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Physiotherapy for Patients with an Ilizarov External Fixator
426
Key Words Ilizarov, survey, rehabilitation.
Physiotherapy for Patients with an Ilizarov External Fixator
by K L Barker M Burns S Littler
A survey of current practice
Summary A postal survey was conducted to investigate current UK physiotherapy practice in the treatment of patients using the Ilizarov fixator. Four hundred questionnaires were distributed to centres known to be using the Ilizarov fixator, or via Specific Interest Groups of the Chartered Society of Physiotherapy. Three main areas were surveyed; depth of experience of Ilizarov fixators, treatment modalities used and problems encountered. The response rate was 68%; 28% reporting that they had experience of Ilizarov fixators. Of those who had treated patients wearing an Ilizarov, 25% of respondents used active exercises, 8% hydrotherapy, 5% splintage, and 7% muscle facilitating techniques to treat their patients. The level of problems treating these patients was high and did not decrease with increased experience or treating greater patient numbers. Patients with acquired deformity, short stature or osteomyelitis received the greatest physiotherapy input and those with acute trauma and foot deformity the least. Eighty per cent of physiotherapists felt more information about rehabilitation of patients with an Ilizarov fixator was needed.
Barker, K L, Burns, M and Littler, S (1999). ‘Physiotherapy for patients with an Ilizarov external fixator: A survey of current practice’, Physiotherapy, 85, 8, 426432.
Introduction The Ilizarov external fixator was developed in the Soviet Union in the 1950s. It was used to treat a wide variety of orthopaedic conditions but was unknown in the West until the early 1980s. Since then it has gained in popularity as a method of treatment for complex orthopaedic conditions. UK physiotherapists are increasingly likely to find themselves treating a patient wearing an Ilizarov fixator. Sales of the Ilizarov external fixator in the UK increased between 1993 and 1997 by 286%, while the number of centres applying the Ilizarov fixators grew from 15 to 44 (Graham, 1999). The fixator consists of tensioned wires attached to a series of rings that encircle the limb and are joined together with threaded rods. It may be used to lengthen or even widen bones, to correct angular or rotational deformities, to immobilise fractures or to move segments of bone. These may be per formed individually, sequentially or simultaneously, giving a system that is
Physiotherapy August 1999/vol 85/no 8
infinitely adjustable (Newschander and Dunst, 1989; Aronson, 1997). Limb lengthening is achieved using the principles of distraction osteogenesis in which the bone is cut (corticotomy or osteotomy) and distracted, causing new bone to form at the corticotomy site in a form of direct membranous ossification (Aronson and Harp, 1990). Generally patients in the fixator are encouraged to apply functional loading through the limb and to use the leg as normally as possible (Ilizarov, 1989; Green, 1990). While the use of the Ilizarov fixator and distraction osteogenesis has allowed complex and innovative orthopaedic procedures to be performed, operations to correct limb length or malalignment deformities are associated with numerous complications. These include the development of muscle contractures, joint stiffness, muscle weakness and joint subluxation (Green, 1990; Paley, 1990; Maffulli and Fixsen, 1995; Holm et al, 1995). These complications are thought to occur because soft tissues, particularly muscle and nerve, have difficulty in adapting to imposed changes in length. These complications present an enormous challenge to physiotherapists involved in the rehabilitation of these patients. There is little published material about physiotherapy for patients with the Ilizarov, no prospective studies in the area of Ilizarov rehabilitation, and no papers published that cite evidence-based practice, although descriptions of physiotherapy regimes in North America have been published (Simard et al, 1992; Green, 1991; Coglianese et al, 1993). In the UK, patients often receive their post-operative physiotherapy some considerable distance from the centre at which their limb reconstruction surgery is performed and by physiotherapists with little experience of Ilizarov fixators.
Professional articles
Clinical experience suggests that a variety of approaches and regimes are used by physiotherapists to rehabilitate patients treated with an Ilizarov fixator. However, these regimes seem to be consultant-led rather than based upon rehabilitation principles. In an attempt to examine the variation in practice in treating patients with the Ilizarov fixator, a postal survey was planned. The purpose was to investigate the range of experiences and physiotherapy modalities used with this group of patients; to identify what is current physiotherapeutic practice and to provide a database of information on current Ilizarov treatment around the country. Method A questionnaire was designed which consisted of both open and closed questions. In some questions respondents were asked to grade their response in closed-ended questions utilising a rating scale (Fink and Kosecoff, 1985). There was also a blank space at the end of the questionnaire in which respondents were asked to add any other information about their experience of treating patients with the Ilizarov fixator that they felt was relevant. The questionnaire was pilot tested on physiotherapists working at four NHS clinics. To establish internal validity, physiotherapists who completed the pilot questionnaire were asked to complete it for a second time two weeks later. Subsequently minor changes were made to the questionnaire, mostly to the syntax used in some of the questions. Four hundred questionnaires were distributed in two ways. First, a list of the centres that had bought the most Ilizarov apparatus was obtained from the manufacturer, and the physiotherapy departments of these centres were sent a questionnaire, Secondly, members of three Specific Interest Groups (SIGs) of the Chartered Society of Physiotherapy were mailed a questionnaire and a covering letter explaining the purpose of the study. The SIGs used were the Association of Orthopaedic Chartered Physiotherapists (AOCP), the Association of Chartered Physiotherapists in Independent Hospitals (ACPIH) and the Association of Paediatric Chartered Physiotherapists (APCP). The letter asked the respondents to complete and return the questionnaire or to designate the most appropriate person in
427
their department to do so. They were informed that all information would be confidential. A self-addressed envelope was enclosed with the questionnaire for return to the audit department at St Peter’s Hospital, Chertsey. The respondents were asked to return their questionnaire even if they had never treated a patient with an Ilizarov fixator in order to gain insight into how common it is for physiotherapists to treat this condition. Data Analysis The results of the survey were analysed using relative frequency tables and content analysis in which responses were converted to relative frequencies (Fink and Kosecoff, 1985). Results Of the 400 questionnaires distributed, 274 were returned, giving a response rate of 68.5%. Of these, only 78 (28%) of the respondents indicated that they had treated a patient with an Ilizarov fixator. The remaining questionnaires were returned by physiotherapists who had no experience of it. Subsequent data analysis only included those respondents who had experience of treating patients with the Ilizarov; of these 26 (33%) had treated patients with Ilizarov fixators on both upper and lower limbs and 50 (67%) had only treated lower-limb patients. Physiotherapists treating these patients worked in a variety of settings; 41% were specialist orthopaedic physiotherapists, 25% paediatric, 17% community and 17% outpatient physiotherapists (fig 1). There was broad agreement about the main objectives of treatment with 35% of respondents listing their principal treatment objective as maintaining joint range of motion and 15% citing promoting weight bearing activity and functional use of the limb. Other objectives were pain control, Out-patient 17%
Authors K L Barker MSc MCSP is a research pysiotherapist in the Ilizafov method based at the Nuffield Orthopaedic Centre NHS Trust, Oxford, She developed the questionnaire and analysed the data. M Burns MCSP is a senior orthopacdlc physiotherapist at St Peter’s Hospital, Chertsey. She developed the questionnaire. S Littler is a member of the clinical audit department at St Peter’s Hospital, Chertsey where the questionnaires were printed and returned.
