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The Use of Casts in the Management of Joint Mobility and Hypertonia Following Brain Injury in Adults: A Systematic Review

PA Mortenson, BScOT, is Occupational Therapist, Children's and Women's Health Centre, Vancouver, British Columbia, Canada, and Graduate Student, School of Rehabilitation Sciences, University of British Columbia, Vancouver
JJ Eng, PT/OT, PhD, is Associate Professor, School of Rehabilitation Sciences, T325-2211 Wesbrook Mall, Vancouver, British Columbia, Canada V6T 2B5 (janicee{at}interchange.ubc.ca), and Scientist, Rehabilitation Research Laboratory, GF Strong Rehab Centre

Address all correspondence to Dr Eng

	Abstract

 
Many controversies exist regarding the practicality, the theoretical premises, and the supporting evidence for the use of casts in the management of joint hypomobility and hypertonia (ie, increase in joint resistance to passive movement resulting from hyperactivity of the stretch reflex and/or changes in the muscles and connective tissues). The purpose of this review was to determine current best practice for the use of casting in the rehabilitation of adults with brain injury. A systematic review was undertaken to find studies that quantified the effectiveness of casting in adults with brain injury. Thirteen articles that presented experimental or case report evidence on casting were analyzed using Sackett's levels of evidence and were examined for scientific rigor. A grade B recommendation is given for the use of casting to increase passive range of motion or to prevent its loss, and implications for further research are provided.

Key Words: Brain Injury • Casting • Muscle spasticity • Rehabilitation

	Introduction

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Reduced joint mobility, hypertonia, and muscle contracture are among the many possible listed sequelae following injury to the central nervous system.^1,2 Hypertonia is the increase in joint resistance to passive movement and results from spasticity (ie, hyperactivity of the stretch reflex) and/or changes in the characteristics of the muscular and connective tissues.^3,4 The application of casts as a technique to manage hypertonia and contractures and to ultimately increase range of motion (ROM) has been described.^5–7 Casts offer a temporary, specific, and noninvasive intervention⁵ as an alternative or complement to other interventions (eg, pharmacological agents). Casts made of either plaster or fiberglass are most commonly applied over the ankle or elbow joints for 3 to 7 days.^8–11 In some instances, the casts are changed sequentially (ie, serial casts) every few days or every week to incrementally increase joint ROM.⁹

The use of casts to control hypertonia was first described in the 1960s in the treatment of children with cerebral palsy.^12,13 Since that time, casting of the ankle joint has been examined and found to be effective in improving joint ROM and reducing hypertonia for children with cerebral palsy.^14,15 Despite the recent use of botulinum toxin for the management of hypertonia, there appears to be a consensus that other interventions, such as casting, are important in cerebral palsy.¹⁶ Casting is also thought to be an important intervention for controlling contractures and hypertonia in adults with brain injury.⁷ Although many different theories exist to support the use of casts in adults with brain injury, the effectiveness of casting for this population has not been firmly established.¹⁷

	Proposed Theories

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Spasticity has been defined as a velocity-dependent increase in the tonic stretch reflex¹⁸ (ie, reflex hyperexcitability) and is one of the principal factors affecting rehabilitation following a lesion in the central nervous system (CNS).^3,4 More recently, the broader term "hypertonia" has been used to quantify the resistance to passive movement and results from spasticity (reflex hyperexcitability), in addition to altered mechanical properties of the muscles and connective tissues.¹ Scientists are only beginning to understand the contributions and interactions of reflex hyperexcitability and altered muscle mechanical properties and functions.^1,19,20 Reflex hyperexcitability and altered muscle mechanics can presumably result in the secondary effects of contractures, muscle weakness, reduced joint active ROM, pain, heterotopic ossification, and clonus.^4,21 There are, however, no clinical tests that examine the effect of altered mechanical properties of muscle. Hypertonia can negatively affect an individual's recovery, can interfere with normal motor function, and can cause discomfort; however, reflex hyperexcitability is also purported to have beneficial effects, including the prevention of muscle wasting and deep vein thrombosis.²²

