ABSTRACT Contracture, or reduced joint mobility, is a common and disabling sequel of spinal cord injury. The primary intervention for the treatment and prevention of contracture is regular

stretch to soft tissues. While the rationale for this intervention appears sound, the effectiveness of stretching has not been verified with well designed clinical trials. One recent

randomised trial suggests there is no clinically worthwhile effect from a typical stretch protocol applied to spinal cord injured patients. Despite the negative results of this first trial,

we argue that therapists should continue administering stretch for the treatment and prevention of contracture until the results of further studies emerge. To maximise the probability of

contracture. Soft tissues most at risk should be targeted, particularly if contracture is likely to impose functionally important limitations. SIMILAR CONTENT BEING VIEWED BY OTHERS

PHYSIOTHERAPY INTERVENTIONS FOR THE TREATMENT OF SPASTICITY IN PEOPLE WITH SPINAL CORD INJURY: A SYSTEMATIC REVIEW Article 09 February 2021 ROBOTIC TECHNOLOGY (ROBERT®) TO ENHANCE MUSCLE

STRENGTH IN THE HIP FLEXOR MUSCLES FOLLOWING SPINAL CORD INJURY: A FEASIBILITY STUDY Article Open access 10 April 2024 EFFECTS OF WHOLE-BODY VIBRATION ON NEUROPATHIC PAIN AND THE

RELATIONSHIP BETWEEN PAIN AND SPASTICITY IN PERSONS WITH SPINAL CORD INJURY Article 25 April 2022 INTRODUCTION Contractures (reduced joint mobility) are due to loss of extensibility in soft

tissues spanning joints, and are a common complication of spinal cord injury.1,2 One study found that spinal cord injured patients had, on average, seven contractures (SD=6.2) at between 6

and 7 weeks after injury.1 Contractures are undesirable for many reasons but primarily because they prevent the performance of motor tasks.1,3,4,5 For example, elbow flexion contractures

make it difficult for tetraplegics with paralysis of triceps muscles to bear weight through the upper limbs, and hence attain independence with transfers.6,7,8 Contractures also create

unsightly deformities and are thought to predispose patients to spasticity, pressure areas, sleep disturbances and pain.1,2,5,8,9,10,11,12 MECHANISMS OF CONTRACTURE Contractures are either

neurally or non-neurally mediated.13 Neurally mediated contractures are due to spasticity (ie, involuntary reflex contraction of muscles)13,14,15,16,17 and are a common sequelae of upper

motor neuron lesions.18 Spasticity is usually managed with medication.18 While some believe that stretching also induces functionally important and lasting reductions in spasticity, this is

yet to be verified with good quality studies. Non-neurally mediated contractures are due to structural adaptations of soft tissues (for reviews see Gossman _et al_,19 Akeson _et al_,20 and

Herbert21,22). Animal studies23,24,25 indicate that such changes occur in response to prolonged immobilisation, particularly immobilisation of soft tissues in shortened positions. Ten days

immobilisation of rabbit ankles in plantarflexed position (the shortened position of the plantarflexor muscles) results in approximately a 10% reduction in resting length of soleus

muscle-tendon units,25 which is sufficient to produce functionally significant loss of ankle joint mobility. Muscle shortening is associated with a decrease in the number of sarcomeres,

changes in the alignment of intramuscular connective tissues and a decrease in tendon resting length.23,24,25,26,27,28,29,30,31,32,33,34 EFFECTS OF MUSCLE STRETCHING Stretch has become a

widely accepted means of treating and preventing contractures in people with spinal cord injuries.35,36,37 For instance, it is now accepted practice in spinal cord injury units for

therapists to routinely administer between 2 and 5 min of stretch a day to each major group of soft tissues, particularly when patients are confined to bed immediately after injury.