Address for Correspondence Mrs K L Barker, Physiotherapy Research Unit, Nuffield Orthopaedic Centre NHS Trust,Windmill Road, Oxford OX3 7LD.
Orthopaedics 41%
Community 17%
Paediatrics 17% Fig 1: Main clinical areas of work
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428 40
Respondents (%)
35 30 25 20 15 10 5 0
Increase ROM
Increase muscle strength
Weight bearing
Pain control
Wound healing
ADL
Teaching
Fig 2: Main treatment objectives
30
Respondents (%)
25 20 15 10 5 0 Active exercise
Hydrotherapy Splintage
Exercise bicycle
Muscle Gait facilitation re-education
Weight bearing exercises
Fig 2: Treatment modalities used 30
Respondents (%)
25 20 15 10 5 0
Class
Hydrotherapy
CPM
Splint
Fig 4: Modalities used in specialist centres
25
Respondents (%)
20 15 10 5 0 Contracture
Pain
Fig 5: Problems experienced Physiotherapy August 1999/vol 85/no 8
Infection
Weight-bearing
Compliance Communication
increasing muscle strength, maintaining mobility and teaching independence in activities of daily living (fig 2). The treatment modalities used to achieve these objectives were diverse: 25% of respondents used active exercises to achieve their treatment goals, 8% hydrotherapy, 5% splintage, 7% exercise bicycles and 7% muscle facilitating techniques. Only 25% of the respondents included gait re-education and 23% weight-bearing exercise as part of their treatment programme (fig 3). In the centres where more than 50 patients a year were treated, 28% used a class or gym setting, 17% hydrotherapy, 14% continuous passive motion machines and 22% splintage (fig 4). Despite the complex nature of the treatment required by this group of patients, only 69% of the respondents were working as part of a multidisciplinary team. The main problems experienced were soft tissue contractures (24%), pain (27%), infection (14%), weight bearing (14%) and patient compliance (4%) (fig 5). Fewer than 10 patients a year were treated with an Ilizarov by 68% of the physiotherapists, 22% treated 10-50 such patients per year and 10% more than 50 patients a year (mean l5, range l-100). There was no reduction in the number of problems experienced in carrying out the treatment programme by physiotherapists who were treating over 50 patients with an Ilizarov per year compared to those who treated fewer than 10 patients a year (fig 6). There was no consensus on the frequency at which these patients should be seen: 43% saw patients on a weekly basis, 32% as necessary at the patient’s or surgeon's request, 3% at monthly intervals, and 22% had no regular pattern but varied the frequency of treatment according to clinical need. Larger centres which ran specialist clinics or exercise classes were more likely to see their patients weekly throughout the time they were wearing a fixator. With other places the amount of physiotherapy input tended to decrease with the time in the frame. Of the paediatric patients, most received their treatment through a combination of community ser vice and physiotherapy departments, but 60% of those who received their physiotherapy in a school setting received no treatment outside term time. The stated criteria for discharge from physiotherapy were numerous and diverse: 35% discharged patients when they were mobile, 8% when the patients had improved muscle strength and 8% at the time of frame removal,
Professional articles
None
Moderate/ Major
Minor
Respondents (%)
100 80 60 40 20 0 Pain
ROM K flex K exte Dorsi
Plant
OFP
Hip Pin site
Pt
Psych
WB
Fig 6a: Difficulties experienced by staff treating fewer than 50 Ilizarov patients a year
100 80 Respondents (%)
A range of other criteria included when the patients were happy, at the end of treatment (unspecified), when the patients were independent, and when pain was controlled and wounds healed. Only 5% stated that patients were discharged when their treatment goals were met. Patients with acquired deformity and short stature received physiotherapy for the longest time with a mean of 18 and 19 months respectively. Patients with osteomyelitis, congenital deformity and nonunion of bone averaged around 9-11 months of treatment, while those who had an Ilizarov frame for acute trauma or correction of foot deformities received an average of seven months physiotherapy input (fig 7). Of the respondents analysed, 30% felt that they did not receive adequate information from the referring centre, and 80% felt that there was a need for more information and more clearly defined protocols of care for these patients. Some respondents suggested that a clinical pathway for the treatment of patients with the Ilizarov fixator should be developed. Comments added to the questionnaire reflected concerns in the areas of communication, clear leadership of patient care, and ensuring patient compliance. Others reported difficulties persuading local services that outpatient treatment might be needed for many months, even after the frame was removed, particularly in days of limited resources and sometimes set time periods for patients to receive treatment.
