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Minick KI, Hunter SJ, Capin JJ, Stevens-Lapsley JE, Snow GL, Woodfield D, Dibblee P, Brennan GP. Improved Outcomes Following a Care Guideline Implementation: Part 1 of an Analysis of 12 355 Patients After Total Knee Arthroplasty. J Orthop Sports Phys Ther 2023; 53:143-150. [PMID: 36507694 PMCID: PMC10243735 DOI: 10.2519/jospt.2022.11369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE: To describe the application and examine the influence of a continuous quality improvement intervention, which had a goal of standardizing care to reduce the proportion of patients who do not have a meaningful improvement in patient-reported outcomes following total knee arthroplasty (TKA). DESIGN: Continuous quality improvement. METHODS: A physical therapy (PT) care guideline was initiated in 2013 for patients following TKA. The Knee Outcome Survey - Activities of Daily Living (KOS-ADL) was measured at every visit, and scores were extracted from a clinical outcomes database to calculate the proportion of patients who did not achieve a minimal clinically important difference. Based on logistic regression analysis, we compared the proportion of patients who did not progress on the KOS-ADL in a non-care guideline group (2008-2012) to a care guideline (CG) group (2014-2019). RESULTS: This study included 12 355 patients (aged 18-92 years) following TKA incurring at least 3 PT visits from 2008 to 2019. The percentage of patients who did not progress in the non-care guideline group was 25.8% and in the care guideline group 14.3% (P<0.001). The relationship between care guideline adherence and lack of progression on the KOS-ADL was statistically significant, X2 (df = 1) = 148.7, P<.001. CONCLUSION: The percentage of patients who did not achieve meaningful progress on the KOS-ADL declined significantly in the 6 years after implementing a TKA care guideline without an increase in the number of clinical visits. The standardized care guideline was associated with meaningful improvements for patients following TKA when applied in conjunction with PT access to outcome data, feedback through audits, performance goals, and financial incentives. J Orthop Sports Phys Ther 2023;53(3):143-150. Epub: 12 December 2022. doi:10.2519/jospt.2022.11369.
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Wang L, Cui JB, Xie HM, Zuo XQ, He JL, Jia ZS, Zhang LN. Effects of Different Static Progressive Stretching Durations on Range of Motion, Myofibroblasts, and Collagen in a Posttraumatic Knee Contracture Rat Model. Phys Ther 2022; 102:6481179. [PMID: 34972861 DOI: 10.1093/ptj/pzab300] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 07/24/2021] [Accepted: 10/19/2021] [Indexed: 11/12/2022]
Abstract
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.
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Affiliation(s)
- Lu Wang
- Department of Rehabilitation Medicine, The First Medical Center, Chinese PLA General Hospital, Beijing, China.,Graduate School, Medical School of Chinese PLA, Beijing, China.,Department of Rehabilitation Medicine, Beijing Tongren Hospital, Beijing, China
| | - Jian-Bo Cui
- Department of Rehabilitation Medicine, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Hui-Min Xie
- Department of Rehabilitation Medicine, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Xiu-Qin Zuo
- Department of Rehabilitation Medicine, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Jia-Le He
- Department of Rehabilitation Medicine, The First Medical Center, Chinese PLA General Hospital, Beijing, China.,Graduate School, Medical School of Chinese PLA, Beijing, China
| | - Zi-Shan Jia
- Department of Rehabilitation Medicine, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Li-Ning Zhang
- Department of Rehabilitation Medicine, The First Medical Center, Chinese PLA General Hospital, Beijing, China
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Aspinall SK, Bamber ZA, Hignett SM, Godsiff SP, Wheeler PC, Fong DT. Medical stretching devices are effective in the treatment of knee arthrofibrosis: A systematic review. J Orthop Translat 2021; 27:119-131. [PMID: 33659182 PMCID: PMC7878963 DOI: 10.1016/j.jot.2020.11.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 10/07/2020] [Accepted: 11/08/2020] [Indexed: 12/04/2022] Open
Abstract
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.
