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Ankle and Knee Joint Contractures in Neurologically-Involved Populations: Physical Therapy Evaluation, Plan of Care, and Special Considerations IntroductionPathophysiology Multiple sclerosis (MS) is an immune-mediated neurodegenerative disease that damages the myelin, nerves, and oligodendrocytes of the central nervous system. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a201f61nogf","properties":{"formattedCitation":"{\\rtf \\super 1\\nosupersub{}}","plainCitation":"1"},"citationItems":[{"id":2373,"uris":[""],"uri":[""],"itemData":{"id":2373,"type":"article-journal","title":"Epidemiology of Multiple Sclerosis","container-title":"Neurologic Clinics","page":"919-939","volume":"34","issue":"4","source":"PubMed","abstract":"The epidemiology of multiple sclerosis (MS) includes a consideration of genetic and environmental factors. Comparative studies of different populations have revealed prevalence and incidence rates that vary with geography and ethnicity. With a prevalence ranging from 2 per 100,000 in Japan to greater than 100 per 100,000 in Northern Europe and North America, the burden of MS is similarly unevenly influenced by longevity and comorbid disorders. Well-powered genome-wide association studies have investigated the genetic substrate of MS, providing insight into autoimmune mechanisms involved in the etiopathogenesis of MS and elucidating possible avenues of biological treatment.","DOI":"10.1016/j.ncl.2016.06.016","ISSN":"1557-9875","note":"PMID: 27720001","journalAbbreviation":"Neurol Clin","language":"eng","author":[{"family":"Howard","given":"Jonathan"},{"family":"Trevick","given":"Stephen"},{"family":"Younger","given":"David S."}],"issued":{"date-parts":[["2016"]]}}}],"schema":""} 1 Cerebral palsy (CP) is a nonprogressive neurologic condition often caused by traumatic birth, prematurity, and newborn hypoxia, all of which can lead to physical deformities and limitations, spasticity, and cognitive deficits, among other symptoms. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a1j50nmall2","properties":{"formattedCitation":"{\\rtf \\super 2\\nosupersub{}}","plainCitation":"2"},"citationItems":[{"id":2375,"uris":[""],"uri":[""],"itemData":{"id":2375,"type":"article-journal","title":"Defining the pathogenesis and pathophysiology of neonatal encephalopathy and cerebral palsy","container-title":"Obstetrics & Gynecology","page":"628-636","volume":"102","issue":"3","source":"ScienceDirect","abstract":"The topics of neonatal encephalopathy and cerebral palsy, as well as hypoxic–ischemic encephalopathy, are of paramount importance to anyone who ventures to deliver infants. Criteria sufficient to define an acute intrapartum hypoxic event as sufficient to cause cerebral palsy have been advanced previously by both The American College of Obstetricians and Gynecologists (ACOG) and the International Cerebral Palsy Task Force. ACOG convened a task force that over the past 3 years reviewed these criteria based upon advances in scientific knowledge. In this review, we cover the slow but steady progression toward defining the pathogenesis and pathophysiology of neonatal encephalopathy and cerebral palsy. Four essential criteria are also advanced as prerequisites if one is to propose that an intrapartum hypoxic–ischemic insult has caused a moderate to severe neonatal encephalopathy that subsequently results in cerebral palsy. Importantly, all four criteria must be met: 1) evidence of metabolic acidosis in fetal umbilical cord arterial blood obtained at delivery (pH less than 7 and base deficit of 12 mmol/L or more), 2) early onset of severe or moderate neonatal encephalopathy in infants born at 34 or more weeks’ gestation, 3) cerebral palsy of the spastic quadriplegic or dyskinetic type, and 4) exclusion of other identifiable etiologies, such as trauma, coagulation disorders, infectious conditions, or genetic disorders. Other cri-teria that together suggest intrapartum timing are also discussed.","DOI":"10.1016/S0029-7844(03)00574-X","ISSN":"0029-7844","journalAbbreviation":"Obstetrics & Gynecology","author":[{"family":"Hankins","given":"Gary D. V"},{"family":"Speer","given":"Michael"}],"issued":{"date-parts":[["2003",9,1]]}}}],"schema":""} 2 Ischemic cerebrovascular accidents (CVA) are due to blockages of blood vessels in the brain leading to deoxygenation and subsequent damage of brain tissue that can arise from a variety of diseases and mechanisms. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"af21tguv0h","properties":{"formattedCitation":"{\\rtf \\super 3\\nosupersub{}}","plainCitation":"3"},"citationItems":[{"id":2378,"uris":[""],"uri":[""],"itemData":{"id":2378,"type":"article-journal","title":"Acute ischemic stroke: Overview of major experimental rodent models, pathophysiology, and therapy of focal cerebral ischemia","container-title":"Pharmacology Biochemistry and Behavior","page":"179-197","volume":"87","issue":"1","source":"ScienceDirect","abstract":"Ischemic stroke is a devastating disease with a complex pathophysiology. Animal modeling of ischemic stroke serves as an indispensable tool first to investigate mechanisms of ischemic cerebral injury, secondly to develop novel antiischemic regimens. Most of the stroke models are carried on rodents. Each model has its particular strengths and weaknesses. Mimicking all aspects of human stroke in one animal model is not possible since ischemic stroke is itself a very heterogeneous disorder. Experimental ischemic stroke models contribute to our understanding of the events occurring in ischemic and reperfused brain. Major approaches developed to treat acute ischemic stroke fall into two categories, thrombolysis and neuroprotection. Trials aimed to evaluate effectiveness of recombinant tissue-type plasminogen activator in longer time windows with finer selection of patients based on magnetic resonance imaging tools and trials of novel recanalization methods are ongoing. Despite the failure of most neuroprotective drugs during the last two decades, there are good chances to soon have effective neuroprotectives with the help of improved preclinical testing and clinical trial design. In this article, we focus on various rodent animal models, pathogenic mechanisms, and promising therapeutic approaches of ischemic stroke.","DOI":"10.1016/j.pbb.2007.04.015","ISSN":"0091-3057","shortTitle":"Acute ischemic stroke","journalAbbreviation":"Pharmacology Biochemistry and Behavior","author":[{"family":"Durukan","given":"Aysan"},{"family":"Tatlisumak","given":"Turgut"}],"issued":{"date-parts":[["2007",5,1]]}}}],"schema":""} 3 Among these three particular neurologic conditions, there are several shared manifestations assessed and treated by physical therapists, one of which is joint contracture. Both myogenic and arthrogenic factors contribute to joint contracture in the neurologic populations, but while myogenic sources are strongly influenced by neurologic dysfunction, arthrogenic changes often result from capsular and other musculoskeletal tissue involvement. The ankle and knee joints are two of the most vulnerable joints to undergo contracture, are frequently affected in the aforementioned populations, and greatly hinder physical autonomy, function, and quality of life when affected. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a2j6ipq36eb","properties":{"formattedCitation":"{\\rtf \\super 4\\nosupersub{}}","plainCitation":"4"},"citationItems":[{"id":1747,"uris":[""],"uri":[""],"itemData":{"id":1747,"type":"article-journal","title":"Noninflammatory Joint Contractures Arising from Immobility: Animal Models to Future Treatments","container-title":"BioMed Research International","volume":"2015","source":"PubMed Central","abstract":"Joint contractures, defined as the limitation in the passive range of motion of a mobile joint, can be classified as noninflammatory diseases of the musculoskeletal system. The pathophysiology is not well understood; limited information is available on causal factors, progression, the pathophysiology involved, and prediction of response to treatment. The clinical heterogeneity of joint contractures combined with the heterogeneous contribution of joint connective tissues to joint mobility presents challenges to the study of joint contractures. Furthermore, contractures are often a symptom of a wide variety of heterogeneous disorders that are in many cases multifactorial. Extended immobility has been identified as a causal factor and evidence is provided from both experimental and epidemiology studies. Of interest is the involvement of the joint capsule in the pathophysiology of joint contractures and lack of response to remobilization. While molecular pathways involved in the development of joint contractures are being investigated, current treatments focus on physiotherapy, which is ineffective on irreversible contractures. Future treatments may include early diagnosis and prevention.","URL":"","DOI":"10.1155/2015/848290","ISSN":"2314-6133","note":"PMID: 26247029\nPMCID: PMC4515492","shortTitle":"Noninflammatory Joint Contractures Arising from Immobility","journalAbbreviation":"Biomed Res Int","author":[{"family":"Wong","given":"Kayleigh"},{"family":"Trudel","given":"Guy"},{"family":"Laneuville","given":"Odette"}],"issued":{"date-parts":[["2015"]]}}}],"schema":""} 4 Joint contracture can be defined as a significant loss of passive range of motion (ROM) of a joint, especially in diarthrodial joints. A diarthrodial joint is the most mobile type of joint, involving both a synovial capsule and synovial fluid in the intraarticular space, which enable maximal safe mobility. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a2bdie50pfc","properties":{"formattedCitation":"{\\rtf \\super 4\\nosupersub{}}","plainCitation":"4"},"citationItems":[{"id":1747,"uris":[""],"uri":[""],"itemData":{"id":1747,"type":"article-journal","title":"Noninflammatory Joint Contractures Arising from Immobility: Animal Models to Future Treatments","container-title":"BioMed Research International","volume":"2015","source":"PubMed Central","abstract":"Joint contractures, defined as the limitation in the passive range of motion of a mobile joint, can be classified as noninflammatory diseases of the musculoskeletal system. The pathophysiology is not well understood; limited information is available on causal factors, progression, the pathophysiology involved, and prediction of response to treatment. The clinical heterogeneity of joint contractures combined with the heterogeneous contribution of joint connective tissues to joint mobility presents challenges to the study of joint contractures. Furthermore, contractures are often a symptom of a wide variety of heterogeneous disorders that are in many cases multifactorial. Extended immobility has been identified as a causal factor and evidence is provided from both experimental and epidemiology studies. Of interest is the involvement of the joint capsule in the pathophysiology of joint contractures and lack of response to remobilization. While molecular pathways involved in the development of joint contractures are being investigated, current treatments focus on physiotherapy, which is ineffective on irreversible contractures. Future treatments may include early diagnosis and prevention.","URL":"","DOI":"10.1155/2015/848290","ISSN":"2314-6133","note":"PMID: 26247029\nPMCID: PMC4515492","shortTitle":"Noninflammatory Joint Contractures Arising from Immobility","journalAbbreviation":"Biomed Res Int","author":[{"family":"Wong","given":"Kayleigh"},{"family":"Trudel","given":"Guy"},{"family":"Laneuville","given":"Odette"}],"issued":{"date-parts":[["2015"]]}}}],"schema":""} 4 Joint contractures can result from three distinct conditions including congenital disorder, chronic disease, and immobility, and are influenced by both genetic and environmental predisposing factors. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a2mc4b5hspe","properties":{"formattedCitation":"{\\rtf \\super 4\\nosupersub{}}","plainCitation":"4"},"citationItems":[{"id":1747,"uris":[""],"uri":[""],"itemData":{"id":1747,"type":"article-journal","title":"Noninflammatory Joint Contractures Arising from Immobility: Animal Models to Future Treatments","container-title":"BioMed Research International","volume":"2015","source":"PubMed Central","abstract":"Joint contractures, defined as the limitation in the passive range of motion of a mobile joint, can be classified as noninflammatory diseases of the musculoskeletal system. The pathophysiology is not well understood; limited information is available on causal factors, progression, the pathophysiology involved, and prediction of response to treatment. The clinical heterogeneity of joint contractures combined with the heterogeneous contribution of joint connective tissues to joint mobility presents challenges to the study of joint contractures. Furthermore, contractures are often a symptom of a wide variety of heterogeneous disorders that are in many cases multifactorial. Extended immobility has been identified as a causal factor and evidence is provided from both experimental and epidemiology studies. Of interest is the involvement of the joint capsule in the pathophysiology of joint contractures and lack of response to remobilization. While molecular pathways involved in the development of joint contractures are being investigated, current treatments focus on physiotherapy, which is ineffective on irreversible contractures. Future treatments may include early diagnosis and prevention.","URL":"","DOI":"10.1155/2015/848290","ISSN":"2314-6133","note":"PMID: 26247029\nPMCID: PMC4515492","shortTitle":"Noninflammatory Joint Contractures Arising from Immobility","journalAbbreviation":"Biomed Res Int","author":[{"family":"Wong","given":"Kayleigh"},{"family":"Trudel","given":"Guy"},{"family":"Laneuville","given":"Odette"}],"issued":{"date-parts":[["2015"]]}}}],"schema":""} 4 For the populations of interest specific to this paper, a combination of these three conditions is common since people with multiple sclerosis or post-stroke are often subjected to increased immobility, and children with cerebral palsy may be born with congenital joint contractures in addition to the chronicity of the disease heightening their risk of joint contracture(s). ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"av7t1rhn9v","properties":{"formattedCitation":"{\\rtf \\super 4\\nosupersub{}}","plainCitation":"4"},"citationItems":[{"id":1747,"uris":[""],"uri":[""],"itemData":{"id":1747,"type":"article-journal","title":"Noninflammatory Joint Contractures Arising from Immobility: Animal Models to Future Treatments","container-title":"BioMed Research International","volume":"2015","source":"PubMed Central","abstract":"Joint contractures, defined as the limitation in the passive range of motion of a mobile joint, can be classified as noninflammatory diseases of the musculoskeletal system. The pathophysiology is not well understood; limited information is available on causal factors, progression, the pathophysiology involved, and prediction of response to treatment. The clinical heterogeneity of joint contractures combined with the heterogeneous contribution of joint connective tissues to joint mobility presents challenges to the study of joint contractures. Furthermore, contractures are often a symptom of a wide variety of heterogeneous disorders that are in many cases multifactorial. Extended immobility has been identified as a causal factor and evidence is provided from both experimental and epidemiology studies. Of interest is the involvement of the joint capsule in the pathophysiology of joint contractures and lack of response to remobilization. While molecular pathways involved in the development of joint contractures are being investigated, current treatments focus on physiotherapy, which is ineffective on irreversible contractures. Future treatments may include early diagnosis and prevention.","URL":"","DOI":"10.1155/2015/848290","ISSN":"2314-6133","note":"PMID: 26247029\nPMCID: PMC4515492","shortTitle":"Noninflammatory Joint Contractures Arising from Immobility","journalAbbreviation":"Biomed Res Int","author":[{"family":"Wong","given":"Kayleigh"},{"family":"Trudel","given":"Guy"},{"family":"Laneuville","given":"Odette"}],"issued":{"date-parts":[["2015"]]}}}],"schema":""} 4 While it can be difficult to diagnose an arthrogenic versus myogenic contracture, differentiation is critical for treatment and plan of care. Additionally, contractures often involve a combination of myogenic and arthrogenic contributions. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"aa6m3vg331","properties":{"formattedCitation":"{\\rtf \\super 4\\nosupersub{}}","plainCitation":"4"},"citationItems":[{"id":1747,"uris":[""],"uri":[""],"itemData":{"id":1747,"type":"article-journal","title":"Noninflammatory Joint Contractures Arising from Immobility: Animal Models to Future Treatments","container-title":"BioMed Research International","volume":"2015","source":"PubMed Central","abstract":"Joint contractures, defined as the limitation in the passive range of motion of a mobile joint, can be classified as noninflammatory diseases of the musculoskeletal system. The pathophysiology is not well understood; limited information is available on causal factors, progression, the pathophysiology involved, and prediction of response to treatment. The clinical heterogeneity of joint contractures combined with the heterogeneous contribution of joint connective tissues to joint mobility presents challenges to the study of joint contractures. Furthermore, contractures are often a symptom of a wide variety of heterogeneous disorders that are in many cases multifactorial. Extended immobility has been identified as a causal factor and evidence is provided from both experimental and epidemiology studies. Of interest is the involvement of the joint capsule in the pathophysiology of joint contractures and lack of response to remobilization. While molecular pathways involved in the development of joint contractures are being investigated, current treatments focus on physiotherapy, which is ineffective on irreversible contractures. Future treatments may include early diagnosis and prevention.","URL":"","DOI":"10.1155/2015/848290","ISSN":"2314-6133","note":"PMID: 26247029\nPMCID: PMC4515492","shortTitle":"Noninflammatory Joint Contractures Arising from Immobility","journalAbbreviation":"Biomed Res Int","author":[{"family":"Wong","given":"Kayleigh"},{"family":"Trudel","given":"Guy"},{"family":"Laneuville","given":"Odette"}],"issued":{"date-parts":[["2015"]]}}}],"schema":""} 4Joint contracture may result from a variety of restricting musculoskeletal tissue including muscle, capsule, tendon, ligament, cartilage, skin, and bone. Muscular spasticity involving the imbalance of neuronal signals to the muscles and fascia are often a source of limited motion in neurologic populations, increasing the risk of joint contracture. Immobility-related joint contracture most commonly involves the joint capsule, but can also include muscular tightening due to atrophic changes. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a1s1oae69gq","properties":{"formattedCitation":"{\\rtf \\super 4\\nosupersub{}}","plainCitation":"4"},"citationItems":[{"id":1747,"uris":[""],"uri":[""],"itemData":{"id":1747,"type":"article-journal","title":"Noninflammatory Joint Contractures Arising from Immobility: Animal Models to Future Treatments","container-title":"BioMed Research International","volume":"2015","source":"PubMed Central","abstract":"Joint contractures, defined as the limitation in the passive range of motion of a mobile joint, can be classified as noninflammatory diseases of the musculoskeletal system. The pathophysiology is not well understood; limited information is available on causal factors, progression, the pathophysiology involved, and prediction of response to treatment. The clinical heterogeneity of joint contractures combined with the heterogeneous contribution of joint connective tissues to joint mobility presents challenges to the study of joint contractures. Furthermore, contractures are often a symptom of a wide variety of heterogeneous disorders that are in many cases multifactorial. Extended immobility has been identified as a causal factor and evidence is provided from both experimental and epidemiology studies. Of interest is the involvement of the joint capsule in the pathophysiology of joint contractures and lack of response to remobilization. While molecular pathways involved in the development of joint contractures are being investigated, current treatments focus on physiotherapy, which is ineffective on irreversible contractures. Future treatments may include early diagnosis and prevention.","URL":"","DOI":"10.1155/2015/848290","ISSN":"2314-6133","note":"PMID: 26247029\nPMCID: PMC4515492","shortTitle":"Noninflammatory Joint Contractures Arising from Immobility","journalAbbreviation":"Biomed Res Int","author":[{"family":"Wong","given":"Kayleigh"},{"family":"Trudel","given":"Guy"},{"family":"Laneuville","given":"Odette"}],"issued":{"date-parts":[["2015"]]}}}],"schema":""} 4 The lack of mechanical stimulation related to immobility is often the underlying etiology in both neurologic and immobility-related contractures. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a4crrd8eie","properties":{"formattedCitation":"{\\rtf \\super 4\\nosupersub{}}","plainCitation":"4"},"citationItems":[{"id":1747,"uris":[""],"uri":[""],"itemData":{"id":1747,"type":"article-journal","title":"Noninflammatory Joint Contractures Arising from Immobility: Animal Models to Future Treatments","container-title":"BioMed Research International","volume":"2015","source":"PubMed Central","abstract":"Joint contractures, defined as the limitation in the passive range of motion of a mobile joint, can be classified as noninflammatory diseases of the musculoskeletal system. The pathophysiology is not well understood; limited information is available on causal factors, progression, the pathophysiology involved, and prediction of response to treatment. The clinical heterogeneity of joint contractures combined with the heterogeneous contribution of joint connective tissues to joint mobility presents challenges to the study of joint contractures. Furthermore, contractures are often a symptom of a wide variety of heterogeneous disorders that are in many cases multifactorial. Extended immobility has been identified as a causal factor and evidence is provided from both experimental and epidemiology studies. Of interest is the involvement of the joint capsule in the pathophysiology of joint contractures and lack of response to remobilization. While molecular pathways involved in the development of joint contractures are being investigated, current treatments focus on physiotherapy, which is ineffective on irreversible contractures. Future treatments may include early diagnosis and prevention.","URL":"","DOI":"10.1155/2015/848290","ISSN":"2314-6133","note":"PMID: 26247029\nPMCID: PMC4515492","shortTitle":"Noninflammatory Joint Contractures Arising from Immobility","journalAbbreviation":"Biomed Res Int","author":[{"family":"Wong","given":"Kayleigh"},{"family":"Trudel","given":"Guy"},{"family":"Laneuville","given":"Odette"}],"issued":{"date-parts":[["2015"]]}}}],"schema":""} 4 Specific to the knee joint, the posterior capsule is most frequently involved in flexion contractures. The posterior capsule of the knee maintains a folded arrangement when flexed, which unfolds when extended. When immobilized in flexion, adjacent folds adhere to one another, reducing synovial capsule length. In addition, the synovial capsule experiences reduced fibroblast proliferation in the synovial fluid without appropriate mechanical stimulation. Finally, the collagen fibers that comprise the posterior capsule become disorganized in their orientation with a surplus of type I collagen fibers, both of which increase stiffness and reduce elasticity of the capsule. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a1qvk32o4qt","properties":{"formattedCitation":"{\\rtf \\super 4\\nosupersub{}}","plainCitation":"4"},"citationItems":[{"id":1747,"uris":[""],"uri":[""],"itemData":{"id":1747,"type":"article-journal","title":"Noninflammatory Joint Contractures Arising from Immobility: Animal Models to Future Treatments","container-title":"BioMed Research International","volume":"2015","source":"PubMed Central","abstract":"Joint contractures, defined as the limitation in the passive range of motion of a mobile joint, can be classified as noninflammatory diseases of the musculoskeletal system. The pathophysiology is not well understood; limited information is available on causal factors, progression, the pathophysiology involved, and prediction of response to treatment. The clinical heterogeneity of joint contractures combined with the heterogeneous contribution of joint connective tissues to joint mobility presents challenges to the study of joint contractures. Furthermore, contractures are often a symptom of a wide variety of heterogeneous disorders that are in many cases multifactorial. Extended immobility has been identified as a causal factor and evidence is provided from both experimental and epidemiology studies. Of interest is the involvement of the joint capsule in the pathophysiology of joint contractures and lack of response to remobilization. While molecular pathways involved in the development of joint contractures are being investigated, current treatments focus on physiotherapy, which is ineffective on irreversible contractures. Future treatments may include early diagnosis and prevention.","URL":"","DOI":"10.1155/2015/848290","ISSN":"2314-6133","note":"PMID: 26247029\nPMCID: PMC4515492","shortTitle":"Noninflammatory Joint Contractures Arising from Immobility","journalAbbreviation":"Biomed Res Int","author":[{"family":"Wong","given":"Kayleigh"},{"family":"Trudel","given":"Guy"},{"family":"Laneuville","given":"Odette"}],"issued":{"date-parts":[["2015"]]}}}],"schema":""} 4 Additional changes include amplified fibrosis of the synovium and a loss of glycosaminoglycans, which play a critical role in water retention, thereby increasing collagen cross-links. