1. No category

Low-Load, Prolonged Stretch in the Treatment of
Knee Flexion Contractures in Nursing Home
Residents
Teresa M Steffen and Louise A Mollinger
PHYS THER. 1995; 75:886-895.
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Research Report
Low-Load, Prolonged Stretch in the Treatment
of Knee Flexion Contractures in Nursing
Home Residents
Background and Purpose. The purpose qf this study zoas to do a pilot test of
the eflectivenes.~ofprolonged stretch (use of a splint) in reducing knee.flexion
contructures more than a traditional program ofpassit~erange of motion
(PROM) in a grozlp of nursing home residents. Subjects. The subjects were 28
nzln-ing home re.sidonts with 10 degrees or more qf kneeflexion contracture
bilatemlly. Eighteevz szll?jects complet~dthe stzidy. Methods. Data were cc~llecfedprior to the i~iitiationofthe intc~nlentionand at monthly intervals during
the 6 moilths of treatment. Repeated measurements were made oJ'hip, k n q
and ankle mnge of motion (ROM); the torque required to maintain passi~~e
knee extension; knco pain; seueral indicaton- of:function; and cogniti~~e
impairment. Both legs uf' each subject received PROM and manual stretching twice a
il~tjek;Z Y I addition, one leg was gi~lena prolonged stretch (tnsc. of a splint),five
times a week. Resrrlts. 'Ihert. were no dzfferences in knee ROM bctweerr the side
that receiz~edprolonged stretching and the side that receiued only PROM and
tnanual stretching at the beginning of the stlicly. No dzjerences in ROM or
torque measurements existed between the side that received prolonged stretchi q arid the side that receil~edonly PROM and mantial stretching at any interval, nor in ROM or torque owr time,fi)r either side. Because of the low statistical power qfthe study, the results should be vitwed with calltion. Conclusion
and Discussion. Physical therapists need to question whether prolonged
stretch.for nursing home residents with kneejlexion contractznres greater than
10 dqqrws is ofarzjl grmter hen@ than PROM and manual stretchiv~g.Investigations of other treatment protocols and treatment doses are needed, including
work in the area of prezjention of kncjejlwion contractllres. For the pilot groinp
of nursing home residents studied, gains i n knee extension did not occur with
the zlse of prolonged stretch for .? h o ~ ~ar sday, 5 days per week. [Steffen TAf,
Mollinger 01.Lou)-load,prolonged stretch in the treatnient of knee.flexiov~contmctzrres in nursing honw residents. Phys Ther. 1995;75886-897.1
1
Teresa M Steffen
Louise A Mollinger
Key Words: Aged, C~otructure,Elderlt: Gerzat~z'c,Knee, Nursing home, Range qf
motion.
TM Steffen. I'lil), I'T, is 1)irector o f l'hysical Therapy, Concol'cli:~ University, 1LX00 N L:~kcShore
Addl-css :ill corrrsponclencc to 1)s Steffen.
Dr. Mequon, W1 53092 (I'SA) ([email protected]~~w.ed~~).
LA Mollinges, I'T, is I'hysical Therapist, Olnni Therapy, 1x10 Kensington I>r, Waukesha, WI 53188.
This resc.:~rch was s u p p o ~ t e din part l,y a grant from the 1:oundation for I'hysical Therapy Inc
T h e study was approved 13). tlie utilization review cornn~itwesof Clernent Manor Health Center,
Grecnfielcl, W , and Villa Clement Nursing Home, Milwaukee, WI. :~ndI,y t h e Mecli~ilDirector of
Sl1oreh:lvc.n Health C e n ~ e r Oconomowoc,
,
WI.
7bi.s articlt~~rwssllhinitlcd hlarch 24.1995, and u~usacccplrd,Jl~tze12, 1995.
40 / 886
The functional consequences of knee
flexion contracture (eg, impaired
weight-bearing activities, difficulty with
bed or chair positioning) ~ n a k eknee
flexion contracture a clinically important condition for physical therapists,
nursing staff, and patients, although
the prevalence of knee flexion contractures in institutionalized elderly
populations appears to be low.' In a
previous study,' we concluded that
I'hysical Therapy / Volume 75, Number 10 / October 1995
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adjusted from 0 (no force resisting
flexion) to 12 (approximately 124
kg-cm of torque). The torque output
on all Dynasplints is calibrated at 30
degrees of flexion by the manufacturer. Gains in range of motion (ROM)
in stiff joints and successful contracture
reduction have been reported with use
of Dynasplints for the knee,H ankle,"
and elbow,lO-l2although none of
these cases were of institutionalized
elderly persons.
Figure I. me e n ~ q d i n in
t place on a 6r)uet.rt'xtrrmity
nursing home residents who show a
decline in anlbulation (decreased
distance, increased need for assist)
and exhibit resistance to passive knee
cxtension may be more likely to develop increased knee flexion contracturc and may benefit from physical
therapy. It is not clear, however, what
that intervention should be, nor at
what intensity or duration it should
continue.
knee flexion contrac-tures.7 Light and
colleagues7 found greater increases in
passive extension in knees treated
with modified Ruck's traction (low
load, prolonged stretch) compared
with knees treated with passive manual stretching (high load, brief stretch).
The Buck's traction was applied for 1
hour, twice a day for 4 weeks, on 11
clients. The weight applied was not
reported.
