o

Q_
CD
Effect of Passive Range of Motion
OU
Exercises on Lower-Extremity
ö
Goniometrie Measurements of
0
to Adults With Cerebral Palsy:
0
A Single-Subject Design
Background and Purpose. People with spastic cerebral palsy often
receive passive stretching that is intended to maintain or increase joint
passive range of motion (PROM) even though the effectiveness of
these exercises has not been definitively demonstrated. The purpose of
this study was to determine the effect of PROM exercises on 6 adults
with spastic quadriplegia and contractures. Participants. Four men and
2 women (X=31 years of age, range=20-44 years) who lived in an
institution for people with mental retardation participated in the study.
Methods. The authors used 2 multiple baseline designs. Three partic-
ipants (group 1) received lower-extremity PROM exercises during
phase A; PROM exercises were discontinued during phase B. Three
participants (group 2) did not receive PROM exercises during phase A;
PROM exercises were initiated during phase B. Data were analyzed
using visual analysis and the C statistic. Results. Results varied with the
method of analysis; however, phase A and phase B measurements,
overall, did not differ for either group. Discussion and Conclusion. This
study demonstrated use of a single-subject design to measure the effect
of PROM exercises on adults with cerebral palsy. The authors con-
cluded that the PROM exercise protocol did not have an effect on the
lower-extremity goniometric measurements of the participants.
[Cadenhead SL, McEwen IR, Thompson DM. Effect of passive range of
motion exercises on lower-extremity goniometric measurements of adults
with cerebral palsy: a single-subject design. Phys Ther. 2002;82:658-669.]

Key W o r d s : Cerebral palsy, Contractures, Passive range of motion. Single-subject design.

Sherri L Cadenhead, Irene R McEwen, David M ITiompson

658 Physical Therapy . Volume 82 . Number 7 . July 2002

C
ontractures are among the most common sec- Passive stretching is one physical therapy intervention
ondary impairments associated with cerebral for the prevention or reduction of contractures associ-
palsy, particularly for people with the spastic ated with cerebral palsy.'"'^' In our experience, clini-
type of cerebral palsy.' Contracture, as it relates to cians frequently advocate a prolonged stretch, with the
cerebral palsy, has been defined in several ways, includ- rationale based in part on a classic study by Tardieu
ing permanent contraction of a muscle,^ high resistance et al.ä Tardieu and colleagues measured the amount of
to passive stretch,^ hypoextensibility,'''' diminished time that the soleus muscles of children with cerebral
range of passive stretch,^ and intrinsic muscle shortening palsy were elongated beyond a minimum threshold
that prevents full range of motion.^ Many interrelated length throughout each day. After 7 months, contrac-
factors have been proposed to cause contractures in tures increased in participants whose soleus muscle was
people with cerebral palsy, including more activation of elongated for only 2 hours per day, but these contrac-
muscles on one side of a joint than on the other side,* tures did not increase in participants whose soleus
changes in connective tissue and muscle length,'^•^ slow muscle was elongated for at least 6 hours a day.
muscle growth,* and positioning.^ People with spastic
cerebral palsy who do not walk and whose voluntary Casting'2 and splinting'-'''''' are 2 interventions that pro-
movement is restricted to the extent that they cannot vide a prolonged stretch and have been shown to be
independently move their joints through the full range effective in preventing or reducing knee and ankle
of motion during daily activities are at particularly high contractures in children with cerebral palsy. Positioning,
risk for developing a contracture.'" such as lying prone, standing in Standers,'^ and sitting
with the hips abducted,"' also can provide a prolonged

SL Cadenhead, PT, MS, PCS, is Early Interventionist, Programs for Infants and Children, Anchorage, Ala. At the time the study was conducted,
she was employed at the Northern Oklahoma Resotirce Center, Enid, Okla.

IR McEwen, PT, PhD, is Presbyterian Health Foundation Presidential Professor, Department of Physical Therapy, University of Oklahoma Health
Sciences Center, PO Box 26901, Oklahoma City, OK 73190 (USA) (irene-mcewen@ouhsc.edu). Address correspondence to Dr McEwen.

DM Thompson, PT, MS, is Assistant Professor, Department of Physical Therapy, University of Oklahoma Health Sciences Center.

All authors provided concept/research design and data analysis. Ms Cadenhead and Dr McEwen provided writing. Ms Cadenhead provided data
collection and project management, and Dr McEwen provided fund procurement. The authors thank the occupational therapist who helped with
data collection, the physical therapist who participated in the interrater reliability study, and the participants' physician who assisted with the study.

This study was conducted in partial fulfillment of the requirements for Ms Cadenhead's postprofessional Master of Science degree from the
University of Oklahoma Health Sciences Center. The study was approved by the University of Oklahoma Health Sciences Center Institutional
Review Board and by the Human Rights Committee of the Northern Oklahoma Resource Center.

The study was partially supported by Preparation of Related Services Personnel grants H029F00056 and H029F30020 from the US Department of
Education, Office of Special Education and Rehabilitative Services. This article, however, does not necessarily reflect the policy of that office, and
official endorsement should not be inferred.

