A survey of practice patterns for rehabilitation post elbow fracture

Enhanced Muscle Endurance Through Self-regulated Dual-Task Exercises in Elbow Fracture Rehabilitation: A Cross-sectional Study

OBJECTIVE

The main objective of this study was to investigate the effect of a self-regulated dual task on muscle endurance within a single rehabilitation session in patients recovering from an elbow fracture.

DESIGN

This is a cross-sectional study of individuals recovering from elbow fractures ( N = 20). Muscle endurance was tested using elastic bands at Borg's CR10 intensity 3-during four conditions: single-task and dual-task for elbow flexion and extension.

RESULTS

The cognitive condition significantly influenced muscle endurance ( P < 0.001), while the type of elbow exercise (flexion or extension) did not show significant differences ( P = 0.592). The perceived difficulty of the tasks showed a significant interaction effect ( P = 0.032). The dual-task condition showed an average increase of about 15 repetitions. A moderate negative correlation was found between the differences in repetitions and the perceived difficulty of the flexion exercise ( r = 0.677, P = 0.001).

CONCLUSIONS

Dual-task with self-regulation enhances muscle endurance among patients recovering from an elbow fracture. However, the improvements seem to depend on the perceived difficulty of the cognitive task. Future randomized controlled trials are required to understand the therapeutic implications of dual-tasking.

Postoperative rehabilitation exercises with addition of blood flow restriction therapy following olecranon fracture: A case report

BACKGROUND

The addition of blood flow restriction therapy (BFRT) to exercise in patients with olecranon fracture treated surgically has not been described in the literature.

PURPOSE

To describe the effects and safety of BFRT exercises in the postoperative rehabilitation of a patient with olecranon fracture.

CASE PRESENTATION

A 27-year-old male with a surgically treated olecranon fracture completed a 12-week postoperative physical therapy programme. The assessment was performed at the start of rehabilitation, 4 and 12 weeks. The patient had elbow pain, decreased active range of motion (AROM), reduced handgrip strength, and limited physical function. The patient was treated with low-intensity resistance exercises with BFRT. The BFRT was applied with three exercises per stage, at 50% of the limb occlusion pressure and 75 repetitions per exercise. At discharge from physical therapy, improvements were observed in pain intensity (5.9-1.4 cm), AROM of elbow flexion (88°-137°) and extension (-22°--2°), AROM of forearm pronation (18°-68°) and supination (34°-78°), handgrip strength (8 kg-47 kg), physical function (22.9%-89.6%), and disability (72.7%-13.6%). These changes reached the minimal clinically important difference at the time of discharge for all measures, except for extension, pronation, and supination AROM.

CONCLUSION

The addition of BFRT to exercise was effective in improving pain, elbow, and wrist AROM, handgrip strength, function, and disability in a patient with surgically treated olecranon fracture. Despite the inherent limitations of our design, we believe these preliminary findings are compelling to warrant future investigations.

Effectiveness of instrument assisted soft tissue mobilization (IASTM) and muscle energy technique (MET) on post-operative elbow stiffness: a randomized clinical trial

BACKGROUND

Stiffness is a common complication following trauma and surgeries around the elbow, which can result in upper limb functional disabilities. Soft tissue mobilization techniques such as Instrument-assisted Soft Tissue Mobilization (IASTM) and Muscle Energy Technique (MET) have limited evidence in elbow rehabilitation. This study aimed to compare their effects on postoperative elbow stiffness.

METHODOLOGY

26 subjects were recruited (13 each group) with postoperative elbow stiffness (minimum 6 weeks post surgery) and randomly allocated in two groups: IASTM and MET. Pain [Numeric Pain Rating Scale NPRS)], ROM (Goniometer), and Function [Disability of Arm, Shoulder and Hand (DASH) and Patient-Specific Functional Scale (PSFS)] were assessed at baseline and post-intervention.

RESULTS

The data of 26 subjects were analyzed and both groups significantly improved in outcome scores post-intervention. The improvements in ROM and function between groups were comparable, but NPRS and PSFS showed greater improvement in the IASTM group (p < 0.05).

