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Elbow Orthosis to Re-establish Elbow Extension Motion

Serap Alsancak, PhD, PT
Haydar Altinkaynak, MSc, ENG,
Hakan Kinik, MD

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ABSTRACT

This study describes a uniaxial elbow orthosis designed at Ankara University Department of Prosthetics and Orthotics as a custom-molded orthosis to improve elbow extension. Five children with post-traumatic elbow flexion contracture were treated using the static progressive elbow orthosis for a mean of 2.2 ± 0.8 months. None of the patients received any physical therapy or surgical treatment for flexion contracture. At the 18-month follow-up evaluation, the median correction was measured at 35º in active extension limitation and 15º in passive extension limitation. The findings show that the elbow orthosis is a safe and effective treatment to consider for children who present with elbow flexion contracture. (J Prosthet Orthot. 2006; 18:106–110.)

Loss of elbow motion described as elbow stiffness requiring orthotic management has numerous potential causes. The most common cause of this kind of contracture is post-traumatic stiffness, followed by ectopic ossification, burns, head injury, and congenital or developmental conditions. Intrinsic contracture is associated with joint articular involvement and may be caused by fractures, osteoarthritis or inflammatory arthritis, or congenital or developmental disease.^1–3

Various methods of treating post-traumatic stiffness have been described. Static progressive and dynamic splinting, serial casting, traction, intermittent compression system, physiotherapy, and surgery are acceptable methods for restoring range of motion (ROM) in contractures.^4–11 Manual passive stretch techniques and especially proprioceptive neuromuscular facilitation techniques such as repeated contractions and hold-relax techniques are used by physical therapists to elongate and improve the muscle tissue flexibility and strength.^12–14 However, manual passive stretching, a common method of physical therapy, can have limited effect and is difficult to apply for joint contractures.^15,16 In addition, elbow joint traction combined with moist heat and active exercise is described to improve elbow extension in cases of flexion contracture.¹⁷

Several studies describe the importance of orthotic design to functional improvement and recommend the use of low-load prolonged stretch orthoses for contracture management.^18–21 Other reports indicate that most elongation during repetitive stretching is achieved with the minimum required number of stretches.^3,22,23 Improvement in soft tissue flexibility is directly related to the gradual increase of low loads. Furthermore, serial casting, often used in treatment of contractures, does not permit daily hygiene, clinical inspection, and air circulation.

Surgical release is suggested for flexion contractures between 60º and 100º flexion. An orthotic intervention is recommended before surgical treatment.¹

In the current study, a static progressive uniaxial elbow orthosis (EO) is presented as an alternative to previously described orthotic and physical therapy approaches in the clinic. The effectiveness of the orthosis for treatment of elbow flexion contracture is discussed.

METHODS AND MATERIALS

The EO is a custom-molded orthosis made from polyamide (4–6 mm thick) cylindrically shaped around the arm and forearm, with a posterior opening large enough to permit comfortable donning and doffing. Velcro straps are used to hold the EO in place. Medial and lateral free elbow joints are manufactured from the polyamide material as part of the orthosis. The mechanical uniaxial elbow joint is applied on the anatomical axis of the elbow.

The U-shaped piece designed to fix the elbow flexion contracture is made up of a double steel bar (14–16 mm wide, 3 mm thick) and a polyamide (4–6 cm wide and 2 mm thick) forearm bracelet.

The interior of the orthosis may be covered with Plastazote (Zotefoams Inc., Walton, KY) (3 mm thick) if needed. The medial and lateral steel bars are placed on the proximal part of the orthosis. Both steel bars move counterclockwise. The distal bars are placed on the bracelet of the orthosis and rotate on the forearm cover according to the elbow's extension (Figure 1 ).

The corrective forces of this EO are applied to the olecranon process and the anterior surfaces of the arm-forearm. The elbow cap covers the olecranon and is attached to the bars by a Velcro strap. The elbow cup is tight enough to provide stretch of the soft tissue to the point when the patient first indicates pain. Because excessive forces may result in edema, the tension of the olecranon cap should be observed carefully. A gentle, low-load prolonged stretch using static progressive method should be applied.

The EOs were used on five patients (two male, three female; mean age, 11.6 ± 5.2 years). Flexion contractures were caused by extra-articular fractures in three patients and burn injuries in two patients. All flexion contractures were unilateral (four right, one left). None of the patients had neurovascular injuries. Orthotic treatment was administered after a mean of 8.6 ± 3.0 months after injury (range, 5–13 months; Table 1 ). None of the patients received any other treatment for flexion contracture before or after orthotic intervention. Lack of joint involvement was confirmed by plain radiographs.

Patients were evaluated for joint range of motion and manual muscle testing before, during, and after treatment and on follow-up by the same independent physiotherapist.

Joint motion was measured with both a standard goniometer and an inclinometer to prevent possible reading errors before, during, and after the orthotic treatment. The standard goniometer was centered over the elbow joint laterally, and the inclinometer was placed on the long axis of the forearm posterior. Flexion contracture was measured in the neutral rotational position of the forearm. Flexion between 30º and 180º was considered normal.¹⁶

Muscle strength was measured using Lovett's manual muscle testing on a scale of 0 to 5, and the results were compared with the sound side.¹⁶ Muscle strength of the patients' shoulder, elbow, and wrist were measured before the use of the EO (BEO) and after use (AEO).

