Elbow Rehab

ELBOW REPLACEMENT IN REHABILITATION

Tania Pascucci
Physioterapist, Frosinone
Italy
31/05/2011

This paper describes a first experience of treating a prosthetic elbow, implanted following a traumatic multi-fragment fracture of the elbow joint in a patient in whom mobilization was prohibited due to difficult engrafting of the prosthesis. The patient was a 67-year-old, left-handed woman who had suffered a traumatic multi-fragment fracture of the left elbow with complete loss of normal articular relations; she had been treated surgically with fixation devices and eight years later undergone elbow replacement surgery. Within the previous two years the patient had undergone four surgical operations: removal of the fixation devices because of rejection, application of a new cerclage (wire) fixation, ulnar nerve neurolysis and elbow replacement. It is important to note that this is a patient who had previously undergone gastric resection, was affected by a blood disorder and presented a high risk of bleeding.

When we saw the patient, on her discharge from hospital eight days after the elbow replacement surgery, she presented functional limitation, diffuse pain both at rest and on even very slight active or passive mobilization (VAS 73/100), extensive periarticular bruising and brachial extravasation extending to the wrist (figure 1).

Figure 1
Extensive periarticular bruising and brachial extravasation extending to the wrist.

Treatment strategy

In view of the patient’s numerous systemic/hematological problems, the only possible approach was application of the NeuroMuscular Taping technique, in accordance with the treatment plan summarized in table 1. The patient initially underwent three treatment sessions: the first two applications were carried out three days apart, while the third was carried out four days after the second. The patient was advised to remove the tape the day before each new application in order to allow her skin at least 12 hours to “recover”. This treatment was not associated with any other type of physical therapy.

First application

Due to the presence of stitches and staples, we used, from the outset, a rather unconventional fan-shaped taping configuration: because of the possibility of an allergic reaction, just one five-strip arrangement of tapes was applied initially (figure 2). The primary objective, given the patient’s overall picture, was to obtain resorption of the hematoma and the edema and remission of the pain which was stopping her from attempting any kind of movement.

When the patient returned, three days after this first application, the bruising was visibly reduced and she said that her arm felt light; however, she was still in pain (VAS 46/100), albeit reduced in intensity (figure 3).

Figure 2
NeuroMuscular Taping in a five-strip fan configuration.
Figure 3
Three days after the first application, the bruising was visibly reduced.

Second application

This time, given that the patient had not suffered any adverse reactions, three five-strip fan-shaped tape constructions were applied, each one extending to the area medial and lateral to the staples in order to act not only on the bruising, but also on the extravasation (figure 4). Three days after the removal of the tapes, the patient reported complete remission of the pain and expressed the desire to try resuming movement.

Figure 4
Second application of NeuroMuscular Taping: three five-strip fan arrangements of tape 
were applied, each one also covering the medial and lateral area.

Third application

The aim of the third application was to achieve complete resorption of the edema and recovery of joint function: three five-strip fan constructions were again applied, trying to cover, with each one, the residual extravasation in order to remove it completely. Within ten days, the bruising had disappeared completely and the patient began to actively mobilize her elbow, albeit cautiously. The patient’s resumption of movement was painless and the subsequent applications targeted, progressively, a series of different objectives.

Given that mobilization against resistance was absolutely contraindicated, the aim of the subsequent NeuroMuscular Taping applications was to facilitate recruitment of the biceps and triceps muscle groups alternately. The NeuroMuscular Taping was used in association with a further fan-shaped construction applied in the anterior or posterior area of the joint, in order to control swelling. The taping protocol that aimed to facilitate muscle recruitment was the following:

  • with the elbow bent to around 45°, application of compressive tape in a Y-shaped configuration over the brachial biceps, with 25% tape stretching for the isometric exercises performed in the studio;
  • with elbow bent to around 45°, application of compressive tape in a Y-shaped configuration over the brachial biceps, with the muscle in isometric contraction and no tape stretching (0%). This tape is then kept in place for a day (i.e. removed at home after 24 hours);
  • decompressive technique; application of tape in a fan-shaped construction in the posterior area of the elbow to be left in place for four days.

After two application cycles, the patient was able to maintain isometric contraction of the brachial biceps muscle without experiencing pain and the retroarticular swelling was substantially reduced, but she presented forearm instability. To correct this instability, present when holding an object with elbow flexed and thus in a condition of isometric contraction of the biceps muscle, a stabilization technique was used. This involved the application of two separate strips, each 2.5 cm wide positioned, applying tension (25% stretching), laterally and medially to the elbow joint (figure 5). Thereafter, over a period of around ten days, the tape tension was gradually reduced to 0% as the patient regained control of the laterolateral oscillations and thus joint stability. The treatment was completed with interventions on the stability of the shoulder (figure 6), on the patient’s posture during the inward rotation of the torso, on edema control during functional recovery and on pain which appeared in the first finger of the left hand.

Figure 5
Stabilization technique with two separate strips, each 2.5 cm wide positioned, applying tension (25%), laterally and medially to the elbow joint.
Figure 6
Shoulder stablization technique: NeuroMuscular Taping applied in a three-strip fan arrangement.

Conclusion

The post-surgical treatment of this patient, based exclusively on NeuroMuscular Taping shows the real efficacy of this technique in situations in which it is not possible to intervene in any other way, either using physical therapy or kinesitherapy (figure 7). The effects were immediate in terms of resorption of the hematoma and edema, with lymph drainage, remission of the pain, and normalization of the blood supply; hence it was possible to obtain motor functional recovery, recovery of skin color, mobilization and normalization of the scar tissue, prevention of scar adhesions and recovery of joint strength and stability, allowing the traumatized joint, now free from tapes, to undergo a normal physiological healing process culminating in complete functional recovery. The present author was satisfied with the clinical findings which must nevertheless pass the scrutiny of primary scientific research.

Figure 7
Thirty days after the treatment, clear resorption of the arm edema and hematoma could be observed.

Table 1. NeuroMuscular Taping: treatment plan

PHASE TECHNIQUE AIMS
Acute Decompressive with five-strip fan constructions, each strip 1 cm wide Drainage of edematous, blood and lymphaic congestion and of stagnant tissue fluids Reduction of pain and inflammation
Subacute Decompressive: application of three 
five-strip fan constructions Total recovery of joint motion Recovery of muscle strength Prevention of inflammation and recurrence 
of edema and pain on resuming motor activity
Muscle recruitment Compressive taping of the brachial biceps 
in a Y-shaped configuration with elbow flexed to around 45° and tension 
(25% stretching) applied on the tape
Compressive taping of the brachial biceps 
in a Y-shaped configuration with elbow flexed to around 45°, no tension 
(0% stretching) applied on the tape and 
with the muscle in isometric contraction
Decompressive, retroarticular fan-shaped construction
Muscle recruitment

 

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