands o€ chest and shoulders weak (C5) or absent chest externally rotated (C4 and above) Loss of C5 and . extensors ± absent* . sitting with arms supported on . using upper limbs to push manual . reaching elbow C6 . ¯exors ± present* lapboard wheelchair . pushing manual wheelchair extension . sitting with elbows actively . sidelying or lying in supine . transferring by bearing weight ¯exed position with elbows extended through upper limbs (C6) . lying in supine position with hands on chest Loss of C4 and . supinators ± absent . sitting with forearms pronated on . sitting with forearms supinated . dressing upper limbs (dependent) forearm above . pronators ± absent lapboard . lying in supine position with arms supination . lying in supine position with beside body and forearms hands on chest or with arms supinated beside body and forearms pronated Loss of C5 . pronators ± absent* . sitting with elbows actively . sitting with forearms pronated . controlling joystick on electric forearm . supinators ± present* ¯exed and forearms actively wheelchair pronation supinated ± due to contraction of . feeding biceps . using hands to passively hold and manipulate objects Loss of C5 . ¯exors ± absent . sitting with elbows actively . sitting with forearms pronated and . using hands to passively hold and wrist . extensors ± absent ¯exed and supinated and hence hands hanging over edge of manipulate objects ¯exion wrist passively extended ± due to lapboard (ie, with wrist in ¯exion) contraction of biceps continued Table 1 continued. Levels of Voluntary control of Activities limited by contractures Type of lesions agonist and antagonist Postures that increase Postures that help prevent and activities that help prevent contracture susceptible muscles susceptibility to contractures contractures contractures Loss of C8 and . ¯exors ± weak (C8) or . sitting with elbows actively . wearing hand splints that position . using hands to passively hold and MCP above absent (C7 and above) ¯exed and supinated (C5) and MCP joints in ¯exion manipulate objects (C5) joint . extensors ± weak hence MCP joints passively . using passive tenodesis grip (C6 ¯exion (C7 and C8) or absent extended and C7) and using hands to (C6 and above) . wearing hand splits that actively hold and manipulate position MCP joints in extension objects (C8) Loss of IP C8 and . extensors ± weak (C7 . wearing hand splints that . wearing hand splints that position . using hands to passively hold and joint above and C8) or absent (C6 position IP joints in ¯exion IP joints in extension manipulate objects (C5) extension and above) . sitting with hand ¯exed around . using passive tenodesis grip (C6 . ¯exors ± weak (C8) object and C7) and using hands to or absent (C7 and above) actively hold and manipulate objects (C8) Loss of C5 and . abductors ± absent . sitting or lying with hands ¯at on . wearing hand splints that position . using thumb to passively hold and thumb above . adductors ± absent a surface thumb in abduction manipulate objects (C5) abduction Loss of hip L4 and . extensors ± absent* . sitting . lying in prone position . standing and/or walking (T10 ± extension above . ¯exors ± present* (L2 . sidelying with hips and knees . lying in supine position with hips L4) with or without orthoses and below) or absent ¯exed extended (L1 and above) . standing and/or walking Loss of hip L4 and . abductors ± absent* . sitting or lying with legs . lying in supine position with . attending to personal hygiene

abduction above . adductors ± present* adducted abduction pillow between legs (independent or dependent) Herbert RD and Harvey injury LA cord spinal in Contracture (L2 and below) or . transferring independently (C6 ± absent (L1 and above) L4) Loss of L3 and . hip ¯exors and knee . sitting . sitting with hips ¯exed and knees . dressing and/or transferring from hip ¯exion above extensors ± absent . sidelying with hips and knees extended (ankles supported on a long sitting position (C6 ± L3) and knee . hip extensors and ¯exed high stool) . getting from ¯oor to standing, or extension knee ¯exors ± absent . lying in supine position with hips chair to standing, with knee (hamstring ¯exed and knees extended (see extension orthoses (T10 ± L3) contracture) Figure 1) Loss of L3 and . knee extensors ± absent. sitting . sitting with knees extended . dressing and/or transferring from knee above . knee ¯exors ± absent . sidelying with knees ¯exed (ankles supported on stool) a long sitting position (C6 ± L3) extension . lying in supine position with . standing and/or walking with or knees extended without knee extension orthoses (T10 ± L3) Loss of L5 and . dorsi¯exors ± absent . sitting in wheelchair with . sitting or lying with feet supported . standing and/or walking with or ankle dorsi- above . plantar¯exors ± footplates too low at 90 degrees without ankle orthoses (T10 ± L5) ¯exion absent . lying in supine position or . standing with wedge or sandbag sidelying without footboards or under heads of metatarsals foot splints continued pnlCord Spinal 5 Contracture in spinal cord injury LA Harvey and RD Herbert 6

