Loss of elbow motion described as elbow stiffness requiring orthotic management has numerous potential causes. The most common cause of this kind of contracture is post-traumatic stiffness, followed by ectopic ossification, burns, head injury, and congenital or developmental conditions. Intrinsic contracture is associated with joint articular involvement and may be caused by fractures, osteoarthritis or inflammatory arthritis, or congenital or developmental disease.1–3
Various methods of treating post-traumatic stiffness have been described. Static progressive and dynamic splinting, serial casting, traction, intermittent compression system, physiotherapy, and surgery are acceptable methods for restoring range of motion (ROM) in contractures.4–11 Manual passive stretch techniques and especially proprioceptive neuromuscular facilitation techniques such as repeated contractions and hold-relax techniques are used by physical therapists to elongate and improve the muscle tissue flexibility and strength.12–14 However, manual passive stretching, a common method of physical therapy, can have limited effect and is difficult to apply for joint contractures.15,16 In addition, elbow joint traction combined with moist heat and active exercise is described to improve elbow extension in cases of flexion contracture.17
Several studies describe the importance of orthotic design to functional improvement and recommend the use of low-load prolonged stretch orthoses for contracture management.18–21 Other reports indicate that most elongation during repetitive stretching is achieved with the minimum required number of stretches.3,22,23 Improvement in soft tissue flexibility is directly related to the gradual increase of low loads. Furthermore, serial casting, often used in treatment of contractures, does not permit daily hygiene, clinical inspection, and air circulation.
Surgical release is suggested for flexion contractures between 60° and 100° flexion. An orthotic intervention is recommended before surgical treatment.1
In the current study, a static progressive uniaxial elbow orthosis (EO) is presented as an alternative to previously described orthotic and physical therapy approaches in the clinic. The effectiveness of the orthosis for treatment of elbow flexion contracture is discussed.
METHODS AND MATERIALS
The EO is a custom-molded orthosis made from polyamide (4–6 mm thick) cylindrically shaped around the arm and forearm, with a posterior opening large enough to permit comfortable donning and doffing. Velcro straps are used to hold the EO in place. Medial and lateral free elbow joints are manufactured from the polyamide material as part of the orthosis. The mechanical uniaxial elbow joint is applied on the anatomical axis of the elbow.
The U-shaped piece designed to fix the elbow flexion contracture is made up of a double steel bar (14–16 mm wide, 3 mm thick) and a polyamide (4–6 cm wide and 2 mm thick) forearm bracelet.
The interior of the orthosis may be covered with Plastazote (Zotefoams Inc., Walton, KY) (3 mm thick) if needed. The medial and lateral steel bars are placed on the proximal part of the orthosis. Both steel bars move counterclockwise. The distal bars are placed on the bracelet of the orthosis and rotate on the forearm cover according to the elbow’s extension (Figure 1).
The corrective forces of this EO are applied to the olecranon process and the anterior surfaces of the arm-forearm. The elbow cap covers the olecranon and is attached to the bars by a Velcro strap. The elbow cup is tight enough to provide stretch of the soft tissue to the point when the patient first indicates pain. Because excessive forces may result in edema, the tension of the olecranon cap should be observed carefully. A gentle, low-load prolonged stretch using static progressive method should be applied.
The EOs were used on five patients (two male, three female; mean age, 11.6 ± 5.2 years). Flexion contractures were caused by extra-articular fractures in three patients and burn injuries in two patients. All flexion contractures were unilateral (four right, one left). None of the patients had neurovascular injuries. Orthotic treatment was administered after a mean of 8.6 ± 3.0 months after injury (range, 5–13 months; Table 1). None of the patients received any other treatment for flexion contracture before or after orthotic intervention. Lack of joint involvement was confirmed by plain radiographs.
Patients were evaluated for joint range of motion and manual muscle testing before, during, and after treatment and on follow-up by the same independent physiotherapist.
Joint motion was measured with both a standard goniometer and an inclinometer to prevent possible reading errors before, during, and after the orthotic treatment. The standard goniometer was centered over the elbow joint laterally, and the inclinometer was placed on the long axis of the forearm posterior. Flexion contracture was measured in the neutral rotational position of the forearm. Flexion between 30° and 180° was considered normal.16
Muscle strength was measured using Lovett’s manual muscle testing on a scale of 0 to 5, and the results were compared with the sound side.16 Muscle strength of the patients’ shoulder, elbow, and wrist were measured before the use of the EO (BEO) and after use (AEO).
