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Mobilizing orthoses in the management of post-traumatic elbow contractures: A survey of Australian hand therapy practice
Journal of Hand Therapy xxx (2020) 1e9
Contents lists available at ScienceDirect
Journal of Hand Therapy journal homepage: www.jhandtherapy.org
Mobilizing orthoses in the management of post-traumatic elbow contractures: A survey of Australian hand therapy practice Germaine Sim MPhil candidate, B Phty, CHT a, b, *, Jennifer Fleming PhD, B OccThy (Hons), FOTARA b, Celeste Glasgow PhD, MSc, B OccThy (Hons) c a
EKCO Hand and Upper Limb Rehabilitation Unit, South Brisbane, QLD, Australia The University of Queensland, School of Health and Rehabilitation Sciences, The University of Queensland, St Lucia, QLD, Australia c Royal Brisbane and Women's Hospital, Occupational Therapy, Herston, QLD, Australia b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 8 July 2019 Received in revised form 10 November 2019 Accepted 31 December 2019 Available online xxx
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. Ó 2020 Hanley & Belfus, an imprint of Elsevier Inc. All rights reserved.
Keywords: Post-traumatic elbow contractures Mobilizing orthoses Survey
Introduction The elbow is a constrained synovial hinge joint that functions to position the hand for activities of daily living. In 1981, Morrey et al1 found that an elbow flexion-extension arc range of motion (ROM)
Conflict of interest: The authors declared no potential conflicts of interest regarding the research, authorship, and publication of this article. Funding: This research was supported by the Australian Government Research Training Program Scholarship. The authors received no financial support for the research and publication of this article. * Corresponding author. EKCO Hand Therapy, 1/600 Stanley Street, South Brisbane, Queensland 4101,Australia. Tel.: þ6137860700; fax: þ61738460744. E-mail address: [email protected] (G. Sim).
of 100 was required for activities of daily living. In a more recent study in 2011, Sardelli et al2 indicated that the functional arc required for modern day tasks is closer to 130 . Trauma is a common cause of elbow stiffness and contractures.3,4 Animal studies show that the joint capsule plays a major role in contracture development, citing its structure as thin and susceptible to thickening and scarring from trauma.5,6 In spite of our advances in elbow injury management, 56% of patients with simple elbow dislocations reported having long-term stiffness.3 In a prospective study on common post-traumatic elbow injuries, patients who reported having poor outcomes at 3 months of follow-up were more prone to chronic contractures, resulting in 12% of the patients requiring further surgical release.4 The likelihood of contractures increases in more severe injuries,7 higher impact mechanisms,8 females,4 and
0894-1130/$ e see front matter Ó 2020 Hanley & Belfus, an imprint of Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jht.2019.12.014
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G. Sim et al. / Journal of Hand Therapy xxx (2020) 1e9
with increased length of immobilization.7 Depending on the severity and direction of contracture, patients can experience difficulties with self-care (eg, eating, dressing and hygiene) with flexion deficits, or reaching and positioning objects with the extension deficits.9 Hence, while a small amount of stiffness may be tolerable, a large contracture can be more painful and debilitating,4 warranting further treatment to improve motion. As improvements in ROM are greatest within the first 3 to 6 months of injury,3,10,11 the focus should be on early intervention within this window of maximal gains. It is assumed that contractures can be prevented by early active mobilization after any trauma of the elbow.12 A randomized controlled trial on patients with simple elbow dislocation13 showed promising results with early mobilization without compromising on stability. When compared to a delayed treatment group that was casted for three weeks, the early mobilization group had significantly better movement and functional recovery at six weeks after injury. However, there were no differences in functional scores at one year. Similarly, the evidence for early mobilization in elbow fractures is scarce14 and further research is needed before generalizing its efficacy to all elbow conditions. Conservative treatment is generally recommended for at least 6 months before performing any surgical release.15-18 Most of the evidence on stretching, joint mobilizations, and heat in posttraumatic elbow contractures is based on expert opinions or in healthy populations.19-22 A consensus among clinicians is that therapy should never be too aggressive and the use of strong passive stretching should be discouraged.23 Placing excessive loads on tissues beyond their normal elastic range can cause tissue microtears and ruptures.24 This triggers pain, inflammation, edema, and fibrosis,25-27 resulting in more stiffness and a greater degree of contracture. Repetitive and forceful maneuvers in animal studies have reported an increased risk of heterotopic ossification.28,29 Casavant and Hastings30 argued that passive ROM and stretches are not necessarily forceful maneuvers. More recently, Birinci et al31 found positive outcomes with stretching
interventions in a prospective cohort after elbow fracture immobilization. At week 6 after injury, participants were randomly allocated to a 6-week program of either proprioceptive neuromuscular facilitation (PNF) or static stretch interventions. Although both groups had positive outcomes, the PNF group had significantly better functional scores, less pain at rest and with activity, and better elbow flexion active ROM. Although the outcomes in this study were promising, the study was limited in sample size and lacked long-term follow-up. Thus, it is not known if such structured stretching regimes alone are enough for contracture resolution. In contrast, most of the evidence on conservative management of elbow contractures concerns elbow mobilizing orthoses.18,19,32-34 These are devices that place the joint in a slightly lengthened position over prolonged periods to stimulate new tissue growth.25,26,35,36 Custom-made or prefabricated, elbow mobilizing orthoses can be classified into three main groups: serial static, static progressive, and dynamic (Fig. 1). The serial static orthosis uses a rigid base, such as a thermoplastic or plaster cast, to apply minimal tension over prolonged periods to a joint at a pain-free end range position.26,27,37 When the tissues have adapted to a new length, the therapist can remold the thermoplastic to a new lengthened position. This process is repeated several times to achieve the desired range. The static progressive orthosis is different in that it has a rigid base and an inelastic mobilizing component, such as a turnbuckle or Velcro strap, to statically maintain the elbow at close to end range.26,38 When the tissues relax into the lengthened position, the patient can independently tighten the tension on the mobilizing component, thus incrementally moving the elbow into further range after a few cycles.27,39 The dynamic orthosis comprises a rigid base and elastic components, such as elastic straps, therabands, or spring coils, to apply a mobilizing force on the joint.26,37 As the ROM changes, the contractile component adjusts itself.26 Over the life of the orthosis, the elastic components may lose tensile strength and may require readjustments or replacement.
Fig. 1. Extension mobilizing orthoses: (A) serial static (B) custom-made three-point static progressive with D-ring, (C) custom-made static progressive turnbuckle, and (D) custommade dynamic with neoprene.
G. Sim et al. / Journal of Hand Therapy xxx (2020) 1e9
In a cohort study using dynamic mobilizing orthoses in hand contractures, Glasgow et al40 observed that joints resistant to ROM changes after heating and stretching had poorer response to orthotic intervention. The change in ROM from cold to warm was used as an assessment of joint stiffness (known as the modified Weeks test). Stiff joints with more mature scar may require greater forces to generate changes in ROM.38,41 Although the recommendations regarding the amount of force in hand orthotic intervention42-44 is 100 to 300 gm cm2, there is a lack of evidence for safe loading limits in the elbow and only an assumption that larger forces will be required for tissue remodeling.44 For now, these limits can be guided by pressure intolerance of the skin,26,39 pain, edema, ROM, and grip strength.41 Currently, there are insufficient data to suggest if any type of orthosis is superior in resolving contractures in the upper limb.10,18,33,42,45 Regarding the stiff post-traumatic elbow, 13 studies were used in a meta-analysis by Müller et al33 to compare the overall ROM outcomes in dynamic, static progressive and serial static orthotic groups, whereas eight studies were used in a systematic review by Veltman et al18 to compare dynamic versus static progressive orthoses. Clinically significant improvements were reported across all groups in both reviews. As such, the reviewers suggested that orthotic prescription could be guided by the patient's and surgeon's preferences. Despite the large number of primary studies on elbow orthoses, another limitation of the current evidence is that the primary studies are mostly retrospective or pre-post interventional studies with no control group for comparison.28,46-55 This makes it difficult to differentiate the real orthotic effect from natural recovery. Hence, this study has three research aims. First, it aimed to investigate therapists' orthotic preferences for varying elbow flexion and extension ROM deficits. The second aim was to investigate the importance of therapist and patient-related factors as well as existing research evidence in guiding orthotic choice for post-traumatic elbow contractures in Australia. The third aim was to gather therapists' recommendations regarding the optimal protocol for various groups of elbow orthoses.
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were conducted to establish any differences in the demographics between completers and noncompleters, as well as differences in orthotic choices between participants with varying AHTA membership status. Responses from open-ended questions were analyzed using framework analysis.57 Inductive content analysis methods, namely “open coding, creating categories, and abstraction”,58 were first used to organize the data. To achieve internal validity, hand-coding was conducted by two experienced hand therapists who reached a consensus on all responses to the openended questions.58 Similar content was grouped together and transferred into Microsoft Excel coding sheets before allocating into categories. During categorization, similar content was merged into a generic category, whereas complex content underwent subdivision into more categories. Each generic category was labeled and clustered under similar themes. As the themes emerged, the evidence-based practice framework, which was conceptualized by Sackett59 and refined for hand conditions by Glasgow and Peters,60 was identified as a suitable thematic framework for further data analysis.57
Results Of 783 members in the AHTA mailing list, 411 members read the electronic survey request. A response rate of 13.2% was achieved with 103 members consenting to the study and completed the membership question. A total of 99 participants completed the remaining demographic questions and continued to complete the survey or part thereof. There were 6 participants who did not use mobilizing orthoses and did not proceed to the questions with the clinical scenarios. The final completion rate was 57% with 59 participants completing the entire survey. Participant demographic information is listed in Table 1. An association was observed between completion and membership status, c2 (1) ¼ 5.668, P ¼ .017, and between completion and years of experience, c2 (4) ¼ 11.362, P ¼ .023. Accredited and life/honorary members and those with more than 15 years of experience were more likely to complete the survey.