This article was submitted March 7, 2001, and was accepted November 13, 2001.

Physical Therapy . Volume 82 . Number 7 . July 2002 Cadenhead et al . 659

Stretch. The effectiveness of most positioning for main- PROM exercises made no difference in 6 of the 7
taining or increasing range of motion of people with lower-extremity measurements. Straight leg raising on
cerebral palsy, however, has not been studied.i^.i? the right side was greater under the 5-day-per-week
Researchers have shown that using a chair to provide a 5- condition than under the twice-a-week condition. As was
to 7-hour adductor stretch per day, along with 1 to 3 the case in the study by McPherson et al,' participants
therapy sessions per week for "progressive manual received positioning and bracing in the classroom and
stretching,"i'5(p984) did prevent adductor muscle contrac- PROM exercises at home throughout the study, which
tures in children with cerebral palsy. " makes the contribution of the PROM exercises unclear.

A practical problem associated with providing a pro- Although research supporting the effectiveness (or inef-
longed stretch using splints, casts, or positioning is that fectiveness) of PROM exercises is limited, we have
adults with severe cerebral palsy often have contractures observed that PROM exercises are commonly used inter-
in manyjoints and limitations in more than one plane of ventions for adults with cerebral palsy in institutions and
movement. Hip motion, for example, typically is community-based programs. These exercises usually are
restricted in abduction, lateral rotation, and exten- carried out by staff who have been taught by physical
sion.'^'^^ Another problem is that the severity of the therapists to do the exercises during times set aside for
contractures can limit positioning options, such as stand- exercise or during daily activities (eg, dressing, bathing).
ing. Passive range of motion (PROM) exercises are Although the performance of PROM exercises often
interventions that are used for contractures of any continues for years, we have observed few attempts to
severity and all limitations of joint PROM. Although determine whether they are effective. A single-subject
some authors have proposed that PROM exercises are research design is one method of gathering evidence in
ineffective^^ (an opinion that is supported by the studies clinical settings to determine whether an intervention is
showing prolonged elongation to be necessary5'i2-i4)^ effective.20 We used a single-subject research design for
other therapists continue to use passive stretching.'o.n this study to examine the effect of PROM exercises on
In 2 studies, researchers found at least minimal benefits lower-extremity PROM measurements of 6 adults with
to PROM exercises for young people with cerebral cerebral palsy.

Method
Over a 2-year period, McPherson et aF examined the
effects of PROM exercises and positioning on knee Participants
flexion contractures of 4 participants between 10 to 18 Six adults (4 men and 2 women; X=31 years of age,
years of age. During the first year of the study, the range=20-44 years) with spastic quadriplegic cerebral
participants received PROM exercises 3 times a day at palsy participated in the study. See Table 1 for descrip-
school and twice a week at home. During the second tions of the participants. All participants lived in a
year, PROM exercises at school were discontinued, and state-operated residential facility for people diagnosed
participants were positioned in prone and supine Stand- with mental retardation. A physician and the first
ers for 1 hour a day. The PROM exercises continued author (SLC) selected participants based on 4 criteria:
twice a week at home. The authors compared PROM (1) having a legal guardian who could be contacted and
measurements for periods of treatment (when school who was willing to sign the informed consent form,
was in session) with PROM measurements for periods of (2) presence of lower-extremity contractures measuring
nontreatment (Christmas and summer vacations). The 20 degrees or greater in at least 3 of the joint motions
participants' PROM measurements increased during the measured in the study (ie, hip extension, hip abduction,
2 school semesters of the first year and the fall semester hip lateral rotation, knee extension, and ankle dorsiflex-
of the second year, and they decreased during 3 of the 4 ion),i3 (3) use of a wheelchair as the primary means of
nontreatment periods. The average increase over the mobility, and (4) current or previous participation in a
year was 4 to 9 degrees, and the average decrease during physical therapy program. Exclusion criteria were: (1) a
nontreatment times was 5 to 10 degrees. history of resisting PROM exercises to the extent that full
PROM was rarely, if ever, achieved, as judged by the first
Miedaner and Renander^^ studied 13 participants who author, (2) a medical condition that might have pre-
were 6 to 20 years of age and assigned the participants to vented the participant from completing the study, (3) a
1 of 2 groups. For 5 weeks, one group received PROM diagnosis of arthritis or other joint disease, (4) lower-
exercises 5 consecutive days a week, and the other group extremity orthopedic surgery within 2 years of the begin-
received PROM exercises 2 nonconsecutive days a week. ning of the study, and (5) a windswept hip deformity
For the next 5 weeks, the frequency of exercise was (limitations of adduction and medial rotation of one hip
reversed for the 2 groups. Changes in PROM measure- and limitation of abduction and lateral rotation of the
ments averaged plus or minus 2.5 degrees. Frequency of

