Postoperative Therapy following Contracture Release of the Elbow

Transcription

1 Postoperative Therapy following Contracture Release of the Elbow Nancy M. Cannon, OTR, CHT Indianapolis, Indiana

2 Topics Importance Pre-Operative Therapy Visit Evaluation Patient education Course of Postoperative Therapy Clinical experience case example Modalities Elbow Release Outcomes Function & ROM Effectiveness of combined surgery & therapy

3 Pre-Operative Therapy Visit Evaluation Pain Initial injury & current status (VAS or 0-10) Range-of-Motion [active & passive] Shoulder, elbow, forearm, wrist, hand Functional Limitations ADLs, vocational & avocational interests Outcome measurement tool Patient Goals Surgery pain motion improve function

4 Patient Education Essential! Understand - Course of Postoperative Therapy Time Commitment Therapy appointments Home therapy program Patience with Recovering Motion & Function Anticipate steady, consistent gains not immediate Persevere with Home Therapy Long recovery 12 to16 weeks

5 Elective Surgery Big Commitment Time Away from work, family & friends, hobbies & social activities Money Cost of surgery & therapy Lost work days

6 Postoperative Therapy 3 5 Days Postop Bulky dressing removed Initial evaluation Edema control Exercises Orthotics Modalities prn

7 Postoperative Therapy Initial Days Pain & edema management 2 nd Week Prioritize exercises to restore function 3 rd 6 th Week [critical time frame] Prioritize orthotics to restore function 6 th 12 th Week Patient persevere with home therapy program 3 Months Begin to resume normal activities

8 Course of Therapy Case Example 56 y/o Male Limited Motion & Function 40º (40º) extension 110º (110º) flexion Goal: hand to face/mouth Surgery: Arthroscopic debridement, ant./post. capsulectomy Open procedure posterior capsulectomy & excision of an olecranon spur Cubital tunnel release

9 Initial Evaluation Therapy Pertinent Medical History Influence recovery [delayed healing, bleeding] Wound Diabetic Medications [blood thinners] Monitor for hematoma Edema Measurements EFC & 3 distally Pain Assessment VAS Baseline ROM Elbow & Forearm

10 Initial Evaluation Therapy Baseline Evaluation Tool Function QuickDASH DASH Patient Rated Elbow Evaluation (PREE) ASES Elbow Mayo Elbow Functional Performance Index Upper Limb Functional Index Upper Extremity Functional Index

11 Edema Control Light Compressive Dressing 4 Kerlix 3 Coban (self-adhering wrap) Continue until suture/staple removal

12 Exercise Shoulder Elbow Forearm Wrist Hand Each two hours minute sessions Initially Patient ONLY Active active-assist self-passive Avoid passive ROM therapist initially Passive ROM Therapist [± 3 Weeks PO] Low load, long duration static stretches Hold end-range15-30 seconds

13 Exercise Elbow AROM Lying Down Provides humeral support isolate the elbow

14 Exercise Elbow AROM Standing Less effective without humeral support

15 Elbow Self-Passive Exercise

16 Exercise Elbow Self-Passive Extension Alternative approaches

17 Exercise Elbow Weighted Elbow Stretches 1-3 pound cuff weights

18 Forearm AROM Exercise

19 Exercise Forearm Self-Passive Rotate proximal to the wrist Avoid twisting the hand

20 PROM Therapist Exercise Preference: wait until approximately 3 weeks Less guarding/apprehension

21 Orthotics Extension Orthosis Night & 2-3 Times/Day Long Arm Orthosis Typically, during the day

22 Suture/Staple Removal 14 Days Postop [minimum] Limits risk of suture line separation & wound issues Scar mobilization (once wound closed)

23 Orthotics 14 Days Postop - Elbow Flexion Custom-fabricated static progressive orthosis Each visit: heat stretch refit orthosis flexion

24 Orthotics 14 Days Postop Elbow Extension Joint Active System Preference: wait until compressive dressing removed 3-4 times a day 30 minute sessions Surgery ensure excellent stability of the elbow