In our experience, clinical practice
related to knee flexion contractures
oken includes manual stretching exercise. prolonged stretch through strapping on a tilt table or application o f
sandbag weights over the distal femur,
use of mechanical traction, wearing of
t~ivalvedplaster casts, and lying in a
prone position with the legs unsupported. Manual stretching and passive
range of motion (PROM) exercise
have been suggested for management
of contracti~res.~-"he general concept is that stretching be done with
mild to rnoclerate force for a prolonged time, although specific guidelines for iudging intensity and duration
are not usu:illy given.
The Dynasplint SystemB*has been
marketed as another method of applying low stretching forces over prolonged periods. Dynasplint knee
braces have appeal because clients
can remain mobile and comfortable,
the splints are easy to apply in a
wheelchair or bed, and the splints are
approved for Medicare reimbursement. The Dynasplint is constructed of
two stainless steel struts (positioned
medially and laterally on the extremity) with cloth straps and velcroBt
closures (applied above and below
the joint) (Fig. 1). In the knee extension Dynasplint, knee motion is allowed, but a compression coil spring
within the struts resists flexion. This
resistance to flexion tends to bias the
knee toward a position of maximum
extension while the patient is inactive
and at rest. The spring tension can be
We are aware of only one previous
study of physical therapy effectiveness
in elderly nursing home residents with
The purposes of this study were (1) to
pilot test the effectiveness of a lowload, prolonged stretch as compared
with a traditional program of PROM
and manual stretching in decreasing
knee flexion contractures in an institutionalized elderly population and (2)
to provide a functional and clinical
description of our study population.
Method
Design
Longitudinal data were collected before and during treatment with prolonged stretch. Each subject had bilateral knee flexion contractures and
could thus serve as his or her own
control. The prolonged stretch intervention was done on one side only,
five times per week. Because we
preferred not to entirely withhold
treatment from the opposite leg, we
chose to provide a protocol of PROM
and manual stretching for both lower
extremities. Thus, the prolonged
stretch was actually an additional
intervention beyond what we considered to be a typical physical therapy
intervention for knee flexion contractures. The PROM and manual stretching was done twice a week because
this is a usual frequency for maintenance therapy in the nursing home
population in the geographic area
where the study was conducted. In
our study, therefore, we compared
prolonged stretching (use of a splint)
with PROM and manual stretching.
Subjects
*Ilyn;lsplir~rSystems InC, 645 Ellrimore Annapolis Mvd, Severna Pdrk, MD 22146-3923,
+ ~ e l c l -IJ.C,A
o Tnc. 406 Brown Ave. 1'0 I3ox 5218, Manchester, NH 03108.
Twenty-eight residents (6 men, 22
women) from three nursing homes
agreed to participate in the study.
Physical Therapy / Vohime 75, Number 10/ October 1995
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of the side of thc cxperiniental treatments. One of three measuring therapists was assigned exclusively to each
study site for the duration of the study.
Figure 2.
range
Positiorzi~zgund technique z~sed.fifor
niea.asuring knee extension passive
(!/' rnotior~and the torque needed to maintain muximum passive knee extension.
Residents with bilateral knee flexion
contractures of 10 degrees or greater
were asked to participate and provided with an explanation of the
study. Informed consent was obtained
from each participant or from a health
care representative or guardian if the
resident was unable to give consent.
Of the otiginal 28 residents, 18 completcd the study, 6 expil-ed, and 4
withdrew. Two residents who withdrew from the study refused to continue the trial of prolonged stretching
within the first month of the intervention; in the other 2 cxses of withclrawal from the study, family members requested discontinuation of the
splint due to perceived discomfort.
Ninety-three percent of the 28 subjects
were alrcady rcceiving physical herapy before participating in the study,
and rnoht (86%) of these subjects came
to therapy twice a week (X=2,
range= 1-3 times per week). The
frequency of diagnoses in major categories in the initial 28 subjects were as
follows: organic brain syndrome
(680/6),cerebrovascular accident (320/6),
Parkinson's disease (21%), arthritis
(50%), and hip fracture (25%). The
subjects had resided in the current
nursing home an average of 3 years
(SD=2.55, range=2 month.+9 years).
Measumment Descriptive data (age,
length of stay In the nurslng home,
and d~agnoses)on each subject were
obtained from the medical record.
Repeated measurements were made
over a 7-month period of PROM (hip
extension, knee extension, and ankle
dorsiflexion), the torque required to
maintain maximum passive knee extension, overall fiinctional level, ambulation and transfer status, cognitive
status, and knee pain. In he first
month, prior to initiation of treatment,
measurement sessions occurred at
2-week intervals in order to obtain
three bilateral baseline measurements.
Thereafter, measurements were repeated monthly throughout the remainder of the study. The physical
therapists performing the measurements were not involved In treatment
of the subjects, nor were they m a r e
Range of motion measurements were
made using a standard 360-degree
goniometer,*which was covered on
one side to prevent the therapist from
reading a value until after the measurement was made. Subjects were on
a therapy mat table for mcasurenients.
Hip extension and ankle dorsiflexion
wcre measured with each subject
positioned supine. For hip extension
measurements, the opposite hip was
flexed maximally within the subiect's
tolerance, and the ipsilateral lower
extremity was free to extend over the
side edge of the nut. For hip extension, the goniometric center of rotation was placed over the greater trochanter, with the stationary arm of thc
goniometer aligned with the lateral
trunk midline and the movable arm
aligned toward the lateral femoral
epicondyle. For ankle dorsiflexion
measurements, the ipsilateral knee
was flexed to minimize length limitations of the two-joint gastrocnemius
muscle. The goniometric center of
rotation for ankle dorsiflexion W;IS
placed just inferior to the lateral malleolus, with the stationary arm of the
goniometer aligned toward the head
of the fibula and the movable arm
parallel to the fifth metatarsal.