Consequently, it is not unusual for therapists to spend between 30 and 60 min a day with each patient, administering stretches. Despite the time, effort and resources devoted to

administering stretches in this way, few rigorously designed studies have examined the effectiveness of this intervention.38 The use of stretch to treat and prevent contractures is usually

justified by animal studies23,39 that indicate the deleterious structural and morphological changes associated with immobilisation in shortened positions can be prevented25 or reversed23 by

prolonged immobilisation in lengthened positions (ie, continuous stretch). Continuous stretch of this kind appears to trigger remodelling of soft tissues. However, while animal studies show

that continuous stretch can reverse deleterious length adaptations in muscles, the effect of shorter periods of stretch is less clear. Only two studies29,40 have investigated the effects of

short periods of daily stretch on soft tissue extensibility. These studies found that when the soleus muscles of mice were immobilised at short lengths, deleterious length adaptations such

as decreases in sarcomere number and muscle resting length could be partly prevented by interrupting the immobilisation with as little as 15 min of stretch each day. Thirty minutes of

stretch was enough to completely prevent these changes. No study has yet examined the effect of less than 15 min daily stretch in an animal model, though stretches of this duration are

typically applied in the clinic. A large number of human studies have examined the effects of stretch on the extensibility of soft tissues. However, the majority of these studies have only

examined the effects of stretch on joint mobility and range of motion within minutes of the cessation of the stretch intervention. Increases in joint mobility observed soon after the

cessation of stretching are primarily due to viscous deformation,41,42,43,44,45,46,47 and need not reflect the structural adaptations of soft tissues required for lasting increases in

extensibility.22 For this reason, studies which only report measurements taken within minutes of the removal of stretch cannot provide evidence about the effectiveness of particular types of

muscle stretching for the treatment and prevention of contracture. Only studies that measure joint mobility many hours or days after the removal of stretch, when the transient effects of

viscous deformation have subsided, can be validly used for this purpose. To our knowledge only one randomised study38 has investigated lasting effects of stretch on contracture in people

with spinal cord injury. This study examined the effect of 4 weeks of 30 min daily stretches (7.5 N.m) to the ankles of recently injured paraplegics and tetraplegics. Ankle mobility was

measured 24 h and again 1 week after the removal of stretch. Despite excellent statistical power, no treatment effect was found. The authors speculated that this may have been because

co-interventions (such as routine positioning of ankles at 90 degrees in wheelchairs) were sufficient to reverse or prevent plantarflexion contractures, and muscle stretching provided no

additional benefit. Alternatively, it may have been that the stretch protocol was of insufficient intensity or duration. These findings differ from those of two well-designed randomised

trials on other populations, both of which found a therapeutic effect with 4–24 h stretch a day in head-injured4 and elderly bedridden patients.48 However, the results of both these studies

may reflect viscous deformation rather than lasting increases in tissue extensibility. Clearly, therefore, more randomised clinical trials are needed to determine if stretch is effective for

the treatment and prevention of contractures, and if so, to clarify the optimal dosage of stretch. CLINICAL IMPLICATIONS OPTIMAL STRETCH PROTOCOL The challenge for therapists is to use the

available evidence to make reasonable decisions about clinical practice. It is disconcerting that the first randomised clinical trial on stretching in spinal cord injured patients found no

clinically worthwhile effect, despite the application of daily stretches well in excess of those typically used in clinical practice (ie, despite the application of 30 min of stretch per

day). However, the rationale supporting the use of stretch is strong. Given the serious consequences of contractures, we do not recommend that therapists discontinue stretching on the basis

of one negative randomised trial. Instead it is probably appropriate that therapists continue to provide stretches to spinal cord injured patients, at least until further randomised trials

indicate otherwise. In the meantime, it may be prudent to apply stretches for as long as is practically possible (ie, for at least 20 min, and perhaps for as long as 12 h a day) in order to

maximise the likelihood of attaining a therapeutically worthwhile effect. If stretches are to be applied for more than a few minutes a day, therapists need to move away from the

labour-intensive tradition of manually applying stretches with their hands. Instead, limbs should be positioned with at-risk soft tissues in stretched positions, and where possible

positioning programs should be incorporated into patients' rehabilitation programs and daily lives. Often only relatively simple equipment is required for this purpose. For example, the

hamstring muscles of patients confined to bed can be readily stretched for sustained periods of time with a splint and pulley device attached to the bed (Figure 1). The extrinsic finger

