784
Effectiveness of Serial Casting in Patients With Severe
Cerebral Spasticity: A Comparison Study
Marcus Pohl, MD, Stefan Rückriem, MA, Jan Mehrholz, PT, Claudia Ritschel, PT, Herwig Strik, MD,
Max R. Pause, MD
ABSTRACT. Pohl M, Rückreim S, Mehrholz J, Ritschel C,
Strik H, Pause MR. Effectiveness of serial casting in patients
with severe cerebral spasticity: a comparison study. Arch Phys
Med Rehabil 2002;83:784-90.
Objective: To compare the improvement and complication
rate between a technique using a short casting interval and a
more conventional changing interval.
Design: A retrospective case-comparison study.
Setting: A rehabilitation center for adults with neurologic
disorders.
Participants: One hundred five patients with cerebral spas-
ticity of different etiologies treated with serial casting to relieve
fixed contractures caused by increased muscle tone.
Intervention: Serial casting of 172 joints (42 elbow, 41
wrist, 21 knee, 68 ankle joints), with cast-changing intervals of
5 to 7 days (group 1: 92 joints, 56 patients), or 1 to 4 days
(group 2: 80 joints, 49 patients).
Main Outcome Measures: Percentage of normal maximum
range of motion (ROM) at the completion of casting and 1
month after discontinuation, and the number of complications
resulting from casting procedure.
Results: Improved percentage ROM immediately after serial
casting and 1 month later in both groups (F⫽1469.5, P⬍.001).
No differences in ROM improvement between groups were
observed (F⫽0.3, P⫽.72). Complications in serial casting were
found in 19.8% of 172 casting procedures, in 29.3% in group
1 and in 8.8% in group 2 (␹2⫽10.2, P⫽.001). Discontinuations
of treatment because of casting complications or other reasons
were observed in 12.8% of the entire sample, in 18.5% in group
1 and in 6.3% in group 2 (␹2⫽4.7 P⫽.03).
Conclusion: Casting is effective in the treatment of fixed
contractures of the upper and lower extremities caused by
increased muscle tone of cerebral origin. Short changing inter-
vals in serial casting provide improvements in ROM compa-
rable with conventional changing intervals, and result in fewer
complications.
Key Words: Casts, surgical; Contracture; Muscle spasticity;
Neurologic disorders; Rehabilitation.
© 2002 by the American Congress of Rehabilitation Medi-
cine and the American Academy of Physical Medicine and
Rehabilitation
From the Department of Neurological Rehabilitation, Klinik Bavaria, Kreischa
(Pohl, Rückriem, Mehrholz, Ritschel); Department of Neurology, Georg-August-
Universität, Göttingen (Strik); and Department of Neurological Rehabilitation, Neu-
rologisches Reha-Zentrum, Magdeburg (Pause), Germany.
Accepted in revised form July 23, 2001.
No commercial party having a direct financial interest in the results of the research
supporting this article has or will confer a benefit upon the authors or upon any
organization with which the authors are associated.
Reprint requests to Marcus Pohl, MD, Dept of Neurological Rehabilitation, Klinik
Bavaria, An der Wolfsschlucht 1-2, D-01731 Kreischa, Germany, e-mail:
pohl@klinik-bavaria.de.
