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Clinical Rehabilitation 2006; 20: 656 Á667 Contracture preventive positioning of thehemiplegic arm in subacute stroke patients: a pilotrandomized controlled trial LD de Jong Rehabilitation Centre ‘de Vogellanden’, Zwolle, The Netherlands, A Nieuwboer Faculty of Physical Education andPhysiotherapy, Department of Biomedical and Rehabilitation Sciences, University of Leuven, Belgium and G AufdemkampeUniversity of Professional Education, Faculty of Health Care, Research Department of Health and Lifestyle and Department ofPhysical Therapy, Utrecht, The Netherlands Received 9th September 2005; returned for revisions 21st November 2005; revised manuscript accepted3rd January 2006.
Objective: To investigate the effectiveness of a contracture preventive positioningprocedure for the hemiplegic arm in subacute stroke patients in addition toconventional physio- and occupational therapy.
Design: A single-blind pilot randomized controlled trial.
Setting: Inpatient neurological units from three rehabilitation centres in theNetherlands.
Subjects: Nineteen subacute stroke patients (minus two drop-outs) with a severemotor deficit of the arm.
Interventions: All subjects underwent conventional rehabilitation care. Nine subjectsadditionally received a positioning procedure for two 30-min sessions a day, five daysa week, for five weeks.
Main measures: Passive range of motion of five arm movements using ahydrogoniometer and resistance to passive movement at the elbow using theAshworth Scale. Secondary outcome measures were pain at the end range ofpassive motions, the arm section of the Fugl-Meyer Assessment and Barthel Indexscores for ADL-independence. Outcome measures were taken after five weeks andadditional measurements after 10 weeks by two assessors blinded to groupallocation.
Results: Comparison of the experimental (n 0/9) with the control subjects (n 0/8)after five weeks showed that additional positioning significantly slowed downdevelopment of shoulder abduction contracture (P 0/0.042, (/5.3 degrees versus (/23 degrees). No other differences were found between the groups.
Conclusions: Applying a contracture preventive positioning procedure for thehemiplegic arm slowed down the development of shoulder abduction contracture.
Positioning did not show significant additional value on other outcome measures.
Since the sample size was small, results of this study need future verification.
Address for correspondence: Lex D de Jong, RehabilitationCentre ‘de Vogellanden’, Department of Physiotherapy, PO Box1057, 8001 BB Zwolle, The Netherlands.
e-mail: l.de.jong@vogellanden.nl Positioning of the hemiplegic arm after stroke increased resistance to passive movement. Second,does a positioning procedure have an effect on Hemiplegic shoulder pain is one of the most pain, motor performance of the arm and indepen- frequent complications after stroke.1 Á 5 Reviews of the literature6 Á 9 provide an overview of thedifferent impairments of the shoulder joint andsummarize the most effective therapeutic interven- tions to prevent hemiplegic shoulder pain. One ofthe factors associated with shoulder pain seems to A single-blind randomized controlled, multi- centre trial was designed to investigate the effec- Poststroke contractures, as reflected by the loss tiveness of a well-defined positioning procedure for of range of motion, are not surprising since the hemiplegic arm in subacute stroke patients.
increasing evidence supports the hypothesis that Rather than the positioning procedure(s) used in immobility after stroke is associated with changes previous studies by Dean et al .22 and Ada et al .21 in muscle due to adaptive mechanical and mor- we additionally applied stretch to the elbow phological changes in muscle fibres.11,12 The flexors. The study was approved by the local proportion of patients with contracture in the medical ethics committee. All subjects gave written hemiplegic arm approximately five months post informed consent prior to participation.