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60 40 20 0 Pain
ROM K flex K exte Dorsi
Plant
OFP
Hip Pin site
Pt
Psych
WB
Fig 6b: Difficulties experienced by staff treating more than 50 Ilizarov patients a year 30
Discussion The sur vey emphasised the variety of treatment approaches used to treat this group of patients. While the argument can be made that these patients require no more than normal good quality orthopaedic physiotherapy, the duration of treatment and the likelihood of soft tissue complications make them a group that require special attention and further study. An assessment of the efficacy of treatment procedures is needed as is research into their rehabilitation. The results from this survey show that physiotherapy for these patients is diverse and varies considerably in its quantity, focus and the modalities used. The high response rate of nearly 70% was very gratifying, particularly as only 28% of those who returned their questionnaire had ever seen a patient with an Ilizarov frame. The fact that so many physiotherapists
Time (Months)
25 20 15 10 5 0 Non-union
Acute Osteomyelitis Congenital trauma
Acquired
Other
Short
Other
foot
Fig 7: Length of treatment with diagnosis
took the time and trouble to return a questionnaire that was unrelated to their experience clearly demonstrates the interest and good will of the profession towards clinical research. It also goes against the accepted wisdom that a good return rate is more likely if the questionnaire is addressed to a specific group, as in this case more than 70% of the respondents were outside the target group and yet a very acceptable Physiotherapy August 1999/vol 85/no 8
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response rate was achieved. The majority of physiotherapists that returned the questionnaire who had experience of treating Ilizarov patients were orthopaedic physiotherapists, followed by paediatric, community and outpatient specialists. While this is what would be expected from a predominantly orthopaedic procedure, the results may also have been influenced by the method used to distribute the questionnaires. The targeting of the SIGs for orthopaedics and paediatrics may have ensured a disproportionately high return rate from these specialities as opposed to the physiotherapy population as a whole. The treatment objectives that were cited by the majority of the respondents were expected, ie increasing joint range, muscle strength and mobility -- but for a number of people the main treatment objectives were pain control, wound healing and promoting psychological acceptance of the frame. These were surprising as they reflect areas which are more usually dealt with by members of other specialist groups rather than by physiotherapists. There was a wide range of modalities used to achieve these treatment goals. The treatment methods used seemed to reflect the objectives of treatment cited, with an emphasis on active and passive exercises, gait re-education and muscle facilitating techniques. Other treatment methods stated were ice therapy, hydrotherapy, exercise bike/pedals, continuous passive motion (CPM) machines and splinting. Interestingly, no one reported using electrotherapy despite the fact that this is widely used by physiotherapists both in the USA and at the Kurgan centre in Russia, where the Ilizarov system was developed. There is also a good rationale for the use of electrotherapy based on the work into electrical stimulation and sarcomere type of Williams and colleagues (1986). In America, neuromuscular electrical stimulation is used in the post-operative period for muscle re-education and facilitation, Folkerts et al (1992) report that during femoral lengthening the quadriceps muscle appears to respond particularly well to electrical stimulation. In Russia the primary aim of electrotherapy is pain relief and a variety of electrical modalities are routinely used to achieve this goal. The patients who received their treatment from a centre where more than 50 patients
Physiotherapy August 1999/vol 85/no 8
per year were treated were more likely to receive their treatment in a specialist exercise class or gym session, They were also more likely to be treated by methods such as hydrotherapy, CPM, splinting and footwear modifications than those treated in centres with fewer patients. This reflected the greater resources and experience available to them in these centres. Obviously, without a large number of referrals it is not an efficient use of the physiotherapists’ time to organise a specialist class. The class situation is similar to the treatment setting used at the large centres in Russia and the USA. In Kurgan, patients receive much of their treatment in the class setting, spending many hours a day practising functional weight-bearing activities in the gymnasium. Outpatients at Mt Washington Pediatric Hospital in the USA receive one hour of hydrotherapy and two hours of therapeutic exercise, functional activities and gait training, five days a week (Folkert et al, 1992). Other centres where such treatment frequencies are not possible use a programme of one to two hours of treatment, three to five times a week, complemented by a home exercise programme of one to two hours a day. Further details of protocols for American hospitals are contained in the articles by Simard et al (1992), Folkerts et al (1992) and Coglianese et al (1993). The time devoted to outpatient physiotherapy in these American practices is much longer than can be provided by most outpatient departments in this country and reflects differences in funding, medical insurance and the way in which these complex orthopaedic procedures are costed. A number of physiotherapists mentioned difficulties with gaining access to the hydrotherapy pool for their patients owing either to worries about hygiene or to consultant preference. These difficulties are more likely to be overcome where there is a greater volume of patients. The prevalence of pin site infections around the wires makes many infection control advisers reluctant to allow patients with the Ilizarov fixator into the hydrotherapy pool. However, those departments which regularly use hydrotherapy for their patients with fixators report few problems with either pin sites or pool hygiene. The main problems that had been experienced in treating patients with the Ilizarov were diverse. Some respondents
Professional articles
cited predominantly physiotherapy-related problems such as joint contractures, lack of weight bearing and muscle weakness. The work of Ilizarov places much emphasis on the need for functional weight bearing as early in the post-operative period as possible. Patients have difficulty in weight bearing effectively due to the surgical procedure, pain and the physical constraints of the fixator. Gait quality is compromised by insufficient weight bearing and a lack of proprioceptive input, thus activities that encourage weight bearing and weight shifting in standing are encouraged. There are some surgeons who delay weight bearing activities until later in the rehabilitation period, believing that there is a greater likelihood of contractures developing if the patient bears weight. This reflects a school of thought that uses the Ilizarov equipment, but does not subscribe to Ilizarov's protocol for the rehabilitation of the patients. In these cases attention is focused on maintenance of joint range and static muscle exercises rather than Ilizarov's more functional approach. A significant number of respondents mentioned problems such as pin site infections, pain and patient compliance, reflecting the complex nature of managing these patients where problems such as untreated pin site infections and poorly controlled pain can significantly impede the successful implementation of a physiotherapy programme. Interestingly, when the problems such as pain, range of motion, etc, were rated for the difficulties that they presented to the treating physiotherapists there was no marked difference between the responses of those who treated fewer than 10 Ilizarov patients a year and those who treated more than 50 patients per year. One might expect that the more experienced physiotherapists would experience fewer problems because of their greater experience of treating these patients. However, it may be that the more experienced physiotherapists see a greater number of complex patients or they have greater insight into the range of problems that can occur in the management of these patients and that this would account for the high level of difficulties that was reported.
