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NeuroRehabilitation 28 (2011) 17–20
DOI 10.3233/NRE-2011-0627
IOS Press

Contracture management for people withspinal cord injuries
Lisa A. Harvey∗, Joanne A. Glinsky, Owen M. Katalinic and Marsha Ben
Rehabilitation Studies Unit, Northern Clinical School, Sydney School of Medicine, University of Sydney, Australia

Abstract. Contractures are a common and disabling problem for people with spinal cord injuries. To date, contractures havelargely been managed with physical interventions such as stretch and passive movements. These are typically administered either
manually or with the assistance of various orthoses, devices or aids. However, the results of recent clinical trials question theeffectiveness of these interventions. They indicate that therapists should not expect to see a change in joint mobility or muscle
extensibility from stretches applied for less than 30 minutes a day over less than 3 months. This suggests that contractures may
be a far more complex and multifactorial problem to manage than previously assumed. This paper challenges clinicians andresearchers to reappraise the effectiveness of current contracture management.
Keywords: Spinal cord injury, contracture, muscle stretchingContractures are a common and debilitating problem
for people with spinal cord injury (SCI) [2,5,8,17,24,30]. They result in unsightly deformities and prevent
people performing motor tasks [12]. In addition, they
are associated with pain, spasticity, sleep disturbancesand skin breakdown. Contractures occur due to a loss
in extensibility of the soft tissue structures spanningjoints [18]. These include skin, ligaments, muscles andjoint capsules. Loss in extensibility in any of thesestructures restricts joint mobility, leads to joint stiffness
and can result in contractures.
Contractures are usually attributed to the direct effects of prolonged immobilization and habitual use ofsoft tissues in their shortened range [14]. In people
with SCI this is thought to occur as a consequence ofpatterns of paralysis combined with prolonged sitting
or lying. For example, people with motor complete
C5 tetraplegia are prone to developing elbow flexion
contractures because they retain voluntary control ofthe biceps muscles but have paralysis of the triceps∗ Corresponding author: Associate Professor Lisa Harvey, Rehabilitation Studies Unit, Sydney School of Medicine, Royal Rehabilitation Centre Sydney, P.O. Box 6, Ryde, NSW 1680, Australia.
Tel.: +61 2 98089236; Fax: +61 2 98099037; E-mail: l.harvey@
usyd.edu.au.

muscles. In addition, people with C5 tetraplegia commonly sit with their elbows positioned in flexion on
the armrests of wheelchairs and lie with their elbows
flexed when in bed. Together these factors increase thetime in which the biceps muscles are immobilized ina shortened position increasing susceptibility to elbow
flexion contractures [2,10].
A large amount of healthcare resources are used forthe treatment and prevention of contractures in people
with SCI. The most widely used interventions for thispurpose are stretch and passive movements. There arevarious ways these interventions can be administered.
For example, stretch can be applied using splints, positioning programs or orthoses, and passive movements
can be administered using mechanical devices or manually by carers and therapists. While stretch and passive movements are perhaps most commonly administered manually, this method limits the dosage of stretchand passive movements that can be realistically applied.
Optimal dosage has never been clarified, although historically, dosage has been based on clinical experience,
anecdotal evidence and animal studies.
Stretch and passive movements have been used since
the early 1900s (or perhaps earlier) and were increasingly advocated as SCI rehabilitation began to evolve
following the First and Second World Wars [21]. Out-ISSN 1053-8135/11/$27.50  2011 – IOS Press and the authors. All rights reserved