0003-9993/02/8306-6851$35.00/0
doi:10.1053/apmr.2002.32821
Arch Phys Med Rehabil Vol 83, June 2002
EVERE DAMAGE TO THE central nervous system, of
S various origin, often causes severe spasticity. Cerebral
1,2
lesions result in reflex hyperexcitability with an increase in
tonic reflexes and exaggerated tendon jerks3 and in altered
mechanical properties of the muscles.4 Both reflex hyperexcit-
ability and altered mechanical properties lead to muscle hyper-
tonia.5 In addition, in patients with extensive supratentorial
damage, spasticity or hypertonia can hardly be distinguished
from additional extrapyramidal symptoms such as rigidity.1
These patients can, nonetheless, experience contractures,4,6-8
although the nature of the causal relation between spasticity
and contracture remains unresolved.5 In the spastic extremities,
muscle hypertonia results in typical flexion joint position and
contractures in reduced mobility of the active and passive range
of motion (ROM) of the joints.9 This reduced joint mobility
caused by hypertonia and contractures complicates patient
care, delays early rehabilitation, and reduces function of the
spastic limb.2,6,10-14 For patients with reduced joint mobility,
serial casting with fiberglass casts is used to achieve a stepwise
reduction of the fixed contracture.2,9,12,14-19 It is suggested that
casting results in a reduction of spasticity and hypertonia.9,20
Although no controlled, objective studies have been performed
on spasticity reduction with casting, the anecdotal evidence is
compelling.9 Serial casting does, however, result in a higher
active and/or passive ROM of the joint and can therefore
simplify patient care and/or enable functional use of the rele-
vant limb.9,12,15 Previous studies of serial casting in patients
with cerebral spasticity were conducted with relatively small
groups of patients; therefore, little is known about the effec-
tiveness of the treatment or its complications.
Serial casting, as it is commonly practiced, can be a lengthy
process. Several cast changes are required to achieve a desir-
able ROM,18 and it is standard practice that each cast be
retained for 5 to 7 days.12,15-18,20 Our experience, however,
suggests that shorter changing intervals can be just as effective
in attaining the desired ROM in a shorter period of time.21
Shorter changing intervals reduce treatment duration and,
therefore, allow the patient to begin rehabilitation more
quickly.
This study had 2 goals: to assess the risks and benefits of
serial casting in general and, more specifically, with shortened
changing intervals.
METHODS
Participants
From January 1997 to January 2001, 105 patients with
spastic joint contractures of cerebral origin were treated with
serial casting in the Department of Neurological Rehabilitation,
Kreischa, Germany. The casts were applied to achieve a step-
wise reduction of the fixed flexed joint contracture. Inclusion
criteria for entering the study were reduced joint mobility,
moderate or severe spasticity (Ashworth Scale scores 3 and
4),22 and a desire to simplify patient care or to enable functional
use of the relevant limb. All 105 patients who were treated with
 EFFECTIVENESS OF SERIAL CASTING ON CONTRACTURES, Pohl 785

serial casting were included in the study. Exclusion criteria for 1. Discontinuation because of casting complications speci-
serial casting were heterotopic ossification, bone fracture or fied in the medical record.
dislocation, deep vein thrombosis, or occlusive arterial disease. 2. Discontinuation because of other reasons documented in
the medical record.
Design 3. No discontinuation of casting procedure.
Duration of the casting procedure, the number of cast changes,
We have practiced serial casting since January 1996. Our and the cast-changing intervals were documented in the cast
team includes a nurse (SR), 2 physical therapists (JM, CR), and protocol. To compare the extension deficits of different joints
a neurologist (MP, HS, or MRP). Because experience is crucial (elbow, wrist, knee, ankle joints), ROM was defined as the
to the effectiveness of the treatment, castings performed in percentage of maximum normal passive ROM. Maximum
1996 were not included in the study. In 1999, we changed the ROM to neutral position was defined as 140° for elbow joint,
cast-changing interval from 5 to 7 days to 1 to 4 days. For this 150° for knee joint, 50° for wrist joint, and 50° for ankle
study, the patients were divided into 2 groups according to their joint.27,28 ROM was documented before casting, after each cast
cast-changing intervals. Patients in group 1 were treated with change, and 1 month after casting treatment.
conventional cast-changing intervals (5–7d) in the years 1997 The therapy for some patients was supported by systemic
and 1998. Patients in group 2 were treated with shorter cast- and/or local antispastic therapy to reduce muscle tone under the
changing intervals (1– 4d) from January 1999 to January 2001. cast (table 1). Therapy with local administration of botulinum
Patients’ functional independence was measured with the toxin was performed (after informed consent of the patient or
FIM™ instrument before casting was done.23,24 The FIM is an patient’s guardian.)