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There was no consensus about the frequency of treatment. While 40% of physiotherapists treated these patients on a weekly basis, 30% treated only on an asneeded basis and the rest had no set criteria for the frequency of treatment provided. The patients who were seen by centres treating more than 50 patients a year were more likely to be seen every week, particularly if they were attending an outpatient exercise class. This again contrasts with the practice in other countries where treatment is more intensive, particularly in the outpatient period, and daily treatment for several hours is the norm. It was of interest that in the paediatric patients a number received their treatment from a physiotherapist based at the school, a service that was restricted to term time only. This potentially left patients with an extended period without treatment during school holidays and may be a factor that should be considered when planning the timing of surgery on children. Patients received physiotherapy for an extended time with an average treatment period of six months (range 0-24 months). Patients who underwent limb reconstruction procedures with the Ilizarov for short stature, acquired deformity, congenital deformity and osteomyelitis received physiotherapy for the longest time and those whose underlying pathology was foot deformity or acute trauma the shortest. The wide range of responses to the question about discharge criteria reflects the lack of a clear protocol of care or care pathway for this group of patients and the considerable variation that exists in physiotherapists’ treatment goals, It was disappointing that only 5% of the respondents linked the discharge of their patients to the achievement of pre-set treatment goals. Finally, the survey did highlight the desire among the respondents for further information about the subject and the problems of feeling isolated and vulnerable when treating isolated cases of such a complex nature. A number of respondents expressed the desire for better guidance on the rehabilitation of this group of patients.
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References Aronson, J and Harp, J (1990). ‘Factors influencing the choice of external fixation for distraction osteogenesis’, in: External Fixation: lnstructional course lectures, American Academy of Orthopaedic Surgeons, 39, 175-183. Aronson, J (1997). ‘Limb lengthening, skeletal reconstruction and bone transport with the Ilizarov method’, Journal of Bone and Joint Surgery, 79-A, 8, 1243-58. Coglianese, D B, Herzenberg, J E and Goulet, J A (1993). ‘Physical therapy management of patients undergoing limb lengthening by distraction osteogenesis’, Journal of Sports Physical Therapy, 17, 3, 124-132. Fink, A and Kosecoff, J (1985). How To Conduct Surveys: A step-by-step guide, Sage Publication, Newbury Park, California. Folkerts, C, Henry, S, Kovelman, H F et al (1992). ‘Rehabilitation of the Ilizarov patient’, Rehabilitation Management, 5, 126-129, Graham, A (1999). Personal communication, Smith and Nephew Surgical Products. Green, S A (1990). ‘Physiotherapy during Ilizarov fixation’, Techniques in Orthopaedics, 5, 4, 61-65. Green, S A (1991). ‘Post-operative management during limb lengthening’, Orthopaedic Clinics of North America, 22, 4, 723-734.
Holm, I, Steen, H, Ludvigsen, P and Bjerkreim, (1995). ‘Unchanged muscle function after bilateral femoral lengthening’, Acta Orthopedica Scandinavia, 66, 3, 258-260. Ilizarov, G A (1989). ‘Tension-stress effect on the genesis and growth of tissues: Part I The influence of stability of fixation and soft tissue preservation’, Clinical Orthopaedics and Related Research, 238, 249-281, Maffulli, N and Fixsen, J A (1995). ‘Muscular strength after callostasis limb lengthening’, Journal of Pediatric Orthopaedics, 15, 212-216. Newschander, G E and Dunst, R M (1989). ‘Limb lengthening with the Ilizarov fixator’, Orthopaedic Nursing, 8, 15-21. Paley, D (1990). ‘Problems, obstacles and complications of limb lengthening by the Ilizarov technique’, Clinical Orthopaedics and Related Research, 250, 81-104. Simard S, Marchant, M and Mencio, G (1992). ‘The Ilizarov procedure: Limb lengthening and its implications’, Physical Therapy, 72, 25-34. Williams, P E, Watt, P, Bicik, V and Goldspink, G (1986). ‘Effect of stretch combined with electrical stimulation on the type of sarcomeres produced at the ends of muscle fibers’, Experimental Neurology, 93, 500-509.
Key Messages ■ The Ilizarov fixator is becoming more frequently encountered by physiotherapists in both specialist and non-specialist orthopaedic settings. ■ Diversity of treatment approaches, patterns of attendance and discharge criteria was found.
Physiotherapy August 1999/vol 85/no 8
■ Patients frquently experienced soft tissue complications. ■ Increasing experience with the Ilizarov fixator did not lead to fewer problems. ■ There is a need for clearly defined rehabilitation protocols.