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a2dt2fm75ck","properties":{"formattedCitation":"{\\rtf \\super 4\\nosupersub{}}","plainCitation":"4"},"citationItems":[{"id":1747,"uris":[""],"uri":[""],"itemData":{"id":1747,"type":"article-journal","title":"Noninflammatory Joint Contractures Arising from Immobility: Animal Models to Future Treatments","container-title":"BioMed Research International","volume":"2015","source":"PubMed Central","abstract":"Joint contractures, defined as the limitation in the passive range of motion of a mobile joint, can be classified as noninflammatory diseases of the musculoskeletal system. The pathophysiology is not well understood; limited information is available on causal factors, progression, the pathophysiology involved, and prediction of response to treatment. The clinical heterogeneity of joint contractures combined with the heterogeneous contribution of joint connective tissues to joint mobility presents challenges to the study of joint contractures. Furthermore, contractures are often a symptom of a wide variety of heterogeneous disorders that are in many cases multifactorial. Extended immobility has been identified as a causal factor and evidence is provided from both experimental and epidemiology studies. Of interest is the involvement of the joint capsule in the pathophysiology of joint contractures and lack of response to remobilization. While molecular pathways involved in the development of joint contractures are being investigated, current treatments focus on physiotherapy, which is ineffective on irreversible contractures. Future treatments may include early diagnosis and prevention.","URL":"","DOI":"10.1155/2015/848290","ISSN":"2314-6133","note":"PMID: 26247029\nPMCID: PMC4515492","shortTitle":"Noninflammatory Joint Contractures Arising from Immobility","journalAbbreviation":"Biomed Res Int","author":[{"family":"Wong","given":"Kayleigh"},{"family":"Trudel","given":"Guy"},{"family":"Laneuville","given":"Odette"}],"issued":{"date-parts":[["2015"]]}}}],"schema":""} 4Prevalence According to a recent cross-sectional study, more than 50% of individuals with MS present with at least one joint contracture, ankle (43.9%) and knee (17%) joint contractures being two of the most common sites of those affected. Based off of these measures, prevalence rates of 28.8% and 5.4% are predicted among the MS population, respectively. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"aqo34ibu6l","properties":{"formattedCitation":"{\\rtf \\super 5\\nosupersub{}}","plainCitation":"5"},"citationItems":[{"id":1750,"uris":[""],"uri":[""],"itemData":{"id":1750,"type":"article-journal","title":"Prevalence of joint contractures and muscle weakness in people with multiple sclerosis","container-title":"Disability and Rehabilitation","page":"1588-1593","volume":"36","issue":"19","source":"PubMed","abstract":"OBJECTIVES: To investigate the prevalence of joint contracture (limited passive range of joint motion) and muscle weakness in a population with multiple sclerosis (MS). A secondary aim was to establish normative data of functional tests of mobility and balance of people with MS who are still ambulant.\nDESIGN: Cross-sectional study.\nSETTING: People with MS living in metropolitan Sydney, Australia.\nPARTICIPANTS: 330 people with MS living in metropolitan Sydney, Australia were randomly sampled on 23 July 2009 from the MS Australia register and invited to participate.\nMAIN OUTCOME MEASURES: Passive range of motion of large joints of the limbs and muscle strength. Tests of walking and balance were also conducted.\nRESULTS: 156 people (109 females, 47 males; mean age 54.2 years; mean time since diagnosis 14.9 years) agreed to participate and were assessed. Fifty-six per cent (56%) of participants had contracture in at least one major joint of upper or lower limb. The most common site of contracture was the ankle (43.9%). Seventy per cent (70%) of participants had muscle weakness in one or more muscle groups. As muscle weakness, joint contractures were present at early stage of MS and the prevalence was associated with the progression of the disease.\nCONCLUSIONS: These data show that in addition to muscle weakness joint contractures are highly prevalent among people with MS, especially in the ankle joint. This implicates that prevention of contracture is crucial in providing rehabilitation to people with MS.","DOI":"10.3109/09638288.2013.854841","ISSN":"1464-5165","note":"PMID: 24236496","journalAbbreviation":"Disabil Rehabil","language":"eng","author":[{"family":"Hoang","given":"Phu Dinh"},{"family":"Gandevia","given":"Simon C."},{"family":"Herbert","given":"Robert D."}],"issued":{"date-parts":[["2014"]]}}}],"schema":""} 5 In a large 2018 cross-sectional study of children with CP, 685 of 3,045 children were identified with a knee contracture of 5 degrees or greater (22%). Higher levels of disability and shortened hamstring muscles were correlated with presence of knee joint contracture. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a1vpcbgtcdb","properties":{"formattedCitation":"{\\rtf \\super 6\\nosupersub{}}","plainCitation":"6"},"citationItems":[{"id":2387,"uris":[""],"uri":[""],"itemData":{"id":2387,"type":"article-journal","title":"Demographic and modifiable factors associated with knee contracture in children with cerebral palsy","container-title":"Developmental Medicine and Child Neurology","page":"391-396","volume":"60","issue":"4","source":"PubMed","abstract":"AIM: To identify the prevalence of knee contracture and its association with gross motor function, age, sex, spasticity, and muscle length in children with cerebral palsy (CP).\nMETHOD: Cross-sectional data for passive knee extension were analysed in 3?045 children with CP (1?756 males, 1?289 females; mean age 8y 1mo [SD 3.84]). CP was classified using the Gross Motor Function Classification System (GMFCS) levels I (n=1?330), II (n=508), III (n=280), IV (n=449), and V (n=478). Pearson's χ2 test and multiple binary logistic regression were applied to analyse the relationships between knee contracture and GMFCS level, sex, age, spasticity, hamstring length, and gastrocnemius length.\nRESULTS: Knee contracture greater than or equal to 5 degrees occurred in 685 children (22%). The prevalence of knee contracture was higher in older children and in those with higher GMFCS levels. Odds ratios (ORs) for knee contracture were significantly higher for children at GMFCS level V (OR=13.17), with short hamstring muscles (OR=9.86), and in the oldest age group, 13 years to 15 years (OR=6.80).\nINTERPRETATION: Knee contracture is associated with higher GMFCS level, older age, and shorter muscle length; spasticity has a small effect. Maintaining muscle length, especially of the hamstrings, is important for reducing the risk of knee contracture.\nWHAT THIS PAPER ADDS: Knee contracture occurs in children with cerebral palsy at all Gross Motor Function Classification System (GMFCS) levels. Knee contracture in children is associated with short hamstring muscles, higher GMFCS level, and older age. Short hamstring muscles present a greater risk for knee contracture than spasticity.","DOI":"10.1111/dmcn.13659","ISSN":"1469-8749","note":"PMID: 29318610","journalAbbreviation":"Dev Med Child Neurol","language":"eng","author":[{"family":"Cloodt","given":"Erika"},{"family":"Rosenblad","given":"Andreas"},{"family":"Rodby-Bousquet","given":"Elisabet"}],"issued":{"date-parts":[["2018"]]}}}],"schema":""} 6 In a study of patients post-stroke, 43% were diagnosed with a joint contracture, which was defined by a 30% or more limitation in joint range motion when compared to the healthy limb. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a1mhuimqeme","properties":{"formattedCitation":"{\\rtf \\super 7\\nosupersub{}}","plainCitation":"7"},"citationItems":[{"id":2391,"uris":[""],"uri":[""],"itemData":{"id":2391,"type":"article-journal","title":"The Prevalence of Joint Contractures, Pressure Sores, Painful Shoulder, Other Pain, Falls, and Depression in the Year After a Severely Disabling Stroke","container-title":"Stroke","page":"3329-3334","volume":"39","issue":"12","source":"www-ahajournals-org.libproxy.lib.unc.edu (Atypon)","abstract":"Background and Purpose— Complications after stroke have been shown to impede rehabilitation, lead to poor functional outcome, and increase cost of care. This inception cohort study sought to investigate the prevalence of immobility-related complications during the first year after severely disabling stroke in relation to functional independence and place of residence.Methods— Over a 7-month period, 600 stroke survivors were identified in the hospital through the Nottingham Stroke Register. Those who had a Barthel Index score ≤10 3 months poststroke and did not have a primary diagnosis of dementia were eligible to participate in the study. Assessments of complications were carried out at 3, 6, and 12 months poststroke.Results— Complications were recorded for 122 stroke survivors (mean age, 76 years; 57% male). Sixty-three (52%) had significant language impairment and of the remaining 59 who were able to complete an assessment of cognitive function, 10 (8%) were cognitively impaired. The numbers of reported complications over 12 months, in rank order, were falls, 89 (73%); contracture, 73 (60%); pain, 67 (55%); shoulder pain, 64 (52%); depression, 61 (50%); and pressure sores, 26 (22%). A negative correlation was found between Barthel Index score and the number of complications experienced (low scores on the Barthel Index correlate with a high number of complications). The highest relative percentages of complications were experienced by patients who were living in a nursing home at the time of their last completed assessment.Conclusions— Immobility-related complications are very common in the first year after a severely disabling stroke. Patients who are more functionally dependent in self-care are likely to experience a greater number of complications than those who are less dependent. Trials of techniques to limit and prevent complication are required.","DOI":"10.1161/STROKEAHA.108.518563","journalAbbreviation":"Stroke","author":[{"literal":"Sackley Catherine"},{"literal":"Brittle Nicola"},{"literal":"Patel Smitaa"},{"literal":"Ellins Julie"},{"literal":"Scott Martin"},{"literal":"Wright Cristine"},{"literal":"Dewey Michael E."}],"issued":{"date-parts":[["2008",12,1]]}}}],"schema":""} 7 All of these prevalence rates indicate the need for strong assessment and treatment skills of physical therapists, the primary initial providers for joint contractures. Brief Anatomic Review of Relevant Ankle and Knee Joint StructuresThe posterior capsule of the knee is the most common source of contracture with knee flexion contractures related to chronic neurologic conditions and immobility related contractures. It has an inner synovial membrane and an outer fibrous membrane that is thicker and tougher. When the knee is flexed, the posterior capsule has many folds to make it compact, which then unfold as the knee is extended. The capsule contains the ligaments, bursae, tendons, and patella, although both the anterior cruciate and posterior cruciate ligaments are intracapsular but extra-articular. The knee capsule is thinnest anteriorly and thickest posteriorly. Several of the enclosed tissues can augment the contracture as well including the ligaments and tendons. Shortening of the hamstring tendons and medial and lateral collateral ligaments can both further reduce the extension of the knee joint. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a17dfulmj36","properties":{"formattedCitation":"{\\rtf \\super 8\\nosupersub{}}","plainCitation":"8"},"citationItems":[{"id":2395,"uris":[""],"uri":[""],"itemData":{"id":2395,"type":"webpage","title":"The Anatomy of the Posterior Aspect of the Knee: An Anatomic Study | Ovid","URL":"","accessed":{"date-parts":[["2019",11,15]]}}}],"schema":""} 8 For an anatomic visual, see Figure I of the Appendix.The articular capsule of the ankle encompasses the multiple joints that comprise the ankle. It is thinnest anteriorly and posteriorly, and thicker laterally on each side where it encases the malleoli. The anterior capsule is very broad in order to encompass all of the structures within it. Additionally, its synovial membrane attaches to the interosseous ligament between the tibia and fibula. Because it is so broad in width, the fibers are primarily oriented transversely. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a1kptjbslsj","properties":{"formattedCitation":"{\\rtf \\super 9\\nosupersub{}}","plainCitation":"9"},"citationItems":[{"id":2400,"uris":[""],"uri":[""],"itemData":{"id":2400,"type":"webpage","title":"Ankle Joint","container-title":"Physiopedia","abstract":"The Ankle Joint, also known as the Talocrural Articulation, is a synovial hinge joint connecting the distal ends of the tibia and fibula in the lower limb with the proximal end of the talus. The ankle joint is maintained by the shape of the talus and its tight fit between the tibia and fibula. In the neutral position, there are strong bony constraints. With increasing plantar flexion, the bony constraints are decreased and the ligaments are more susceptible to strain and injury. The articulation between the tibia and the talus bears more weight than that between the smaller fibula and the talus.&#160;&#91;1&#93;","URL":"","language":"en","accessed":{"date-parts":[["2019",11,15]]}}}],"schema":""} 9 The talocrural, also called tibiotalar, joint is the synovial diarthrodial joint responsible for plantar flexion and dorsiflexion, occurring primarily in the sagittal plane. The ligaments and bony structures of the ankle are primary responsible for ankle stability, specifically the talocrural joint. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"alklcvl9bk","properties":{"formattedCitation":"{\\rtf \\super 10\\nosupersub{}}","plainCitation":"10"},"citationItems":[{"id":2402,"uris":[""],"uri":[""],"itemData":{"id":2402,"type":"article-journal","title":"Biomechanics of the ankle","container-title":"Orthopaedics and Trauma","page":"232-238","volume":"30","issue":"3","source":"PubMed Central","abstract":"This paper provides an introduction to the biomechanics of the ankle, introducing the bony anatomy involved in motion of the foot and ankle. The complexity of the ankle anatomy has a significant influence on the biomechanical performance of the joint, and this paper discusses the motions of the ankle joint complex, and the joints at which it is proposed they occur. It provides insight into the ligaments that are critical to the stability and function of the ankle joint. It describes the movements involved in a normal gait cycle, and also highlights how these may change as a result of surgical intervention such as total joint replacement or fusion.","DOI":"10.1016/j.mporth.2016.04.015","ISSN":"1877-1327","note":"PMID: 27594929\nPMCID: PMC4994968","journalAbbreviation":"Orthop Trauma","author":[{"family":"Brockett","given":"Claire L."},{"family":"Chapman","given":"Graham J."}],"issued":{"date-parts":[["2016",6]]}}}],"schema":""} 10 The principle source of ankle contracture is uncontrolled plantar flexor muscle forces either due to spasticity or other muscle imbalances, which allow shortening of joint structures including tendons, ligaments, and the capsule, leading to subsequent contracture at the joint. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a27heojatof","properties":{"formattedCitation":"{\\rtf \\super 11\\nosupersub{}}","plainCitation":"11"},"citationItems":[{"id":2405,"uris":[""],"uri":[""],"itemData":{"id":2405,"type":"article-journal","title":"Treatment of upper motoneuron plantarflexion contractures by using an adjustable ankle-foot orthosis","container-title":"Archives of Physical Medicine and Rehabilitation","page":"270-273","volume":"82","issue":"2","source":"ScienceDirect","abstract":"Grissom SP, Blanton S. Treatment of upper motoneuron plantarflexion contractures by using an adjustable ankle-foot orthosis. Arch Phys Med Rehabil 2001;82:270-3. Objective: To assess the effectiveness of an adjustable ankle-foot orthosis in the treatment of plantarflexion contractures after central nervous system injury or disease. Design: Prospective, nonrandomized, interventional trial. Setting: University medical center's acute inpatient rehabilitation hospital. Participants: Nine ankles with plantarflexion contractures that could not be passively reduced to less than neutral position occurring in 6 patients with stroke or other acquired brain injury. Intervention: To assure differentiation between spastic deformity and true contracture, patients received a 2% lidocaine block of the posterior tibial nerve. The adjustable ankle-foot orthosis was then applied on the affected ankle for 23 hours per day for 14 days. Adjustments to increase dorsiflexion passive range of motion (PROM) ranged from 0° to 4.5° and were attempted every 48 to 72 hours. Main Outcome Measures: Dorsiflexion PROM at the ankle with the knee extended. Results: Increased PROM (average, 20.1°; range, 6°-36°) was statistically significant (p =.0078). Complications related to pressure with erythema or blister formation associated with pain occurred in 44% of treated ankles at some time during the 2-week trial period. Conclusion: Plantarflexion contractures can be significantly reduced by using the adjustable ankle-foot orthosis with minimal complications.","DOI":"10.1053/apmr.2001.19018","ISSN":"0003-9993","journalAbbreviation":"Archives of Physical Medicine and Rehabilitation","author":[{"family":"Grissom","given":"Samuel P."},{"family":"Blanton","given":"Sarah"}],"issued":{"date-parts":[["2001",2,1]]}}}],"schema":""} 11 For anatomic visual of the ankle joint, see Figure II of the Appendix. EvaluationAssessment of Joint ContractureThorough evaluation of a potential ankle or knee joint contracture should include inspection, active and passive ROM with goniometric measurements, manual muscle testing, gait analysis if patient is ambulatory, spasticity testing, joint mobilization, and muscle flexibility testing. The two components of joint contracture are arthrogenic and/or myogenic in nature. Arthrogenic sources or joint contracture include joint capsule tightening along with shortening of ligaments, the synovial membrane, and other changes. This is contrasted from myogenic sources of contracture, which involve shortening of the muscles. These two types exclude a third, neurologic-based contributor: spasticity, which is related to hyper-reflexive activity, and contributes to the myogenic joint contracture. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"askoru9qpf","properties":{"formattedCitation":"{\\rtf \\super 12\\nosupersub{}}","plainCitation":"12"},"citationItems":[{"id":2447,"uris":[""],"uri":[""],"itemData":{"id":2447,"type":"article-journal","title":"Effects of joint immobilization on changes in myofibroblasts and collagen in the rat knee contracture model","container-title":"Journal of Orthopaedic Research","page":"1998-2006","volume":"35","issue":"9","source":"Wiley Online Library","abstract":"The purpose of this study was to examine the time-dependent changes in the development of joint capsule fibrosis and in the number of myofibroblasts in the joint capsule after immobilization, using a rat knee contracture model. Both knee joints were fixed in full flexion for 1, 2, and 4 weeks (immobilization group). Untreated rats were bred for each immobilization period (control group). Histological analysis was performed to evaluate changes in the amount and density of collagen in the joint capsule. The changes in type I and III collagen mRNA were examined by in situ hybridization. The number of myofibroblasts in the joint capsule was assessed by immunohistochemical methods. In the immobilization group, the amount of collagen increased within 1 week and the density of collagen increased within 2 weeks, as compared with that in the control group. Type I collagen mRNA-positive cell numbers in the immobilization group increased at all time points. However, type III collagen mRNA-positive cell numbers did not increase. Myofibroblasts in the immobilization group significantly increased compared with those in the control group at all time points, and they increased significantly with the period of immobilization. These results suggest that joint capsule fibrosis with overexpression of type I collagen occurs and progresses within 1 week after immobilization, and an increase in myofibroblasts is related to the mechanism of joint capsule fibrosis. The findings suggest the need for a treatment targeting accumulation of type I collagen associated with an increase in myofibroblasts. ? 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:1998–2006, 2017.","DOI":"10.1002/jor.23498","ISSN":"1554-527X","language":"en","author":[{"family":"Sasabe","given":"Ryo"},{"family":"Sakamoto","given":"Junya"},{"family":"Goto","given":"Kyo"},{"family":"Honda","given":"Yuichiro"},{"family":"Kataoka","given":"Hideki"},{"family":"Nakano","given":"Jiro"},{"family":"Origuchi","given":"Tomoki"},{"family":"Endo","given":"Daisuke"},{"family":"Koji","given":"Takehiko"},{"family":"Okita","given":"Minoru"}],"issued":{"date-parts":[["2017"]]}}}],"schema":""} 12 It is difficult to distinguish decreased joint ROM due to tightening and shortening of structures within the joint from excessive muscular activity related to spasticity in the neurologic populations. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a27ctv0d5vk","properties":{"formattedCitation":"{\\rtf \\super 13\\nosupersub{}}","plainCitation":"13"},"citationItems":[{"id":2432,"uris":[""],"uri":[""],"itemData":{"id":2432,"type":"article-journal","title":"Spasticity in adults with cerebral palsy and multiple sclerosis measured by objective clinically applicable technique","container-title":"Clinical Neurophysiology","page":"2010-2021","volume":"129","issue":"9","source":"ScienceDirect","abstract":"Objective\nThe present study evaluated ankle stiffness in adults with and without neurological disorders and investigated the accuracy and reproducibility of a clinically applicable method using a dynamometer.\nMethods\nMeasurements were obtained from 8 healthy subjects (age 39.3), 9 subjects with spastic cerebral palsy (CP) (age 39.8) and 8 subjects with multiple sclerosis (MS) (age 49.9). Slow and fast dorsiflexion stretches of the ankle joint were performed to evaluate passive muscle-tendon-joint stiffness, reflex mediated stiffness and range of movement (ROM), respectively. Intra/inter-rater reliability for passive and reflex mediated ankle muscle stiffness was assessed for all groups.\nResults\nSubjects with CP and MS showed significantly larger values of passive stiffness in the triceps surae muscle tendon complex and smaller ROM compared to healthy individuals, while no significant difference in reflex mediated stiffness. Measurements of passive muscle-tendon-joint stiffness and reflex mediated stiffness showed good to excellent inter- and intra-rater reliability (ICC: 0.62–0.91) in all groups.\nConclusion\nIncreased stiffness was found in subjects with CP and MS with a clinically applicable method that provides valid and reproducible measurement of passive ankle muscle-tendon-joint stiffness and reflex mediated stiffness.\nSignificance\nThe present technique may provide important supplementary information for the clinician.","DOI":"10.1016/j.clinph.2018.07.004","ISSN":"1388-2457","journalAbbreviation":"Clinical Neurophysiology","author":[{"family":"Yamaguchi","given":"Tomofumi"},{"family":"Hvass Petersen","given":"Tue"},{"family":"Kirk","given":"Henrik"},{"family":"Forman","given":"Christian"},{"family":"Svane","given":"Christian"},{"family":"Kofoed-Hansen","given":"Mathilde"},{"family":"Boesen","given":"Finn"},{"family":"Lorentzen","given":"Jakob"}],"issued":{"date-parts":[["2018",9,1]]}}}],"schema":""} 13 While hand-held dynamometers have not been implemented into clinical settings for reasons of time efficiency and difficulty of use, these devices measure muscle stiffness while calculating electromyographic (EMG) activity to improve differentiation of neural and structural contributions to lost ROM. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a16hsd012r7","properties":{"formattedCitation":"{\\rtf \\super 14\\nosupersub{}}","plainCitation":"14"},"citationItems":[{"id":2436,"uris":[""],"uri":[""],"itemData":{"id":2436,"type":"article-journal","title":"A clinical measurement to quantify spasticity in children with cerebral palsy by integration of multidimensional signals","container-title":"Gait & Posture","page":"141-147","volume":"38","issue":"1","source":"PubMed","abstract":"Most clinical tools for measuring spasticity, such as the Modified Ashworth Scale (MAS) and the Modified Tardieu Scale (MTS), are not sufficiently accurate or reliable. This study investigated the clinimetric properties of an instrumented spasticity assessment. Twenty-eight children with spastic cerebral palsy (CP) and 10 typically developing (TD) children were included. Six of the children with CP were retested to evaluate reliability. To quantify spasticity in the gastrocnemius (GAS) and medial hamstrings (MEH), three synchronized signals were collected and integrated: surface electromyography (sEMG); joint-angle characteristics; and torque. Muscles were manually stretched at low velocity (LV) and high velocity (HV). Spasticity parameters were extracted from the change in sEMG and in torque between LV and HV. Reliability was determined with intraclass-correlation coefficients and the standard error of measurement; validity by assessing group differences and correlating spasticity parameters with the MAS and MTS. Reliability was moderately high for both muscles. Spasticity parameters in both muscles were higher in children with CP than in TD children, showed moderate correlation with the MAS for both muscles and good correlation to the MTS for the MEH. Spasticity assessment based on multidimensional signals therefore provides reliable and clinically relevant measures of spasticity. Moreover, the moderate correlations of the MAS and MTS with the objective parameters further stress the added value of the instrumented measurements to detect and investigate spasticity, especially for the GAS.","DOI":"10.1016/j.gaitpost.2012.11.003","ISSN":"1879-2219","note":"PMID: 23218728","journalAbbreviation":"Gait Posture","language":"eng","author":[{"family":"Bar-On","given":"L."},{"family":"Aertbeli?n","given":"E."},{"family":"Wambacq","given":"H."},{"family":"Severijns","given":"D."},{"family":"Lambrecht","given":"K."},{"family":"Dan","given":"B."},{"family":"Huenaerts","given":"C."},{"family":"Bruyninckx","given":"H."},{"family":"Janssens","given":"L."},{"family":"Van Gestel","given":"L."},{"family":"Jaspers","given":"E."},{"family":"Molenaers","given":"G."},{"family":"Desloovere","given":"K."}],"issued":{"date-parts":[["2013",5]]}}}],"schema":""} 14 For these neurologically-involved populations, distinguishing transient spasticity from a joint contracture is imperative to determining appropriate treatment courses. Specific hyper-reflexive activity is distinct from involuntary muscle hyperactivity, often referred to as spastic dystonia. Muscle hyperactivity can lead to fixed shortening, and is treated differently than arthrogenic sources of stiffness and immobility. For the purposes of this paper, muscle spasticity and spastic dystonia will be considered neurologic-related myogenic sources of joint contracture. Ankle joint dynamometers are a relatively new device that should be utilized if possible to help distinguish spasticity sources of lost joint ROM. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"LkVqtLQo","properties":{"formattedCitation":"{\\rtf \\super 13,15\\nosupersub{}}","plainCitation":"13,15"},"citationItems":[{"id":2432,"uris":[""],"uri":[""],"itemData":{"id":2432,"type":"article-journal","title":"Spasticity in adults with cerebral palsy and multiple sclerosis measured by objective clinically applicable technique","container-title":"Clinical Neurophysiology","page":"2010-2021","volume":"129","issue":"9","source":"ScienceDirect","abstract":"Objective\nThe present study evaluated ankle stiffness in adults with and without neurological disorders and investigated the accuracy and reproducibility of a clinically applicable method using a dynamometer.