Burn Injury Complications Impacting Rehabilitation

Successful post-burn rehabilitation requires an understanding of a wide range of complications to maximize functional recovery. This article reviews a range of potential challenges including burn scar contracture, amputation, peripheral nerve injury, heterotopic ossification, dysphagia, altered skin physiology, pain, and pruritis. The overall focus is to serve as a guide for post-injury therapy and rehabilitation spanning the phases of care and considering evidence-based approaches, prevention, and treatment with an ultimate goal of aiding in the functional recovery and long-term quality of life for burn survivors.

Serial Casting as an Effective Method for Burn Scar Contracture Rehabilitation: A Case Series

Guidelines and protocols for orthoses in burn scar contracture rehabilitation are limited. The current study aims to determine the optimal frequency of casting, potentially facilitating the development of a serial casting protocol. Previous literature supporting casting has low generalizability due to methodology limitations. Seven patients with burn scar contracted joints, who did not respond to traditional therapy, were recruited in this study. Patients were serially casted once, three times, or five times a week. Joint range of motion was maximized with stretching and exercise techniques before every new cast application. Across all patients, active range of motion increased from 65.8 ± 27.8° to 108.1 ± 23.3° with casting; or from 57.8 ± 16.2% to 96.7 ± 2.9% of normal. Similarly, scars improved from 9.5 ± 1.5 to 4.9 ± 1.4 on the Modified Vancouver Scar Scale score. This therapeutic effect was achieved within an average of 8.5 ± 3.7 d and 4.0 ± 2.2 new cast applications. Given the study findings, the procedures outlined could be used to develop a standardized serial casting protocol for burn scar contracture rehabilitation.

EFFECT OF THE COMBINED UTILIZATION OF STATIC PROGRESSIVE STRETCHING AND PHONOPHORESIS WITH HYDROCORTISONE IN REHABILITATION OF KNEE CONTRACTURES CAUSED BY ARTHROFIBROSIS

Arthrofibrosis is the abnormal proliferation of fibrous tissue in a joint with an unclear etiopathogenesis that leads to loss of motion, pain, muscle weakness, swelling, and functional limitation. Various methods of therapy are utilized to treat the aforementioned pathology and among them are also aggressive approaches such as static progressive stretching. The goal of the current study was to establish the superiority of the effect of the combined utilization of static progressive stretching and hydrocortisone phonophoresis over standard therapeutic exercise programs for the rehabilitation process of knee contractures caused by arthrofibrosis. 29 patients between the ages of 18 and 60 (mean age 42±4.3 y.o.) participated in the prospective randomized controlled study, 19 male (65%) and 10 female (35%) with clinical signs of type III and IV contracture of the knee, extension limitation ˃10° and flexion deficit ˃25° when compared to the uninjured side. A minimum of 3 months had passed since the initial injury or the surgical intervention in all cases. 10 male and 5 female patients were randomly distributed to Group I (experimental group) while 9 male and 5 female patients were distributed into Group II (control group) accordingly. The patients from Group I underwent a 2-week long treatment course (10 procedures) with highly concentrated (10%) hydrocortisone phonophoresis before the inception of the standard rehabilitation program while the patients from Group II went through a rehabilitation course consisting solely of static progressive stretching and a home exercise program. The effect of static progressive stretching in the rehabilitation process of knee contractures caused by arthrofibrosis is greatly improved after the utilization of ultraphonophoresis with highly concentrated hydrocortisone alongside standard home exercise programs and this effect is especially apparent in the cases of patients with type III arthrofibrosis and knee flexion contractures.

[Self-made finger flexion band and its application in patients with burn scar contracture on the back of hand]

Scar contracture after burn on the back of hand can easily lead to the limitation of flexion function of fingers, which seriously affects daily life activities. Generally, comprehensive rehabilitation treatment is adopted for scar contracture on the back of hand, among which wearing braces is an effective treatment method. However, some braces will limit the normal finger joints or must wait until all the affected fingers heal before they can be worn, and the wearing operation is quite complicated. In order to solve these problems, the author designed and made a finger flexion band, which was used to stretch the patients with limited flexion of finger caused by scar contracture after burn on the back of hand, and achieved good therapeutic effect. According to the measured hand size, the finger flexion band is cut and spliced from the fabric commonly used in daily life. The finger flexion band is designed with finger sleeve, which will not limit the normal finger joints, can interfere with the healed finger in advance, fix the corresponding fingers better, and improve the treatment comfort, especially for children who do not cooperate with the braces wearing. This finger flexion band is simple to make, cheap, convenient to use, and suitable for clinical promotion.