Key Words Ilizarov, survey, rehabilitation.
Physiotherapy for Patients with an Ilizarov External Fixator
by K L Barker M Burns S Littler
A survey of current practice
Summary A postal survey was conducted to investigate current UK physiotherapy practice in the treatment of patients using the Ilizarov fixator. Four hundred questionnaires were distributed to centres known to be using the Ilizarov fixator, or via Specific Interest Groups of the Chartered Society of Physiotherapy. Three main areas were surveyed; depth of experience of Ilizarov fixators, treatment modalities used and problems encountered. The response rate was 68%; 28% reporting that they had experience of Ilizarov fixators. Of those who had treated patients wearing an Ilizarov, 25% of respondents used active exercises, 8% hydrotherapy, 5% splintage, and 7% muscle facilitating techniques to treat their patients. The level of problems treating these patients was high and did not decrease with increased experience or treating greater patient numbers. Patients with acquired deformity, short stature or osteomyelitis received the greatest physiotherapy input and those with acute trauma and foot deformity the least. Eighty per cent of physiotherapists felt more information about rehabilitation of patients with an Ilizarov fixator was needed.
Barker, K L, Burns, M and Littler, S (1999). ‘Physiotherapy for patients with an Ilizarov external fixator: A survey of current practice’, Physiotherapy, 85, 8, 426432.
Introduction The Ilizarov external fixator was developed in the Soviet Union in the 1950s. It was used to treat a wide variety of orthopaedic conditions but was unknown in the West until the early 1980s. Since then it has gained in popularity as a method of treatment for complex orthopaedic conditions. UK physiotherapists are increasingly likely to find themselves treating a patient wearing an Ilizarov fixator. Sales of the Ilizarov external fixator in the UK increased between 1993 and 1997 by 286%, while the number of centres applying the Ilizarov fixators grew from 15 to 44 (Graham, 1999). The fixator consists of tensioned wires attached to a series of rings that encircle the limb and are joined together with threaded rods. It may be used to lengthen or even widen bones, to correct angular or rotational deformities, to immobilise fractures or to move segments of bone. These may be per formed individually, sequentially or simultaneously, giving a system that is
Physiotherapy August 1999/vol 85/no 8
infinitely adjustable (Newschander and Dunst, 1989; Aronson, 1997). Limb lengthening is achieved using the principles of distraction osteogenesis in which the bone is cut (corticotomy or osteotomy) and distracted, causing new bone to form at the corticotomy site in a form of direct membranous ossification (Aronson and Harp, 1990). Generally patients in the fixator are encouraged to apply functional loading through the limb and to use the leg as normally as possible (Ilizarov, 1989; Green, 1990). While the use of the Ilizarov fixator and distraction osteogenesis has allowed complex and innovative orthopaedic procedures to be performed, operations to correct limb length or malalignment deformities are associated with numerous complications. These include the development of muscle contractures, joint stiffness, muscle weakness and joint subluxation (Green, 1990; Paley, 1990; Maffulli and Fixsen, 1995; Holm et al, 1995). These complications are thought to occur because soft tissues, particularly muscle and nerve, have difficulty in adapting to imposed changes in length. These complications present an enormous challenge to physiotherapists involved in the rehabilitation of these patients. There is little published material about physiotherapy for patients with the Ilizarov, no prospective studies in the area of Ilizarov rehabilitation, and no papers published that cite evidence-based practice, although descriptions of physiotherapy regimes in North America have been published (Simard et al, 1992; Green, 1991; Coglianese et al, 1993). In the UK, patients often receive their post-operative physiotherapy some considerable distance from the centre at which their limb reconstruction surgery is performed and by physiotherapists with little experience of Ilizarov fixators.
Professional articles
Clinical experience suggests that a variety of approaches and regimes are used by physiotherapists to rehabilitate patients treated with an Ilizarov fixator. However, these regimes seem to be consultant-led rather than based upon rehabilitation principles. In an attempt to examine the variation in practice in treating patients with the Ilizarov fixator, a postal survey was planned. The purpose was to investigate the range of experiences and physiotherapy modalities used with this group of patients; to identify what is current physiotherapeutic practice and to provide a database of information on current Ilizarov treatment around the country. Method A questionnaire was designed which consisted of both open and closed questions. In some questions respondents were asked to grade their response in closed-ended questions utilising a rating scale (Fink and Kosecoff, 1985). There was also a blank space at the end of the questionnaire in which respondents were asked to add any other information about their experience of treating patients with the Ilizarov fixator that they felt was relevant. The questionnaire was pilot tested on physiotherapists working at four NHS clinics. To establish internal validity, physiotherapists who completed the pilot questionnaire were asked to complete it for a second time two weeks later. Subsequently minor changes were made to the questionnaire, mostly to the syntax used in some of the questions. Four hundred questionnaires were distributed in two ways. First, a list of the centres that had bought the most Ilizarov apparatus was obtained from the manufacturer, and the physiotherapy departments of these centres were sent a questionnaire, Secondly, members of three Specific Interest Groups (SIGs) of the Chartered Society of Physiotherapy were mailed a questionnaire and a covering letter explaining the purpose of the study. The SIGs used were the Association of Orthopaedic Chartered Physiotherapists (AOCP), the Association of Chartered Physiotherapists in Independent Hospitals (ACPIH) and the Association of Paediatric Chartered Physiotherapists (APCP). The letter asked the respondents to complete and return the questionnaire or to designate the most appropriate person in
427
their department to do so. They were informed that all information would be confidential. A self-addressed envelope was enclosed with the questionnaire for return to the audit department at St Peter’s Hospital, Chertsey. The respondents were asked to return their questionnaire even if they had never treated a patient with an Ilizarov fixator in order to gain insight into how common it is for physiotherapists to treat this condition. Data Analysis The results of the survey were analysed using relative frequency tables and content analysis in which responses were converted to relative frequencies (Fink and Kosecoff, 1985). Results Of the 400 questionnaires distributed, 274 were returned, giving a response rate of 68.5%. Of these, only 78 (28%) of the respondents indicated that they had treated a patient with an Ilizarov fixator. The remaining questionnaires were returned by physiotherapists who had no experience of it. Subsequent data analysis only included those respondents who had experience of treating patients with the Ilizarov; of these 26 (33%) had treated patients with Ilizarov fixators on both upper and lower limbs and 50 (67%) had only treated lower-limb patients. Physiotherapists treating these patients worked in a variety of settings; 41% were specialist orthopaedic physiotherapists, 25% paediatric, 17% community and 17% outpatient physiotherapists (fig 1). There was broad agreement about the main objectives of treatment with 35% of respondents listing their principal treatment objective as maintaining joint range of motion and 15% citing promoting weight bearing activity and functional use of the limb. Other objectives were pain control, Out-patient 17%
Authors K L Barker MSc MCSP is a research pysiotherapist in the Ilizafov method based at the Nuffield Orthopaedic Centre NHS Trust, Oxford, She developed the questionnaire and analysed the data. M Burns MCSP is a senior orthopacdlc physiotherapist at St Peter’s Hospital, Chertsey. She developed the questionnaire. S Littler is a member of the clinical audit department at St Peter’s Hospital, Chertsey where the questionnaires were printed and returned.