\nMethods\nMeasurements were obtained from 8 healthy subjects (age 39.3), 9 subjects with spastic cerebral palsy (CP) (age 39.8) and 8 subjects with multiple sclerosis (MS) (age 49.9). Slow and fast dorsiflexion stretches of the ankle joint were performed to evaluate passive muscle-tendon-joint stiffness, reflex mediated stiffness and range of movement (ROM), respectively. Intra/inter-rater reliability for passive and reflex mediated ankle muscle stiffness was assessed for all groups.\nResults\nSubjects with CP and MS showed significantly larger values of passive stiffness in the triceps surae muscle tendon complex and smaller ROM compared to healthy individuals, while no significant difference in reflex mediated stiffness. Measurements of passive muscle-tendon-joint stiffness and reflex mediated stiffness showed good to excellent inter- and intra-rater reliability (ICC: 0.62–0.91) in all groups.\nConclusion\nIncreased stiffness was found in subjects with CP and MS with a clinically applicable method that provides valid and reproducible measurement of passive ankle muscle-tendon-joint stiffness and reflex mediated stiffness.\nSignificance\nThe present technique may provide important supplementary information for the clinician.","DOI":"10.1016/j.clinph.2018.07.004","ISSN":"1388-2457","journalAbbreviation":"Clinical Neurophysiology","author":[{"family":"Yamaguchi","given":"Tomofumi"},{"family":"Hvass Petersen","given":"Tue"},{"family":"Kirk","given":"Henrik"},{"family":"Forman","given":"Christian"},{"family":"Svane","given":"Christian"},{"family":"Kofoed-Hansen","given":"Mathilde"},{"family":"Boesen","given":"Finn"},{"family":"Lorentzen","given":"Jakob"}],"issued":{"date-parts":[["2018",9,1]]}}},{"id":2430,"uris":[""],"uri":[""],"itemData":{"id":2430,"type":"article-journal","title":"Botulinum toxin type A injection increases range of motion in hip, knee and ankle joint contractures of children with cerebral palsy","container-title":"Eklem Hastaliklari Ve Cerrahisi = Joint Diseases & Related Surgery","page":"155-162","volume":"30","issue":"2","source":"PubMed","abstract":"OBJECTIVES: This study aims to evaluate the clinical outcomes of children with spastic type cerebral palsy (CP) treated with botulinum toxin type A (BoNT-A) injection for lower limb contracture and the influence of age, gender, functional level and degree of initial contracture on treatment outcomes.\nPATIENTS AND METHODS: Clinical records at pre-BoNT-A injection and post-BoNT-A injections of 153 sessions of a total of 118 consecutive children (67 boys, 51 girls; mean age 5.9±2.6 years; range, 2.5-16 years) were retrospectively evaluated. Degrees of pre- and post-injection contracture were evaluated. Post-injection supplemental casting for 10 days was recorded in all cases. Less than 20° of hip flexion contracture, more than 30° of hip abduction, a negative prone Ely test, less than 50° of popliteal angle and at least 5° of ankle dorsiflexion values at post-injection were accepted as sufficient clinical improvement.\nRESULTS: Sufficient post-injection range of motion (ROM) was observed in 80% of cases with hip flexion contracture, in 45% of cases with hip adduction contracture, in 84% of cases with knee flexion contracture and in 77% of cases with ankle equinus contracture. Prone Ely test that was positive in 60% of cases with knee extension contracture was negative at post-injection. Improvement in contractures were prominent in children with lesser degree initial contractures.\nCONCLUSION: Botulinum toxin type A injection increases ROM in hip, knee and ankle joint contractures in CP. Although age, gender and functional level may influence the clinical outcomes, pre-treatment level of contracture is the main determinant in improvement in ROM at post-injection.","DOI":"10.5606/ehc.2019.65453","ISSN":"1309-0313","note":"PMID: 31291865","journalAbbreviation":"Eklem Hastalik Cerrahisi","language":"eng","author":[{"family":"Akta?","given":"Erdem"},{"family":"?mero?lu","given":"Hakan"}],"issued":{"date-parts":[["2019",8]]}}}],"schema":""} 13,15 Dynamic dynamometers are gaining momentum in the literature, but have yet to be implemented in clinic, while stationary dynamometers are still able to produce reliable reports of torque and stiffness, which can then be used to distinguish passive pathophysiologic changes such as joint capsule tightening from spasticity in neurologic populations. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a2ehbumnjd4","properties":{"formattedCitation":"{\\rtf \\super 13\\nosupersub{}}","plainCitation":"13"},"citationItems":[{"id":2432,"uris":[""],"uri":[""],"itemData":{"id":2432,"type":"article-journal","title":"Spasticity in adults with cerebral palsy and multiple sclerosis measured by objective clinically applicable technique","container-title":"Clinical Neurophysiology","page":"2010-2021","volume":"129","issue":"9","source":"ScienceDirect","abstract":"Objective\nThe present study evaluated ankle stiffness in adults with and without neurological disorders and investigated the accuracy and reproducibility of a clinically applicable method using a dynamometer.\nMethods\nMeasurements were obtained from 8 healthy subjects (age 39.3), 9 subjects with spastic cerebral palsy (CP) (age 39.8) and 8 subjects with multiple sclerosis (MS) (age 49.9). Slow and fast dorsiflexion stretches of the ankle joint were performed to evaluate passive muscle-tendon-joint stiffness, reflex mediated stiffness and range of movement (ROM), respectively. Intra/inter-rater reliability for passive and reflex mediated ankle muscle stiffness was assessed for all groups.\nResults\nSubjects with CP and MS showed significantly larger values of passive stiffness in the triceps surae muscle tendon complex and smaller ROM compared to healthy individuals, while no significant difference in reflex mediated stiffness. Measurements of passive muscle-tendon-joint stiffness and reflex mediated stiffness showed good to excellent inter- and intra-rater reliability (ICC: 0.62–0.91) in all groups.\nConclusion\nIncreased stiffness was found in subjects with CP and MS with a clinically applicable method that provides valid and reproducible measurement of passive ankle muscle-tendon-joint stiffness and reflex mediated stiffness.\nSignificance\nThe present technique may provide important supplementary information for the clinician.","DOI":"10.1016/j.clinph.2018.07.004","ISSN":"1388-2457","journalAbbreviation":"Clinical Neurophysiology","author":[{"family":"Yamaguchi","given":"Tomofumi"},{"family":"Hvass Petersen","given":"Tue"},{"family":"Kirk","given":"Henrik"},{"family":"Forman","given":"Christian"},{"family":"Svane","given":"Christian"},{"family":"Kofoed-Hansen","given":"Mathilde"},{"family":"Boesen","given":"Finn"},{"family":"Lorentzen","given":"Jakob"}],"issued":{"date-parts":[["2018",9,1]]}}}],"schema":""} 13 For a visual of the dynamic ankle dynamometer, see Figure 3 of the Appendix.Spasticity is identified by fast angular motion of the joint. To distinguish either of these two sources of myogenic contracture from arthrogenic contracture, clinicians must measure ROM at a fast angular velocity and compare the ROM to that of a slow angular velocity. Faster angular velocities will elicit the reflexive activity, thereby reducing the attained ROM. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a2nag1s3v3o","properties":{"formattedCitation":"{\\rtf \\super 13\\nosupersub{}}","plainCitation":"13"},"citationItems":[{"id":2432,"uris":[""],"uri":[""],"itemData":{"id":2432,"type":"article-journal","title":"Spasticity in adults with cerebral palsy and multiple sclerosis measured by objective clinically applicable technique","container-title":"Clinical Neurophysiology","page":"2010-2021","volume":"129","issue":"9","source":"ScienceDirect","abstract":"Objective\nThe present study evaluated ankle stiffness in adults with and without neurological disorders and investigated the accuracy and reproducibility of a clinically applicable method using a dynamometer.\nMethods\nMeasurements were obtained from 8 healthy subjects (age 39.3), 9 subjects with spastic cerebral palsy (CP) (age 39.8) and 8 subjects with multiple sclerosis (MS) (age 49.9). Slow and fast dorsiflexion stretches of the ankle joint were performed to evaluate passive muscle-tendon-joint stiffness, reflex mediated stiffness and range of movement (ROM), respectively. Intra/inter-rater reliability for passive and reflex mediated ankle muscle stiffness was assessed for all groups.\nResults\nSubjects with CP and MS showed significantly larger values of passive stiffness in the triceps surae muscle tendon complex and smaller ROM compared to healthy individuals, while no significant difference in reflex mediated stiffness. Measurements of passive muscle-tendon-joint stiffness and reflex mediated stiffness showed good to excellent inter- and intra-rater reliability (ICC: 0.62–0.91) in all groups.\nConclusion\nIncreased stiffness was found in subjects with CP and MS with a clinically applicable method that provides valid and reproducible measurement of passive ankle muscle-tendon-joint stiffness and reflex mediated stiffness.\nSignificance\nThe present technique may provide important supplementary information for the clinician.","DOI":"10.1016/j.clinph.2018.07.004","ISSN":"1388-2457","journalAbbreviation":"Clinical Neurophysiology","author":[{"family":"Yamaguchi","given":"Tomofumi"},{"family":"Hvass Petersen","given":"Tue"},{"family":"Kirk","given":"Henrik"},{"family":"Forman","given":"Christian"},{"family":"Svane","given":"Christian"},{"family":"Kofoed-Hansen","given":"Mathilde"},{"family":"Boesen","given":"Finn"},{"family":"Lorentzen","given":"Jakob"}],"issued":{"date-parts":[["2018",9,1]]}}}],"schema":""} 13 For objective, more reliable measures of ‘fast’ versus ‘slow’ angular velocity testing at the joint, use of the dynamic or static dynamometers are suggested. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a1hem0rt43t","properties":{"formattedCitation":"{\\rtf \\super 13\\nosupersub{}}","plainCitation":"13"},"citationItems":[{"id":2432,"uris":[""],"uri":[""],"itemData":{"id":2432,"type":"article-journal","title":"Spasticity in adults with cerebral palsy and multiple sclerosis measured by objective clinically applicable technique","container-title":"Clinical Neurophysiology","page":"2010-2021","volume":"129","issue":"9","source":"ScienceDirect","abstract":"Objective\nThe present study evaluated ankle stiffness in adults with and without neurological disorders and investigated the accuracy and reproducibility of a clinically applicable method using a dynamometer.\nMethods\nMeasurements were obtained from 8 healthy subjects (age 39.3), 9 subjects with spastic cerebral palsy (CP) (age 39.8) and 8 subjects with multiple sclerosis (MS) (age 49.9). Slow and fast dorsiflexion stretches of the ankle joint were performed to evaluate passive muscle-tendon-joint stiffness, reflex mediated stiffness and range of movement (ROM), respectively. Intra/inter-rater reliability for passive and reflex mediated ankle muscle stiffness was assessed for all groups.\nResults\nSubjects with CP and MS showed significantly larger values of passive stiffness in the triceps surae muscle tendon complex and smaller ROM compared to healthy individuals, while no significant difference in reflex mediated stiffness. Measurements of passive muscle-tendon-joint stiffness and reflex mediated stiffness showed good to excellent inter- and intra-rater reliability (ICC: 0.62–0.91) in all groups.\nConclusion\nIncreased stiffness was found in subjects with CP and MS with a clinically applicable method that provides valid and reproducible measurement of passive ankle muscle-tendon-joint stiffness and reflex mediated stiffness.\nSignificance\nThe present technique may provide important supplementary information for the clinician.","DOI":"10.1016/j.clinph.2018.07.004","ISSN":"1388-2457","journalAbbreviation":"Clinical Neurophysiology","author":[{"family":"Yamaguchi","given":"Tomofumi"},{"family":"Hvass Petersen","given":"Tue"},{"family":"Kirk","given":"Henrik"},{"family":"Forman","given":"Christian"},{"family":"Svane","given":"Christian"},{"family":"Kofoed-Hansen","given":"Mathilde"},{"family":"Boesen","given":"Finn"},{"family":"Lorentzen","given":"Jakob"}],"issued":{"date-parts":[["2018",9,1]]}}}],"schema":""} 13 Fast velocities are oftentimes considered moving the knee through its full available ROM in less than one second, while slow velocities are considered moving the knee through its full available ROM in at least 5 seconds or more. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a23rku04qq0","properties":{"formattedCitation":"{\\rtf \\super 16\\nosupersub{}}","plainCitation":"16"},"citationItems":[{"id":2460,"uris":[""],"uri":[""],"itemData":{"id":2460,"type":"article-journal","title":"Neuro-musculoskeletal simulation of instrumented contracture and spasticity assessment in children with cerebral palsy","container-title":"Journal of NeuroEngineering and Rehabilitation","volume":"13","source":"PubMed Central","abstract":"Background\nIncreased resistance in muscles and joints is an important phenomenon in patients with cerebral palsy (CP), and is caused by a combination of neural (e.g. spasticity) and non-neural (e.g. contracture) components. The aim of this study was to simulate instrumented, clinical assessment of the hamstring muscles in CP using a conceptual model of contracture and spasticity, and to determine to what extent contracture can be explained by altered passive muscle stiffness, and spasticity by (purely) velocity-dependent stretch reflex.\n\nMethods\nInstrumented hamstrings spasticity assessment was performed on 11 children with CP and 9 typically developing children. In this test, the knee was passively stretched at slow and fast speed, and knee angle, applied forces and EMG were measured. A dedicated OpenSim model was created with motion and muscles around the knee only. Contracture was modeled by optimizing the passive muscle stiffness parameters of vasti and hamstrings, based on slow stretch data. Spasticity was modeled using a velocity-dependent feedback controller, with threshold values derived from experimental data and gain values optimized for individual subjects. Forward dynamic simulations were performed to predict muscle behavior during slow and fast passive stretches.\n\nResults\nBoth slow and fast stretch data could be successfully simulated by including subject-specific levels of contracture and, for CP fast stretches, spasticity. The RMS errors of predicted knee motion in CP were 1.1?±?0.9° for slow and 5.9?±?2.1° for fast stretches. CP hamstrings were found to be stiffer compared with TD, and both hamstrings and vasti were more compliant than the original generic model, except for the CP hamstrings. The purely velocity-dependent spasticity model could predict response during fast passive stretch in terms of predicted knee angle, muscle activity, and fiber length and velocity. Only sustained muscle activity, independent of velocity, was not predicted by our model.\n\nConclusion\nThe presented individually tunable, conceptual model for contracture and spasticity could explain most of the hamstring muscle behavior during slow and fast passive stretch. Future research should attempt to apply the model to study the effects of spasticity and contracture during dynamic tasks such as gait.\n\nElectronic supplementary material\nThe online version of this article (doi:10.1186/s12984-016-0170-5) contains supplementary material, which is available to authorized users.","URL":"","DOI":"10.1186/s12984-016-0170-5","ISSN":"1743-0003","note":"PMID: 27423898\nPMCID: PMC4947289","journalAbbreviation":"J Neuroeng Rehabil","author":[{"family":"Krogt","given":"Marjolein Margaretha","non-dropping-particle":"van der"},{"family":"Bar-On","given":"Lynn"},{"family":"Kindt","given":"Thalia"},{"family":"Desloovere","given":"Kaat"},{"family":"Harlaar","given":"Jaap"}],"issued":{"date-parts":[["2016",7,16]]}}}],"schema":""} 16 If using a dynamic dynamometer, slow angular velocities are considered ~20°/sec, while fast velocities are performed as quickly as possible, and typically ~300°/sec. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a1j6ibe6b99","properties":{"formattedCitation":"{\\rtf \\super 13\\nosupersub{}}","plainCitation":"13"},"citationItems":[{"id":2432,"uris":[""],"uri":[""],"itemData":{"id":2432,"type":"article-journal","title":"Spasticity in adults with cerebral palsy and multiple sclerosis measured by objective clinically applicable technique","container-title":"Clinical Neurophysiology","page":"2010-2021","volume":"129","issue":"9","source":"ScienceDirect","abstract":"Objective\nThe present study evaluated ankle stiffness in adults with and without neurological disorders and investigated the accuracy and reproducibility of a clinically applicable method using a dynamometer.\nMethods\nMeasurements were obtained from 8 healthy subjects (age 39.3), 9 subjects with spastic cerebral palsy (CP) (age 39.8) and 8 subjects with multiple sclerosis (MS) (age 49.9). Slow and fast dorsiflexion stretches of the ankle joint were performed to evaluate passive muscle-tendon-joint stiffness, reflex mediated stiffness and range of movement (ROM), respectively. Intra/inter-rater reliability for passive and reflex mediated ankle muscle stiffness was assessed for all groups.\nResults\nSubjects with CP and MS showed significantly larger values of passive stiffness in the triceps surae muscle tendon complex and smaller ROM compared to healthy individuals, while no significant difference in reflex mediated stiffness. Measurements of passive muscle-tendon-joint stiffness and reflex mediated stiffness showed good to excellent inter- and intra-rater reliability (ICC: 0.62–0.91) in all groups.\nConclusion\nIncreased stiffness was found in subjects with CP and MS with a clinically applicable method that provides valid and reproducible measurement of passive ankle muscle-tendon-joint stiffness and reflex mediated stiffness.\nSignificance\nThe present technique may provide important supplementary information for the clinician.","DOI":"10.1016/j.clinph.2018.07.004","ISSN":"1388-2457","journalAbbreviation":"Clinical Neurophysiology","author":[{"family":"Yamaguchi","given":"Tomofumi"},{"family":"Hvass Petersen","given":"Tue"},{"family":"Kirk","given":"Henrik"},{"family":"Forman","given":"Christian"},{"family":"Svane","given":"Christian"},{"family":"Kofoed-Hansen","given":"Mathilde"},{"family":"Boesen","given":"Finn"},{"family":"Lorentzen","given":"Jakob"}],"issued":{"date-parts":[["2018",9,1]]}}}],"schema":""} 13To objectively identify ROM deficits characteristic of joint contracture, goniometry has been proven reliable. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a1dk4trj8oq","properties":{"formattedCitation":"{\\rtf \\super 17\\nosupersub{}}","plainCitation":"17"},"citationItems":[{"id":2452,"uris":[""],"uri":[""],"itemData":{"id":2452,"type":"webpage","title":"Quantitative Evaluation of Lower Extremity Joint Contractures in Spinal Muscular Atrophy: Implications for Motor Function | Ovid","URL":"","accessed":{"date-parts":[["2019",11,19]]}}}],"schema":""} 17 Goniometric measurements of ankle and knee ROM, most commonly focusing on ankle dorsiflexion and knee extension, should be performed passively so as to not allow muscular weakness or spasticity to bias measurements. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"anona8r0r2","properties":{"formattedCitation":"{\\rtf \\super 18\\nosupersub{}}","plainCitation":"18"},"citationItems":[{"id":2458,"uris":[""],"uri":[""],"itemData":{"id":2458,"type":"article-journal","title":"Effectiveness of a programme comprising serial casting, botulinum toxin, splinting and motor training for contracture management: a randomized controlled trial","container-title":"Clinical Rehabilitation","page":"1035-1044","volume":"33","issue":"6","source":"PubMed","abstract":"OBJECTIVE: To determine the effectiveness of a programme comprising serial casting, botulinum toxin, splinting and motor training in contracture management.\nDESIGN: A randomized trial with concealed allocation and assessor blinding, a deferred treatment cross-over design within the control group, was conducted.\nSETTING: Inpatient Brain Injury Unit of a rehabilitation centre.\nSUBJECTS: A total of 10 patients with severe acquired brain injury (13 ankles).\nINTERVENTIONS: The intervention group received botulinum toxin and then serial casting. The control group was placed on a wait list for six weeks (control phase) and then received the same interventions as the intervention group (intervention phase). Both groups received splinting and motor training following serial casting.\nMAIN MEASURES: The primary outcome was passive ankle dorsiflexion range. Secondary outcomes included spasticity, ankle dorsiflexor strength, Functional Independence Measure score for the walking item and walking speed.\nRESULTS: The mean between-group difference for passive ankle dorsiflexion range at completion of casting was 26° (95% confidence interval (CI): 17-35); at Week 2, after casting was 24° (95% CI: 14-33). The mean within-group differences for passive ankle dorsiflexion at completion of casting, Week 2 after casting and Week 8 after casting were 26° (95% CI: 20-31), 26° (95% CI: 18-33) and 24° (95% CI: 19-30), respectively. These improvements were sustained at Week 2 and Week 8 after casting.\nCONCLUSIONS: A programme for contracture management comprising serial casting, botulinum toxin, motor training and splinting can be useful in improving joint range.","DOI":"10.1177/0269215519831337","ISSN":"1477-0873","note":"PMID: 30813776","shortTitle":"Effectiveness of a programme comprising serial casting, botulinum toxin, splinting and motor training for contracture management","journalAbbreviation":"Clin Rehabil","language":"eng","author":[{"family":"Leung","given":"Joan"},{"family":"King","given":"Clayton"},{"family":"Fereday","given":"Sarah"}],"issued":{"date-parts":[["2019",6]]}}}],"schema":""} 18 There is a large gap in the literature objectively defining ankle and knee joint contractures, but Singer et al. define them for the traumatic brain injury population, which can be applied to other neurologically-affected populations. Diagnosing a plantar flexion contracture requires a maximal passive ROM of less than or equal to 0° of dorsiflexion with the knee extended as measured on at least two occasions. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"agf745ged5","properties":{"formattedCitation":"{\\rtf \\super 19\\nosupersub{}}","plainCitation":"19"},"citationItems":[{"id":2465,"uris":[""],"uri":[""],"itemData":{"id":2465,"type":"article-journal","title":"Non-surgical management of ankle contracture following acquired brain injury","container-title":"Disability and Rehabilitation","page":"335-345","volume":"26","issue":"6","source":"Taylor and Francis+NEJM","abstract":"Background and purpose: The purpose of this study was to document the outcome of non-surgical management of equinovarus ankle contracture in a cohort of patients with acquired brain injury admitted to a specialist Neurosurgical Rehabilitation Unit.Methods: This prospective descriptive study examined all patients with a new diagnosis of moderate to severe acquired brain injury (Glasgow Coma Scale score ? 12) admitted for rehabilitation over a 1 year period. Ankle dorsiflexion range and plantarflexor/invertor muscle activity were evaluated weekly during the period of hospitalization. Contracture was defined as maximal passive range of motion ? 0° dorsiflexion, with the knee extended, on a minimum of two measurement occasions. Patients were retrospectively allocated to one of four treatment outcome categories according to ankle dorsiflexion range, type of intervention required and response to treatment.Results: Ankle contracture was identified in 40 of the 105 patients studied. Contracture resolved with a standard physiotherapy treatment programme, including prolonged weight-bearing stretches and motor re-education, in 23 patients. Contracture persisted or worsened in 17 of 40 cases, all of whom exhibited dystonic muscle overactivity producing sustained equinovarus posturing. Ten of 17 cases required serial plaster casting ( ± injection of botulinum toxin type A) in order to achieve a functional range of ankle motion. Remediation of ankle contracture was not considered a priority in the remaining seven patients due to the severity of their overall disability.Conclusion: The incidence of ankle contracture identified in this population was considerably less than previously reported. Reduced dorsiflexion range was remediated with standard physiotherapy treatment in over half of the cases. Additional treatment with serial casting ± botulinum toxin type-A injection was required to correct persistent or worsening contracture in one quarter of cases. Dystonic extensor muscle overactivity was a major contributor to persistent or progressive ankle contracture.","DOI":"10.1080/0963828032000174070","ISSN":"0963-8288","note":"PMID: 15204485","author":[{"family":"Singer","given":"B. J."},{"family":"Dunne","given":"J. W."},{"family":"Singer","given":"K. P."},{"family":"Jegasothy","given":"G. M."},{"family":"Allison","given":"G. T."}],"issued":{"date-parts":[["2004",3,18]]}}}],"schema":""} 19 Knee joint flexion contractures are commonly considered lacking 10° or more of extension. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a2pbgfidkvq","properties":{"formattedCitation":"{\\rtf \\super 20\\nosupersub{}}","plainCitation":"20"},"citationItems":[{"id":2469,"uris":[""],"uri":[""],"itemData":{"id":2469,"type":"article-journal","title":"Total knee arthroplasty treatment of rheumatoid arthritis with severe versus moderate flexion contracture","container-title":"Journal of Orthopaedic Surgery and Research","page":"41","volume":"8","source":"PubMed Central","abstract":"Background\nThis study aims to explore the technique of soft tissue balance and joint tension maintenance in total knee arthroplasty (TKA) for the rheumatoid arthritis (RA) patients with flexion contracture of the knee.\n\nMethods\nThis retrospective study reviewed flexion contracture deformity of RA patients who underwent primary TKA and ligament and soft tissue balancing. Based on the flexion contracture deformity, the remaining 76 patients available for analysis were divided into two groups, i.e., severe flexion group (SF) and moderate flexion group (MF).\n\nResults\nThere were no intraoperative complications in this study. All patients had improved Knee Society Rating System scores and range of motion. The flexion contracture was completely corrected in MF and SF patients. There were no cases of patellar dislocation, but three cases had mild mediolateral instability in severe flexion group. Four knees (two knees in SF versus two knees in MF) had transient peroneal nerve palsy but recovered after conservative therapy.