Methods The electronic survey was developed on SurveyMonkey and pilot tested on 10 experienced hand therapists. The survey included five clinical case scenarios of postsurgical elbows, with scenarios 1 to 3 with extension deficits and scenarios 4 to 5 with flexion deficits. The scenarios were as follows: scenario (1) week 8 after surgery with 55 extension deficit; scenario (2) week 12 with 30 extension deficit; scenario (3) week 12 with 55 extension deficit; scenario (4) week 8 with flexion deficit (100 flexion); scenario (5) week 12 with limited flexion. A combination of multiple-choice questions and open-ended questions was used to gather therapists' orthotic preferences for each scenario, reasons for choice, and orthotic protocol. This mixed methods approach was used to provide a more in-depth explanation for the multiple-choice responses56 on the factors guiding orthotic prescription. Ethical approval was gained through the University of Queensland Institutional Human Research Ethics Committee. After seeking gatekeepers' approval from the Australian Hand Therapy Association (AHTA), the electronic survey was distributed to hand therapists through the AHTA mailing list. A reminder email was sent after 1 month and the survey closed after 2 months. The final data analyses included data from both completed and incomplete surveys. Responses to multiple-choice questions were analyzed descriptively. Raw data were extracted from SurveyMonkey to Excel and IBM SPSS statistics program (version 25) for further analysis. Pearson's chi-square test and Fisher's exact test
Table 1 Demographic information of the participants Demographics Membership status (n ¼ 103)c Accreditedb/life/honorary Associate Others/affiliates Undergraduate (n ¼ 99) Occupational therapist Physiotherapist Years of experience (n ¼ 99)c <3 y 3 to <6 y 6 to <10 y 10 to <15 y 15 y Practice setting (n ¼ 99) Public Private Public and private Researcher Research and public Research and private
No. (%) of participants
No. of noncompletersa
No. of completers
66 (64%) 37 (36%) 0 (0%)
23 21 0
43 16 0
67 (67%) 32 (33%)
23 17
44 15
5 20 20 17 37
(5%) (20%) (20%) (17%) (37%)
3 12 11 6 8
2 8 9 11 29
25 59 12 1 1 1
(25%) (60%) (12%) (1%) (1%) (1%)
13 20 5 1 0 1
12 39 7 0 1 0
a Noncompleters consented to the survey but did not complete the final survey question. Data from noncompleters were included in the final data analysis. b Accredited members are qualified hand and upper limb therapists who have met the AHTA requirements and standards of competency. c An association was observed using the Pearson's chi-square test (P < .05).
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G. Sim et al. / Journal of Hand Therapy xxx (2020) 1e9
Fig. 2. Modalities most commonly used by therapists for post-traumatic elbows (n ¼ 99). ROM ¼ range of motion.
Stretches, heat, mobilizing orthoses, and massage were the most commonly used modalities in rehabilitation for regaining ROM in post-traumatic elbows (Fig. 2). Data regarding therapists' most used directional orthosis and the estimated number of mobilizing orthoses prescribed per year are presented in Table 2. Extension orthoses The results for therapists' preference for extension orthoses are presented in Table 3. At week 8 after surgery in scenario 1, there was a clear preference for serial static orthoses (n ¼ 65, 78.3%), followed by custom-made three-point static progressive (n ¼ 11, 13.3%). Orthotic preference was more varied at week 12. In scenario 2, therapists were presented with a smaller extension deficit of 30 , and in this case, the custom-made three-point static progressive orthosis (n ¼ 31, 38.8%) was the most popular, followed by serial static (n ¼ 23, 28.8%) and custom-made dynamic (n ¼ 11, 13.8%). Although in scenario 3 with a larger extension deficit of 55 , custom-made turnbuckle static progressive (n ¼ 25, 33.8%) was the most popular orthosis, followed by serial static (n ¼ 18, 24.3%) and custom-made three-point static progressive (n ¼ 17, 23%). No associations were observed between orthotic choice and AHTA membership status in scenarios 1 to 3 (P < .05). The recommended daily orthotic use, that is, total end range time (TERT) per day (daily TERT), for the different classes of extension orthoses are presented in Table 4. The most common orthotic regime was 6 to 12 hour for both serial static (n ¼ 52, 80%) and static progressive (n ¼ 40, 61.5%) orthoses. Within this group, 53.8% of serial static (n ¼ 28) and 60% of static progressive orthotic users (n ¼ 15) indicated that overnight use was ideal. Dynamic orthosis users preferred a lower daily TERT of 3 to 6 hour (n ¼ 25, 38.5%) with shorter intermittent day use. Flexion orthoses The results for therapists' preference for flexion orthoses are presented in Table 5. At week 8 after surgery in scenario 4, the most popular choice was “no orthosis” (27.9%). This was followed by custom-made dynamic orthosis with hinge (18%) as the most popular orthosis. At week 12 in scenario 5, both custom-made dynamic orthoses with and without hinges were tied as most popular (27.1%), followed closely by custom-made static progressive orthosis with hinge (24.4%). In scenario 4, no association was observed between orthotic choices and membership status (P < .05). An association was observed in scenario 5, c2 (4) ¼ 13.970,
P ¼ .006, such that the accredited and life/honorary members were more likely to choose the custom-made dynamic flexion orthosis with hinge than the associate members. There were more mixed findings for recommended orthotic dosage for flexion orthoses (Table 6). Serial static users preferred 6 to 12 hour (39%). Static progressive users had an equal preference for 6 to 12 hour (39%) and 3 to 6 hour (39%). Dynamic users prefer 3 to 6 hour (44.1%). Therapists generally agreed on shorter sessions intermittently in the day as flexion orthoses tend to not be well tolerated at night. Therapists more likely to report nonuse of flexion orthoses, with 39.9% for serial static, 15.3% for static progressive, and 17% for dynamic. Reasons for orthotic choice As all five scenarios had similar results, the results have been presented collectively in Figure 3. The most common reasons for orthotic choice for scenarios 1 to 5 were “perceived effectiveness,” “ease for patients to apply and wear,” and “ease of fabrication/ previous experience/comfortable with design.” Results of openended questions regarding orthotic prescription are presented in Table 7. Discussion The general consensus in the literature is that mobilizing orthoses are beneficial in regaining elbow ROM after trauma.18,32,33 However, it is debatable if mobilizing orthoses should be used early in elbow rehabilitation to optimize gains. General practice for orthotic choice post-traumatic elbow fractures was first investigated by Macdermid et al21 who surveyed hand therapists from the United States and Canada. Although their study was able to identify the patterns of orthotic use for protection after surgery, the use of mobilizing orthoses to restore ROM was not reflected. In this study, most Australian hand therapists reported using mobilizing orthoses in post-traumatic elbow management (n ¼ 99, 89.9%). Several therapists commented on the need for early orthotic intervention
Table 2 Description of therapists' orthotic use Directional orthosis most used (n ¼ 96)
No. (%) of participants
Flexion Extension Do not use
5 (5.2%) 85 (88.5%) 6 (6.3%)
G. Sim et al. / Journal of Hand Therapy xxx (2020) 1e9
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Table 3 Preference for extension orthosis Type of orthosis
Membership status
Scenario 1 Week 8 FFD 55 (n ¼ 83)
Scenario 2 Week 12 FFD 30 (n ¼ 80)
Scenario 3 Week 12 FFD 55 (n ¼ 74)
Serial static orthosis
Total Accredited/Life/Honorary Associate Total Accredited/Life/Honorary Associate Total Accredited/Life/Honorary Associate Total Accredited/Life/Honorary Associate Total Accredited/Life/Honorary Associate Total Accredited/Life/Honorary Associate Total Accredited/Life/Honorary Associate Total Accredited/Life/Honorary Associate
65 (78.3%) 46 19 11 (13.3%) 7 4 1 (1.2%) 1 0 2 (2.4%) 1 1 2 (2.4%) 0 2 0 (0%) 0 0 0 (0%) 0 0 2 (2.4%) 2 0
23 (28.8%) 15 8 31 (38.8%) 22 9 8 (10%) 6 2 11 (13.8%) 10 1 0 (0%) 0 0 3 (3.8%) 1 2 1 (1.3%) 0 1 3 (3.3%) 1 2
18 (24.3%) 12 6 17 (23%) 11 6 25 (33.8%) 18 7 12 (16.2%) 10 2 1 (1.4%) 0 1 0 (0%) 0 0 0 (0%) 0 0 1 (1.4%) 0 1
Custom-made three-point static progressive orthosis Custom-made turnbuckle static progressive orthosis Custom-made dynamic orthosis
Prefabricated dynamic orthosis
Prefabricated static progressive
Others
No orthosis
the later stage of healing, it also requires regular readjustments by the therapist as the patient's ROM improves. This may not be a practical option for patients who are unable to attend therapy sessions regularly. To manage extension deficits at week 12, therapists agreed on the custom-made three-point orthosis and custom-made turnbuckle orthosis to manage FFD 30 and 55 a respectively. These orthotic choices reflect an acknowledgment of the proposed biomechanical strengths of each design based on mathematical analysis. Chinchalkar et al64 analyzed the forces applied on the elbow by two different static progressive orthoses at varying degrees of contracture. It was proposed that the turnbuckle design provided mechanical advantage and rotational forces in FFD above 30 , whereas the three-point extension design was mechanically more effective in regaining terminal extension. However, these theories have not been validated empirically and thus remain as hypotheses. In scenarios 2 and 3, our findings indicate a preference for static progressive over dynamic orthoses in managing chronic elbow contractures. Patient factors that influenced therapists' preference for static progressive orthoses included patient comfort, motivation, and available time for orthotic use. It is also believed that patients can tolerate static progressive orthoses for longer durations than dynamic orthoses.48 Based on low-load prolonged stretch traction or casting techniques,24,62,65 traditional orthotic regimes support a prolonged TERT that exceeds 6 hour per day.43,46,47,53-55,66 Our survey reflected the same findings, with 6 to 12 hour as the preferred daily TERT for static progressive orthosis.