18-item, 7-level scale that assesses severity of patient disability
and the functional outcome of rehabilitation.23 The FIM con- Statistics
sists of 6 subscores on self-care, sphincter control, transfer, To determine the statistical differences with respect to fre-
locomotion, communication, and social cognition. It has good quencies between the groups the chi-square test for homoge-
test-retest and interrater reliability.25 FIM ratings were mea- neity was used. If the degree of freedom was equal to 1, the
sured by a team consisting of the physician, the nurse, the chi-square was corrected with the Yates correction. For com-
occupational therapist, and the physical therapists assigned to parison of interval scaled measurements, the Mann-Whitney U
the patient. test was used if the Lilliefors test was significant (comparison
The serial casts were applied with fast-hardening fiberglass
material (Cellacast Xtra,威a Scotchcast威b). The material is per-
meable to air (air/humidity permeability quotient: Cellacast,
2985.0g/m2; Scotchcast, 3794.4g/m2), according to the manu- Table 1: Patient Characteristics of Entire Sample (Nⴝ105)
facturers’ specifications. The respiratory activity of the cast
material prevents excessive moisture on the skin. Group 1 Group 2
(cast-changing (cast-changing
Serial casting procedures have been described in detail in interval 5–7d, interval 1–4d,
various articles.9,12-15,17,18 Therefore, the procedure used here 92 Joints, 80 Joints,
will be only briefly described. Preparation for serial casting Characteristics n⫽56) n⫽49)
involved manually extending the fixed flexed joint. Next, the
Median age (y)* 38.2 44.6
extremity was covered with a stockinet, and a circular padding
Sex†
was applied. The padding should not to be too thick, to avoid
Female/Male 16/40 8/41
friction and movements of the extremity under the cast. The
Diagnosis†
stretched position of the joint was then fixed by up to 6 layers
Ischemic stroke 8 11
of hardcast. Each cast was changed after 5 to 7 (group 1) or 1
Intracerebral hemorrhage 12 7
to 4 days (group 2). Serial casting was discontinued when
Traumatic brain injury 19 24
either maximum possible extension (defined as ⬍10% exten-
Cerebral hypoxia 6 5
sion deficit) was attained or when 2 serial cast changes resulted
Subarachnoidal hemorrhage 5 1
in no further reduction of extension deficit. The joint mobility
Other 6 1
achieved after completion of the serial casting was, in most
Median duration of illness (d)* 121 130
cases, maintained by joint splints administered intermittently.
Ashworth Scale scores†
Serial casting procedures were practiced according to a special
Score 3 9 11
protocol. Every complication was recorded either during a
Score 4 47 38
daily cast visit of a member of the team or during the cast-
Antispastic therapy
changing. Complications were classified as follows:
Local (botulinum toxin)† 6 4
1. Development of a pressure ulcer. The National Pressure
Systemic (baclofen or tizanidine)† 18 16
Ulcer Advisory Panel (NPUAP) 4-stage classification
Indications for serial casting†
system was used for pressure ulcer staging.26
To simplify patient care 28 18
2. Development of pain because of casting.
To enable functional use of the
3. Development of swelling under or at cast ends. The casts
relevant limb 28 31
were applied so that one’s little finger could fit between
Treated joints† 92 80
the cast end and the extremity. The onset of swelling was
Elbow 23 19
the point at which one’s little finger no longer fit under
Knee 21 20
the cast.
Ankle 34 34
4. Other complications documented in the medical record.
Wrist 14 7
5. No complications.
Furthermore, discontinuations of treatment were recorded as * P⬎.05 (not significant) by Mann-Whitney U test (for medians).
follows: †
P⬎.05 (not significant) by ␹2 test (for frequencies).

Arch Phys Med Rehabil Vol 83, June 2002

786 EFFECTIVENESS OF SERIAL CASTING ON CONTRACTURES, Pohl

Fig 1. Means and SDs of FIM

subscores of groups 1 and 2 at
the beginning of serial cast-
ing. Although there was a
trend for a higher mean of FIM
subscores in group 2, groups
did not differ in ANOVA (Pⴝ.06).

