Review of Physical Therapy Alternatives for
Reducing Muscle Contracture
Dianne B Cherry
PHYS THER. 1980; 60:877-881.
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Review of Physical Therapy Alternatives for
Reducing Muscle Contracture
DIANNE B. CHERRY, MS
Passive stretching is a technique frequently used to treat muscle contractures;
however, because it can activate the stretch reflex and has little carry-over, it
may not be as effective as other modes. Four approaches to treating muscle
contracture are described: 1) activation or strengthening of the weak opponent,
2) local inhibition of the contracted muscle, 3) general inhibition of hypertonus,
and 4) passive lengthening. Specific examples of techniques, their rationales,
and suggestions for use of each are discussed.
Key Words: Contracture, Exercise therapy, Muscles, Physical therapy.
A primary objective of physical therapy is maintaining or regaining range of motion in cases of
orthopedic or neuromuscular dysfunction, in order to
prevent or reduce myostatic contracture. A muscle
may become tight and develop a myostatic contracture if the joint it crosses does not go through full
range of motion regularly. Manual passive stretching
of the tight structures is frequently used to prevent or
reduce such contractures.1-4 Passive stretching is the
most obvious and direct solution; unfortunately,
stretching may be of limited effectiveness and is often
painful.4 Research in kinesiology and neurophysiology provides some alternatives to passive stretching.
These alternatives will be reviewed, and the purposes
and rationale of each will be considered.
There are many possible causes of myostatic contracture, which can be understood as an intrinsic
muscle shortening sufficient to prevent full range of
motion, though at the end of the available range there
is a resiliency or spring. The problems of limited
range of motion caused by capsulitis, bony deformity,
skin or soft tissue contracture, or fixed irreversible
muscle contracture of long-standing duration are best
treated by modalities and methods other than those
to be discussed here. Individual muscles will not be
discussed, since contracture can present a problem in
almost any muscle. For clarity, the tight or contracted
muscle will always be referred to as the antagonist,
for it opposes the motion desired, while its opponent
Ms. Cherry is Assistant Professor of Physical Therapy, Department of Health Science, Cleveland State University, Cleveland, OH
44115 (USA).
This article was submitted September 19, 1978, and accepted December 18, 1979.
on the other side of the joint will be referred to as the
agonist, whose movement would be in the direction
desired to reduce the contracture.
CAUSES OF CONTRACTURE
Most definitions of muscle contracture include the
concept that a muscle or group of muscles has
shortened sufficiently to prevent complete range of
motion of the joint or joints it crosses.2-4 The shortening may be caused by intrinsic adaptive change in
response to prolonged positioning, as often occurs
after orthopedic immobilization.2 Another cause is
poor positioning, as in poliomyelitis or myelomeningocele with dynamic imbalance of muscle power,
when a stronger, unopposed muscle shortens and is
never lengthened by its weak opponent.1, 5 Contracture may also result from influences extrinsic to the
muscle; for instance, CNS damage can cause spasticity and prolonged fixed postures.2 The result may be
the same as in intrinsically caused contracture, with
the spasticity "accompanied by reciprocal inhibition
and weakness in the antagonist muscle group, giving
rise to unbalanced muscle pull and the development
of contractures."6 (Wyke's use of the term antagonist
is opposite to the meaning used in this article.)
ALTERNATIVE APPROACHES TO REDUCING
MUSCLE CONTRACTURE
Passive stretching uses forced motion to restore the
normal range of motion when this range is limited by
loss of soft tissue elasticity.3 Its effect on muscles is to
lengthen the elastic portion of the muscle passively,
allowing greater length and hence greater range at
Volume 60 / Number 7, July 1980
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877
I. Activation or Strengthening of the Weak Agonist
A. Resistance or load
1. maximal resistance in diagonal spiral patterns
2. progressive resistance exercises
B. Unconscious automatic righting and equilibrium
reactions
C. Facilitatory techniques
1. vibration to agonist
2. quick icing and brushing
3. tapping
4. EMG feedback
5. manual contacts
6. traction
7. approximation
8. repeated contractions
9. quick stretch
II. Local Inhibition
A. Vibration to agonist
Figure. Summary of suggested
III. General Inhibition
A. Key points of control
B. Slow rocking
C. Slow rhythmical rotation of pelvis
on thorax
D. Moving surface
E. Inverted position
IV. Passive Lengthening
A. Prolonged positioning
1. orthoses and splints
2. adaptive equipment
3. positioning for activities of daily
living
B. Manual passive stretch
techniques for reducing muscle
the affected joints. However, "any increase in range
obtained by forced motion will be lost unless maintained by active motion or by supportive devices."3
Passive motion requires no participation by the patient and results in no motor learning, so it does not
improve the capacity for active motion of the tight
muscle or its opponent. Muscle tightness is therefore
likely to recur. Also, inasmuch as passive lengthening
stimulates the stretch reflex,7, 8 which causes the muscle to contract even more, passive stretching becomes
a self-defeating activity. Thus, passive stretch may
not be the technique of choice in treating muscle
tightness. Alternative solutions for lengthening contracted muscles should be explored.