18L.A. Harvey et al. / Contracture management in SCI

breaks of polio in the mid 20th century drew further attention to the problems of contracture and theimportance of appropriate physiotherapy and nursing
care [16,22]. As early as the 1950s, there were recommendations that passive movements be performed for
two to three minutes every few hours in people withparalysis from different pathologies [19]. Sir Ludwig
Guttmann, considered one of the pioneers of SCI rehabilitation, advocated passive movements three times
a day [6]. The rationale for passive movements andstretch is reasonable. That is, if contractures result fromthe inability of individuals to move joints, then perhaps
therapists moving and stretching individuals’ joints canavoid the consequences of immobility for them.
During the 1980s increasing emphasis was placedon prolonged stretch as can be administered throughpositioning programs, splints, standing frames and orthoses [4,20,23]. The perceived importance of prolonged stretch arose from animal studies [25–29].
These studies highlighted the adaptable nature of animal muscles and soft tissues. In particular, they indicated the need for prolonged and sustained stretch tostimulate the addition of muscle sarcomeres in seriesnecessary for lasting changes in muscle extensibility.
Of course it was never clear whether the muscles ofpeople with SCI were as responsive to stretch as themuscles of small animals. However, in the absence ofclear evidence from human studies, it became common
for therapists to recommended 20 to 30 minutes of sustained stretch per muscle a day for the prevention andtreatment of contractures.
It is only in the last ten years with the increasing emphasis on evidence-based practice that therapists havebegun to revisit the issue of contracture management.
In particular they have examined issues around dosage
and asked questions about the relative effectiveness of
passive movements and stretches administered in different ways. This has partly been driven by underlying
concerns that five minutes, twenty minutes or even one
hour of any intervention (including stretch) is not sufficient to attain a therapeutic effect. Therapists’ time andefforts may be better spent on other rehabilitation interventions that inadvertently place muscles in lengthened
positions through regular practice of functional tasks
and activities of daily living.
Our research group has devoted over ten years in an
attempt to gain a better understanding of contracture
management in people with SCI and other neurological conditions [1,7,9,11,13]. Over this time our longheld beliefs have been challenged and we have cometo the conclusion that far less is understood about therole of passive movements and stretch than is generallyassumed. Only one randomized controlled trial has examined the effectiveness of passive movements in people with SCI. This trial used the ankle as a model to explore the more generic question of the effectiveness ofpassive movements [13]. Twenty people with tetraplegia living in the community had one ankle randomized
to a control group and the other to an experimentalgroup. Carers administered passive movements to participants’ experimental ankles for 10 minutes, 10 times
a week for 6 months. The control ankles were left untreated. The results of this trial indicated that there wasa small added benefit of applying passive movements
for six months (between-group mean difference = 4
degrees, 95% CI 2 to 6 degrees). There are two important questions to arise from this trial. First, can we expect this small effect to increase if passive movements
are applied for a longer time? If so, this intervention
may prove worthwhile provided it is applied for manyyears. Second, can we expect to see the same effectfrom just 2–3 minutes of passive movements each day(compared with the 20 minutes a day applied in thistrial), as is typically applied to each joint in the clinicalsetting? This would seem unlikely. Two to three minutes is a very small dosage of passive movements forpeople who are unable to move their paralyzed joints
for the remaining part of each day.
There is an equivocal lack of clarity surrounding thedosage of sustained stretch required to treat and prevent contractures in people with SCI. Five randomized
controlled trials have looked at various combinations
and dosages of stretch applied to people with SCI [1,3,7,9,11]. Three of these trials demonstrated that stretchbased interventions were ineffective when compared to
no intervention or usual care [7,9,11]. The key findingsof these trials were that thirty minutes of stretch each
weekday for 4 weeks does not significantly change ankle mobility (between-group mean difference = 0 degrees, 95% CI −3 to 3 degrees) or hamstring extensibility (between-group mean difference = 1 degree, 95%CI −2 to 5 degrees) in people with SCI; and twelve
hours of stretch a day over a 3-month period does not
reduce thumb web space contracture in people withneurological conditions including SCI (between-groupmean difference = 1 degree, 95% CI −1 to 2 degrees).
One trial demonstrated a small effect on ankle mobility
from thirty minutes of tilt-table stretch, three times perweek for 12 weeks (between-group mean difference
4 degrees, 95% CI 2 to 6 degrees) [1] and one trial
provided insufficient data to determine between-groupdifferences [3]. A single definitive conclusion can beL.A. Harvey et al. / Contracture management in SCI

drawn from the results of these trials. That is, therapists
should not expect to see a clinically meaningful change
in joint mobility or muscle extensibility from stretches
applied for less than 30 minutes a day over less than 3months. If stretches are to be applied for more than 30
minutes then devices, splints and orthoses need to beused.
The results of trials in people with SCI have been
duplicated in trials involving other patient groups performed by other investigators. A recent Cochrane systematic review investigating stretch interventions forthe treatment and prevention of contractures identified
thirty five randomized controlled trials [15]. These involved 1,391 participants and all examined the effectiveness of stretch for the treatment and prevention ofcontractures. Stretch in these trials was administered inmany different ways. Twenty four trials involved 782
people with neurological conditions including SCI. The
results indicated that stretch has no clinically important short-term or long-term effects on joint mobility inpeople with neurological conditions. The pooled meandifference reflecting the short-term effects of stretch(that is the effects present between 24 hours and one
week after the cessation of stretch) was 1 degree (95%CI 0 to 3 degrees). The equivalent pooled mean difference reflecting the long-term effects of stretch (thatis the effects present greater than one week after thecessation of stretch) was 0 degrees (95% CI −2 to 2degrees).
Most trials investigating stretch in people with SCI(and other neurological conditions) have examined theadded benefit of stretch over and above usual care provided to both experimental and control groups. In
these studies stretch or passive movements may havebeen administered inadvertently as part of usual careas participants moved during daily activities or rehabilitation programs. For example passive movements
and stretch can occur during regular change in position
for skin care, extensive practice of functional activities, and sports to encourage participation. Therefore,
while the results of the randomised controlled trials in
people with SCI indicate that stretch as typically applied by therapists does not produce lasting increases
in joint mobility, it is unclear whether stretch applied
as part of usual care has any effect on joint mobility.
This issue has not been investigated because there isno ethically acceptable research model where all formsof stretch and passive movement administered as partof rehabilitation or usual care can be denied to control
participants.
The evidence to date indicates that stretch applied
for less than 3 months confers little or no added benefit

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over and above usual care in people with SCI. Thereis a small benefit from passive movements compared
to usual care when applied for 6 months but it is unclear whether this benefit is clinically worthwhile. The
effects of stretch or passive movements performed formore than 3 to 6 months, respectively, remains unknown.

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