Static progressive stretch for the treatment of knee stiffness

Arthrofibrosis of the knee in pediatric orthopedic surgery

Arthrofibrosis is a challenging complication associated with knee injuries in both children and adults. While much is known about managing arthrofibrosis in adults, it is necessary to understand its unique aspects and management strategies in the pediatric population. This paper provides an overview of arthrofibrosis in pediatric orthopedic surgery, focusing on its causes, implications, classifications, and management. This paper is a comprehensive review of the literature and existing research on arthrofibrosis in pediatric patients. Arthrofibrosis is characterized by excessive collagen production and adhesions, leading to restricted joint motion and pain. It is associated with an immune response and fibrosis within and around the joint. Arthrofibrosis can result from various knee injuries in pediatric patients, including tibial spine fractures, ACL and PCL injuries, and extra-articular procedures. Technical factors at the time of surgery play a role in the development of motion loss and should be addressed to minimize complications. Preventing arthrofibrosis through early physical therapy is recommended. Non-operative management, including dynamic splinting and serial casting, has shown some benefits. New pharmacologic approaches to lysis of adhesions have shown promise. Surgical interventions, consisting of arthroscopic lysis of adhesions (LOA) and manipulation under anesthesia (MUA), can significantly improve motion and functional outcomes. Arthrofibrosis poses unique challenges in pediatric patients, demanding a nuanced approach that includes prevention, early intervention with non-operative means, and improvements in surgical techniques. Modern pharmacological interventions offer promise for the future. Customized interventions and research focused on pediatric patients are critical for optimal outcomes.

Efficacy of a high-intensity home stretching device and traditional physical therapy in non-operative management of adhesive capsulitis - a prospective, randomized control trial

BACKGROUND

Historically, in-person physical therapy serves as a foundational component of nonoperative treatment of adhesive capsulitis (AC). This study compares the effectiveness of an at-home high-intensity stretch (HIS) device to traditional physical therapy (PT) and to PT in combination with the HIS device. We hypothesize that the HIS device will be as effective as PT alone or as combination therapy in the first-line treatment of AC and use of the HIS device will exhibit improvement at higher rate.

METHODS

Thirty-four patients with idiopathic adhesive capsulitis and a minimum of 12 months follow-up were included in this study. Patients were randomized into one of the three groups: HIS device, PT alone, or HIS device + PT. Passive range of motion (ROM), American Shoulder and Elbow Surgeons (ASES), and Simple Shoulder Test (SST) scores were measured. Additionally, patient satisfaction, compliance and complications were recorded. Paired t-test, ANOVA and Chi-squared tests were used in analysis.

RESULTS

Final ROM in all planes improved for all groups compared to baseline (p < 0.001), with only HIS device group able to restore > 95% of contralateral ROM in all planes at final follow-up. Patients with PT alone were on average slowest to improve ROM from baseline, at 3 months, 6 months, and 1 year in all planes except internal rotation. ASES and SST scores improved for all groups when compared to baseline (p < 0.001). Use of HIS-device resulted in greater improvement in SST and ASES Total scores compared to PT alone (p = 0.045, and p = 0.048, respectively).

CONCLUSIONS

Use of an at-home high-intensity stretching device for conservative treatment of idiopathic adhesive capsulitis improves outcomes in ROM and in ASES and SST scores both when used as an adjunct to physical therapy and when used alone.

TRIAL REGISTRATION

The study protocol was registered at www.

CLINICALTRIALS

gov (20/05/2022, NCT05384093).

Postoperative subacute static progressive stretch does not increase the risk of distal lower limb venous thromboembolism

PURPOSE

Static progressive stretch (SPS) can be applied to treat chronic joint stiffness. However, the impacts of subacute application of SPS to the distal lower limbs, where deep vein thrombosis (DVT) is common, on venous thromboembolism remain unclear. This study aims to explore the risk of venous thromboembolism events following subacute application of SPS.

METHODS

A retrospective cohort study was conducted on patients diagnosed with DVT following a lower extremity orthopedic surgery before being transferred to the rehabilitation ward from May 2017 to May 2022. Patients with unilateral lower limb comminuted para-articular fractures, transferred to rehabilitation ward for further treatment within 3 weeks after operation, followed up more than 12 weeks since initial manual physiotherapy, and diagnosed DVT by ultrasound before rehabilitation course were included in the study. Patients with polytrauma, without evidence of previous peripheral vascular disease or incompetence, had medication for thrombosis treatment or prophylaxis before the operation, detected with paralysis due to nervous system impairment, infected after operation during the regime, or with acute progression of DVT were excluded. The included patients were randomized to the standard physiotherapy and the SPS integrated groups for observation. Associated DVT and pulmonary embolism data were collected during the physiotherapy course to compare the groups. SSPS 28.0 and GraphPad Prism 9 were used for data processing. p < 0.05 was set significant difference.