in elbows that are slow to progress, citing 12 weeks after injury as the window of maximal gains.3,10 Our study found that extension mobilizing orthoses were commonly used by Australian hand therapists (n ¼ 85, 88.5%). This may reflect a high prevalence of extension deficits after trauma.61 With injury, myofibroblastic activity heightens in the anterior joint capsule,6 resulting in scarring, thickening, and predisposing the elbow to flexion contractures. In scenario 1 (week 8 after injury with 55 extension deficit), our results show that serial static extension orthosis was the most popular choice (n ¼ 65, 78.3%). Using the evidence-based practice clinical reasoning model to guide orthotic choice, therapists weighed patient's preferences against the therapists' clinical expertise and current available evidence. Some therapists reported choosing a serial static orthosis based on its perceived effectiveness. This is surprising as there is only one low-quality research study, comprising three participants with varying severity of elbow contractures, which supports the use of serial extension casting and orthotic use to regain ROM.62 Regarding biological factors such as stage of healing and pain, therapists explained that orthotic tension had to be appropriate to that stage of healing, adding that orthotic intervention was sometimes not appropriate at week 8 after injury because of inadequate tissue healing. The combination of high pain irritability41,63 and excessive loads24 plays a role in triggering inflammation, which further increases edema and fibrosis.25-27 Other important factors in the decision-making process included patient factors and clinical expertise. Although a serial static orthosis provides flexibility for progression to a different style in Table 4 Recommendations for daily TERT for extension orthotic use
Do not use <3 h 3 to <6 h 6-12 h >12 h TERT ¼ total end range time.
Serial static orthoses (n ¼ 65)
Static progressive orthoses (n ¼ 65)
Dynamic orthoses (n ¼ 65)
2 0 7 52 4
2 2 15 40 6
15 3 25 18 1
(3.1%) (0%) (10.8%) (80%) (6.2%)
(3.1%) (3.1%) (23.1)% (61.5%) (9.23%)
(27.7%) (4.6%) (38.5%) (27.7%) (1.5%)
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Table 5 Preference for flexion orthosis Type of orthosis
Membership status
Scenario 4 8 wk elbow flexion to 100 (n ¼ 61)
Scenario 5 12 wk limited elbow flexion (n ¼ 55)
Serial static orthosis
Total Accredited/Life/Honorary Associate Total Accredited/Life/Honorary Associate Total Accredited/Life/Honorary Associate Total Accredited/Life/Honorary Associate Total Accredited/Life/Honorary Associate Total Accredited/Life/Honorary Associate Total Accredited/Life/Honorary Associate Total Accredited/Life/Honorary Associate Total Accredited/Life/Honorary Associate
9 (14.8%) 6 3 11 (18%) 9 2 9 (14.8%) 9 0 9 (14.8%) 5 4 6 (9.8%) 3 3 0 (0%) 0 0 0 (0%) 0 0 0 (0%) 0 0 17 (27.9%) 13 4
0 (0%) 0 0 16 (27.1%) 16 0 16 (27.1%) 12 4 15 (24.4%) 8 7 6 (10.2%) 2 4 0 (0%) 0 0 0 (0%) 0 0 0 (0%) 0 0 6 (10.2%) 5 1
Custom-made dynamic flexion orthosis with hinge Custom-made dynamic flexion orthosis without hinge Custom-made static progressive flexion orthosis with hinge Custom-made static progressive flexion orthosis without hinge Prefabricated dynamic flexion
Prefabricated static progressive orthosis
Others
No orthosis
These findings conflict with those of previous researchers, such as Bonutti et al,49 who had presented retrospective data on the use of a 30-minute thrice daily protocol using the Joint Active Systems elbow orthosis. This type of protocol was introduced as a less timeintensive alternative as patients were more likely to accept the orthotic intervention and increase in compliance. This protocol has been used in clinical studies and is accepted as general practice.10,33,67 However, therapists need to consider the risk of patients overtensioning the orthosis too quickly, resulting in negative effects such as microtears and increasing joint stiffness.24,37 Another common comment was the preference for overnight use instead of daytime use in serial static and static progressive extension orthoses. Experts often recommended night use as it would not compromise on functional use in the day.37,38 On the other hand, Galluci et al54 reported that a third of patients treated with dynamic elbow orthoses were intolerant to prolonged night use. It was postulated that continuous tension by the dynamic components caused muscle spasms, resulting in pain, poor tolerance, and eventual disuse of the orthoses.20,46,68 It is also possible that the tension used in these studies was too high to be tolerated for prolonged night use. Without known safe loading limits in the elbow, the therapists need to carefully monitor the patient's tissue response to the orthosis and modify the orthotic parameters accordingly to ameliorate any adverse reactions. This is an area in need of further research. Therapists in our survey sample also considered using a combination of orthoses such as static
progressive or dynamic in the day and serial static at night to overcome these potential difficulties. In contrast to extension orthoses, our study identified that there was no clear preference for any orthotic design in both flexion scenarios. Some therapists felt that the hinge provided greater mechanical advantage by absorbing compressive forces and maximizing rotational forces, notably in flexion angles less than 110 , which aligns with the recommendations of Szekeres.69 Others did not “see the point of the hinge” as they were time consuming, difficult to fabricate and added unnecessary costs to the patient. Some therapists also reported that flexion was more easily achieved than extension, prioritizing other conservative interventions such as passive ROM stretches, weighted stretches, and flexion straps. Among other conservative treatments, passive joint mobilizations20,61 and PNF techniques31,61 were also suggested in the literature. Some therapists indicated that functional use should be prioritized over orthotic use. This is possibly due to the high flexion demand in functional tasks such as using a cellular telephone that requires approximately 142 .2 Although flexion deficits are less prevalent, this type of contracture is harder to resolve.11,61 Therapists commented on the importance of clinical expertise in such contractures because of the lack of rehabilitation guidelines. Therefore, therapists reported using a combination of critical thinking, ability to evaluate outcomes, and modify treatment, using orthotic designs that are adaptable, having the experience and proficiency in fabricating.
Table 6 Recommendations for daily TERT for flexion orthotic use Recommended daily TERT
Serial static orthoses (n ¼ 59)
Static progressive orthoses (n ¼ 59)
Dynamic orthoses (n ¼ 59)
Do not use <3 h 3<6h 6-12 h >12 h
23 1 10 23 2
9 2 23 23 2
10 5 26 17 1
TERT ¼ total end range time.
(39%) (1.7%) (17%) (39%) (3.4%)
(15.3%) (3.4%) (39%) (39%) (3.4%)
(17%) (8.5%) (44.1%) (28.8%) (1.7%)
G. Sim et al. / Journal of Hand Therapy xxx (2020) 1e9
0.0%
10.0%
20.0%
7
30.0%
40.0%
50.0%
60.0%
70.0%
Surgeon's preference Prefabricated and convenient Ease of fabrication/previous experience/comfortable with design Effectiveness Easy for patients to apply and wear Patient's pain/tolerance Patient comfort Cost of splint
Week 8: extension deficit 55◦(n=79) Week 12: extension deficit 30◦(n=77)
Esthetics
Week 12: extension deficit 55◦(n=73) Week 8: limited to 100◦(n=47)
Others
Week 12: limited flexion (n=53) Fig. 3. Reasons for orthotic choice.
Some therapists felt that prolonged flexion splinting is not well tolerated because of vascular and ulnar nerve compromise. This is reflected in the recommendations for the shorter daily TERT of 3 to 6 hour, particularly when mobilizing into larger flexion angles. In scenario 5, the more experienced therapists also chose orthoses with dynamic components instead of static progressive ones. This may reflect that therapists perceived that dynamic flexion orthoses are better tolerated.
Interestingly, this research has identified prefabricated orthoses as the least popular choice in both flexion and extension scenarios. Prefabricated orthoses are widely used in earlier studies on elbow contractures.10,28,49-53,70 In contrast, our responders described prefabricated orthoses to be bulky and heavy, which contributed to the poor fit and conformity to the patient. Therapists reported poor patient comfort, tolerance, decreased compliance, and lower perceived effectiveness. Other disadvantages include the high costs
Table 7 Results of thematic analysis of open-ended questions Evidence-based practice Patient's values and preferences
Clinical expertise
Current available evidencea
Ease of application
Adaptability/flexibility 1. Adaptable to ROM changes while maintaining mechanical advantage 2. Ease of modification of orthosis to a different style 3. Combination of orthoses (hybrid design)
Theory 1. Multimodal treatment 2. Preventative early intervention 3. Hierarchy of intervention
Reflection 1. Individualized treatment vs evidence-based guidelines 2. Ability to evaluate outcomes and modify treatment 3. Consider competing treatment goals
Biomechanical principles 1. Mechanical effectiveness of orthosis at various angles of contracture 2. High vs low orthotic forces 3. Inelastic vs elastic mobilization 4. Daily TERT 5. Low load prolonged stress
Costs to patient
Experience 1. Successes and failures 2. Exposure to design and effectiveness
Clinical circumstance and setting 1. Availability of resources 2. Sole therapist vs group 3. Surgeon's preference
Proficiency 1. Confidence in skills 2. Ability to fabricate 3. Speed
Biological factors 1. Stage of healing 2. Time from injury 3. Joint end feel 4. Responsiveness to treatment (weeks test) 5. Magnitude of contracture 6. Direction of capsular injury 7. Edema 8. Pain 9. Heterotopic ossification 10. Ulnar nerve/vascular compromise in flexion
Comfort 1. Adjustability and fit to individual differences 2. Orthotic weight and profile Functional use, life demands, work Motivation
Management style Therapist vs patient controlled a
Current available evidence includes all Oxford The Centre for Evidence-Based Medicine (CEBM) Levels of Evidence from systematic reviews to expert opinions.