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Affiliation(s)
- Sara K. Aspinall
- National Centre for Sport and Exercise Medicine, School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
| | - Zoe A. Bamber
- National Centre for Sport and Exercise Medicine, School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
- Division of Orthopaedics, Trauma and Sports Medicine, School of Medicine, Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Sue M. Hignett
- Loughborough Design School, Loughborough University, Loughborough, UK
| | - Steven P. Godsiff
- Department of Orthopaedic Surgery, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Patrick C. Wheeler
- National Centre for Sport and Exercise Medicine, School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
- Department of Sport and Exercise Medicine, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Daniel T.P. Fong
- National Centre for Sport and Exercise Medicine, School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
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Aspinall SK, Wheeler PC, Godsiff SP, Hignett SM, Fong DTP. The STAK tool: evaluation of a new device to treat arthrofibrosis and poor range of movement following total knee arthroplasty and major knee surgery. Bone Jt Open 2020; 1:465-473. [PMID: 33215140 PMCID: PMC7667223 DOI: 10.1302/2633-1462.18.bjo-2020-0096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
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.
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Affiliation(s)
- Sara K Aspinall
- National Centre for Sport and Exercise Medicine, School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
| | - Patrick C Wheeler
- Department of Sport and Exercise Medicine, University Hospitals of Leicester, Leicester, UK
| | - Steven P Godsiff
- Department of Orthopaedic Surgery, University Hospitals of Leicester, Leicester, UK
| | - Sue M Hignett
- Loughborough Design School, Loughborough University, Loughborough, UK
| | - Daniel T P Fong
- National Centre for Sport and Exercise Medicine, School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
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Bhave A, Sodhi N, Anis HK, Ehiorobo JO, Mont MA. Static progressive stretch orthosis-consensus modality to treat knee stiffness-rationale and literature review. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:S256. [PMID: 31728380 DOI: 10.21037/atm.2019.06.55] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
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.
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Affiliation(s)
- Anil Bhave
- Department of Physical Therapy, Rubin Institute for Advanced Orthopaedics, Sinai Hospital, Baltimore, MD, USA
| | - Nipun Sodhi
- Department of Orthopaedic Surgery, Long Island Jewish Medical Center, Northwell Health, New York, NY, USA
| | - Hiba K Anis
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Joseph O Ehiorobo
- Department of Orthopaedic Surgery, Lenox Hill Hospital, Northwell Health, New York, NY, USA
| | - Michael A Mont
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, USA.,Department of Orthopaedic Surgery, Lenox Hill Hospital, Northwell Health, New York, NY, USA
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Thompson R, Novikov D, Cizmic Z, Feng JE, Fideler K, Sayeed Z, Meftah M, Anoushiravani AA, Schwarzkopf R. Arthrofibrosis After Total Knee Arthroplasty: Pathophysiology, Diagnosis, and Management. Orthop Clin North Am 2019; 50:269-279. [PMID: 31084828 DOI: 10.1016/j.ocl.2019.02.005] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Arthrofibrosis is the pathologic stiffening of a joint caused by an exaggerated inflammatory response. As a common complication following total knee arthroplasty (TKA), this benign-appearing connective tissue hyperplasia can cause significant disability among patients because the concomitant knee pain and restricted range of motion severely hinder postoperative rehabilitation, clinical outcomes, and basic activities of daily living. The most effective management for arthrofibrosis in the setting of TKA is prevention, including preoperative patient education programs, aggressive postoperative physical therapy regimens, and anti-inflammatory medications. Operative treatments include manipulation under anesthesia, arthroscopic debridement, and quadricepsplasty.
