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:

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)

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

Given the earlier discussion, our specific evidence-based practice question is: What evidence exists to support or refute the use of mobilization or adjunctive interventions to mitigate elbow stiffness in patients after joint trauma or surgery?

Evidence of Mobilizations

Active Mobilization

1. Level III evidence exists that active motion alone is effective after closed reduction of elbow dislocation. Twenty consecutive patients from a naval academy with closed posterior elbow dislocations were treated prospectively on a rapid motion, functional regimen. Final ROM averaged 24 to 139 degrees. All patients attained final extension within 5 degrees of the contralateral side; within an average of 19 days after reduction of the dislocation. Arm circumference returned to normal at an average of 6.5 days.²

2. Two Level II evidence reports indicate that early active ROM is more effective than late ROM after cubital tunnel decompression and medial epicondylectomy. Warwick compared early versus ROM exercises after cubital tunnel release and medial epicondylectomy. Fifty-seven consecutive cases were studied and divided into 2 groups. Physical therapy consisting of active and passive ROM exercises was started 14 days after surgery for the first group and 3 days after surgery for the second group. Fifty-two percent of the patients in the delayed motion group sustained flexion contractures of more than 5 degrees compared with only 4% of the patients in the early motion group. Patient starting exercise earlier returned to work in half the time. A second smaller trial in 45 consecutive procedures patients were randomized to rehabilitation at an average of 3 days after surgery or an average of 14 days after surgery. Flexion contracture of more than 5 degrees was observed in 5% of the early mobilization group compared with 52% of the late mobilization group (P < 0.001). On average, patients in the early mobilization group returned to work twice as early as those in the late mobilization group and did not experience any adverse effects on their grip strength or other hand functions.³

3. Level II evidence exists that splinting for more than 3 weeks is detrimental to achieving ROM after elbow dislocation. In 45 patients with a simple elbow dislocation/closed reduction (61 months after injury), the overall results were good or excellent with regard to pain and function. The most common finding was a loss of terminal extension (9% had a lack of extension up to 30 degrees). Better results were observed in those immobilized either less than 2 weeks or for 2 to 3 weeks as compared with those who were immobilized more than 3 weeks.⁴

Mobilization Splinting

1. Level 3 evidence has been found that static progressive stretch splinting for 1 to 3 months is effective in patients who had limited success with other treatment modalities including serial casting, dynamic splinting, physical therapy, and/or surgery; results were an average of 31 degrees or 69% improvement. All patients expressed satisfaction, with no complications and no deterioration in ROM at the 1-year follow-up evaluation.⁵

2. Multiple Level III or IV studies support that low-load prolonged stretch orthoses can reduce elbow joint contractures. In one study (17 patients; 12 with elbow contracture), secondary neurologic and orthopedic pathologies improved; elbow results were not summarized separately⁶ in another⁷.

3. Level IV evidence has been reported that a dynamic supination splint that does not cross the humeroulnar and humeroradial joints is effective in increasing ROM. Eleven subjects treated for various elbow and/or wrist fractures leading to losses of forearm supination significantly increased their passive ROM from 34.0 degrees at the initial visit to 82.3 degrees at discharge, and active range of motion from 27.0 to 72.3 degrees. Surface electromyography (EMG) confirmed the passive nature of the splint: Average supinator EMG activity was 7.9 mV at rest, 7.8 mV in the splint, and 68.0 mV with maximal isometric contraction.⁸

4. Level II evidence exists that CPM is an effective adjunct to surgery in treating elbow stiffness secondary to heterotopic periarticular ossifications. Heterotopic ossificans was surgically excised in 16 elbows of 14 patients with traumatic brain injury, an average of 18.9 months after the end of coma. During the follow-up period, all the elbows showed improvement in ROM, and the arc of flexion averaged 95 degrees in the surgery group, versus 116 degrees in the surgery/CPM group. Authors attribute their better outcomes compared with those obtained by previous investigators to be due to the prolonged application of continuous passive motion after surgery.⁹

Evidence of Adjunctive Interventions.

Level II evidence exists that cryotherapy is effective in managing muscle stiffness and pain related to a bout of damage-inducing eccentric exercise (8 sets of 5 maximal reciprocal contractions at 0.58 rad × sec⁻¹) of the elbow flexors on an isokinetic dynamometer (n = 15 female subjects). Subjects in the cryotherapy group immersed their exercised arm in cold water (15°C) for 15 minutes immediately after eccentric exercise and then every 12 hours for 15 minutes for a total of seven sessions. Relaxed elbow angle was greater and creatine kinase activity lower for the cryotherapy group than the control group on days 2 and 3 after the eccentric exercise.¹⁰

Level V (Expert Recommendations)

A variety of Level V recommendations were extracted from review articles.