Theories have been proposed that offer different possible neurophysiological and mechanical mechanisms for the potential positive effects of casting on reflex hyperexcitability and mechanical changes. These mechanisms include the stretch imposed by the cast, the warmth provided by the enclosed structure, and the stability provided by the external structure.^5–7,17 Prolonged stretch has been shown to reduce reflex hyperexcitability.^23,24 Mechanical stretches applied to the elbow flexors for 30 minutes in adults with stroke have resulted in an increased stretch threshold (ie, the joint rotational speed at which the stretch reflex response occurs as measured by electromyography).²³ Similarly, Schmit et al²⁴ showed a reduction in the stretch reflex–induced torque of the elbow flexors, but not in that of the extensors, after 20 to 30 repetitive 10-second stretches in adults with brain injury. Recently, Tsai et al²⁵ measured reduced motoneuron excitability as measured by the H-reflex with 30 minutes of passive ankle dorsiflexion using a tilt table in adults with stroke who had increased resistance to passive ankle dorsiflexion as graded by the Ashworth scale. Thus, the prolonged stretch created by casting joints and muscles affected by CNS lesions has been hypothesized to stimulate the Golgi tendon organs and subsequently Ib afferent fibers, which create an inhibitory response to the alpha motoneurons.^6,26 The type II muscle afferents also have been postulated to result in inhibition of the alpha motoneurons following a prolonged stretch.²⁵ Whether this occurs in patients, however, is a matter of conjecture.

The provision of neutral warmth and even total pressure from the circumferential cast may reduce cutaneous sensory input to the spinal cord, thereby reducing the overall level of excitability of interneurons and motoneurons; however, this theory has little supporting evidence.²⁷ Two research groups^28,29 have evaluated the effect of circumferential pressure through the use of an air splint over 5 minutes in subjects without lesions in the CNS and those with hypertonia secondary to spinal cord injury or cerebrovascular accident (CVA). They found a reduction of alpha motoneuron reflex excitability, as measured by H-reflex amplitude. This effect, however, did not persist when the application of pressure was removed.

Casting, presumably by promoting normal reflex patterns through external stability and opportunities for normalized sensory input, such as weight bearing, may aid the development of normal movement and CNS accommodation.^6,30 At this time, no evidence exists to support these hypotheses regarding casting.⁵ Substantial evidence, however, exists that interventions that promote normal weight bearing and sensory input (eg, body support treadmill locomotion) can enhance postural and locomotor control in people with stroke or spinal cord injury.^31,32

Casting immobilizes the joints and muscle for periods of time, and this can affect muscle and connective tissues mechanics in addition to neural mechanisms of spasticity.³³ In animal models, skeletal muscle has shown the ability to lengthen in response to being held in a lengthened position by casts.^34,35 Immobilization by casting for 4 weeks in a lengthened position resulted in the addition of sarcomeres in series, and conversely, muscles held in a shortened position showed a loss of sarcomeres in series.^34,35 Sarcomere numbers returned to normal within 4 weeks after the immobilization period.³⁵ According to Lieber and Friden,³⁶ remodeling in response to immobilization appears to alter the length-tension properties so that the maximum isometric tension is found at the muscle length corresponding to the angle of immobilization. It is not known, however, whether this type of remodeling is similar to what occurs in the muscle of people with CNS lesions. Muscles in people who have hypertonia have extremely long sarcomere lengths³⁶ and increased intrinsic stiffness³⁷ compared with muscles in people without hypertonia. In addition, the extent to which muscles undergo sarcogenesis is likely dependent on the location of the muscles.³⁸

	Objective of the Systematic Review

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Casting has been described as being a labor-intensive, lengthy (casts are worn over several weeks or even months), and relatively expensive method of treatment.^8,27,39 Therapists are believed to require additional skill to be proficient at casting. Moreover, pressure sores must be avoided, and therapists need to monitor the limb for circulatory problems.^7,10 In addition, many controversies exist regarding the theoretical premises for the use of casts in the management of people with CNS lesions and their changes in muscle as well as their joint hypomobility. The drive for evidence-based practice in rehabilitation, whereby therapists use "research evidence together with clinical knowledge and reasoning to make decisions about interventions,"^40(p131) is steadily increasing. The purpose of this article is to report on "best practice" for the use of casting during rehabilitation following brain injury. To achieve this, we sought to systematically examine the level of evidence supporting the use of casting.

	Methods

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A systematic literature search and review was conducted to meet the objective of our systematic review. MEDLINE and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases were used to search the literature. These databases were accessed online through the local university's library system in October 2001, May 2002, and January 2003. The search was limited to articles written in English and was conducted for the time period of January 1982 to week 3 of January 2003.