flexor muscles of the hand can be stretched with a simple wooden device (Figure 2), and the shoulder extensor muscles of seated tetraplegics can be stretched by positioning the arms on high

tables (Figure 3). Hand splints are also an effective way of positioning soft tissues in lengthened positions. A splint that immobilises the metacarpophalangeal (MCP) joints in flexion and

interphalangeal (IP) joints in extension may help prevent MCP hyperextension and IP flexion contractures49 (both of which are common in tetraplegics with lesions at or above C5, particularly

if oedema is also present). Stretches applied in any of these ways can be readily sustained and easily administered by therapists and carers. Of course care needs to be taken to ensure that

strategies instigated to prevent contractures in one group of soft tissues does not promote contractures in the antagonistic group of soft tissues. PREVENTING AND ANTICIPATING CONTRACTURES

It is widely believed that contractures can be more readily prevented than treated and that less stretch is required to maintain than increase the extensibility of soft tissues. Though the

validity of these beliefs has not yet been substantiated, therapists are well advised to concentrate efforts on preventing contractures. For example, supination contractures of the forearm

(a common contracture of tetraplegics with C5 lesions) may be prevented by ensuring patients spend equal lengths of time each day sitting with forearms pronated and supinated. Minor

modifications to the arm rests of wheelchairs may be required, but otherwise this is a relatively simple positioning protocol to implement. In contrast, once supination contractures are

established it is difficult to effectively stretch the forearm, and often cumbersome splints are required.50 In the same way, hip and shoulder adductor contractures may be prevented in

patients confined to bed by simply positioning patients for at least some of each day with shoulders2 and legs abducted rather than adducted. FACTORS THAT PREDISPOSE PATIENTS TO CONTRACTURES

The skill of preventing contractures largely lies in accurately predicting them.51 At-risk soft tissues are those habitually held in shortened positions. Fortunately, it is possible to

predict soft tissues likely to be held at short lengths by looking at factors such as the pattern of innervation, pain, oedema, independence with various activities of daily living (ADL),

and the position in which the patient spends the majority of each day (ie, in bed or in a wheelchair; see Table 1). For example, patients with complete C5 and C6 tetraplegia are susceptible

to elbow flexion contractures. These patients have paralysis of the triceps but not biceps muscles. Consequently, they tend to sit and lie with their elbows flexed. The problem is

particularly apparent in patients nursed in a supine position for extended periods of time. From this position it is difficult for patients with paralysis of the triceps muscles to passively

extend their elbows once flexed. Pain increases susceptibility to contracture because it increases the tendency to contract non-paralysed muscles, which in turn increases the time soft

tissues spend in shortened positions. Independence with activities of daily living also helps predict susceptibility to particular types of contactures. For instance, C6 tetraplegics who

transfer independently throughout the day, passively extend their elbows while bearing weight through their upper limbs6,7,8 and are therefore less likely to develop elbow flexion

contractures than more dependent C5 or C6 tetraplegics. The pattern and extent of spasticity will also influence susceptibility to contracture.18 This is not only because spasticity directly

influences the extensibility of muscles (ie, contributes to neurally-mediated contractures, as discussed above) but also because spasticity increases the time that muscles and surrounding

soft tissues spend in shortened positions.13,16,52,53 For example, constant spasticity of elbow flexor muscles may increase the amount of time the elbow remains in a flexed posture, and

hence initiate structural adaptations of the soft tissues spanning the flexor aspect of the elbow. However, just as spasticity can indirectly contribute to contracture, so too can it prevent

it. Patients otherwise susceptible to elbow flexion contractures can benefit from regular and strong elbow extensor spasticity (this pattern of spasticity is more common in C5 than C6

tetraplegics), because the spasticity can act to minimise the length of time the elbow spends in a flexed position. IMPLICATIONS OF CONTRACTURES FOR INDIVIDUALS WITH SPINAL CORD INJURIES The

implications of slight losses of extensibility in soft tissues varies with level of motor function (see Table 1). Thus, while most contractures are undesirable, the prevention of some is

more important than others. Slight loss of extensibility in the soft tissues spanning the flexor aspect of the elbow will have few functional implications for C5 tetraplegics unable to bear

weight through the upper limbs. However, the same loss can prevent C6 tetraplegics from attaining independence with transfers.6,7,8 In the same way, slight loss of extensibility in soft

tissues spanning the plantar aspect of the ankle (eg, the soleus muscle) will have little functional implication for a high-level wheelchair-dependent tetraplegic but marked implications for

a walking low-level paraplegic. Clearly, concentrated effort should be directed at preventing loss of extensibility where such loss will impose important functional limitations. EXCESSIVE