660 . Cadenhead et al Physical Therapy . Volume 82 . Number 7 . July 2002

Table 1.
Participant Characteristics

Age Orthopedic
Participant (y) Sex Surgery Functional Status

lA 23 Female Spine, hips, knees Followed simple commands, repeatedly vocalized nonwords. Assisted minimally with
transfers and other activities of daily living (ADL). Independent wheelchair mobility
on level terrain.
IB 32 Male None Could not talk, but appeared to have good receptive communication. Dependent for all
ADL and wheelchair mobility.
lC 20 Male Spine, hips, knees Used manual signs to make requests. Independent wheelchair, mobility on level terrain
with assistance with doors. Independent in some transfers and ADL.
2A 32 Male None Communicated with facial expressions. Dependent for all ADL and wheelchair mobility.
2B 44 Male Spine Laughed, screamed, and pulled others to him to communicate. Moved wheelchair short
distances and needed assistance for all ADL.
2C 33 Female None Communicated with facial expressions. Assisted minimally with transfers. Dependent for
ADL and wheelchair mobility.

opposite hip2i) that prevented positioning for goniomet- Design

ric measurements. The study consisted of 2 multiple-baseline designs, each
with 3 participants.22 During phase A, group 1 partici-
We planned the study to be a single-subject, multiple- pants, who had been receiving PROM exercises 3 times
baseline design with 6 participants, 3 of whom received per week, continued to receive PROM exercises. During
PROM exercises (group 1) and 3 of whom had not phase B, PROM exercises were discontinued. Group 2
received PROM exercises for at least 6 months before participants received no PROM exercises during phase
the start of the study (group 2). All participants had A, and PROM exercises were provided during phase B.
previously received PROM exercises and developmental
therapy for many years, but PROM exercises had been As is customary in multiple-baseline designs, the dura-
discontinued for group 2 participants after they demon- tion of each phase for each participant was individual-
strated fairly stable PROM measurements over time, as ized, and the initiation of phase B was staggered across
determined by annual physical therapy examinations. the participants as each participant's PROM measure-
We wanted to know whether the PROM of participants ments became stable.^^ por the majority of the joints
who were receiving PROM exercises would change when measured, PROM measurements were considered stable
the exercises were discontinued and whether the PROM when they were within 5 degrees of each other^^ over a
of participants who had not been receiving the exercises period of at least 3 out of 4 weeks. Stability, or a stable
would change when exercises were provided. trend (increasing or decreasing measurements at a
constant rate of change) over a period of 3 out of 4
Table 1 lists characteristics of the 6 participants. All were weeks, was the criterion for discontinuing PROM exer-
diagnosed as having mental retardation, but the true cises for group 1 participants or for beginning PROM
abilities of people with severe cerebral palsy and limited exercises for group 2 participants. All participants were
communication skills can be difficult to measure. The measured each week for 16 consecutive weeks. Phase A
musculoskeletal status and functional abilities of the 2 measurements for group 1 participants were established
groups were similar, but the average age of the group 1 after 5 weeks for participant lA, after 8 weeks for
participants was 25 years (range=20-32 years), and the participant IB, and after 11 weeks for participant lC. For
average age of the group 2 participants was 36 years group 2 participants, phase A measurements were estab-
(range = 32-44 years). The older age of the group 2 lished after 4 weeks for participant 2A, after 8 weeks for
participants probably contributed to the decision to participant 2B, and after 11 weeks for participant 2C.
discontinue their PROM exercises, which had occurred
before the first author started working at the institution. Passive Range of Motion Program
These 6 participants were selected for the study because The independent variable was a PROM exercise pro-
they were the first people who met the inclusion criteria gram for the joint motions of hip extension, hip abduc-
and whose legal guardians provided us with informed tion, hip lateral rotation, knee extension, and ankle
consent. dorsifiexion. The first author instructed physical therapy
aides in the PROM exercise protocol. Instruction
included verbal explanation, demonstration, observa-

Physical Therapy . Volume 82 . Number 7 . July 2002 Cadenhead et al . 661

tion of the aides performing each exercise, feedback on Goniometrie Measurements
their performance, and written instructions with pictures Our study's dependent variables were bilateral gonio-
illustrating how to perform each exercise. The exercises metric measurements of hip extension, hip abduction,
were based on PROM exercises published by Bezner^* hip lateral rotation, and ankle dorsiflexion as well as 2
and Kisner and Colby.^^ For each of the participants, the measurements of knee extension: one with the hip
investigator monitored one exercise session a week flexed and the other with the hip extended. Measure-
throughout the study to ensure that the physical therapy ments were taken each week using a 30.48-cm (12-in)
aides adhered to the protocol. plastic goniometer with a 360-degree scale. Although the
reliability of goniometry for measuring joint limitations
The protocol was based on 2 studies in which the due to contractures has been questioned,28.29 investiga-
effectiveness of PROM exercise for young people with tors often have used a goniometer to measure the joint
cerebral palsy was studied.'^-'^ In both studies, the PROM PROM of people with cerebral palsy.'''^ To promote
exercises consisted of moving an extremity passively to consistency in measurements, the 16 measurement ses-
the end of the PROM and holding this position for 20 to sions for each participant were done on the same day of
60 seconds, then repeating this stretch 5 times. Research- the week and at the same time of day, with the partici-
ers studying people with and without neuromusculo- pant lying on a firm, vinyl-covered, high-low mat table.
skeletal impairments have found that one 30-second Semipermanent marks were made on each participant's
stretch 5 days a week is as effective in increasing ham- bony landmarks with a laundry marker to identify the
string muscle length as one 60-second stretch or three goniometer's fulcrum, stationary arm, and measurement
30- or 60-second stretches.'^''•2''' Based on our experience arm positions. Color photographs of the measurement
with people with cerebral palsy, however, we believe that positions and specific written instructions for the 6 joint
more than one repetition is beneficial because resistance motions were available for the aides and therapists to
to passive stretch seems to decrease with repetition. review throughout the study.