"Casting," "brain injury," and "head injury" were used as key words for the search because we believe they reflect the intervention and condition in question. "Spasticity" also was added as a key word because spasticity management is often cited as the primary reason for using casts following CNS injury, even though authors frequently fail to define the term or they use it to represent different phenomena.⁷ The search was conducted using the basic field index (ie, of titles, abstracts, and subject headings) and using the "AND" operator in 2 combinations: "spasticity AND brain injury AND casting" and "spasticity AND head injury AND casting." Using this method, the search combinations generated 8 and 3 articles, respectively, in MEDLINE and 23 and 3 articles, respectively, in CINAHL. After reviewing these articles, we believed that the CINAHL search results were more complete than the MEDLINE results for this particular topic. An additional search of CINAHL, therefore, was conducted using the combination of key words "casts OR serial casting," and 301 articles were identified. The titles and abstracts of these references were then examined, and articles that were not related to the proposed question (eg, those pertaining to orthopedic, burn, or cerebral palsy interventions) were removed. The remaining articles identified from this process were then reviewed for additional references, and another 2 studies^41,42 were identified.

Following this screening process, 25 articles remained for further review for appropriateness and analysis. Articles were included in the subsequent analysis if: (1) they were experimental or quasi-experimental reports, (2) casting was identified as the independent variable or primary intervention, (3) subjects had what the authors called spasticity and a diagnosis of an acquired brain injury, and (4) subjects were adults. Articles in which subjects were children (under the age of 16 years) or the subjects had a diagnosis of cerebral palsy were excluded. The search was limited to adults because the adaptive response of muscles and tendons to imposed increases in length varies based on age.^43,44 Only 2 case reports^45,46 of casting for pediatric subjects with brain injury were found, which was not enough to conduct a separate review of evidence for this population. We decided to exclude cases of cerebral palsy because children with cerebral palsy have altered muscle properties and movement dynamics, in part, due to abnormally short muscles and long tendons compared with children without cerebral palsy.⁴⁷

A qualitative review process was used to account for the variety of study designs, outcome measures, and analyses used. The rigor (quality) of the studies was identified using a modified version⁴⁸ of Sackett's 1981⁴⁹ critical appraisal criteria (random assignment, blinding, intervention monitoring, dropouts, reliability and validity of measurements, confounding factors).⁴⁸ When information within an article was not sufficient to ascertain if a criterion had been fulfilled, a "No" rating was given. The level of evidence (eg, level I=large randomized controlled trial, low error risk; level II=small randomized trial, moderate to high error risk; level III=nonrandomized design; level IV=case series, no control; level V=case report) supported by each study design and the grade of recommendation for identified outcomes (eg, A=supported by at least one level I study; B=supported by at least one level II study; C=supported by level III, IV, or V evidence) were then determined as described by Sackett⁵⁰ and Butler and Campbell.⁵¹

	Results

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We found 13 articles^{8,10,11,26,27,39,41,42,52–56} describing results following the use of casting in adult populations with brain injury (Tab. 1). The number of subjects in each study ranged from 1 to 105. With the exception of 4 studies,^8,26,27,56 the primary diagnosis for subjects in all studies was traumatic brain injury (TBI). Two studies^27,56 included subjects with either CVAs or TBIs. One study⁸ included subjects with various neurological conditions causing spasticity (TBI, CVA, cerebral hypoxia, cerebral ischemia, and "other"). One article²⁶ was a case report of a woman who had a cerebral aneurysm. Casts were applied to the ankle plantar flexors in 10 studies,^{8,10,11,27,39,41,42,52,55,56} the elbow flexors in 5 studies,^{8,26,27,53,54} the knee flexors in 3 studies,^8,11,27 the wrist flexors in 2 studies,^8,53 and the combined ankle plantar flexors and knee flexors in 1 study.¹¹ Total wearing times varied from 1 to 4 days to a mean of 102 days in the study by Kent et al.³⁹ Of the 10 studies on ankle casts, 4 studies^41,42,52,56 had subjects bear weight (standing and walking) through the casts. The other 6 studies^{8,10,11,27,39,55} did not explicitly state if any subjects were weight bearing while wearing the casts, but a number of conditions were present that suggested that subjects had limited weight bearing, including agitation,⁵⁵ a low level of consciousness,^10,11,55 and a low functional level.^10,55

	Discussion

Top Abstract Introduction Proposed Theories Objective of the Systematic... Methods Results Discussion Conclusion References

 
Although casting has been used since the 1960s for people with brain injurie,^7,17 only 13 studies relating to adult brain injury were found. Of these studies, only 4 studies^8,52,54,56 had been published in the last 6 years. In addition, all or most of the studies reviewed had problems with several quality criteria (eg, co-intervention, lack of random assignment, lack of blinding, poor measurement reliability and validity). This likely reflects difficulties in performing randomized and well-controlled studies in a clinical context.