CONCLUSION

IASTM and MET were both effective in improving outcomes in postoperative elbow stiffness. IASTM was more effective in improving pain and patient-specific function.

Mobilizing orthoses in the management of post-traumatic elbow contractures: A survey of Australian hand therapy practice

STUDY DESIGN

Mixed-methods survey.

INTRODUCTION

Elbow stiffness and contractures often develop after trauma. There is a lack of evidence on mobilizing orthoses and the factors guiding orthotic prescription.

PURPOSE OF STUDY

To investigate hand therapists' orthotic preferences for varying extension and flexion deficits, and describe the factors affecting orthotic choice for post-traumatic elbow contractures.

METHODS

103 members responded to the electronic survey via the Australian Hand Therapy Association mailing list. Five post-surgical scenarios were used to gather information regarding orthotic preferences, reasons and orthotic protocol: (1) week 8 with 55° extension deficit; (2) week 12 with 30° extension deficit; (3) week 12 with 55° extension deficit; (4) week 8 with flexion limited to 100°; (5) week 12 with limited flexion.

RESULTS

Most responders (89.9%) used mobilizing orthoses, predominantly for extension (88.5%). Orthotic preferences for scenarios 1 to 5 were (1) serial static (78.3%); (2) custom-made three-point static progressive (38.8%); (3) custom-made turnbuckle static progressive (33.8%); (4) "no orthosis" (27.9%); and (5) custom-made hinged (27.1%) and nonhinged (27.1%) dynamic. Choices were based on "effectiveness," "ease for patients to apply and wear," and "ease of fabrication/previous experience/comfortable with design." The recommended daily dosage for extension was 6 to 12 hour.

DISCUSSION

This is the first known study that reflects on the use of mobilizing orthoses in post-traumatic elbows in Australia.

CONCLUSIONS

Mobilizing orthoses are used routinely for post-traumatic elbows in Australia. Extension deficits are managed with serial static and static progressive orthoses at weeks 8 and 12, respectively. Research is needed to assess whether orthotic intervention before 12 weeks is beneficial in reducing contractures.

Investigating the Effects of Physical Therapy Timing, Intensity and Duration on Post-Traumatic Joint Contracture in a Rat Elbow Model

BACKGROUND

Post-traumatic joint contracture (PTJC), characterized by loss of motion and permanent stiffness, affects up to 50% of patients following elbow joint dislocation or fracture. Mechanisms governing successful conservative treatment methods aimed at preventing elbow PTJC and avoiding operative treatments (e.g., physical therapy) are poorly understood. Using a previously established rat model of elbow PTJC, the purpose of this study was to explore the effect of varying timing, intensity and duration of active, functional exercise on joint motion outcomes.

METHODS

Following a surgically-induced unilateral elbow dislocation in rats, injured limbs were immobilized in bandages for 42 days followed by free mobilization for 42 additional days producing long-term PTJC. This work summarizes several studies (Phases I-III) that investigated the effects of early versus delayed therapy (timing), free mobilization versus forced treadmill walking (intensity), and limited-time versus unlimited use (duration) on elbow PTJC.

RESULTS

Joint motion outcomes in therapy groups showed no improvements compared to non-treated injured animals when therapy began day 14 post-injury or later regardless of timing, intensity or duration. Improved joint range-of-motion was only achieved when bandages were permanently removed at day 3 post-injury, regardless of whether added treadmill walking was performed.

CONCLUSION

Early motion is essential to preserving range-of-motion following traumatic elbow injury in a rat model.

