What Is the Optimal Rehabilitative Approach to Post-Traumatic Elbow Stiffness?

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Chapter 23 What Is the Optimal Rehabilitative Approach to Post-Traumatic Elbow Stiffness?

JOY C. MACDERMID, PT, PhD

CHALLENGES IN IMPLEMENTING EVIDENCE-BASED PRACTICE IN THIS CASE

Evidence-based practice dictates that we use best available evidence when making clinical decisions. In this regard, the question posed in this chapter presents a number of challenges:

1. Rehabilitation is an area of clinical practice, not a specific intervention. Studies are designed to answer whether specific approaches within rehabilitation are effective, and not to answer the broad question posed above.

2. Rehabilitation programs are multimodal. Studies that evaluate isolated components of rehabilitation must necessarily detect the isolated smaller effect sizes that contribute to the overall rehabilitation program, and thus would require extremely large sample sizes to be fully powered. Ideally, studies should be designed to compare the treatment of interest with one that is substantially different in philosophy or intensity (ideally a placebo), but standards of practice, ethics, and professional beliefs often restrict this approach.

3. Unlike surgery, which happens at a single point in time, recovery and rehabilitation occurs over time. Goals, interventions, and effectiveness of rehabilitation can vary at different time points, complicating the comparison across different studies. For example, in the acute rehabilitation phase, the focus of rehabilitation for a stiff elbow would be restoration of joint mobility, whereas later the focus might be strengthening, functional endurance, retraining, and work accommodation. (Joint mobility is the focus of this clinical question, with interventions subgrouped into joint mobility interventions, adjunctive interventions, and functional interventions.)

4. Classification and definition of the various techniques/options involved in rehabilitation have not been agreed on.

5. Description of the various techniques involved in rehabilitation in most studies is insufficient to fully understand what has been done. (I have attempted to deal with item 4 by creating specific definitions but was limited by item 5.)

6. Like orthopedic surgery research, the majority of studies are of low quality (see the following paragraph).

The net result of these problems is that there is difficulty locating sufficient high-quality evidence to make comprehensive specific recommendations for rehabilitation of post-traumatic elbow stiffness. This became evident in the first attempts at searching the literature, where few relevant studies could be identified using the classic approaches to searching the literature.

Despite these challenges, evidence-based practice does provide guidance on how to proceed when specific high-quality evidence is lacking. One approach is to include lower levels of evidence; thus, this chapter includes any studies that addressed rehabilitation of the stiff elbow (Levels I–IV) and then separately lists peer-reviewed published expert opinions. A second approach used was the extrapolation of results from studies that were similar to the specific problem of interest. For this reason, this chapter includes a systematic review that addressed rehabilitation of stiffness after trauma to other upper extremity joints. In this case an ESB approach required multiple literature searches and an understanding of the clinical issues to find appropriate and useful evidence.

OPTIONS

To be clear about what is being administered in any joint mobility intervention, one has to be able to describe the active ingredient of the intervention (in a way that others could replicate it). This is not characteristic of how interventions are described in the literature. I proposed a classification system by which the nature of specific rehabilitative interventions designed for joint mobility may be understood. It is important to define the composition and intensity of the intervention using consistent terminology to understand or replicate any given intervention. The composition of the intervention is defined by who delivers the active ingredient (patient, therapist, mobilization device, constraint device) and what type of mobilization is performed (defined by activation mode, arc of movement, and end range time). Intensity is defined by the force applied, the number of repetitions per session, and the number of sessions per day.

DEFINING THE COMPOSITION AND INTENSITY OF JOINT MOBILITY INTERVENTIONS (FIGURE 1)

A Composition of Intervention

a Patient: patient delivers the stimulus

b Therapist: the therapist delivers the stimulus

• Mobilization device: A device whose purpose is to directly mobilize specific impaired joints. It is applied to patient, usually under direction of the health professional (includes dynamic and static splints, as well as CPM).

• Constraint device: A device whose purpose is to immobilize specific unimpaired joints, and thereby indirectly mobilize impaired joints; supplied to the patient usually under direction of health professional (includes blocking splints and casting of unaffected joints).

2. Type of movement (activation mode, arc of movement, end range time)

a. Activation mode

• Active: active muscle contraction is used to produce movement

• Passive: passive force is used to produce movement

• Combined activation: combination of active and passive movement

b. Arc of movement

• Physiologic: The body segment is moved throughout a defined range that is consistent with the normal movement of the joint; this is sometimes referred to as range of motion (ROM) exercise because patients or through a ROM (can be active or passive); but to avoid confusion, this chapter uses the more specific term physiologic motion; note blocking of motion refers to a restriction on the full physiologic arc of motion.

• Accessory: The body segment is moved to produce the accessory joint “play” movement that occurs during normal physiologic motion; this is sometimes referred to a “joint mobilization,” but as the latter terms encompass other techniques, the more specific term accessory motion is used here.

• End range: The body segment is maintained at the end of the available range of the joint.

• Manipulation: The body segment is thrust beyond is available end range of the joint.

c. End range time

• Intermittent: The joint is maintained at its end range time for a variable amount of time and then released and returned in cyclic fashion.

• Sustained: The joint is maintained at its end range time for a sustained amount of time (often based/progressed according to tolerance).

B Intensity of intervention

1. Force applied

Ideally, force applied and specific end range time should be described, particularly for splinting Conversely, these can be described as:

• low load where the joint is held at the end of range with minimal mobilizing force (intended to grow tissue extensibility)

• moderate deforming load where a tolerable load is applied to move the segment and lengthen tissue to improve extensibility

• thrust where force is intended to disrupt tissue adhesions/blocks.

Number of repetitions per application or set

Number of sets or applications per day

Figure 1 describes some common mobilization interventions using their common names and categories: active, passive, and manipulation. These fall on a continuum of increasingly intense mobility interventions. The common names are associated with the more specific terminology defined below to define the different delivery/control methods (patient, therapist, mobilization device).

FIGURE 23-1 Physiological movement: the body segment is moved throughout a defined range that is consistent with the normal movement of the joint. Accessory movement: the body segment is moved to produce the accessory joint “play” movement that occurs during normal physiologic motion; End range: the body segment is maintained at the end of the available range of the joint. The intensity of intervention should be defined by the Force applied, and duration (including the number of repetitions or time/application or set and the number of sets or applications/day).* Device is monitored by a person.

ADJUNCTIVE INTERVENTIONS

The second group of rehabilitation intervention used to manage joint mobility must be considered adjunctive. These are interventions that support the main goal—that is, joint mobility by facilitating the mobilization intervention. Interventions that are designed to control pain or promote tissue extensibility as a prerequisite to improving joint mobility are the most common that would fit in this category.

The final groups of interventions are considered to be functional. These are interventions designed to restore function. They may or may not improve joint stiffness but are implemented with the goal of restoring the patient to maximum function and quality of life. Examples include strengthening programs, work hardening, adaptive devices, education, or functional splinting. Given our question, these issues are not addressed in this chapter.

DEFINING AN ANSWERABLE QUESTION

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