Back in 2008 I organized a group study for our team on the monograph “treatment & rehabilitation of fractures”. The biggest impact of this book was that there was no mention of PROM (passive joint mobilization) exercises in the entire book for any part of the fracture rehabilitation program. The emphasis throughout the book is on AROM/AAROM (active/assisted joint mobilization). This challenges the accepted concept of “early PROM, mid-term/AAROM, and late resistance training”. The author’s view is worthy of our consideration.
In the case of elbow fractures, many scholars recommend avoiding PROM because of the serious problem of heterotopic ossification (HO), which affects joint ROM, and the reason for this recommendation is that PROM causes and accelerates the onset of HO. I clearly remember a few years ago, I was reading the American Rehabilitation Physician’s Examinations in the Tan Weiyat Professional Review Test Collection (2003 publication, 755 questions), and there was a question about HO in its solution, p132, which said, “Once HO is diagnosed, early treatment should include continuous range of motion exercises and bracing. Cold compresses should be used as an adjunctive therapy.
There is no information to suggest that early range of motion contact exacerbates inflammation and bone production.” I recently studied the American Academy of Orthopaedic Trauma OTA on the management of distal humeral fractures and found that the authors similarly emphasize avoiding PROM and advocate AROM/AAROM Huizhou Central People’s Hospital Department of Orthopaedics Zhehui Wu
In our department for patients with elbow fractures with secure internal fixation we use early treatment with CPM of the elbow joint, is our practice scientific in this way? Is it possible to use PROM in the postoperative rehabilitation program, and if the patient develops HO, do we need to stop PROM and what kind of adjustment to the rehabilitation program is needed? With this series of questions and confusion, I reviewed some literature on HO of the elbow joint.
1. Acute swelling phase (2 weeks after injury/surgery)
The most important thing in this phase is to control the swelling and reduce the inflammatory response.
Trivia: I remember 3 years ago in an orthopedic rehabilitation study class, a professor said during the lecture that “swelling is the culprit of joint stiffness”. This statement stuck in my mind and was the most rewarding thing I learned from attending that class. At that time, she recommended the purchase of cryocuffs (cuffs for each joint and limb) for those who are in a position to do so. When I returned to Shanghai, the first thing I did was to purchase this device.
Bleeding in the acute phase after an injury and/or surgery can cause significant swelling of the tissue. And swelling can cause scar formation and adhesions. That is why we pay attention to cold compresses and pressure bandages in the acute phase. Normally, our practice is that we give cryocuff treatment within 2 days after the patient’s surgery. For the elimination of swelling, of course, the most basic elevation of the affected limb is also included. Other effective measures, you can give your practice or opinion.
Also the management of pain is important. It allows the patient to participate to the maximum extent in the treatment procedure. Medications, TENS?
Depending on the degree of stability of the internal fixation, ROM therapy should be started as early as the surgeon allows, emphasizing regular training and AROM exercises.
2. Inflammatory phase (2-6 weeks after injury/operation)
The main feature of this phase is the appearance of a large amount of proliferating and at the same time disorganized scar tissue. This proliferation is active and the scar tissue is also very extensible. We should take advantage of the extensibility of the scar during this phase and intervene with our therapeutic measures to obtain the maximum possible joint mobility.
If passive motion with full joint mobility is allowed, treatment focuses on “self-passive stretching” with weighted traction and dynamic/static progressive bracing. The use of braces is the most effective means of obtaining ROM at this stage.
Unfortunately, too few patients have access to specialized dynamic or static progressive distraction braces. The reasons for this are not only the high cost of imported braces and the lack of domestic braces, but also the lack of concepts and knowledge of orthopaedic surgeons and rehabilitation workers in this area. This is why I personally feel that there is such a big gap between the final outcome of our patients after distal humerus surgery and that reported by OTA in the US (75% excellent rate, the standard for excellent rate is 15°-140°). The biggest aspect of our disparity is in the brace piece. Without the brace, the results we get in exchange for the few hours of therapy per day cannot be maintained. Because the most common phrase for ROM training is “time for space”.
For elbow ROM training, it is a generally accepted fact that flexion is easier to recover, usually 2-3 months after surgery, while extension is slower to recover, usually 4-6 months or longer. In line with the recommendations of foreign scholars, we often recommend that patients train extension at bedtime and then wear an elbow extension brace at night. Flexion mobility exercises are performed the following morning. When the swelling starts to subside, we can use moist heat therapy before ROM exercises or before wearing the brace.
Even if the flat film reveals HO, I agree with the opinion of foreign scholars and continue with ROM exercises.
Our rehabilitation goal is also the functional ROM of the elbow joint, 100° (30°, 130°), which allows the patient to perform more than 90% of the daily movements.
Strength training should not be neglected. This is the active rehabilitation that everyone is now emphasizing. Strength training not only restores strength to the muscles but also maximizes ROM, and encourages the patient to use the affected limb more often in ADL.
3. Fibrosis phase (6-12 weeks after injury/operation)
During this phase, the scar tissue is fully formed and undergoes fibrous reorganization by movement and stress, so this phase is also the effective period of rehabilitation. I always tell my patients that 3 months post-op is your “honeymoon period”.
This is the period when the brace can be applied with moderate intensity, as the fracture has healed. It is still important to wear the brace regularly for a long period of time to obtain the most amount of soft tissue stretching.
The role of resistance strength training in increasing ROM should also not be overlooked.
It is well known that as the disease progresses, it becomes more difficult to increase ROM. Therefore, we should cherish the “honeymoon period” of 3 months after surgery and encourage patients to actively participate and cooperate with treatment. Actively carry out perioperative rehabilitation. It would be a great pity if the patient missed the honeymoon period and then came back for rehabilitation after the contracture of the joint. Whose fault is it?
4. Late stage (3-6 months after injury/operation)
Whether it is neurological rehabilitation or orthopedic rehabilitation, there is a concept of time window. As mentioned earlier, 3 months after fracture surgery is the “honeymoon period” of rehabilitation, while in the fourth stage, the efficacy of rehabilitation is greatly reduced, but still effective.
For patients who come to the clinic for rehabilitation 6 months or more after surgery, these patients have not received early rehabilitation, so their joint stiffness is more severe, and their rehabilitation is not as effective as it could be at this time. We usually advise patients that conservative treatment is not effective and requires a lot of time, effort and money with little gain.
In the case of knee contracture, we have had a lot of success in combining surgical release with rehabilitation for advanced patients. In the case of the elbow joint, the surgeon may find the end result unsatisfactory based on previous experience. This is an area where we are still accumulating. A review of the literature shows that in recent years, good results have been reported with resection of the contracted elbow capsule, and these reports have increased the enthusiasm of surgeons to perform incisional release of elbow stiffness.
At this stage, the brace is continued as long as ROM can be increased. When the ROM goal is reached or the ROM plateau is reached, the brace is discontinued. Discontinuation of the brace requires a slow reduction in wear time and cannot be completely discontinued at once.
Strength training is recommended for a minimum of six months. It is unrealistic for patients to come to the hospital for such a long period of time. On one hand, we can develop a home rehabilitation program (HEP), and on the other hand, community-based rehabilitation is a strong guarantee that patients can receive rehabilitation treatment nearby.