RESULTS

In total of 154 patients with DVT participating in this study, 75 of them were treated with additional SPS for postoperative rehabilitation. The participants in the SPS group showed improved range of motion (12.3° ± 6.7°). However, in the SPS group, there was no difference in thrombosis volume between the start and termination (p = 0.106, p = 0.787, respectively), although difference was seen intra-therapy (p < 0.001). Contingency analysis revealed the pulmonary embolism incidence (OR = 0.703) in the SPS group compared to the mean physiotherapy.

CONCLUSION

The SPS technique is a safe and reliable option to prevent potential joint stiffness without aggravating the risk of distal DVT for postoperative patients suffering from relevant trauma.

Efficacy of non-operative treatment of patients with knee arthrofibrosis using high-intensity home mechanical therapy: a retrospective review of 11,000+ patients

Background

Recovery from knee surgery or injury can be hindered by knee arthrofibrosis, which can lead to motion limitations, pain and delayed recovery. Surgery or prolonged physical therapy are often treatment options for arthrofibrosis, but they can result in increased costs and decreased quality of life. A treatment option that can regain lost motion without surgery would help minimize risks and costs for the patient. The purpose of this study was to determine treatment efficacy of high-intensity home mechanical stretch therapy in patients with knee arthrofibrosis.

Methods

Records were reviewed for 11,000+ patients who were prescribed a high-intensity stretch device to regain knee flexion. Initial and last recorded knee flexion and days between measurements were available for 9842 patients (Dataset 1). Dataset 2 was a subset of 966 patients from Dataset 1. These 966 patients had separate more rigorous measurements available from physical therapy notes (Dataset 3) in addition to data from the internal database (Dataset 2). Within and between dataset statistics were calculated using t tests for comparison of means and Cohen’s d for determination of effect size.

Results

All dataset showed significant gains in flexion (p < 0.01). Mean initial flexion, last recorded flexion and flexion gain were 79.5°, 108.4°, and 29.9°, respectively in Dataset 1. Differences between Datasets 2 and 3 had small effect sizes (Cohen’s d < 0.17). The were no significant differences when comparing workers’ compensation and non-workers’ compensation patients. The average last recorded flexion for all datasets was above the level required to perform activities of daily living. Motion gains were recorded in under 60 days from device delivery.

Conclusions

High-intensity home mechanical stretch therapy was effective in restoring knee flexion, generally in 2 months or less, and in avoiding additional surgery in severe motion loss patients regardless of sex, age, or workers’ compensation status. We believe high-intensity stretching should be considered in any patient who is at risk for a secondary motion loss surgery, because in over 90% of these patients, the complications and costs associated with surgery can be avoided.

Effects of Different Static Progressive Stretching Durations on Range of Motion, Myofibroblasts, and Collagen in a Posttraumatic Knee Contracture Rat Model

OBJECTIVE

The purpose of this study was to investigate the effects of different durations of static progressive stretching (SPS) on posttraumatic knee contracture in rats, including range of motion (ROM), gait analysis, myofibroblast proliferation, and collagen regulation.

METHODS

The posttraumatic knee contracture model was established, and male Wistar rats were randomly divided into the 20-minute SPS treatment, 30-minute SPS treatment (S30), 40-minute SPS treatment, untreated, immobilization, and control groups. At Week 1, 2, and 4 of treatment intervention, joint ROM and gait were measured and compared. Knee joint samples stained with hematoxylin and eosin and Masson trichrome were used to observe alterations in pathological structures. Collagen density and cell numbers in the posterior joint capsule were used to assess joint capsule fibrosis and inflammation. Immunohistochemistry was used to detect type I collagen and α-smooth muscle actin expression.

RESULTS

The S30 group improved the most; ROM, stance, mean intensity, print area, and stride length were 115 (SD = 5) degrees, 0.423 (SD = 0.074) seconds, 156.020 (SD = 7.952), 2.116 (SD = 0.078) cm2, and 11.758 (SD = 0.548) cm, respectively. The numbers of myofibroblasts, fibroblasts, and inflammatory cells decreased, and collagen proliferation was significantly suppressed in the S30 group compared with the other groups.

CONCLUSION

S30 significantly improved posttraumatic knee contracture in rats, with reduced type I collagen and α-smooth muscle actin expression, decreased the numbers of myofibroblasts and inflammatory cells, suppressed fibrotic and inflammatory changes in the joint capsule, and increased joint mobility. This study provided basic evidence for an optimal standard-of-care treatment approach for posttraumatic knee joint contracture in rats, which may have significance for humans.