During week 1 of orthotic treatment, all patients wore an orthosis daily for a total of 6 hours, removing the device every 2 hours for 30 minutes. In the following weeks, two of the patients wore the orthosis at night and three of the patients who had flexion contractures >45° wore the orthosis full-time with the orthosis removed three times per day for 1 hour. All patients used stockinettes in their orthoses.
A home exercise program of gentle passive stretching to strengthen elbow extensors was suggested for three patients with elbow contractures after 18 months of follow-up.
Manual muscle testing before the orthotic treatment showed the elbow extensor and forearm pronators were good (grade 4) for three patients with fractures and normal (grade 5) for two patients with burn injuries. The other muscle groups (shoulder, elbow, and wrist muscles) were evaluated as normal (grade 5). Within 18 months, elbow extensor and pronator strength increased to normal (grade 5) for three patients.
According to the goniometric measurements, there were no limitations on the patients’ shoulder and wrist motions. However, there were active pronation limitations between 10° and 25° and supination limitations between 15° and 20°. After orthotic treatment, there was a gain in active motion between 0° and 5° pronation and 0° and 10° supination.
There was also active/passive limitation in elbow extension and flexion. Thus, the measurements were taken as active range of motion (AROM) and passive range of motion (PROM) before, during (DEO), and after the orthotic treatment. The DEO measurements were taken two to six times at 2-week intervals. The AEO measurements were taken 18 months after the first DEO measurement. None of the patients used the EO for the full 18 months. The improvements of elbow AROM and PROM are shown in Table 2. The EOs were worn for a mean of 2.2 ± 0.8 months; two patients wore their orthoses for 3 months, two for 2 months, and one for 1 month.
Active and passive extension and flexion limitations are presented in Table 3.
According to the Wilcoxon rank test, the decreases in active and passive extension limitations between BEO and DEO, and between BEO and AEO were statistically significant (p < 0.05; Table 4). The change in active and passive extension limitation between DEO and AEO was not significant. The changes in active and passive flexion limitations between BEO and DEO, BEO and AEO, and DEO and AEO were not significant. Table 5 shows the corrective effect of the EO on elbow limitations during orthotic treatment.
Few studies report on the use of various orthoses designed to produce static progressive or low-load prolonged stretch for the purpose of decreasing flexion contractures.24 This study presents the effect of a static progressive EO on active and passive elbow extension limitation. The static progressive orthotic treatment provides load that can be tolerated comfortably by patients. Our study supports the findings of many researches on elbow ROM with the use of EOs.8,15,19–21,25,26 In these studies, the age range is 18 to70 years, and the duration of use is 1 to 8 months.
Bonutti et al.8 studied 20 patients with an average age of 32.9 years and reported a 31° increase in ROM after 1 to 3 months of orthosis use (17° increase in extension and 14° in flexion ROM). The patients of Bonutti et al. wore their orthosis for one or two 30-minute sessions per day.8
Recently, Gelinas et al.25 studied 22 patients (mean age, 39 years) who used a turnbuckle orthosis to apply a static progressive stretch technique. The orthosis was used 20 hours per day for an average of 4.5 months. After orthotic treatment, the mean flexion contracture decreased to 26° ± 10°.25
Furthermore, Shewring et al.27 reported an average increase of 30° in ROM extension of 21 patients (average age, 33.5 years) using a dynamic sling. After 6 months, the ROM increased by 5° to reach a total of 35°.27
In our study, five patients were treated with the EO; no surgical or standard physical therapy treatment was applied. Measurements taken 18 months after the onset of EO use showed an increase of active extension (minimum 25°, maximum 40°; median 35°) and of active flexion (minimum 0°, maximum 15°; median 5°). The rapid increase of extension ROM after EO could be related to factors such as the patients’ young age, the EO design, and its static progressive stretch characteristics.
No complications were noted from the use of the orthosis, similar to the findings of other studies.8,15,18-20,25 The EO is light, of simple construction, inexpensive, and easy to don/doff and clean. It was designed to reduce pressure and eliminate friction and does not need new alignment during the orthotic treatment period. It is cosmetically acceptable and has adequate ventilation.
Our EO was used only for flexion contracture. We did not modify the orthosis to improve elbow flexion. Thus, we believe that the median correction of extension contracture of 5° in active motion is directly related to active use of the elbow in daily living during and after the orthotic treatment. Home exercises were effective in preventing deterioration of flexion contracture for three patients.
In the current study, use of a uniaxial elbow orthosis in five young patients with flexion contractures produced an increase in both active and passive ROM with no complications, surgical intervention, or conventional physical therapy. Future studies will incorporate use of the EO on large numbers of patients from different age groups with different joint flexion and extension contractures.
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