stroke was reported to be as high as 54%.13In conjunction with contracture, resistance to passive movement14 and spasticity develops in Using a sampling method of convenience, sub- some patients.13 Spasticity was found to be present jects were recruited from three rehabilitation in 26% of acute hemiparetic patients and in 28% centres in the Netherlands (Apeldoorn, Doorn three months after stroke in the study by Sommer- and Zwolle). All stroke patients admitted between feld et al .15 Spasticity (or more specifically, hyper- March 2003 (one centre participated as from tonus) seems to be another cofactor in the January 2004) and January 2005 were initially development of hemiplegic shoulder pain.6 It is related to a decrease in joint passive range of Subjects had to meet the following inclusion motion16 and correlates both to motor impair- criteria: (1) first ever stroke as defined by the ments15,17 and limitations in activities of daily World Health Organization23 and maximally 12 weeks post stroke; (2) a medial cerebral artery Considering the above discussed impairments in stroke, established by means of computerized and around the hemiplegic shoulder it is hypothe- tomography/magnetic resonance imaging (CT/ sized that prevention of contracture11,12,14,19 and MRI); (3) no premorbid impairments of the maintaining an optimal pain free range of joint affected arm; (4) no severe shoulder pain; (5) motion6 is an important therapeutic intervention no use of antispasticity drugs; (6) no use of in stroke rehabilitation. Several authors suggest pain-reducing drugs except for paracetamol, (7) and describe different methods to prevent contrac- no planned date of discharge and (8) able to ture (i.e. different positioning procedures).11,20 give written informed consent. Subjects with fair Recently, Ada et al .21 showed for the first time to good recovery of the arm (as defined by that upper-limb positioning prevented shoulder Brunnstrom’s stages of recovery 4, 5 or 624 and external rotation contracture. However, questions judged by the physician) were excluded. Patients remain as to whether recovery of selective arm who met the inclusion criteria were then referred to movements, spasticity, pain and independence in a physiotherapist, who administered tests to ex- ADL were affected by this intervention. Therefore, clude patients with (9) severe neglect (a difference the present pilot trial addressed the following of more than three O’s on the letter cancellation questions: Does a positioning procedure for the test,25 severe loss of position sense (scores 2 and 3 hemiplegic arm prevent (1) contracture as reflected on the Thumb Finding Test26,27) and cognitive by a decrease in passive range of motion and (2) impairment scoring lower than 23 points on the Mini-Mental State Examination.28 Á 30 Subjects administered according to the recommendations with aphasia that could not answer the ques- of Bohannon and Smith39 and Koolstra et al .40 tions of the Mini-Mental State Examination weretested by means of the language comprehension subitems of the Akense Afasie Test31 (minimum 67 Secondary outcome measures were (3) pain, (4) points). Finally, patients who were able to prevent motor performance of the hemiplegic arm and (5) contracture by producing voluntary movement, independence in ADL. Subjects were asked to having a Fugl-Meyer arm score of more than 18 report if they felt pain at the end range of each points on the shoulder/elbow/forearm subscales,32 performance was assessed using the 66-point armsection of the Fugl-Meyer Assessment,32 a test that is both valid41,42 and reliable42 Á 45 and assesses the Primary outcome measures were (1) passive subject’s reflexes, the ability to perform 21 different range of motion using a masked fluid-filled volitional arm movements and co-ordination on an goniometer (MIE Medical Research Ltd., Leeds, ordinal scale. Independence in ADL was assessed UK) and (2) resistance to passive movement using a validated and reliable Dutch translation of using a Dutch translation of the original 5-point A pretrial power analysis was conducted using For standardization purposes of the passive published data of shoulder external rotation range range of motion testing procedures the assessors of motion of the involved shoulder joint in were trained beforehand,34,35 shoulder abduction hemiplegic people.2,4,10,37,47,48 When a power of 80% was used with a standard deviation of ments34,36,37 and two raters were used simultane- 20 degrees and a significance level of 0.05 (two ously. The first rater carried out one ‘warming-up’ sided), 17 participants were required for each movement prior to the actual passive movement, the second rater measured the maximum rangewith a masked goniometer. Inter-rater reliability ofthe measurement protocol was explored simulta- neously. Intraclass correlation coefficients (ICC Subjects were randomly assigned to one of the type 3,1) were calculated for three different data- two groups using opaque, sealed envelopes con- sets, representing the three different evaluations taining leaflets with either a capital A (experimen- tal group) or a capital B (control group).