of age, duration of illness, and number of cast changes between differences in the percentage of maximum ROM between
groups). groups 1 and 2 (F⫽13.8, P⬍.001) and an overall significant
An effect of the factor order (groups 1 or 2) with reference improvement of the percentage of maximum ROM after serial
to the FIM subscores was evaluated with analysis of variance casting for the entire sample (F⫽1469.5, P⬍.001).
(ANOVA). Differences with reference to ROM were evaluated Although average percentage of maximum ROM after cast-
with ANOVA for repeated measures with an independent ing was greater in group 2, baseline ROM was also greater in
group factor order (groups 1 and 2), a second independent this group; thus these differences were determined to be insig-
factor treatment (elbow, wrist, knee, ankle joints), and a de- nificant (ANOVA: interaction between “order” and “repeated
pendent factor repeated measurements (percentage of maxi- measure”; F⫽.33, P⫽.72). Significant, however, were the
mum ROM before, at cessation of, and 1 month after casting). gains in the percentage of maximum ROM of the treated joints
The Scheffé test was used for testing post hoc mean differ- for the entire sample (ANOVA: interaction between the factors
ences. “treatment” and “repeated measure”; F⫽5.8, P⫽.03).
The post hoc Scheffé test revealed significant differences
RESULTS between first and second (group 1: P⬍.001; group 2: P⬍.001)
Ninety-two joints of 56 patients were assigned to group 1, and first and third ROM measurement (group 1: P⬍.001; group
and 80 joints of 49 patients were assigned to group 2. The
median cast-changing intervals were 6.9 days in group 1 and
2.7 days in group 2. The patients’ characteristics are listed in
table 1. The 2 groups were comparable in age, gender distri-
bution, diagnosis, indications for serial casting, duration of
illness, baseline Ashworth Scale scores distribution, and dis-
tribution of additional treatment with systemic or local anti-
spastic therapy. Elbow, wrist, knee, and ankle joints were
treated with serial casting. The numbers and types of treated
joints were comparable between the groups (table 1).
The means and standard deviations (SDs) of FIM subscores
in both groups are shown in figure 1. Although there was a
trend for higher mean FIM subscores in group 2 (fig 1), no
corresponding effect was found in the ANOVA (Wilks ␭⫽0.9,
Rao R⫽2.1, P⫽.06).
The mean ⫾ SD overall casting duration was 32.6⫾20.6
days in group 1 and 9.3⫾5.6 days in group 2. The mean
numbers of cast changes were 4.4⫾2.1 in group 1 and 3.5⫾1.4
in group 2 (P⫽.01, Mann-Whitney U test).
The results of serial casting for both groups, with reference
to the percentage of maximum ROM, are shown in figure 2. Fig 2. Means and SDs of the percentage of maximum ROM before,
ANOVA for repeated measures revealed overall significant at the end of, and 1 month after completion of casting.

Arch Phys Med Rehabil Vol 83, June 2002

 EFFECTIVENESS OF SERIAL CASTING ON CONTRACTURES, Pohl
Fig 3. Means and SDs of the
percentage of maximum ROM
of the different joints before,
at the end of, and 1 month af-
ter completion of casting.
2: P⬍.001) and no differences between second and third ROM
measurement (group 1: P⫽.54; group 2: P⫽.99).
Additionally, the Scheffé test revealed significant differ-
ences in ROM gains between ankle joints and elbow joints
(group 1: P⫽.001; group 2: P⫽.90), and between ankle joints
and knee joints (group 1: P⫽.04; group 2: P⫽.03). No signif-
icant differences in ROM gains were found between ankle and
wrist joints (group 1: P⫽.08; group 2: P⫽.98), elbow and knee
joints (group 1: P⫽.98; group 2: P⫽.30), wrist and elbow
joints (group 1: P⫽1.0; group 2: P⫽1.0), and wrist and knee
joints (group 1: P⫽1.0; group 2: P⫽.96). The results of serial
casting for the different joints, referring to the percentage of
maximum ROM, are shown in figure 3.