Address for Correspondence Mrs K L Barker, Physiotherapy Research Unit, Nuffield Orthopaedic Centre NHS Trust,Windmill Road, Oxford OX3 7LD.
Orthopaedics 41%
Community 17%
Paediatrics 17% Fig 1: Main clinical areas of work
Physiotherapy August 1999/vol 85/no 8
428 40
Respondents (%)
35 30 25 20 15 10 5 0
Increase ROM
Increase muscle strength
Weight bearing
Pain control
Wound healing
ADL
Teaching
Fig 2: Main treatment objectives
30
Respondents (%)
25 20 15 10 5 0 Active exercise
Hydrotherapy Splintage
Exercise bicycle
Muscle Gait facilitation re-education
Weight bearing exercises
Fig 2: Treatment modalities used 30
Respondents (%)
25 20 15 10 5 0
Class
Hydrotherapy
CPM
Splint
Fig 4: Modalities used in specialist centres
25
Respondents (%)
20 15 10 5 0 Contracture
Pain
Fig 5: Problems experienced Physiotherapy August 1999/vol 85/no 8
Infection
Weight-bearing
Compliance Communication
increasing muscle strength, maintaining mobility and teaching independence in activities of daily living (fig 2). The treatment modalities used to achieve these objectives were diverse: 25% of respondents used active exercises to achieve their treatment goals, 8% hydrotherapy, 5% splintage, 7% exercise bicycles and 7% muscle facilitating techniques. Only 25% of the respondents included gait re-education and 23% weight-bearing exercise as part of their treatment programme (fig 3). In the centres where more than 50 patients a year were treated, 28% used a class or gym setting, 17% hydrotherapy, 14% continuous passive motion machines and 22% splintage (fig 4). Despite the complex nature of the treatment required by this group of patients, only 69% of the respondents were working as part of a multidisciplinary team. The main problems experienced were soft tissue contractures (24%), pain (27%), infection (14%), weight bearing (14%) and patient compliance (4%) (fig 5). Fewer than 10 patients a year were treated with an Ilizarov by 68% of the physiotherapists, 22% treated 10-50 such patients per year and 10% more than 50 patients a year (mean l5, range l-100). There was no reduction in the number of problems experienced in carrying out the treatment programme by physiotherapists who were treating over 50 patients with an Ilizarov per year compared to those who treated fewer than 10 patients a year (fig 6). There was no consensus on the frequency at which these patients should be seen: 43% saw patients on a weekly basis, 32% as necessary at the patient’s or surgeon's request, 3% at monthly intervals, and 22% had no regular pattern but varied the frequency of treatment according to clinical need. Larger centres which ran specialist clinics or exercise classes were more likely to see their patients weekly throughout the time they were wearing a fixator. With other places the amount of physiotherapy input tended to decrease with the time in the frame. Of the paediatric patients, most received their treatment through a combination of community ser vice and physiotherapy departments, but 60% of those who received their physiotherapy in a school setting received no treatment outside term time. The stated criteria for discharge from physiotherapy were numerous and diverse: 35% discharged patients when they were mobile, 8% when the patients had improved muscle strength and 8% at the time of frame removal,
Professional articles
None
Moderate/ Major
Minor
Respondents (%)
100 80 60 40 20 0 Pain
ROM K flex K exte Dorsi
Plant
OFP
Hip Pin site
Pt
Psych
WB
Fig 6a: Difficulties experienced by staff treating fewer than 50 Ilizarov patients a year
100 80 Respondents (%)
A range of other criteria included when the patients were happy, at the end of treatment (unspecified), when the patients were independent, and when pain was controlled and wounds healed. Only 5% stated that patients were discharged when their treatment goals were met. Patients with acquired deformity and short stature received physiotherapy for the longest time with a mean of 18 and 19 months respectively. Patients with osteomyelitis, congenital deformity and nonunion of bone averaged around 9-11 months of treatment, while those who had an Ilizarov frame for acute trauma or correction of foot deformities received an average of seven months physiotherapy input (fig 7). Of the respondents analysed, 30% felt that they did not receive adequate information from the referring centre, and 80% felt that there was a need for more information and more clearly defined protocols of care for these patients. Some respondents suggested that a clinical pathway for the treatment of patients with the Ilizarov fixator should be developed. Comments added to the questionnaire reflected concerns in the areas of communication, clear leadership of patient care, and ensuring patient compliance. Others reported difficulties persuading local services that outpatient treatment might be needed for many months, even after the frame was removed, particularly in days of limited resources and sometimes set time periods for patients to receive treatment.