ICCs were high, ranging between 0.78 and 0.99 Anticipating a patient drop-out of 10%, a total (detailed procedures and results will be published of 38 envelopes (19 As, 19 Bs) were distributed over three separate boxes to make sure that bothgroups were evenly distributed over both arms of Ashworth grading of resistance to passive movement the study. An independent person carried out the Reliability of the original Ashworth Scale in randomization procedure. The envelopes were stroke subjects was established for the elbow shuffled and drawn blindfolded. Treatment was flexors.38 We developed and used a Dutch transla- initiated immediately after baseline measurement tion of the original Ashworth Scale and simulta- and within one week of the randomization proce- neously explored the interrater reliability of this dure. Outcome measurements were taken five translation. Agreement between our two raters weeks later. Final measurements took place 10 when rating the resistance to passive extension of weeks after baseline measurements. The same two the elbow during the three different evaluations raters, unaware of group allocation and not was fair to moderate (percentages of agreement involved in the treatment of subjects, carried out between 67% and 83%, weighted kappa ranging all the measurements. Blinding was achieved by from 0.484 to 0.773). The Ashworth gradings were reminding the subjects before every measurement Positioning of the hemiplegic arm after stroke that they should not reveal allocation to the allocated to the control group received no addi- tional therapy or positioning procedures.
To document the contents of each physio- and All subjects received ‘conventional’ rehabi- occupational therapy session during the 10 weeks litation treatment according to their clinical of the experiment, therapists were asked to com- need as prescribed by the subject’s primary care plete a checklist after every therapy session. The rehabilitation physician. Additionally, the subjects checklist was based upon the International Classi- allocated to the experimental group were asked to fication of Functioning, Disability and Health carry out the prescribed positioning procedure for (ICF) of the World Health Organization.49 By five weeks, twice a day for half an hour on keeping this sort of therapy diary, possible con- weekdays (a total of 25 h in five weeks). Subjects founding effects of the type and amount of (move- still admitted after five weeks were asked to ment) therapy for the arm were recorded.
participate for another five weeks for follow-uppurposes. Positioning was carried out by the nursing staff under supervision of trained research Ratio-level characteristics of subjects in the physical therapists who instructed how the posi- experimental and control group were compared tioning procedure should be carried out. Care was using a Student’s t -test and nominal level char- taken that while moving the arm into position, the acteristics by means of a chi-square test. All shoulder was moved with sufficient external rota- primary and secondary outcome measures were tion to avoid impingement or damage to the compared at baseline and at five weeks between rotator cuff muscles. The arm was positioned groups using the Student’s t -test (range of motion), with as much shoulder abduction, shoulder ex- Mann ÁWhitney U -test (Ashworth Scale, Fugl- ternal rotation, elbow extension and supination of Meyer Assessment, Barthel Index) and a chi- the forearm as the subject could endure without square test (pain score). One subject from the any pain. The arm was always supported by a experimental group (who became too ill to parti- pillow and, if necessary, held in position with a cipate any further) and one from the control group sandbag (Figure 1). Patients were instructed not to (who developed severe shoulder pain and refused change the position of the trunk to keep the m.
further measurements) were not included in the pectoralis major elongated. Nursing staff regis- analyses because of drop-out before the five week tered whether the procedure was carried out as measurement (Figure 2). Results of the 10-week prescribed and noted possible deviations. Subjects measurements between the groups were not ana-lysed statistically due to the small sample size andhigh drop-out rate. All statistical procedures werecarried out using SPSS for Windows (version10.0.5). Level of significance was set at P 0/0.05.
Figure 2 shows the flow of subjects through eachstage of the trial. Half of all eligible subjects werejudged as already having reached Brunnstrom’sfourth stage of recovery on admission, and werethus excluded. Eventually, only 19 subjects met allinclusion criteria and were randomly assigned tothe experimental group (n 0/10) or the control The experimental positioning procedure.
group (n 0/9). The nine men and eight women who Reasons for (primary) exclusion*
More than 12 weeks post-stroke (n = 2), no first strokein middle cerebral artery (n = 13), fair to good recoveryof involved upper limb (n = 71), use of spasticityreducing medication (n = 5), use of pain reducingmedication (n = 8), planned date of discharge (n = 5),refused/could not (to) participate, (n = 18),unknown/missing data (n = 5).
Reasons for (secondary) exclusion*
Severe neglect/sensory impairments (n = 13), severecognitive impairments (n = 2), reasonable/good upperlimb function (FMA>18 points shoulder /elbow subtests)(n = 8), severe aphasia (n = 1).
Experimental Group Baseline
Control Group Baseline
Five week outcome data
Five week outcome data
botulinum toxin, 1 due totreatment with botulinum Ten week follow-up data
Ten week follow-up data
Flow of subjects through each stage of the trial from initial screening by rehabilitation physician to outcome measurement. *If subjects were excluded for more than one reason all reasons were mentioned separately.