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Affiliation(s)
- Ryan Thompson
- Department of Orthopaedic Surgery, NYU Langone Orthopedics, NYU Langone Health, 301 East 17th Street, New York, NY 10003, USA; Department of Surgery, Chicago Medical School, North Chicago, IL, USA
| | - David Novikov
- Department of Orthopaedic Surgery, NYU Langone Orthopedics, NYU Langone Health, 301 East 17th Street, New York, NY 10003, USA
| | - Zlatan Cizmic
- Department of Orthopaedic Surgery, NYU Langone Orthopedics, NYU Langone Health, 301 East 17th Street, New York, NY 10003, USA
| | - James E Feng
- Department of Orthopaedic Surgery, NYU Langone Orthopedics, NYU Langone Health, 301 East 17th Street, New York, NY 10003, USA
| | - Kathryn Fideler
- Department of Orthopaedic Surgery, NYU Langone Orthopedics, NYU Langone Health, 301 East 17th Street, New York, NY 10003, USA; Department of Orthopaedic Surgery, Wexner Medical Center, Ohio State University, Columbus, OH, USA
| | - Zain Sayeed
- Department of Orthopaedic Surgery, NYU Langone Orthopedics, NYU Langone Health, 301 East 17th Street, New York, NY 10003, USA; Department of Surgery, Chicago Medical School, North Chicago, IL, USA
| | - Morteza Meftah
- Department of Orthopaedic Surgery, NYU Langone Orthopedics, NYU Langone Health, 301 East 17th Street, New York, NY 10003, USA
| | - Afshin A Anoushiravani
- Department of Orthopaedic Surgery, NYU Langone Orthopedics, NYU Langone Health, 301 East 17th Street, New York, NY 10003, USA; Department of Orthopaedic Surgery, Albany Medical Center, Albany, NY, USA
| | - Ran Schwarzkopf
- Division of Adult Reconstructive Surgery, Department of Orthopaedic Surgery, NYU Langone Orthopedics, NYU Langone Health, 301 East 17th Street, New York, NY 10003, USA.
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Rutherford RW, Jennings JM, Dennis DA. Enhancing Recovery After Total Knee Arthroplasty. Orthop Clin North Am 2017; 48:391-400. [PMID: 28870300 DOI: 10.1016/j.ocl.2017.05.002] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Richard W Rutherford
- Colorado Joint Replacement, Porter Adventist Hospital, 2535 S. Downing Street, Denver, CO 80210, USA.
| | - Jason M Jennings
- Colorado Joint Replacement, Porter Adventist Hospital, 2535 S. Downing Street, Denver, CO 80210, USA
| | - Douglas A Dennis
- Colorado Joint Replacement, Porter Adventist Hospital, 2535 S. Downing Street, Denver, CO 80210, USA; Department of Biomedical Engineering, University of Tennessee, Knoxville, TN, USA; Department of Mechanical and Materials Engineering, University of Denver, Denver, CO, USA; Department of Orthopaedics, University of Colorado School of Medicine, Denver, CO, USA
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Kalson NS, Borthwick LA, Mann DA, Deehan DJ, Lewis P, Mann C, Mont MA, Morgan-Jones R, Oussedik S, Williams FMK, Toms A, Argenson JN, Bellemans J, Bhave A, Furnes O, Gollwitzer H, Haddad FS, Hofmann S, Krenn V. International consensus on the definition and classification of fibrosis of the knee joint. Bone Joint J 2017; 98-B:1479-1488. [PMID: 27803223 DOI: 10.1302/0301-620x.98b10.37957] [Citation(s) in RCA: 86] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2016] [Accepted: 06/07/2016] [Indexed: 12/12/2022]
Abstract
AIMS The aim of this consensus was to develop a definition of post-operative fibrosis of the knee. PATIENTS AND METHODS An international panel of experts took part in a formal consensus process composed of a discussion phase and three Delphi rounds. RESULTS Post-operative fibrosis of the knee was defined as a limited range of movement (ROM) in flexion and/or extension, that is not attributable to an osseous or prosthetic block to movement from malaligned, malpositioned or incorrectly sized components, metal hardware, ligament reconstruction, infection (septic arthritis), pain, chronic regional pain syndrome (CRPS) or other specific causes, but due to soft-tissue fibrosis that was not present pre-operatively. Limitation of movement was graded as mild, moderate or severe according to the range of flexion (90° to 100°, 70° to 89°, < 70°) or extension deficit (5° to 10°, 11° to 20°, > 20°). Recommended investigations to support the diagnosis and a strategy for its management were also agreed. CONCLUSION The development of standardised, accepted criteria for the diagnosis, classification and grading of the severity of post-operative fibrosis of the knee will facilitate the identification of patients for inclusion in clinical trials, the development of clinical guidelines, and eventually help to inform the management of this difficult condition. Cite this article: Bone Joint J 2016;98-B:1479-88.