Complications in the entire sample were observed in 34 of
172 joints (19.8%) treated with serial casting. Complications
were observed in 29.3% in group 1 and in 8.8% in group 2
787
(␹2⫽10.2, P⫽.001). The distribution of complications is
shown in figure 4.
Treatment was discontinued in 22 of 172 (12.8%) serial
casting procedures. Reasons for discontinuation are listed in
table 2. The overall discontinuation rate was significantly
higher in group 1 (␹2⫽4.7, P⫽.03). The Yates corrected chi-
square revealed no differences in discontinuation rate for treat-
ment reasons only (␹2⫽ 2.8, P⫽.09) for complications apart
from the casting only (␹2⫽0.8, P⫽.40) between the 2 groups
(table 2).
DISCUSSION
This study examined the effectiveness of serial casting in
patients with fixed contractures of the upper and lower extrem-
ities caused by cerebral spasticity. The case-comparison design
Fig 4. Number of complica-
tions in groups 1 and 2. Over-
all number of complications
differed between both groups
(␹2ⴝ10.2, Pⴝ.001).
Arch Phys Med Rehabil Vol 83, June 2002
788 EFFECTIVENESS OF SERIAL CASTING ON CONTRACTURES, Pohl
Table 2: Reasons for Discontinuation of Serial Casting
Group 1 Group 2
(cast-changing (cast-changing
interval 5–7d, interval 1–4d,
92 Joints, 80 Joints,
Reasons for Discontinuation n⫽56) n⫽49)
Casting complications* 11 3 In contrast to the numerous smaller studies in the litera-
NPUAP stage 1 1 2
NPUAP stage 2 7 0
Pain 1 1
Swelling 2 0
Other reasons* 6 2
Worsening of physical status 0 2
Hospitalization for acute condition 5 0
Epileptic seizure 1 0
Total discontinuations† 17 5 ties.27,28 To make the effect of casting comparable between the
* P⬎.05 (not significant; Yates corrected ␹2 test).
†
P⫽.03 (significant; Yates corrected ␹2 test).
compared the effectiveness and safety of short versus conven-
tional changing intervals in these patients.
Serial casting is a common therapy used in the management
of the sequelae of cerebral spasticity.2,12,14,15,29 Casting is used
in addition, or as an alternative, to physical9,18,29-31 and/or
medical therapies.2,10,13,19,32-34 Indications for serial casting in-
clude difficulties in patient care and reduced function of the
relevant limb resulting from joint contractures.9,12,13,29,31 These
indications were also found in this study. An improved passive
ROM after serial casting in all treated patients—still present 1
month after treatment—was observed. This improvement sup-
ports the results of different studies with smaller patient groups
or single joint investigations.15,17-19,31,35 Although serial casting
is used frequently, possible complications and side effects
resulting from this method are mentioned only in review arti-
cles.12,29 There is, however, a lack of documented incidence of
such complications and side effects. This study showed an
overall complication rate of 19.8% and an interruption rate of
12.8% in 172 treated joints.
Several publications recommend a cast-changing interval of
5 to 7 days in serial casting with fiberglass material in patients
with cerebral spasticity.12,15,18,29,30,36 There has, however, been
no investigation to prove or disprove that this recommendation
leads to an optimal result. The results of this study show that a
cast-changing interval of less than 5 days is superior to the
conventional cast-changing interval because it results in a
reduction of complications and discontinuation rates. Differ-
ences in the rate of discontinuations are possibly influenced by
the longer treatment time in the group with conventional cast-
changing intervals (see table 2). In our experience, complica-
tions can be reduced by an experienced and multidisciplinary
casting team consisting of a nurse, a physical or occupational
therapist, and a physician. Other investigators support this
observation.12,15,33 Because patients were treated with short
cast-changing intervals only during the 2 last years, the lower
incidence of complications in this group may partly be attrib-
uted to the casting team being more experienced. To minimize
the impact of this factor on the study’s results, only patients
who were treated after the casting team had a year’s experience
were included.