Intra-articular leiomyoma of the knee mimicking a ganglion cyst in a child: A case report and review of literature

INTRODUCTION AND IMPORTANCE

Angioleiomyoma is a rare benign soft tissue tumor of smooth muscle getting its origin from the muscular layer of vessel walls. The localized type of leiomyoma occurs on the skin, deep soft tissues, in the genitourinary, gastrointestinal, and respiratory tracts.

CASE PRESENTATION

We report a case of a 16-year-old patient who presented with an intra-articular leiomyoma developed in the anterior cruciate ligament and treated with arthroscopy.

CLINICAL DISCUSSION

Angioleiomyoma can occur anywhere in the body and is most often seen in the extremities, particularly the lower limbs, but is very rare in the knee joint. Angioleiomyoma should be included in the differential diagnosis of nodular lesions mimicking loose body, such as lipomas, inclusion cysts, ganglion, pigmented villonodular synovitis (PVNS), fibroma, nodular synovitis, hemangioma, synovial sarcoma, myopericytoma, leiomyosarcomas, glomus tumor.

CONCLUSION

Angioleiomyoma related to the cruciate ligaments of the knee should be considered in the differential diagnosis of a painful knee especially when associated with a decreased of range of motion of knee. The arthroscopic debridement should be considered the treatment of choice in order to reliably restore active ROM.

Printing a static progressive orthosis for hand rehabilitation

BACKGROUND

Static progressive orthosis is used for the treatment of severe joint contracture after trauma and/or surgery. However, a custom-fabricated static progressive splint would be expensive and labor intensive. Especially, owing to very limited payment under the current Taiwanese National Health Insurance, the incentives to fabricate a patient-specific splint are insufficient for a therapist. To ease splint construction, we introduced three-dimensional (3D)-printed "shark fin"-shaped device works as a static progressive orthosis for the hand rehabilitation. The aim of this study was to describe and demonstrate the newly designed device.

METHODS

This study included a 46-year male suffered from a left distal radius fracture and underwent open reduction internal fixation and a 23-year male with the right thumb flexor pollicis longus rupture, requiring tendon repair. Both subjects used this "shark fin"-shaped device to stretch for increasing range of motion (ROM) of wrist extension and the thumb.

RESULTS

The patient receiving ulnar shortening surgery used this device to stretch for increasing ROM of wrist extension. The active ROM of wrist extension improved from 30° to 50°. The other patient with the right thumb flexor pollicis longus rupture suffered from thumb contracture; the ROMs of the metacarpophalangeal (MCP) joint and interphalangeal (IP) joint were 40°-55° and 20°-25°, respectively. After tenolysis surgery, his ROMs of the MCP and IP joints were improved to 10°-35° and 40°-65°, respectively. Following physical therapy by applying the device, his ROMs of the MCP and IP joints were further increased to 0°-40° and 25°-70°, respectively.

CONCLUSION

Incorporating the "shark fin"-shaped orthosis into hand rehabilitation increased the ROM of wrist extension for a patient with distal radius fracture and improved the ROM of the MCP and IP joints in another patient after tenolysis surgery.

Medical stretching devices are effective in the treatment of knee arthrofibrosis: A systematic review

AIMS

This systematic review examines the available evidence on the use of medical stretching devices to treat knee arthrofibrosis, it suggests a focus for future studies addressing limitations in current research and identifies gaps in the published literature to facilitate future works.

MATERIALS AND METHODS

Articles were identified using the Cochrane Library, MEDLINE, PubMed and SCOPUS databases. Articles from peer reviewed journals investigating the effectiveness of medical stretching devices to increase range of movement when treating arthrofibrosis of the knee were included.

RESULTS

A total of 13 studies (558 participants) met the inclusion criteria with the devices falling into the following categories; CPM, load control or displacement control stretching devices. A statistically significant increase in range of movement was demonstrated in CPM, load-control and displacement-control studies (p ​< ​0.001). The results show that the stretch doses applied using the CPM, load-control devices were performed over a considerably longer treatment time and involved significantly more additional physiotherapy compared to the displacement-control and patient actuated serial stretching devices.

CONCLUSION

The systematic review indicates that load-control and displacement-control devices are effective in increasing range of movement in the treatment of knee arthrofibrosis. Displacement-control devices involving patient actuated serial stretching techniques, may be more effective in increasing knee flexion than those utilising static progressive stretch.The paucity of research in this field indicates that more randomised controlled trials are required to investigate the superiority of the different types of displacement-control stretching devices and which of these would be most effective for use in clinical practice and to compare these with standard physiotherapy treatment.