Pain increases susceptibility to contracture because it increases the tendency to contract non-paralysed muscles, which in turn increases the time soft tissues spend in shortened positions. Independence with activities of daily living also helps predict susceptibility

sions have been to particular types of contactures. For instance, C6 tetraplegics who transfer independently throughout the s of daily living that e of strength between e€ect of each level of day, passively extend their elbows while bearing weight through their upper limbs6±8 and are therefore less likely to develop elbow ¯exion contractures than more dependent C5 or C6 tetraplegics. The pattern and extent of spasticity will also in¯uence 18 wearing ankle orthoses (T10 ± L5) standing (T10 ± L5) susceptibility to contracture. This is not only because Activities limited by contractures . . spasticity directly in¯uences the extensibility of muscles (ie, contributes to neurally-mediated contractures, as discussed above) but also because spasticity increases the time that muscles and surrounding soft tissues spend in shortened positions.13,16,52,53 For example, constant spasticity of elbow ¯exor muscles may increase the amount of time the elbow remains in a ¯exed posture, and hence initiate structural adaptations of the soft tissues spanning the ¯exor aspect of the elbow. However, just as spasticity can indirectly contribute to contracture, so too can it prevent it. Patients otherwise susceptible to elbow ¯exion contractures can bene®t from regular and strong elbow extensor spasticity (this wearing shoes sitting or lying with feet and toes and/or shoes (L5 and above) pattern of spasticity is more common in C5 than C6 . . tetraplegics), because the spasticity can act to minimise the length of time the elbow spends in a ¯exed position.

Implications of contractures for individuals with spinal cord injuries The implications of slight losses of extensibility in soft tissues varies with level of motor function (see Table 1). Thus, while most contractures are undesirable, the prevention of some is more important than others. Slight loss of extensibility in the soft tissues spanning the ¯exor aspect of the elbow will have few functional implications for C5 tetraplegics unable to bear weight through the upper limbs. However, the same loss can prevent C6 tetraplegics from attaining independence sitting in wheelchair with not wearing shoeslying in supine position or standing 6±8 . footplates supported . . sidelying without footboardsfoot or splints with transfers. In the same way, slight loss of extensibility in soft tissues spanning the plantar aspect of the ankle (eg, the soleus muscle) will have little functional implication for a high-level wheelchair- dependent tetraplegic but marked implications for a walking low-level paraplegic. Clearly, concentrated e€ort should be directed at preventing loss of extensi- bility where such loss will impose important functional limitations. extensors ± absent ¯exors ± absent forefoot over front edge of . . Excessive tissue extensibility can hinder function Sometimes excessive extensibility is just as undesirable as limited extensibility and can prevent patients from performing important functional tasks. Excessive

Levels of Voluntary control of extensibility in the hamstring muscles can prevent C6 tetraplegics from sitting unsupported on a bed with

continued. knees extended,37 a skill important for independent dressing and transferring. Provided the hamstring muscles are not excessively extensible, the passive length of the hamstring muscles prevents the patient Table 1 Type ofcontractureLoss susceptible of toe lesions muscles L5 and agonist and antagonist Postures that increase susceptibility to contractures Postures that contractures help prevent and activities that help prevent contractures extension above The table indicateslesion the on level strength of ofagonist lesion agonist and and that antagonist antagonist muscles isincrease muscles (ie, associated is susceptibility good with indicated. strength toconsidered the Asterisks in contractures identify and greatest agonist situations the and and susceptibility in poor description to that which or of each contractures help no patterns major are strength prevent of commonly function-limiting in contractures. due weaknesses antagonist type to muscles). has For of imbalanc Also been contracture. the included simpli®ed. The sake are (MCP: postures of metacarpophalangeal. and brevity activitie IP: interphalangeal) the table is not comprehensive, only complete le

Spinal Cord Contracture in spinal cord injury LA Harvey and RD Herbert 7

falling forwards into full hip ¯exion37 (Figure 4a). However, the hamstring muscles can not prevent the a body falling forward if they are too extensible (Figure 4c). Therefore patients with excessive hamstring extensibility are disadvantaged because they must rely on their upper limbs to support their body. On the other hand, limited hamstring extensibility will prevent the patient from positioning the center of mass anterior to the hips, causing the body to fall backwards (Figure 4b). In this instance at least, there is a ®ne line between sucient and excessive extensibility, and some patients may bene®t from strategies that promote, rather than prevent, loss of extensibility.