Physiology and technique must be considered in
selecting the most appropriate method to reduce contracture (Figure). Integrity of the muscle and surrounding muscles and their innervation are important
considerations. When tightness is caused by spasticity,
the spastic muscle responds to stretch differently than
does normal muscle. The spastic muscle or muscle
group is characterized by exaggerated resistance to
passive stretch and, frequently, powerful reciprocal
inhibition of its opponent.9 Tightness caused by spasticity and tightness of a normal muscle adaptively
shortened because of plaster immobilization may require different modes of intervention. Treatment is
more effective in preventing contractures from spasticity than it is in reducing it. The ability of the
patient to cooperate and participate in treatment is
another factor to be considered in selecting a method
of treatment.
Four approaches to lengthening or stretching reversible muscle contractures will be discussed. One
approach is to activate or strengthen the weak, over-
878
B. Neutral warmth
C. Prolonged icing
D. Hold-relax/contract-relax
contracture.
stretched agonist opposing the tight muscle. A second
approach is to inhibit selectively the tight muscle so
it will tolerate being stretched without immediate
activation of the stretch reflex. A third approach is to
reduce hypertonus, when present, in the limb or the
entire body to allow a spastic tight muscle group to
relax and be lengthened. The last approach is passive
lengthening. Some of these methods may be used
simultaneously—one may enhance another. Many of
the techniques proposed have been found to be empirically effective but must be validated by clinical
research.
Activating or Strengthening the Weak Agonist
The agonist working in opposition to a contracted
muscle is in a position of excess length, to which it
has adapted by changing its spindle bias.8, 10 The
agonist is unable to shorten effectively against the
contracture in its antagonist. If innervation is intact
and the agonist has the ability to function at all, a
double benefit will be gained by improving its ability
to contract. If the agonist becomes stronger, it will be
able to counter the contracture of the antagonist and
pull the joint through more complete range. Also, the
antagonist will be reciprocally inhibited,10 allowing
itself to be stretched because the stretch reflex is also
inhibited. Ultimately, if the weak agonist can be
activated and strengthened, better muscle balance
around the joint may result, reducing the potential
for recurrence of myostatic contracture.4, 7
Strengthening the muscle opposing a contracted
muscle is an approach that may be applied to almost
any kind of patient in whom the agonist can be
activated. Techniques that improve or facilitate the
PHYSICAL THERAPY
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function of the weak agonist are very useful for the agonist fail. Also, even if the agonist can be
orthopedic rehabilitation as well as for treating neu- activated, it will move through more complete range
rological problems because if innervation is intact, of motion if the stretch reflex of the tight antagonist
muscles are likely to respond to treatment most opti- can be inhibited; therefore, inhibition of the tight
mally. Examples of clinical problems in which acti- muscle should be considered. Inhibition can be devation of the weak agonist may be effective are muscle veloped locally within a limb segment or it can be
contracture in the remainder of an amputated limb, obtained more generally within the limb and entire
after immobilization for a fracture or other reasons, body by way of the CNS.
lower motor neuron lesions in which some intact
Local inhibition is useful for localized tightness,
innervation remains, and spasticity and hypertonus.
especially within one muscle group at one joint, such
Selection of technique will depend on the nature of as after plaster immobilization following injury or
the problem and the ability of the patient to cooper- surgery. Vibration to the opposing muscle group
ate. Effective strengthening methods that employ re- causes reciprocal inhibition to the contracted mussistance or load on the muscle include maximal re- cle.10, 15 Neutral warmth causes decreased gamma mosistance in diagonal spiral patterns11 and progressive tor neuron activity; prolonged icing causes slower
resistance exercises.12 Methods that use unconscious nerve conduction and diminished spindle and myautomatic responses to activate the weak agonist in- otatic reflex activity.19 The hold-relax and contractclude elicitation of the righting and equilibrium re- relax techniques of proprioceptive neuromuscular faactions.10, 13, 14 The long-term effectiveness of these cilitation11 work by means of successive induction,
techniques results from demanding that muscles prac- when a muscle is inhibited after a contraction while
tice skills that they will be expected to perform when its opponent is facilitated.10 The hold-relax procedure
has been found to be more effective than passive
therapy is completed.