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to patients and long wait time for the orthosis. Fess71 also advocated caution when applying prefabricated orthoses. In her comparison study of four widely used prefabricated dynamic orthoses for varying angles of PIPJ flexion contractures, Fess found that these orthoses exhibited rotational forces up to six times more than the recommended dose, which was 100 to 300 gm cm2. High forces like these can cause tissue inflammation and ultimately lead to orthotic discontinuation.35 Thus, therapists should assess the orthotic fit and design when choosing a prefabricated orthosis and carefully monitor the patient's tissue response to prevent the adverse effects.26 This study is not without limitations. First, this survey was based on a convenience sample of hand therapists through the AHTA mailing list and thus excluded any hand therapist not registered with the association. Second, the response rate (n ¼ 103, 13.2%) and completion rate (n ¼ 59, 57%) was lower than expected.72 This could be attributed to errors during the distribution of the survey, such as invalid email addresses or autoprogrammed email filters that sifts out “junk mail.” To meet the research aims, the electronic survey had extensive questions that predicted a longer completion time. Therapists unable to commit time may not have responded or completed the survey. Due to the increased number of dropouts later in the survey, readers should also exercise caution in interpreting the results for the flexion scenarios. However, there was a large proportion of experienced hand therapists (in terms of membership status and years of experience) among the survey completers. As such, we believe that this study has generally achieved the aims of gaining data on Australian therapists' preferred orthoses for various angles of contractures, and insight into the patient-related factors, therapist-related factors, and current evidence in orthotic prescription for elbow contractures. Conclusions Our electronic survey demonstrates that Australian clinicians routinely prescribe extension mobilizing orthoses at weeks 8 and 12, with serial static and static progressive orthoses, respectively. Future research is needed to assess whether prescribing mobilizing orthoses 12 weeks after injury is more beneficial than standard conservative therapy in reducing elbow contractures. There is also a need for further research regarding the suitable parameters and orthotic force in the elbow. Acknowledgments The authors thank Lara Griffiths, President of the Australian Hand Therapy Association for permitting the dissemination of the survey, EKCO Hand Therapy and Nick Antoniou for their picture contributions. References 1. Morrey BF, Askew L, Chao E. A biomechanical study of normal functional elbow motion. J Bone Joint Surg Am. 1981;63(6):872e877. 2. Sardelli M, MacWilliams BA, Tashjian RZ, MacWilliams BA. Functional elbow range of motion for contemporary tasks. J Bone Joint Surg. 2011;93(5):471. 3. Myden C, Hildebrand K. Elbow joint contracture after traumatic injury. J Shoulder Elbow Surg. 2011;20(1):39. 4. Anakwe ER, Middleton DS, Jenkins JP, McQueen MM, Court-Brown MC. Patientreported outcomes after simple dislocation of the elbow. J Bone Joint Surg Am. 2011;93(13):1220e1226. 5. Lake SP, Castile RM, Borinsky S, Dunham CL, Havlioglu N, Galatz LM. Development and use of an animal model to study post-traumatic stiffness and contracture of the elbow. J Orthop Res. 2016;34(2):354e364. 6. Morrey BF, Sanchez-Sotelo J, Morrey ME. Morrey's the Elbow and its Disorders. 5th ed. Philadelphia, PA: Elsevier; 2018. 7. Dunham CL, Castile RM, Havlioglu N, Chamberlain AM, Galatz LM, Lake SP. Persistent motion loss after free joint mobilization in a rat model of posttraumatic elbow contracture. J Shoulder Elbow Surg. 2017;26(4):611e618.
8. Zheng W, Liu J, Song J, Fan C. Risk factors for development of severe posttraumatic elbow stiffness. Int Orthop. 2018;42(3):595e600. 9. Hildebrand KA. Posttraumatic elbow joint contractures: defining pathologic capsular mechanisms and potential future treatment paradigms. J Hand Surg. 2013;38(11):2227e2233. 10. Lindenhovius ALC, Doornberg JN, Brouwer KM, Jupiter JB, Mudgal CS, Ring D. A prospective randomized controlled trial of dynamic versus static progressive elbow splinting for posttraumatic elbow stiffness. J Bone Joint Surg Am. 2012;94(8):694. 11. Giannicola G, Polimanti D, Bullitta G, Sacchetti FM, Cinotti G. Critical time period for recovery of functional range of motion after surgical treatment of complex elbow instability: prospective study on 76 patients. Injury. 2014;45(3):540e545. 12. Kodde IF, van Rijn J, van Den Bekerom M, Eygendaal D. Surgical treatment of post-traumatic elbow stiffness: a systematic review. J Shoulder Elbow Surg. 2013;22:574e580. 13. Iordens GIT, Van Lieshout EMM, Schep NWL, et al. Early mobilisation versus plaster immobilisation of simple elbow dislocations: results of the FuncSiE multicentre randomised clinical trial. Br J Sports Med. 2017;51(6):531. 14. Harding P, Rasekaba T, Smirneos L, Holland AE. Early mobilisation for elbow fractures in adults. Cochrane Database Syst Rev. 2011;(6):CD008130. 15. Woods D, Giangarra CE. Post-traumatic elbow stiffness. In: Clinical Orthopaedic Rehabilitation. Philadelphia, PA: Elsevier Inc; 2018:74e76.e71. 16. Bhabra G, Modi CS, Lawrence T. Managing the stiff elbow. Orthop Trauma. 2016;30(4):329e335. 17. Mellema J, Lindenhovius A, Jupiter J. The posttraumatic stiff elbow: an update. Curr Rev Musculoskelet Med. 2016;9(2):190e198. 18. Veltman E, Doornberg J, Eygendaal D, van den Bekerom M. Static progressive versus dynamic splinting for posttraumatic elbow stiffness: a systematic review of 232 patients. Arch Orthop Trauma Surg. 2015;135(5):613e617. 19. Paul R, Chan R. Nonsurgical treatment of elbow stiffness. J Hand Surg. 2013;38(10):2002e2004. 20. Jones V. Conservative management of the post-traumatic stiff elbow: a physiotherapist’s perspective. Shoulder Elbow. 2016;8(2):134e141. 21. Macdermid JC, Vincent JI, Kieffer L, Kieffer A, Demaiter J, Macintosh S. A survey of practice patterns for rehabilitation post elbow fracture. Open Orthop J. 2012;6(1):429e439. 22. Nakano J, Yamabayashi C, Scott A, Reid WD. The effect of heat applied with stretch to increase range of motion: a systematic review. Phys Ther Sport. 2012;13(3):180e188. 23. Lindenhovius ALC, Jupiter JB. The posttraumatic stiff elbow: a review of the literature. J Hand Surg. 2007;32(10):1605e1623. 24. Brand PW. Mechanical factors in joint stiffness and tissue growth. J Hand Ther. 1995;8(2):91e96. 25. Brand PW. Lessons from Hot feet: a note on tissue remodeling. J Hand Ther. 2002;15(2):133e135. 26. Colditz JC. Therapists' management of the stiff hand. In: Skirven TM, ed. Rehabilitation of the Hand and Upper Extremity. 6th ed. Philadelphia, PA: Mosby; 2011. 27. Altman E. Therapist's management of the stiff elbow. In: Skirven TM, ed. Rehabilitation of the Hand and Upper Extremity. 6th ed. Philadelphia, PA: Mosby; 2011:1075e1088. 28. Marinelli A, Bettelli G, Guerra E, Nigrisoli M, Rotini R. Mobilization brace in post-traumatic elbow stiffness. Musculoskelet Surg. 2010;94(suppl 1):37e45. 29. Michelsson JE, Rauschning W. Pathogenesis of experimental heterotopic bone formation following temporary forcible exercising of immobilized limbs. Clin Orthop Relat Res. 1983;176:265e272. 30. Casavant A, Hastings H. Heterotopic ossification about the elbow: a Therapist's guide to evaluation and management. J Hand Ther. 2006;19(2):255e266. 31. Birinci T, Razak Ozdincler A, Altun S, Kural C. A structured exercise programme combined with proprioceptive neuromuscular facilitation stretching or static stretching in posttraumatic stiffness of the elbow: a randomized controlled trial. Clin Rehabil. 2018;33(2):241e252. 32. Chen B, Lin J, Liu L, Niu W. Static progressive orthoses for elbow contracture: a systematic review. J Healthc Eng. 2017;2017:7498094. 33. Müller AM, Sadoghi P, Lucas R, et al. Effectiveness of bracing in the treatment of nonosseous restriction of elbow mobility: a systematic review and metaanalysis of 13 studies. J Shoulder Elbow Surg. 2013;22(8):1146e1152. 34. Michlovitz SL, Harris BA, Watkins MP. Therapy interventions for improving joint range of motion: a systematic review. J Hand Ther. 2004;17(2):118. 35. Fess EE. Splints: mechanics versus convention. J Hand Ther. 1995;8(2):124e 130. 36. Brand PW, Hollister AM, Thompson DE. Mechanical resistance. In: Brand PW, Hollister AM, eds. Clinical Mechanics of the Hand. 3rd ed. St. Louis: Mosby; 1999:184e214. 37. Glasgow C, Tooth L, Fleming J. Which splint? Dynamic versus static progressive splinting to mobilise stiff joints in the hand. Br J Hand Ther. 2008;13(4):104e110. 38. Schultz-Johnson K. Static progressive splinting. J Hand Ther. 2002;15(2): 163e178. 39. Wilton JC, Dival TA. Splint prescription: clinical reasoning issues. In: Hand Splinting: Principles of Design and Fabrication. London: W.B. Saunders; 1997. 40. Glasgow C, Tooth LR, Fleming J, Peters S. Dynamic splinting for the stiff hand after trauma: predictors of contracture resolution. J Hand Ther. 2011;24(3): 195e206.