TISSUE EXTENSIBILITY CAN HINDER FUNCTION Sometimes excessive extensibility is just as undesirable as limited extensibility and can prevent patients from performing important functional

tasks. Excessive extensibility in the hamstring muscles can prevent C6 tetraplegics from sitting unsupported on a bed with knees extended,37 a skill important for independent dressing and

transferring. Provided the hamstring muscles are not excessively extensible, the passive length of the hamstring muscles prevents the patient falling forwards into full hip flexion37 (Figure

4a). However, the hamstring muscles can not prevent the body falling forward if they are too extensible (Figure 4c). Therefore patients with excessive hamstring extensibility are

disadvantaged because they must rely on their upper limbs to support their body. On the other hand, limited hamstring extensibility will prevent the patient from positioning the center of

mass anterior to the hips, causing the body to fall backwards (Figure 4b). In this instance at least, there is a fine line between sufficient and excessive extensibility, and some patients

may benefit from strategies that promote, rather than prevent, loss of extensibility. LIMITED TISSUE EXTENSIBILITY SOMETIMES ASSISTS FUNCTION In unique circumstances, contractures can assist

functional movement. An effective passive tenodesis grip in C6 and C7 tetraplegics depends on contractures in the flexor pollicis longus and extrinsic finger flexor muscles.54,55,56,57,58

Contractures in these muscles ensure that active wrist extension passively pulls the fingers and thumb into flexion. In this way, objects can be passively held between the thumb and index

finger or in the palm of the hand. The challenge for therapists is to instigate appropriate interventions that promote loss of extensibility in the extrinsic finger and thumb flexor muscles

while avoiding contractures in the joints of the hand.54 SUMMARY While stretch has become the cornerstone of physiotherapy practice and an integral aspect of spinal cord injury

rehabilitation programs, confidence in the effectiveness of this intervention is not yet justified. Strategies that position soft tissues in stretched positions for prolonged periods of time

may be most effective. Factors such as pattern of innervation, pain, spasticity, oedema and ability to perform functional activities will help predict contractures. Concentrated effort

should be directed at preventing loss of extensibility where such loss will impose important functional limitations. REFERENCES * Yarkony GM, Bass LM, Keenan V, Meyer PR . Contractures

complicating spinal cord injury: incidence and comparison between spinal cord centre and general hospital acute care _Paraplegia_ 1985 23: 265–271 CAS  PubMed  Google Scholar  * Scott JA,

Donovan WH . The prevention of shoulder pain and contracture in the acute tetraplegia patient _Paraplegia_ 1981 19: 313–319 CAS  PubMed  Google Scholar  * Kagaya H, Sharma M, Kobetic R,

Marsolais EB . Ankle, knee, and hip moments during standing with and without joint contractures: Simulation study for functional electrical stimulation _Am J Phys Med Rehabil_ 1998 77: 49–54

Article  CAS  PubMed  Google Scholar  * Moseley AM . The effect of casting combined with stretching on passive ankle dorsiflexion in adults with traumatic head injuries _Phys Ther_ 1997 77:

240–247 Article  CAS  PubMed  Google Scholar  * Cooper JE, Shwedyk E, Quanbury AO, Miller J, Hildebrand D . Elbow joint restriction: effect on functional upper limb motion during

performance of three feeding activities _Arch Phys Med Rehabil_ 1993 74: 805–809 Article  CAS  PubMed  Google Scholar  * Harvey LA, Crosbie J . Weight bearing through flexed upper limbs in

tetraplegics with paralyzed triceps brachii muscles _Spinal Cord_ 1999 37: 780–785 Article  CAS  PubMed  Google Scholar  * Harvey L, Crosbie J . Effect of elbow flexion contractures on the

ability of C5 and C6 tetraplegics to perform a weight relief manoeuvre _Phys Res Int_ 2001 6: 76–82 CAS  Google Scholar  * Grover J, Gellman H, Waters RL . The effect of a flexion

contracture of the elbow on the ability to transfer in patients who have tetraplegia at the sixth cervical level _J Bone Jt Surg (Am)_ 1996 78: 1397–1400 Article  CAS  Google Scholar  *