All studies reviewed were conducted during the acute or subacute stage of recovery. Subjects therefore were receiving full rehabilitative services and, in some instances, medical and pharmaceutical treatment. As a result, contamination and co-intervention were impossible to avoid. Likewise, randomly assigning subjects to groups that received casting or groups that did not receive casting presents potential ethical and professional dilemmas for those therapists who use casting as a standard intervention for spasticity after brain injury. Moseley⁵² and Hill⁵³ were able to avoid this problem by using a double crossover design, in which all subjects received some form of treatment at all times but in a randomized and controlled order. The strength of these prospective studies was compromised because there were small numbers of subjects. We believe, however, that this might be expected, given the limited number of eligible subjects likely to be available in any one institution during the course of a study on this topic. Unfortunately, the largest and most recent study⁸ used historic comparison groups instead of a randomized design, which lowered the study's level of evidence, despite the large number (N=105) of subjects studied. Finally, blinding subjects to the intervention would have been impossible. In some cases, however, subjects were at a low level of consciousness during the time of intervention.

With the exception of 2 studies,^8,27 a major limitation of all studies was the lack of any follow-up beyond the evaluation at the time of the final cast removal. Lehmkuhl and colleagues²⁷ reported that, for those subjects with follow-up data, the majority of subjects maintained their gains in PROM over a period ranging from 5 to 684 days after casting. Fifteen of the 19 people maintained or gained further PROM in their elbow joints due to casting, 3 of the 6 people maintained PROM in their ankle joints, and 2 of the 3 people maintained PROM in their knee joints. Pohl and colleagues⁸ reported that, for both groups casted in their study, gains in PROM were maintained, with no differences between measurements taken at the end of treatment and 1 month following treatment (Tab. 2). In their case reports, King²⁶ and Zachazewski et al⁴² commented that gains in PROM were maintained, but details on the time frame of these observations were not available.

Effect of Casting

When the 13 studies are grouped by area of measured outcome, 3 effect categories emerge: changes in spasticity, PROM, and "function." After compiling the information obtained from the quality and level of evidence reviews, we believe that comments can be made regarding quality issues and effects of casting for each of these categories. Grades of recommendation can then be given based on the level of evidence demonstrated by the studies,⁵⁰ and clinical guidelines can be created for what is "best practice" for the use of casts.

Spasticity.
The reduction of spasticity is often cited as the primary goal of casting; however, only 5 of the 12 studies measured properties of spasticity as an outcome. In all 5 studies, there were reports of "improvement" to some extent in spasticity levels following casting. Measuring spasticity, however, presented a challenge. How spasticity was operationally defined and measured and how results were interpreted varied among the 5 studies. Two studies^26,55 relied on reports of clinically recognizable improvements. Hill⁵³ operationally defined spasticity as both the joint angle (measured by goniometry) at which a stretch reflex was elicited and the ability to perform rapid alternating motions. Before and during casting, Childers and colleagues⁵⁴ used electromyographic measurements of H-reflex amplitude, both with and without continuous vibration to the muscle tendon. They reported a reduction of the vibratory inhibition index with casting and attributed these changes to a decrease in motoneuron excitability resulting from the cast. This measure of reflex hyperexcitability (static H-reflex modulation), however, should be interpreted with caution because Levin and Hui-Chan³ found that the severity of spasticity might not be fully described by reflex testing alone.

In the 5 studies^{11,26,53–55} that measured components of spasticity, the rigor of measurements varied. In 2 studies,^53,54 changes reached statistical significance. At least one strong level II study is needed to award a grade B recommendation,⁵⁰ and therefore only a grade C recommendation can be supported by this review for the use of casts in reducing spasticity after brain injury.

PROM.
In 10 studies,^{8,10,11,26,27,41,52,53,55,56} changes in PROM as the outcome of casting were investigated, and all but one⁵⁶ reported improvements in PROM following casting. Jones⁵⁶ found no difference; however, the purpose of Jones' study was to investigate the effect of casting on gait variables and assistance required to promote external stability during ambulation. Consequently, all the subjects were ambulatory, and change in PROM was a secondary, not a primary, outcome. In contrast, subjects in the other 9 studies were either not ambulating or they had severe restrictions in PROM. The results of improved PROM following casting in these 9 studies were consistent and, in the 6 studies^{8,27,41,52,53,55} in which statistical analysis was conducted, were demonstrated to be significant (Tab. 1).