Limited tissue extensibility sometimes assists function In unique circumstances, contractures can assist functional movement. An e€ective passive tenodesis grip in C6 and C7 tetraplegics depends on contractures in the ¯exor pollicis longus and extrinsic ®nger ¯exor b muscles.54 ± 58 Contractures in these muscles ensure that active wrist extension passively pulls the ®ngers and thumb into ¯exion. In this way, objects can be passively held between the thumb and index ®nger or in the palm of the hand. The challenge for therapists is to instigate appropriate interventions that promote loss of extensibility in the extrinsic ®nger and thumb ¯exor muscles while avoiding contractures in the joints of the hand.54

Summary While stretch has become the cornerstone of phy- siotherapy practice and an integral aspect of spinal cord injury rehabilitation programs, con®dence in the c e€ectiveness of this intervention is not yet justi®ed. Strategies that position soft tissues in stretched positions for prolonged periods of time may be most e€ective. Factors such as pattern of innervation, pain, spasticity, oedema and ability to perform functional activities will help predict contractures. Concentrated e€ort should be directed at preventing loss of extensibility where such loss will impose important functional limitations. Figure 4 The in¯uence of hamstring extensibility on the ability of C6 tetraplegics to sit with their hips ¯exed and knees extended. If the hamstring muscles have optimal Acknowledgements extensibility (a), they will passively limit hip ¯exion while the knee is maintained in extension. Provided the center of The ®nancial support of the Motor Accident Authority of mass of the trunk, head and arms are anterior to the hips, the NSW. patient will be able to sit unsupported and will be free to use upper limbs for purposeful tasks such as dressing. If the hamstring muscles have limited extensibility (b), tension in References the hamstring muscles will passively prevent hip ¯exion and the patient will be unable to position the center of mass anterior to the hip joint. Consequently, the patient will tend 1 Yarkony GM, Bass LM, Keenan V and Meyer PR. to fall backwards and need to use the upper limbs to prop the Contractures complicating spinal cord injury: incidence body. If the hamstring muscles are excessively extensible (c), and comparison between spinal cord centre and general they will o€er no resistance to hip ¯exion and the patient will hospital acute care. Paraplegia 1985; 23: 265 ± 271. fall forwards (head will fall between knees). In this scenario 2 Scott JA and Donovan WH. The prevention of shoulder the patient will be dependent on their upper limbs to support pain and contracture in the acute tetraplegia patient. the body Paraplegia 1981; 19: 313 ± 319.