The STAK tool: evaluation of a new device to treat arthrofibrosis and poor range of movement following total knee arthroplasty and major knee surgery

Aims

This study aims to evaluate a new home medical stretching device called the Self Treatment Assisted Knee (STAK) tool to treat knee arthrofibrosis.

Methods

35 patients post-major knee surgery with arthrofibrosis and mean range of movement (ROM) of 68° were recruited. Both the STAK intervention and control group received standard physiotherapy for eight weeks, with the intervention group additionally using the STAK at home. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Oxford Knee Scores (OKS) were collected at all timepoints. An acceptability and home exercise questionnaire capturing adherence was recorded after each of the interventions.

Results

Compared to the control group, the STAK intervention group made significant gains in mean ROM (30° versus 8°, p < 0.0005), WOMAC (19 points versus 3, p < 0.0005), and OKS (8 points versus 3, p < 0.0005). The improvements in the STAK group were maintained at long-term follow-up. No patients suffered any complications relating to the STAK, and 96% of patients found the STAK tool ‘perfectly acceptable’.

Conclusion

The STAK tool is effective in increasing ROM and reducing pain and stiffness. Patients find it acceptable and adherence to treatment was high. This study indicates that the STAK tool would be of benefit in clinical practice and may offer a new, cost-effective treatment for arthrofibrosis.

Cite this article: Bone Joint Open 2020;1-8:465–473.

Static progressive stretch orthosis-consensus modality to treat knee stiffness-rationale and literature review

The current literature supports static progressive stretch (SPS) orthoses as the consensus modality to treat joint stiffness as an adjunct to manual therapy. Over 50 published studies prove the efficacy and safety of this modality as an adjunct to therapy to improve range of motion (ROM) as well as decrease stiffness and pain. Data from a large prospective study on SPS effectiveness identified a 90% improvement in ROM, 84% reduction in stiffness and swelling, 70% reduction in pain, and no reports of complications or injury. Another 13 studies evaluating patients with knee stiffness have shown excellent results with SPS, and a reduced need for manipulation under anesthesia or additional surgeries. The bidirectional SPS device allows for ROM therapy in both flexion and extension, uses short, 5-minute incremental stretches for up to a 30-minute session applied 1 to 3 times per day for 8 weeks, though treatment might be needed for longer durations (8 to 12 weeks) in cases with chronic stiffness/contracture, to improve motion and significantly reduces need for manipulation or surgery for treatment of knee fibrosis. Earlier application of SPS therapy, even immediately postoperative following corrective surgery for motion loss, can greatly improve the results for patients who have limitations in knee motion.

Myofascial pain and treatment: Editorial

The first article featured in this quarter's overview deserves special attention. Margalef and colleagues developed the first viable animal model of trigger points (TrPs). They also provided evidence of glycosaminoglycans (GAGs) near TrPs, which is a new finding that deserves further scientific inquiry (Margalef et al 2019). In 2011, Stecco et al. already mentioned a possible role of hyaluronan, which constitutes a subgroup of GAGs, in the etiology of myofascial pain (Stecco et al 2011). Mayoral Del Moral and colleagues published an excellent study that showed very good inter-examiner reliability for identifying subjects with MPS for identifying specific muscles (Mayoral Del Moral et al 2018). Sollmann and colleagues described a new and objective method to identify TrPs, using T2 mapping with quantitative MRI-based techniques (Sollmann et al 2016). As usual, many new dry needling (DN) studies, reviews, manual TrP papers and case reports are included. Finally, we would like to thank Dr. Michelle Finnegan for her contributions to this overview paper during the past 5 years. Dr. Finnegan will be focusing on other professional endeavors and she will not return as a contributing author.

Short-term effects of mobilisation with movement in patients with post-traumatic stiffness of the knee joint

BACKGROUND

Mobilisation with movement treatment techniques have been used to increase the range of motion following pathologies associated with shoulder, elbow and ankle joints. Lack of posterior tibial glide and reflex muscle inhibition are common physical impairments in individuals with post-traumatic stiffness of the knee joint. Current evidence is lacking for the benefits of mobilisation with movement treatment techniques for the knee joint disorders.

OBJECTIVE

The purpose of this study was to investigate the short-term effects of mobilisation with movement techniques following post-traumatic stiffness of the knee joint.

METHODS

Twenty consecutive patients with post-traumatic stiffness of the knee joint with a minimum available 80° knee flexion range of motion were included. One group pre-to-post-test study design was employed, in which the active knee flexion range of motion was used as an outcome measure. The mobilisation with movement treatment techniques was implemented with three sets of ten repetitions on each treatment occasion for a period of 3 days.

RESULTS

The mobilisation with movement treatment techniques significantly improved the active knee flexion range of motion (p = 0.000) from pre-treatment to post-treatment.