Passive knee extension w;a measured
w ~ t hthe subject positioned side lying,
with the top leg supported on an
elevated board to allow the hip to be
in neutral relative to abduction and
adduction. In addition, the hip was
passively moved into maximum extension and held by an assistant and by a
vertical post on the board supporting
the leg (Fig. 2). The knee extension
nleasurement was rrrade after the
therapist passively extended the knee,
attempting three times to reach maximum extension and holdlng this extension for a count of 10 each time
When this final extension position was
reached, an assistant held the extended position as the therapist me.-sured ROM.
br red Sammons Inc. PO Box 32, Brookfield, IL 60513-0032.
42 / 888
Physical Therapy /Volume 75, Number 10 / October 1995
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.
Table 1
Anzh~ibtiona n d Tran.yfer Status scoreI5
Patient Scoring Scale
0-Total
Dependence
1-Maxirr~al Assistance
2-Moderate
Assistance
tered the study. Treating therapists
were asked to stop any ROM or
stretching exercises to the lower extremities other than those specified for
the study protocol dunng the study
period. Functional training or strengthening exercise could be continued or
started if mdicated.
3 4 o n s t a n t Minimal Assistance
4--Occasional Minimal Assistance
5-Verbal
Cues Required
6-Supervision
Required
7-Independent
Directions for Scoring
Assistance: The patient cannot complete the activity without being physically assisted by another
person.
Verbal Cues: The patient can complete the activity but requires verbal cues because he or she is
unable to remember the steps necessary to accomplish it, has poor judgment, or does not
initiate the activity.
Supervision: The patient can complete the activity alone but requires supervision because he or she
feels insecure about performing the activity.
Independent: The patient normally can perform the activity safely with or without assistive devices,
feels secure alone, and initiates the activity and completes it in a practical amount of time.
To describe the resistance usually
encountered in passively extending
the knee of subjects with flexion contractures, we used a SPARK hand-held
dynamomete? to measure the force
required to hold the knee in maximum extension. A mark was made on
the lateral aspect of the measured leg,
at approximately the level where the
Achilles tendon blends with the muscle belly. After maximum knee extension was achieved, an assistant held
this extt:nded position by placing the
dynamo~meterperpendicularly on the
posterior leg at the level of the skin
mark (Fig. 2). The dynamometer force
reading was multiplied by the distance
from the skin mark to the lateral knee
joint line to provide a torque value.
The force measurement was taken
simultaneously w ~ t hthe measurement
of knee extension. After the initial
mc.asurement, the knee was allowed
to flex, and then the extension procedure was repeated to provide two
more force measurements. The measuring therapist was asked to rate the
pain associated with passive knee
motion (al~\ent/present)based on the
subject's verbal response or facial
expression.
At the first, third, and last measurement sessions, the treating therapist
scored the subject's overall functional
level using the Barthel Index.l3 The
reliability of this index has been previously reported. l 4 The treating therapist
also rated the need for assistance with
ambulation and transfers each month
using a previously described eightpoint scale1; (Tab. 1). Type of assistive
ambulatory device and ambulation
endurance were also recorded. Staff at
each site administered the Short Portato
ble Mental Status Que~tionnaire'~
describe the cognitive status of each
subject at the first, sixth, and ninth
(last) intervals in the study. The reliability and validity of this questionnaire have been rep0rted.1"~'
Treatment. Treatment for the knee
flexion contractures was initiated at
the beginning of tlw second month of
the study and continued through the
seventh month. Use of the prolonged
stretch was alternately assigned to the
right or left knee as each subject en-
"SPARK Instruments and Ac~clrmicsInc. PO Box i123. Coralville, I A 52241.
Each subject received PROM exercise
to both lower extremities twice a
week by on-site physical therapists
trained in a standardized protocol. The
exercise protocol was agreed on by
four therapists with geriatric experience and was designed to give a manual stretch into hip-knee extension
and ankle dorsdlexion. Each leg was
moved into exTension and held for 10
seconds at the point of maximum
resistance. This procedure w l ~repeated until maximum knee extension
was reached and then held for 1
minute. The leg was flexed and then
moved into this sustained position of
extension two more times. Five repetitions of ankle dorsdlexion with the
knee extended were each held for 5
seconds.
A trained physical therapy aide ap-
plied the splint to the assigned leg five
times a week, after initial fitting by the
treating therapist. Wearing time of the
splint was progressed from 1 hour to 3
hours by the end of the first week. We
chose this duration because we
wanted the physical therapy staff to
directly apply and remove the splints.
This application and removal of the
splints necessitated coordination with
nursing schedules for bathing and
cares. The tension setting on the splint
was initially 0 and progressed to 6
(62.2 kg-cm) between weeks 2 and 5
of the study. In our initial trials with
subjects, we found that many nursing
home residents could not tolerate
settings greater than 6. To sinipllfy
data analysis, we chose a tension
setting of 6 as a maximum for all subjects. The aide kept a log of subject
tolerance and response to the splint.
The Dynasplint fit and use were regularly monitored by the physical therapist involved in treatment. All the
subjects in two of the nursing homes
were checked for fit by the designer
of the splint, who also owns the con]-
Physical Therapy /Volume 75, Number 10 / October 1995
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pany that makes the splint. Some
padding and cuff changes were made
subsequent to his visit.
We monitored the treatment protocol,
splint fit, and the measurement protocol on a weekly basis. We were not,
however, involved directly with treatment or mtYdsurement.