Spinal Cord Contracture in spinal cord injury LA Harvey and RD Herbert 8

3 Kagaya H, Sharma M, Kobetic R and Marsolais EB. 23 Tabary JC, Tabary C, Tardieu C, Tardieu G and Ankle, knee, and hip moments during standing with and Goldspink G. Physiological and structural changes in without joint contractures: Simulation study for func- the cats' soleus muscle due to immobilization at di€erent tional electrical stimulation. Am J Phys Med Rehabil lengths by plaster casts. J Physiol 1972; 224: 231 ± 244. 1998; 77: 49 ± 54. 24 Tabary JC, Tardieu C, Tardieu G and Tabary C. 4 Moseley AM. The e€ect of casting combined with Experimental rapid sarcomere loss with concomitant stretching on passive ankle dorsi¯exion in adults with hypoextensibility. Muscle Nerve 1981; 4: 198 ± 203. traumatic head injuries. Phys Ther 1997; 77: 240 ± 247. 25 Herbert RD and Balnave RJ. The e€ect of position of 5 Cooper JE, Shwedyk E, Quanbury AO, Miller J and immobilisation on resting length, resting sti€ness, and Hildebrand D. Elbow joint restriction: e€ect on functional weight of the soleus muscle of the rabbit. J Orthop Res upper limb motion during performance of three feeding 1993; 11: 358 ± 366. activities. Arch Phys Med Rehabil 1993; 74: 805 ± 809. 26 Williams PE and Goldspink G. The e€ect of immobiliza- 6 Harvey LA and Crosbie J. Weight bearing through ¯exed tion on the longitudinal growth of striated muscle ®bres. upper limbs in tetraplegics with paralyzed triceps brachii J Anat 1973; 116: 45 ± 55. muscles. Spinal Cord 1999; 37: 780 ± 785. 27 Williams PE and Goldspink G. Changes in sarcomere 7 Harvey L and Crosbie J. E€ect of elbow ¯exion length and physiological properties in immobilized contractures on the ability of C5 and C6 tetraplegics to muscle. J Anat 1978; 127: 459 ± 468. perform a weight relief manoeuvre. Phys Res Int 2001; 6: 28 Williams PE, Catanese T, Lucey EG and Goldspink G. 76 ± 82. The importance of stretch and contractile activity in the 8 Grover J, Gellman H and Waters RL. The e€ect of a prevention of connective tissue accumulation in muscle. J ¯exion contracture of the elbow on the ability to transfer Anat 1988; 158: 109 ± 114. in patients who have tetraplegia at the sixth cervical level. 29 Williams PE. E€ect of intermittent stretch on immobi- J Bone Jt Surg (Am) 1996; 78: 1397 ± 1400. lised muscle. Ann Rheum Dis 1988; 47: 1014 ± 1016. 9 Freehafer AA. Flexion and supination deformities of the 30 Williams PE and Goldspink G. Connective tissue changes elbow in tetraplegics. Paraplegia 1977; 15: 221 ± 225. in immobilised muscle. JAnat1984; 138: 343 ± 350. 10 Dalyan M, Sherman A and Cardenas DD. Factors 31 Goldspink G et al. E€ect of denervation on the associated with contractures in acute spinal cord injury. adaptation of sarcomere number and muscle extensibility Spinal Cord 1998; 36: 405 ± 408. to the functional length of the muscle. J Physiol 1974; 11 Waring WP and Maynard FM. Shoulder pain in acute 236: 733 ± 742. traumatic tetraplegia. Paraplegia 1991; 29: 37 ± 42. 32 Goldspink DF. The in¯uence of immobilization and 12 Silfverskiold J and Waters RL. Shoulder pain and stretch on protein turnover of rat skeletal muscle. J functional disability in spinal cord injury patients. Clin Physiol 1977; 264: 267 ± 282. Orthop Rel Res 1991; 272: 141 ± 145. 33 Witzmann FA, Kim DH and Fitts RH. Hindlimb 13 Sinkjaer T et al. Non-re¯ex and re¯ex mediated ankle immobilisation: length-tension and contractile properties joint sti€ness in multiple sclerosis patients with spasti- of skeletal muscle. J Appl Phys 1982; 53: 335 ± 345. city. Muscle Nerve 1993; 16: 69 ± 76. 34 Tardieu G, Thuilleux G, Tardieu C and Huet de la Tour 14 Herman R. The myotatic re¯ex. Clinico-physiological E. Long-term e€ects of surgical elongation of the tendo aspects of spasticity and contracture. Brain 1970; 93: calcaneus in the normal cat. Dev Med Child Neurol 1979; 273 ± 312. 21: 83 ± 94. 15 Lamontagne A, Malouin F, Richards CL and Dumas F. 35 Adkins HE. Clinics in Physical Therapy. Spinal Cord Evaluation of re¯ex- and nonre¯ex-induced muscle Injury: Churchill Livingstone: New York 1985. resistance to stretch in adults with spinal cord injury 36 Bromley I. Tetraplegia and Paraplegia: a Guide for using hand-held and isokinetic dynamometry. Phys Ther Physiotherapists. Churchill Livingstone: New York 1976. 1998; 78: 964 ± 975. 37 Somers MF. Spinal Cord Injury: Functional Rehabilita- 16 O'Dwyer NJ and Ada L. Re¯ex hyperexcitability and tion. Appleton and Lange: Norwalk, Connecticut 1992. muscle contracture in relation to spastic hypertonia. Curr 38 Harvey LA, Crosbie J and Herbert RD. Does regular Opin Neurol 1996; 9: 451 ± 455. stretch produce lasting increases in joint range of motion? 17 Sinkjaer T and Magnussen I. Passive, intrinsic and re¯ex- A systematic review. Phys Res Int 2001; in press. mediated sti€ness in the ankle extensors of hemiparetic 39 Tardieu C, Tabary JC, Tardieu G and Tabary C. patients. Brain 1994; 117: 355 ± 363. Adaptation of sarcomere numbers to the length imposed 18 Dietz V. Spastic movement disorder. Spinal Cord 2000; on the muscle. In: Guba F, Marechal G and Takacs O 38: 389 ± 393. (eds) Mechanism of Muscle Adaptation to Functional 19 Gossman MR, Sahrmann SA and Rose SJ. Review of Requirements. Pergamon Press: Elmsford, NY 1971, pp length-associated changes in muscle. Experimental evi- 99 ± 114. dence and clinical implications. Phys Ther 1982; 62: 40 Williams PE. Use of intermittent stretch in the prevention 1799 ± 1808. of serial sarcomere loss in immobilised muscle. Ann 20 Akeson WH et al. E€ects of immobilization on joints. Rheum Dis 1990; 49: 316 ± 317. Clin Orthop Rel Res 1987; 219: 28 ± 37. 41 Yang L et al. E€ects of joint motion constraints on the 21 Herbert R. Adaptations of muscle and connective tissue. gait of normal subjects and their implications on the In: Gass E and Refshauge K (eds). Musculoskeletal further development of hybrid FES orthosis for para- Physiotherapy: Clinical Science and Practice. Butter- plegic persons. J Biomechanics 1996; 29: 217 ± 226. worth-Heinemann: London 1995. 42 Bohannon RW. E€ect of repeated eight-minute muscle 22 Herbert RD. The prevention and treatment of sti€ joints. loading on the angle of straight-leg raising. Phys Ther In: Crosbie W and McConnell J (eds). Key Issues in 1984; 64: 491 ± 497. Musculoskeletal Physiotherapy. Butterworth Heinemann: London 1993, pp 114 ± 141.