Measurement issues, however, presented areas of weakness for 8 of the studies. The use of a PROM measure must be accompanied by evidence of the reliability and validity of the measurements produced. The reliability of PROM measurements of the ankle obtained by goniometry has been demonstrated to be poor^59,60 and is dependent on a variety of factors (eg, type of disease or injury, type of instrumentation).⁶¹ We believe, therefore, that reliability must be established for each study, not assumed. In order for a measurement to be valid, it must first be reliable, and Moseley's studies^41,52 therefore were the only studies that met the quality criterion for validity.

The changes reported represented what are arguably clinically meaningful improvements for either the positive improvement in PROM or the prevention of loss of PROM. For example, the joint most commonly targeted for casting was the ankle (10 studies) and the reported mean change scores in PROM as assessed by goniometry ranged from a gain of 10.4 degrees to a gain of 26 degrees. Given that the normal dorsiflexion range is 20 degrees, this indicates that a number of subjects commenced treatment in plantar flexion. Changes in the elbow were investigated in 5 studies,^{8,26,27,53,54} and reported improvements ranged from 35.2 to 75 degrees. Hill⁵³ did not report changes. Three groups of investigators^8,11,27 reported positive changes in knee PROM ranging from +15 degrees to +27 degrees. Of the 9 studies^{8,10,11,26,27,41,52,53,55} reporting positive changes in PROM, one study¹⁰ used a historical control group, and the authors reported an improvement in PROM in the casted group and also reported a loss of PROM in the historic group that had not received casting. Pohl and colleagues⁸ examined the effect of duration of cast change intervals and found no difference on PROM gains between shorter and longer intervals, but they did find a lower complication rate with shorter change intervals. Finally, 2 studies^52,53 of the 9 studies that reported improvements in PROM met the criteria for Sackett's level II evidence (the highest in this review) and received the highest scores in the review of quality. Therefore, a grade B level of recommendation can be given for the use of casts in improving PROM or preventing the loss of PROM that results from the complications of brain injury and subsequent spasticity.

Function.
Trends regarding the effect of casting on "function" could not be identified from the inconsistent results identified in this review, and no grade level of recommendation is given. Only 4 groups of investigators^39,42,53,56 measured aspects of "function" or ambulation. Kent et al,³⁹ Hill,⁵³ and Jones⁵⁶ were unable to find improvements using different functional classification scales. Jones,⁵⁶ however, reported improvements in walking speed using visual analysis of data, and Zachazewski et al⁴² reported improvements in gait. Perhaps the scales used did not have the sensitivity to measure the impact of casting and associated improvements in increased PROM on function and ambulation. One study⁸ used ratings from the Functional Independence Measure to establish similarity in functional level between historic groups, but did not gather rating scores after casting. Improvements in PROM, however, cannot be assumed to directly translate into improvements in function.

Despite recent conclusions that serial casting be considered as an adjunct to therapy to improve functional mobility,¹⁷ therefore, the level of evidence available from research to date does not support this statement nor does it negate this claim. A recommendation for further research would be to include sensitive measures of function that measure levels of activity and participation according to the International Classification of Functioning, Disability, and Health classification.⁶²

	Conclusion

Top Abstract Introduction Proposed Theories Objective of the Systematic... Methods Results Discussion Conclusion References

 
Of the 3 possible outcomes that have been suggested as a rationale for casting (improved PROM, decreased spasticity, and improved function), only the outcome of improved PROM has sufficient evidence to support the use of casts as current "best practice." Future research on casting for adults with brain injuries should use rigorous research designs and evaluate the effects on spasticity (a term that should use an operational definition shared by researchers), muscle function, functional independence, and activity and participation limitations. Additional research also is needed to determine the optimal timing and duration of cast applications as well as the longitudinal effects of casting on muscle force production and whether gains in PROM are accompanied by muscle atrophy as a result of the immobilization.

	Footnotes

 
Both authors provided concept/research design, writing, and data collection and analysis. Dr Eng provided project management. The authors thank the Canadian Institute of Health Research for a salary support award to Dr Eng.

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