429
60 40 20 0 Pain
ROM K flex K exte Dorsi
Plant
OFP
Hip Pin site
Pt
Psych
WB
Fig 6b: Difficulties experienced by staff treating more than 50 Ilizarov patients a year 30
Discussion The sur vey emphasised the variety of treatment approaches used to treat this group of patients. While the argument can be made that these patients require no more than normal good quality orthopaedic physiotherapy, the duration of treatment and the likelihood of soft tissue complications make them a group that require special attention and further study. An assessment of the efficacy of treatment procedures is needed as is research into their rehabilitation. The results from this survey show that physiotherapy for these patients is diverse and varies considerably in its quantity, focus and the modalities used. The high response rate of nearly 70% was very gratifying, particularly as only 28% of those who returned their questionnaire had ever seen a patient with an Ilizarov frame. The fact that so many physiotherapists
Time (Months)
25 20 15 10 5 0 Non-union
Acute Osteomyelitis Congenital trauma
Acquired
Other
Short
Other
foot
Fig 7: Length of treatment with diagnosis
took the time and trouble to return a questionnaire that was unrelated to their experience clearly demonstrates the interest and good will of the profession towards clinical research. It also goes against the accepted wisdom that a good return rate is more likely if the questionnaire is addressed to a specific group, as in this case more than 70% of the respondents were outside the target group and yet a very acceptable Physiotherapy August 1999/vol 85/no 8
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response rate was achieved. The majority of physiotherapists that returned the questionnaire who had experience of treating Ilizarov patients were orthopaedic physiotherapists, followed by paediatric, community and outpatient specialists. While this is what would be expected from a predominantly orthopaedic procedure, the results may also have been influenced by the method used to distribute the questionnaires. The targeting of the SIGs for orthopaedics and paediatrics may have ensured a disproportionately high return rate from these specialities as opposed to the physiotherapy population as a whole. The treatment objectives that were cited by the majority of the respondents were expected, ie increasing joint range, muscle strength and mobility -- but for a number of people the main treatment objectives were pain control, wound healing and promoting psychological acceptance of the frame. These were surprising as they reflect areas which are more usually dealt with by members of other specialist groups rather than by physiotherapists. There was a wide range of modalities used to achieve these treatment goals. The treatment methods used seemed to reflect the objectives of treatment cited, with an emphasis on active and passive exercises, gait re-education and muscle facilitating techniques. Other treatment methods stated were ice therapy, hydrotherapy, exercise bike/pedals, continuous passive motion (CPM) machines and splinting. Interestingly, no one reported using electrotherapy despite the fact that this is widely used by physiotherapists both in the USA and at the Kurgan centre in Russia, where the Ilizarov system was developed. There is also a good rationale for the use of electrotherapy based on the work into electrical stimulation and sarcomere type of Williams and colleagues (1986). In America, neuromuscular electrical stimulation is used in the post-operative period for muscle re-education and facilitation, Folkerts et al (1992) report that during femoral lengthening the quadriceps muscle appears to respond particularly well to electrical stimulation. In Russia the primary aim of electrotherapy is pain relief and a variety of electrical modalities are routinely used to achieve this goal. The patients who received their treatment from a centre where more than 50 patients
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per year were treated were more likely to receive their treatment in a specialist exercise class or gym session, They were also more likely to be treated by methods such as hydrotherapy, CPM, splinting and footwear modifications than those treated in centres with fewer patients. This reflected the greater resources and experience available to them in these centres. Obviously, without a large number of referrals it is not an efficient use of the physiotherapists’ time to organise a specialist class. The class situation is similar to the treatment setting used at the large centres in Russia and the USA. In Kurgan, patients receive much of their treatment in the class setting, spending many hours a day practising functional weight-bearing activities in the gymnasium. Outpatients at Mt Washington Pediatric Hospital in the USA receive one hour of hydrotherapy and two hours of therapeutic exercise, functional activities and gait training, five days a week (Folkert et al, 1992). Other centres where such treatment frequencies are not possible use a programme of one to two hours of treatment, three to five times a week, complemented by a home exercise programme of one to two hours a day. Further details of protocols for American hospitals are contained in the articles by Simard et al (1992), Folkerts et al (1992) and Coglianese et al (1993). The time devoted to outpatient physiotherapy in these American practices is much longer than can be provided by most outpatient departments in this country and reflects differences in funding, medical insurance and the way in which these complex orthopaedic procedures are costed. A number of physiotherapists mentioned difficulties with gaining access to the hydrotherapy pool for their patients owing either to worries about hygiene or to consultant preference. These difficulties are more likely to be overcome where there is a greater volume of patients. The prevalence of pin site infections around the wires makes many infection control advisers reluctant to allow patients with the Ilizarov fixator into the hydrotherapy pool. However, those departments which regularly use hydrotherapy for their patients with fixators report few problems with either pin sites or pool hygiene. The main problems that had been experienced in treating patients with the Ilizarov were diverse. Some respondents
Professional articles
cited predominantly physiotherapy-related problems such as joint contractures, lack of weight bearing and muscle weakness. The work of Ilizarov places much emphasis on the need for functional weight bearing as early in the post-operative period as possible. Patients have difficulty in weight bearing effectively due to the surgical procedure, pain and the physical constraints of the fixator. Gait quality is compromised by insufficient weight bearing and a lack of proprioceptive input, thus activities that encourage weight bearing and weight shifting in standing are encouraged. There are some surgeons who delay weight bearing activities until later in the rehabilitation period, believing that there is a greater likelihood of contractures developing if the patient bears weight. This reflects a school of thought that uses the Ilizarov equipment, but does not subscribe to Ilizarov's protocol for the rehabilitation of the patients. In these cases attention is focused on maintenance of joint range and static muscle exercises rather than Ilizarov's more functional approach. A significant number of respondents mentioned problems such as pin site infections, pain and patient compliance, reflecting the complex nature of managing these patients where problems such as untreated pin site infections and poorly controlled pain can significantly impede the successful implementation of a physiotherapy programme. Interestingly, when the problems such as pain, range of motion, etc, were rated for the difficulties that they presented to the treating physiotherapists there was no marked difference between the responses of those who treated fewer than 10 Ilizarov patients a year and those who treated more than 50 patients per year. One might expect that the more experienced physiotherapists would experience fewer problems because of their greater experience of treating these patients. However, it may be that the more experienced physiotherapists see a greater number of complex patients or they have greater insight into the range of problems that can occur in the management of these patients and that this would account for the high level of difficulties that was reported.