The post-traumatic stiff elbow: A review

Upper extremity function is highly dependent on elbow motion in order to adequately position the hand in space. Loss of this motion due to stiffness following trauma can cause patients substantial disability, leading to difficulties with performing activities of daily living. Post-traumatic elbow stiffness is challenging to treat, and therefore prevention is of paramount importance. Key measures that can be used to prevent elbow stiffness are early surgical intervention for fracture or joint instability, as well as active mobilisation, which helps to prevent oedema and an increase in viscosity of inflammatory exudates. Other options include splinting and continuous passive mobilisation. Once non-operative methods of addressing post-traumatic stiffness have been exhausted, arthrolysis of the stiff elbow can be performed via open or arthroscopic means depending on the type of pathology involved (intrinsic or extrinsic contracture) and experience of the surgeon with elbow arthroscopy. The particular open approach used depends on several factors, which include the formation and location of any heterotopic ossification present. Improvements in range of motion can be expected with both open and arthroscopic techniques, which can be effective and rewarding for patients. Post-operative rehabilitation, particularly early active mobilisation, should be considered essential in order to optimise patient outcomes following surgery. This review aims to explore elbow stiffness following traumatic aetiology, assessing its pathogenesis and prevention, as well as reviewing surgical treatment options and post-operative rehabilitation.

The Efficacy of Tele-Rehabilitation Program for Improving Upper Limb Function among Adults Following Elbow Fractures: A Pilot Study

Background: Active mobilization post-elbow fractures reduces the incidence of complications. Occupational therapists use tele-rehabilitation, incorporating technology into their practices. There is a lack of evidence-based trials regarding the integration of tele-rehabilitation during treatment. We therefore aimed to compare tele-rehabilitation treatment outcomes with conventional rehabilitation in improving the upper limb function post-elbow fractures. Methods: Eighteen participants post-elbow surgery due to fracture were divided into two groups according to age and fracture type. The groups received one month of treatment: the tele-rehabilitation group (N = 9, median age 33.0 ± 27.9 years, range 18.5–61.0) received 1–2 tele-rehabilitation treatments per week via a biofeedback system of elbow motion (the ArmTutor and 3D Tutor systems, MediTouch Ltd., Netanya, Israel) and 1–2 treatments in an outpatient clinic, and the control group (N = 9, median age 60.0 ± 37.0 years, range 20.5–73.0) received 3–4 treatments per week in the clinic. Both groups were instructed to self-practice at home. Four evaluations were performed: before and after the intervention, and 3 months and 1 year from surgery. The outcome measures included the Jebsen–Taylor hand function test; the disabilities of the arm, shoulder, and hand questionnaire; the patient-rated elbow evaluation; satisfaction; passive and active range of motion (ROM); and strength measurements. Results: Findings demonstrated a significant improvement in the ROM and in functional assessments in both groups. No statistically significant differences were found between the groups. The subjects in the tele-rehabilitation group reported a higher level of satisfaction and needed less help from a family member during practice. Conclusions: Tele-rehabilitation programs could be incorporated in the framework of treatment following elbow fractures. Tele-rehabilitation is a cost-effective treatment, suitable for patients with accessibility difficulties or who have difficulty arriving at the clinic.

Psychosocial factors affecting variation in patient-reported outcomes after elbow fractures

BACKGROUND

The purpose of this study was to identify factors associated with limitations in function measured by patient-reported outcome measures (PROMs) 6-9 months after elbow fractures in adults from a range of demographic, injury, psychological, and social variables measured within a week and 2-4 weeks after injury.

METHODS

We enrolled 191 adult patients sustaining an isolated elbow fracture and invited them to complete PROMs at their initial visit to the orthopedic outpatient clinic (within a maximum of 1 week after fracture), between 2 and 4 weeks, and between 6 and 9 months after injury; 183 patients completed the final assessment. Bivariate analysis was performed, followed by multivariable regression analysis accounting for multicollinearity. This was evaluated using partial R², correlation matrices, and variable inflation factor assessment.

RESULTS

There was a correlation between multiple variables within a week of injury and 2-4 weeks after injury with PROMs 6-9 months after injury in bivariate analysis. Kinesiophobia measured within a week of injury and self-efficacy measured at 2-4 weeks were the strongest predictors of limitations 6-9 months after injury in multivariable regression. Regression models accounted for substantial variance in all PROMs at both time points.

CONCLUSIONS

Developing effective coping strategies to overcome fears related to movement and reinjury and finding ways of persevering with activity despite pain within a month of injury may enhance recovery after elbow fractures. Heightened fears around movement and suboptimal coping ability are modifiable using evidence-based behavioral treatments.