The aides performed 5 repetitions of each passive joint When measuring each joint motion, the first author,
motion, holding the position at the end of the range for designated as therapist 1, moved the extremity passively
20 seconds during each repetition. They were instructed through the full available PROM for 3 repetitions. A slow
to move the joint only to the point of resistance and to 30-second stretch was applied on the third repetition to
avoid forcing the movement. They also were given "differentiate a reflex or active muscle contraction from
instructions for obtaining as much motion as possible, the structural limitation of the muscle, tendon, or joint
such as moving slowly, providing a gentle continuous capsule."29(p66i) This procedure was intended to mini-
stretch, avoiding pressure on the balls of the feet or mize resistance to passive stretch and identify the end of
palms of the hand, and bending an adjacent joint if the PROM. The joint PROM was measured at the end of
movement was difficult to initiate. the 30-second stretch by an occupational therapist (ther-
apist 2). Although having someone other than the
The aides could do the 5 exercises in any order that they principal investigator move the limb through the PROM
chose. Participants were placed in a supine position for (to control for potential bias) would be the preferred
all exercises except hip extension. For the hip extension method, another person with the necessary skill was not
exercise, participants were positioned prone with their available for the number of measurement sessions
hips at the edge of the table. The aides' hand placements required. To help control for bias, therapist 2 was not
were done as illustrated in informed of the participants' group assignments and
their progress within and between the phases of the
The PROM exercise sessions were carried out 3 times per study.
week. Each session lasted for approximately 30 to 45
minutes, including time for transferring, positioning, The testing sequence was consistent for every measure-
and talking with the participant. In the studies^ß-^^ of ment session,^" and the procedures for positioning and
people without neuromusculoskeletal impairments, the hand placement were standardized for each joint
researchers did not examine frequencies other than 5 motion.^1 First, each participant's right lower extremity
days per week. They provided no rationale for using this was measured in the following order: (1) knee extension
frequency. We selected a frequency of 3 days per week in the supine position with the hip extended^^; (2) knee
because, in our experience, it is a frequency often used extension in the supine position with the hip flexed to
for adults with cerebral palsy living in institutions and 90 degrees, as indicated by a goniometer that was fixed
because Miedaner and Renander^^ found that PROM at 90 degrees and positioned on the mat table at the level
did not differ when their participants received PROM of the greater trochanter'^; (3) ankle dorsiflexion in the
exercises 2 times a week or 5 times a week. supine position with the knee extended and the calca-
neus in as neutral a position as possible in an attempt

662 . Cadenhead et al Physical Therapy . Volume 82 . Number 7 . July 2002

to distinguish between ankle and forefoot Table 2.
Interrater Reliability Intraclass Correlation Coefficients (ICC [3,1])
(4) hip abduction in the supine position with the hip
extended and the lower leg positioned off of the end of
ICC
the table^'^; (5) hip lateral rotation in the supine position
with the lower leg positioned off of the end of the Joint Motion Right Left
table^**; and (6) hip extension in the prone position with Hip abduction .966 .967
the hips at the edge of the table, the pelvis level, and the Hip extension .981 .942
knee flexed.'^-^ While the participant was positioned Hip lateral rotation .785 .869
prone, left hip extension was measured. Then, the Knee extension, hip extended .982 .980
remaining left lower-extremity joints were measured in Knee extension, hip flexed 90° .988 .814
Ankle dorsiflexion .978 .877
the same order as the joints ofthe right lower extremity.
Because all of the participants had knee flexion contrac-
tures and because of the importance of knee extension
with hip flexion for wheelchair seating, knee extension
was measured with the hip extended as far as possible points went in an upward direction and a decrease in
and with the hip flexed to 90 degrees. Flexing the hip to PROM when they went in a downward direction.
90 degrees also was intended to control any effects on
knee PROM if hip extension changed over the course of We first analyzed the graphed data through visual anal-
the study. ysis, a traditional method of interpreting single-subject
research,^"^ to determine whether PROM improved,
Reliability decreased, or did not change across the 2 phases.
To determine interrater reliability, approximately 18% Through visual analysis, investigators look grossly at
of the measurements, including 2 or 3 measurement level, trend, variability, and slope of the graphed data.'"'
sessions per participant, were repeated independently by We used trend data more than level data because
another physical therapist (therapist 3) throughout the changes in level (eg, rapid change in PROM) were not
duration of the study. Therapist 3 participated only in expected and were due possibly to measurement error.
the reliability study and did not know the participants' We also used visual analysis of trends in conjunction with
group assignments and progress. Therapist 3 followed phase values and changes in slope between phases to
the measurement protocol while therapist 1 (the first determine trend change scores (eg, a joint motion with
author) measured the joint PROM. Therapist 1 used a a low trend phase value [3 or less] and a low slope
goniometer that was masked on one side with paper to [approximately 1.0 to 1.05] indicated no change). We
prevent her from seeing the result until after therapist 2 disregarded outlier data points (defined as a data point
(the occupational therapist) had recorded each mea- that was 20 degrees greater than or less than the data
surement. ^^ Before the study was initiated, the 3 thera- points immediately before and after it) if at least 5 other
pists practiced the measurement, positioning, and data points were available in that phase, and we consid-
stretching techniques until they achieved agreement ered data that remained consistently variable across
within 5 degrees per joint measurement. We chose to phases to demonstrate no change.
determine interrater reliability rather than intrarater
reliability because (1) we were concerned that memory Investigators have noted that visual analysis alone may
would affect 2 trials by one rater separated by a short lead to inconsistent results.-^^^9 For this reason and
interval and (2) if interrater agreement was acceptable, because small treatment effects were expected,*' we also
intrarater agreement also was likely to be acceptable. used the C statistic to further analyze the data.'"*'''^