During week 1 of orthotic treatment, all patients wore an orthosis daily for a total of 6 hours, removing the device every 2 hours for 30 minutes. In the following weeks, two of the patients wore the orthosis at night and three of the patients who had flexion contractures >45º wore the orthosis fulltime with the orthosis removed three times per day for 1 hour. All patients used stockinettes in their orthoses.

A home exercise program of gentle passive stretching to strengthen elbow extensors was suggested for three patients with elbow contractures after 18 months of follow-up.

RESULTS

Manual muscle testing before the orthotic treatment showed the elbow extensor and forearm pronators were good (grade 4) for three patients with fractures and normal (grade 5) for two patients with burn injuries. The other muscle groups (shoulder, elbow, and wrist muscles) were evaluated as normal (grade 5). Within 18 months, elbow extensor and pronator strength increased to normal (grade 5) for three patients.

According to the goniometric measurements, there were no limitations on the patients' shoulder and wrist motions. However, there were active pronation limitations between 10º and 25º and supination limitations between 15º and 20º. After orthotic treatment, there was a gain in active motion between 0º and 5º pronation and 0º and 10º supination.

There was also active/passive limitation in elbow extension and flexion. Thus, the measurements were taken as active range of motion (AROM) and passive range of motion (PROM) before, during (DEO), and after the orthotic treatment. The DEO measurements were taken two to six times at 2-week intervals. The AEO measurements were taken 18 months after the first DEO measurement. None of the patients used the EO for the full 18 months. The improvements of elbow AROM and PROM are shown in Table 2 . The EOs were worn for a mean of 2.2 ± 0.8 months; two patients wore their orthoses for 3 months, two for 2 months, and one for 1 month.

Active and passive extension and flexion limitations are presented in Table 3 .

According to the Wilcoxon rank test, the decreases in active and passive extension limitations between BEO and DEO, and between BEO and AEO were statistically significant (p < 0.05; Table 4 ). The change in active and passive extension limitation between DEO and AEO was not significant. The changes in active and passive flexion limitations between BEO and DEO, BEO and AEO, and DEO and AEO were not significant. Table 5 shows the corrective effect of the EO on elbow limitations during orthotic treatment.

DISCUSSION

Few studies report on the use of various orthoses designed to produce static progressive or low-load prolonged stretch for the purpose of decreasing flexion contractures.²⁴ This study presents the effect of a static progressive EO on active and passive elbow extension limitation. The static progressive orthotic treatment provides load that can be tolerated comfortably by patients. Our study supports the findings of many researches on elbow ROM with the use of EOs.^{8,15,19–21,25,26} In these studies, the age range is 18 to 70 years, and the duration of use is 1 to 8 months.

Bonutti et al.⁸ studied 20 patients with an average age of 32.9 years and reported a 31º increase in ROM after 1 to 3 months of orthosis use (17º increase in extension and 14º in flexion ROM). The patients of Bonutti et al. wore their orthosis for one or two 30-minute sessions per day.⁸

Recently, Gelinas et al.²⁵ studied 22 patients (mean age, 39 years) who used a turnbuckle orthosis to apply a static progressive stretch technique. The orthosis was used 20 hours per day for an average of 4.5 months. After orthotic treatment, the mean flexion contracture decreased to 26º ± 10º.²⁵ Furthermore, Shewring et al.²⁷ reported an average increase of 30º in ROM extension of 21 patients (average age, 33.5 years) using a dynamic sling. After 6 months, the ROM increased by 5º to reach a total of 35º.²⁷

In our study, five patients were treated with the EO; no surgical or standard physical therapy treatment was applied. Measurements taken 18 months after the onset of EO use showed an increase of active extension (minimum 25º, maximum 40º; median 35º) and of active flexion (minimum 0º, maximum 15º; median 5º). The rapid increase of extension ROM after EO could be related to factors such as the patients' young age, the EO design, and its static progressive stretch characteristics.

No complications were noted from the use of the orthosis, similar to the findings of other studies.^{8,15,18-20,25} The EO is light, of simple construction, inexpensive, and easy to don/ doff and clean. It was designed to reduce pressure and eliminate friction and does not need new alignment during the orthotic treatment period. It is cosmetically acceptable and has adequate ventilation.

Our EO was used only for flexion contracture. We did not modify the orthosis to improve elbow flexion. Thus, we believe that the median correction of extension contracture of 5º in active motion is directly related to active use of the elbow in daily living during and after the orthotic treatment. Home exercises were effective in preventing deterioration of flexion contracture for three patients.

CONCLUSION

In the current study, use of a uniaxial elbow orthosis in five young patients with flexion contractures produced an increase in both active and passive ROM with no complications, surgical intervention, or conventional physical therapy. Future studies will incorporate use of the EO on large numbers of patients from different age groups with different joint flexion and extension contractures.

Correspondence to: Professor Serap Alsancak, Ankara University, Dikimevi Vocational School of Health, Medical Faculty Campus, 06590 Dikimevi, Ankara, Turkey; e-mail: .

