Passive Stretching Does Not Enhance Outcomes in Patients With Plantarflexion Contracture After Cast Immobilization for Ankle Fracture: A Randomized Controlled Trial

doi:10.1016/j.apmr.2004.11.017

Archives of Physical Medicine and Rehabilitation

Volume 86, Issue 6, June 2005, Pages 1118-1126

Presented to the 8th International Physiotherapy Congress, May 15–18, 2004, Adelaide, Australia.

https://doi.org/10.1016/j.apmr.2004.11.017 Get rights and content

Abstract

Moseley AM, Herbert RD, Nightingale EJ, Taylor DA, Evans TM, Robertson GJ, Gupta SK, Penn J. Passive stretching does not enhance outcomes in patients with plantarflexion contracture after cast immobilization for ankle fracture: a randomized controlled trial. Arch Phys Med Rehabil 2005;86:1118–26.

Objective

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.

Design

Assessor-blinded, randomized controlled trial.

Setting

Hospital physical therapy outpatient departments.

Participants

Adults with plantarflexion contracture (N=150) after cast immobilization for ankle fracture. All subjects were weight bearing or partial weight bearing.

Interventions

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.

Main Outcome Measures

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.

Results

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.

Conclusions

The addition of passive stretching confers no benefit over exercise alone for the treatment of plantarflexion contracture after cast immobilization for ankle fracture.

Section snippets

Participants

Subjects were recruited from the plaster clinics of 2 large teaching hospitals (Royal North Shore Hospital and Royal Prince Alfred Hospital, Sydney, Australia). All patients referred to the outpatient PT service who met the following criteria were invited to participate: (1) ankle fracture treated with cast immobilization (with or without surgical fixation), (2) cast removed in preceding 5 days, (3) approval received from orthopedic specialist to weight-bear as tolerated or partial weight-bear,

Participants

The subject flow is illustrated in figure 1. One hundred thirty-nine subjects (139/150; 93%) completed the 4-week assessment and 134 (134/150; 89%) completed the 3-month assessment.

Subject characteristics and baseline values of primary variables are listed in table 1. There were no clinically important differences between the groups at baseline for any of the variables listed in table 1, although there were more right-sided fractures in the short duration stretch group than in the exercise only

Discussion

The principal finding of this trial was that the addition of a program of passive stretches confers no benefit over exercise alone in treating plantarflexion contracture after cast immobilization for ankle fracture. There were no statistically significant or clinically worthwhile differences between the exercise only, short-duration stretch plus exercise, and long-duration stretch plus exercise groups for perceived disability or passive dorsiflexion ROM. This result is consistent with those of

Conclusions

The addition of a program of passive stretches confers no benefit over exercise alone for the treatment of plantarflexion contracture after cast immobilization for ankle fracture.

Acknowledgments

The contributions of Stephanie Lanzarone and Adrian Byak, who were employed as assessors, and Dr Jeffrey Petchell (Orthopaedic Surgeon, Royal Prince Alfred Hospital), who performed the fracture severity ratings, are gratefully acknowledged.