If the agonist is extremely weak or inhibited or stretching in lengthening the hamstring muscles in
both, facilitatory techniques may enhance its function normal individuals.20
and increase its strength, thereby enabling it to oppose
the tight antagonist effectively. These facilitation
techniques use exteroceptive and proprioceptive stimGeneral Inhibition
ulation, causing summation in the CNS, which lowers
the threshold of efferent, or muscle action, response.
Carefully applied stimulation may make it easier for
Another approach to passive stretching is based on
the desired muscle to respond.10 Many different kinds inhibition of muscle tone throughout the body, which
of techniques facilitate the function of a weak muscle. may be accomplished through both somatic and auFor example, vibration,10, 15 quick icing and brush- tonomic components of the CNS. Generalized inhiing,7, 16 and tapping14 may be done easily with simple bition may be particularly effective when hypertonus
equipment. Electromyographic (EMG) feedback has or spasticity interferes with normal movement. Inhibeen effective in improving control in muscles oppos- bition causing a reduction of hypertonus may allow
ing spasticity.17 Proprioceptive neuromuscular facili- greater active or passive range of motion because the
tation includes a variety of techniques such as manual stretch reflex would not respond as readily to movecontacts, traction, approximation,18 repeated contrac- ment. Spasticity can be considered a release-fromtions, quick stretch, and resistance.11 All of these inhibition phenomenon. Therefore, methods that detechniques, used individually or in combination, en- velop inhibition may decrease spasticity and improve
able a therapist to elicit a response from a weak or motor control.6 Inhibitory techniques may also be
inhibited muscle that the patient alone is unable to effective when a patient's neuromuscular control is
activate adequately.
inadequate (because of age, mental status, or CNS
Vibration may be particularly useful when the an- dysfunction) to participate in the activation of the
tagonist is spastic and the agonist is very much in- agonist or the hold-relax technique. Bobath9, 21 and
hibited. Applying vibration to the weak agonist can Rood16 have both developed techniques that use genhelp cause activation in that muscle and simultaneous eralized inhibition of hypertonus. Bobath has dereciprocal inhibition in its spastic antagonist, allowing scribed particular movement patterns of proximal
easier movement in the desired direction.15
joints ("key points of control") that affect tone of the
trunk and limbs.14, 21 By these patterns of movement
Local Inhibition
the tight or spastic muscle groups may be inhibited
and, simultaneously, normal movement facilitated.
An agonist may be unable to contract at all, or a This technique enables the patient to develop active
muscle may be so tight that attempts to strengthen agonist control at the same time, enhancing effective-
Volume 60 / Number 7, July 1980
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879
ness of the treatment. When the spastic limb is inhibited, its muscles will not respond to stretch as
readily, permitting the limb to move through more
complete range of active motion and preventing the
development of myostatic contractures.
Ayres has proposed that slow rocking, which provides vestibular stimulation of low frequency, inhibits
the reticular formation of the CNS and has a calming
effect.22 It is a technique employed by parents of
infants over the ages and is probably the basis for
such calming measures as using wind-up swinging
chairs and walking the floor. For the individual with
spasticity, slow rocking may help reduce tone to allow
normal movement.
Little has been written about several other inhibitory techniques, learned empirically by those therapists working with very spastic patients. One such
technique is slow, rhythmical rotation about the body
axis, frequently the pelvis rotating on the thorax. It
may be done manually by the therapist, and certain
spastic individuals may learn to rotate themselves.
This slow rotation reduces hypertonus in the limbs
and trunk, allowing more freedom of movement and
more normal movement. The rationale for this technique has not been described but may be related to
Bobath's "key points of control"14, 21 and elicitation
of normal righting reactions.13
Another little-described or -explained technique
that may empirically be found effective in decreasing
spasticity is to treat the patient on a slightly moving
surface, such as that provided by a ball, bolster, or
equilibrium board. The rationale of this technique is
twofold: 1) the slightly moving surface is relaxing,
probably like the effect of a rocking chair or other
gentle motion and 2) carefully graded and planned
movement of the supporting surface requires subtle
equilibrium responses as the patient adjusts to being
moved. With careful monitoring, normal muscle action to maintain balance may develop and the patient
with spasticity may learn to move in a more normal
way.14
The head-down or inverted position may be useful
for general inhibition of tone.16, 22, 23 Gellhorn describes the influence of increased blood pressure in
the head as stimulating the carotid sinus in the neck
and causing a generalized parasympathetic effect.23
Reduction of muscle tone is one result and can be
noted in small children during inversion for postural
drainage, for they often relax completely, some to the
point of falling asleep. Hyperactive or irritable children may be calmed in this position. A person with
hypertonus who can tolerate inversion may benefit
by the general reduction in tone, for movement may
be less restricted, muscles may relax, and potential
contractures may be easier to prevent.