\n\nConclusions\nTKA can be performed successfully in the RA knees with severe flexion contracture. It is very important in TKA to maintain the joint stability in the condition of severe flexion contracture deformity of the RA knee.","DOI":"10.1186/1749-799X-8-41","ISSN":"1749-799X","note":"PMID: 24229435\nPMCID: PMC3829704","journalAbbreviation":"J Orthop Surg Res","author":[{"family":"Yan","given":"Denglu"},{"family":"Yang","given":"Jing"},{"family":"Pei","given":"Fuxing"}],"issued":{"date-parts":[["2013",11,15]]}}}],"schema":""} 20 While knee extension is the position cited by the literature when measuring ankle dorsiflexion, it can also be argued that flexing the knee may improve passive ROM measures since spastic muscle tone is often coupled with muscles at adjacent joints. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"ao1o7fjtkf","properties":{"formattedCitation":"{\\rtf \\super 21\\nosupersub{}}","plainCitation":"21"},"citationItems":[{"id":2605,"uris":[""],"uri":[""],"itemData":{"id":2605,"type":"webpage","title":"Neuromechanical coupling in the regulation of muscle tone and joint stiffness - Needle - 2014 - Scandinavian Journal of Medicine &amp; Science in Sports - Wiley Online Library","URL":"","accessed":{"date-parts":[["2019",12,1]]}}}],"schema":""} 21 Therefore, if the knee is extended, it can elicit hip extension and ankle plantar flexion as well. Identifying the effect of muscle tone on the individual’s adjacent joints and their respective ranges of motion may improve results; however, measuring ankle dorsiflexion is more difficult with a flexed knee since the proximal limb is no longer easily stabilized. In addition to the objective measures of joint contracture including dynamometer and goniometric measures of velocity-dependent losses in ROM and reduced passive joint ROM, there are several other criteria needed to assess and evaluate joint contractures. For ambulatory patients, gait evaluation is necessary since both the knee and ankle joints are critical for functional gait and stability. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a2j9k0v2mqj","properties":{"formattedCitation":"{\\rtf \\super 22\\nosupersub{}}","plainCitation":"22"},"citationItems":[{"id":2468,"uris":[""],"uri":[""],"itemData":{"id":2468,"type":"webpage","title":"Effectiveness of Serial Stretch Casting for Resistant or Recurrent Knee Flexion Contractures Following Hamstring Lengthening in Children With Cerebral Palsy | Ovid","URL":"","accessed":{"date-parts":[["2019",11,19]]}}}],"schema":""} 22 Approximately 5° of dorsiflexion is necessary for typical walking during advancement of the opposite limb, therefore, a loss of ROM to 0° or more is going to be detrimental to ambulation. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a1kic8t7oos","properties":{"formattedCitation":"{\\rtf \\super 23\\nosupersub{}}","plainCitation":"23"},"citationItems":[{"id":2478,"uris":[""],"uri":[""],"itemData":{"id":2478,"type":"webpage","title":"Gait","container-title":"Physiopedia","abstract":"Bipedal walking is an important characteristic of humans.&#91;1&#93; This page presents information about the different phases of the gait cycle, &#160;important functions of the foot while walking and gait analysis which is a key skill for physiotherapists.","URL":"","language":"en","accessed":{"date-parts":[["2019",11,19]]}}}],"schema":""} 23 Similarly, full knee extension occurs in various phases of walking such as initial heel contact and midstance and while standing. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"ape6lu168e","properties":{"formattedCitation":"{\\rtf \\super 23\\nosupersub{}}","plainCitation":"23"},"citationItems":[{"id":2478,"uris":[""],"uri":[""],"itemData":{"id":2478,"type":"webpage","title":"Gait","container-title":"Physiopedia","abstract":"Bipedal walking is an important characteristic of humans.&#91;1&#93; This page presents information about the different phases of the gait cycle, &#160;important functions of the foot while walking and gait analysis which is a key skill for physiotherapists.","URL":"","language":"en","accessed":{"date-parts":[["2019",11,19]]}}}],"schema":""} 23 Individuals with CP and MS often address energy conservation during PT, and especially among children with CP, crouch gait can lead to excessive muscle work and gait inefficiency. Therefore, addressing risk and potential knee flexion contractures can assist with unloading some of this muscle inefficiency. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a2i1pip3cr4","properties":{"formattedCitation":"{\\rtf \\super 24\\nosupersub{}}","plainCitation":"24"},"citationItems":[{"id":2498,"uris":[""],"uri":[""],"itemData":{"id":2498,"type":"article-journal","title":"Limits to passive range of joint motion and the effect on crouch gait in children with cerebral palsy","container-title":"Gait & Posture","page":"165","volume":"7","issue":"2","source":"ScienceDirect","DOI":"10.1016/S0966-6362(98)90241-7","ISSN":"0966-6362","journalAbbreviation":"Gait & Posture","author":[{"family":"Orendurff","given":"Michael S."},{"family":"Chung","given":"James S."},{"family":"Pierce","given":"Rosemary A."}],"issued":{"date-parts":[["1998",3,1]]}}}],"schema":""} 24 For non-ambulatory patients, assessment of the safety and ease of transfers and positioning that can affect daily function is important to comprehensively examine joint contracture.Joint mobilizations serve to improve the accessory motions at a joint that may be reduced due to capsular constriction, connective tissue adhesions, and other tissue shortening. Mobilizations are graded from I to IV and are both an evaluation and treatment tool, specifically examining the joint capsule. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a122janp1pp","properties":{"formattedCitation":"{\\rtf \\super 25\\nosupersub{}}","plainCitation":"25"},"citationItems":[{"id":2561,"uris":[""],"uri":[""],"itemData":{"id":2561,"type":"webpage","title":"Joint Mobilization - an overview | ScienceDirect Topics","URL":"","accessed":{"date-parts":[["2019",11,26]]}}}],"schema":""} 25 The hypothesized physiologic effects of joint mobilizations are the disrupting of adhesions and capsular restrictions within the joint as well as reflexive relaxation achieved through the stimulation of mechanoreceptors within the joint. One of the listed contraindications to joint mobilizations are neurologic signs, which will be present in all of the patient populations examined in this paper, therefore, joint mobilization assessment should only be assessed once determinants of spasticity have been ruled out and once consent has been provided by the patient or caregiver. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"aia639qqc1","properties":{"formattedCitation":"{\\rtf \\super 25\\nosupersub{}}","plainCitation":"25"},"citationItems":[{"id":2561,"uris":[""],"uri":[""],"itemData":{"id":2561,"type":"webpage","title":"Joint Mobilization - an overview | ScienceDirect Topics","URL":"","accessed":{"date-parts":[["2019",11,26]]}}}],"schema":""} 25 Manual muscle testing is a foundational method to assess the strength of muscles surrounding the ankle and knee joints that could indicate a potential muscular weakness associated or underlying the contracture. Similarly, if an antagonistic muscle is overpowering an agonist muscle or co-contracting with the agonist muscle being assessed, one can rule in a source of muscular imbalance contributing to the loss in ROM. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a1nv1g29vi","properties":{"formattedCitation":"{\\rtf \\super 26\\nosupersub{}}","plainCitation":"26"},"citationItems":[{"id":2564,"uris":[""],"uri":[""],"itemData":{"id":2564,"type":"webpage","title":"Manual Muscle Testing: A Method of Measuring Extremity Muscle Strength Applied to Critically Ill Patients","URL":"","accessed":{"date-parts":[["2019",11,26]]}}}],"schema":""} 26Lastly, subjective report by the patient and/or caregiver(s) is important to evaluate and take into account for treatment approach. Pain is frequently accompanied by both transient and persistent contractures, and on behalf of the caregiver, difficulty with proper positioning is a common toll. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"GNXBsddd","properties":{"formattedCitation":"{\\rtf \\super 27,28\\nosupersub{}}","plainCitation":"27,28"},"citationItems":[{"id":2482,"uris":[""],"uri":[""],"itemData":{"id":2482,"type":"article-journal","title":"Impact of multilevel joint contractures of the hips, knees and ankles on the Gait Profile score in children with cerebral palsy","container-title":"Clinical Biomechanics","page":"8-14","volume":"59","source":"ScienceDirect","abstract":"Background\nChildren with cerebral palsy are at risk of developing muscle contractures, often contributing to pain, structural deformities and mobility limitations. With the increasing use of gait indices to summarise the findings of three dimensional gait analysis (3DGA), the purpose of this study is to determine whether there is a relationship between multilevel joint contractures and the Gait Profile Score in children with cerebral palsy.\nMethods\nThe Gait Profile Score, calculated from 3D gait analysis, and passive range of motion, strength and spasticity of the hips, knees and ankles in the sagittal plane were measured in 145 children with cerebral palsy (mean age:11?years,4?months; SD:2?years,10?months) (83 males) enrolled in the NSW Paediatric Gait Analysis Service Research Registry from 2011 to 2016. The relationships between these physical measures and the Gait Profile Score were explored using bivariate and multivariate correlations.\nFindings\nReduced hip extension, knee extension and ankle dorsiflexion (knee extended) range of motion were correlated with a higher (worse) Gait Profile Score (r?=??0.348 to ?0.466, p?<?.001). Children with all joints contracted had a significantly higher Gait Profile Score (mean 17.5°, SD 6.2°) than those with no contractures (mean 11.0°, SD 2.3°) or ankle contractures only (mean 12.8°, SD 5.1°) (p?<?.05). Knee flexion weakness, reduced hip extension and ankle dorsiflexion (knee extended) range of motion predicted 47% of the Gait Profile Score.\nInterpretation\nThe Gait Profile Score is a sensitive measure for demonstrating the relationship between multilevel sagittal plane joint contractures and kinematic gait. Clinically, this supports the use of the Gait Profile Score as a simplified measure to understand the contribution of contractures to functional gait limitations. Monitoring knee flexion strength, and hip extension and ankle dorsiflexion (knee extended) range of motion may assist clinicians in prioritising interventions to improve gait in this population.","DOI":"10.1016/j.clinbiomech.2018.08.002","ISSN":"0268-0033","journalAbbreviation":"Clinical Biomechanics","author":[{"family":"Holmes","given":"Sarah J."},{"family":"Mudge","given":"Anita J."},{"family":"Wojciechowski","given":"Elizabeth A."},{"family":"Axt","given":"Matthias W."},{"family":"Burns","given":"Joshua"}],"issued":{"date-parts":[["2018",11,1]]}}},{"id":2485,"uris":[""],"uri":[""],"itemData":{"id":2485,"type":"article-journal","title":"Evaluation of the effectiveness of the sliding sheet in repositioning care in terms of working time and subjective fatigue: A comparative study with an experimental design","container-title":"International Journal of Nursing Studies","page":"103389","volume":"99","source":"ScienceDirect","abstract":"Background\nManual patient handling is a major cause of low back pain among healthcare staff. The sliding sheet is an assistive device designed to aid healthcare staff performing patient repositioning in bed. The use of sliding sheets in healthcare facilities is currently relatively rare because of the perceived additional time required compared with non-assisted handling. However, the details of the time difference between techniques and the barriers to the use of sliding sheets have not been examined in depth.\nObjectives\nWe sought to evaluate differences in working time and subjective fatigue between the use of sliding sheets and non-assisted handling techniques for patient repositioning, in order to understand the factors preventing the use of sliding sheets among nurses.\nDesign\nWe conducted a comparative study with an experimental design.\nSettings\nThe study was conducted in the nursing practice room at a university in Japan.\nParticipants\nWe recruited 30 pairs of nurses and care receivers. All nurses were under 60 years old, with experience in lateral turning and repositioning in the process of changing diapers in clinical settings. Those with a previous or current medical history of low back pain were excluded. Care receivers were older adults (65–80 years old). We excluded adults with bedsores, body mass index values >30, or restricted joint motion due to femoral trochanteric fracture or compression fracture. Thus, 27 pairs were included in the final analysis.\nMethods\nThe care receivers were instructed to behave as if they were bedridden patients with no limb movement, and as if they had contracture and difficulty communicating. Nurses repositioned the patient using three techniques assigned as interventions in random order: repositioning by one person using a sliding sheet (Sheet), repositioning by two people without a sliding sheet (Double), and repositioning by one person without a sliding sheet (Single). Working time was the primary endpoint for comparative analysis among the three technique conditions.\nResults\nThe results revealed that the Sheet technique required significantly more time than the non-assisted techniques. However, when total staff time was taken into consideration, the Sheet technique outperformed the Double technique. Moreover, the Sheet technique was associated with significantly lower levels of subjective fatigue, compared with the Double technique.\nConclusions\nThe use of a sliding sheet can substantially reduce caregiver burden when performing patient repositioning, and requires less staff time than manual techniques involving more than one caregiver.","DOI":"10.1016/j.ijnurstu.2019.103389","ISSN":"0020-7489","shortTitle":"Evaluation of the effectiveness of the sliding sheet in repositioning care in terms of working time and subjective fatigue","journalAbbreviation":"International Journal of Nursing Studies","author":[{"family":"Omura","given":"Yuka"},{"family":"Yamagami","given":"Yuki"},{"family":"Hirota","given":"Yutaka"},{"family":"Nakatani","given":"Eiji"},{"family":"Tsujimoto","given":"Tomomi"},{"family":"Inoue","given":"Tomoko"}],"issued":{"date-parts":[["2019",11,1]]}}}],"schema":""} 27,28 Therefore, both pain and caregiver difficulties are relevant considerations among patients with joint contractures, and should be considered when creating the plan of care. Overall, there is a gap in the literature regarding formal and comprehensive joint contracture evaluation, especially in regards to specific sub-populations, but similar to any other physical impairment, it is important to identify all levels of the ICF model affected by the contracture including structural, activity, and participation. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a18uqpp4uj0","properties":{"formattedCitation":"{\\rtf \\super 29\\nosupersub{}}","plainCitation":"29"},"citationItems":[{"id":2495,"uris":[""],"uri":[""],"itemData":{"id":2495,"type":"article-journal","title":"Development of a complex intervention to improve participation of nursing home residents with joint contractures: a mixed-method study","container-title":"BMC Geriatrics","volume":"18","source":"PubMed Central","abstract":"Background\nJoint contractures in nursing home residents limit the capacity to perform daily activities and restrict social participation. The purpose of this study was to develop a complex intervention to improve participation in nursing home residents with joint contractures.\n\nMethods\nThe development followed the UK Medical Research Council framework using a mixed-methods design with re-analysis of existing interview data using a graphic modelling approach, group discussions with nursing home residents, systematic review of intervention studies, structured 2-day workshop with experts in geriatric, nursing, and rehabilitation, and group discussion with professionals in nursing homes.\n\nResults\nGraphic modelling identified restrictions in the use of transportation, walking within buildings, memory functions, and using the hands and arms as the central target points for the intervention. Seven group discussions with 33 residents revealed various aspects related to functioning and disability according the International Classification of Functioning, Disability and Health domains body functions, body structures, activities and participation, environmental factors, and personal factors. The systematic review included 17 studies with 992 participants: 16 randomised controlled trials and one controlled trial. The findings could not demonstrate any evidence in favour of an intervention. The structured 2-day expert workshop resulted in a variety of potential intervention components and implementation strategies. The group discussion with the professionals in nursing homes verified the feasibility of the components and the overall concept. The resulting intervention, Participation Enabling CAre in Nursing (PECAN), will be implemented during a 1-day workshop for nurses, a mentoring approach, and supportive material. The intervention addresses nurses and other staff, residents, their informal caregivers, therapists, and general practitioners.\n\nConclusions\nIn view of the absence of any robust evidence, the decision to use mixed methods and to closely involve both health professionals and residents proved to be an appropriate means to develop a complex intervention to improve participation of and quality of life in nursing home residents. We will now evaluate the PECAN intervention for its impact and feasibility in a pilot study in preparation for an evaluation of its effectiveness in a definitive trial.\n\nTrial registration\nGerman clinical trials register, reference number DRKS00010037 (12 February 2016).","URL":"","DOI":"10.1186/s12877-018-0745-z","ISSN":"1471-2318","note":"PMID: 29490617\nPMCID: PMC5831216","shortTitle":"Development of a complex intervention to improve participation of nursing home residents with joint contractures","journalAbbreviation":"BMC Geriatr","author":[{"family":"Saal","given":"Susanne"},{"family":"Meyer","given":"Gabriele"},{"family":"Beutner","given":"Katrin"},{"family":"Klingshirn","given":"Hanna"},{"family":"Strobl","given":"Ralf"},{"family":"Grill","given":"Eva"},{"family":"Mann","given":"Eva"},{"family":"K?pke","given":"Sascha"},{"family":"Bleijlevens","given":"Michel H. C."},{"family":"Bartoszek","given":"Gabriele"},{"family":"Stephan","given":"Anna-Janina"},{"family":"Hirt","given":"Julian"},{"family":"Müller","given":"Martin"}],"issued":{"date-parts":[["2018",2,28]]}}}],"schema":""} 29Differential DiagnosisThe most important diagnoses to differentiate between when examining a potential joint contracture are myogenic contracture, arthrogenic contracture, and sources of muscular inflexibility. Differentiating between the first two sources of contracture helps determine the appropriate plan of care, while muscular inflexibility can mask as a joint contracture, but requires a different treatment approach. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a2km25imii0","properties":{"formattedCitation":"{\\rtf \\super 13\\nosupersub{}}","plainCitation":"13"},"citationItems":[{"id":2432,"uris":[""],"uri":[""],"itemData":{"id":2432,"type":"article-journal","title":"Spasticity in adults with cerebral palsy and multiple sclerosis measured by objective clinically applicable technique","container-title":"Clinical Neurophysiology","page":"2010-2021","volume":"129","issue":"9","source":"ScienceDirect","abstract":"Objective\nThe present study evaluated ankle stiffness in adults with and without neurological disorders and investigated the accuracy and reproducibility of a clinically applicable method using a dynamometer.\nMethods\nMeasurements were obtained from 8 healthy subjects (age 39.3), 9 subjects with spastic cerebral palsy (CP) (age 39.8) and 8 subjects with multiple sclerosis (MS) (age 49.9). Slow and fast dorsiflexion stretches of the ankle joint were performed to evaluate passive muscle-tendon-joint stiffness, reflex mediated stiffness and range of movement (ROM), respectively. Intra/inter-rater reliability for passive and reflex mediated ankle muscle stiffness was assessed for all groups.\nResults\nSubjects with CP and MS showed significantly larger values of passive stiffness in the triceps surae muscle tendon complex and smaller ROM compared to healthy individuals, while no significant difference in reflex mediated stiffness. Measurements of passive muscle-tendon-joint stiffness and reflex mediated stiffness showed good to excellent inter- and intra-rater reliability (ICC: 0.62–0.91) in all groups.\nConclusion\nIncreased stiffness was found in subjects with CP and MS with a clinically applicable method that provides valid and reproducible measurement of passive ankle muscle-tendon-joint stiffness and reflex mediated stiffness.\nSignificance\nThe present technique may provide important supplementary information for the clinician.","DOI":"10.1016/j.clinph.2018.07.004","ISSN":"1388-2457","journalAbbreviation":"Clinical Neurophysiology","author":[{"family":"Yamaguchi","given":"Tomofumi"},{"family":"Hvass Petersen","given":"Tue"},{"family":"Kirk","given":"Henrik"},{"family":"Forman","given":"Christian"},{"family":"Svane","given":"Christian"},{"family":"Kofoed-Hansen","given":"Mathilde"},{"family":"Boesen","given":"Finn"},{"family":"Lorentzen","given":"Jakob"}],"issued":{"date-parts":[["2018",9,1]]}}}],"schema":""} 13As previously mentioned, spasticity is a common co-existing symptom and source of lost joint ROM that must be differentiated from structural changes causing decreased ROM. Spasticity is commonly confused or blended with arthrogenic joint contractures. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"akal36bo5p","properties":{"formattedCitation":"{\\rtf \\super 13\\nosupersub{}}","plainCitation":"13"},"citationItems":[{"id":2432,"uris":[""],"uri":[""],"itemData":{"id":2432,"type":"article-journal","title":"Spasticity in adults with cerebral palsy and multiple sclerosis measured by objective clinically applicable technique","container-title":"Clinical Neurophysiology","page":"2010-2021","volume":"129","issue":"9","source":"ScienceDirect","abstract":"Objective\nThe present study evaluated ankle stiffness in adults with and without neurological disorders and investigated the accuracy and reproducibility of a clinically applicable method using a dynamometer.\nMethods\nMeasurements were obtained from 8 healthy subjects (age 39.3), 9 subjects with spastic cerebral palsy (CP) (age 39.8) and 8 subjects with multiple sclerosis (MS) (age 49.9). Slow and fast dorsiflexion stretches of the ankle joint were performed to evaluate passive muscle-tendon-joint stiffness, reflex mediated stiffness and range of movement (ROM), respectively. Intra/inter-rater reliability for passive and reflex mediated ankle muscle stiffness was assessed for all groups.\nResults\nSubjects with CP and MS showed significantly larger values of passive stiffness in the triceps surae muscle tendon complex and smaller ROM compared to healthy individuals, while no significant difference in reflex mediated stiffness. Measurements of passive muscle-tendon-joint stiffness and reflex mediated stiffness showed good to excellent inter- and intra-rater reliability (ICC: 0.62–0.91) in all groups.\nConclusion\nIncreased stiffness was found in subjects with CP and MS with a clinically applicable method that provides valid and reproducible measurement of passive ankle muscle-tendon-joint stiffness and reflex mediated stiffness.\nSignificance\nThe present technique may provide important supplementary information for the clinician.","DOI":"10.1016/j.clinph.2018.07.004","ISSN":"1388-2457","journalAbbreviation":"Clinical Neurophysiology","author":[{"family":"Yamaguchi","given":"Tomofumi"},{"family":"Hvass Petersen","given":"Tue"},{"family":"Kirk","given":"Henrik"},{"family":"Forman","given":"Christian"},{"family":"Svane","given":"Christian"},{"family":"Kofoed-Hansen","given":"Mathilde"},{"family":"Boesen","given":"Finn"},{"family":"Lorentzen","given":"Jakob"}],"issued":{"date-parts":[["2018",9,1]]}}}],"schema":""} 13 Shortening of mid-substance muscle tissue is seen in both neurologic and orthopedic populations and can be reversed in most cases. While this is not touched on extensively in the literature, muscular inflexibility is important to differentiate from a joint contracture since it does not require as extensive an examination or dramatic intervention. For example, the Thomas test and the 90/90 Straight Leg Raise for rectus femoris and hamstring flexibility, respectively, are superb resources for differentiating a muscle tightness from a transient or persistent joint contracture. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a1prs4b5v03","properties":{"formattedCitation":"{\\rtf \\super 30,31\\nosupersub{}}","plainCitation":"30,31"},"citationItems":[{"id":2489,"uris":[""],"uri":[""],"itemData":{"id":2489,"type":"article-journal","title":"EVALUATING THE RELATIONSHIP BETWEEN CLINICAL ASSESSMENTS OF APPARENT HAMSTRING TIGHTNESS: A CORRELATIONAL ANALYSIS","container-title":"International Journal of Sports Physical Therapy","page":"253-263","volume":"14","issue":"2","source":"PubMed Central","abstract":"Background\nHamstring tightness is a common condition typically assessed via the active knee extension (AKE), passive straight leg raise (PSLR), V-sit and reach (VSR), and finger-floor-distance (FFD).\n\nPurpose\nThe purpose of this study was to investigate the relationships between four common clinical tests of apparent hamstring tightness. A secondary purpose was to compare the differences in correlations between sub-groups based on positive test findings.\n\nStudy Design\nDescriptive, correlational laboratory design.\n\nMethods\nRecreationally active individuals (N = 81; 23.7?±?5.9 years) performed the AKE, PSLR, VSR, and FFD in a randomized order, and subsequent correlational analyses were conducted.\n\nResults\nStrong correlations were identified between the VSR and FFD (r = -.798, r2 = .637, p?<?.001); moderate correlations were demonstrated between the PSLR and FFD (r = -.565, r2 = .319, p?<?.001) and PSLR and VSR (r = .536, r2 = .287, p?<?.001). Low correlations were found between the PSLR and AKE (r = -.284, r2 = .081, p = 0.01), AKE and VSR (r = -.297, r2 = .088, p = .007), and AKE and FFD (r = .263, r2 = .069, p = .018). If one assessment was identified in a subject as dysfunctional, all relationships were affected, regardless of which assessment was dysfunctional.\n\nConclusions\nThe AKE, one of the most common measures for apparent hamstring tightness, has low correlations with the other assessments. Based on the findings of this study, it is possible that not all assessments of AHT are measuring the same phenomena, with each involving different factors of perceived hamstring length.\n\nLevel of Evidence\nLevel 2b.","ISSN":"2159-2896","note":"PMID: 30997277\nPMCID: PMC6449015","shortTitle":"EVALUATING THE RELATIONSHIP BETWEEN CLINICAL ASSESSMENTS OF APPARENT HAMSTRING TIGHTNESS","journalAbbreviation":"Int J Sports Phys Ther","author":[{"family":"Hansberger","given":"Brittany L."},{"family":"Loutsch","given":"Rick"},{"family":"Hancock","given":"Christy"},{"family":"Bonser","given":"Robert"},{"family":"Zeigel","given":"Alli"},{"family":"Baker","given":"Russell T."