G. Sim et al. / Journal of Hand Therapy xxx (2020) 1e9 41. Flowers KR. A proposed decision hierarchy for splinting the stiff joint, with an emphasis on force application parameters. J Hand Ther. 2002;15(2):158e162. 42. Young N, Terrington N, Francis D, Robinson LS. Orthotic management of fixed flexion deformity of the proximal interphalangeal joint following traumatic injury: a systematic review. Hong Kong J Occup Ther. 2018;31:3e13. 43. Valdes K, Boyd JD, Povlak SB, Szelwach MA. Efficacy of orthotic devices for increased active proximal interphalangeal extension joint range of motion: a systematic review. J Hand Ther. 2019;32(2):184e193. 44. Fess EE, McCollum M. The influence of splinting on healing tissues. J Hand Ther. 1998;11(2):157e161. 45. Li-Tsang C, Leung K, Mak A. The effect of corrective splinting on flexion contracture of rheumatoid fingers. J Hand Ther. 2002;15(2):185e191. 46. Gelinas J, Faber K, Patterson S, King G. The effectiveness of turnbuckle splinting for elbow contractures. J Bone Joint Surg Am. 2000;82(1):74e78. 47. Bhat AK, Bhaskaranand K, Nair SG. Static progressive stretching using a turnbuckle orthosis for elbow stiffness: a prospective study. J Orthop Surg. 2010;18(1):76e79. 48. Green D, McCoy H. Turnbuckle orthotic correction of elbow-flexion contractures after acute injuries. J Bone Joint Surg Am. 1979;61(7):1092e1095. 49. Bonutti PM, Windau JE, Ables BA, Miller BG. Static progressive stretch to reestablish elbow range of motion. Clin Orthop Relat Res. 1994;(303):128e134. 50. Doornberg JN, Ring D, Jupiter JB. Static progressive splinting for posttraumatic elbow stiffness. J Orthop Trauma. 2006;20(6):400e404. 51. Ulrich SD, Bonutti PM, Seyler TM, Marker DR, Morrey BF, Mont MA. Restoring range of motion via stress relaxation and static progressive stretch in posttraumatic elbow contractures. J Shoulder Elbow Surg. 2010;19(2):196e201. 52. Hepburn GR. Case studies: contracture and stiff joint management with DynasplintÔ. J Orthop Sports Phys Ther. 1987;8(10):498e504. 53. Hepburn GR, Crivelli KJ. Use of elbow dynasplint for reduction of elbow flexion contractures: a case study. J Orthop Sports Phys Ther. 1984;5(5):269e274. 54. Gallucci G, Boretto J, Dávalos M, Alfie V, Donndorff A, Carli P. The use of dynamic orthoses in the treatment of the stiff elbow. Eur J Orthop Surg Traumatol. 2014;24(8):1395e1400. 55. Gallucci GL, Boretto JG, Dávalos MA, Donndorff A, Alfie VA, De Carli P. Dynamic splint for the treatment of stiff elbow. Shoulder Elbow. 2011;3(1):52e55. 56. Creswell JW. Research Design: Qualitative, Quantitative, and Mixed Methods Approaches. 4th ed. Thousand Oaks, CA: SAGE Publications; 2014. 57. Srivastava A, Thomson SB. Framework analysis: a qualitative methodology for applied policy research. J Adm Gov. 2009;4(2):72e79.
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58. Elo S, Kyngäs H. The qualitative content analysis process. J Adv Nurs. 2008;62(1):107e115. 59. Sackett D. Available at: https://guides.mclibrary.duke.edu/c.php?g¼1582 01&p¼1036021. Accessed September 18, 2018. 60. Glasgow C, Peters S. Extension orthoses and the stiff proximal interphalangeal joint following hand trauma: a review of current clinical practice in the Australian context. Hand Ther. 2016;21(3):77e84. 61. Dávila SA, Johnston-Jones K. Managing the stiff elbow: operative, nonoperative, and postoperative techniques. J Hand Ther. 2006;19(2):268e281. 62. Zander CL, Healy NL. Elbow flexion contractures treated with serial casts and conservative therapy. J Hand Surg. 1992;17(4):694e697. 63. Monument MJ, Hart DA, Salo PT, Hildebrand KA, Dean Befus A. Posttraumatic elbow contractures: targeting neuroinflammatory fibrogenic mechanisms. J Orthop Sci. 2013;18(6):869e877. 64. Chinchalkar SJ, Pearce J, Athwal GS. Static progressive versus three-point elbow extension splinting: a mathematical analysis. J Hand Ther. 2009;22(1):37e43. 65. Light KE, Nuzik S, Personius W, Barstrom A. Low-load prolonged stretch vs. high-load brief stretch in treating knee contractures. Phys Ther. 1984;64(3): 330e333. 66. Flowers KR, Lastayo P. Effect of total end range time on improving passive range of motion. J Hand Ther. 1994;7(3):150e157. 67. Wilwerding-Peck J. Mobilization splints: dynamic, serial static, and static progressive splinting. In: Coppard BM, Lohman H, Shultz-Johnson K, eds. Introduction to Splinting: A Clinical-Reasoning & Problem-Solving Approach. 2nd ed. St. Louis: Mosby; 2001:252e263. 68. Bruno RJ, Lee ML, Strauch RJ, Rosenwasser MP. Posttraumatic elbow stiffness: evaluation and management. J Am Acad Orthop Surg. 2002;10(2):106e116. 69. Szekeres M. A biomechanical analysis of static progressive elbow flexion splinting. J Hand Ther. 2006;19(1):34e38. 70. Bonutti P, Donatelli R, Hotz MW. Paper no.134: evaluation of a 30-minute protocol to restore range of motion via stress relaxation and static progressive stretch. In: American Academy of Orthopaedic Surgeons Conference. 2002. 71. Fess EE. Force magnitude of commercial spring-coil and spring-wire splints designed to extend the proximal interphalangeal joint. J Hand Ther. 1988;1(2): 86e90. 72. Penwarden R. Response Rate Statistics for Online Surveys -What Numbers Should You Be Aiming for?; 2014. Available at: http://fluidsurveys.com/university/ response-rate-statistics-online-surveys-aiming/. Accessed September 17, 2018.
Contents lists available at ScienceDirect
Journal of Hand Therapy journal homepage: www.jhandtherapy.org
Mobilizing orthoses in the management of post-traumatic elbow contractures: A survey of Australian hand therapy practice Germaine Sim MPhil candidate, B Phty, CHT a, b, *, Jennifer Fleming PhD, B OccThy (Hons), FOTARA b, Celeste Glasgow PhD, MSc, B OccThy (Hons) c a
EKCO Hand and Upper Limb Rehabilitation Unit, South Brisbane, QLD, Australia The University of Queensland, School of Health and Rehabilitation Sciences, The University of Queensland, St Lucia, QLD, Australia c Royal Brisbane and Women's Hospital, Occupational Therapy, Herston, QLD, Australia b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 8 July 2019 Received in revised form 10 November 2019 Accepted 31 December 2019 Available online xxx
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. Ó 2020 Hanley & Belfus, an imprint of Elsevier Inc. All rights reserved.
Keywords: Post-traumatic elbow contractures Mobilizing orthoses Survey
Introduction The elbow is a constrained synovial hinge joint that functions to position the hand for activities of daily living. In 1981, Morrey et al1 found that an elbow flexion-extension arc range of motion (ROM)
Conflict of interest: The authors declared no potential conflicts of interest regarding the research, authorship, and publication of this article. Funding: This research was supported by the Australian Government Research Training Program Scholarship. The authors received no financial support for the research and publication of this article. * Corresponding author. EKCO Hand Therapy, 1/600 Stanley Street, South Brisbane, Queensland 4101,Australia. Tel.: þ6137860700; fax: þ61738460744. E-mail address: [email protected] (G. Sim).
