It is the recommendation of these therapists that the patient with a post-traumatic immobilized elbow with impaired motion and/or strength be referred for outpatient occupational or physical therapy interventions as soon as possible after the immobilization period. It has been shown that patients who have been allowed early mobilization or referred to physical therapy sooner have gone onto have, fewer complications, fewer residual symptoms, and faster gains in range of motion and strength than those who have delayed motion and/or therapy (Nash et al., 2004 [M]; Keppler et al., 2005 [C]; Dias et al., 1987 [C]). The following clinical guidelines are based upon the best research available at this time related to the basic science of healing and principles of rehabilitation. It is recommended that this will be utilized from day one when a patient comes out of their cast and incorporated into their plan of care.

It is recommended that a clinic based physical therapy plan be initiated, as indicated by the patient's current impairments. It is recommended that the patient and family are instructed in a home program of range of motion and strengthening and that they will be followed at least once weekly by physical therapy for progression of program until goals are met or patient's progress has plateaued (Friedrich, Cermack, & Maderbacher, 1996 [C], Griffith, 2002 [E]).

1. Inflammatory/Acute Phase (0 to 2 weeks after injury)
   • Recommended Goals: Control pain, minimize and prevent edema, protect healing structures, maintain stability, maintain and progress (gently) range of motion (ROM).
   • Recommended ROM Interventions: Begin active range of motion (AROM) and active assisted range of motion (AAROM) at the elbow when stability has been achieved; begin AROM of all non-involved joints; AROM and AAROM will promote healing of bone and articular cartilage, it will also help increase the tensile strength of soft tissues and minimize intra-articular adhesions (Davila & Johnston-Jones, 2006 [S]).
   • Recommended Strengthening Interventions: Isometrics at the elbow musculature (only if not contraindicated); grip strengthening exercises (Davila & Johnston-Jones, 2006 [S]).
   • Recommended Modalities: Superficial cold modalities to help reduce the acute inflammation (Nadler, Weingand & Kruse, 2004 [S]).
   • Recommended Precautions: It is recommended to avoid pronation/supination with collateral ligament involvement and avoid excessive pain and stress with AROM and AAROM (Davila & Johnston-Jones, 2006 [S], Local Consensus [E]).

2. Fibroplastic/Subacute Phase (2 to 8 weeks after injury)
   • Recommended Goals: Continue to decrease edema, increase ROM, increase function, increase strength
   • Recommended ROM Interventions: Continue with AROM and AAROM with increased force of contraction; recommended to begin gentle passive range of motion (PROM) at 6 weeks postop/injury (Local Consensus [E]); recommended technique for PROM is be slow prolonged stretching with at least a 30 second hold, doing 4 to 5 repetitions (Bandy & Irion, 1994 [D]).
   • Recommended Strengthening Interventions: Progression to isotonic strengthening exercises (Davila & Johnston-Jones, 2002 [E]) for healing fractures, weight-bearing exercises will help increase bone mineral density with healing bone (MacKelvie, Khan & McKay, 2002 [M]).
   • Recommended Modalities: Superficial heat (20 minutes) or ultrasound may be used immediately prior to stretching to increase tissue extensibility (Draper et al., 1998 [B]; Draper & Ricard, 1995 [C]; Taylor, Waring, & Brashear, 1995 [C]); superficial cold at end of session to reduce any acute inflammation of tissue (Nadler, Weingand & Kruse, 2004 [S]).
   • Precautions: It is recommended that the therapist take caution with amount of force applied to target tissue; PROM force will be within tissue tolerance (comfortable, short of pain) so as to lengthen and remodel the tissue, not cause inflammatory response (Bandy & Irion, 1994 [D]; Davila & Johnston-Jones, 2006 [S]).

3. Remodeling/Return to Activity Phase (2 to 6 months after injury)
   • Recommended Goals: To continue to increase ROM, strength and function; progress to sport specific exercises as indicated
   • Recommended ROM: Continue with above interventions of AROM, AAROM and PROM; may introduce joint mobilization techniques if loss of motion can be attributed to joint stiffness (Michlovitz, Harris, & Watkins, 2004 [M]; Davila & Evelyn, 2002 [E])
   • Recommended Strengthening: Progressive resistive strengthening with weights and bands are appropriate
   • Recommended Modalities: Superficial heat (20 minutes) or ultrasound (3MHz, 1.5 W/cm² for 7 minutes) can be used immediately prior to stretching to increase tissue extensibility (Draper et al., 1998 [B]; Draper & Ricard, 1995 [C], Taylor Waring & Brashear, 1995 [C]); superficial cold at end of session to reduce any acute inflammation of tissue (Nadler, Weingand & Kruse, 2004 [S]).
   • Precautions: It is recommended that joint mobilization techniques be delayed until 6 to 8 weeks after injury or fracture union is evident (be in close contact with referring physician regarding implementation of this intervention) (Local Consensus [E]).

4. Splinting

   It is recommended to wait until sufficient healing and fracture stability has occurred prior to initiating splinting to regain ROM in order to avoid pain, inflammation, ligamentous insufficiency, and heterotropic ossification (Szekeres, 2006 [O], Chinchalkar & Szekeres, 2004 [S]). Splinting is most effective if initiated in the first 3 months, moderately effective from 3 to 6 months, and has variable effectiveness when initiated 6 to 12 months post injury (Morrey, 2002 [E]).