}],"issued":{"date-parts":[["2019",4]]}}},{"id":2492,"uris":[""],"uri":[""],"itemData":{"id":2492,"type":"article-journal","title":"Reliability Limits Of The Modified Thomas Test For Assessing Rectus Femoris Muscle Flexibility About The Knee Joint","container-title":"Journal of Athletic Training","page":"470-476","volume":"43","issue":"5","source":"PubMed Central","abstract":"Context:\nThe modified Thomas test is commonly used in the clinical setting to assess flexibility about the thigh region.\n\nObjective:\nTo evaluate the clinical reliability of the modified Thomas test for evaluating the flexibility of the rectus femoris muscle about the knee joint.\n\nDesign:\nDescriptive laboratory study using a test-retest design.\n\nSetting:\nInstitution-based clinical orthopaedic setting.\n\nPatients Or Other Participants:\nFifty-seven individuals between the ages of 18 and 45 years with no history of trauma participated. Of those, 54 completed the study.\n\nIntervention(s):\nThree Board-certified athletic therapists with an average of 12.67 years of sport medicine expertise assessed rectus femoris flexibility using pass/fail and goniometer scoring systems. A retest session was completed 7 to 10 days later.\n\nMain Outcome Measure(s):\nParametric and nonparametric tests were used to compare participants' test-retest results.\n\nResults:\nChance-corrected κ values (intrarater x? ?=? 0.40, 95% confidence interval [CI] ?=? 0.30, 0.54; interrater x? ?=? 0.33, 95% CI ?=? 0.23, 0.41) indicated generally poor levels of reliability for pass/fail scoring. Intraclass correlation coefficient (ICC) values (intrarater x? ?=? 0.67, 95% CI ?=? 0.55, 0.76; interrater x? ?=? 0.50, 95% CI ?=? 0.40, 0.60) indicated fair to moderate levels of reliability for goniometer data. Measurement error values (standard error of measurement ?=? 7°, method error ?=? 6°, and coefficient of variation ?=? 13%) and Bland-Altman plots (with 95% limits of agreement) further demonstrated the degree of intrarater variance for each examiner when conducting the test.\n\nConclusions:\nThese results call into question the statistical reliability of the modified Thomas test and provide clinicians with important information regarding its reliability limits when used to clinically assess flexibility of the rectus femoris muscle about the knee joint in a physically active population. More research is needed to ascertain the variables that may confound the statistical reliability of this orthopaedic technique.","ISSN":"1062-6050","note":"PMID: 18833309\nPMCID: PMC2547866","journalAbbreviation":"J Athl Train","author":[{"family":"Peeler","given":"Jason D"},{"family":"Anderson","given":"Judy E"}],"issued":{"date-parts":[["2008"]]}}}],"schema":""} 30,31Variability in Severity Contractures vary in severity based on parameters of permanence and degrees of lost ROM. Contractures are labeled as either transient or persistent/progressive. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a1ktllpp67h","properties":{"formattedCitation":"{\\rtf \\super 19\\nosupersub{}}","plainCitation":"19"},"citationItems":[{"id":2465,"uris":[""],"uri":[""],"itemData":{"id":2465,"type":"article-journal","title":"Non-surgical management of ankle contracture following acquired brain injury","container-title":"Disability and Rehabilitation","page":"335-345","volume":"26","issue":"6","source":"Taylor and Francis+NEJM","abstract":"Background and purpose: The purpose of this study was to document the outcome of non-surgical management of equinovarus ankle contracture in a cohort of patients with acquired brain injury admitted to a specialist Neurosurgical Rehabilitation Unit.Methods: This prospective descriptive study examined all patients with a new diagnosis of moderate to severe acquired brain injury (Glasgow Coma Scale score ? 12) admitted for rehabilitation over a 1 year period. Ankle dorsiflexion range and plantarflexor/invertor muscle activity were evaluated weekly during the period of hospitalization. Contracture was defined as maximal passive range of motion ? 0° dorsiflexion, with the knee extended, on a minimum of two measurement occasions. Patients were retrospectively allocated to one of four treatment outcome categories according to ankle dorsiflexion range, type of intervention required and response to treatment.Results: Ankle contracture was identified in 40 of the 105 patients studied. Contracture resolved with a standard physiotherapy treatment programme, including prolonged weight-bearing stretches and motor re-education, in 23 patients. Contracture persisted or worsened in 17 of 40 cases, all of whom exhibited dystonic muscle overactivity producing sustained equinovarus posturing. Ten of 17 cases required serial plaster casting ( ± injection of botulinum toxin type A) in order to achieve a functional range of ankle motion. Remediation of ankle contracture was not considered a priority in the remaining seven patients due to the severity of their overall disability.Conclusion: The incidence of ankle contracture identified in this population was considerably less than previously reported. Reduced dorsiflexion range was remediated with standard physiotherapy treatment in over half of the cases. Additional treatment with serial casting ± botulinum toxin type-A injection was required to correct persistent or worsening contracture in one quarter of cases. Dystonic extensor muscle overactivity was a major contributor to persistent or progressive ankle contracture.","DOI":"10.1080/0963828032000174070","ISSN":"0963-8288","note":"PMID: 15204485","author":[{"family":"Singer","given":"B. J."},{"family":"Dunne","given":"J. W."},{"family":"Singer","given":"K. P."},{"family":"Jegasothy","given":"G. M."},{"family":"Allison","given":"G. T."}],"issued":{"date-parts":[["2004",3,18]]}}}],"schema":""} 19 The transient contractures are commonly treatable with conservative measures, while the persistent and progressive contractures may require surgical and/or other medical treatment. Asking the patient and/or caregiver questions about the timeline of changes in joint motion can assist with the determination of whether a joint is a transient or persistent/progressive contracture. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"ach9g4pgs9","properties":{"formattedCitation":"{\\rtf \\super 19\\nosupersub{}}","plainCitation":"19"},"citationItems":[{"id":2465,"uris":[""],"uri":[""],"itemData":{"id":2465,"type":"article-journal","title":"Non-surgical management of ankle contracture following acquired brain injury","container-title":"Disability and Rehabilitation","page":"335-345","volume":"26","issue":"6","source":"Taylor and Francis+NEJM","abstract":"Background and purpose: The purpose of this study was to document the outcome of non-surgical management of equinovarus ankle contracture in a cohort of patients with acquired brain injury admitted to a specialist Neurosurgical Rehabilitation Unit.Methods: This prospective descriptive study examined all patients with a new diagnosis of moderate to severe acquired brain injury (Glasgow Coma Scale score ? 12) admitted for rehabilitation over a 1 year period. Ankle dorsiflexion range and plantarflexor/invertor muscle activity were evaluated weekly during the period of hospitalization. Contracture was defined as maximal passive range of motion ? 0° dorsiflexion, with the knee extended, on a minimum of two measurement occasions. Patients were retrospectively allocated to one of four treatment outcome categories according to ankle dorsiflexion range, type of intervention required and response to treatment.Results: Ankle contracture was identified in 40 of the 105 patients studied. Contracture resolved with a standard physiotherapy treatment programme, including prolonged weight-bearing stretches and motor re-education, in 23 patients. Contracture persisted or worsened in 17 of 40 cases, all of whom exhibited dystonic muscle overactivity producing sustained equinovarus posturing. Ten of 17 cases required serial plaster casting ( ± injection of botulinum toxin type A) in order to achieve a functional range of ankle motion. Remediation of ankle contracture was not considered a priority in the remaining seven patients due to the severity of their overall disability.Conclusion: The incidence of ankle contracture identified in this population was considerably less than previously reported. Reduced dorsiflexion range was remediated with standard physiotherapy treatment in over half of the cases. Additional treatment with serial casting ± botulinum toxin type-A injection was required to correct persistent or worsening contracture in one quarter of cases. Dystonic extensor muscle overactivity was a major contributor to persistent or progressive ankle contracture.","DOI":"10.1080/0963828032000174070","ISSN":"0963-8288","note":"PMID: 15204485","author":[{"family":"Singer","given":"B. J."},{"family":"Dunne","given":"J. W."},{"family":"Singer","given":"K. P."},{"family":"Jegasothy","given":"G. M."},{"family":"Allison","given":"G. T."}],"issued":{"date-parts":[["2004",3,18]]}}}],"schema":""} 19 Contractures are also often labeled as mild, moderate or severe. These terms are used loosely, without objective identification. In a study on patients post-knee arthroplasty, moderate knee flexion contractures were considered losses of 10° to 30° of knee extension, while severe knee flexion contractures were considered losses of 30° or more of extension. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a1m44u9mfra","properties":{"formattedCitation":"{\\rtf \\super 20\\nosupersub{}}","plainCitation":"20"},"citationItems":[{"id":2469,"uris":[""],"uri":[""],"itemData":{"id":2469,"type":"article-journal","title":"Total knee arthroplasty treatment of rheumatoid arthritis with severe versus moderate flexion contracture","container-title":"Journal of Orthopaedic Surgery and Research","page":"41","volume":"8","source":"PubMed Central","abstract":"Background\nThis study aims to explore the technique of soft tissue balance and joint tension maintenance in total knee arthroplasty (TKA) for the rheumatoid arthritis (RA) patients with flexion contracture of the knee.\n\nMethods\nThis retrospective study reviewed flexion contracture deformity of RA patients who underwent primary TKA and ligament and soft tissue balancing. Based on the flexion contracture deformity, the remaining 76 patients available for analysis were divided into two groups, i.e., severe flexion group (SF) and moderate flexion group (MF).\n\nResults\nThere were no intraoperative complications in this study. All patients had improved Knee Society Rating System scores and range of motion. The flexion contracture was completely corrected in MF and SF patients. There were no cases of patellar dislocation, but three cases had mild mediolateral instability in severe flexion group. Four knees (two knees in SF versus two knees in MF) had transient peroneal nerve palsy but recovered after conservative therapy.\n\nConclusions\nTKA can be performed successfully in the RA knees with severe flexion contracture. It is very important in TKA to maintain the joint stability in the condition of severe flexion contracture deformity of the RA knee.","DOI":"10.1186/1749-799X-8-41","ISSN":"1749-799X","note":"PMID: 24229435\nPMCID: PMC3829704","journalAbbreviation":"J Orthop Surg Res","author":[{"family":"Yan","given":"Denglu"},{"family":"Yang","given":"Jing"},{"family":"Pei","given":"Fuxing"}],"issued":{"date-parts":[["2013",11,15]]}}}],"schema":""} 20 Another study defines minimal knee flexion contracture as a loss of 5-10°, mild as 11-15°, moderate as 16-20°, and severe as greater than 20°. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a15kg2ifvvf","properties":{"formattedCitation":"{\\rtf \\super 32\\nosupersub{}}","plainCitation":"32"},"citationItems":[{"id":2586,"uris":[""],"uri":[""],"itemData":{"id":2586,"type":"webpage","title":"Joint Contractures Resulting From Prolonged Immobilization: Etiology, Prevention, and Management | Ovid","URL":"","accessed":{"date-parts":[["2019",11,26]]}}}],"schema":""} 32 Ankle dorsiflexion of <10° was considered a contracture. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a25ul9mbon1","properties":{"formattedCitation":"{\\rtf \\super 33\\nosupersub{}}","plainCitation":"33"},"citationItems":[{"id":2587,"uris":[""],"uri":[""],"itemData":{"id":2587,"type":"article-journal","title":"The Tardieu Scale differentiates contracture from spasticity whereas the Ashworth Scale is confounded by it","container-title":"Clinical Rehabilitation","page":"173-182","volume":"20","issue":"2","source":"PubMed","abstract":"OBJECTIVE: To compare the Tardieu Scale as a clinical measure of spasticity after stroke with the Ashworth Scale.\nDESIGN: Cross-sectional study.\nPARTICIPANTS: Sixteen people, living in the community three years after their stroke.\nMAIN MEASURES: The Ashworth Scale and Tardieu Scale as well as laboratory measures of spasticity (stretch-induced electromyographic (EMG) activity) and contracture (maximum passive joint excursion) were collected from the affected elbow flexors and extensors and ankle plantarflexors and dorsiflexors by three examiners who were blinded to the results of the other measures.\nRESULTS: The percentage exact agreement (PEA) between the Tardieu Scale and a laboratory measure of spasticity was 100% for both the elbow flexors and ankle plantarflexors. This was significantly (P= 0.02) greater than the PEA of 63% for both muscles between the Ashworth Scale and the same laboratory measure of spasticity. For contracture, the PEA between the Tardieu Scale and a laboratory measure was 94% for both the elbow flexors and the ankle plantarflexors. Pearson correlation coefficients between the Tardieu Scale and laboratory measures of spasticity were 0.86 for the elbow flexors and 0.62 for the ankle plantarflexors and between the Tardieu Scale and laboratory measures of contracture were 0.89 for the elbow flexors and 0.84 for the ankle plantarflexors.\nCONCLUSION: In all cases that spasticity was overestimated by the Ashworth Scale, participants had a contracture. These findings suggest that the Tardieu Scale differentiates spasticity from contracture whereas the Ashworth Scale is confounded by it.","DOI":"10.1191/0269215506cr922oa","ISSN":"0269-2155","note":"PMID: 16541938","journalAbbreviation":"Clin Rehabil","language":"eng","author":[{"family":"Patrick","given":"Emily"},{"family":"Ada","given":"Louise"}],"issued":{"date-parts":[["2006",2]]}}}],"schema":""} 33When immobilization is the primary source of joint contracture, the contracture development can be broken down into two primary phases: the early stage and the later stage. During the early stage, it is primarily a myogenic source of contracture including changes of the attaching muscles, tendons, and fascia. As the contracture continues to develop and become more persistent and chronic, the arthrogenic source of contracture becomes involved, which includes changes in the bone, cartilage, capsule, and ligaments. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"am9d9kdf4o","properties":{"formattedCitation":"{\\rtf \\super 34\\nosupersub{}}","plainCitation":"34"},"citationItems":[{"id":2565,"uris":[""],"uri":[""],"itemData":{"id":2565,"type":"article-journal","title":"The mechanisms and treatments of muscular pathological changes in immobilization-induced joint contracture: A literature review","container-title":"Chinese Journal of Traumatology","page":"93-98","volume":"22","issue":"2","source":"PubMed Central","abstract":"The clinical treatment of joint contracture due to immobilization remains difficult. The pathological changes of muscle tissue caused by immobilization-induced joint contracture include disuse skeletal muscle atrophy and skeletal muscle tissue fibrosis. The proteolytic pathways involved in disuse muscle atrophy include the ubiquitin-proteasome-dependent pathway, caspase system pathway, matrix metalloproteinase pathway, Ca2+-dependent pathway and autophagy-lysosomal pathway. The important biological processes involved in skeletal muscle fibrosis include intermuscular connective tissue thickening caused by transforming growth factor-β1 and an anaerobic environment within the skeletal muscle leading to the induction of hypoxia-inducible factor-1α. This article reviews the progress made in understanding the pathological processes involved in immobilization-induced muscle contracture and the currently available treatments. Understanding the mechanisms involved in immobilization-induced contracture of muscle tissue should facilitate the development of more effective treatment measures for the different mechanisms in the future.","DOI":"10.1016/j.cjtee.2019.02.001","ISSN":"1008-1275","note":"PMID: 30928194\nPMCID: PMC6488749","shortTitle":"The mechanisms and treatments of muscular pathological changes in immobilization-induced joint contracture","journalAbbreviation":"Chin J Traumatol","author":[{"family":"Wang","given":"Feng"},{"family":"Zhang","given":"Quan-Bing"},{"family":"Zhou","given":"Yun"},{"family":"Chen","given":"Shuang"},{"family":"Huang","given":"Peng-Peng"},{"family":"Liu","given":"Yi"},{"family":"Xu","given":"Yuan-Hong"}],"issued":{"date-parts":[["2019",4]]}}}],"schema":""} 34 The myogenic causes of contracture are more easily reversed. The timeline for when each component of a contracture develops is not well researched, and remains largely unknown, but it has been found that a contracture caused by immobilization for two weeks can usually be completely resolved, but periods of immobilization greater than four weeks result in more permanent damage. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a2mo81um8lp","properties":{"formattedCitation":"{\\rtf \\super 34\\nosupersub{}}","plainCitation":"34"},"citationItems":[{"id":2565,"uris":[""],"uri":[""],"itemData":{"id":2565,"type":"article-journal","title":"The mechanisms and treatments of muscular pathological changes in immobilization-induced joint contracture: A literature review","container-title":"Chinese Journal of Traumatology","page":"93-98","volume":"22","issue":"2","source":"PubMed Central","abstract":"The clinical treatment of joint contracture due to immobilization remains difficult. The pathological changes of muscle tissue caused by immobilization-induced joint contracture include disuse skeletal muscle atrophy and skeletal muscle tissue fibrosis. The proteolytic pathways involved in disuse muscle atrophy include the ubiquitin-proteasome-dependent pathway, caspase system pathway, matrix metalloproteinase pathway, Ca2+-dependent pathway and autophagy-lysosomal pathway. The important biological processes involved in skeletal muscle fibrosis include intermuscular connective tissue thickening caused by transforming growth factor-β1 and an anaerobic environment within the skeletal muscle leading to the induction of hypoxia-inducible factor-1α. This article reviews the progress made in understanding the pathological processes involved in immobilization-induced muscle contracture and the currently available treatments. Understanding the mechanisms involved in immobilization-induced contracture of muscle tissue should facilitate the development of more effective treatment measures for the different mechanisms in the future.","DOI":"10.1016/j.cjtee.2019.02.001","ISSN":"1008-1275","note":"PMID: 30928194\nPMCID: PMC6488749","shortTitle":"The mechanisms and treatments of muscular pathological changes in immobilization-induced joint contracture","journalAbbreviation":"Chin J Traumatol","author":[{"family":"Wang","given":"Feng"},{"family":"Zhang","given":"Quan-Bing"},{"family":"Zhou","given":"Yun"},{"family":"Chen","given":"Shuang"},{"family":"Huang","given":"Peng-Peng"},{"family":"Liu","given":"Yi"},{"family":"Xu","given":"Yuan-Hong"}],"issued":{"date-parts":[["2019",4]]}}}],"schema":""} 34 One study found that arthrogenic contribution to a contracture due to immobilization could be identified starting at 1 week, causing a reduction in ROM of approximately 11.5 degrees, which increased to 43.5 degrees by 4 weeks. The arthrogenic involvement of the joint contractures was identified as 40% at 1 week, but was 63% at 4 weeks, indicating increasing arthrogenic contribution as the severity of the contracture increases. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a16rc1l2tsb","properties":{"formattedCitation":"{\\rtf \\super 12\\nosupersub{}}","plainCitation":"12"},"citationItems":[{"id":2447,"uris":[""],"uri":[""],"itemData":{"id":2447,"type":"article-journal","title":"Effects of joint immobilization on changes in myofibroblasts and collagen in the rat knee contracture model","container-title":"Journal of Orthopaedic Research","page":"1998-2006","volume":"35","issue":"9","source":"Wiley Online Library","abstract":"The purpose of this study was to examine the time-dependent changes in the development of joint capsule fibrosis and in the number of myofibroblasts in the joint capsule after immobilization, using a rat knee contracture model. Both knee joints were fixed in full flexion for 1, 2, and 4 weeks (immobilization group). Untreated rats were bred for each immobilization period (control group). Histological analysis was performed to evaluate changes in the amount and density of collagen in the joint capsule. The changes in type I and III collagen mRNA were examined by in situ hybridization. The number of myofibroblasts in the joint capsule was assessed by immunohistochemical methods. In the immobilization group, the amount of collagen increased within 1 week and the density of collagen increased within 2 weeks, as compared with that in the control group. Type I collagen mRNA-positive cell numbers in the immobilization group increased at all time points. However, type III collagen mRNA-positive cell numbers did not increase. Myofibroblasts in the immobilization group significantly increased compared with those in the control group at all time points, and they increased significantly with the period of immobilization. These results suggest that joint capsule fibrosis with overexpression of type I collagen occurs and progresses within 1 week after immobilization, and an increase in myofibroblasts is related to the mechanism of joint capsule fibrosis. The findings suggest the need for a treatment targeting accumulation of type I collagen associated with an increase in myofibroblasts. ? 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:1998–2006, 2017.","DOI":"10.1002/jor.23498","ISSN":"1554-527X","language":"en","author":[{"family":"Sasabe","given":"Ryo"},{"family":"Sakamoto","given":"Junya"},{"family":"Goto","given":"Kyo"},{"family":"Honda","given":"Yuichiro"},{"family":"Kataoka","given":"Hideki"},{"family":"Nakano","given":"Jiro"},{"family":"Origuchi","given":"Tomoki"},{"family":"Endo","given":"Daisuke"},{"family":"Koji","given":"Takehiko"},{"family":"Okita","given":"Minoru"}],"issued":{"date-parts":[["2017"]]}}}],"schema":""} 12Relevant Outcome MeasuresGoniometric measures of joint ROM are important for test-retest assessments, indicating improvements or lack thereof with various treatments. For standard goniometric measurements, repeating the measure three times to find a mean of the three improves accuracy of the measure. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a1ekdr2opin","properties":{"formattedCitation":"{\\rtf \\super 35\\nosupersub{}}","plainCitation":"35"},"citationItems":[{"id":2516,"uris":[""],"uri":[""],"itemData":{"id":2516,"type":"article-journal","title":"Analysis of the reliability and reproducibility of goniometry compared to hand photogrammetry","container-title":"Acta Ortopedica Brasileira","page":"139-149","volume":"20","issue":"3","source":"PubMed Central","abstract":"Objective:\nTo evaluate the intra- and inter-examiner reliability and reproducibility of goniometry\nin relation to photogrammetry of hand, comparing the angles of thumb abduction, PIP\njoint flexion of the II finger and MCP joint flexion of the V finger.\n\nMethods:\nThe study included 30 volunteers, who were divided into three groups: one group of 10\nphysiotherapy students, one group of 10 physiotherapists, and a third group of 10\ntherapists of the hand. Each examiner performed the measurements on the same hand mold,\nusing the goniometer followed by two photogrammetry software programs;\nCorelDraw? and ALCimagem?.\n\nResults:\nThe results revealed that the groups and the methods proposed presented inter-examiner\nreliability, generally rated as excellent (ICC 0.998 I.C. 95% 0.995 - 0.999). In the\nintra-examiner evaluation, an excellent level of reliability was found between the three\ngroups. In the comparison between groups for each angle and each method, no significant\ndifferences were found between the groups for most of the measurements.\n\nConclusion:\nGoniometry and photogrammetry are reliable and reproducible methods for evaluating\nmeasurements of the hand. However, due to the lack of similar references, detailed\nstudies are needed to define the normal parameters between the methods in the joints of\nthe hand. Level of Evidence II, Diagnostic Study.","DOI":"10.1590/S1413-78522012000300003","ISSN":"1413-7852","note":"PMID: 24453594\nPMCID: PMC3718433","journalAbbreviation":"Acta Ortop Bras","author":[{"family":"Carvalho","given":"Rosana Martins Ferreira","non-dropping-particle":"de"},{"family":"Mazzer","given":"Nilton"},{"family":"Barbieri","given":"Claudio Henrique"}],"issued":{"date-parts":[["2012"]]}}}],"schema":""} 35 There are several more official outcome measures that are useful when assessing joint contractures including the Gait Profile Score (GPS), Knee Society Score (KSS), Tardieu Scale, Barthel Index, and Motor Assessment Scale (MAS). ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a2d75t8ja27","properties":{"formattedCitation":"{\\rtf \\super 36\\nosupersub{}}","plainCitation":"36"},"citationItems":[{"id":2519,"uris":[""],"uri":[""],"itemData":{"id":2519,"type":"article-journal","title":"Outcome measures in older persons with acquired joint contractures: a systematic review and content analysis using the ICF (International Classification of Functioning, Disability and Health) as a reference","container-title":"BMC Geriatrics","volume":"16","source":"PubMed Central","abstract":"Background\nJoint contractures are a common health problem in older persons with significant impact on activities of daily living. We aimed to retrieve outcome measures applied in studies on older persons with joint contractures and to identify and categorise the concepts contained in these outcome measures using the ICF (International Classification of Functioning, Disability and Health) as a reference.\n\nMethods\nElectronic searches of Medline, EMBASE, CINAHL, Pedro and the Cochrane Library were conducted (1/2002-8/2012). We included studies in the geriatric rehabilitation and nursing home settings with participants aged ≥ 65 years and with acquired joint contractures. Two independent reviewers extracted the outcome measures and transferred them to concepts using predefined conceptual frameworks. Concepts were subsequently linked to the ICF categories.