Positioning of the hemiplegic arm after stroke completed the study were between 36 and 63 years on entry into the study (P 0/ 0.60). Despite a of age. Eleven out of 17 subjects had an affected slight increase in both groups after five weeks, left side (right hemisphere). Subjects from the the differences between the groups did not reach experimental group started to use the positioning significance (P 0/0.917). Subjects from the ex- procedure around a mean (SD) of 35.7 (8.2) days perimental group started out with higher median post stroke. There were no differences between the scores on the Fugl-Meyer Assessment than the groups with respect to these characteristics.
controls (16 versus 8.5 points), but this difference As shown in Table 1, both groups received a was not significant between the groups. After five comparable total amount of time spent on physio- weeks the subjects from the experimental group and occupational therapy. The experimental group improved their ability to make selective move- received more physiotherapy and less occupational ments of the hemiplegic arm. The control group therapy for the hemiplegic arm after five weeks, on the other hand hardly showed any improve- but the differences were not statistically significant.
ments at all. The difference between the groups The nine subjects from the experimental group was significant (P 0/0.038). Both groups showed had the hemiplegic arm positioned for an average improvements in independence in ADL during of approximately 20 hours (80% compliance to the five weeks of participation. Barthel Index scores did not differ significantly at entry of thestudy or after five weeks. Of all participatingsubjects, approximately 65% reported pain at the end range of the shoulder movements and 35% of the elbow and forearm movements. There comparable in both groups at entry into the study (Table 2). It is of note that the shoulder groups at this point. The pain at end of motion external rotation and flexion ranges tended to the subjects reported in the elbow and forearm be larger in the experimental group, but these hardly changed over the first five weeks, but differences were not significant. In the course of increased for the shoulder movements to ap- the first five weeks a clear decrease was seen in proximately 76% of the subjects. Again, there the range of motion of both groups, especially in shoulder abduction range of motion was signifi-cantly greater in the experimental group (P 0/0.042). Table 2 also shows that none of the other movement directions were significantly Having participated for five weeks in the primary study, 10 subjects were able to partici- pate for a further period of five weeks. During gradings were not different between the groups these five weeks, the remaining four subjects Means (standard deviations) of content of treatment sessions and time spent in the positioning procedure at five EXP, experimental group; CON, control group; OT, occupational therapy; PT, physiotherapy.
a Data from one control subject missing.
Positioning of the hemiplegic arm after stroke from the experimental group received consider- passive stretch at five weeks. Fugl-Meyer Assess- ably more hours of physio- and occupational ment scores in the experimental group were therapy and had the hemiplegic arm positioned already larger on entry into the study, a differ- for an additional average of 19 h (76% of ence that reached significance after five weeks.
compliance to intervention). Added to the first This trend seemed to continue after 10 weeks for the remaining subjects of the experimental group, positioning (78% compliance to total interven- but was probably biased by baseline differences.
tion). Ten-week data are shown in Table 4.
The percentage of subjects with pain at the endrange of the shoulder movements remained highin both groups from baseline to 10 weeks.
Especially in the first five weeks of the trial the participating subjects of both groups gainedmore independence of ADL function as indicated The aim of this pilot study was to investigate the effectiveness of a contracture preventive position- One major limitation of this study was that it was ing procedure for subacute stroke patients with a underpowered. We aimed to select 34 subacute severe motor deficit of their hemiplegic arm.
stroke patients, but after nearly two years the trial had to be terminated because of set time limits, groups showed a clear decrease in the passive leaving only 19 subjects who met all inclusion range of motion of most arm movements.
criteria. This suggests that the inclusion criteria Applying the positioning procedure for five were too strict. However, most patients were weeks slowed down the development of shoulder excluded because we considered their arm function abduction contracture. Descriptive analysis of as too ‘active’ for a ‘passive’ preventive positioning the 10-week measurements showed further de- procedure. Therefore, the patients included in this creases of passive range of motion in both study were representative of the target population, groups. No significant differences were found confirming the appropriateness of this inclusion between the groups with respect to resistance to criterion. Since only stroke patients eligible forclinical rehabilitation services were included in this Means (standard deviations) of the different vari- study, people with severe stroke and/or severe ables of the remaining 10 subjects after 10 weeks of cognitive disabilities were excluded, hence reducing Another possible limitation of the study was that the positioning procedure was carried out byseveral different nurses under the supervision of four physiotherapists trained in carrying out the positioning procedure. Regular checks of the positioning procedure by an independent assessor would have increased the rigour of this metho- dology. The current procedure however reflected the standard method of working in a Dutch rehabilitation centre. Compliance to the protocol was not perfect (80%) because some subjects Prevention of contracture in stroke patients is deemed very important in the stroke rehabilitation PROM, passive range of motion; ER, shoulder external literature.11,20 Dean et al .22 reported unclear rotation; FLX, shoulder flexion; ABD, shoulder abduction; effects of a contracture preventive positioning EXT, elbow extension; SUP, forearm supination; AS-EE, protocol, mainly attributed to limited sample Ashworth grade for elbow extension; IQR, interquartile range;FMA, Fugl-Meyer Assessment armscore; BI, Barthel Index.