Development of an EMG-Based Muscle Health Model for Elbow Trauma Patients

Wearable robotic braces have the potential to improve rehabilitative therapies for patients suffering from musculoskeletal (MSK) conditions. Ideally, a quantitative assessment of health would be incorporated into rehabilitative devices to monitor patient recovery. The purpose of this work is to develop a model to distinguish between the healthy and injured arms of elbow trauma patients based on electromyography (EMG) data. Surface EMG recordings were collected from the healthy and injured limbs of 30 elbow trauma patients while performing 10 upper-limb motions. Forty-two features and five feature sets were extracted from the data. Feature selection was performed to improve the class separation and to reduce the computational complexity of the feature sets. The following classifiers were tested: linear discriminant analysis (LDA), support vector machine (SVM), and random forest (RF). The classifiers were used to distinguish between two levels of health: healthy and injured (50% baseline accuracy rate). Maximum fractal length (MFL), myopulse percentage rate (MYOP), power spectrum ratio (PSR) and spike shape analysis features were identified as the best features for classifying elbow muscle health. A majority vote of the LDA classification models provided a cross-validation accuracy of 82.1%. The work described in this paper indicates that it is possible to discern between healthy and injured limbs of patients with MSK elbow injuries. Further assessment and optimization could improve the consistency and accuracy of the classification models. This work is the first of its kind to identify EMG metrics for muscle health assessment by wearable rehabilitative devices.

Effects of muscle energy technique on pain, range of motion and function in patients with post-surgical elbow stiffness: A randomized controlled trial

Background:

Elbow is a very functional joint. Elbow stiffness is a significant cause of disability hampering the function of the upper extremity as a whole. Muscle Energy Techniques (METs) are relatively pain-free techniques used in clinical practice for restricted range of motion (ROM).

Objective:

To study the effects of MET on pain, ROM and function given early in the rehabilitation in post-surgical elbow stiffness.

Methods:

An RCT was conducted on 30 patients post elbow fracture fixation. Group 1 was given MET immediately post removal of immobilization while Group 2 received MET 1 week later along with the rehabilitation protocol. Pain (Visual Analogue Scale), ROM (goniometry) and function (Disability of Arm, Shoulder and Hand questionnaire) were assessed pre and post 3 weeks.

Results:

Group 1 showed greater improvement than Group 2, mean flexion and extension change between groups being 11.7±2.8, 95%CI(5.9,17.4) and 8.5±2.0, 95%CI(4.4,12.7), respectively. VAS and DASH scores improved better in Group 1, mean change being 1.2±0.2, 95%CI(0.6,1.8) and 18.2±2.2, 95%CI(13.5,22.8) for VAS and DASH scores, respectively.

Conclusion:

MET can be used as an adjunct to the rehabilitation protocol to treat elbow stiffness and can be given safely in the early stages of post elbow fracture rehabilitation managed surgically with open reduction and rigid internal fixation.

A structured exercise programme combined with proprioceptive neuromuscular facilitation stretching or static stretching in posttraumatic stiffness of the elbow: a randomized controlled trial

Objectives:

To compare the different stretching techniques, proprioceptive neuromuscular facilitation (PNF) stretching and static stretching, in patients with elbow stiffness after a treated elbow fracture.

Design:

Randomized-controlled, single-blind study.

Setting:

Department of physiotherapy and rehabilitation.

Subjects:

Forty patients with posttraumatic elbow stiffness (24 women; mean age, 41.34 ± 7.57 years).

Intervention:

PNF stretching group ( n = 20), hold-relax PNF stretching combined with a structured exercise programme (two days per week for six weeks); static stretching group ( n = 20), static stretching combined with a structured exercise programme (two days per week for six weeks).

Main measures:

The primary outcome is the Disabilities of the Arm, Shoulder and Hand (DASH). The secondary outcomes are active range of motion (AROM), visual analogue scale (VAS), Tampa Scale for Kinesiophobia, Short Form-12 and Global Rating of Change. Participants were assessed at baseline, after a six-week intervention period and one-month later (follow-up).