Spinal Cord Contracture in spinal cord injury LA Harvey and RD Herbert 9

43 Magnusson SP et al. Viscoelastic response to repeated 51 Ada L and Canning A. Anticipating and avoiding muscle static stretching in the human hamstring muscle. Scand J shortening. In: Ada L and Canning A (eds) Key Issues in Med Sci Sports 1995; 5: 342 ± 347. Neurological Physiotherapy. Butterworth Heinemann: 44 Magnusson SP, Simonsen EB, Aagaard P and Kjaer M. London 1990. Biomechanical responses to repeated stretches in human 52 O'Dwyer NJ, Ada L and Neilson PD. Spasticity and hamstring muscle in vivo. Am J Sports Med 1996a; 24: muscle contracture following stroke. Brain 1996; 119: 622 ± 628. 1737 ± 1749. 45 Magnusson SP et al. Viscoelastic stress relaxation during 53 Siegler S and Carr E. A method for discriminating static stretch in human skeletal muscle in the absence of between spasticity and contracture at the ankle joint EMG activity. Scand J Med Sci Sports 1999b; 6: 323 ± during locomotion in neurologically impaired persons. 328. Study Institute and Conference: Biomechanics of Human 46 Toft E et al. Passive tension of the ankle before and after Movement. Formia, Italy, 1986. stretching. Am J Sp Med 1989; 17: 489 ± 494. 54 Harvey LA. Principles of conservative non-orthotic 47 Duong B, Low M, Moseley A and Herbert R. Time management for a tenodesis grip. J Hand Ther 1996; 9: course of stress relaxation in human ankles. Clin Biomech 238 ± 242. 2001; in press. 55 Curtin M. An analysis of tetraplegic hand grips. Br J Occ 48 Light KE, Nuzik S, Personius W and Barstrom A. Low- Ther 1999; 62: 444 ± 450. load prolonged stretch versus high-load brief stretch in 56 DiPasquale-Lehnerz P. Orthotic intervention for devel- treating knee contractures. Phys Ther 1984; 64: 330 ± 333. opment of hand function with C-6 tetraplegia. Am J 49 Prosser R. Splinting in the management of proximal Occup Ther 1994; 48: 138 ± 144. interphalangeal joint ¯exion contracture. J Hand Ther 57 Doll U, Maurer-Burkhard B, Spahn B and Fromm B. 1996; 9: 378 ± 386. Functional hand development in tetraplegia. Spinal Cord 50 Hokken W, Kalkman S, Blanken WC and van Asbeck 1998; 36: 818 ± 821. FW. A dynamic pronation orthosis for the C6 tetraplegic 58 Harvey L, Batty J, Jones R and Crosbie J. Hand function arm. Arch Phys Med Rehabil 1993; 74: 104 ± 105. in C6 and C7 tetraplegics. Spinal Cord 2001; 39: 37 ± 43.

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