Freehafer AA . Flexion and supination deformities of the elbow in tetraplegics _Paraplegia_ 1977 15: 221–225 CAS  PubMed  Google Scholar  * Dalyan M, Sherman A, Cardenas DD . Factors

associated with contractures in acute spinal cord injury _Spinal Cord_ 1998 36: 405–408 Article  CAS  PubMed  Google Scholar  * Waring WP, Maynard FM . Shoulder pain in acute traumatic

tetraplegia _Paraplegia_ 1991 29: 37–42 CAS  PubMed  Google Scholar  * Silfverskiold J, Waters RL . Shoulder pain and functional disability in spinal cord injury patients _Clin Orthop Rel

Res_ 1991 272: 141–145 Google Scholar  * Sinkjaer T _et al_. Non-reflex and reflex mediated ankle joint stiffness in multiple sclerosis patients with spasticity _Muscle Nerve_ 1993 16: 69–76

Article  CAS  PubMed  Google Scholar  * Herman R . The myotatic reflex. Clinico-physiological aspects of spasticity and contracture _Brain_ 1970 93: 273–312 Article  CAS  PubMed  Google

Scholar  * Lamontagne A, Malouin F, Richards CL, Dumas F . Evaluation of reflex- and nonreflex-induced muscle resistance to stretch in adults with spinal cord injury using hand-held and

isokinetic dynamometry _Phys Ther_ 1998 78: 964–975 Article  CAS  PubMed  Google Scholar  * O'Dwyer NJ, Ada L . Reflex hyperexcitability and muscle contracture in relation to spastic

hypertonia _Curr Opin Neurol_ 1996 9: 451–455 Article  CAS  PubMed  Google Scholar  * Sinkjaer T, Magnussen I . Passive, intrinsic and reflex-mediated stiffness in the ankle extensors of

hemiparetic patients _Brain_ 1994 117: 355–363 Article  PubMed  Google Scholar  * Dietz V . Spastic movement disorder _Spinal Cord_ 2000 38: 389–393 Article  CAS  PubMed  Google Scholar  *

Gossman MR, Sahrmann SA, Rose SJ . Review of length-associated changes in muscle. Experimental evidence and clinical implications _Phys Ther_ 1982 62: 1799–1808 Article  CAS  PubMed  Google

Scholar  * Akeson WH _et al_. Effects of immobilization on joints _Clin Orthop Rel Res_ 1987 219: 28–37 CAS  Google Scholar  * Herbert R . Adaptations of muscle and connective tissue In:

Gass E and Refshauge K (eds) _Musculoskeletal Physiotherapy: Clinical Science and Practice_ Butterworth-Heinemann: London 1995 Google Scholar  * Herbert RD . The prevention and treatment of

stiff joints. In: Crosbie W and McConnell J (eds) _Key Issues in Musculoskeletal Physiotherapy_ Butterworth Heinemann: London 1993 pp. 114–141 Google Scholar  * Tabary JC, Tabary C, Tardieu

C, Tardieu G, Goldspink G . Physiological and structural changes in the cats' soleus muscle due to immobilization at different lengths by plaster casts _J Physiol_ 1972 224: 231–244

Article  CAS  PubMed  PubMed Central  Google Scholar  * Tabary JC, Tardieu C, Tardieu G, Tabary C . Experimental rapid sarcomere loss with concomitant hypoextensibility _Muscle Nerve_ 1981