\n\nResults\nFrom the 1057 abstracts retrieved, 60 studies met the inclusion criteria. We identified 52 single outcome measures and 24 standardised assessment instruments. A total of 1353 concepts were revealed from the outcome measures; 96.2 % could be linked to 50 ICF categories in the 2nd level; 3.8 % were not categorised. Fourteen of the 50 categories (28 %) belonged to the component Body Functions, 4 (8 %) to the component Body Structures, 26 (52 %) to the component Activities and Participation, and 6 (12 %) to the component Environmental Factors.\n\nConclusions\nThe ICF is a valuable reference for identifying and quantifying the concepts of outcome measures on joint contractures in older people. The revealed ICF categories remain to be validated in populations with joint contractures in terms of clinical relevance and personal impact.\n\nElectronic supplementary material\nThe online version of this article (doi:10.1186/s12877-016-0213-6) contains supplementary material, which is available to authorized users.","URL":"","DOI":"10.1186/s12877-016-0213-6","ISSN":"1471-2318","note":"PMID: 26860991\nPMCID: PMC4748463","shortTitle":"Outcome measures in older persons with acquired joint contractures","journalAbbreviation":"BMC Geriatr","author":[{"family":"Bartoszek","given":"Gabriele"},{"family":"Fischer","given":"Uli"},{"family":"Müller","given":"Martin"},{"family":"Strobl","given":"Ralf"},{"family":"Grill","given":"Eva"},{"family":"Nadolny","given":"Stephan"},{"family":"Meyer","given":"Gabriele"}],"issued":{"date-parts":[["2016",2,9]]}}}],"schema":""} 36 The Gait Profile Score has been utilized in children with CP to help identify functional limitations due to multiple different joint contractures; however, it requires use of 3D camera analysis equipment that may not be available at many clinics. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a1hk7i9httf","properties":{"formattedCitation":"{\\rtf \\super 37\\nosupersub{}}","plainCitation":"37"},"citationItems":[{"id":2480,"uris":[""],"uri":[""],"itemData":{"id":2480,"type":"webpage","title":"Impact of multilevel joint contractures of the hips, knees and ankles on the Gait Profile score in children with cerebral palsy. - PubMed - NCBI","abstract":"PubMed comprises more than 30 million citations for biomedical literature from MEDLINE, life science journals, and online books. Citations may include links to full-text content from PubMed Central and publisher web sites., Clin Biomech (Bristol, Avon). 2018 Nov;59:8-14. doi: 10.1016/j.clinbiomech.2018.08.002. Epub 2018 Aug 8.","URL":"","language":"en","author":[{"family":"pubmeddev","given":""},{"family":"al","given":"Holmes SJ","suffix":"et"}],"accessed":{"date-parts":[["2019",11,19]]}}}],"schema":""} 37 Instead, the Observational Gait Scale (OGS) can be performed without expensive technological assistance and is still reliable and valid in assessing gait in children with CP. It also contains specific sections assessing the ankle and knee. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a24fn623f0p","properties":{"formattedCitation":"{\\rtf \\super 38\\nosupersub{}}","plainCitation":"38"},"citationItems":[{"id":2525,"uris":[""],"uri":[""],"itemData":{"id":2525,"type":"article-journal","title":"Reliability and validity of the Observational Gait Scale in children with spastic diplegia","container-title":"Developmental Medicine & Child Neurology","page":"4-11","volume":"45","issue":"1","source":"Wiley Online Library","abstract":"The aim of this study was to establish the reliability and validity of visual gait assessment in children with spastic diplegia, who were community or household ambulators, using a modified version of the Physicians Rating Scale, known as the Observational Gait Scale (OGS). Two clinicians viewed edited split-screen video recordings of 20 children/adolescents (11 males, 9 females; mean age 12 years, range 6 to 21 years) made at the time of three-dimensional gait analysis (3-DGA). Walking ability in each child was scored at initial assessment and reassessed from the same videos three months later using the first seven sections of the OGS. Validity of the OGS score was determined by comparison with 3-DGA. The OGS was found to have acceptable interrater and intrarater reliability for knee and foot position in mid-stance, initial foot contact, and heel rise with weighted kappas (wk) ranging from 0.53 to 0.91 (intrarater) and 0.43 to 0.86 (interrater). Comparison with 3-DGA suggests that these sections might also have high validity(wk range 0.38–0.94). Base of support and hind foot position had lower interrater and intrarater reliabilities (wk 0.29 to 0.71 and wk 0.30 to 0.78 respectively) and were not easily validated by 3-DGA.","DOI":"10.1111/j.1469-8749.2003.tb00852.x","ISSN":"1469-8749","language":"en","author":[{"family":"Mackey","given":"Anna H."},{"family":"Lobb","given":"Glenis L."},{"family":"Walt","given":"Sharon E."},{"family":"Stott","given":"N. Susan"}],"issued":{"date-parts":[["2003"]]}}}],"schema":""} 38 The Tardieu Scale is an outcome measure that examines muscle reactions to three velocities of stretch in addition to the angle of muscle reaction. It has been determined more effective in differentiating spasticity from joint contracture than the Modified Ashworth Scale. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a2bd5k17arc","properties":{"formattedCitation":"{\\rtf \\super 33\\nosupersub{}}","plainCitation":"33"},"citationItems":[{"id":2587,"uris":[""],"uri":[""],"itemData":{"id":2587,"type":"article-journal","title":"The Tardieu Scale differentiates contracture from spasticity whereas the Ashworth Scale is confounded by it","container-title":"Clinical Rehabilitation","page":"173-182","volume":"20","issue":"2","source":"PubMed","abstract":"OBJECTIVE: To compare the Tardieu Scale as a clinical measure of spasticity after stroke with the Ashworth Scale.\nDESIGN: Cross-sectional study.\nPARTICIPANTS: Sixteen people, living in the community three years after their stroke.\nMAIN MEASURES: The Ashworth Scale and Tardieu Scale as well as laboratory measures of spasticity (stretch-induced electromyographic (EMG) activity) and contracture (maximum passive joint excursion) were collected from the affected elbow flexors and extensors and ankle plantarflexors and dorsiflexors by three examiners who were blinded to the results of the other measures.\nRESULTS: The percentage exact agreement (PEA) between the Tardieu Scale and a laboratory measure of spasticity was 100% for both the elbow flexors and ankle plantarflexors. This was significantly (P= 0.02) greater than the PEA of 63% for both muscles between the Ashworth Scale and the same laboratory measure of spasticity. For contracture, the PEA between the Tardieu Scale and a laboratory measure was 94% for both the elbow flexors and the ankle plantarflexors. Pearson correlation coefficients between the Tardieu Scale and laboratory measures of spasticity were 0.86 for the elbow flexors and 0.62 for the ankle plantarflexors and between the Tardieu Scale and laboratory measures of contracture were 0.89 for the elbow flexors and 0.84 for the ankle plantarflexors.\nCONCLUSION: In all cases that spasticity was overestimated by the Ashworth Scale, participants had a contracture. These findings suggest that the Tardieu Scale differentiates spasticity from contracture whereas the Ashworth Scale is confounded by it.","DOI":"10.1191/0269215506cr922oa","ISSN":"0269-2155","note":"PMID: 16541938","journalAbbreviation":"Clin Rehabil","language":"eng","author":[{"family":"Patrick","given":"Emily"},{"family":"Ada","given":"Louise"}],"issued":{"date-parts":[["2006",2]]}}}],"schema":""} 33 It is less of an outcome measure for assessing joint contractures, and more useful as a differential diagnostic tool to rule in or rule out spasticity-sourced reductions in joint ROM. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a1j05o77d0i","properties":{"formattedCitation":"{\\rtf \\super 39\\nosupersub{}}","plainCitation":"39"},"citationItems":[{"id":1272,"uris":[""],"uri":[""],"itemData":{"id":1272,"type":"webpage","title":"Ashworth Scale / Modified Ashworth Scale","container-title":"Shirley Ryan AbilityLab - Formerly RIC","abstract":"Tests resistance to passive movement about a joint with varying degrees of velocity","URL":"","language":"en","accessed":{"date-parts":[["2019",9,10]]}}}],"schema":""} 39 For similar use as the Tardieu Scale, the Unified Dystonia Rating Scale can rule in or rule out postural dystonia that may be affecting joint ROM and masking as a joint contracture. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"seFS36nj","properties":{"formattedCitation":"{\\rtf \\super 40,41\\nosupersub{}}","plainCitation":"40,41"},"citationItems":[{"id":2529,"uris":[""],"uri":[""],"itemData":{"id":2529,"type":"webpage","title":"Unified Dystonia Rating Scale (UDRS)","URL":"","accessed":{"date-parts":[["2019",11,22]]}}},{"id":2530,"uris":[""],"uri":[""],"itemData":{"id":2530,"type":"article-journal","title":"Assessments and Outcome Measures of Cerebral Palsy","container-title":"Cerebral Palsy - Current Steps","source":"","abstract":"In cerebral palsy (CP), numerous primary problems are observed including muscle tone problems, muscle weakness, insufficient selective motor control, postural control, and balance problems. In the persistence of these problems for a long period, secondary problems including torsional deformities, joint contractures, scoliosis, and hip dysplasia can occur in time, and strategies formed by children to cope with these problems make up the tertiary problems. Hence, the most accurate and brief assessment of all of these problems mentioned above is crucial to determine an effective and precise physiotherapy program. In the assessment of children with CP, it is very important to receive a detailed story consisting of the birth story, to question underlying medical situations and to carry out physical assessment. In clinics, gross motor function, muscle tone, muscle length, muscle strength, and joint range of motion assessments are the most preferred ones.","URL":"","DOI":"10.5772/64254","language":"en","author":[{"family":"Akba?","given":"Ay?e Numano?lu"}],"issued":{"date-parts":[["2016",9,21]]},"accessed":{"date-parts":[["2019",11,22]]}}}],"schema":""} 40,41 Both the Barthel Index and MAS are aimed at evaluating how joint mobility affects daily functional activities. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a1v5qm6qe1i","properties":{"formattedCitation":"{\\rtf \\super 36\\nosupersub{}}","plainCitation":"36"},"citationItems":[{"id":2519,"uris":[""],"uri":[""],"itemData":{"id":2519,"type":"article-journal","title":"Outcome measures in older persons with acquired joint contractures: a systematic review and content analysis using the ICF (International Classification of Functioning, Disability and Health) as a reference","container-title":"BMC Geriatrics","volume":"16","source":"PubMed Central","abstract":"Background\nJoint contractures are a common health problem in older persons with significant impact on activities of daily living. We aimed to retrieve outcome measures applied in studies on older persons with joint contractures and to identify and categorise the concepts contained in these outcome measures using the ICF (International Classification of Functioning, Disability and Health) as a reference.\n\nMethods\nElectronic searches of Medline, EMBASE, CINAHL, Pedro and the Cochrane Library were conducted (1/2002-8/2012). We included studies in the geriatric rehabilitation and nursing home settings with participants aged ≥ 65 years and with acquired joint contractures. Two independent reviewers extracted the outcome measures and transferred them to concepts using predefined conceptual frameworks. Concepts were subsequently linked to the ICF categories.\n\nResults\nFrom the 1057 abstracts retrieved, 60 studies met the inclusion criteria. We identified 52 single outcome measures and 24 standardised assessment instruments. A total of 1353 concepts were revealed from the outcome measures; 96.2 % could be linked to 50 ICF categories in the 2nd level; 3.8 % were not categorised. Fourteen of the 50 categories (28 %) belonged to the component Body Functions, 4 (8 %) to the component Body Structures, 26 (52 %) to the component Activities and Participation, and 6 (12 %) to the component Environmental Factors.\n\nConclusions\nThe ICF is a valuable reference for identifying and quantifying the concepts of outcome measures on joint contractures in older people. The revealed ICF categories remain to be validated in populations with joint contractures in terms of clinical relevance and personal impact.\n\nElectronic supplementary material\nThe online version of this article (doi:10.1186/s12877-016-0213-6) contains supplementary material, which is available to authorized users.","URL":"","DOI":"10.1186/s12877-016-0213-6","ISSN":"1471-2318","note":"PMID: 26860991\nPMCID: PMC4748463","shortTitle":"Outcome measures in older persons with acquired joint contractures","journalAbbreviation":"BMC Geriatr","author":[{"family":"Bartoszek","given":"Gabriele"},{"family":"Fischer","given":"Uli"},{"family":"Müller","given":"Martin"},{"family":"Strobl","given":"Ralf"},{"family":"Grill","given":"Eva"},{"family":"Nadolny","given":"Stephan"},{"family":"Meyer","given":"Gabriele"}],"issued":{"date-parts":[["2016",2,9]]}}}],"schema":""} 36 Finally, the Knee Society Score was created for patients post-knee arthroplasty, but identifies risk and severity of contracture at the knee, and can be generalized to other populations with reduced ROM at the knee. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"al21g6chag","properties":{"formattedCitation":"{\\rtf \\super 42\\nosupersub{}}","plainCitation":"42"},"citationItems":[{"id":2524,"uris":[""],"uri":[""],"itemData":{"id":2524,"type":"webpage","title":"Knee Society Score - Orthopaedic Scores","URL":"","accessed":{"date-parts":[["2019",11,22]]}}}],"schema":""} 42 Examples of the score sheets for the OGS and Tardieu Scale along with a link to the online version of the Knee Society Score are located in Appendix B. Treatment and Plan of CareConservative Treatment OptionsWhile the most effective method of treatment of joint contractures is prevention, this is not always plausible in patients seen in physical therapy. Oftentimes, physical therapists evaluate patients who are either at the beginning stages of contracture or who have a persistent contracture that needs to be treated through modification of their environment. Once a contracture has been confirmed, treatment must be initiated as soon as possible. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a92b50kchj","properties":{"formattedCitation":"{\\rtf \\super 11\\nosupersub{}}","plainCitation":"11"},"citationItems":[{"id":2405,"uris":[""],"uri":[""],"itemData":{"id":2405,"type":"article-journal","title":"Treatment of upper motoneuron plantarflexion contractures by using an adjustable ankle-foot orthosis","container-title":"Archives of Physical Medicine and Rehabilitation","page":"270-273","volume":"82","issue":"2","source":"ScienceDirect","abstract":"Grissom SP, Blanton S. Treatment of upper motoneuron plantarflexion contractures by using an adjustable ankle-foot orthosis. Arch Phys Med Rehabil 2001;82:270-3. Objective: To assess the effectiveness of an adjustable ankle-foot orthosis in the treatment of plantarflexion contractures after central nervous system injury or disease. Design: Prospective, nonrandomized, interventional trial. Setting: University medical center's acute inpatient rehabilitation hospital. Participants: Nine ankles with plantarflexion contractures that could not be passively reduced to less than neutral position occurring in 6 patients with stroke or other acquired brain injury. Intervention: To assure differentiation between spastic deformity and true contracture, patients received a 2% lidocaine block of the posterior tibial nerve. The adjustable ankle-foot orthosis was then applied on the affected ankle for 23 hours per day for 14 days. Adjustments to increase dorsiflexion passive range of motion (PROM) ranged from 0° to 4.5° and were attempted every 48 to 72 hours. Main Outcome Measures: Dorsiflexion PROM at the ankle with the knee extended. Results: Increased PROM (average, 20.1°; range, 6°-36°) was statistically significant (p =.0078). Complications related to pressure with erythema or blister formation associated with pain occurred in 44% of treated ankles at some time during the 2-week trial period. Conclusion: Plantarflexion contractures can be significantly reduced by using the adjustable ankle-foot orthosis with minimal complications.","DOI":"10.1053/apmr.2001.19018","ISSN":"0003-9993","journalAbbreviation":"Archives of Physical Medicine and Rehabilitation","author":[{"family":"Grissom","given":"Samuel P."},{"family":"Blanton","given":"Sarah"}],"issued":{"date-parts":[["2001",2,1]]}}}],"schema":""} 11 Identifying whether the contracture is due to a muscular imbalance from spasticity or inflexibility, a dysfunction of other musculoskeletal tissue(s) such as the joint capsule, or a combination of the two is critical in determining the treatment plan of care. Long-duration stretching is a highly utilized treatment intervention in reducing severity of joint contractures, especially those of myogenic nature. There is large variability in parameters of long-duration stretching, but the underlying principle remains the same. Collagenous tissue, which comprises the great majority of musculoskeletal tissues, can become very tense with immobility due to the formation of adhesions, tightening of tissues, and disorganization of collagen fibers within the tissues. As a low level of tension within the elastic range is applied at a steady state to a joint, the fibers gradually accommodate to the new length: a principle known as creep. By maintaining the same level of stress, the tissues accommodate over time and are able to strain to a greater extent.57 This same principle has been shown effective in increasing sarcomere length in myogenic tissue. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a1l5jlq4m3k","properties":{"formattedCitation":"{\\rtf \\super 11\\nosupersub{}}","plainCitation":"11"},"citationItems":[{"id":2405,"uris":[""],"uri":[""],"itemData":{"id":2405,"type":"article-journal","title":"Treatment of upper motoneuron plantarflexion contractures by using an adjustable ankle-foot orthosis","container-title":"Archives of Physical Medicine and Rehabilitation","page":"270-273","volume":"82","issue":"2","source":"ScienceDirect","abstract":"Grissom SP, Blanton S. Treatment of upper motoneuron plantarflexion contractures by using an adjustable ankle-foot orthosis. Arch Phys Med Rehabil 2001;82:270-3. Objective: To assess the effectiveness of an adjustable ankle-foot orthosis in the treatment of plantarflexion contractures after central nervous system injury or disease. Design: Prospective, nonrandomized, interventional trial. Setting: University medical center's acute inpatient rehabilitation hospital. Participants: Nine ankles with plantarflexion contractures that could not be passively reduced to less than neutral position occurring in 6 patients with stroke or other acquired brain injury. Intervention: To assure differentiation between spastic deformity and true contracture, patients received a 2% lidocaine block of the posterior tibial nerve. The adjustable ankle-foot orthosis was then applied on the affected ankle for 23 hours per day for 14 days. Adjustments to increase dorsiflexion passive range of motion (PROM) ranged from 0° to 4.5° and were attempted every 48 to 72 hours. Main Outcome Measures: Dorsiflexion PROM at the ankle with the knee extended. Results: Increased PROM (average, 20.1°; range, 6°-36°) was statistically significant (p =.0078). Complications related to pressure with erythema or blister formation associated with pain occurred in 44% of treated ankles at some time during the 2-week trial period. Conclusion: Plantarflexion contractures can be significantly reduced by using the adjustable ankle-foot orthosis with minimal complications.","DOI":"10.1053/apmr.2001.19018","ISSN":"0003-9993","journalAbbreviation":"Archives of Physical Medicine and Rehabilitation","author":[{"family":"Grissom","given":"Samuel P."},{"family":"Blanton","given":"Sarah"}],"issued":{"date-parts":[["2001",2,1]]}}}],"schema":""} 11 Stress-relaxation is a similar, but different principle for long-duration stretching. Stress-relaxation stresses a joint to induce a certain level of strain, but rather than letting the tissue accommodate to that level of stress, the stress is increased as the strain is imposed. To differentiate from creep in which the load of stress is maintained, stress-relaxation maintains the level of strain by increasing loads of stress. Both creep and stress-relaxation achieve tissue relaxation.57 A common application of creep is the Dynasplint. It is a spring-loaded device for the joint, providing a constant moment of extension at the knee.57 A visual of the knee Dynasplint can be found in Figure 4 of Appendix C. Serial casting or splinting is the common method of applying stress-relaxation at a joint. The Joint Active System (JAS) applies a constant level of strain to a joint with successful outcomes. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a6529l7goj","properties":{"formattedCitation":"{\\rtf \\super 43\\nosupersub{}}","plainCitation":"43"},"citationItems":[{"id":2569,"uris":[""],"uri":[""],"itemData":{"id":2569,"type":"post-weblog","title":"JAS EZ Knee Extension","container-title":"JAS","abstract":"The JAS EZ Knee Extension offers a no-compromise approach to Range of Motion (ROM) therapy — 48° flexion, 36° hyperextension — in a lightweight, easy-fit, single-patient use device. (Available in US domestic markets only)","URL":"","language":"en-US","accessed":{"date-parts":[["2019",11,26]]}}}],"schema":""} 43 Images of the JAS for the knee and ankle can be found in Figure 5 of Appendix C. These two dynamic splinting methods of treating joint contracture have been studied in the literature, which found that it is both safe and effective for treating lower extremity joint contractures, and most effective when following joint-specific protocols. However, protocols are very variable and non-specific throughout the literature. Furia et al. performed a systematic review looking at prolonged duration of low levels of torque on lower extremity joint contractures and found that earlier applications and longer durations of stretching were directly correlated with greater improvements in active ROM. Unlike serial casting, dynamic splinting greatly reduces adverse events through the prevention of skin breakdown. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a2jmhbu0m4k","properties":{"formattedCitation":"{\\rtf \\super 44\\nosupersub{}}","plainCitation":"44"},"citationItems":[{"id":2455,"uris":[""],"uri":[""],"itemData":{"id":2455,"type":"article-journal","title":"Systematic Review of Contracture Reduction in the Lower Extremity with Dynamic Splinting","container-title":"Advances in Therapy","page":"763-770","volume":"30","issue":"8","source":"PubMed Central","abstract":"Introduction\nJoint contractures are relatively common disorders that can result in significant, long-term morbidity. Initial treatment is non-operative and often entails the use of mechanical modalities such as dynamic and static splints. Although widely utilized, there is a paucity of data that support the use of such measures. The purpose of this systematic review was to evaluate the safety and efficacy of dynamic splinting as it is used to treat joint contracture in lower extremities, and to determine if duration on total hours of stretching had an effect on outcomes.\n\nMethods\nReviews of PubMed, Science Direct, Medline, AMED, and EMBASE websites were conducted to identify the term ‘contracture reduction’ in manuscripts published from January 2002 to January 2012. Publications selected for inclusion were controlled trials, cohort studies, or case series studies employing prolonged, passive stretching for lower extremity contracture reduction. A total of 354 abstracts were screened and eight studies (487 subjects) met the inclusion criteria. The primary outcome measure was change in active range of motion (AROM).\n\nResults\nThe mean aggregate change in AROM was 23.5? in the eight studies examined. Dynamic splinting with prolonged, passive stretching as home therapy treatment showed a significant direct, linear correlation between the total number of hours in stretching and restored AROM. No adverse events were reported.\n\nDiscussion\nDynamic splinting is a safe and efficacious treatment for lower extremity joint contractures. Joint specific stretching protocols accomplished greater durations of end-range stretching which may be considered to be responsible for connective tissue elongation.","DOI":"10.1007/s12325-013-0052-1","ISSN":"0741-238X","note":"PMID: 24018464\nPMCID: PMC3779086","journalAbbreviation":"Adv Ther","author":[{"family":"Furia","given":"John P."},{"family":"Willis","given":"F. Buck"},{"family":"Shanmugam","given":"Ram"},{"family":"Curran","given":"Sarah A."}],"issued":{"date-parts":[["2013"]]}}}],"schema":""} 44 Of the eight studies included in the systematic review by Furia and colleagues, improvements in joint active ROM varied from 7 to 31 degrees. The joints included in the study were the knee, ankle, and toes. One precaution noted for physical therapists treating patients with joint contracture is that very forceful attempts to increase ROM can worsen the patient’s symptoms, therefore, low levels of load application through dynamic splinting are much safer and effective. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a2aajb9culs","properties":{"formattedCitation":"{\\rtf \\super 44\\nosupersub{}}","plainCitation":"44"},"citationItems":[{"id":2455,"uris":[""],"uri":[""],"itemData":{"id":2455,"type":"article-journal","title":"Systematic Review of Contracture Reduction in the Lower Extremity with Dynamic Splinting","container-title":"Advances in Therapy","page":"763-770","volume":"30","issue":"8","source":"PubMed Central","abstract":"Introduction\nJoint contractures are relatively common disorders that can result in significant, long-term morbidity. Initial treatment is non-operative and often entails the use of mechanical modalities such as dynamic and static splints. Although widely utilized, there is a paucity of data that support the use of such measures. The purpose of this systematic review was to evaluate the safety and efficacy of dynamic splinting as it is used to treat joint contracture in lower extremities, and to determine if duration on total hours of stretching had an effect on outcomes.\n\nMethods\nReviews of PubMed, Science Direct, Medline, AMED, and EMBASE websites were conducted to identify the term ‘contracture reduction’ in manuscripts published from January 2002 to January 2012. Publications selected for inclusion were controlled trials, cohort studies, or case series studies employing prolonged, passive stretching for lower extremity contracture reduction. A total of 354 abstracts were screened and eight studies (487 subjects) met the inclusion criteria. The primary outcome measure was change in active range of motion (AROM).