We thank Weppler1 for her interest in our article.2 She raises 5 issues, which we address in turn:
Issue 1. The conclusion is not justified because there are not enough clinical trials and the existing clinical trials have not explored all possible combinations of stretch administered to all types of joints and muscles in every type of patient with neurological conditions (as indicated in Weppler's Tables 1 and 2).
Response: We explored the possibility through multiple meta-regressions that the response to stretch varies depending on a range of factors, including those factors identified by Weppler. These results are reported in the full publication of the Cochrane systematic review.3 There was no indication that any of these factors influence outcome. In fact, the results were surprisingly consistent across all disability groups, joints, muscles, and modes of stretch application. We do not agree with Weppler's suggestion that clinical trials are required for every possible combination of disability group, muscle, joint, and mode of stretch application. Apart from all else, as Weppler's Tables 1 and 2 indicate, 144 trials would be required to generate 2 trials for each combination of factors.
Issue 2. The clinically important change was set without regard for factors such as the type of joint, severity of the contracture, and involved muscles.
Response: …
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- Issue 1. The conclusion is not justified because there are not enough clinical trials and the existing clinical trials have not explored all possible combinations of stretch administered to all types of joints and muscles in every type of patient with neurological conditions (as indicated in Weppler's Tables 1 and 2).
- Issue 2. The clinically important change was set without regard for factors such as the type of joint, severity of the contracture, and involved muscles.
- Issue 3. Although stretch had no effect on joint range of motion measured with a standardized torque, it may have had an effect within the muscle or on the ability of the muscle to actively generate force or on other measures of joint mobility.
- Issue 4. The review should have investigated the effects of stretch on patients' perceptions of stretch.
- Issue 5. The review did not provide an alternative suggestion for contracture management.
- Statement 1. “Many of the studies demonstrated significant positive effects of stretching….”
- Statement 2. “The 4 studies involving only the direct application of stretch showed the potential of several stretching interventions to prevent contracture formation. For example, 2 of the direct stretch studies demonstrated a significant treatment effect in contracture prevention.”
- Statement 3. “Overall, the studies involving splinting and casting suggested that these interventions are more effective in preventing and treating contractures when combined with passive stretching programs than when used alone.”
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