Reliability was represented by an intraclass correlation Nourbakhsh and Ottenbacher''^ used 3 statistical meth-
coefficient (ICC), model 3,1.2235 Table 2 shows that ods for single-subject data—the split-middle method of
coeflîcients were between .785 for right hip lateral trend estimation, the two-standard deviation bandwidth
rotation and .988 for right knee extension with the hip method, and the C statistic—to analyze the same 42
flexed to 90 degrees. graphs. They found somewhat different results using
each method and concluded that researchers should use
Data Analysis several approaches to analyze single-subject data, one of
which should be visual analysis. We chose the C statistic
The goniometric measurements collected over the as the other method because many of the graphs showed
course of the study were recorded on 12 graphs for each a visually obvious trend, which made the two-standard
participant (one graph for each of the 6 right and left deviation bandwidth method inappropriate,*2 and
joint motions), for a total of 72 graphs. The graphs were because the split-middle method of trend estimation
oriented to show an increase in PROM when the data often is inconsistent with visual analysis.

Physical Therapy . Volume 82 . Number 7 . July 2002 Cadenhead et al . 663

With the C statistic, phase A data are analyzed first to Visual analysis of participant lC's data showed no differ-
determine whether a statistically significant trend exists. ence in PROM between phases for 9 of the 12 measure-
Statistical significance is determined by dividing C by its ments. During phase B, right hip lateral rotation and
standard error, which gives a z value that can be inter- right knee extension with the hip flexed 90 degrees
preted using the normal probability table for z decreased. This finding was supported by the z values.
scores.'*''.42 if a trend is not found, the phase B data are Visual analysis indicated that left hip abduction
appended to the phase A data, and the combined data increased during phase B. The visual analysis did not
are reanalyzed using the same procedure. If a trend is support the z values, which indicated a difference in
found in the phase A data, a less powerful alternative right hip extension and left knee extension with the hip
procedure can be used to construct separate data series flexed 90 degrees. Reinspection of the graphs again
from phase A and phase B data and to compare them. A indicated no change, which was supported by the mean
significant z score indicates that the trend in phase A and PROM during the 2 phases. The long baseline with an
phase B are different.''° We used a 1-tailed test with an increasing trend in the baseline data may have affected
alpha of .05 (z> 1.645). The unidirectional hypothesis the C statistic results.
was that PROM would bè greater during the phase in
which PROM exercises were provided. Group 2
Table 4 shows the means, standard deviations, visual
Results analysis results, and z values for the 36 graphs for group
2. Group 2 participants did not receive PROM exercises
Group 1 during phase A and PROM exercises were provided
Table 3 shows the means, standard deviations, visual during phase B.
analysis results, and z values of the 36 graphs for group 1
participants. This group received PROM exercises dur- Visual analysis of the data for participant 2A showed no
ing phase A and PROM exercises were discontinued change in 7 of the 12 PROM measurements. Visual
during phase B. analysis indicated an increase in 2 measurements during
phase B: left knee extension with the hip extended and
Visual analysis of the data of participant lA indicated no left knee extension with the hip flexed 90 degrees. The
change in PROM between phase A and phase B for 10 of z values supported these 2 observations and indicated no
the 12 joints measured. The rate of increase in left hip other increases in PROM during phase B. Visual analysis
extension decreased during phase B and a downward indicated a decrease in 3 measurements when PROM
trend occurred in right ankle dorsiflexion during phase exercises were provided during phase B: right hip exten-
B. Both observations were supported by the z values. The sion, right knee extension with the hip extended, and
z values also indicated a difference between phases in right ankle dorsiflexion.
bilateral hip lateral rotation and knee extension with the
hip flexed 90 degrees. Visual analysis indicated that the Visual analysis of participant 2B's data indicated no
reason for the discrepancy was probably the increasing change in 8 of the 12 measurements. Visual analysis
trend during the relatively short phase A, which leveled showed a negative change in 4 measurements during
off during phase B. phase B: bilateral hip lateral rotation and dorsiflexion.
No positive changes were identified with visual analysis
Visual analysis of participant lB's data identified no or the z values.
change in 7 of the 12 measurements. Right and left hip
lateral rotation showed a downward trend in phase B Visual analysis of the data of participant 2C indicated no
and ankle dorsiflexion decreased bilaterally during change in 8 of the 12 PROM measurements. A negative
phase B. Left hip abduction increased during phase B. change was observed during phase B in 3 PROM mea-
The z values supported a difference in these 5 measure- surements: bilateral hip lateral rotation and right ankle
ments. The z values also indicated a difference in right dorsiflexion. Visual analysis and the z value indicated an
and left knee extension with the hip flexed 90 degrees, increase in right hip abduction during phase B.
which visual analysis had not revealed. We examined the
graphs again to try to determine the reason for the In summary, visual analysis of the grouped data for the
discrepancy and saw that PROM increased during phase subjects in group 1 showed no change in 28 of 36 joints
B (also indicated by the means), but not enough to say when PROM exercises were discontinued. Visual analysis
with any confidence that a difference existed. The z showed decreased PROM in 8 joints, results that the z
values could not support a difference because we used a values supported. Visual analysis also showed an increase
1-tailed test, and the direction of any difference was in in PROM for 2 of the 36 joints after PROM exercises
the opposite direction. were discontinued. The z values indicated a decrease in
4 joint PROM measurements when PROM exercises