880
Passive Lengthening
Three different approaches to avoid eliciting the
stretch reflex when lengthening a contracted muscle
have been described. There are times, however, when
none of these methods may be used, either because
the agonist is too weak to respond or because attempts
to inhibit the antagonist tone are unsuccessful. In
conditions of weakness or paralysis, the neurophysiological mechanism may be so disturbed that the
muscle may not respond to stimulation. Advanced
stages of muscular dystrophy and peripheral neuropathies are examples of disabilities that may require
direct passive lengthening because in each condition
the tight muscle and its opponent are unresponsive to
other measures of intervention.
If passive lengthening is selected as the appropriate
alternative, there are two kinds of techniques from
which to choose. One technique is prolonged holding
of the desired position at the point of maximum
tolerated length of the contracted muscle.10 The
stretch receptors of a muscle will become less sensitive
to stretch applied very slowly and maintained for a
long time.24 A variety of methods may be employed.
Orthoses and splints may be used to hold joints in
desired positions.14 Adaptive equipment may enable
an individual to function in certain positions more
readily. For example, a barrel chair for hip abduction
in sitting for a person with an adduction tendency or
a prone standing board for extension in weight bearing for persons with lower extremity flexor problems
may be effective. Individuals can be taught which
positions for sitting, sleeping, and other daily activities will be most helpful in correcting muscle shortness. For example, individuals with muscular dystrophy may be taught to use a long sitting position to
maintain hamstring muscle length. The advantages of
positioning are that it 1) avoids the position of contracture for the duration of the positioning, 2) may be
maintained over a long period so that treatment
effectiveness is prolonged, 3) may be incorporated
into the patient's daily routine, which increases the
likelihood of its being done regularly, and 4) is usually
painless.
If the above treatment suggestions are inapplicable
or ineffective, the technique of manual passive
stretching of the tight antagonist may be employed.4
Passive stretching is likely to be most effective in
individuals whose stretch reflex is inhibited, either by
cortical effort at relaxation or in paralytic conditions.
Very slowly applied passive stretch is likely to be the
most effective technique, for it should avoid eliciting
the stretch reflex and may cause the muscle to be
locally inhibited.24 An example of the latter is myelomeningocele, in which severe weakness or paralysis
PHYSICAL THERAPY
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and tightness are often present in the same muscle.
Only positioning and passive exercises will be effective in gaining range at those joints that have no
active movement.
SUMMARY
Passive stretch to a contracted muscle has several
disadvantages. It does not improve active motion of
the opposing muscles and may elicit a stretch reflex
contraction in the contracted muscle if innervation to
the spinal cord is intact. This reflex contraction is
undesirable because it interferes with the desired
motion. Also, stretching is often painful.
Four approaches to reducing muscle contracture
have been described. Ideally, the weak opponent
muscle or agonist should be strengthened, if possible,
to enable it to move the joint through full range and
prevent recurrence or further development of the
muscle contracture. Other alternatives that may be
used before, or instead of, strengthening the weak
agonist include specific local inhibition to the contracted muscle or general inhibition to the limb or
entire body. If the stretch reflex can be inhibited, the
agonist may contract more easily and the tight muscle
may be stretched more easily and effectively. Finally,
prolonged maintenance in the desired position by
means of adaptive equipment and splints and performing activities of daily living may be more comfortable and more effective than passive manual
stretching because the procedures are carried out for
longer periods.
The variety of techniques available for treatment
of muscle contractures challenges physical therapists
to gain an understanding of the principles on which
the techniques are based and to develop skill in their
application. Research is needed to establish which
procedures are most effective for what kinds of problems, as well as to determine the scientific rationale
of procedures empirically found to be effective. Research may also lead to development of additional
techniques.
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Volume 60 / Number 7, July 1980
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881
Review of Physical Therapy Alternatives for
Reducing Muscle Contracture
Dianne B Cherry
PHYS THER. 1980; 60:877-881.
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