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SERAP ALSANCAK, PhD, PT, is affiliated with Ankara University, Dikimevi Vocational School of Health, Ankara, Turkey.

HAYDAR ALTINKAYNAK, MSc, ENG, is affiliated with Ankara University, Dikimevi Vocational School of Health, Ankara, Turkey.

HAKAN KINIK, MD, is affiliated with Ankara University, Dikimevi Vocational School of Health, Ankara, Turkey.

References:

1. Mansat P, Morrey BF, Hotchkiss RN. Extrinsic contracture: the column procedure. In: Morrey BF, ed. The Elbow and Its Disorders , 3rd ed. Philadelphia: WB Saunders; 2000:447–456.
2. Souren LE, Franssen EH, Reisberg B. Contractures and loss of function in patients with Alzheimer's disease. J Am Geriatr Soc 1995;43:650–655.
3. Urbaniak JR, Handsen PE, Beissinger SF, et al. Correction of post-traumatic flexion contracture of the elbow by anterior capsulectomy. J Bone Joint Surg Am 1985;67:1160–1164.
4. Matsuzaki K, Nakatani N, Harada M, Tamaki T. Treatment of supracondylar fracture of humerus in child skeletal traction in a brace. J Bone Joint Surg Br 2004;86:232–238.
5. Rodriguez MEC. Therapeutic options in the management of articular contractures in haemophiliacs. Haemophilia 1999;5: 5–9.
6. Jansen CM, Windau JE, Bonutti PM, Brillhart MV. Treatment of a knee contracture using a knee orthosis incorporating stressrelaxation techniques. Phys Ther 1996;76:182–186.
7. Melvin JL. Orthotic treatment of the hand. What's new? Bull Rheum Dis 1995;44:5–8.
8. Bonutti PM, Windau JE, Ables BA, Miller BG. Static progressive stretch to reestablish elbow range of motion. Clin Orthop 1994; 303:128–134.
9. Leman CJ. Splints and accessories following burn reconstruction. Clin Plast Surg 1992;19:721–731.
10. Yates P, Cornwell J, Scott GL, Atkins RM. Treatment of haemophilic flexion deformities using the Flowtron intermittent compression system. Br J Haematol 1992;82:384–387.
11. Zander CL, Healy NL. Elbow flexion contractures treated with serial casts and conservative therapy. J Hand Surg Am 1992;17: 694–697.
12. Frank C, Akeson WH, Woo SL, et al. Physiology and therapeutic value of passive joint motion. Clin Orthop Relat Res 1984;185: 113–125.
13. Gossman MR, Sharmann SA, Rose SJ. Review of lengthassociated changes in muscle. Phys Ther 1982;62:1799–1808.
14. Chalmers G. Re-examination of the possible role of Golgi tendon organ and muscle spindle reflexes in proprioceptive neuromuscular facilitation muscle stretching. Sports Biomech 2004;3: 159–183.
15. Charlton P, Ferguson D, Peacock C, Stallard J. Preliminary clinical experience of a contracture correction device. Prosthet Orthot Int 1999;23:163–168.
16. Kottke FJ, Lehmann JF. Krusen's Handbook of Physical Medicine and Rehabilitation, 4th ed. Philadelphia: WB Saunders; 1990.
17. Gibson KR. Effect of manual traction on elbow flexion contractures. Phys Ther 1984;64:749.
18. Parker BC. A dynamic elbow extension splint. Am J Occup Ther 1987;41:825–826.
19. Mackay-Lyons M. Low-load, prolonged stretch in treatment of elbow flexion contractures secondary to head trauma: A case report. Phys Ther 1989;69:292–296.
20. Nuismer BA, Ekes AM, Holm MB. The use of low-load prolonged stretch devices in rehabilitation programs in the Pacific Northwest. Am J Occup Ther 1997;51:538–543.
21. Keeping P, Major R. Use of a spring contracture correction orthosis for the management of a fixed flexion contracture of the elbow. Prosthet Orthot Int 1999;23:82–84.
22. Taylor DC, Dalton JD, Seaber AV, Garrett WE. Viscoelastic properties of muscle-tendon units. The biomechanical effects of stretching. Am J Sports Med 1990;18:300–309.
23. Sady SP, Wortman MA, Blanke D. Flexibility training: ballistic, static, or proprioceptive neuromuscular facilitation. Arch Phys Med Rehabil 1982;63:261–263.
24. Hijmans JM, Postema K, Geertzen JHB. Elbow orthoses: a review of literature. Prosthet Orthot Int 2004;28:263–272.
25. Gelinas JJ, Faber KJ, Patterson SD, King GJW. The effectiveness of turnbuckle splinting for elbow contractures. J Bone Joint Surg 2000;82B:74–78.
26. Hepburn GR. Case studies: contracture and stiff joint management with Dynasplint. J Orthop Sport Phys Ther 1987;8: 498–504.
27. Shewring DJ, Beaudet M, Carvell JE. Reversed dynamic slings: results of use in the treatment of post traumatic flexion contractures of the elbow. Injury 1991;22:400–402.