664 . Cadenhead et al Physical Therapy . Volume 82 . Number 7 . July 2002

Table 3.
Goniometrie Data (in Degrees) for Group 1 Participants Who Received Passive Range of Motion (PROM) Exercises During Phase A and Did Not
Receive PROM Exercises During Phase B

Phase A Phase B
Visual Phase
X SD X SD Analysis" Az*

Participant A
Hip extension
Right -14.2 4.4 -8.3 2.5 0 -0.36 1.55
Left -35.2 12.3 -22.4 3.1 — 0.95 2.82''
Hip abduction
Right 3.2 6.6 8.0 2.9 0 -0.72 0.47
Left 21.2 6.1 23.6 3.6 0 -0.44 -0.29
Hip lateral rotation
Right 34.4 10.0 48.9 2.9 0 1.43 3.37''
Left 20.0 5.2 25.9 5.1 0 1.86= 2.07''
Knee extension (hip extended)
Right -61.4 3.4 -64.3 2.0 0 -1.31 0.16
Left -73.6 6.4 -66.8 3.3 0 -1.44 1.05
Knee extension (hip flexed 90°)
Right -70.8 4.1 -67.6 2.5 0 1.16 1.84''
Left -67.0 1.2 -65.8 2.6 0 0.24 1.69''
Ankle dorsiflexion
Right 20.4 5.3 22.8 3.6 - 1.79= 1.74''
Left 24.6 16.0 39.4 6.4 0 1.68= 1.31
Participant B
Hip extension
Right -15.0 4.8 -12.0 3.5 0 -0.63 -0.14
Left -24.5 4.8 -19.5 4.5 0 -1.38 0.58
Hip abduction
Right 2.1 9.5 -7.2 3.5 0 2.21 = 2.14''
Left 2.9 5.5 8.0 5.4 + 1.72= 1.68
Hip lateral rotation
Right 27.9 5.5 27.0 9.8 - 2.14= 2.40''
Left 25.1 8.2 26.9 5.3 - 1.50 1.75''
Knee extension (hip extended)
Right -70.0 4.4 -66.0 4.7 0 -1.07 -0.92
Left -67.9 5.4 -62.0 5.8 0 1.07 1.28
Knee extension (hip flexed 90°)
Right -92.8 8.4 -79.8 6.1 0 1.09 2.17''
Left -88.9 9.5 -75.3 5.5 0 2.12= 1.73''
Ankle dorsiflexion
Right 48.1 6.5 44.3 6.2 _ 1.88= 2.50''
Left 43.8 9.8 36.8 7.3 - 1.95= 1.92''
Participant C
Hip extension
Right -17.7 4.4 -18.8 2.8 0 2.56= 2.23='
Left -26.1 4.9 -26.4 3.4 0 1.01 1.39
Hip abduction
Right 25.0 5.9 23.6 5.7 0 0.73 0.04
Left 3.3 6.1 10.6 6.1 + -1.76= -0.19
Hip lateral rotation
Right 39.1 11.8 39.6 12.1 - 2.94= 1.88=*
Left 37.2 7.2 31.2 2.2 0 1.75= 0.77
Knee extension (hip extended)
Right -65.3 5.8 -63.6 2.0 0 -0.72 -0.76
Left -78.2 4.4 -69.0 1.9 0 2.17= 1.57
Knee extension (hip flexed 90°)
Right -82.0 9.4 -82.6 2.1 _ 2.11 = 2.19''
Left -81.2 6.7 -78.0 2.0 _ 2.43= 1.71''
Ankle dorsiflexion
Right 36.0 7.7 33.0 9.6 0 2.30= 1.41
Left 28.0 7.4 24.2 2.8 0 1.15 1.48

°0=no difference In PROM measurements between phase A and phase B, —=negative change in PROM measurements in phase B, and +=posiüve change in
PROM measurements in pha.se B.
* Derived from C statistic.
"Significant trend in phase A data (/is.05).
''Significant negative change in PROM in phase B (l-tailed / ^ .