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There was no consensus about the frequency of treatment. While 40% of physiotherapists treated these patients on a weekly basis, 30% treated only on an asneeded basis and the rest had no set criteria for the frequency of treatment provided. The patients who were seen by centres treating more than 50 patients a year were more likely to be seen every week, particularly if they were attending an outpatient exercise class. This again contrasts with the practice in other countries where treatment is more intensive, particularly in the outpatient period, and daily treatment for several hours is the norm. It was of interest that in the paediatric patients a number received their treatment from a physiotherapist based at the school, a service that was restricted to term time only. This potentially left patients with an extended period without treatment during school holidays and may be a factor that should be considered when planning the timing of surgery on children. Patients received physiotherapy for an extended time with an average treatment period of six months (range 0-24 months). Patients who underwent limb reconstruction procedures with the Ilizarov for short stature, acquired deformity, congenital deformity and osteomyelitis received physiotherapy for the longest time and those whose underlying pathology was foot deformity or acute trauma the shortest. The wide range of responses to the question about discharge criteria reflects the lack of a clear protocol of care or care pathway for this group of patients and the considerable variation that exists in physiotherapists’ treatment goals, It was disappointing that only 5% of the respondents linked the discharge of their patients to the achievement of pre-set treatment goals. Finally, the survey did highlight the desire among the respondents for further information about the subject and the problems of feeling isolated and vulnerable when treating isolated cases of such a complex nature. A number of respondents expressed the desire for better guidance on the rehabilitation of this group of patients.
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References Aronson, J and Harp, J (1990). ‘Factors influencing the choice of external fixation for distraction osteogenesis’, in: External Fixation: lnstructional course lectures, American Academy of Orthopaedic Surgeons, 39, 175-183. Aronson, J (1997). ‘Limb lengthening, skeletal reconstruction and bone transport with the Ilizarov method’, Journal of Bone and Joint Surgery, 79-A, 8, 1243-58. Coglianese, D B, Herzenberg, J E and Goulet, J A (1993). ‘Physical therapy management of patients undergoing limb lengthening by distraction osteogenesis’, Journal of Sports Physical Therapy, 17, 3, 124-132. Fink, A and Kosecoff, J (1985). How To Conduct Surveys: A step-by-step guide, Sage Publication, Newbury Park, California. Folkerts, C, Henry, S, Kovelman, H F et al (1992). ‘Rehabilitation of the Ilizarov patient’, Rehabilitation Management, 5, 126-129, Graham, A (1999). Personal communication, Smith and Nephew Surgical Products. Green, S A (1990). ‘Physiotherapy during Ilizarov fixation’, Techniques in Orthopaedics, 5, 4, 61-65. Green, S A (1991). ‘Post-operative management during limb lengthening’, Orthopaedic Clinics of North America, 22, 4, 723-734.
Holm, I, Steen, H, Ludvigsen, P and Bjerkreim, (1995). ‘Unchanged muscle function after bilateral femoral lengthening’, Acta Orthopedica Scandinavia, 66, 3, 258-260. Ilizarov, G A (1989). ‘Tension-stress effect on the genesis and growth of tissues: Part I The influence of stability of fixation and soft tissue preservation’, Clinical Orthopaedics and Related Research, 238, 249-281, Maffulli, N and Fixsen, J A (1995). ‘Muscular strength after callostasis limb lengthening’, Journal of Pediatric Orthopaedics, 15, 212-216. Newschander, G E and Dunst, R M (1989). ‘Limb lengthening with the Ilizarov fixator’, Orthopaedic Nursing, 8, 15-21. Paley, D (1990). ‘Problems, obstacles and complications of limb lengthening by the Ilizarov technique’, Clinical Orthopaedics and Related Research, 250, 81-104. Simard S, Marchant, M and Mencio, G (1992). ‘The Ilizarov procedure: Limb lengthening and its implications’, Physical Therapy, 72, 25-34. Williams, P E, Watt, P, Bicik, V and Goldspink, G (1986). ‘Effect of stretch combined with electrical stimulation on the type of sarcomeres produced at the ends of muscle fibers’, Experimental Neurology, 93, 500-509.
Key Messages ■ The Ilizarov fixator is becoming more frequently encountered by physiotherapists in both specialist and non-specialist orthopaedic settings. ■ Diversity of treatment approaches, patterns of attendance and discharge criteria was found.
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■ Patients frquently experienced soft tissue complications. ■ Increasing experience with the Ilizarov fixator did not lead to fewer problems. ■ There is a need for clearly defined rehabilitation protocols.