4: 198–203 Article  CAS  PubMed  Google Scholar  * Herbert RD, Balnave RJ . The effect of position of immobilisation on resting length, resting stiffness, and weight of the soleus muscle of

the rabbit _J Orthop Res_ 1993 11: 358–366 Article  CAS  PubMed  Google Scholar  * Williams PE, Goldspink G . The effect of immobilization on the longitudinal growth of striated muscle

fibres _J Anat_ 1973 116: 45–55 CAS  PubMed  PubMed Central  Google Scholar  * Williams PE, Goldspink G . Changes in sarcomere length and physiological properties in immobilized muscle _J

Anat_ 1978 127: 459–468 CAS  PubMed  PubMed Central  Google Scholar  * Williams PE, Catanese T, Lucey EG, Goldspink G . The importance of stretch and contractile activity in the prevention

of connective tissue accumulation in muscle _J Anat_ 1988 158: 109–114 CAS  PubMed  PubMed Central  Google Scholar  * Williams PE . Effect of intermittent stretch on immobilised muscle _Ann

Rheum Dis_ 1988 47: 1014–1016 Article  CAS  PubMed  PubMed Central  Google Scholar  * Williams PE, Goldspink G . Connective tissue changes in immobilised muscle _J Anat_ 1984 138: 343–350

PubMed  PubMed Central  Google Scholar  * Goldspink G _et al_. Effect of denervation on the adaptation of sarcomere number and muscle extensibility to the functional length of the muscle _J

Physiol_ 1974 236: 733–742 Article  CAS  PubMed  PubMed Central  Google Scholar  * Goldspink DF . The influence of immobilization and stretch on protein turnover of rat skeletal muscle _J

Physiol_ 1977 264: 267–282 Article  CAS  PubMed  PubMed Central  Google Scholar  * Witzmann FA, Kim DH, Fitts RH . Hindlimb immobilisation: length-tension and contractile properties of

skeletal muscle _J Appl Phys_ 1982 53: 335–345 CAS  Google Scholar  * Tardieu G, Thuilleux G, Tardieu C, Huet de la Tour E . Long-term effects of surgical elongation of the tendo calcaneus

in the normal cat _Dev Med Child Neurol_ 1979 21: 83–94 Article  CAS  PubMed  Google Scholar  * Adkins HE . _Clinics in Physical Therapy. Spinal Cord Injury_ Churchill Livingstone: New York

1985 Google Scholar  * Bromley I . _Tetraplegia and Paraplegia: a Guide for Physiotherapists_ Churchill Livingstone: New York 1976 Google Scholar  * Somers MF . _Spinal Cord Injury:

Functional Rehabilitation_ Appleton and Lange: Norwalk, Connecticut 1992 Google Scholar  * Harvey LA, Crosbie J, Herbert RD . Does regular stretch produce lasting increases in joint range of

motion? A systematic review _Phys Res Int_ 2001 in press * Tardieu C, Tabary JC, Tardieu G, Tabary C . Adaptation of sarcomere numbers to the length imposed on the muscle. In: Guba F,

Marechal G and Takacs O (eds) _Mechanism of Muscle Adaptation to Functional Requirements_ Pergamon Press: Elmsford, NY 1971 pp. 99–114 Google Scholar  * Williams PE . Use of intermittent

stretch in the prevention of serial sarcomere loss in immobilised muscle _Ann Rheum Dis_ 1990 49: 316–317 Article  CAS  PubMed  PubMed Central  Google Scholar  * Yang L _et al_. Effects of

joint motion constraints on the gait of normal subjects and their implications on the further development of hybrid FES orthosis for paraplegic persons _J Biomechanics_ 1996 29: 217–226

Article  CAS  Google Scholar  * Bohannon RW . Effect of repeated eight-minute muscle loading on the angle of straight-leg raising _Phys Ther_ 1984 64: 491–497 Article  CAS  PubMed  Google

Scholar  * Magnusson SP _et al_. Viscoelastic response to repeated static stretching in the human hamstring muscle _Scand J Med Sci Sports_ 1995 5: 342–347 Article  CAS  PubMed  Google

Scholar  * Magnusson SP, Simonsen EB, Aagaard P, Kjaer M . Biomechanical responses to repeated stretches in human hamstring muscle in vivo _Am J Sports Med_ 1996a 24: 622–628 Article  CAS 