Physical Therapy . Valume 82 . Number 7 . July 2002 Cadenhead et al . 665

Table 4.
Goniometrie Data (in Degrees) for Group 2 Participants Who Did Not Receive Passive Range of Motion (PROM) Exercises During Phase A and
Received PROM Exercises During Phase B

Phase A Phase B
Visual Phase
X SD X SD Analysis" Az* z*-

Participant A
Hip extension
Right -23.5 11.4 -20.7 4.3 - 1.01 1.00
Left -27.3 7.3 -14.0 3.8 0 1.45 3.38
Hip abduction
Right 3.3 1.5 7.0 4.2 0 -1.72= 0.14
Left 17.25 2.5 22.2 5.2 0 1.72 -0.03
Hip lateral rotation
Right 22.5 9.1 30.4 12.7 0 1.36 1.16
Left 27.0 7.8 36.2 12.4 0 1.63 0.91
Knee extension (hip extended)
Right -53.8 3.3 -53.7 6.8 - 1.65= 0.89
Left -50.0 10.9 -19.8 6.0 + -1.58 2.40^*
Knee extension (hip flexed 90°)
Right -75.8 6.0 -61.1 3.7 0 1.66= 0.46
Left -81.5 16.8 -61.0 6.9 + 0.44 2.23''
Ankle dorsifiexion
Right 35.0 5.6 37.6 5.9 - 1.19 1.68
Left 29.3 5.9 33.1 4.9 0 -1.07 -0.63
Participant B
Hip extension
Right -36.6 4.0 -34.1 3.3 0 0.37 1.26
Left -32.9 5.7 -25.0 3.7 0 0.92 2.13
Hip abduction
Right -12.1 11.5 -11.3 12.6 0 0.34 0.08
Left 2.4 4.1 4.6 4.9 0 0.39 1.39
Hip lateral rotation
Right 19.0 7.3 14.9 8.3 - 1.31 2.69
Left 41.9 4.4 38.4 10.0 - 0.33 2.79
Knee extension (hip extended)
Right -81.6 7.3 -73.0 8.0 0 -1.44 0.58
Left -59.0 4.7 -55.9 3.6 0 0.18 0.77
Knee extension (hip flexed 90°)
Right -81.1 4.7 -77.4 3.4 0 2.28= 0.94
Left -69.1 3.1 -66.1 3.3 0 0.13 0.38
Ankle dorsifiexion
Right 15.8 6.2 17.5 5.6 - 2.56= 2.50
Left 18.8 8.5 14.6 12.2 - 1.93= 0.86
Participant C
Hip extension
Right -7.2 4.9 -5.2 2.6 0 1.37 1.51
Left -23.0 4.1 -24.2 1.9 0 -1.10 -0.98
Hip abduction
Right 5.2 5.5 14.0 5.8 + 1.41 2.20''
Left 1.9 5.3 3.2 2.9 0 2.32= -0.21
Hip lateral rotation
Right 27.0 11.9 36.8 6.1 - 3.09= 1.12
Left 27.8 7.2 39.4 5.1 — 2.18= 1.89
Knee extension (hip extended)
Right -26.0 10.1 -16.8 3.9 0 2.80= 1.72
Left -73.1 10.7 -69.6 6.3 0 1.16 0.96
Knee extension (hip flexed 90°)
Right -26.2 8.5 -20.6 2.2 0 1.73= 0.52
Left -62.8 9.0 -63.0 3.9 0 -0.36 -0.27
Ankle dorsifiexion
Right 15.0 12.6 19.6 • 7.9 . - -1.75= 1.83
Left 6.5 9.2 8.0 4.5 0 -2.08= 1.31
''0=no difference in PROM measurements between phase A and phase B — ^negative change in PROM measurements in phase B, + = positive change in PROM
measurements in phase B.
' Derived from C statistic.
"Significant trend in phase A data {PS.05).
''Significant positive change in PROM measurements in phase B (1-taiIed