Data Analysis
The Statistical Package for the Social
Sciences-PC+ software programll was
used for data analysis. We did t tests
on knee, ankle, and hip ROM; torque;
pain; Barthel Index scores; transfers;
ambulation status; and ambulation
endurance to compare those subjects
who completed the study and those
subjects who withdrew or expired.
Paired t tests were also done to identify differences between sides in either
ROM or torque at the beginning of the
study. A repeated-measures multivariate analysis of variance (MANOVA)
and paired t tests were done to establish whether any dfierences existed
between sides at any interval or on
either side across time in knee ROM.
Longitudinal knee extension data on
each subject were graphed to allow
study of individual variation from the
group data.
Rater Reliability
Ambulationltransfers. Two physical
therapists experienced in geriatrics
independently rated the ambulation
and transfer abilities of 16 nursing
home residents who were not involved in the study. The intraclass
correlation coefficient (ICC[2,1])'8
showed good interrater reliability for
this assessment tool (transfers= .982,
ambulation level=.960, assistive ambulatory device= 1.00, ambulation
endurance= 1.00).
Range of motion. To test the intrarater reliability of the three measuring therapists on knee ROM measurements, each therapist repeated ROM
nleasures on 8 to 10 lower extremities.
"SPSS Inc, 4 4 N Michigan Ave. C h i c a ~ o IL
. 60611.
44 / 890
A complete set of study measurements
was made, the subject was allowed to
briefly relax the extremity, and then
the repeat measurements were made
within one session. The ICC (2,l)
showed good intrarater reliability of
repeated measurements of ROM at the
knee ( 98 on the right, .99 on the left).
Repeated knee extension measurements varied an average of 2 degrees
(range=OO-15").
Variance in Repeated Toque
Measures
Repeated measures of the torque
required to maintain passive knee
extension showed high reproducibility
within a given nleasurement session
(N= 25-28). Intraclass correlation coefficients (2,1) for repeated torque measures within each of the three baseline
intervals were as follows: baseline
1-right side= ,729, left side= ,778:
baseline 2-right side= ,828, left
side= ,874; baseline +right
side= ,903, left side = ,872. An average
of the three repeated torque measures
at any given interval was used in the
data analysis.
Variance in Repeated Baseline
Measures
A previous study on knee flexion
contracturesl led us to conclude that
there may be some degree of variance
in nleasurement of contractures over
time (especially in the presence of
resistance to passive motion) unrelated
to the reliability of the measuring
therapist. Three consecutive baseline
measures of ROM and torque were
made at 2-week intervals prior to the
initiation of treatment to identify the
stability of these variables. Table 2
presents ICC values for baseline measures repeated over l month. We used
an average of the three baseline measures of ROM and torque in our analysis of the longitudinal data.
Table 2.
Intracluss Correlation COe$lcie?zts,fi)rRepeated Basditze Measurements of'Torqzre and Range of Motion
(N= 24)
Right
Side
Left
Side
Torquea
,528
,380
Knee extension
.897
,884
Hip extension
,678
,647
Ankle dorsiflexion
,612
,592
" A n average of the three repeated torque
values at each baseline intrnal was used for
this calculation.
Results
Descriptive Data
Table 3 describes the 18 subjects who
completed the study. Sixteen of these
subjects were female. Fourteen (78%)
of the subjects had 8 to 10 errors on
the Short Portable Mental Status Questionnaire, indicating severely impaired
intellectual function; 2 subjects
showed moderately impaired function
(5-7 errors); 1 subject showed mildly
impaired function; and 1 subject had
n o errors (intact intellechlal function).
All of the subjects had Barthel Index
scores below 60 (100 possible points),
which Granger and colleagueslkonsider an indication of serious limitations in personal care independence.
Thirteen subjects had scores below 40
(unquestionable severe disability), and
12 subjects scored below 20 (total
dependence). Twelve subjects (71%)
were nonambulatory, and the remainder required supervision (1 subject),
minimal assistance (3 subjects), or
moderate assistance (1 subject) to
ambulate. None of the subjects were
independent in ambulation. All of the
ambulatory subjects used a walker for
support but had varied endurance
when ambulating from 7.6 to 91.4 nl
(25-300 ft). Most of the subjects were
totally dependent for transfers (53%)
or required maximum assistance to
pivot (24%). Only 1 subject was independent with transfers, and the remainder required minimal to moderate
assistance to pivot. Knee pain during
Physical Therapy /Volume 75, Number 10 / October 1995
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Table 3.
Description of Subjects Who Completed the Stu~ly(N= 18f'
--
-
~
-
X
SD
Median
Range
Age (Y)
Short Portable Mental Status
Questionnaire (no. of
Statistical Analysis
O t o 10
error^)^
Barthel indexc
0 to 59
Transfer statusC
0 to 7
Ambulation statusc
0 to 6
Knee extension
(")d,e
Prolonged stretch
PROM* and manual
stretch
Hip extension (")de
Prolonged stretch
PROM and manual stretch
Ankle dorsiflexion
The t tests showed that, at the initiation of the study, the sitbjects who
completed the study (n= 18) were not
different from those who withdrew or
expired (n= 10) in ROM at the knee,
ankle, or hip; torque; pain; Barthel
Index scores; transfer ability; ambulation status; and ambulation endurance.
Paired t tests also demonstrated no
dserence between sides in knee, hip,
or ankle ROM or torque prior to initiation of treatment.