Results:

After treatment, improvement in the mean DASH score was slightly better in the PNF stretching group (8.66 ± 6.15) compared with the static stretching group (19.25 ± 10.30) ( p = 0.03). The overall group-by-time interaction for the 2 × 3 mixed-model analysis of covariance (ANCOVA) was also significant for elbow flexion AROM (mean change for PNF stretching group; static stretching group; 41.10, 34.42, p = 0.04), VAS-rest (–1.31, –1.08, p = 0.03) and VAS-activity (–3.78, –3.47, p = 0.01) in favour of PNF stretching group. The other outcomes did not differ significantly between the two groups.

Conclusion:

The study demonstrated that the structured exercise programme combined with PNF stretching might be effective in patients with posttraumatic elbow stiffness with regard to improving function, elbow flexion AROM, pain at rest and during activity.

Rehabilitation after plate fixation of upper and lower extremity fractures

Post-operative rehabilitation and weight-bearing protocols are important to fracture fixation outcomes, yet there is a dearth in the literature concerning universal treatment guidelines following plate fixation of extremity fractures. There are controversies regarding time to allow weight-bearing and range of motion for most fractures of the upper and lower extremity. This lack of a consensus has led to varying practice guidelines and differing anecdotal protocols between treating surgeons. This review attempts to establish consensus guidelines for the post-operative rehabilitation required for patients following plate fixation of common upper and lower extremity fractures.

Cross-cultural adaptation and psychometric testing of the Arabic version of the Patient-Rated Wrist Hand Evaluation (PRWHE-A) in Saudi Arabia

PURPOSES

The purposes of this study was to 1) perform a cross-cultural Arabic translation for the Patient-Rated Wrist and Hand Evaluation (PRWHE-A) using standardized guidelines and, 2) to test the psychometrics properties of the translated measure.

METHODS

A total of 48 patients with variety of hand disabilities, a mean age of 47 ± 16 years were recruited and assessed two times. The intraclass correlation coefficient (ICC) was used for assessing test-retest reliability of the PRWHE-A and its subscales while Cronbach's alpha (CA) was used for assessing the internal consistency. Construct validity was assessed by examining the strength of the correlation between the PRWHE-A and the Arabic version of the Disability of the Arm, Shoulder and Hand (DASH-A).

RESULTS

The PRWHE-A demonstrated excellent test-retest reliability (ICC= 0.97) and internal consistency (CA= 0.96). The DASH-A demonstrated moderately to low correlation (r= 0.64) with the PRWHE-A.

CONCLUSIONS

The results of this study indicated that PRWHE-A is a reliable and valid assessment tool and can be used in patients with different wrist/hand disabilities whose primary language is Arabic.

Conservative management of the post-traumatic stiff elbow: a physiotherapist's perspective

Elbow stiffness is a common consequence following trauma with the management of this condition posing a challenge to therapists and surgeons alike. This paper discusses the role of conservative treatment, such as exercise and splinting, in the prevention and management of the stiff elbow, along with a review of available evidence, to justify their usage.

Hand therapist use of patient report outcome (PRO) in practice: a survey study

PURPOSE

The purpose of this survey was to gain greater insight into hand therapists' use of Patient Report Outcome (PRO) measures.

METHODS

An 11-question survey that evaluated therapists' perceptions, preferences, and patterns of use of patient report outcome measures was sent to members of ASHT.

RESULTS

A total of 633 ASHT members participated in the survey study. A large majority of participants (92%) responded affirmatively to using a PRO measure in practice. The DASH was reported as the most frequently used measure (90%). The majority of therapists (84%) discuss the results of the outcome measurement score with their patients. Of the participants who use more than one outcome measure, 44% report that this allows them to better establish their patient's functional and physical limitations.

CONCLUSION

The findings in this study suggest that a large percentage of hand therapists are currently including a PRO measure in their hand therapy practice.