666 . Cadenhead et al Physical Therapy . Volume 82 . Number 7 . July 2002

were discontinued, which was not supported by visual gered phase A and 16-week available time frame meant
analysis. that participants received from 5 to 12 weeks of PROM
exercises. The results, however, are consistent with the
Visual analysis of the data of all 3 subjects in group 2 views held by some authors "*•''* that passive exercise is
showed no change in PROM for 23 of 36 joints when not effective in the management of contractures associ-
PROM exercises were provided. Visual analysis and the z ated with cerebral palsy. The results are not consistent
values indicated an increase in PROM in 3 joints when with the results of the studies by McPherson et aF and
PROM exercises were provided during phase B. Visual Miedaner and Renander,'^ who found modest PROM
analysis indicated a decrease in 10 measurements during increases following PROM intervention.
phase B.
One reason for the inconsistency may be the age of the
Discussion and Conclusions participants. Our participants were between 20 and 44
For both groups of participants, our results showed no years of age, and their contractures could have been less
consistent differences in lower-extremity PROM mea- responsive to change than participants in the other
surements when the participants received and did not studies who were between 6 and 20 years of age. Another
receive PROM exercises. Most of the participants dem- difference in the studies is that their participants
onstrated a gradual increase in PROM in phase A and received positioning and other co-interventions, which
showed little change in motion during phase B, regard- our participants did not receive. These co-interventions,
less of whether PR^OM exercises were discontinued or rather than the PROM exercises, could have been
provided during phase B. As a result of the study, PROM responsible for the change.
exercises were discontinued for all participants.
The studies also differed in the number of participants,
The gradual increase in PROM during phase A appeared the length of the intervention, the joints investigated,
to be the result of the participants' increasing coopera- and the research design. McPherson et aF used a group
tion with the person taking the PROM measurements design to study knee extension of 4 participants over a
over the first few weeks of the study. Although an 2-year period. Miedaner and Renander'^ also used a
exclusion criterion was resistance to PROM to an extent group design and studied the hip, knee, and ankle
that joint range could not be achieved, the participants PROM of 13 participants over 10 weeks. Our study was
did appear to guard against full PROM initially. The similar to these previous studies in the limited number
participants also demonstrated week-to-week variability of participants, but our use of a single-subject design
in measurements that we believe were unlikely to be enabled us to analyze the effects of intervention for each
related to real change in joint PROM. participant, which the group designs do not permit.
Some of the participants in the previous studies may not
We are not aware of research that has examined consis- have benefited from the intervention, but the analyses of
tency of goniometric measurements of adults with spas- group data would have obscured the individual effects.
tic quadriplegic cerebral palsy; however, Harris and
colleagues*-'' found wide daily variations when measuring The amount of PROM exercise also may have contrib-
a child with spastic quadriplegia, and they concluded uted to lack of changes in the measurements. Although
that a change of 10 to 15 degrees may not represent real the PROM protocol was based on the literature related
change. We contend that our interrater reliability esti- to people with cerebral palsy,''''^ research with people
mates were excellent to good; however, we assessed without neuromusculoskeletal deficits indicate that
reliability by having 2 therapists measure the participants stretching for one 30-second stretch 5 times per week is
on the same day, one immediately after the other. effective.^''•2^ Although this amount cannot be general-
Day-to-day variation in participants would not have been ized to people with neuromusculoskeletal impairments,
affected by—or detected by—our method. Future it may be worth investigating. Another consideration is
research to examine test-retest reliability of goniometric the length of the intervention. Our 16-week study may
measurements of adults with spastic quadriplegia and not have been long enough to show an effect of PROM
cognitive impairments, with time between measure- exercises or an effect of discontinuing them.
ments, could be useful.
The results of our study cannot necessarily be general-
Despite the variability of our measurements, we showed ized to other adults with cerebral palsy, particularly those
that, for the 6 adults with cerebral palsy, PROM exercises with characteristics that differ from those of our partic-
did not appear to generally affect lower-extremity gonio- ipants. The external validity of single-subject research is
metric measurements over a 16-week period of time. A demonstrated by replication,-"^ and our design and
limitation of our study was that all participants did not methods lend themselves well to the clinical setting and
receive the same amount of PROM exercises. The stag- could be used by other clinicians to determine whether

Pbysical Therapy . Volume 82 . Number 7 . July 2002 Cadenhead et al . 667

PROM exercise is effective for individual clients. Repli- 10 Holt S, Baagoe S, Lillelund F, Magnusson SP. Passive resistance of
cation of the study with other people with similar the hamstring muscles in children with severe multiple disabilities? Dev
Med Child NeuroL 2000;42:541-544.
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future studies, a larger number of data points and a 11 Olney SJ, Wright MJ. Gerebral palsy. In: Gampbell SK, Vander
Linden DW, Palisano RJ, eds. Physical Therapy for Children. 2nd ed.
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Philadelphia, Pa: WB Saunders Go; 2000:533-570.
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12 Brouwer B, Davidson LK, Olney SJ. Serial casting in idiopathic
toe-walkers and children with spastic cerebral palsy. / Pediatr Orthop.
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14 Hainsworth F, Harrison MJ, Sheldon TA, Roussounis SH. A prelim-
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15 Stuberg WA. Considerations related to weight-bearing programs in
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person's satisfaction with them. Intervention, we believe, 16 Lespargot A, Renaudin E, Khouri N, Robert M. Extensibility of hip
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