(")d,g
Table 4 shows the t-test results for the
side that received prolonged stretching
and the side that received only PROM
and manual stretching over the duration of the study. The t tests showed
no difference in knee ROM between
sides at any nleasurement interval. The
repeated-measures MANOVA showed
no difference between sides in knee
ROM at any interval and no difference
in knee ROM between intervals for
either side.
Prolonged stretch
PROM and manual stretch
Torque ( k g . . ~ m ) ~
Prolonged stretch
PROM and manual stretch
"Data colltrcted at baseline intervals.
" Data
passive extension was rated as present
in 9 knees (50%) on the side that
received prolonged stretching and in
11 knees (61Yo) on the side that received only PROM and manual
stretching at the initiation of the study.
from haselinc 1 interval.
-
' I>a[a fromi baseline 3 interval.
" ~ v e r a ~ofethree baseline measures.
"O0=full extension; values shown indicate lack of full extension
l'ROM=passive range o f molion.
Individual Data
"Minus sign indicates lack o f dorsiflexion beyond neutral.
Table 4.
Measurement
Interval
Restllts of Paired t Tests o f Knee Extension O w r 6 Months
Prolonged
Stretch
-
N
Xb
SD
PROMe and
Manual
Stretch
Xb
SD
Baselinec
28
37
23
38
21
Month 2
24
38
24
40
23
Month 3
23
41
25
42
25
Month 4
19
36
24
38
22
Month 5
19
37
24
36
23
Month 6
19
36
25
37
22
Month 7
18
34
24
36
23
" PROM=passive range of motion.
"Values i~ldicatelack of full knee extension.
' Baseline is the average of the three measurements ohrained prior to initiation of treatment
t
At the beginning of the study, 10 of
the 18 subjects had differences of 10
degrees or greater between the side
that received prolonged stretching and
the side that received only PROM and
manual stretching (Tab. 5). 'I'hese
dzerences were in both directions.
Similarly, at the end of the study, 8
subjects had diferences of 10 degrees
or greater between knees, with differences occurring in both directions
The differences in extension between
knees were of similar magnitude and
in the same direction at the beginning
and end of the study for almost all
subjects.
At the end of the study, 58% of the
knees (12 knees receiving prolonged
stretching, 9 knees receiving only
PROM and manual stretching) showed
a gain in extension, 33% of the knees
Physical Therapy / Volume 75, Number 10 / October 1995
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Table 5.
Average Knee Extetzsion (in Degrees) of Eucb Subjectfor Side That
Received Prok~ng~d
Stretch and,for Side %at Receizjed Pussi~leRange of Molion
(PROM) and Manual Stretch at the Bcginnittg and End o f the Stzdy iyN= 18)
Knee Flexion Contracture (")
Subject
No.
Side
Difference
Base- Between
linea Sides
Endb
-
1
-
32
PROM and manual stretch
52
50
2
Prolonged stretch
33
24
9
9
PROM and manual stretch
22
15
7
Prolonged stretch
58
56
2
PROM and manual stretch
74
Prolonged stretch
12
-16
PROM and manual stretch
15
Prolonged stretch
12
9
- 22
48
40
Prolonged stretch
29
26
PROM and manual stretch
22
79
PROM and manual stretch
14
Prolonged stretch
53
PROM and manual stretch
50
Prolonged stretch
11
-6
18
PROM and manual stretch
Prolonged stretch
7
8
7
7
8
3
I
65
8
3
9
Two subjects showed bilateral changes
greater than 10 dcgrces, one with
hilaterdl gains (sublect 8) and the
other with bilateral losses (subject 16)
(four knees). Only onc subject (sut~ject
11) showed what might be considered
a positive treatment effect.
Cost
1
-36
6
2
3
72
-3
5
0
-18
-16
4
-
32
11
3
-
Prolonged stretch
- 20
2
Difference
Between GainILoss
Sides
(Baseline-End)
( 5 knees receiving prolonged stretching, 7 knees receiving only PROM and
manual stretching) showed a loss of
extension, and 8% of the knees ( 1
knee receiving prolonged stretching, 2
knees receiving only PROM and manual stretching) showed no change.
Most of the end-study gains and losses
in extension (790/0),however, were
less than 10 degrees, and 58% of the
gains and losses were 5 degrees or
less.
0
The cost of using thc Dyn;lsplint includes splint rental or purchase; therapist time for initial evaluation and
splint fitting; therapist time for at least
monthly monitoring of KOM, functional status, and splint fit; and possibly physical therapy aide time fur
daily application and removal of the
splint (approximately 15 minutes per
day per nursing home resident). In
nursing homes in which restorative
nursing care is assigned to specially
trained nursing assist;~nts,the task of
applying and removing the splint
could be done by the nursing assistants and not require a therapy charge.
PROM and manual stretch
10
Prolonged stretch
11
Prolonged stretch
The Medicare benefits of our clients
covered thc cost of renting [he Dynasplint at the time of the study. In
1991, at the time of data collection, the
Medicarc allowable charge fur rental
of the Dynasplint was $150 per month
and $721 for purchase of the unit.
Current Medicare regulations require
that functional gains be made and
documented in order to receive continued rcimbursernent for the
Dynasplint.
PROM and manual stretch
PROM and manual stretch
12
Prolonged stretch
13
Prolonged stretch
PROM and manual stretch
38
42
-4
14
Prolonged stretch
25
24
1
PROM and manual stretch
- 20
-19
PROM and manual stretch
46 i 892
44
44
0
Continued on next page
Discussion
Our study does not support the use of
the splint for 3 hours per day, 5 days
per week, at an averdge setting of 6
i62 kg-crn) as an effe'ective treatment
Physical Therapy / Volume 75, Number 10 / October 1995
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Table 5.