CONCLUSIONS

The findings from this study demonstrated immediate benefits in outcomes following mobilisation with movement treatment techniques in a cohort of patients with post-traumatic stiffness of the knee joint.

Dynamic Splinting in Children and Adolescents With Stiffness After Knee Surgery

PURPOSE

The purpose of this study was to investigate the indications and outcomes of dynamic splinting (DS) of the arthrofibrotic knee in the pediatric population.

METHODS

Seventy-four patients (41 males, 33 females) with postoperative arthrofibrosis treated with DS after an index knee surgery were reviewed. Median age was 13 years (range, 4 to 18 y), and median follow-up was 17 months (interquartile range, 10 to 28 mo). Demographics, index surgery procedure, preoperative and postoperative knee range of motion (ROM) measurements, treatment length and subsequent need for manipulation under anesthesia (MUA), and surgical lysis of adhesions (LOA) were evaluated. A ROM deficit was defined as lack of extension ≥10 degrees or lack of flexion <130 degrees. Successful improvement of ROM was defined as an increase of ≥10 degrees in flexion, extension, or both. There were 23 patients with flexion deficit only, 17 with extension deficit only, and 34 with combined flexion and extension deficits. Wilcoxon signed-rank test was used to assess median improvement in ROM. Patients were classified into 4 surgical groups: anterior cruciate ligament (ACL) reconstruction without meniscal repair (n=19), ACL reconstruction with meniscal repair (n=12), tibial spine fracture repair (n=21), and other (n=22). Multivariable logistic regression was used to identify independent predictors of failure of DS requiring MUA and LOA.

RESULTS

A total of 57 patients with flexion deficits showed median improvement of 30 degrees in flexion (95% confidence interval, 0-90 degrees; P<0.001), and 51 patients with extension deficits showed median improvement of 7 degrees in extension (95% confidence interval, 0-60 degrees; P<0.001). DS was associated with ROM improvement in 84% and avoided the need for surgery in 58% of all 74 patients included in the study. Multivariate analysis of the ACL with meniscus repair subgroup revealed that each 1-month delay in DS treatment was associated with a 5-fold increased risk of undergoing a LOA (P=0.007). Thirty-six (63%) patients with flexion deficit avoided need for surgery, whereas 26 (51%) patients with extension deficits avoided surgery.

CONCLUSIONS

Our data suggest that DS is an effective method to increase knee ROM and reduce the need for subsequent MUA/LOA in the pediatric and adolescent patient with arthrofibrosis after an index knee surgery.

LEVEL OF EVIDENCE

Level IV-retrospective case series.

Enhancing Recovery After Total Knee Arthroplasty

There have been multiple successful efforts to improve and shorten the recovery period after elective total joint arthroplasty. The development of rapid recovery protocols through a multidisciplinary approach has occurred in recent years to improve patient satisfaction as well as outcomes. Bundled care payment programs and the practice of outpatient total joint arthroplasty have provided additional pressure and incentives for surgeons to provide high-quality care with low cost and complications. In this review, the evidence for modern practices are reviewed regarding patient selection and education, anesthetic techniques, perioperative pain management, intraoperative factors, blood management, and postoperative rehabilitation.

Prevention and Management of Post-operative Complications Following ACL Reconstruction

PURPOSE OF REVIEW

The goal of this paper is to review the current management and prevention of post-operative complications after anterior cruciate ligament (ACL) reconstruction. Trends in rehabilitation techniques will be presented, in addition to suggestions for interventions and expected milestones in ACL reconstruction recovery.

RECENT FINDINGS

ACL reconstruction protocols have evolved to more of a criterion-based progression rather than a tissue-healing time frame. Given the evolution of ACL surgical reconstruction techniques and rehabilitation protocols, the risk of post-operative complications can arise both early and late in the recovery process. This paper will discuss the role of preventative measures as it applies to the post-operative patient with ACL reconstruction. Short-term complications following ACL reconstruction include infection and deficits to knee motion and strength, whereas long-term complications include secondary ACL injury to either the involved or contralateral knee and lack of ability to return to high-level sports following this procedure. Future research should continue to address the multifactorial causes of secondary ACL injury and limited ability of patients to return to high level activities.