PubMed  Google Scholar  * Magnusson SP _et al_. Viscoelastic stress relaxation during static stretch in human skeletal muscle in the absence of EMG activity _Scand J Med Sci Sports_ 1999b 6:

323–328 Article  Google Scholar  * Toft E _et al_. Passive tension of the ankle before and after stretching _Am J Sp Med_ 1989 17: 489–494 Article  CAS  Google Scholar  * Duong B, Low M,

Moseley A, Herbert R . Time course of stress relaxation in human ankles _Clin Biomech_ 2001 in press * Light KE, Nuzik S, Personius W, Barstrom A . Low-load prolonged stretch versus

high-load brief stretch in treating knee contractures _Phys Ther_ 1984 64: 330–333 Article  CAS  PubMed  Google Scholar  * Prosser R . Splinting in the management of proximal interphalangeal

joint flexion contracture _J Hand Ther_ 1996 9: 378–386 Article  CAS  PubMed  Google Scholar  * Hokken W, Kalkman S, Blanken WC, van Asbeck FW . A dynamic pronation orthosis for the C6

tetraplegic arm _Arch Phys Med Rehabil_ 1993 74: 104–105 CAS  PubMed  Google Scholar  * Ada L, Canning A . Anticipating and avoiding muscle shortening. In: Ada L and Canning A (eds) _Key

Issues in Neurological Physiotherapy_ Butterworth Heinemann: London 1990 Google Scholar  * O'Dwyer NJ, Ada L, Neilson PD . Spasticity and muscle contracture following stroke _Brain_

1996 119: 1737–1749 Article  PubMed  Google Scholar  * Siegler S, Carr E. . A method for discriminating between spasticity and contracture at the ankle joint during locomotion in

neurologically impaired persons. Study Institute and Conference: Biomechanics of Human Movement. Formia, Italy 1986 * Harvey LA . Principles of conservative non-orthotic management for a

tenodesis grip _J Hand Ther_ 1996 9: 238–242 Article  CAS  PubMed  Google Scholar  * Curtin M . An analysis of tetraplegic hand grips _Br J Occ Ther_ 1999 62: 444–450 Article  Google Scholar

  * DiPasquale-Lehnerz P . Orthotic intervention for development of hand function with C-6 tetraplegia _Am J Occup Ther_ 1994 48: 138–144 Article  CAS  PubMed  Google Scholar  * Doll U,

Maurer-Burkhard B, Spahn B, Fromm B . Functional hand development in tetraplegia _Spinal Cord_ 1998 36: 818–821 Article  CAS  PubMed  Google Scholar  * Harvey L, Batty J, Jones R, Crosbie J

. Hand function in C6 and C7 tetraplegics _Spinal Cord_ 2001 39: 37–43 Article  CAS  PubMed  Google Scholar  Download references ACKNOWLEDGEMENTS The financial support of the Motor Accident

Authority of NSW. AUTHOR INFORMATION AUTHORS AND AFFILIATIONS * Moorong Spinal Injuries Unit, Royal Rehabilitation Centre, Sydney, Australia LA Harvey * School of Physiotherapy, University

of Sydney, Australia RD Herbert Authors * LA Harvey View author publications You can also search for this author inPubMed Google Scholar * RD Herbert View author publications You can also

search for this author inPubMed Google Scholar RIGHTS AND PERMISSIONS Reprints and permissions ABOUT THIS ARTICLE CITE THIS ARTICLE Harvey, L., Herbert, R. Muscle stretching for treatment

and prevention of contracture in people with spinal cord injury. _Spinal Cord_ 40, 1–9 (2002). https://doi.org/10.1038/sj.sc.3101241 Download citation * Published: 30 January 2002 * Issue

Date: January 2002 * DOI: https://doi.org/10.1038/sj.sc.3101241 SHARE THIS ARTICLE Anyone you share the following link with will be able to read this content: Get shareable link Sorry, a

shareable link is not currently available for this article. Copy to clipboard Provided by the Springer Nature SharedIt content-sharing initiative KEYWORDS * spinal cord injury * contracture

* stretch