Cot~titzi~ed
Knee Flexion Contracture (")
Subject
No.
Side
15
Prolonged stretch
16
Prolonged stretch
Difference
Difference
Base- Between
Between Gain/Loss
linea Sides
Endb Sides
(Baseline-End)
PROM and manual stretch
PROM and manual stretch
17
Prolonged stretch
PROM and manual stretch
18
Prolonged stretch
PROM and manual stretch
-
"
Avemge of three I),t\el~nemedaurement\ o b t ~ ~ n over
e d 1-month p e r ~ o d
" Aberage
of two final medhurementh obtained ovcr 1-month period
for decreasing knee flexion contractures in elderly nursing home residents
any more than a traditional twice-aweek prograrn of PROM and manual
stretching. Our study, however, must
be viewed as a pilot study because the
numlwr of subjects in our sample
lacked statistical power (beta=.90,
N=18) to differentiate fully whether
the splint, at this dosage, is ineffective.
Post hoc power analysis indicates that
160 subjects would be needed in this
study to conclude, with 800% confidence, that no change occurred with
the experimental treatment with the
effect size we observed.
We believe there were multiple
strengths in the study design, which
give the results clinical relevance (ie,
each subject had bilateral contractures
and served as his or her own control,
treatment was randomly assigned to
either leg, the subjects showed wide
variation in the initial severity of the
contractures, the study was conducted
at three different sites, diferent therapists performed treatment and measurement, and the investigators did not
do the actual treatment or data collection). In addition, on average, there
was no difference in knee ROM be-
tween the side that received prolongetl stretching and the side that
received only PROM and manual
stretching prior to adding the
treatment.
Recognizing that group averages may
not be helpful in guiding individual
treatnlent decisions, we felt that study
and presentation of the individual
subject data was important. The group
data showed no difference in extension between knees at any interval.
Individual analysis showed that more
than half of the subjects had differences of 10 degrees or greater berween sides at the beginning of the
study. Bilateral knee flexlon contractures appear as likely to be of different
magnitudes as to be the same Available diagnoses did not explain this
side-to-side difference in knee flexion
contractures, except possibly in 2
subjects who had a history of hip
fracture on the side of the greater
knee flexion contracture Other suhjects with unilateral diagnoses, such as
hip fracture (n=3) or hemiparesis
(n=5), did not have greater knee
flexion contractures on the side of the
unilateral problem.
In interpreting the clinical significance
of change in knee extension across
time, measurement reliability must be
considered. The high reliability of our
raters in measuring knee extension
and the good reproducibility of knee
extension when measured across our
baseline intervals gave us confidence
in our measurers and gave an indication of the stability of knee extension
prior to beginning the treatment. Because repeated measures of knee
extension within one session could
differ as much as 15 degrees, gains or
losses greater than 15 degrees can be
considered true change. This cutoff
point for true change is probably very
conservative, because the avenge
diference between repeated measures
of knee extension was only 2 degrees.
Interestingly, in a similar study, Light
and colleagues~also used 15 degrees
as the test for change in knee extension over a 4-week intervention period. Using the 15-degree criterion,
only three subjects showed change in
knee extension over time in our study.
Subjecc 8 had a bilateral gain in knee
extension, subject 16 had a bilateral
loss of knee extension, and subject 15
gained extension on the side that
received PROM and manual stretching
only. Like many of the subjects in the
study, these three suljects were
nonambulatory and had severe cognitive impairment, Barthe1 Index scores
t~elow20 points, and poor transfer
skills (subjects 8 and 16 were totally
dependent, and subject 15 could pivot
only with maximum assistance). Of
these three subjects, only subject 15
improved in any measure of function,
and this improvement was of questionable significance (ie, at the final
measurement interval, his ambulation
rating progressed from nonambulatory
to ambulatory with maximum assistance of two persons). Like the three
subjects who nlet the 15-degree test
for change in knee extension, subject
11 (with what might be considered a
positive treatment effect) was nonambulatory and totally dependent for
transfers, showed severe cognitive
impairment, had a Harthel Index score
of 0, and showed no functional improvement over time.
Physical Therapy / Volume 75, Number 10 / October 1995
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The bilateral change of simrlar magnitude in subjects 8 and 16 suggests that
change, in either direction, may be
occurring in spite of treatment. For
rnost of the subjects, gains or losses in
knec exten4ion were of 5imilar rmgnitude and direction, regardless of the
similarity in knee extension between
sides at the beginning of the study.
Measures of functional changc are also
important in interpreting the meaningfulness of change in knee extension
across time. A change in ROM is of
questionable value without a coincident improvement in function. Subject
15 is the only subject who in~proved
in ambulation, but this irnprovement
was only one rating Ivvel, from
nonambulatory to requiring maximum
zrssistance. Only two subjects improved in transfer ability during the
study. Subject 1 improved from a
score of 1 to 2 within the first month
of intenlention, and subject 10 improved from 2 to 3 within the fourth
month. These improvements in transfer ability cannot be explained in
terms of treatment or change in knee
extension. With only one sul>ject
showing improvenlent in function
along with gain in knec extension
(and that gain on the side that received PROM and manual stretching),
we find that neither the average data
nor the individual data are encouraging for use of the experimental treatment protocol.