Novel Protocol for Knee Mobilization Under Femoral and Sciatic Nerve Blocks for Postoperative Knee Stiffness

The purpose of this study was to evaluate the effectiveness of intermittent femoral and sciatic nerve blocks combined with an in-house physiotherapy protocol for treating postoperative knee stiffness. Sixty-eight patients with postoperative knee stiffness were evaluated for passive knee flexion and extension at different time points, beginning preoperatively and continuing throughout a median 10-month follow-up after mobilization intervention. Sciatic and femoral nerve catheters were activated 1 hour prior to each physiotherapy session, which was performed twice per day and supported by a continuous passive range of motion machine. Median time from admission to catheter removal was 4 days (range, 1-8 days). Mean hospital length of stay was 7 days (range, 2-19 days). Overall mean flexion increased significantly from pretreatment (74°) to discharge (109°; P<.01). There was no significant difference in mean flexion at 6-week follow-up compared with that at discharge (108°; P=.764), but there was a significant increase in flexion at final follow-up (120°; P=.002). Overall mean knee extension lag decreased significantly from pretreatment (5°) to discharge (0.4°; P=.001). There was no significant increase in mean extension lag from discharge to final follow-up (1°; P=.2). Overall, 11 patients underwent revision surgery for persistent stiffness. This novel protocol for continuous knee mobilization under perineural blocks is a valuable alternative to knee manipulation under anesthesia for this select group of procedures. The 2 techniques produced a similar early range of motion gain, but the reported protocol resulted in less range of motion loss at follow-up and fewer possible complications. [Orthopedics. 2016; 39(4):e708-e714.].

The effect of end-of-range grade A+ knee mobilisation following acute primary total knee arthroplasty: A randomised controlled trial

Background/Aims:

Although the number of total knee arthroplasty procedures being performed is increasing worldwide, the rehabilitation protocols following surgery are poorly studied in the literature. Research suggests that exercise therapy and joint mobilisation are recommended in the later stages of osteoarthritis. However, best practice for rehabilitation in the immediate postoperative period is yet to be determined. This prospective randomised controlled trial examined whether adding grade A+ joint mobilisation to the standard in-hospital rehabilitative approach would increase pain (based on recordings of pain intensity on the visual analogue scale) and improve range of motion in the knee.

Methods:

Participants (n=32; mean±SD age: 71.1± 8.9 years) undergoing primary total knee arthroplasty at a university hospital were randomly assigned to two equal groups. Measurements were recorded before surgery and on the first, third and seventh days following total knee arthroplasty. All participants received standard care postoperatively, with participants in the experimental group receiving additional grade A+ joint mobilisation for knee flexion and extension twice a day for 20 minutes using the JAS Knee system (Joint Active Systems®, Effingham, Illinois).

Results:

There were no statistically significant differences in visual analogue scale scores or range of motion in all measurements (p > 0.05). Increased range of motion at a faster pace was observed in the obese subgroup of patients (p = 0.016). Other factors such as age, body mass index, type of anaesthesia and implant model did not influence the final outcome.

Conclusions:

Early grade A+ joint mobilisation combined with the standard in-hospital rehabilitative approach is safe to be used during the post-acute phase of rehabilitation after total knee arthroplasty. Despite increasing trends in the obese subgroup of patients, adding grade A+ joint mobilisation to the standard protocol did not significantly improve overall range of motion. The results of this study and heterogeneities in the literature identify the need for further research and development in this area.

Manipulation under anaesthesia versus low stretch device in poor range of motion after TKA

PURPOSE

The purpose of this study was to evaluate the effectiveness of two frequently used non-operative treatment techniques for a stiff knee after total knee arthroplasty.

METHODS

Sixty-four patients with a stiff knee after total knee arthroplasty (TKA) were randomized into a manipulation under anaesthesia group, or a low load stretch (stretch) group. The patients were followed up for 6 weeks and were evaluated for maximum flexion and extension, range of motion (ROM), pain, stiffness and function.

RESULTS

Both groups showed a significant increase in knee flexion in this study. Only the stretch group showed a significant increase in extension ROM. In both groups, a significant increase in Western Ontario and McMaster Universities was observed. No significant difference was observed between both groups for the flexion or extension ROM, or for any of the pain, function or stiffness scores during this study.

CONCLUSIONS

The results of this study showed that the stretch technique had equal or superior results concerning ROM and function compared to manipulation under anaesthesia. The stretch technique achieved this without requiring the patient to undergo in-hospital treatment or anaesthesia, limiting the costs and the risks for complications. The results of this study showed that stretching is a valuable tool for treating joint contractures of the knee. Therefore, the use of this stretching technique may be an excellent first choice of treatment modality in patients with slow progress of knee flexion or persistent knee stiffness following TKA, prior to manipulation under anaesthesia or lysis of adhesions.

Efficacy of a static progressive stretch device as an adjunct to physical therapy in treating adhesive capsulitis of the shoulder: a prospective, randomised study

BACKGROUND

Stress relaxation and static progressive stretch are techniques used for non-surgical restoration of shoulder range of motion for patients with adhesive capsulitis.

OBJECTIVES

To compare a static progressive stretch device plus traditional therapy with traditional therapy alone for the treatment of adhesive capsulitis of the shoulder.