of 100 was required for activities of daily living. In a more recent study in 2011, Sardelli et al2 indicated that the functional arc required for modern day tasks is closer to 130 . Trauma is a common cause of elbow stiffness and contractures.3,4 Animal studies show that the joint capsule plays a major role in contracture development, citing its structure as thin and susceptible to thickening and scarring from trauma.5,6 In spite of our advances in elbow injury management, 56% of patients with simple elbow dislocations reported having long-term stiffness.3 In a prospective study on common post-traumatic elbow injuries, patients who reported having poor outcomes at 3 months of follow-up were more prone to chronic contractures, resulting in 12% of the patients requiring further surgical release.4 The likelihood of contractures increases in more severe injuries,7 higher impact mechanisms,8 females,4 and
0894-1130/$ e see front matter Ó 2020 Hanley & Belfus, an imprint of Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jht.2019.12.014
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G. Sim et al. / Journal of Hand Therapy xxx (2020) 1e9
with increased length of immobilization.7 Depending on the severity and direction of contracture, patients can experience difficulties with self-care (eg, eating, dressing and hygiene) with flexion deficits, or reaching and positioning objects with the extension deficits.9 Hence, while a small amount of stiffness may be tolerable, a large contracture can be more painful and debilitating,4 warranting further treatment to improve motion. As improvements in ROM are greatest within the first 3 to 6 months of injury,3,10,11 the focus should be on early intervention within this window of maximal gains. It is assumed that contractures can be prevented by early active mobilization after any trauma of the elbow.12 A randomized controlled trial on patients with simple elbow dislocation13 showed promising results with early mobilization without compromising on stability. When compared to a delayed treatment group that was casted for three weeks, the early mobilization group had significantly better movement and functional recovery at six weeks after injury. However, there were no differences in functional scores at one year. Similarly, the evidence for early mobilization in elbow fractures is scarce14 and further research is needed before generalizing its efficacy to all elbow conditions. Conservative treatment is generally recommended for at least 6 months before performing any surgical release.15-18 Most of the evidence on stretching, joint mobilizations, and heat in posttraumatic elbow contractures is based on expert opinions or in healthy populations.19-22 A consensus among clinicians is that therapy should never be too aggressive and the use of strong passive stretching should be discouraged.23 Placing excessive loads on tissues beyond their normal elastic range can cause tissue microtears and ruptures.24 This triggers pain, inflammation, edema, and fibrosis,25-27 resulting in more stiffness and a greater degree of contracture. Repetitive and forceful maneuvers in animal studies have reported an increased risk of heterotopic ossification.28,29 Casavant and Hastings30 argued that passive ROM and stretches are not necessarily forceful maneuvers. More recently, Birinci et al31 found positive outcomes with stretching
interventions in a prospective cohort after elbow fracture immobilization. At week 6 after injury, participants were randomly allocated to a 6-week program of either proprioceptive neuromuscular facilitation (PNF) or static stretch interventions. Although both groups had positive outcomes, the PNF group had significantly better functional scores, less pain at rest and with activity, and better elbow flexion active ROM. Although the outcomes in this study were promising, the study was limited in sample size and lacked long-term follow-up. Thus, it is not known if such structured stretching regimes alone are enough for contracture resolution. In contrast, most of the evidence on conservative management of elbow contractures concerns elbow mobilizing orthoses.18,19,32-34 These are devices that place the joint in a slightly lengthened position over prolonged periods to stimulate new tissue growth.25,26,35,36 Custom-made or prefabricated, elbow mobilizing orthoses can be classified into three main groups: serial static, static progressive, and dynamic (Fig. 1). The serial static orthosis uses a rigid base, such as a thermoplastic or plaster cast, to apply minimal tension over prolonged periods to a joint at a pain-free end range position.26,27,37 When the tissues have adapted to a new length, the therapist can remold the thermoplastic to a new lengthened position. This process is repeated several times to achieve the desired range. The static progressive orthosis is different in that it has a rigid base and an inelastic mobilizing component, such as a turnbuckle or Velcro strap, to statically maintain the elbow at close to end range.26,38 When the tissues relax into the lengthened position, the patient can independently tighten the tension on the mobilizing component, thus incrementally moving the elbow into further range after a few cycles.27,39 The dynamic orthosis comprises a rigid base and elastic components, such as elastic straps, therabands, or spring coils, to apply a mobilizing force on the joint.26,37 As the ROM changes, the contractile component adjusts itself.26 Over the life of the orthosis, the elastic components may lose tensile strength and may require readjustments or replacement.
Fig. 1. Extension mobilizing orthoses: (A) serial static (B) custom-made three-point static progressive with D-ring, (C) custom-made static progressive turnbuckle, and (D) custommade dynamic with neoprene.
G. Sim et al. / Journal of Hand Therapy xxx (2020) 1e9
In a cohort study using dynamic mobilizing orthoses in hand contractures, Glasgow et al40 observed that joints resistant to ROM changes after heating and stretching had poorer response to orthotic intervention. The change in ROM from cold to warm was used as an assessment of joint stiffness (known as the modified Weeks test). Stiff joints with more mature scar may require greater forces to generate changes in ROM.38,41 Although the recommendations regarding the amount of force in hand orthotic intervention42-44 is 100 to 300 gm cm2, there is a lack of evidence for safe loading limits in the elbow and only an assumption that larger forces will be required for tissue remodeling.44 For now, these limits can be guided by pressure intolerance of the skin,26,39 pain, edema, ROM, and grip strength.41 Currently, there are insufficient data to suggest if any type of orthosis is superior in resolving contractures in the upper limb.10,18,33,42,45 Regarding the stiff post-traumatic elbow, 13 studies were used in a meta-analysis by Müller et al33 to compare the overall ROM outcomes in dynamic, static progressive and serial static orthotic groups, whereas eight studies were used in a systematic review by Veltman et al18 to compare dynamic versus static progressive orthoses. Clinically significant improvements were reported across all groups in both reviews. As such, the reviewers suggested that orthotic prescription could be guided by the patient's and surgeon's preferences. Despite the large number of primary studies on elbow orthoses, another limitation of the current evidence is that the primary studies are mostly retrospective or pre-post interventional studies with no control group for comparison.28,46-55 This makes it difficult to differentiate the real orthotic effect from natural recovery. Hence, this study has three research aims. First, it aimed to investigate therapists' orthotic preferences for varying elbow flexion and extension ROM deficits. The second aim was to investigate the importance of therapist and patient-related factors as well as existing research evidence in guiding orthotic choice for post-traumatic elbow contractures in Australia. The third aim was to gather therapists' recommendations regarding the optimal protocol for various groups of elbow orthoses.
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were conducted to establish any differences in the demographics between completers and noncompleters, as well as differences in orthotic choices between participants with varying AHTA membership status. Responses from open-ended questions were analyzed using framework analysis.57 Inductive content analysis methods, namely “open coding, creating categories, and abstraction”,58 were first used to organize the data. To achieve internal validity, hand-coding was conducted by two experienced hand therapists who reached a consensus on all responses to the openended questions.58 Similar content was grouped together and transferred into Microsoft Excel coding sheets before allocating into categories. During categorization, similar content was merged into a generic category, whereas complex content underwent subdivision into more categories. Each generic category was labeled and clustered under similar themes. As the themes emerged, the evidence-based practice framework, which was conceptualized by Sackett59 and refined for hand conditions by Glasgow and Peters,60 was identified as a suitable thematic framework for further data analysis.57
Results Of 783 members in the AHTA mailing list, 411 members read the electronic survey request. A response rate of 13.2% was achieved with 103 members consenting to the study and completed the membership question. A total of 99 participants completed the remaining demographic questions and continued to complete the survey or part thereof. There were 6 participants who did not use mobilizing orthoses and did not proceed to the questions with the clinical scenarios. The final completion rate was 57% with 59 participants completing the entire survey. Participant demographic information is listed in Table 1. An association was observed between completion and membership status, c2 (1) ¼ 5.668, P ¼ .017, and between completion and years of experience, c2 (4) ¼ 11.362, P ¼ .023. Accredited and life/honorary members and those with more than 15 years of experience were more likely to complete the survey.
Methods The electronic survey was developed on SurveyMonkey and pilot tested on 10 experienced hand therapists. The survey included five clinical case scenarios of postsurgical elbows, with scenarios 1 to 3 with extension deficits and scenarios 4 to 5 with flexion deficits. The scenarios were as follows: scenario (1) week 8 after surgery with 55 extension deficit; scenario (2) week 12 with 30 extension deficit; scenario (3) week 12 with 55 extension deficit; scenario (4) week 8 with flexion deficit (100 flexion); scenario (5) week 12 with limited flexion. A combination of multiple-choice questions and open-ended questions was used to gather therapists' orthotic preferences for each scenario, reasons for choice, and orthotic protocol. This mixed methods approach was used to provide a more in-depth explanation for the multiple-choice responses56 on the factors guiding orthotic prescription. Ethical approval was gained through the University of Queensland Institutional Human Research Ethics Committee. After seeking gatekeepers' approval from the Australian Hand Therapy Association (AHTA), the electronic survey was distributed to hand therapists through the AHTA mailing list. A reminder email was sent after 1 month and the survey closed after 2 months. The final data analyses included data from both completed and incomplete surveys. Responses to multiple-choice questions were analyzed descriptively. Raw data were extracted from SurveyMonkey to Excel and IBM SPSS statistics program (version 25) for further analysis. Pearson's chi-square test and Fisher's exact test
Table 1 Demographic information of the participants Demographics Membership status (n ¼ 103)c Accreditedb/life/honorary Associate Others/affiliates Undergraduate (n ¼ 99) Occupational therapist Physiotherapist Years of experience (n ¼ 99)c <3 y 3 to <6 y 6 to <10 y 10 to <15 y 15 y Practice setting (n ¼ 99) Public Private Public and private Researcher Research and public Research and private
No. (%) of participants
No. of noncompletersa
No. of completers
66 (64%) 37 (36%) 0 (0%)
23 21 0
43 16 0
67 (67%) 32 (33%)
23 17
44 15
5 20 20 17 37
(5%) (20%) (20%) (17%) (37%)
3 12 11 6 8
2 8 9 11 29
25 59 12 1 1 1
(25%) (60%) (12%) (1%) (1%) (1%)
13 20 5 1 0 1
12 39 7 0 1 0
a Noncompleters consented to the survey but did not complete the final survey question. Data from noncompleters were included in the final data analysis. b Accredited members are qualified hand and upper limb therapists who have met the AHTA requirements and standards of competency. c An association was observed using the Pearson's chi-square test (P < .05).
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G. Sim et al. / Journal of Hand Therapy xxx (2020) 1e9
Fig. 2. Modalities most commonly used by therapists for post-traumatic elbows (n ¼ 99). ROM ¼ range of motion.