Our findings d o not concur with those
of Light et a1,7 although our study
sample and tiesign seem similar to
theirs. Use of Buck's traction for 2
I~oursper day clearly resulted in gains
in knee extension in their subjects,
whereas 3 hours of splint use per day
did not result in gains for our subjects.
It may be that a static stretch is more
effective than the dynamic prolonged
stretch. Another factor that may account for each of the gains made in
our subjects is the rnaxirn~~m
tension
setting used on the splints. Our maximum spring tension setting of 6, chosen for subject wearing tolerance,
corresponcls to a torque of 62.2 kg-cm;
this torque is well below the mean
and median torques required to maintain maxirn~~rn
knee extension in our
subjects (Tab. 3). It is likely (ILL( higher
splint tension settings and longer
wearing times are necessary to achieve
increases in knee extension in this
population. HepburnHreported an
average of 45% irrlprovcment in knee
extension in four suhjects (mean
age=50 years) after 11 weeks of Dynasplint use. The average tension
setting was 8, and wearing time was 8
to 12 hours per day in Hepburn's
subjects. Whether elderly nursing
home residents with severe cognitive
impairment, who w<~uld
rely on multiple caregivers for splint application,
could tolerdte ancl comply with these
increases in torque and wearing time
seems questionable. The question rnay
be worth exploring, howcver, in individual case studies.
knee KOM alone, but also in terms of
improved function.
Acknowledgments
\Ve thank the physical therapy staff
and administration of Shared Therapeutic Services Inc for assisting and
supporting us in completion of this
study; the nursing and social services
staff of the three nursing homes for
their cooperation; Don Neum~n,PhD,
PT, Marquctte IJniversity, Milwaukee,
Wis, Tor his consult:~tionconcerning
this study; and Sheryl Kelber, Uiostatistician, and Carol I'orth, PhD, KN,
School of Nursing, Klniversity of
WJisconsin-Milwaukee,for their cons~dtation on the analysis.
W'e also thank George Hepburn, I'T,
Another previous studyr?also suggests
that stretching is only effective over a
long period of time. Tardieu et allH
studied children with cerebral palsy
with plantar-flexor contractures. They
found that children who showed no
progression in contracture over a
7-month period were getting at least 6
hours of stretch per day to the soleus
nluscle. This stretch was achieved
through daily activity as well as a
therapy program; thus, it was sporadic
over a 24-hour period. This required
length of
certainly casts doubt
on the possible benefit of ROM and
manual stretch exercise at any frequency per week.
Conctusion
Use of the Dynasplint fol- 3 Iio~rrsper
day, 5 days per week, at a tension
setting of 6 (62.2 kg-cm torque) did
not clearly result in reduction of knee
flexion contracture or improvement in
function in this pilot study of 18 elderly nursing home residents with
bilateral knee flexion contractures.
Further research is needed to assess
the elfecliveness of other interventions
for managing knee flexion contractures in the geriatric population. This
research needs to address variations in
dosage for low-load, prolonged stretch
111elhodssuch as use of the Dynasplint. The benefit of these interventions cannot be measured in terms of
Dynasplint Systems Inc, for his suggestions, assistance, and training of three
therapists in appropriate use and fit of
the Dynasplint, and Dynasplint Systems Inc for provision of Dynasplints
in two cases and for all costs alwve
Medicare reimbursement (no supplemental insurances were billed).
References
1 MOllingcsr LA, Steffen TM. Knee flexion contracturcs in institutionalized elderly:
preva, .
lrnct>,se\.erity, stability, ancl related v:lri:lhlzs
P h y Ther. 1993;73:437-446
2 Kottke FJ, Pauley IIL, I'tak RA. The r:ltionale for prolongetI stretching for correction of
shortening of c;)nnective tissue Arch Ph.v.s
,Wed Kehahil. 1966;47:?45-352.
3 Wynn I'arry CB. Stretching. In: B~smajian
J V , ed. Mrinipi~lulion,Trucliorz, and Mussugr.
3rd ed. l%;llti~korc,
Md: Williamh & Wilkins;
198i:li7-171.
4 Kottke FJ, 1,ehmans IF. Krusm s Handbook
v/'Pl~.ysi~al
~lledicinecind Kehahilitatio~~.
4th
ed. I'hiladelohia. 1% WB S;~undersCo: 1990.
Cherry
Of physical therapy al
ternarives for recl~icingmusclc c,ontracture.
Plys 7her. 15)80;60:877-881.
4 Yarkony GM. I'rc\rention and management
of col1traclures. In: lk~planI'E, ed. 711ePructice of'Phvsicul Medicine. Snrin~field.Ill:
7 Light KE, Nuzik S, I'ersonius W, Sarstrom
A. Low-l<):iclprolonged strrtch vs high-load
stretch in Lre;lt,nK knee ct,n,ractures,
~ h > mpr
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198'1,64 330-333
8 Hephurn GR. Case studies: contract~u-eand
sliff joint manigcmen\ with 1)ynasplint.
,I Orlbop Sporf.~1'h.y~ They. 1987;8:498-504.
9 Richard RL. lones 1.M. Miller SF. Finlcv RK.
Treatment of exposed hilateral achilles tendons with use of the 1)yn:lsplint. a P:IW rePOfl. P ~ I '7' b c ~
lC)X8;68.9X9-991.
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10 MacK:~y-LyonsM. Low-lox[, prolonged
stretch in treatment of elhow flexion contracturcs secondary to head trauma: a case report
ph_vs Ther. 1980;6Y:LYL-L96.
11 Hepburn GR, Crivell~Kj. Use of elbow
Ilvnasplint for recluction of ell~owflexion
contractures: case st~ldy.J Orrhop Sports Phys
71,cr. 1984;5:26Y -274.