DESIGN

Prospective, randomised controlled trial.

PARTICIPANTS

Sixty patients with adhesive capsulitis of the shoulder were assigned at random to an experimental group or a control group.

INTERVENTIONS

Both groups received three traditional therapy sessions per week for 4 weeks. In addition, the experimental group used a static progressive stretch device for 4 weeks.

MAIN OUTCOME MEASURES

The primary outcome measure was shoulder range of motion (active and passive shoulder abduction, and passive shoulder external rotation). The secondary outcome measures were function [measured by the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire] and pain [measured using a visual analogue scale (VAS)].

RESULTS

At baseline, there were no differences between the two groups. However, after the intervention, there were significant (P<0.05) differences between the groups for all outcome parameters: 0.3 for mean VAS scores [95% confidence interval (CI) -0.6 to 1.1], -10.1 for DASH scores (95% CI -21.0 to 0.9), 21.2° for shoulder passive external rotation (95% CI 16.8 to 25.7), 26.4° for shoulder passive abduction (95% CI 17.4 to 35.3), and 27.7° for shoulder active abduction (95% CI 20.3 to 35.0). At 12-month follow-up, the differences between the groups were maintained and even increased for mean shoulder range of motion, VAS scores and DASH scores, with significant differences (P<0.001) between the groups: -2.0 for VAS scores (95% CI -2.9 to -1.2), -53.8 for DASH scores (95% CI -64.7 to -42.9), 47.9° for shoulder passive external rotation (95% CI 43.5 to 52.3), 44.9° for shoulder passive abduction (95% CI 36.0 to 53.8), and 94.3° for shoulder active abduction (95% CI 87.0 to 101.7).

CONCLUSION

Use of a static progressive stretch device in combination with traditional therapy appears to have beneficial long-term effects on shoulder range of motion, pain and functional outcomes in patients with adhesive capsulitis of the shoulder. At 12-month follow-up, the experimental group had continued to improve, while the control group had relapsed.

Torque measures of common therapies for the treatment of loss of knee flexion

BACKGROUND

Conservative treatment protocols to effectively treat knee flexion motion restrictions are dependent in part on the torque applied to the joint.

HYPOTHESES

Clinicians apply greater torque with the test leg in a simulated prone position than in a seated position. Clinicians also apply greater torque than a dynamic splint or a static progressive stretch brace. Finally, clinicians apply a torque equal to the high-intensity stretch device.

STUDY DESIGN

bservational study.

METHODS

An instrumented test leg was used to record peak torque applied by 14 licensed clinicians (7 women, 7 men; age, 44.3 ± 10.2 years; height, 172.9 ± 13.2 cm; weight, 72.6 ± 13.0 kg) during knee flexion mobilizations and 3 types of mechanical therapy (dynamic splint, static progressive stretch, and high-intensity stretch).

RESULTS

The dynamic splint applied 5.1 ± 0.1 N·m, while the static progressive stretch brace applied 20.8 ± 2.2 N·m. Clinicians applied 49.5 ± 22.4 N·m with the test leg in a seated position and 55.8 ± 22.0 N·m with the leg in a prone position. The high-intensity stretch device applied up to 214.7 ± 29.2 N·m. All comparisons were statistically significant (P ≤ 0.02) with the exception of the 2 testing positions (P = 0.94).

CONCLUSIONS

The results demonstrate that the torques applied to the knee differ between passive stretching therapies. Clinicians should be cognizant of these torque differences when constructing treatment protocols for patients with limited knee flexion range of motion.

Self-adjusting, isostatic exoskeleton for the human knee joint

A knee-joint exoskeleton design that can apply programmable torques to the articulation and that self-adjusts to its physiological movements is described. Self-adjustment means that the articular torque is automatically produced around the rotational axis of the joint. The requirements are first discussed and the conditions under which the system tracks the spatial relative movements of the limbs are given. If these conditions are met, the torque applied to the joint takes into account the possible relative movements of the limbs without introducing constraints. A prototype was built to demonstrate the applicability of these principles and preliminary tests were carried out to validate the design.

High-intensity mechanical therapy for loss of knee extension for worker's compensation and non-compensation patients

Background

Knee flexion contractures have been associated with increased pain and a reduced ability to perform activities of daily living. Contractures can be treated either surgically or conservatively, but these treatment options may not be as successful with worker's compensation patients. The purposes of retrospective review were to 1) determine the efficacy of using adjunctive high-intensity stretch (HIS) mechanical therapy to treat flexion contractures, and 2) compare the results between groups of worker's compensation and non-compensation patients.

