Advertisement

The Effects of Stretching in Spasticity: A Systematic Review

      Abstract

      Bovend'Eerdt TJ, Newman M, Barker K, Dawes H, Minelli C, Wade DT. The effects of stretching in spasticity: a systematic review.

      Objectives

      To investigate the general effect of stretching on spasticity and to explore the complexity of stretching in patients with spasticity.

      Data Sources

      Two researchers independently performed a systematic literature search using the databases: Medline, PEDro, Cochrane library, Web of Science, CINAHL, and Allied and Complementary Medicine.

      Study Selection

      Studies on adults receiving a stretching technique to reduce spasticity were included.

      Data Extraction

      Randomized controlled trials (RCTs) were assessed on the PEDro scale for methodologic quality. Thirteen items from the CONSORT list and the Critical Appraisal Skills Program guideline were used to assess the methodologic quality of the other studies.

      Data Synthesis

      RCTs (n=10) and other clinical trials (n=11) were included. The methodologic quality of the RCTs was low, varying between 4 and 8 on the PEDro scale. All studies show great diversity at the levels of methodology, population, intervention, and outcome measures making a meta-analysis not feasible. Both manual and mechanical stretching methods were studied. Stretching protocols were generally inadequately described and poorly standardized. The outcome measures used often assessed impairments such as available range of motion but were unable to distinguish between neural and nonneural components of spasticity. Associated functional benefits were not usually investigated. Although there is some positive evidence supporting the immediate effects of 1 stretching session, it remains unclear how long these effects abide and its long-term consequences.

      Conclusions

      There is a wide diversity in studies investigating the effects of stretching on spasticity, and the available evidence on its clinical benefit is overall inconclusive. We recognize the need for consensus on a paradigm for stretching and for good-quality studies. Future research should address this issue and should investigate the clinical importance of the short- and long-term effects.

      Key Words

      List of Abbreviations:

      AMED (Allied and Complementary Medicine), CASP (Critical Appraisal Skills Program), MS (multiple sclerosis), RCT (randomized controlled trial), ROM (range of motion)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Barnes M.P.
        Upper motor neurone syndrome and spasticity.
        Cambridge Univ Pr, Cambridge2001
        • Sommerfeld D.K.
        • Eek E.U.
        • Svensson A.K.
        • Holmqvist L.W.
        • von Arbin M.H.
        Spasticity after stroke: its occurrence and association with motor impairments and activity limitations.
        Stroke. 2004; 35: 134-139
        • Welmer A.K.
        • von Arbin M.
        • Widen Holmqvist L.
        • Sommerfeld D.K.
        Spasticity and its association with functioning and health-related quality of life 18 months after stroke.
        Cerebrovasc Dis. 2006; 21: 247-253
        • Barnes M.P.
        • Kent R.M.
        • Semlyen J.K.
        • McMullen K.M.
        Spasticity in multiple sclerosis.
        Neurorehabil Neural Repair. 2003; 17: 66-70
        • Vender J.R.
        • Hughes M.
        • Hughes B.D.
        • Hester S.
        • Holsenback S.
        • Rosson B.
        Intrathecal baclofen therapy and multiple sclerosis: outcomes and patient satisfaction.
        Neurosurg Focus. 2006; 21: e6
        • Lance J.W.
        Spasticity: disorder of motor control.
        Year Book Medical Publishers, Chicago1980
        • Burridge J.H.
        • Wood D.E.
        • Hermens H.J.
        • et al.
        Theoretical and methodological considerations in the measurement of spasticity.
        Disabil Rehabil. 2005; 27: 69-80
        • Pandyan A.D.
        • Gregoric M.
        • Barnes M.P.
        • et al.
        Spasticity: clinical perceptions, neurological realities and meaningful measurement.
        Disabil Rehabil. 2005; 27: 2-6
        • Platz T.
        • Pinkowski C.
        • van Wijck F.
        • Kim I.H.
        • di Bella P.
        • Johnson G.
        Reliability and validity of arm function assessment with standardized guidelines for the Fugl-Meyer Test, Action Research Arm Test and Box and Block Test: a multicentre study.
        Clin Rehabil. 2005; 19: 404-411
        • Hsu A.L.
        • Tang P.F.
        • Jan M.H.
        Analysis of impairments influencing gait velocity and asymmetry of hemiplegic patients after mild to moderate stroke.
        Arch Phys Med Rehabil. 2003; 84: 1185-1193
        • Bhakta B.B.
        • Cozens J.A.
        • Chamberlain M.A.
        • Bamford J.M.
        Impact of botulinum toxin type A on disability and carer burden due to arm spasticity after stroke: a randomised double blind placebo controlled trial.
        J Neurol Neurosurg Psychiatry. 2000; 69 ([published erratum in: J Neurol Neurosurg Psychiatry 2001;70:821]): 217-221
        • Lieber R.L.
        • Steinman S.
        • Barash I.A.
        • Chambers H.
        Structural and functional changes in spastic skeletal muscle.
        Muscle Nerve. 2004; 29: 615-627
        • Nielsen J.B.
        • Crone C.
        • Hultborn H.
        The spinal pathophysiology of spasticity—from a basic science point of view.
        Acta Physiol. 2007; 189 (Oxf): 171-180
        • Alter M.J.
        Science of flexibility.
        2nd ed. Human Kinetics, Champaign1996
        • Gracies J.M.
        Pathophysiology of impairment in patients with spasticity and use of stretch as a treatment of spastic hypertonia.
        Phys Med Rehabil Clin N Am. 2001; 12 (vi): 747-768
        • Stokes M.
        Physical management of neurological rehabilitation.
        2nd ed. Elsevier Mosby, London2004
        • Harvey L.
        • Herbert R.
        • Crosbie J.
        Does stretching induce lasting increases in joint ROM?.
        Physiother Res Int. 2002; 7: 1-13
        • Mortenson P.A.
        • Eng J.J.
        The use of casts in the management of joint mobility and hypertonia following brain injury in adults: a systematic review.
        Phys Ther. 2003; 83: 648-658
        • Cicerone K.D.
        • Dahlberg C.
        • Malec J.F.
        • et al.
        Evidence-based cognitive rehabilitation: updated review of the literature from 1998 through 2002.
        Arch Phys Med Rehabil. 2005; 86: 1681-1692
        • Sherrington C.
        • Herbert R.D.
        • Maher C.G.
        • Moseley A.M.
        PEDro.
        Man Ther. 2000; 5: 223-226
        • National Health Services
        Critical appraisal skills programme.
        (Accessed March 13, 2008)
        • Altman D.G.
        • Schulz K.F.
        • Moher D.
        • et al.
        The revised CONSORT statement for reporting randomized trials: explanation and elaboration.
        Ann Intern Med. 2001; 134: 663-694
        • Ben M.
        • Harvey L.
        • Denis S.
        • et al.
        Does 12 weeks of regular standing prevent loss of ankle mobility and bone mineral density in people with recent spinal cord injuries?.
        Aust J Physiother. 2005; 51: 251-256