12 Richard KL. lJse of the Dynasplint to correct elbow fltxion burn contracture: a case
report. J Bum Cure Rehtrhil. 1986;7:151-152
1.3 Mahoney FI, Barthel DW. Functional
evaluation: the Barthel Intlex. Md State .Wed,[.
Felxuary 1965:61-65.
14 Granger CV, Albrecht GL, Hamilton BB.
Outcome of comprehensive medical
rehabilitation measurement by I'ULSES Profile
ancl the Barthel Index. Arch Phys Mcri Rehahil. 1979;60:145-154.
15 Steffrn TM, Mryer AD. l'hysical therapists'
notes and outcomes of physical therapy. I'hys
Tb-her.1985:65:213-217,
16 l'feiffer E. A Short I'ort;ll~leMental Status
Questionnaire for the assessment of orgtnic
br;rin deficit in elderly patients. , [ A m Geriatr
Soc. 1975;23:433-441.
17 Smyer MA, Hofland BF. jonas EA. Validity
study of the Short I'ona1,le Mental Status
Questionnaire for the eltlrrly. J A m G'critrtr
Soc. lC)79:2?:263-269.
18 Shrout I'E, Fleisb J . Intraclass correlations:
uses in assessing rater relialility. P ~ c h o 13ull.
l
1979;86:420-428.
19 Rirdieu C, Lespdr,qot A, Talmry C. Hret
MU. For how long IIILIS~the soleus muscle he
tretched each clay to pre\.enr contract~lre?
n e v wed Child Netrrol. 1988;30.3-10.
Invited Commentary
I applaud Dr Steffen and Ms Mollinger
for their research on this important
and timely topic focusing on the effectiveness of physical therapy for nursing home residents. Increasing life
spans have resulted in a growing
populariori of older adults who experirnce functional limitation, placing a
greater demand on physical therapists
working in the area of geriatric reha1)ilitation.JThe frail nursing home
population is especially challenging
for physical therapists because agerelated changes may impede the effec. ~ is known
tiveness of t r e ~ t m e n tLittle
about how to modify physical therapy
to accomrnodate for advancing age,
and there is a dearth of research to
guide us in selecting the most effective
treatment regimens.
Contract~lreis due to stiffening of
periarticular connective tissue (PCT)
such as ligaments, joint capsules, muscles, tendons, and skin.' When
stretched, PCT undergoes increasing
stress until it reaches plasticity, where
it may become pcmlanently defomled. If PCT is stretched beyond
plasticity, complete failure will occur.
In older people, contracture usually
steins from an interaction between
advanced age and physical inactivity."
As an individual ages and becomes
less active, there is an increased crosslinking of collagen fibers, leading to
increased stiffness. The PCT becomes
less elastic, and rupture of ligaments
and tendons can occur at a shorter
maximum length than in younger
people. In older adults. these agerelated changes are often augmented
by neurological insult due to nervous
system disorders that affectmotor
control, such as cerebrovascular accident and Parkinbon's disease.
Once the contracture is present, the
main goal of physical therapy is to
increase range of motion (ROM). Steffen and Mollinger tested the effectiveness of the Dynasplint to accomplish
this aim using a well-designed controlled study. They concluded that
there were no differences in knee
KOM between the side that received
prolonged stretching and the side that
received only passive range of motion
(PROM) and manual stretching at the
beginning of the study, or at any time
interval during the study. The researchers further stated that results of
this study differed from those of Light
et al," who demonstrated improvement in knee ROM following the use
of Buck's traction for 2 hours per day.
There are some notable differences
hetween the two study samples that
may contribute to discrepancies in the
findings. One inclusion criterion in the
Light et a1 study was a n ~ i n i ~ ~ ~ u m
knee flexion contrachire of 30 degrees, and baseline knee flexion contrrctures ranged between 30 and 132
degrees. Subjects in the Steffen and
Mollinger study had baseline knee
flexion contractures ranging between
11 and 79 degrees, so these subjects
did not have as much ROM to be
gained comp.ared with subjects in the
Light et al study. Steffen and Mollinger
did not see a difference in knee extension between knees that received a
prolonged stretch and knees that received only PROM and manual stretch
with a splint setting corresponding to
a torque of 62.2 kg-cm. Furthermore,
they noted that most of the end-sh~dy
gains or losses in extension were less
than 10 degrees and more that half of
the gains and losses were 5 degrees or
less. All of this evidence suggesttS that
the amount of torque needed for knee
flexion contractures could vary according to the level of the severity. Perhaps more severe knee flexion contractures require stronger torques than
less severe knee flexion contractllrcs.
A challenge to researchers is to determine the amount of torque needed for
knee flexion contractures of dfiering
severity given the age-related changes
in PCT. For frail older adults, an increase in torque applied by the Dynasplint may lead to other consequences, such as tissue trauma or
stretching the wrong joint^.^ Further
definition of passive joint motion for
older adults, including the mechanism
of action, ciose-responsiveness, and
specific tissue effects, is ~ a r r a n t e d . ~
Another explanation for the negative
results obtained by Steffen and
Mollinger is that 93% of the original 28
subjects were already receiving ongo-
Physical Therapy/ Volume 75, Number 10 / October 1995
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Low-Load, Prolonged Stretch in the Treatment of
Knee Flexion Contractures in Nursing Home
Residents
Teresa M Steffen and Louise A Mollinger
PHYS THER. 1995; 75:886-895.
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