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Affiliation(s)
| | - L A Borthwick
- Newcastle University, Newcastle upon Tyne NE2 4HH, UK
| | - D A Mann
- Newcastle University, Newcastle upon Tyne NE2 4HH, UK
| | - D J Deehan
- Freeman Hospital, Newcastle Hospitals NHS Trust, High Heaton, Newcastle upon Tyne, NE7 7DN, UK
| | - P Lewis
- South Australian Health and Medical Institute, Adelaide, South Australia, Australia
| | - C Mann
- Norfolk and Norwich University NHS Trust, Norwich, UK
| | - M A Mont
- Cleveland Clinic , Cleveland, Ohio, USA
| | | | - S Oussedik
- Institute of Sport, Exercise and Health, University College London Hospitals, 235 Euston Road, London NW1 2BU, UK
| | - F M K Williams
- King's College London, St Thomas' Hospital, London SE1 7EH, UK
| | - A Toms
- Royal Devon and Exeter Hospital, Exeter, UK
| | - J N Argenson
- Sainte-Marguerite Hospital, Aix-Marseille University, Marseille, France
| | | | - A Bhave
- Sinai Hospital, Baltimore, Maryland, USA
| | - O Furnes
- University of Bergen, Bergen, Norway
| | - H Gollwitzer
- Klinik für Orthopädie und Sportorthopädie, Klinikum rechts der Isar der Technischen Universität, Ismaninger Str. 22, 81675 Munich, Germany
| | - F S Haddad
- University College London Hospitals, 235 Euston Road, London NW1 2BU, UK
| | - S Hofmann
- LKH Stolzalpe Hospital & Teaching Hospital University Clinic Graz, Austria
| | - V Krenn
- MVZ-Zentrum für Histologie, Zytologie und Molekulare Diagnostik, Trier, Germany
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Costa CR, McElroy MJ, Johnson AJ, Lamm BM, Mont MA. Use of a static progressive stretch orthosis to treat post-traumatic ankle stiffness. BMC Res Notes 2012; 5:348. [PMID: 22762507 PMCID: PMC3532337 DOI: 10.1186/1756-0500-5-348] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2011] [Accepted: 06/11/2012] [Indexed: 05/26/2023] Open
Abstract
Background Chronic ankle stiffness can develop for numerous reasons after traumatic injury, and may adversely affect patient gait, mobility, and function. Although standard physical therapeutic techniques typically resolve this stiffness, some cases may be recalcitrant to these measures, making it difficult to restore range-of-motion. The purpose of this study was to evaluate a static progressive stretch orthosis for the treatment of chronic ankle stiffness. Methods Twenty-six patients (26 ankles) who had chronic post-traumatic ankle stiffness were studied. The patients began treatment at a mean of 47 weeks (range, 6 to 272 weeks) following their initial injury using a static progressive stretch orthosis. A patient-directed protocol was used for 30 minutes per day, 1 to 3 times per day, until the range-of-motion was considered to have plateaued. Mean treatment time was 10 weeks (range, 3 to 19 weeks). Treatment duration, range-of-motion, and complications with the device were assessed. Results The overall mean improvement in motion (combined dorsiflexion and plantar flexion) was 17 degrees (range, 2 to 44 degrees). There was a mean improvement in dorsiflexion of 9 degrees (range, -2 to 20 degrees), and a mean improvement of 8 degrees of plantar flexion (range, -10 to 35 degrees). There were no reports of numbness or skin problems. Conclusions The outcomes of this study suggest that a patient-directed treatment protocol using a static progressive stretch orthosis was an effective ancillary method for the treatment of chronic post-traumatic ankle stiffness that was refractory to standard physical therapy techniques.
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Affiliation(s)
- Christopher R Costa
- Center for Joint Preservation and Replacement at the Rubin Institute for Advanced Orthopedics, Baltimore, MD, USA
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