size and insufficient dosage. Ada et al .21 found a Data from one control subject missing.
that 30 min of daily positioning for four weeks significantly prevented shoulder external rotation In this study, motor performance was assessed contracture. Compared with the procedures used by the arm section of the Fugl-Meyer Assess- by Dean et al . and Ada et al . we also stretched the ment. The score on this measure represents the elbow flexors using a positioning procedure that capability of making several synergistic move- was prescribed for 60 min each working day for ments, and so it is not an objective measure of five consecutive weeks over and above standard useful functional motor performance. Despite the fact that motor performance recovered signifi- As in the study of Dean et al ., our subjects cantly more in the experimental group, it is started the experimental positioning procedure in unlikely that the passive stretching procedure or around their fifth week post stroke, three alone led to significant differences in motor weeks later than the subjects in the study by Ada performance. The experimental group’s higher et al . Dean et al . found a mean decrease in baseline scores possibly emphasized the motor shoulder external rotation of respectively 11 and scores after five weeks. The effect of more arm 14 degrees in the experimental and control therapy between five and 10 weeks probably groups after six weeks of positioning. Ada biased this difference even more. At the start ofthe study, nearly 65% of all subjects (n et al . found decreases of 6.1 and 17.9 degrees pain at the end range of shoulder motions. This respectively after five weeks. In line with those is in concordance with the findings of other results, our subjects showed not only a 19.2 authors.1,4,5 Five weeks into the study, 76% of all (experimental group) and 18.4 (control group) subjects reported pain at end of motion and of decrease in shoulder external rotation, but also the remaining 10 participants after 10 weeks 83% decreases in shoulder abduction and flexion.
still reported pain. Pain felt at the end range of Despite the apparent decreases in the range of motion was present and increased in both groups motion, shoulder abduction was significantly during the trial. It is unlikely that this was larger in our experimental group after five weeks.
caused by the positioning procedure. As no Given the nearly similar positioning procedures single subject reported an inconvenience during to the study of Ada et al ., no other explanation the positioning procedure it seems justified to can be given for the lack of benefit in shoulder conclude that this kind of positioning is safe and external rotation except for the difference in harmless as long as it is performed within the statistical power or the differences in fixation, allowing the weight of the lower arm to pull the Fifteen to thirty minutes of daily stretching shoulder joint into more or less external rotation.
may be enough for healthy active animal muscles Resistance to passive movement of the elbow to prevent contracture50,51 but positioning proce- flexors as quantified by the Ashworth Scale was dures for hemiparetic arms of stroke patients not influenced by the positioning despite the examined so far at the very most only seem to (submaximal) stretching of the elbow flexors.
slow down the development of some contrac-ture(s). To uncover larger significant effects, maybethe positioning procedure should be applied for more than 1 h each day. However, we doubt thatthis is feasible within a clinical rehabilitation . Preventive positioning of the hemiplegic arm setting because of all the other time-consuming therapeutic activities during the day.
shoulder abduction passive range of motion Slowing down the development of contractures using positioning procedures may be a prerequisite for the recovery of arm function, but we argue that . Effects of positioning procedures on spasti- combinations of more types of treatment are city, motor performance, pain and indepen- needed to have more impact on hemiplegic arm dence in activities in daily life still remain recovery. Especially stroke patients with very poor arm function could benefit from combined pre-ventive measures since they have limited abilities to Positioning of the hemiplegic arm after stroke ‘actively’ train their hemiplegic arm. Positioning national rehabilitation hospital in Turkey. Am J procedures in conjunction with the use of electrical Phys Med Rehabil 2004; 83: 713 Á19.
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