• Nonoperative management of stiffness should be considered for up to 6 months (after contracture).^11–13 Note: Evidence has been found that even prolonged contractures benefit from splinting.

• More recent contractures are more likely to respond to nonoperative management.¹²

• Ice and inflammatory medication are useful adjuncts.^12,13

• Overly aggressive physical therapy may increase pain, stiffness, and swelling, and possibly lead to HO.¹³

• Night splinting should be used in the direction of greatest limitation.¹²

• Splinting for 20 hours of wear alternating directions with intermittent exercise is effective.¹²

• Staging of intervention should include cryotherapy, gentle passive and active ROM exercise during inflammatory stage; thermal modalities and activities of daily living are added during fibroblastic stage; in the remodeling stage, all modalities and strengthening exercises are indicated.¹⁴

• Low-load passive exercise progressed to active, then end-range exercise/stretch.¹⁴

• Exercise of 5 to 10 repetitions every 2 to 3 hours is progressed to 15 to 20 repetitions every hour based on tissue response.¹⁴

• Forearm/pronation exercise should be performed at 90 degrees of elbow flexion to protect ligaments.¹⁴

• Joint mobilization (increased from lesser grades to end range mobilizations) are effective when combined with splinting.¹⁴

• Splinting for mobilization should be avoided for 3 to 6 weeks after injury.¹⁴

• The static progressive flexion cuff, serial static extension splint, static progressive turnbuckle splints for flexion/extension, and either a static progressive or dynamic splint for pronation/supination are affective mobilizing splint choices.¹⁴

• Splinting can start with 1–2 hours, 3–4 times/day in the fibroblastic phase combined with night and splinting.¹⁴

• Splinting is more effective when combined with intensive therapy.^11,14

• Traditional treatment during the day and night and use of CPM is effective.¹⁴

• CPM is used when fractures/ligament repairs are stable.¹⁴

• Ultrasound is less useful for improving tissue extensibility at the elbow (vs. hot packs or whirlpool) because of the size and depth of tissue.¹⁴

• EMG biofeedback is useful for re-educating agonist muscles or to reduce antagonist activity that contributes to joint stiffness.¹⁴

• Injury-specific guidelines (Level V)¹⁴

Fracture distal humerus

Early ROM begins on day 1 (if triceps sparing extension is allowed).

Home programs should consist of elevation/ice, active-assisted flexion, gravity-assisted extension, active pronation/supination, maintained exercise shoulder/wrist and hand.

Once callus forms, passive ROM and mobilization splinting are added.

Radial head fractures

elbow extension and flexion should be performed in pronation (supination increases the radiocapitellar load).

Forearm rotation should be performed with elbow flexed to 90 degrees.

Fractures with open reduction with internal fixation without ligament injury are positioned in a collar and cuff for day use and an elbow extension splint at night.

If the lateral collateral ligament is deficient, the elbow is splinted in 90-degree flexion and forearm pronation during the day.

Early active flexion/extension with the elbow greater than 90 degrees is started on day 1.

Strengthening can start at 8 weeks, progressing from pronation to supination.

Coronoid fractures

Early active ROM within a stable arc is indicated.

Extension should be blocked by a splints for last 40 to 60 degrees (block reduced 10 degrees/week); for total use of 4 to 6 weeks.

Passive extension/mobilizations delayed until fracture is healed.

Pronation/supinations performed at 90 degrees out of splint.

Early contracture control is needed—serial extension splinting starts at 4 weeks.

Strengthening delayed until 8 to 10 weeks.

Elbow dislocations

Initially, patients are splinted in a posterior elbow splint holding the joint at 90 degrees for 5 to 7 days.

If stable, elbow ROM in an unrestricted range is initiated; if stability is a concern, extension protection is indicated.

Passive elbow flexion stretches are avoided for 6 weeks.

AREAS OF UNCERTAINTY

The following issues have not been resolved in relation to optimal rehabilitation of post-trauma elbow stiffness:

SUMMARY OF RECOMMENDATIONS

Fair evidence exists to suggest the following conclusions:

The preponderance of evidence supports a role for a progressive rehabilitation program, although the specifics of an optimal rehabilitation program cannot be defined on the basis of current exercise. Further research and consensus exercise around condition-specific restrictions and more consistent use of outcome measures would benefit the field. Table 23-2 provides a summary or recommendations for the treatment of post-traumatic elbow stiffness.

TABLE 23-2 Summary of Recommendations

ACKNOWLEDGMENT

J.C.M. was funded by a New Investigator Award, Canadian Institutes of Health Research.