   Contraindications: Poor skin quality, bony blocks, loose bodies, or any other intra-articular restrictions seen on x-ray. Discontinue splint use if sensory or motor changes occur with use (Zander & Healy, 1992 [C], Morrey, 2002 [E]). Close communication with the referring physician is essential to ensure safe use of splinting and casting.

5. Recommended Timeframe for Splinting
   1. Inflammatory Phase (0 to 2 weeks), splinting and casting can be used to protect the joint (Chinchalkar & Szekeres, 2004 [S]).
   2. Fibroplastic Phase (2 to 8 weeks) splinting and casting may be used to help restore or gain range of motion.
   3. Remodeling Phase (2 to 6 months) progressively increase ROM with splinting to enhance collagen orientation and plastic elongation of tissues (Davila & Johnston-Jones, 2006 [S]; Chinchalkar & Szekeres, 2004 [S]).

6. Types of Splints
   1. Static Progressive Splints: These splints operate on principle of stress relaxation (Gelinas et al., 2000 [C]; Bonutti et al., 1994 [D]) and are used to regain ROM. Examples: Joint Active Systems (JAS), turnbuckle splints

      Pro: Can be worn for shorter periods of time, worn to patient comfort, adjustable tension. Operating on principle of stress relaxation, there may be less likelihood of irritation and inflammation (Morrey, 2002 [E]). This type of brace may be more effective for gaining extension (Davila & Johnston-Jones, 2006 [S]). JAS makes one splint for flexion and extension

      Con: Rely on patient to continuously adjust the splint

      Static Progressive Splints Guidelines:

      1. Recommend wear splint 30 minutes to 2 hours 3 to 4 times per day (Bonutti et al., 1994 [D]; Chinchalkar & Szekeres, 2004 [S]; Davila & Evelyn, 2002 [E]).
      2. Recommend 20 hours wear time, including use at night (Gelinas et al., 2000 [C]; Morrey, 2002 [E]).
   2. Serial Static Splinting: (also includes serial casting and night extension splints)

      Pro: night splints are recommended for use in combination with other splinting to help maintain gains made through the day (Davila & Johnston-Jones, 2006 [S]; Chinchalkar & Szekeres, 2004 [S]).

      Serial Static Splinting Guidelines:

      Recommend night splinting to maintain gained motion and compliments use of static progressive stretches (Chinchalkar & Szekeres, 2004 [S]). It is also helpful if flexion contracture is less than 30° (Davila & Johnston-Jones, 2006 [S]).

   3. Dynamic Splinting: These splints operate on the principle of creep and usually requires 8 to 12 hours of wear time per session (Bonutti et al., 1994 [D]).

      Pro: May be more effective for gaining flexion during the Remodeling Phase (Davila & Johnston-Jones, 2006 [S])

      Con: Operating on principle of creep, this may cause inflammation, which may lead to additional swelling and scarring. Requires longer wear time (Bonutti et al., 1994 [D]; Morrey, 2002 [E]). Need separate splints for flexion and extension

      Dynamic Splinting Guidelines:

      No specific recommendations available in the peer reviewed literature. Dynasplint recommends extended wear time of at least 8 to 10 hours (Dynasplint_Systems, 1996 [E]).

7. Cincinnati Children's Hospital Medical Center Occupational Therapist/Physical Therapist (CCHMC OT/PT) Recommendation for Splint and Brace Use:
   1. It is recommended that night splinting be considered for soft tissue restrictions if there is a lack of progress after 2 weeks of physical therapy.
   2. Also recommended is use of static progressive splint for flexion or extension contractures if there is a soft tissue restriction and there is a lack of sufficient progress after 2 weeks of intervention. One example of this type of brace is the JAS. Static progressive is the splint of choice for this situation; however, dynamic splinting (Dynasplint_Systems, 1996 [E]) can be considered if necessary (insurance will not reimburse static progressive splint, or MD will not refer this type of brace, patient/family preference or patient/family will not be able to utilize static progressive splint properly) (Local Consensus [E]).

8. Recommended Discharge Criteria
   1. Equal ROM of involved and uninvolved elbow
   2. Strength within functional limits or equal to the uninvolved extremity (Local Consensus[E]).
   3. Meet patient/family goals for occupational/physical therapy

9. Consults
   1. It is recommended that contact with the patient's medical doctor for a referral to OT for evaluation and possible splint fabrication if a patient exhibits significant lack of motion of the hand and/or wrist due to nerve damage (Griffith, 2002 [E], Local Consensus [E]).
   2. It is recommended that if a patient exhibits a hard end feel or has not shown progress for 4 to 6 weeks, they be referred back to their physician (Davila & Johnston-Jones, 2006 [S], Local Consensus [E]).

10. Education

    It is recommended that education for the patient and family:

    • Begin upon initial evaluation and continue throughout the course of occupational/physical therapy services
    • Be geared to the developmental age of the patient and the learning abilities of the family/caregivers
    • Address relevant topics such as treatment plan, expected progress and outcomes, recreational and functional activities and selection of splinting/bracing options

Definitions:

Evidence Grading Scale

A: Randomized controlled trial: large sample
B: Randomized controlled trial: small sample
C: Prospective trial or large case series
D: Retrospective analysis
E: Expert opinion or consensus
F: Basic laboratory research
S: Review article
M: Meta-analysis or systematic review
Q: Decision analysis
O: Other evidence