25 Orthotics Supination/Pronation Pre-Fabricated Joint Active System Stat-A-Dyne Custom-fabricate forearm/wrist component

26 Orthotics Wearing Schedule Restore Functional ROM Delicate balance Flexion over extension Supination over pronation 3:1 ratio

27 Isometrics Biceps Brachialis Brachioradialis Triceps

28 NMES Facilitate ROM & Build Endurance

29 Orthotics Custom-Fabricated Triceps Cuff Persistent triceps pain - pain & ROM Initiated 3 weeks postop

30 Triceps Stretch Exercise Important exercise posterior capsular release Heat & stretch

31 Hand Weights Strengthening 6 Weeks Mid-range Endurance over strength

32 ROM 6 Weeks Postop Elbow extension: 20 (15 ); flexion: 140 (145 ) Functional Improvements Wash face, brush his hair/teeth, eat with right hand Concerns Triceps weakness & lack of full elbow extension Outcome [4 months] Preop extension 40 & 110 flexion 55 AROM elbow: extension 15 & 140º flexion Reported no functional limitations at 3 months po

33 Modalities Elbow Releases Cryotherapy Icing Cryocuff Game Ready System Postop CPM

34 CPM Literature Elbow Release Favorable JBJS 2004 Additional gain of 7 statistically significant Unfavorable JHS 2009 No difference in final ROM

35 Outcomes: Surgical Release Elbow Journal of Shoulder & Elbow Surgery, patients CPM (initial 3-5 days) ROM exercises 2-3 times/day 30 minute sessions LAS between ex/night Extension improved from 36 to 14 Flexion improved from 96 to

36 Outcomes: Surgical Release Elbow JBJS, patients ROM: elbow flexion 55 & elbow extension 29 DASH improved 20 points

37 Outcomes: Surgical Release Elbow JHS, patients Elbow flexion: preop 93 postop 125 Elbow extension: preop 48 postop 21 Forearm supination: preop 44 postop 69 Forearm pronation: preop 49 postop

38 Outcomes: Surgical Release Elbow Journal of Trauma, patients Postop: Indwelling pain catheter CPM 4-6 hours/day starting 1 st postop day CPM continued 8-12 weeks Night extension orthosis Elbow flexion/extension: improved 59 Forearm supination/pronation: improved 26

39 Outcomes: Surgical Release Elbow Journal of Arthroscopic & Related Surgery 2006 Arthroscopic Release of the Elbow 22 patients Flexion improved 19 Extension improved 19

40 Summary Thoughts Prioritize Edema Control & Pain Management Initial days postop Utilize Orthotics Maximize Functional Motion 3 rd to 6 th week critical time frame Measure Every Visit Adjust the rehab program lack of progress Stay Focused on the Patient s Goals for Surgery Prioritize therapy accordingly Surgery combined with Therapy = Effective!

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42 Case Example 25 y/o male, rock climbing fall Dx: Chronic posterolateral dislocation left elbow, with coronoid fracture Elbow contracture Arc of motion: 5º extension to 35º flexion Surgery: Radical capsular release with anterior/posterior capsulectomy; reconstruction LCLC, triceps repair, reattachment flexor-pronator origin, fascial arthroplasty ulno-trochlear joint, EBI external fixator

43 X-rays Case Example

44 5 Days Postop Case Example

45 5 Days Postop Elbow extension 10º Elbow flexion 100º Case Example

46 Case Example Active Supination/Pronation Elbow Flexed

47 Case Example 7 Days Postop Elbow flexion 100º Elbow extension - 0º

48 7 Days Postop Case Example

49 2 ½ Weeks Postop Case Example

50 3 Weeks Postop Case Example

51 3 Weeks Postop - Case Example Increased flexion to 120º

52 Case Example Removed Set Screws for AROM

53 3 Weeks Postop Case Example Passive & active elbow flexion to 120º Passive elbow extension to 0º

54 4 Weeks Postop Case Example

55 Case Example Fixator removed at 6 weeks postop Active, passive ROM excellent early ROM