        • Bohannon R.W.
        Tilt table standing for reducing spasticity after spinal cord injury.
        Arch Phys Med Rehabil. 1993; 74: 1121-1122
        • Bohannon R.W.
        • Larkin P.A.
        Passive ankle dorsiflexion increases in patients after a regimen of tilt table-wedge board standing.
        Phys Ther. 1985; 65: 1676-1678
        • Kunkel C.F.
        • Scremin A.M.
        • Eisenberg B.
        • Garcia J.F.
        • Roberts S.
        • Martinez S.
        Effect of “standing” on spasticity, contracture, and osteoporosis in paralyzed males.
        Arch Phys Med Rehabil. 1993; 74: 73-78
        • Richardson D.
        The use of the tilt-table to effect passive tendo-Achilles stretch in a patient with head injury.
        Physiother Theory Pract. 1991; 7: 45-50
        • Singer B.J.
        • Dunne J.W.
        • Singer K.P.
        • Jegasothy G.M.
        • Allison G.T.
        Non-surgical management of ankle contracture following acquired brain injury.
        Disabil Rehabil. 2004; 26: 335-345
        • Tsai K.H.
        • Yeh C.Y.
        • Chang H.Y.
        • Chen J.J.
        Effects of a single session of prolonged muscle stretch on spastic muscle of stroke patients.
        Proc Natl Sci Counc Repub China B. 2001; 25: 76-81
        • Wu C.L.
        • Huang M.H.
        • Lee C.L.
        • Liu C.W.
        • Lin L.J.
        • Chen C.H.
        Effect on spasticity after performance of dynamic-repeated-passive ankle joint motion exercise in chronic stroke patients.
        Kaohsiung J Med Sci. 2006; 22: 610-617
        • Chua S.G.
        • Kong K.H.
        Complete semimembranosus rupture following therapeutic stretching after a traumatic brain injury.
        Brain Inj. 2006; 20: 669-672
        • Eng J.J.
        • Levins S.M.
        • Townson A.F.
        • Mah-Jones D.
        • Bremner J.
        • Huston G.
        Use of prolonged standing for individuals with spinal cord injuries.
        Phys Ther. 2001; 81: 1392-1399
        • Fleuren J.F.
        • Nederhand M.J.
        • Hermens H.J.
        Influence of posture and muscle length on stretch reflex activity in poststroke patients with spasticity.
        Arch Phys Med Rehabil. 2006; 87: 981-988
        • Kiser T.S.
        • Reese N.B.
        • Maresh T.
        • et al.
        Use of a motorized bicycle exercise trainer to normalize frequency-dependent habituation of the H-reflex in spinal cord injury.
        J Spinal Cord Med. 2005; 28: 241-245
        • Nuyens G.E.
        • De Weerdt W.J.
        • Spaepen Jr, A.J.
        • Kiekens C.
        • Feys H.M.
        Reduction of spastic hypertonia during repeated passive knee movements in stroke patients.
        Arch Phys Med Rehabil. 2002; 83: 930-935
        • Schmit B.D.
        • Dewald J.P.
        • Rymer W.Z.
        Stretch reflex adaptation in elbow flexors during repeated passive movements in unilateral brain-injured patients.
        Arch Phys Med Rehabil. 2000; 81: 269-278
        • Singer B.
        • Dunne J.
        • Singer K.P.
        • Allison G.
        Evaluation of triceps surae muscle length and resistance to passive lengthening in patients with acquired brain injury.
        Clin Biomech. 2002; 17 (Bristol, Avon): 152-161
        • Harvey L.A.
        • Byak A.J.
        • Ostrovskaya M.
        • Glinsky J.
        • Katte L.
        • Herbert R.D.
        Randomised trial of the effects of four weeks of daily stretch on extensibility of hamstring muscles in people with spinal cord injuries.
        Aust J Physiother. 2003; 49: 176-181
        • Turton A.J.
        • Britton E.
        A pilot randomized controlled trial of a daily muscle stretch regime to prevent contractures in the arm after stroke.
        Clin Rehabil. 2005; 19: 600-612
        • Bakheit A.M.
        • Maynard V.
        • Shaw S.
        The effects of isotonic and isokinetic muscle stretch on the excitability of the spinal alpha motor neurones in patients with muscle spasticity.
        Eur J Neurol. 2005; 12: 719-724
        • Maynard V.
        • Bakheit A.M.
        • Shaw S.
        Comparison of the impact of a single session of isokinetic or isotonic muscle stretch on gait in patients with spastic hemiparesis.
        Clin Rehabil. 2005; 19: 146-154
        • de Jong L.D.
        • Nieuwboer A.
        • Aufdemkampe G.
        Contracture preventive positioning of the hemiplegic arm in subacute stroke patients: a pilot randomized controlled trial.
        Clin Rehabil. 2006; 20: 656-667
        • Harvey L.A.
        • Batty J.
        • Crosbie J.
        • Poulter S.
        • Herbert R.D.
        A randomized trial assessing the effects of 4 weeks of daily stretching on ankle mobility in patients with spinal cord injuries.
        Arch Phys Med Rehabil. 2000; 81: 1340-1347
        • Bressel E.
        • McNair P.J.
        The effect of prolonged static and cyclic stretching on ankle joint stiffness, torque relaxation, and gait in people with stroke.