\n\nResults\nThe mean aggregate change in AROM was 23.5? in the eight studies examined. Dynamic splinting with prolonged, passive stretching as home therapy treatment showed a significant direct, linear correlation between the total number of hours in stretching and restored AROM. No adverse events were reported.\n\nDiscussion\nDynamic splinting is a safe and efficacious treatment for lower extremity joint contractures. Joint specific stretching protocols accomplished greater durations of end-range stretching which may be considered to be responsible for connective tissue elongation.","DOI":"10.1007/s12325-013-0052-1","ISSN":"0741-238X","note":"PMID: 24018464\nPMCID: PMC3779086","journalAbbreviation":"Adv Ther","author":[{"family":"Furia","given":"John P."},{"family":"Willis","given":"F. Buck"},{"family":"Shanmugam","given":"Ram"},{"family":"Curran","given":"Sarah A."}],"issued":{"date-parts":[["2013"]]}}}],"schema":""} 44Serial casting is also utilized to treat patients with joint contracture. For children with CP, a protocol for casting has been created and implemented, in which a long-leg fiberglass cast increases extension at standard rate of 5 degrees per week following goniometric measurements. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a1ct3d6k8ve","properties":{"formattedCitation":"{\\rtf \\super 22\\nosupersub{}}","plainCitation":"22"},"citationItems":[{"id":2468,"uris":[""],"uri":[""],"itemData":{"id":2468,"type":"webpage","title":"Effectiveness of Serial Stretch Casting for Resistant or Recurrent Knee Flexion Contractures Following Hamstring Lengthening in Children With Cerebral Palsy | Ovid","URL":"","accessed":{"date-parts":[["2019",11,19]]}}}],"schema":""} 22 Repeated wedging is used each week to increase knee extension by 5 degrees, but can be altered should skin breakdown or other adverse events occur. By goniometric measure, the knee flexion contractures began at a mean -16.7 ± 7.8°, ranging from -7 to -50°, and by the end of the intervention, were reduced to -5.6 ± 4.5° with a range of 0 to -28. At a 1-year follow-up, the knee flexion angle was -10.1 ± 7.3°, indicating maintenance of about half of the improvement, but not complete maintenance. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a1j0piplbj0","properties":{"formattedCitation":"{\\rtf \\super 22\\nosupersub{}}","plainCitation":"22"},"citationItems":[{"id":2468,"uris":[""],"uri":[""],"itemData":{"id":2468,"type":"webpage","title":"Effectiveness of Serial Stretch Casting for Resistant or Recurrent Knee Flexion Contractures Following Hamstring Lengthening in Children With Cerebral Palsy | Ovid","URL":"","accessed":{"date-parts":[["2019",11,19]]}}}],"schema":""} 22 Another study on serial casting of lower extremities of children with CP reduced both spasticity as measured by the Modified Ashworth Scale, improved ambulatory abilities, and improved ROM of the hip, knee, and ankles. The hip and knee improvements were maintained, while increases in ankle ROM were not. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a2itlc6fmrf","properties":{"formattedCitation":"{\\rtf \\super 45\\nosupersub{}}","plainCitation":"45"},"citationItems":[{"id":2453,"uris":[""],"uri":[""],"itemData":{"id":2453,"type":"article-journal","title":"Effect of serial casting in spastic cerebral palsy","container-title":"The Indian Journal of Pediatrics","page":"997-1002","volume":"75","issue":"10","source":"Springer Link","abstract":"ObjectiveCerebral palsy (CP) is a range of non progressive syndromes of posture and motor impairment due to an insult to developing brain. Spasticity and incoordination are major causes of disability in these children which can be managed by different modalities like casting, botulinum toxin, surgery etc. Cast application in spastic equinus is a well established procedure in CP but cast application in patients of CP with bilateral involvement of hip, knee and ankle is not document.MethodsA study was conducted on 22 children of spastic CP in age range of 3–8 years with bilateral involvement of hip, knee and ankle in 20 cases, hip and ankle in one case and only ankle in one case. Sixty eight % children were spastic diplegics. Serial weekly cast with (11 cases) or without abductor bar (11 cases) was applied for four weeks. They were followed up variably with an average period of 7 months.ResultsSignificant improvement was noticed in range of motion around hip, knee and ankle which as maintained over hip and knee after average follow up. Spasticity was also reduced as measured by Modified Ashworth Scale (MAS). This ultimately improved the ambulatory status and functional ability of these children.ConclusionThus serial casting is a very simple, safe and cost effective procedure which can be applied even in children with mental sub normality having all three major joints involved bilaterally.","DOI":"10.1007/s12098-008-0100-z","ISSN":"0973-7693","journalAbbreviation":"Indian J Pediatr","language":"en","author":[{"family":"Jain","given":"Shweta"},{"family":"Mathur","given":"Navnendra"},{"family":"Joshi","given":"Mrinal"},{"family":"Jindal","given":"Rajeshwari"},{"family":"Goenka","given":"Sunil"}],"issued":{"date-parts":[["2008",10,1]]}}}],"schema":""} 45 A study by Pohl et al. also saw improvements in adults with neurologic disorders with fixed joint contractures due to cerebral spasticity. Casts were changed either every 5 to 7 days or every 1 to 4 days. Shorter changing intervals better reduced adverse events and led to greater improvements in ROM. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a16i7m4jj0h","properties":{"formattedCitation":"{\\rtf \\super 46\\nosupersub{}}","plainCitation":"46"},"citationItems":[{"id":2575,"uris":[""],"uri":[""],"itemData":{"id":2575,"type":"article-journal","title":"Effectiveness of serial casting in patients with severe cerebral spasticity: a comparison study","container-title":"Archives of Physical Medicine and Rehabilitation","page":"784-790","volume":"83","issue":"6","source":"PubMed","abstract":"OBJECTIVE: To compare the improvement and complication rate between a technique using a short casting interval and a more conventional changing interval.\nDESIGN: A retrospective case-comparison study.\nSETTING: A rehabilitation center for adults with neurologic disorders.\nPARTICIPANTS: One hundred five patients with cerebral spasticity of different etiologies treated with serial casting to relieve fixed contractures caused by increased muscle tone.\nINTERVENTION: Serial casting of 172 joints (42 elbow, 41 wrist, 21 knee, 68 ankle joints), with cast-changing intervals of 5 to 7 days (group 1:92 joints, 56 patients), or 1 to 4 days (group 2:80 joints, 49 patients).\nMAIN OUTCOME MEASURES: Percentage of normal maximum range of motion (ROM) at the completion of casting and 1 month after discontinuation, and the number of complications resulting from casting procedure.\nRESULTS: Improved percentage ROM immediately after serial casting and 1 month later in both groups (F=1469.5, P<.001). No differences in ROM improvement between groups were observed (F=0.3, P=.72). Complications in serial casting were found in 19.8% of 172 casting procedures, in 29.3% in group 1 and in 8.8% in group 2 (chi(2)=10.2, P=.001). Discontinuations of treatment because of casting complications or other reasons were observed in 12.8% of the entire sample, in 18.5% in group 1 and in 6.3% in group 2 (chi(2)=4.7 P=.03).\nCONCLUSION: Casting is effective in the treatment of fixed contractures of the upper and lower extremities caused by increased muscle tone of cerebral origin. Short changing intervals in serial casting provide improvements in ROM comparable with conventional changing intervals, and result in fewer complications.","DOI":"10.1053/apmr.2002.32821","ISSN":"0003-9993","note":"PMID: 12048656","shortTitle":"Effectiveness of serial casting in patients with severe cerebral spasticity","journalAbbreviation":"Arch Phys Med Rehabil","language":"eng","author":[{"family":"Pohl","given":"Marcus"},{"family":"Rückriem","given":"Stefan"},{"family":"Mehrholz","given":"Jan"},{"family":"Ritschel","given":"Claudia"},{"family":"Strik","given":"Herwig"},{"family":"Pause","given":"Max R."}],"issued":{"date-parts":[["2002",6]]}}}],"schema":""} 46 While serial casting and manual static stretching have also been found to be effective, dynamic splinting reduces the risk of adverse events, is much more functional than serial casts, and does not require as frequent visits to therapy as manual stretching does. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a26sop1ksj9","properties":{"formattedCitation":"{\\rtf \\super 47\\nosupersub{}}","plainCitation":"47"},"citationItems":[{"id":2577,"uris":[""],"uri":[""],"itemData":{"id":2577,"type":"article-journal","title":"Case Studies: Contracture and Stiff Joint Management with Dynasplint?","container-title":"Journal of Orthopaedic & Sports Physical Therapy","page":"498-504","volume":"8","issue":"10","source":" (Atypon)","abstract":"This study investigated the efficacy of using Dynasplint LPS? (low, prolonged-stretch) devices for restoring range of motion in cases where either immobilization stiffness or an established contracture had developed at the elbow or knee. Patients treated with Dynasplint, a force adjustable device for use in clinic and at home and capable of providing low levels of force over prolonged periods of time, resulted in a 61% additional increase in range of motion at the elbow or knee in 13 case studies in spite of the fact that 9 of the 13 subjects had already undergone previous and, oftentimes, intensive physical therapy programs designed for the same purpose of restoring range of motion. Dynasplint knee and elbow devices were found to be highly effective and efficient tools for speeding recovery from immobilization stiffness and to correct established contractures in 13 subjects who had suffered elbow fractures (8), knee fractures (2), surgeries (2), and a stroke (1).","DOI":"10.2519/jospt.1987.8.10.498","ISSN":"0190-6011","shortTitle":"Case Studies","journalAbbreviation":"J Orthop Sports Phys Ther","author":[{"family":"Hepburn","given":"George R."}],"issued":{"date-parts":[["1987",4,1]]}}}],"schema":""} 47While both principles of creep and stress-relaxation have been identified as successful means of eliciting structural elongation in multiple studies, a systematic review by Katalinic et al. suggests that even these longer-duration forms of stretching do not lead to significant improvements in joint ROM. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a1vltvg3frt","properties":{"formattedCitation":"{\\rtf \\super 48\\nosupersub{}}","plainCitation":"48"},"citationItems":[{"id":1776,"uris":[""],"uri":[""],"itemData":{"id":1776,"type":"article-journal","title":"Effectiveness of Stretch for the Treatment and Prevention of Contractures in People With Neurological Conditions: A Systematic Review","container-title":"Physical Therapy","page":"11-24","volume":"91","issue":"1","source":"academic.","abstract":"Background. Contractures are a disabling complication of neurological conditions that are commonly managed with stretch.Objective. The purpose of this systema","DOI":"10.2522/ptj.20100265","ISSN":"0031-9023","shortTitle":"Effectiveness of Stretch for the Treatment and Prevention of Contractures in People With Neurological Conditions","journalAbbreviation":"Phys Ther","language":"en","author":[{"family":"Katalinic","given":"Owen M."},{"family":"Harvey","given":"Lisa A."},{"family":"Herbert","given":"Robert D."}],"issued":{"date-parts":[["2011",1,1]]}}}],"schema":""} 48 One important factor not taken into consideration by Katalinic et al. was the severity or phase of contracture examined in each study. The persistent/progressive contractures are likely arthrogenic in nature, and no longer myogenic in nature, requiring medical attention in addition to or in the place of conservative intervention. Although stretching was not clinically or significantly effective in the studies included in the systematic review, the contractures identified may have been persistent or progressive, which are not typically treated with conservative measures. Rather, transient joint contractures should be treated with conservative interventions such as stretching and weight bearing activity. To contrast the findings by Katalinic et al., the study by Singer and colleagues included participants diagnosed with transient ankle contractures who were able to significantly improve ankle ROM with conservative treatment including progressive stretching and weight bearing activities. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a11jt8fs7uc","properties":{"formattedCitation":"{\\rtf \\super 19\\nosupersub{}}","plainCitation":"19"},"citationItems":[{"id":2465,"uris":[""],"uri":[""],"itemData":{"id":2465,"type":"article-journal","title":"Non-surgical management of ankle contracture following acquired brain injury","container-title":"Disability and Rehabilitation","page":"335-345","volume":"26","issue":"6","source":"Taylor and Francis+NEJM","abstract":"Background and purpose: The purpose of this study was to document the outcome of non-surgical management of equinovarus ankle contracture in a cohort of patients with acquired brain injury admitted to a specialist Neurosurgical Rehabilitation Unit.Methods: This prospective descriptive study examined all patients with a new diagnosis of moderate to severe acquired brain injury (Glasgow Coma Scale score ? 12) admitted for rehabilitation over a 1 year period. Ankle dorsiflexion range and plantarflexor/invertor muscle activity were evaluated weekly during the period of hospitalization. Contracture was defined as maximal passive range of motion ? 0° dorsiflexion, with the knee extended, on a minimum of two measurement occasions. Patients were retrospectively allocated to one of four treatment outcome categories according to ankle dorsiflexion range, type of intervention required and response to treatment.Results: Ankle contracture was identified in 40 of the 105 patients studied. Contracture resolved with a standard physiotherapy treatment programme, including prolonged weight-bearing stretches and motor re-education, in 23 patients. Contracture persisted or worsened in 17 of 40 cases, all of whom exhibited dystonic muscle overactivity producing sustained equinovarus posturing. Ten of 17 cases required serial plaster casting ( ± injection of botulinum toxin type A) in order to achieve a functional range of ankle motion. Remediation of ankle contracture was not considered a priority in the remaining seven patients due to the severity of their overall disability.Conclusion: The incidence of ankle contracture identified in this population was considerably less than previously reported. Reduced dorsiflexion range was remediated with standard physiotherapy treatment in over half of the cases. Additional treatment with serial casting ± botulinum toxin type-A injection was required to correct persistent or worsening contracture in one quarter of cases. Dystonic extensor muscle overactivity was a major contributor to persistent or progressive ankle contracture.","DOI":"10.1080/0963828032000174070","ISSN":"0963-8288","note":"PMID: 15204485","author":[{"family":"Singer","given":"B. J."},{"family":"Dunne","given":"J. W."},{"family":"Singer","given":"K. P."},{"family":"Jegasothy","given":"G. M."},{"family":"Allison","given":"G. T."}],"issued":{"date-parts":[["2004",3,18]]}}}],"schema":""} 19Ankle foot orthoses (AFOs) are another conservative measure that can be taken for individuals at risk of ankle contracture. It is most commonly used as a prophylactic measure, in which the ankle is held at a neutral position to prevent plantar flexion contractures. There are both rigid and articulated AFOs, the latter of which allows movement into greater than 0 degrees of dorsiflexion. Articulated AFOs benefit gait speed, peak dorsiflexion, and reduce energy expenditure, but rigid AFOs are noted as more beneficial for children with CP who have severe impairments through their ability to prevent muscle contractures. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a22hdmqbe5h","properties":{"formattedCitation":"{\\rtf \\super 49\\nosupersub{}}","plainCitation":"49"},"citationItems":[{"id":2582,"uris":[""],"uri":[""],"itemData":{"id":2582,"type":"webpage","title":"Comparison of Articulated and Rigid Ankle-Foot Orthoses in Children With Cerebral Palsy: A Systematic Review | Ovid","URL":"","accessed":{"date-parts":[["2019",11,26]]}}}],"schema":""} 49 In the inpatient setting, AFOs can and should be utilized as a prophylactic measure for patients post-stroke to prevent contracture development on the affected side. In addition, heat modalities and strengthening of antagonistic muscle groups can maximize potential gains in range of motion at the affected joint. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a27agipgnak","properties":{"formattedCitation":"{\\rtf \\super 11\\nosupersub{}}","plainCitation":"11"},"citationItems":[{"id":2405,"uris":[""],"uri":[""],"itemData":{"id":2405,"type":"article-journal","title":"Treatment of upper motoneuron plantarflexion contractures by using an adjustable ankle-foot orthosis","container-title":"Archives of Physical Medicine and Rehabilitation","page":"270-273","volume":"82","issue":"2","source":"ScienceDirect","abstract":"Grissom SP, Blanton S. Treatment of upper motoneuron plantarflexion contractures by using an adjustable ankle-foot orthosis. Arch Phys Med Rehabil 2001;82:270-3. Objective: To assess the effectiveness of an adjustable ankle-foot orthosis in the treatment of plantarflexion contractures after central nervous system injury or disease. Design: Prospective, nonrandomized, interventional trial. Setting: University medical center's acute inpatient rehabilitation hospital. Participants: Nine ankles with plantarflexion contractures that could not be passively reduced to less than neutral position occurring in 6 patients with stroke or other acquired brain injury. Intervention: To assure differentiation between spastic deformity and true contracture, patients received a 2% lidocaine block of the posterior tibial nerve. The adjustable ankle-foot orthosis was then applied on the affected ankle for 23 hours per day for 14 days. Adjustments to increase dorsiflexion passive range of motion (PROM) ranged from 0° to 4.5° and were attempted every 48 to 72 hours. Main Outcome Measures: Dorsiflexion PROM at the ankle with the knee extended. Results: Increased PROM (average, 20.1°; range, 6°-36°) was statistically significant (p =.0078). Complications related to pressure with erythema or blister formation associated with pain occurred in 44% of treated ankles at some time during the 2-week trial period. Conclusion: Plantarflexion contractures can be significantly reduced by using the adjustable ankle-foot orthosis with minimal complications.","DOI":"10.1053/apmr.2001.19018","ISSN":"0003-9993","journalAbbreviation":"Archives of Physical Medicine and Rehabilitation","author":[{"family":"Grissom","given":"Samuel P."},{"family":"Blanton","given":"Sarah"}],"issued":{"date-parts":[["2001",2,1]]}}}],"schema":""} 11,57PharmacologicIn depth detail of the pharmacologic and surgical interventions for joint contractures is beyond the scope of this paper, but it is important and useful for physical therapists to have general knowledge and understanding about the commonly used interventions. Pharmacologically, there are not many interventions used for treating patients with joint contractures, but Botulinum Toxin (Botox) Type A has been used for reducing spasticity, and can also reduce the risk of fixed shortening occurring in myogenic joint contractures. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a26e1k5mi9u","properties":{"formattedCitation":"{\\rtf \\super 15\\nosupersub{}}","plainCitation":"15"},"citationItems":[{"id":2430,"uris":[""],"uri":[""],"itemData":{"id":2430,"type":"article-journal","title":"Botulinum toxin type A injection increases range of motion in hip, knee and ankle joint contractures of children with cerebral palsy","container-title":"Eklem Hastaliklari Ve Cerrahisi = Joint Diseases & Related Surgery","page":"155-162","volume":"30","issue":"2","source":"PubMed","abstract":"OBJECTIVES: This study aims to evaluate the clinical outcomes of children with spastic type cerebral palsy (CP) treated with botulinum toxin type A (BoNT-A) injection for lower limb contracture and the influence of age, gender, functional level and degree of initial contracture on treatment outcomes.\nPATIENTS AND METHODS: Clinical records at pre-BoNT-A injection and post-BoNT-A injections of 153 sessions of a total of 118 consecutive children (67 boys, 51 girls; mean age 5.9±2.6 years; range, 2.5-16 years) were retrospectively evaluated. Degrees of pre- and post-injection contracture were evaluated. Post-injection supplemental casting for 10 days was recorded in all cases. Less than 20° of hip flexion contracture, more than 30° of hip abduction, a negative prone Ely test, less than 50° of popliteal angle and at least 5° of ankle dorsiflexion values at post-injection were accepted as sufficient clinical improvement.\nRESULTS: Sufficient post-injection range of motion (ROM) was observed in 80% of cases with hip flexion contracture, in 45% of cases with hip adduction contracture, in 84% of cases with knee flexion contracture and in 77% of cases with ankle equinus contracture. Prone Ely test that was positive in 60% of cases with knee extension contracture was negative at post-injection. Improvement in contractures were prominent in children with lesser degree initial contractures.\nCONCLUSION: Botulinum toxin type A injection increases ROM in hip, knee and ankle joint contractures in CP. Although age, gender and functional level may influence the clinical outcomes, pre-treatment level of contracture is the main determinant in improvement in ROM at post-injection.","DOI":"10.5606/ehc.2019.65453","ISSN":"1309-0313","note":"PMID: 31291865","journalAbbreviation":"Eklem Hastalik Cerrahisi","language":"eng","author":[{"family":"Akta?","given":"Erdem"},{"family":"?mero?lu","given":"Hakan"}],"issued":{"date-parts":[["2019",8]]}}}],"schema":""} 15 While Botox is useful in preventing fixed contractures such as those that are primarily arthrogenic, it is only effective in treating the early, myogenic phase of joint contracture. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"avpjk3jg91","properties":{"formattedCitation":"{\\rtf \\super 15\\nosupersub{}}","plainCitation":"15"},"citationItems":[{"id":2430,"uris":[""],"uri":[""],"itemData":{"id":2430,"type":"article-journal","title":"Botulinum toxin type A injection increases range of motion in hip, knee and ankle joint contractures of children with cerebral palsy","container-title":"Eklem Hastaliklari Ve Cerrahisi = Joint Diseases & Related Surgery","page":"155-162","volume":"30","issue":"2","source":"PubMed","abstract":"OBJECTIVES: This study aims to evaluate the clinical outcomes of children with spastic type cerebral palsy (CP) treated with botulinum toxin type A (BoNT-A) injection for lower limb contracture and the influence of age, gender, functional level and degree of initial contracture on treatment outcomes.\nPATIENTS AND METHODS: Clinical records at pre-BoNT-A injection and post-BoNT-A injections of 153 sessions of a total of 118 consecutive children (67 boys, 51 girls; mean age 5.9±2.6 years; range, 2.5-16 years) were retrospectively evaluated. Degrees of pre- and post-injection contracture were evaluated. Post-injection supplemental casting for 10 days was recorded in all cases. Less than 20° of hip flexion contracture, more than 30° of hip abduction, a negative prone Ely test, less than 50° of popliteal angle and at least 5° of ankle dorsiflexion values at post-injection were accepted as sufficient clinical improvement.\nRESULTS: Sufficient post-injection range of motion (ROM) was observed in 80% of cases with hip flexion contracture, in 45% of cases with hip adduction contracture, in 84% of cases with knee flexion contracture and in 77% of cases with ankle equinus contracture. Prone Ely test that was positive in 60% of cases with knee extension contracture was negative at post-injection. Improvement in contractures were prominent in children with lesser degree initial contractures.\nCONCLUSION: Botulinum toxin type A injection increases ROM in hip, knee and ankle joint contractures in CP. Although age, gender and functional level may influence the clinical outcomes, pre-treatment level of contracture is the main determinant in improvement in ROM at post-injection.","DOI":"10.5606/ehc.2019.65453","ISSN":"1309-0313","note":"PMID: 31291865","journalAbbreviation":"Eklem Hastalik Cerrahisi","language":"eng","author":[{"family":"Akta?","given":"Erdem"},{"family":"?mero?lu","given":"Hakan"}],"issued":{"date-parts":[["2019",8]]}}}],"schema":""} 15Surgical Surgical operation is the primary means of treating fixed joint contractures that has demonstrated lasting long-term effects. For children with CP, one of the common surgical solutions to knee flexion contracture is distal hamstrings lengthening. A study of 85 patients with CP underwent tenotomies of the semitendinosus, semimembranosus, gracilis, and biceps femoris muscles, of which only the semitendinosus was completely tenotomized. Mean popliteal angles prior to surgery ranged from 58.56° to 76.82°, depending upon age group. Post-operatively, popliteal angles increased to 101.94° to 130.5°. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a5ag8f6umi","properties":{"formattedCitation":"{\\rtf \\super 50\\nosupersub{}}","plainCitation":"50"},"citationItems":[{"id":2583,"uris":[""],"uri":[""],"itemData":{"id":2583,"type":"article-journal","title":"Operative Treatment of the Knee Contractures in Cerebral Palsy Patients","container-title":"Medical Archives","page":"182-183","volume":"68","issue":"3","source":"PubMed Central","abstract":"Introduction:\nKnee flexion is one of the main problems of the lower extremities in cerebral palsy patients. Many operative procedures are recommended for contractures of the knee in cerebral palsy patients. We performed simple operation and analyzed the results after operative treatment with nine years follow up.\n\nMethod:\n85 patients with spastic cerebral palsy were treated in period 2001 – 2010. 40 were ambulatory and 45 non ambulatory with ability to stand with support. All of them underwent same surgical procedure with distal hamstrings lengthening. Tenotomies were performed on m. semitendinosus, m. semimembranosus, m. gracillis and biceps femoris. Only m. semitendinosus was tenotomized completely, other muscles were tenotomized only on tendinous part. The patients had a plaster immobilization for five days after the surgery with the knee extended.\n\nResults:\nAll 85 patients had improvement of the popliteal angle pre and post operative respectively. Improvement in the crouch gait was noticed in the period of rehabilitation. We had no complication with the wound. Three of the patients had overcorrection and achieved recurvatum of the knees.