There are no long-term follow-up data on serial casting in
the literature. Furthermore, such data would be difficult to
assess because multiple external factors could influence the
long-term results. These are also influenced by the original goal
Arch Phys Med Rehabil Vol 83, June 2002
of the casting treatment. In patients in which simplifying pa-
tient care is sought, splints are used after serial casting to
maintain gains in ROM. In patients for whom improved func-
tion is sought, the course of the illness and motivation of the
patient are more significant factors in ROM retention. These
observations are supported by other investigators.12,15
ture,17-19,31,36-38 the large number of subjects and joints in our
sample shows reasonable evidence of the effectiveness of serial
casting, as achieved through both strategies. In addition, the
homogeneity of the entire group, with good comparability of
the defined subgroups, strengthens the validity of the results.
The absolute passive ROM is an appropriate and reliable
measurement tool,15,18,28 but the maximum absolute ROM var-
ies considerably between the different joints of the extremi-
different joints, we used the percentage of maximum ROM. A
clear effect of the interaction of the factors treatment and
repeated measurement was observed in the ANOVA. The best
casting results, defined by an improved percentage of maxi-
mum ROM, were found for ankle joints in both groups (fig 3).
This observation is supported by others.12,15
An effect of the interaction of order and repeated measure-
ment on ROM values was not observed. End of serial casting
is defined as attainment of maximum or sufficient ROM (ide-
ally 100%).12,15,18 Possible reasons for not attaining this goal
are lack of experience of the casting team and/or factors attrib-
utable to the patient’s condition. The final ROM values for both
groups were similar, as would be expected because of the
homogeneity of the patients in each group. Nevertheless, the
mean of nearly 1 more cast change (4.4 in group 1, 3.5 in group
2, P⫽.01) was necessary in group 1 to reach the same result.
Therefore, the entire casting duration was extended. This result
may suggest that shorter changing intervals are preferable to
conventional changing intervals. This suggestion should be
substantiated by further study.
The results of the study contradict the common fear that fast
(forced) serial casting with short changing intervals can injure
muscle tendons, bands, or joint capsules.39 Bands and tendons,
being formed connective tissues, are able to withstand only
small alterations in length and width.40 By contrast, unformed
connective tissues, such as joint capsules, respond to extension
by lengthening.40 In addition, the muscles play the most im-
portant role in contractures.4,5,7,41 It is suggested that an im-
provement in ROM through serial casting results from a re-
duction in muscle tone12,16,20,42,43 and improved flexibility of
the collagen network through destruction of cross links.9,40
That bands and tendons might be damaged through shorter
changing intervals is not to be feared. In addition, through
serial casting a decrease of baseline force under the cast to 20%
of the initial value occurs within the first 24 hours in patients
with severe spasticity.42 After this initial dramatic decrease,
further reduction of baseline force tails off quickly. This data
supports the suggestion that shorter changing intervals may be
more appropriate.
Limitations of the study are the facts that the study was not
randomized and that the 2 groups were not run concurrently. It
is possible that during the time intervening between the 2
groups, other practice changes were introduced that were not
fully accounted for. In addition, the use of systemic and local
antispastic therapy might have biased the study, although there
were no differences in distribution of the application between
the groups.
The study showed a comparable effectiveness of conven-
tional and of the above proposed casting method with short
 EFFECTIVENESS OF SERIAL CASTING ON CONTRACTURES, Pohl
changing intervals. The new method offers some advantages:
(1) a reduction in complication and discontinuation rates; and
(2) a reduction of treatment duration, leaving the patient or
patient’s guardian more favorably disposed to the treatment
and, for some patients, allowing an earlier integration of an
achieved function of the relevant limb in the rehabilitation
process.
CONCLUSION
This study suggests that casting is effective in the treatment
of fixed joint contractures of the upper and lower extremities
caused by increased muscle tone of cerebral origin. In addition,
short changing intervals (1– 4d) in serial casting can be an
effective and safe treatment for these patients. A casting pro-
cedure with shorter cast changes is equal in its effect on ROM
improvement but superior in reducing complications and treat-
ment duration.
Acknowledgment: We thank Derek Barton for helpful comments
on the manuscript.
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