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Joint immobilization is often used to treat orthopedic disorders, including ligament injuries, fractures, and dislocation. ( Ardevol et al., 2002; Eiff et al., 1994; Hendey, 2016; Kim et al., 2003; Lysholm et al., 1982; Moseley et al., 2005; Paterson et al., 2010). Joint immobilization facilitates healing of the injured tissues by avoiding the harmful stimuli such as excessive lengthening of joint tissues, but exerts adverse effects on uninjured tissues via the reduction of mechanical stress (Kannus and Jarvinen, 1990).
Although knee immobilization may deteriorate the mechanical parameters of the anterior cruciate ligament, such as stiffness and failure strength, it is unknown whether it induces laxity in the whole joint. We examined the effects of immobilization on anterior-posterior joint laxity and mechanical properties of the anterior cruciate ligament, as well as histological and gene expression profiles of the joint capsule in rat knee joints.
Unilateral rat knees were immobilized using an external fixator. Non-immobilized contralateral knees were used as controls. After 3 weeks, anterior-posterior laxity in the whole joint (i.e., a complex of bones, ligaments, and capsule) and stiffness and failure strength in the anterior cruciate ligament were examined using a universal testing machine. Moreover, the knee joint capsule was histologically analyzed, and the expression levels of genes related to collagen turnover in the posterior joint capsule were examined.
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These results suggest that 3 weeks of joint immobilization alters the biomechanical integrity in the knee joint without altering the mechanical properties of the anterior cruciate ligament. Changes in the joint capsule may contribute to the immobilization-induced increase in anterior-posterior laxity.
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Stretch for the treatment and prevention of contracture: an abridged republication of a Cochrane Systematic Review
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There was no obvious explanation for this but the extreme results all favouring the experimental condition seemed implausible. Therefore, 18 studies with a total of 865 participants were included in the present analyses.36–42,44–54 The participants included frail elderly and people with ankle fracture, anklylosing spondylitis, oral submucous fibrosis, post radiation therapy to the breast, post-radiation therapy to the jaw, progressive systemic sclerosis, total knee replacement, arthritis, Dupuytren’s contractures, shoulder adhesive capsulitis/frozen shoulder, hallux limitus, wrist fracture and burns.
Is stretch effective for the treatment and prevention of contractures in people with neurological and non-neurological conditions?
A Cochrane Systematic Review with meta-analyses of randomised trials.
People with or at risk of contractures.
Trials were considered for inclusion if they compared stretch to no stretch, or stretch plus co-intervention to co-intervention only. The stretch could be administered in any way.
The outcome of interest was joint mobility. Two sets of meta-analyses were conducted with a random-effects model: one for people with neurological conditions and the other for people with non-neurological conditions. The quality of evidence supporting the results of the two sets of meta-analyses was assessed using GRADE.
Eighteen studies involving 549 participants examined the effectiveness of stretch in people with neurological conditions, and provided useable data. The pooled mean difference was 2 deg (95% CI 0 to 3) favouring stretch. This was equivalent to a relative change of 2% (95% CI 0 to 3). Eighteen studies involving 865 participants examined the effectiveness of stretch in people with non-neurological conditions, and provided useable data. The pooled standardised mean difference was 0.2 SD (95% CI 0 to 0.3) favouring stretch. This translated to an absolute mean increase of 1 deg (95% CI 0 to 2) and a relative change of 1% (95% CI 0 to 2). The GRADE level of evidence was high for both sets of meta-analyses.
Stretch does not have clinically important effects on joint mobility. [Harvey LA, Katalinic OM, Herbert RD, Moseley AM, Lannin NA, Schurr K (2017) Stretch for the treatment and prevention of contracture: an abridged republication of a Cochrane Systematic Review. Journal of Physiotherapy 63: 67–75]
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Supported by the University of Sydney and National Health and Medical Research Council, Australia.

No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the author(s) or upon any organization with which the author(s) is/are associated.

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Original articlePassive Stretching Does Not Enhance Outcomes in Patients With Plantarflexion Contracture After Cast Immobilization for Ankle Fracture: A Randomized Controlled Trial

Abstract

Objective

Design

Setting

Participants

Interventions

Main Outcome Measures

Results

Conclusions

Section snippets

Participants

Participants

Discussion

Conclusions

Acknowledgments

Bone

Man Ther

Aust J Physiother

J Hand Ther

Arch Phys Med Rehabil

Aust J Physiother

Neuromuscul Disord

J Hand Surg [Br]

Arch Phys Med Rehabil

J Hand Surg [Br]

Aust J Physiother

Injury

Clin Biomech (Bristol, Avon)

Pain

Pain

Epidemiology of fractures in 15,000 adultsthe influence of age and gender

J Bone Joint Surg Am

Fractures about the ankle

J Bone Joint Surg Am

Comparison of passive stiffness variables and range of motion in uninvolved and involved ankle joints of patients following ankle fractures

Phys Ther

A study of function and residual joint stiffness after functional bracing of tibial shaft fractures

Clin Orthop

The effect of position of immobilisation on resting length, resting stiffness, and weight of the soleus muscle of the rabbit

J Orthop Res

Physiological and structural changes in the cat’s soleus muscle due to immobilization at different lengths by plaster casts

J Physiol

Connective tissue changes in immobilised muscle

J Anat

Original article
Passive Stretching Does Not Enhance Outcomes in Patients With Plantarflexion Contracture After Cast Immobilization for Ankle Fracture: A Randomized Controlled Trial