The use of braces in the rehabilitation treatment of the post-traumatic elbow

The elbow, the middle joint of the upper limb, enables the hand to be placed at various distances from the body. The articular, muscular and neuromotor complexity of the elbow is such that it is often prone to stiffness, especially if immobilized for long periods of time. Therefore, mobilization of the posttraumatic elbow must be started early. In the presence of lesions to the ligamentous structures, the joint must be protected to prevent these structures from being placed under tension during movement. Rehabilitation of the elbow includes the use of braces. Different types of brace are used depending on clinical situation and the objectives to be achieved. They can have fixed protection or locked articulation, allow an adjustable range of movement to restrict flexion-extension and pronation-supination, or allow dynamic and static progressive movement. The latter plays a special role in conservative treatment and following surgical release. However, the effectiveness of braces in the rehabilitation treatment of elbow stiffness depends on the patient's compliance. Their use requires a considerable amount of physician time to achieve the objectives envisaged by the rehabilitation program.

Development and Initial Validation of the Satisfaction and Recovery Index (SRI) for Measurement of Recovery from Musculoskeletal Trauma

Background:

There is a need for a generic patient-reported outcome (PRO) that is patient-centric and offers sound properties for measuring the process and state of recovery from musculoskeletal trauma. This study describes the construction and initial validation of a new tool for this purpose.

Methods:

A prototype tool was constructed through input of academic and clinical experts and patient representatives. After evaluation of individual items, a 9-item Satisfaction and Recovery Index (SRI) was subject to psychometric evaluation drawn from classical test theory. Subjects were recruited through online and clinical populations, from those reporting pain or disability from musculoskeletal trauma. The full sample (N = 129) completed the prototype tool and a corresponding region-specific disability measure. A subsample (N = 46) also completed the Short-Form 12 version 2 (SF12vs). Of that, a second subsample (N = 29) repeated all measures 3 months later.

Results:

A single factor ‘health-related satisfaction’ was extracted that explained 71.1% of scale variance, Cronbach’s alpha = 0.95. A priori hypotheses for cross-sectional correlations with region-specific disability measures and the generic Short-form 12 component scores were supported. The SRI tool was equally responsive to change, and able to discriminate between recovered/non-recovered subjects, at a level similar to that of the region-specific measures and generally better than the SF-12 subscales.

Conclusion:

The new SRI tool, as a measure of health-related satisfaction, shows promise in this initial evaluation of its properties. It is generic, patient-centered, and shows overall measurement properties similar to that of region-specific measures while allowing the potential benefit of comparison between clinical conditions. Despite early promising results, additional properties need to be explored before the tool can be endorsed for routine clinical use.

Patient-reported outcomes: state-of-the-art hand surgery and future applications

Patient-reported outcome measures (PRO) can provide reliable and valid estimates of patient status and response to interventions to complete the final step in an evidence-based patient interaction. A variety of PRO are relevant to upper extremity surgery and rehabilitation outcomes. PRO provide feasible tools for clinical research or practice, although use in clinical decision making lags behind research applications. Recent trends in clinical measurement include better integration of International Classification of Functioning, Disability and Health in content validation, more modern methods of evaluating scaling properties (Rasch analysis), consensus exercise on establishing core measures, electronic data collection, and computer-adaptive testing.

Elbow rehabilitation in traumatic pathology

The elbow, intermediate joint of the upper limb, frequently undergoes to pathological events and is especially prone to stiffness. Rehabilitation plays an important role in recovering functional activities. For the rehabilitation team, this goal always represents a challenge, as the treatment has to be continuously modeled and calibrated on the needs of the individual patient, even many times during the same rehabilitation cycle. Containing the effects of immobilization, avoiding to excessively stress the healing tissues, satisfying specific clinical criteria before moving to the next rehabilitation stage, basing the rehabilitation plan on up-to-date clinical and scientific data that can be adapted to each patient and to his/her needs are the basic principles of the rehabilitation plan, which can be chronologically grouped into four rehabilitation stages. After summarizing the general principles of elbow treatment, the specific principles of rehabilitation after elbow fractures and elbow instability are presented, and then the rehabilitative approach to the most frequent and feared pathological conditions of the elbow, namely stiffness, is described.