\n\nConclusion:\nWe consider this procedure very simple with satisfying improvement of standing, walking and sitting abilities in children with spastic cerebral palsy.","DOI":"10.5455/medarh.2014.68.182-183","ISSN":"0350-199X","note":"PMID: 25568529\nPMCID: PMC4240335","journalAbbreviation":"Med Arch","author":[{"family":"Bozinovski","given":"Zoran"},{"family":"Popovski","given":"Neron"}],"issued":{"date-parts":[["2014",6]]}}}],"schema":""} 50 Similarly, Achilles lengthening is the surgical procedure commonly performed on ankles with plantar flexion contractures, in which a short transverse incision is made on the heel. If more severe, two or three incisions may be necessary for further lengthening. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"aga9geri2n","properties":{"formattedCitation":"{\\rtf \\super 51\\nosupersub{}}","plainCitation":"51"},"citationItems":[{"id":2592,"uris":[""],"uri":[""],"itemData":{"id":2592,"type":"article-journal","title":"Z-lengthening of the Achilles Tendon with Transverse Skin Incision","container-title":"Clinics in Orthopedic Surgery","page":"208-215","volume":"6","issue":"2","source":"PubMed Central","abstract":"Background\nThe risk of various complications after Achilles tendon lengthening is mainly related to the length of surgical exposure and the lengthening method. A comprehensive technique to minimize the complications is required.\n\nMethods\nThe treatment of Achilles tendon tightness in 57 patients (95 ankles) were performed by using a short transverse incision on a skin crease of the heel and by Z-lengthening of the tendon. In the severe cases, two or three transverse incisions were required for greater lengthening of the tendon, and a serial cast or Ilizarov apparatus was applied for the gradual correction. The results of these 95 ankles were compared to those of 18 ankles, which underwent percutaneous sliding lengthening, and to the 19 ankles, which received Z-lengthening with a medial longitudinal incision.\n\nResults\nThe functional and cosmetic satisfaction was achieved among those who underwent the tendon lengthening with the new technique. The mean American Orthopaedic Foot & Ankle Society (AOFAS) score improved from 56.1 to 81.8. The second operations to correct recurrence were performed in the two cerebral palsy patients.\n\nConclusions\nThe new technique has a low rate of complications such as scarring, adhesion, total transection, excessive lengthening, and recurrence of shortening. The excellent cosmesis and the short operation time are the additional advantages.","DOI":"10.4055/cios.2014.6.2.208","ISSN":"2005-291X","note":"PMID: 24900904\nPMCID: PMC4040383","journalAbbreviation":"Clin Orthop Surg","author":[{"family":"Kim","given":"Hui Taek"},{"family":"Oh","given":"Jong Seok"},{"family":"Lee","given":"Jong Seo"},{"family":"Lee","given":"Tae Hoon"}],"issued":{"date-parts":[["2014",6]]}}}],"schema":""} 51 Another surgical technique for the treatment of knee flexion contractures is a posterior knee capsulotomy, or a posterior capsule release. This technique is often utilized in older children with CP for which lengthening of hamstring tendons and conservative measures are ineffective. Posterior knee capsulotomies are performed by resecting all scar tissue, then detaching the posterior capsule from its femoral attachment. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a1vrjkb12im","properties":{"formattedCitation":"{\\rtf \\super 52,53\\nosupersub{}}","plainCitation":"52,53"},"citationItems":[{"id":2595,"uris":[""],"uri":[""],"itemData":{"id":2595,"type":"article-journal","title":"Role of posterior capsulotomy for the treatment of extension deficits of the knee","container-title":"Knee Surgery, Sports Traumatology, Arthroscopy","page":"237-241","volume":"4","issue":"4","source":"Springer Link","abstract":"Chronic flexion contracture of the knee is difficult to treat, especially in cases with long-standing extension deficits and with generalised arthrofibrosis. We present a technique combining arthroscopic or open anterior debridement with a posterior capsulotomy. This capsulotomy is performed via a posteromedial incision and a posteromedial arthrotomy. All scar tissue is resected, and the entire posterior capsule is detached from its femoral attachment. Of 24 patients treated with arthroscopic arthrolysis and posterior capsulotomy from 1989 to 1993, 21 were reviewed with a mean follow-up of 18 months (range 6–38 months). The mean extension deficit preoperatively was 17° (range 10–30°), and symptoms had persisted from 6 months to 7 years. Extension improved to a mean value of 2°; no patient had more than 5° of extension deficit at follow-up. The knee function improved significantly (Lysholm Score preoperative 62, postoperative 88, Tegner Scale preoperative 2.2, postoperative 4.0). No neurovascular complications were observed, and we conclude that posterior capsulotomy is a safe and efficient adjunct procedure to anterior arthrolysis and is indicated in cases with chronic flexion contracture.","DOI":"10.1007/BF01567970","ISSN":"1433-7347","journalAbbreviation":"Knee Surg, Sports traumatol, Arthroscopy","language":"en","author":[{"family":"Lobenhoffer","given":"H. P."},{"family":"Bosch","given":"U."},{"family":"Gerich","given":"T. G."}],"issued":{"date-parts":[["1996",12,1]]}}},{"id":2449,"uris":[""],"uri":[""],"itemData":{"id":2449,"type":"article-journal","title":"Treatment of knee contracture in cerebral palsy by hamstring lengthening, posterior capsulotomy, and quadriceps mechanism shortening","container-title":"Developmental Medicine & Child Neurology","page":"802-805","volume":"43","issue":"12","source":"onlinelibrary.","abstract":"Results of surgery to correct fixed flexion contracture of the knee and improve voluntary knee extension in 39 knees in 20 children (11 females, 9 males; mean age 12 years 8 months, age range 5 to 20...","DOI":"10.1111/j.1469-8749.2001.tb00166.x","ISSN":"1469-8749","language":"en","author":[{"family":"Beals","given":"Rodney K."}],"issued":{"date-parts":[["2001",12,1]]}}}],"schema":""} 52,53 Similarly, capsular releases can be performed at the ankle to reverse adhesive or other changes causing contracture when conservative measures are unsuccessful. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a2f4ttbb37t","properties":{"formattedCitation":"{\\rtf \\super 54\\nosupersub{}}","plainCitation":"54"},"citationItems":[{"id":1791,"uris":[""],"uri":[""],"itemData":{"id":1791,"type":"article-journal","title":"Arthroscopic Capsular Release of the Ankle Joint","container-title":"Arthroscopy Techniques","page":"e1281-e1286","volume":"5","issue":"6","source":"PubMed Central","abstract":"Adhesive capsulitis of the ankle is also known as frozen ankle and results in marked fibrosis and contracture of the ankle capsule. Arthroscopic capsular release is indicated for symptomatic frozen ankle that is resistant to conservative treatment. It is contraindicated for ankle stiffness due to degenerative joint disease, intra-articular malunion, or adhesion of the extensors of the ankle. The procedure consists of endoscopic posterior ankle capsulectomy and arthroscopic anterior ankle capsulotomy. It has the advantages of being minimally invasive surgery and allowing early postoperative vigorous mobilization of the ankle joint.","DOI":"10.1016/j.eats.2016.07.019","ISSN":"2212-6287","note":"PMID: 28149726\nPMCID: PMC5263115","journalAbbreviation":"Arthrosc Tech","author":[{"family":"Lui","given":"Tun Hing"}],"issued":{"date-parts":[["2016",11,7]]}}}],"schema":""} 54 The arthroscopic capsular release techniques at the ankle are minimally invasive and allow vigorous mobilization shortly after the procedure. Capsulotomies are especially effective for patients who are in the later stage of contracture, in which changes are arthrogenic and commonly involve the joint capsule. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"ajuqvi2afp","properties":{"formattedCitation":"{\\rtf \\super 54\\nosupersub{}}","plainCitation":"54"},"citationItems":[{"id":1791,"uris":[""],"uri":[""],"itemData":{"id":1791,"type":"article-journal","title":"Arthroscopic Capsular Release of the Ankle Joint","container-title":"Arthroscopy Techniques","page":"e1281-e1286","volume":"5","issue":"6","source":"PubMed Central","abstract":"Adhesive capsulitis of the ankle is also known as frozen ankle and results in marked fibrosis and contracture of the ankle capsule. Arthroscopic capsular release is indicated for symptomatic frozen ankle that is resistant to conservative treatment. It is contraindicated for ankle stiffness due to degenerative joint disease, intra-articular malunion, or adhesion of the extensors of the ankle. The procedure consists of endoscopic posterior ankle capsulectomy and arthroscopic anterior ankle capsulotomy. It has the advantages of being minimally invasive surgery and allowing early postoperative vigorous mobilization of the ankle joint.","DOI":"10.1016/j.eats.2016.07.019","ISSN":"2212-6287","note":"PMID: 28149726\nPMCID: PMC5263115","journalAbbreviation":"Arthrosc Tech","author":[{"family":"Lui","given":"Tun Hing"}],"issued":{"date-parts":[["2016",11,7]]}}}],"schema":""} 54 Posterior capsulotomies are commonly performed in conjunction with hamstring lengthening, and sometimes with quadriceps mechanism shortening. A common technique for quadriceps mechanism shortening is shortening of the infrapatellar tendon followed by attaching it back to the patella at its shortened length. This is often accompanied with hamstring lengthening and/or posterior capsular releases in patients with simultaneous quadriceps weakness. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"aehhsidrcu","properties":{"formattedCitation":"{\\rtf \\super 53\\nosupersub{}}","plainCitation":"53"},"citationItems":[{"id":2449,"uris":[""],"uri":[""],"itemData":{"id":2449,"type":"article-journal","title":"Treatment of knee contracture in cerebral palsy by hamstring lengthening, posterior capsulotomy, and quadriceps mechanism shortening","container-title":"Developmental Medicine & Child Neurology","page":"802-805","volume":"43","issue":"12","source":"onlinelibrary.","abstract":"Results of surgery to correct fixed flexion contracture of the knee and improve voluntary knee extension in 39 knees in 20 children (11 females, 9 males; mean age 12 years 8 months, age range 5 to 20...","DOI":"10.1111/j.1469-8749.2001.tb00166.x","ISSN":"1469-8749","language":"en","author":[{"family":"Beals","given":"Rodney K."}],"issued":{"date-parts":[["2001",12,1]]}}}],"schema":""} 53 Again, this technique is primarily for individuals with fixed contractures. ConclusionsIn conclusion, the evaluation and treatment of joint contractures in neurologically-involved populations are complex and often require close monitoring. Prophylactic measures allowing total prevention are the best treatment option, but often not an option for patients. Identifying the timeline and performing a comprehensive examination enables practitioners to create an optimal plan of care. Generally, for joint contractures of myogenic nature, conservative measures are very successful and safe to use. Arthrogenic contractures, while more complicated, are usually initially treated conservatively, but often require surgical operation to effectively treat. The neurologically-involved populations that are at high risk of joint contracture include, but are not limited to cerebral palsy, multiple sclerosis, and stroke. Overall, the literature is still deficient in terms of effective treatment options and standardization of interventions, but there are both conservative and surgical options proven successful for various clinical presentations. The presence of spasticity can exacerbate losses of joint ROM and increases the complexity of treatment interventions. Identification of fixed contractures and subsequent referral to neurologists with detailed notes of exam findings at the joint are important for streamlining appropriate treatment for these patients. Appendices A-C: Appendix A: Anatomic ReviewsAppendix B: Outcome MeasuresAppendix C: Treatment Devices Appendix A. Anatomic ReviewsFigure 1. Relevant Anatomy of the Knee center62517100The posterior capsule of the knee encloses the patella, ligaments, menisci, and bursae of the knee. While the anterior and posterior cruciate ligaments of the knee are intracapsular, they are considered extra-articular because their tibial attachments are outside the capsule. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"avts49fop5","properties":{"formattedCitation":"{\\rtf \\super 8\\nosupersub{}}","plainCitation":"8"},"citationItems":[{"id":2395,"uris":[""],"uri":[""],"itemData":{"id":2395,"type":"webpage","title":"The Anatomy of the Posterior Aspect of the Knee: An Anatomic Study | Ovid","URL":"","accessed":{"date-parts":[["2019",11,15]]}}}],"schema":""} 8Figure 2. Relevant Anatomy of the Ankle JointThe ankle joint is comprised of a few joints, all of which the ankle joint capsule is responsible for encasing. The ankle joint capsule encompasses a broad surface area, making it thinner with thin fibers. It is thickest laterally where it encases the medial and lateral malleoli. The joint capsule reaches superiorly as far as the interosseous membrane between the tibia and fibula and laterally branches out to blend with the transverse ligament. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a2aulfn8uuh","properties":{"formattedCitation":"{\\rtf \\super 9\\nosupersub{}}","plainCitation":"9"},"citationItems":[{"id":2400,"uris":[""],"uri":[""],"itemData":{"id":2400,"type":"webpage","title":"Ankle Joint","container-title":"Physiopedia","abstract":"The Ankle Joint, also known as the Talocrural Articulation, is a synovial hinge joint connecting the distal ends of the tibia and fibula in the lower limb with the proximal end of the talus. The ankle joint is maintained by the shape of the talus and its tight fit between the tibia and fibula. In the neutral position, there are strong bony constraints. With increasing plantar flexion, the bony constraints are decreased and the ligaments are more susceptible to strain and injury. The articulation between the tibia and the talus bears more weight than that between the smaller fibula and the talus.&#160;&#91;1&#93;","URL":"","language":"en","accessed":{"date-parts":[["2019",11,15]]}}}],"schema":""} 9center21104000Figure 3. Setup of Dynamic Ankle DynamometerThe dynamic ankle dynamometer is not yet used in clinical settings, but has been gaining momentum in recent literature. It is able to measure angular force through an accelerometer, joint movement through angular displacement of the device with passive dorsiflexion of the ankle joint, and reflex-mediated muscle activity as determined by EMG. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"aolau867j9","properties":{"formattedCitation":"{\\rtf \\super 13\\nosupersub{}}","plainCitation":"13"},"citationItems":[{"id":2432,"uris":[""],"uri":[""],"itemData":{"id":2432,"type":"article-journal","title":"Spasticity in adults with cerebral palsy and multiple sclerosis measured by objective clinically applicable technique","container-title":"Clinical Neurophysiology","page":"2010-2021","volume":"129","issue":"9","source":"ScienceDirect","abstract":"Objective\nThe present study evaluated ankle stiffness in adults with and without neurological disorders and investigated the accuracy and reproducibility of a clinically applicable method using a dynamometer.\nMethods\nMeasurements were obtained from 8 healthy subjects (age 39.3), 9 subjects with spastic cerebral palsy (CP) (age 39.8) and 8 subjects with multiple sclerosis (MS) (age 49.9). Slow and fast dorsiflexion stretches of the ankle joint were performed to evaluate passive muscle-tendon-joint stiffness, reflex mediated stiffness and range of movement (ROM), respectively. Intra/inter-rater reliability for passive and reflex mediated ankle muscle stiffness was assessed for all groups.\nResults\nSubjects with CP and MS showed significantly larger values of passive stiffness in the triceps surae muscle tendon complex and smaller ROM compared to healthy individuals, while no significant difference in reflex mediated stiffness. Measurements of passive muscle-tendon-joint stiffness and reflex mediated stiffness showed good to excellent inter- and intra-rater reliability (ICC: 0.62–0.91) in all groups.\nConclusion\nIncreased stiffness was found in subjects with CP and MS with a clinically applicable method that provides valid and reproducible measurement of passive ankle muscle-tendon-joint stiffness and reflex mediated stiffness.\nSignificance\nThe present technique may provide important supplementary information for the clinician.","DOI":"10.1016/j.clinph.2018.07.004","ISSN":"1388-2457","journalAbbreviation":"Clinical Neurophysiology","author":[{"family":"Yamaguchi","given":"Tomofumi"},{"family":"Hvass Petersen","given":"Tue"},{"family":"Kirk","given":"Henrik"},{"family":"Forman","given":"Christian"},{"family":"Svane","given":"Christian"},{"family":"Kofoed-Hansen","given":"Mathilde"},{"family":"Boesen","given":"Finn"},{"family":"Lorentzen","given":"Jakob"}],"issued":{"date-parts":[["2018",9,1]]}}}],"schema":""} 13Appendix B. Outcome MeasuresObservational Gait Scale ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a1nrfgejirb","properties":{"formattedCitation":"{\\rtf \\super 55\\nosupersub{}}","plainCitation":"55"},"citationItems":[{"id":2527,"uris":[""],"uri":[""],"itemData":{"id":2527,"type":"article-journal","title":"Carbon Modular Orthosis (Ca.M.O.): An innovative hybrid modular ankle-foot orthosis to tune the variable rehabilitation needs in hemiplegic cerebral palsy.","container-title":"NeuroRehabilitation","page":"447-457","volume":"40","issue":"3","source":"Semantic Scholar","abstract":"BACKGROUND\nHemiplegic Celebral Palsy (CP) children commonly use AFO orthoses as walking aids. It is known that AFOs may have a detrimental effect on gait. To enhance mechanical properties of AFOs we developed an innovative, custom-made, carbon, ankle-foot orthosis (Ca.M.O) which offers the opportunity to tune its response to the patient's gait characteristics and/or functional maturity.\n\n\nOBJECTIVE\nTo assess the efficacy of Ca.M.O. in improving gait in a group of hemiplegic CP children and to compare its performances with those of commonly prescribed AFO.\n\n\nMETHODS\nA clinical and instrumental gait analysis was performed on a group of 15 spastic hemiplegic children (WINTERS-GAGE type I-II) walking barefoot, with commonly prescribed AFOs and with Ca.M.O.Temporal, kinematic and kinetic data were collected with an 8 cameras optoelectronic system and 2 force plates.\n\n\nRESULTS\nStudied variables were comparable walking with Ca.M.O. and with the commonly prescribed AFO and are significantly different (p?<?0.01) with respect to barefoot condition.\n\n\nCONCLUSIONS\nBoth types of orthoses normalize the kinematics of the first and second ankle rocker. The main advantage of Ca.M.O. is its modularity that allows to tune its effect on gait in relationship with the progress or involution of the child's functional development.","DOI":"10.3233/NRE-161432","shortTitle":"Carbon Modular Orthosis (Ca.M.O.)","author":[{"family":"Tavernese","given":"Emanuela"},{"family":"Petrarca","given":"Maurizio"},{"family":"Rosellini","given":"Giulia"},{"family":"Stanislao","given":"Eugenio Di"},{"family":"Pisano","given":"Alessandra"},{"family":"Rosa","given":"Giuseppe Di"},{"family":"Castelli","given":"Eleanora"}],"issued":{"date-parts":[["2017"]]}}}],"schema":""} 55:Tardieu Scale:The Tardieu Scale is an evidenced outcome measure for differentiating spasticity from joint contractures. It takes into account the velocity of stretch and the muscle reaction in addition to the angle at which the muscle reacts. It is not a specific tool for assessing a joint contracture, but is useful in performing a differential diagnosis, especially in the neurologically-involved populations. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a20jj8r7kbj","properties":{"formattedCitation":"{\\rtf \\super 33\\nosupersub{}}","plainCitation":"33"},"citationItems":[{"id":2587,"uris":[""],"uri":[""],"itemData":{"id":2587,"type":"article-journal","title":"The Tardieu Scale differentiates contracture from spasticity whereas the Ashworth Scale is confounded by it","container-title":"Clinical Rehabilitation","page":"173-182","volume":"20","issue":"2","source":"PubMed","abstract":"OBJECTIVE: To compare the Tardieu Scale as a clinical measure of spasticity after stroke with the Ashworth Scale.\nDESIGN: Cross-sectional study.\nPARTICIPANTS: Sixteen people, living in the community three years after their stroke.\nMAIN MEASURES: The Ashworth Scale and Tardieu Scale as well as laboratory measures of spasticity (stretch-induced electromyographic (EMG) activity) and contracture (maximum passive joint excursion) were collected from the affected elbow flexors and extensors and ankle plantarflexors and dorsiflexors by three examiners who were blinded to the results of the other measures.\nRESULTS: The percentage exact agreement (PEA) between the Tardieu Scale and a laboratory measure of spasticity was 100% for both the elbow flexors and ankle plantarflexors. This was significantly (P= 0.02) greater than the PEA of 63% for both muscles between the Ashworth Scale and the same laboratory measure of spasticity. For contracture, the PEA between the Tardieu Scale and a laboratory measure was 94% for both the elbow flexors and the ankle plantarflexors. Pearson correlation coefficients between the Tardieu Scale and laboratory measures of spasticity were 0.86 for the elbow flexors and 0.62 for the ankle plantarflexors and between the Tardieu Scale and laboratory measures of contracture were 0.89 for the elbow flexors and 0.84 for the ankle plantarflexors.\nCONCLUSION: In all cases that spasticity was overestimated by the Ashworth Scale, participants had a contracture. These findings suggest that the Tardieu Scale differentiates spasticity from contracture whereas the Ashworth Scale is confounded by it.","DOI":"10.1191/0269215506cr922oa","ISSN":"0269-2155","note":"PMID: 16541938","journalAbbreviation":"Clin Rehabil","language":"eng","author":[{"family":"Patrick","given":"Emily"},{"family":"Ada","given":"Louise"}],"issued":{"date-parts":[["2006",2]]}}}],"schema":""} 33Knee Society Score:The following link provides access to the online Knee Society Score sheet that provides automatic scoring upon being filled out, and also provides ranges for excellent, good, fair, and poor knee function. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a1ba6qiuqn6","properties":{"formattedCitation":"{\\rtf \\super 36,42\\nosupersub{}}","plainCitation":"36,42"},"citationItems":[{"id":2519,"uris":[""],"uri":[""],"itemData":{"id":2519,"type":"article-journal","title":"Outcome measures in older persons with acquired joint contractures: a systematic review and content analysis using the ICF (International Classification of Functioning, Disability and Health) as a reference","container-title":"BMC Geriatrics","volume":"16","source":"PubMed Central","abstract":"Background\nJoint contractures are a common health problem in older persons with significant impact on activities of daily living. We aimed to retrieve outcome measures applied in studies on older persons with joint contractures and to identify and categorise the concepts contained in these outcome measures using the ICF (International Classification of Functioning, Disability and Health) as a reference.\n\nMethods\nElectronic searches of Medline, EMBASE, CINAHL, Pedro and the Cochrane Library were conducted (1/2002-8/2012). We included studies in the geriatric rehabilitation and nursing home settings with participants aged ≥ 65 years and with acquired joint contractures. Two independent reviewers extracted the outcome measures and transferred them to concepts using predefined conceptual frameworks. Concepts were subsequently linked to the ICF categories.\n\nResults\nFrom the 1057 abstracts retrieved, 60 studies met the inclusion criteria. We identified 52 single outcome measures and 24 standardised assessment instruments. A total of 1353 concepts were revealed from the outcome measures; 96.2 % could be linked to 50 ICF categories in the 2nd level; 3.8 % were not categorised. Fourteen of the 50 categories (28 %) belonged to the component Body Functions, 4 (8 %) to the component Body Structures, 26 (52 %) to the component Activities and Participation, and 6 (12 %) to the component Environmental Factors.\n\nConclusions\nThe ICF is a valuable reference for identifying and quantifying the concepts of outcome measures on joint contractures in older people. The revealed ICF categories remain to be validated in populations with joint contractures in terms of clinical relevance and personal impact.\n\nElectronic supplementary material\nThe online version of this article (doi:10.1186/s12877-016-0213-6) contains supplementary material, which is available to authorized users.","URL":"","DOI":"10.1186/s12877-016-0213-6","ISSN":"1471-2318","note":"PMID: 26860991\nPMCID: PMC4748463","shortTitle":"Outcome measures in older persons with acquired joint contractures","journalAbbreviation":"BMC Geriatr","author":[{"family":"Bartoszek","given":"Gabriele"},{"family":"Fischer","given":"Uli"},{"family":"Müller","given":"Martin"},{"family":"Strobl","given":"Ralf"},{"family":"Grill","given":"Eva"},{"family":"Nadolny","given":"Stephan"},{"family":"Meyer","given":"Gabriele"}],"issued":{"date-parts":[["2016",2,9]]}}},{"id":2524,"uris":[""],"uri":[""],"itemData":{"id":2524,"type":"webpage","title":"Knee Society Score - Orthopaedic Scores","URL":"","accessed":{"date-parts":[["2019",11,22]]}}}],"schema":""} 36,42 C. Treatment DevicesFigure 4. Knee Joint DynasplintThe Dynasplint is an application for the knee joint to induce the principle of creep for the purposes of pushing the knee joint into extension. It is commonly used for the treatment of knee flexion contractures. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a1e28a93ijo","properties":{"formattedCitation":"{\\rtf \\super 56\\nosupersub{}}","plainCitation":"56"},"citationItems":[{"id":2568,"uris":[""],"uri":[""],"itemData":{"id":2568,"type":"webpage","title":"Knee Extension Splint | Dynamic Knee Splint","URL":"","accessed":{"date-parts":[["2019",11,26]]}}}],"schema":""} 56Figure 5. Joint Active System for the Knee and Ankle JointsThe Joint Active System (JAS) is an application of an increasing level of strain at a joint that is progressed as the tissues at the joint accommodate to the current level of stress imposed. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a2nt4p89jc4","properties":{"formattedCitation":"{\\rtf \\super 43\\nosupersub{}}","plainCitation":"43"},"citationItems":[{"id":2569,"uris":[""],"uri":[""],"itemData":{"id":2569,"type":"post-weblog","title":"JAS EZ Knee Extension","container-title":"JAS","abstract":"The JAS EZ Knee Extension offers a no-compromise approach to Range of Motion (ROM) therapy — 48° flexion, 36° hyperextension — in a lightweight, easy-fit, single-patient use device. (Available in US domestic markets only)","URL":"","language":"en-US","accessed":{"date-parts":[["2019",11,26]]}}}],"schema":""} 43 It is another method of treating joint contractures. Bibliography ADDIN ZOTERO_BIBL {"custom":[]} CSL_BIBLIOGRAPHY 1. Howard J, Trevick S, Younger DS. Epidemiology of Multiple Sclerosis. Neurol Clin. 2016;34(4):919-939. doi:10.1016/j.ncl.2016.06.0162. Hankins GDV, Speer M. Defining the pathogenesis and pathophysiology of neonatal encephalopathy and cerebral palsy. 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