Stretches, heat, mobilizing orthoses, and massage were the most commonly used modalities in rehabilitation for regaining ROM in post-traumatic elbows (Fig. 2). Data regarding therapists' most used directional orthosis and the estimated number of mobilizing orthoses prescribed per year are presented in Table 2. Extension orthoses The results for therapists' preference for extension orthoses are presented in Table 3. At week 8 after surgery in scenario 1, there was a clear preference for serial static orthoses (n ¼ 65, 78.3%), followed by custom-made three-point static progressive (n ¼ 11, 13.3%). Orthotic preference was more varied at week 12. In scenario 2, therapists were presented with a smaller extension deficit of 30 , and in this case, the custom-made three-point static progressive orthosis (n ¼ 31, 38.8%) was the most popular, followed by serial static (n ¼ 23, 28.8%) and custom-made dynamic (n ¼ 11, 13.8%). Although in scenario 3 with a larger extension deficit of 55 , custom-made turnbuckle static progressive (n ¼ 25, 33.8%) was the most popular orthosis, followed by serial static (n ¼ 18, 24.3%) and custom-made three-point static progressive (n ¼ 17, 23%). No associations were observed between orthotic choice and AHTA membership status in scenarios 1 to 3 (P < .05). The recommended daily orthotic use, that is, total end range time (TERT) per day (daily TERT), for the different classes of extension orthoses are presented in Table 4. The most common orthotic regime was 6 to 12 hour for both serial static (n ¼ 52, 80%) and static progressive (n ¼ 40, 61.5%) orthoses. Within this group, 53.8% of serial static (n ¼ 28) and 60% of static progressive orthotic users (n ¼ 15) indicated that overnight use was ideal. Dynamic orthosis users preferred a lower daily TERT of 3 to 6 hour (n ¼ 25, 38.5%) with shorter intermittent day use. Flexion orthoses The results for therapists' preference for flexion orthoses are presented in Table 5. At week 8 after surgery in scenario 4, the most popular choice was “no orthosis” (27.9%). This was followed by custom-made dynamic orthosis with hinge (18%) as the most popular orthosis. At week 12 in scenario 5, both custom-made dynamic orthoses with and without hinges were tied as most popular (27.1%), followed closely by custom-made static progressive orthosis with hinge (24.4%). In scenario 4, no association was observed between orthotic choices and membership status (P < .05). An association was observed in scenario 5, c2 (4) ¼ 13.970,
P ¼ .006, such that the accredited and life/honorary members were more likely to choose the custom-made dynamic flexion orthosis with hinge than the associate members. There were more mixed findings for recommended orthotic dosage for flexion orthoses (Table 6). Serial static users preferred 6 to 12 hour (39%). Static progressive users had an equal preference for 6 to 12 hour (39%) and 3 to 6 hour (39%). Dynamic users prefer 3 to 6 hour (44.1%). Therapists generally agreed on shorter sessions intermittently in the day as flexion orthoses tend to not be well tolerated at night. Therapists more likely to report nonuse of flexion orthoses, with 39.9% for serial static, 15.3% for static progressive, and 17% for dynamic. Reasons for orthotic choice As all five scenarios had similar results, the results have been presented collectively in Figure 3. The most common reasons for orthotic choice for scenarios 1 to 5 were “perceived effectiveness,” “ease for patients to apply and wear,” and “ease of fabrication/ previous experience/comfortable with design.” Results of openended questions regarding orthotic prescription are presented in Table 7. Discussion The general consensus in the literature is that mobilizing orthoses are beneficial in regaining elbow ROM after trauma.18,32,33 However, it is debatable if mobilizing orthoses should be used early in elbow rehabilitation to optimize gains. General practice for orthotic choice post-traumatic elbow fractures was first investigated by Macdermid et al21 who surveyed hand therapists from the United States and Canada. Although their study was able to identify the patterns of orthotic use for protection after surgery, the use of mobilizing orthoses to restore ROM was not reflected. In this study, most Australian hand therapists reported using mobilizing orthoses in post-traumatic elbow management (n ¼ 99, 89.9%). Several therapists commented on the need for early orthotic intervention
Table 2 Description of therapists' orthotic use Directional orthosis most used (n ¼ 96)
No. (%) of participants
Flexion Extension Do not use
5 (5.2%) 85 (88.5%) 6 (6.3%)
G. Sim et al. / Journal of Hand Therapy xxx (2020) 1e9
5
Table 3 Preference for extension orthosis Type of orthosis
Membership status
Scenario 1 Week 8 FFD 55 (n ¼ 83)
Scenario 2 Week 12 FFD 30 (n ¼ 80)
Scenario 3 Week 12 FFD 55 (n ¼ 74)
Serial static orthosis
Total Accredited/Life/Honorary Associate Total Accredited/Life/Honorary Associate Total Accredited/Life/Honorary Associate Total Accredited/Life/Honorary Associate Total Accredited/Life/Honorary Associate Total Accredited/Life/Honorary Associate Total Accredited/Life/Honorary Associate Total Accredited/Life/Honorary Associate
65 (78.3%) 46 19 11 (13.3%) 7 4 1 (1.2%) 1 0 2 (2.4%) 1 1 2 (2.4%) 0 2 0 (0%) 0 0 0 (0%) 0 0 2 (2.4%) 2 0
23 (28.8%) 15 8 31 (38.8%) 22 9 8 (10%) 6 2 11 (13.8%) 10 1 0 (0%) 0 0 3 (3.8%) 1 2 1 (1.3%) 0 1 3 (3.3%) 1 2
18 (24.3%) 12 6 17 (23%) 11 6 25 (33.8%) 18 7 12 (16.2%) 10 2 1 (1.4%) 0 1 0 (0%) 0 0 0 (0%) 0 0 1 (1.4%) 0 1
Custom-made three-point static progressive orthosis Custom-made turnbuckle static progressive orthosis Custom-made dynamic orthosis
Prefabricated dynamic orthosis
Prefabricated static progressive
Others
No orthosis
the later stage of healing, it also requires regular readjustments by the therapist as the patient's ROM improves. This may not be a practical option for patients who are unable to attend therapy sessions regularly. To manage extension deficits at week 12, therapists agreed on the custom-made three-point orthosis and custom-made turnbuckle orthosis to manage FFD 30 and 55 a respectively. These orthotic choices reflect an acknowledgment of the proposed biomechanical strengths of each design based on mathematical analysis. Chinchalkar et al64 analyzed the forces applied on the elbow by two different static progressive orthoses at varying degrees of contracture. It was proposed that the turnbuckle design provided mechanical advantage and rotational forces in FFD above 30 , whereas the three-point extension design was mechanically more effective in regaining terminal extension. However, these theories have not been validated empirically and thus remain as hypotheses. In scenarios 2 and 3, our findings indicate a preference for static progressive over dynamic orthoses in managing chronic elbow contractures. Patient factors that influenced therapists' preference for static progressive orthoses included patient comfort, motivation, and available time for orthotic use. It is also believed that patients can tolerate static progressive orthoses for longer durations than dynamic orthoses.48 Based on low-load prolonged stretch traction or casting techniques,24,62,65 traditional orthotic regimes support a prolonged TERT that exceeds 6 hour per day.43,46,47,53-55,66 Our survey reflected the same findings, with 6 to 12 hour as the preferred daily TERT for static progressive orthosis.
in elbows that are slow to progress, citing 12 weeks after injury as the window of maximal gains.3,10 Our study found that extension mobilizing orthoses were commonly used by Australian hand therapists (n ¼ 85, 88.5%). This may reflect a high prevalence of extension deficits after trauma.61 With injury, myofibroblastic activity heightens in the anterior joint capsule,6 resulting in scarring, thickening, and predisposing the elbow to flexion contractures. In scenario 1 (week 8 after injury with 55 extension deficit), our results show that serial static extension orthosis was the most popular choice (n ¼ 65, 78.3%). Using the evidence-based practice clinical reasoning model to guide orthotic choice, therapists weighed patient's preferences against the therapists' clinical expertise and current available evidence. Some therapists reported choosing a serial static orthosis based on its perceived effectiveness. This is surprising as there is only one low-quality research study, comprising three participants with varying severity of elbow contractures, which supports the use of serial extension casting and orthotic use to regain ROM.62 Regarding biological factors such as stage of healing and pain, therapists explained that orthotic tension had to be appropriate to that stage of healing, adding that orthotic intervention was sometimes not appropriate at week 8 after injury because of inadequate tissue healing. The combination of high pain irritability41,63 and excessive loads24 plays a role in triggering inflammation, which further increases edema and fibrosis.25-27 Other important factors in the decision-making process included patient factors and clinical expertise. Although a serial static orthosis provides flexibility for progression to a different style in Table 4 Recommendations for daily TERT for extension orthotic use
Do not use <3 h 3 to <6 h 6-12 h >12 h TERT ¼ total end range time.