        Phys Ther. 2002; 82: 880-887
        • Carey J.R.
        Manual stretch: effect on finger movement control and force control in stroke subjects with spastic extrinsic finger flexor muscles.
        Arch Phys Med Rehabil. 1990; 71: 888-894
        • Hale L.A.
        • Fritz V.U.
        • Goodman M.
        Prolonged static muscle stretch reduces spasticity.
        S Afr J Physiother. 1995; 51: 3-6
        • Rochester L.
        • Vujnovich A.
        • Newstead D.
        • Williams M.
        The influence of eccentric contractions and stretch on alpha motoneuron excitability in normal subjects and subjects with spasticity.
        Electromyogr Clin Neurophysiol. 2001; 41: 171-177
        • Yeh C.Y.
        • Tsai K.H.
        • Chen J.J.
        Effects of prolonged muscle stretching with constant torque or constant angle on hypertonic calf muscles.
        Arch Phys Med Rehabil. 2005; 86: 235-241
        • Brar S.P.
        • Smith M.B.
        • Nelson L.M.
        • Franklin G.M.
        • Cobble N.D.
        Evaluation of treatment protocols on minimal to moderate spasticity in multiple sclerosis.
        Arch Phys Med Rehabil. 1991; 72: 186-189
        • Al-Zamil Z.M.
        • Hassan N.
        • Hassan W.
        Reduction of elbow flexor and extensor spasticity following muscle stretch.
        J Neurol Rehabil. 1995; 9: 161-165
        • Chung S.
        • Bai Z.
        • Rymer W.Z.
        • Zhang L.Q.
        Changes of reflex, non-reflex and torque generation properties of spastic ankle plantar flexors induced by intelligent stretching.
        Conf Proc IEEE Eng Med Biol Soc. 2005; 4: 3672-3675
        • Zhang L.Q.
        • Chung S.G.
        • Bai Z.
        • et al.
        Intelligent stretching of ankle joints with contracture/spasticity.
        IEEE Trans Neural Syst Rehabil Eng. 2002; 10: 149-157
        • Suzuki T.
        • Saitoh E.
        • Tani M.
        • et al.
        Effect of continued stretching of the affected arm in patients with cerebrovascular diseases by examining H-reflex characteristics.
        Electromyogr Clin Neurophysiol. 2003; 43: 51-56
        • Hummelsheim H.
        • Münch B.
        • Bütefisch C.
        • Neumann S.
        Influence of sustained stretch on late muscular responses to magnetic brain stimulation in patients with upper motor neuron lesions.
        Scand J Rehabil Med. 1994; 26: 3-9
        • Odeen I.
        • Knutsson E.
        Evaluation of the effects of muscle stretch and weight load in patients with spastic paraplegia.
        Scand J Rehabil Med. 1981; 13: 117-121
        • Selles R.W.
        • Li X.
        • Lin F.
        • Chung S.G.
        • Roth E.J.
        • Zhang L.Q.
        Feedback-controlled and programmed stretching of the ankle plantarflexors and dorsiflexors in stroke: effects of a 4-week intervention program.
        Arch Phys Med Rehabil. 2005; 86: 2330-2336
        • Yeh C.Y.
        • Chen J.J.
        • Tsai K.H.
        Quantitative analysis of ankle hypertonia after prolonged stretch in subjects with stroke.
        J Neurosci Methods. 2004; 137: 305-314
        • Mattsson E.
        • Brostrom L.A.
        • Borg J.
        • Karlsson J.
        Walking efficiency before and after long-term muscle stretch in patients with spastic paraparesis.
        Scand J Rehabil Med. 1990; 22: 55-59
        • Odeen I.
        Reduction of muscular hypertonus by long-term muscle stretch.
        Scand J Rehabil Med. 1981; 13: 93-99
        • Ansari N.N.
        • Naghdi S.
        • Moammeri H.
        • Jalaie S.
        Ashworth Scales are unreliable for the assessment of muscle spasticity.
        Physiother Theory Pract. 2006; 22: 119-125
        • Rosche J.
        • Paulus C.
        • Maisch U.
        • Kaspar A.
        • Mauch E.
        • Kornhuber H.H.
        The effects of therapy on spasticity utilizing a motorized exercise-cycle.
        Spinal Cord. 1997; 35: 176-178
        • Williams P.E.
        Effect of intermittent stretch on immobilised muscle.
        Ann Rheum Dis. 1988; 47: 1014-1016
        • Williams P.E.
        Use of intermittent stretch in the prevention of serial sarcomere loss in immobilised muscle.
        Ann Rheum Dis. 1990; 49: 316-317
        • Tsao C.
        • Mirbagheri M.M.
        Upper limb impairments associated with spasticity in neurological disorders.
        J Neuroeng Rehabil. 2007; 4: 45
        • Nuyens G.
        • De Weerdt W.
        • Ketelaer P.
        • Spaepen A.
        • Staes F.
        Torque variations during repeated passive isokinetic knee movements in persons with multiple sclerosis.
        J Rehabil Med. 2001; 33: 85-89
        • Cadenhead S.L.
        • McEwen I.R.
        • Thompson D.M.
        Effect of passive range of motion exercises on lower-extremity goniometric measurements of adults with cerebral palsy: a single-subject design.
        Phys Ther. 2002; 82: 658-669