Physical Address
304 North Cardinal St.
Dorchester Center, MA 02124
Elbow Stiffness: Rehabilitation After Surgical Contracture Release
Introduction
The basic science and surgical procedures to restore motion in patients with elbow stiffness have been thoroughly reviewed in the previous three chapters. Unfortunately, recurrence of stiffness is not uncommon, maintenance of the range of motion (ROM) achieved in surgery is difficult, and the rehabilitation program after contracture release is paramount for the final outcome of any of the procedures discussed previously. In general, improvements in flexion and extension are easier to obtain and maintain than improvements in pronation and supination.
Many of the rehabilitation principles and tools that are used for the postoperative management of elbow stiffness are discussed in depth in Chapter 14, Chapter 15, Chapter 16, Chapter 17 . In this chapter we will provide an overview of how we apply all these principles and techniques specifically after surgery for stiffness.
Rehabilitation after elbow contracture release is aimed at maintaining the ROM obtained intraoperatively. Stretching of the elbow joint in flexion and extension and the forearm in pronation and supination is the mainstay of postoperative treatment. This can be accomplished with physical therapy, continuous passive motion, dynamic orthosis, or static adjustable orthosis. Our preference is to use a combination of continuous passive motion and static adjustable orthosis. Modulation of the inflammatory response is extremely important in the early phases of rehabilitation. Adjunctive radiation therapy, pharmacologic treatments, and manipulation under anesthesia are used selectively.
The program of rehabilitation needs to be tailored to each individual. Our impression is that maintaining motion in patients undergoing an arthroscopic osteocapsular arthroplasty for primary osteoarthritis is much simpler and predictable than surgical release of posttraumatic contractures, especially when there is the need to perform extensive open exposures, remove heterotopic ossification, or perform additional reconstructive procedures. Keeping in mind that each patient may need to be managed slightly differently, we think it is useful to have a general protocol that applies to most patients and can be modified as needed ( Table 56.1 ).
TABLE 56.1
Overview of a Protocol for Rehabilitation of the Elbow After Contracture Release
| Postoperative Period | Stages of Rehabilitation |
|---|---|
| Up to first 24 postoperative hours | Modulate inflammatory response (RICE) |
| Weeks 1–4 | Continuous passive motion |
| Up to month 3 | Physical therapy or orthosis |
| Adjunctive modalities |
|
RICE, Rest, ice, compression, elevation.
Modulation of the Inflammatory Response
Inflammation is likely linked to recurrence of stiffness. A number of treatment modalities may be used to modulate the inflammatory response. In the operating room, a compressive dressing is applied and the elbow is immobilized in extension using a plaster or thermoplastic splint. The elbow should be kept elevated above the level of the heart, typically using blankets or pillows to support the upper extremity ( Fig. 56.1 ). Active wrist and finger flexion and extension should be promoted, and ice may also be applied frequently, especially over the first 2 days after surgery.
Continuous Passive Motion
The principles and practice of continuous passive motion are reviewed in detail in Chapter 15 . The main goal of continuous passive motion (CPM) is to physically squeeze surgical hematoma and soft tissue edema outside of the elbow joint. CPM is also believed to be helpful in maintaining a healthy cartilage and preventing intraarticular adhesions. The benefit of CPM is best obtained by moving the elbow joint through its entire ROM. The following paragraphs summarize how we use CPM after surgery for elbow stiffness.
Settings
The CPM machine is placed so that the patient can rest the arm comfortably by the bedside or when sitting in a comfortable chair. The height should be adjusted so that the elbow will rest higher than the level of the patient's heart, which as discussed previously helps prevent edema. The speed setting should be set at maximum so that the elbow is mostly taken from one end of motion to the other without spending too much time in the midarc. The stop bolts should be set so that they allow a complete arc of motion.
Application
All circumferential postsurgical wrappings are removed and replaced with a single elastic sleeve (failure to do so may cause soft tissue injury secondary to shear stresses). The elbow is placed in the CPM machine so that the elbow flexion crease points straight up and is perfectly centered over the hinge. The arm is secured to the CPM with two wide soft bands around the forearm and arm ( Fig. 56.2 ).
Our preference is to start the CPM machine at maximum speed and provide the patient with the control knob to start and stop. The patient first works on getting as much extension as possible: the elbow is let go passively into extension, and the patient stops the machine when extension becomes uncomfortable. After 1 to 2 minutes in the stop position, blood and fluid have been squeezed out of the soft tissues and patients are typically able to get a few more degrees of extension. This process of gaining progressive extension is continued until maximum extension is achieved. The patients best understand the rationale of this process by thinking that they are “milking” blood and fluid out of their elbow.
The same process is then repeated for flexion: patients use the CPM machine to flex the elbow as much as tolerated, then stop for 1 to 2 minutes in the flexed position, then try to regain a few more degrees, by “milking” the elbow. Achieving maximum flexion is oftentimes more difficult than achieving maximum extension. Once the patient has worked on the ends of ROM, the CPM machine is run continuously. The amount of flexion provided by the CPM machine may be increased by using folded towels underneath the forearm; extension may be increased by using folded towels underneath the arm. The overall position of the arm should be checked to make sure that the elbow flexion crease is properly aligned and the CPM machine is being effective.
Length of Use
The number of hours spent per day on the CPM machine and the overall duration of the procedure will vary according to the response of the elbow; some patients are able to maintain their motion on their own with limited use of the CPM, whereas others lose motion very quickly if the elbow is outside of the CPM early on.
In the first few days after surgery, we recommend use of the CPM as much as possible, all day and night if tolerated, with stops for meals and bathroom privileges. The CPM should be stopped with the elbow in extension, as opposed to in midflexion, in order to avoid a rebound of edema. As time goes by, patients try to reduce the number of hours spent on the CPM machine based on how hard it is to resume full ROM once back on CPM. Most patients use the CPM machine for 2–3 weeks on average.
You're Reading a Preview
Become a Clinical Tree membership for Full access and enjoy Unlimited articles
If you are a member. Log in here