Serial static orthoses (n ¼ 65)
Static progressive orthoses (n ¼ 65)
Dynamic orthoses (n ¼ 65)
2 0 7 52 4
2 2 15 40 6
15 3 25 18 1
(3.1%) (0%) (10.8%) (80%) (6.2%)
(3.1%) (3.1%) (23.1)% (61.5%) (9.23%)
(27.7%) (4.6%) (38.5%) (27.7%) (1.5%)
6
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Table 5 Preference for flexion orthosis Type of orthosis
Membership status
Scenario 4 8 wk elbow flexion to 100 (n ¼ 61)
Scenario 5 12 wk limited elbow flexion (n ¼ 55)
Serial static orthosis
Total Accredited/Life/Honorary Associate Total Accredited/Life/Honorary Associate Total Accredited/Life/Honorary Associate Total Accredited/Life/Honorary Associate Total Accredited/Life/Honorary Associate Total Accredited/Life/Honorary Associate Total Accredited/Life/Honorary Associate Total Accredited/Life/Honorary Associate Total Accredited/Life/Honorary Associate
9 (14.8%) 6 3 11 (18%) 9 2 9 (14.8%) 9 0 9 (14.8%) 5 4 6 (9.8%) 3 3 0 (0%) 0 0 0 (0%) 0 0 0 (0%) 0 0 17 (27.9%) 13 4
0 (0%) 0 0 16 (27.1%) 16 0 16 (27.1%) 12 4 15 (24.4%) 8 7 6 (10.2%) 2 4 0 (0%) 0 0 0 (0%) 0 0 0 (0%) 0 0 6 (10.2%) 5 1
Custom-made dynamic flexion orthosis with hinge Custom-made dynamic flexion orthosis without hinge Custom-made static progressive flexion orthosis with hinge Custom-made static progressive flexion orthosis without hinge Prefabricated dynamic flexion
Prefabricated static progressive orthosis
Others
No orthosis
These findings conflict with those of previous researchers, such as Bonutti et al,49 who had presented retrospective data on the use of a 30-minute thrice daily protocol using the Joint Active Systems elbow orthosis. This type of protocol was introduced as a less timeintensive alternative as patients were more likely to accept the orthotic intervention and increase in compliance. This protocol has been used in clinical studies and is accepted as general practice.10,33,67 However, therapists need to consider the risk of patients overtensioning the orthosis too quickly, resulting in negative effects such as microtears and increasing joint stiffness.24,37 Another common comment was the preference for overnight use instead of daytime use in serial static and static progressive extension orthoses. Experts often recommended night use as it would not compromise on functional use in the day.37,38 On the other hand, Galluci et al54 reported that a third of patients treated with dynamic elbow orthoses were intolerant to prolonged night use. It was postulated that continuous tension by the dynamic components caused muscle spasms, resulting in pain, poor tolerance, and eventual disuse of the orthoses.20,46,68 It is also possible that the tension used in these studies was too high to be tolerated for prolonged night use. Without known safe loading limits in the elbow, the therapists need to carefully monitor the patient's tissue response to the orthosis and modify the orthotic parameters accordingly to ameliorate any adverse reactions. This is an area in need of further research. Therapists in our survey sample also considered using a combination of orthoses such as static
progressive or dynamic in the day and serial static at night to overcome these potential difficulties. In contrast to extension orthoses, our study identified that there was no clear preference for any orthotic design in both flexion scenarios. Some therapists felt that the hinge provided greater mechanical advantage by absorbing compressive forces and maximizing rotational forces, notably in flexion angles less than 110 , which aligns with the recommendations of Szekeres.69 Others did not “see the point of the hinge” as they were time consuming, difficult to fabricate and added unnecessary costs to the patient. Some therapists also reported that flexion was more easily achieved than extension, prioritizing other conservative interventions such as passive ROM stretches, weighted stretches, and flexion straps. Among other conservative treatments, passive joint mobilizations20,61 and PNF techniques31,61 were also suggested in the literature. Some therapists indicated that functional use should be prioritized over orthotic use. This is possibly due to the high flexion demand in functional tasks such as using a cellular telephone that requires approximately 142 .2 Although flexion deficits are less prevalent, this type of contracture is harder to resolve.11,61 Therapists commented on the importance of clinical expertise in such contractures because of the lack of rehabilitation guidelines. Therefore, therapists reported using a combination of critical thinking, ability to evaluate outcomes, and modify treatment, using orthotic designs that are adaptable, having the experience and proficiency in fabricating.
Table 6 Recommendations for daily TERT for flexion orthotic use Recommended daily TERT
Serial static orthoses (n ¼ 59)
Static progressive orthoses (n ¼ 59)
Dynamic orthoses (n ¼ 59)
Do not use <3 h 3<6h 6-12 h >12 h
23 1 10 23 2
9 2 23 23 2
10 5 26 17 1
TERT ¼ total end range time.
(39%) (1.7%) (17%) (39%) (3.4%)
(15.3%) (3.4%) (39%) (39%) (3.4%)
(17%) (8.5%) (44.1%) (28.8%) (1.7%)
G. Sim et al. / Journal of Hand Therapy xxx (2020) 1e9
0.0%
10.0%
20.0%
7
30.0%
40.0%
50.0%
60.0%
70.0%
Surgeon's preference Prefabricated and convenient Ease of fabrication/previous experience/comfortable with design Effectiveness Easy for patients to apply and wear Patient's pain/tolerance Patient comfort Cost of splint
Week 8: extension deficit 55◦(n=79) Week 12: extension deficit 30◦(n=77)
Esthetics
Week 12: extension deficit 55◦(n=73) Week 8: limited to 100◦(n=47)
Others
Week 12: limited flexion (n=53) Fig. 3. Reasons for orthotic choice.
Some therapists felt that prolonged flexion splinting is not well tolerated because of vascular and ulnar nerve compromise. This is reflected in the recommendations for the shorter daily TERT of 3 to 6 hour, particularly when mobilizing into larger flexion angles. In scenario 5, the more experienced therapists also chose orthoses with dynamic components instead of static progressive ones. This may reflect that therapists perceived that dynamic flexion orthoses are better tolerated.
Interestingly, this research has identified prefabricated orthoses as the least popular choice in both flexion and extension scenarios. Prefabricated orthoses are widely used in earlier studies on elbow contractures.10,28,49-53,70 In contrast, our responders described prefabricated orthoses to be bulky and heavy, which contributed to the poor fit and conformity to the patient. Therapists reported poor patient comfort, tolerance, decreased compliance, and lower perceived effectiveness. Other disadvantages include the high costs
Table 7 Results of thematic analysis of open-ended questions Evidence-based practice Patient's values and preferences
Clinical expertise
Current available evidencea
Ease of application
Adaptability/flexibility 1. Adaptable to ROM changes while maintaining mechanical advantage 2. Ease of modification of orthosis to a different style 3. Combination of orthoses (hybrid design)
Theory 1. Multimodal treatment 2. Preventative early intervention 3. Hierarchy of intervention
Reflection 1. Individualized treatment vs evidence-based guidelines 2. Ability to evaluate outcomes and modify treatment 3. Consider competing treatment goals
Biomechanical principles 1. Mechanical effectiveness of orthosis at various angles of contracture 2. High vs low orthotic forces 3. Inelastic vs elastic mobilization 4. Daily TERT 5. Low load prolonged stress
Costs to patient
Experience 1. Successes and failures 2. Exposure to design and effectiveness
Clinical circumstance and setting 1. Availability of resources 2. Sole therapist vs group 3. Surgeon's preference
Proficiency 1. Confidence in skills 2. Ability to fabricate 3. Speed
Biological factors 1. Stage of healing 2. Time from injury 3. Joint end feel 4. Responsiveness to treatment (weeks test) 5. Magnitude of contracture 6. Direction of capsular injury 7. Edema 8. Pain 9. Heterotopic ossification 10. Ulnar nerve/vascular compromise in flexion
Comfort 1. Adjustability and fit to individual differences 2. Orthotic weight and profile Functional use, life demands, work Motivation
Management style Therapist vs patient controlled a
Current available evidence includes all Oxford The Centre for Evidence-Based Medicine (CEBM) Levels of Evidence from systematic reviews to expert opinions.
8
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to patients and long wait time for the orthosis. Fess71 also advocated caution when applying prefabricated orthoses. In her comparison study of four widely used prefabricated dynamic orthoses for varying angles of PIPJ flexion contractures, Fess found that these orthoses exhibited rotational forces up to six times more than the recommended dose, which was 100 to 300 gm cm2. High forces like these can cause tissue inflammation and ultimately lead to orthotic discontinuation.35 Thus, therapists should assess the orthotic fit and design when choosing a prefabricated orthosis and carefully monitor the patient's tissue response to prevent the adverse effects.26 This study is not without limitations. First, this survey was based on a convenience sample of hand therapists through the AHTA mailing list and thus excluded any hand therapist not registered with the association. Second, the response rate (n ¼ 103, 13.2%) and completion rate (n ¼ 59, 57%) was lower than expected.72 This could be attributed to errors during the distribution of the survey, such as invalid email addresses or autoprogrammed email filters that sifts out “junk mail.” To meet the research aims, the electronic survey had extensive questions that predicted a longer completion time. Therapists unable to commit time may not have responded or completed the survey. Due to the increased number of dropouts later in the survey, readers should also exercise caution in interpreting the results for the flexion scenarios. However, there was a large proportion of experienced hand therapists (in terms of membership status and years of experience) among the survey completers. As such, we believe that this study has generally achieved the aims of gaining data on Australian therapists' preferred orthoses for various angles of contractures, and insight into the patient-related factors, therapist-related factors, and current evidence in orthotic prescription for elbow contractures. Conclusions Our electronic survey demonstrates that Australian clinicians routinely prescribe extension mobilizing orthoses at weeks 8 and 12, with serial static and static progressive orthoses, respectively. Future research is needed to assess whether prescribing mobilizing orthoses 12 weeks after injury is more beneficial than standard conservative therapy in reducing elbow contractures. There is also a need for further research regarding the suitable parameters and orthotic force in the elbow. Acknowledgments The authors thank Lara Griffiths, President of the Australian Hand Therapy Association for permitting the dissemination of the survey, EKCO Hand Therapy and Nick Antoniou for their picture contributions. References 1. Morrey BF, Askew L, Chao E. A biomechanical study of normal functional elbow motion. J Bone Joint Surg Am. 1981;63(6):872e877. 2. Sardelli M, MacWilliams BA, Tashjian RZ, MacWilliams BA. Functional elbow range of motion for contemporary tasks. J Bone Joint Surg. 2011;93(5):471. 3. Myden C, Hildebrand K. Elbow joint contracture after traumatic injury. J Shoulder Elbow Surg. 2011;20(1):39. 4. Anakwe ER, Middleton DS, Jenkins JP, McQueen MM, Court-Brown MC. Patientreported outcomes after simple dislocation of the elbow. J Bone Joint Surg Am. 2011;93(13):1220e1226. 5. Lake SP, Castile RM, Borinsky S, Dunham CL, Havlioglu N, Galatz LM. Development and use of an animal model to study post-traumatic stiffness and contracture of the elbow. J Orthop Res. 2016;34(2):354e364. 6. Morrey BF, Sanchez-Sotelo J, Morrey ME. Morrey's the Elbow and its Disorders. 5th ed. Philadelphia, PA: Elsevier; 2018. 7. Dunham CL, Castile RM, Havlioglu N, Chamberlain AM, Galatz LM, Lake SP. Persistent motion loss after free joint mobilization in a rat model of posttraumatic elbow contracture. J Shoulder Elbow Surg. 2017;26(4):611e618.
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