Methods

Fifty-six patients (19 women, 37 men, age = 51.5 ± 17.0 years) with flexion contractures were treated with HIS mechanical therapy as an adjunct to outpatient physical therapy. Mechanical therapy was only prescribed for those patients whose motion had reached a plateau when treated with physical therapy alone. Patients were asked to perform six, 10-minute bouts of end-range stretching per day with the ERMI Knee Extensionater^(r) (ERMI, Inc., Atlanta, GA). Passive knee extension was recorded during the postoperative visit that mechanical therapy was prescribed, 3 months after beginning mechanical therapy, and at the most recent follow-up. We used a mixed-model 2 × 3 ANOVA (group × time) to evaluate the change in passive knee extension between groups over time.

Results

Regardless of group, the use of adjunctive HIS mechanical therapy resulted in passive knee extension deficits that significantly improved from 10.5° ± 5.2° at the initial visit to 2.6° ± 3.5° at the 3 month visit (p < 0.001). The degree of extension was maintained at the most recent follow-up (2.0° ± 2.9°), which was significantly greater than the initial visit (p < 0.001), but did not differ from the 3 month visit (p = 0.23). The gains in knee extension did not differ between worker's compensation and non-compensation patients (p = 0.56).

Conclusions

We conclude that the adjunctive use of HIS mechanical therapy is an effective treatment option for patients with knee flexion contractures, regardless of whether the patient is being treated as part of a worker's compensation claim or not.

Joint contractures in the intensive care unit: association with resource utilization and ambulatory status at discharge

PURPOSE

The objectives of our study were (1) to explore the link between joint contractures acquired in the ICU and the ambulatory status of patients at discharge home, to determine (2) when and how many patients received physiotherapy services in ICU and on the hospital ward, and (3) the differences in the use of hospital resources in the presence or absence of joint contractures.

METHOD

Data on ICU joint contractures were extracted from an existing contracture database containing information on 155 Canadian patients with a tertiary ICU stay of 14 days or more.

RESULTS

Of 155 patients, 115 (74.2%) received a range of motion assessment in the ICU. The assessment took place a median of 7 days (IQR 0-36) after ICU admission. Significantly fewer patients with joint contractures than without joint contractures were mobilized on the hospital ward (21/38 [55.3%] vs. 27/34 [79.4%], P = 0.03). At discharge home, more patients with joint contractures had a low ambulatory status (38 [64.4%]) compared with patients without joint contractures (26 [51.0%]; P = 0.002).

CONCLUSION

The median delay of 7 days before musculoskeletal assessment in the ICU together with failure to assess 26% of patients may have allowed the development of contractures, which affected the patients' ambulatory status at discharge from hospital.

Static progressive stretch improves range of motion in arthrofibrosis following total knee arthroplasty

Arthrofibrosis is a relatively common complication after total knee arthroplasty that negatively affects function and quality of life. Static progressive stretching is a technique that has shown promising results in the treatment of contractures of the elbow, ankle, wrist and knee. This study evaluated a static progressive stretching device as a treatment method for patients who had refractory knee stiffness after total knee arthroplasty. Twenty-five patients who had knee stiffness and no improvement with conventional physical therapy modalities were treated with the device. After a median of 7 weeks (range, 3-16 weeks), the median increase in range of motion was 25 degrees (range, 8-82 degrees). The median gain in knee active flexion was 19 degrees (range, 5-80 degrees). Ninety-two percent of patients were satisfied with the results. The authors believe static progressive stretching devices may be an effective method for increasing the ranges of motion and satisfaction levels of patients who develop arthrofibrosis after total knee arthroplasty.

Evaluation of a custom device for the treatment of flexion contractures after total knee arthroplasty

Knee flexion contractures can severely impair function after total knee arthroplasties. We evaluated the use of a custom-molded knee device to treat 47 patients who had knee flexion contractures (mean, 22 degrees; range, 10 degrees-40 degrees) after primary or revision total knee arthroplasties and who had failed conventional therapeutic methods. The device was used for 30 to 45 minutes per session two to three times per day in conjunction with standard physical therapy modalities two to three times per week. Twenty-seven of 29 patients who underwent primary total knee arthroplasty and 13 of 18 patients who underwent revisions achieved full extension after a mean treatment time of 9 weeks (range, 6-16 weeks). Full knee extension was maintained at a minimum followup of 18 months (mean, 24 months; range, 18-36 months). The mean Knee Society knee and functional scores improved from 50 points and 34 points to 91 points and 89 points, respectively. This protocol had comparable rates of improvement in knee extension with less treatment time when compared with other nonoperative treatments reported in the literature. The custom knee device may be a useful adjunct to a physical therapy regimen for knee flexion contractures after total knee arthroplasty.

LEVEL OF EVIDENCE

Level IV, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.