[Preliminary study of robot-assisted ankle rehabilitation for children with cerebral palsy]

OBJECTIVE

To propose a kind of robotic ankle-foot rehabilitation system for children with cerebral palsy and to preliminarily verify its feasibility in clinical application.

METHODS

A robot assisted ankle-foot rehabilitation system was specially designed and developed for children with cerebral palsy and a preliminary clinical study was conducted in Department of Rehabilitation Medicine, Peking University First Hospital. Modified Tardieu Scale and joint biomechanical properties (ankle plantar flexion resistance torque under different ankle dorsiflexion angles) were measured to analyze the muscle tone and soft tissue compliance of the ankle plantar flexors pre- and post-robotic training intervention. Six children with cerebral palsy (4 girls and 2 boys, mean age: 7 years) were recruited in this study. Each subject received 5 session robotic training and each session included 10-cycle passive stretching and static hold. SPSS 19.0 software was used for data statistical analysis.

RESULTS

Both R1 and R2 angles of Modified Tardieu Scale for ankle plantar flexors after training were significantly higher than those before the treatments (Gastrocnemius: P_R1=0.003, P_R2=0.029; Soleus: P_R1=0.002, P_R2=0.034). The difference between R2 and R1 was of no statistical difference before and after the training (P=0.067 and P=0.067, respectively). After training, the ankle plantar flexion resistance torque under different dorsiflexion angles (0°, 10°, 20°, 30°) were significantly reduced than those before training (P=0.001, P=0.001, P=0.014, P=0.002, respectively).

CONCLUSION

The robot assisted ankle-foot rehabilitation system can improve the contracture and soft tissue compliance of cerebral palsy children's ankle plantar flexors. All the children in the study were well tolerated and interested with the training, easy to accept and cooperate with it. This device may be suitable for application in the rehabilitation of children with cerebral palsy. However, further randomized clinical trials with larger sample size are still needed to verify the long term efficacy of this device.

Acquired muscle contractures in the dog and cat. A review of the literature and case report

Canine and feline muscle contracture is reported to affect several different muscles, is associated with a number of predisposing factors, and a varying prognosis depending upon which muscle is affected. Most patients suffer some form of trauma weeks to months before the contracture is present. The clinical signs include: lameness, pain, weakness, decreased range of motion, a firmness noted throughout the entire muscle, and usually a characteristic gait. Pre-disposing factors for muscle contracture include: compartment syndrome, infection, trauma, repetitive strains, fractures, infectious diseases, immune-mediated diseases, neoplasia, and ischaemia . There does appear to be some breed and age predilection, however, the sex of the animal does not have an appreciable influence. In general, muscle contractures of the forelimb respond better to treatment and carry a better prognosis than muscle contractures of the hindlimb.

Relief of knee flexion contracture and gait improvement following adaptive training for an assist device in a transtibial amputee: A case study

BACKGROUND

Management of a knee contracture is important for regaining gait ability in transtibial amputees. However, there has been little study of prosthesis training for enhancing mobility and improving range of motion in cases of restricted knee extension.

OBJECTIVE

This study aimed to evaluate the effects of adaptive training for an assist device (ATAD) for a transtibial amputee with a knee flexion contracture (KFC). A male transtibial amputee with KFC performed 4 months of ATAD with a multidisciplinary team. During the ATAD, the passive range of motion (PROM) in the knee, amputee mobility predictor (AMP) assessment, center of pressure (COP) on a force plate-equipped treadmill, gait features determined by three-dimensional motion analysis, and Short-Form 36 Item Health Survey (SF-36) scores were evaluated.

RESULTS

Following ATAD, PROM showed immediate improvement (135.6 ± 2.4° at baseline, 142.5 ± 1.7° at Step 1, 152.1 ± 1.8° at Step 2, 165.8 ± 1.9° at Step 3, and 166.0 ± 1.4° at Step 4); this was followed by an enhanced COP. Gradually, gait features also improved. Additionally, the AMP score (5 at baseline to 29 at Step 4) and K-level (K0 at baseline to K3 at Step 4) increased after ATAD. Along with these improvements, the SF-36 score also improved.

CONCLUSIONS

ATAD could be beneficial for transtibial amputees by relieving knee contractures and improving gait.

Prevalence of functioning and disability in older patients with joint contractures: a cross-sectional study

BACKGROUND

Joint contractures are a common problem for older, frail people, particularly in rehabilitation, nursing home and homecare settings. Joint contractures are underreported and sparsely empirically investigated despite their high prevalence.

AIM

The objective of this study was to examine the prevalence of functional impairments, activity limitations and participation restrictions of patients with joint contractures using the International Classification of Functioning, Disability and Health (ICF) as a framework. We also examined contextual factors as potential mediators for functioning and disability.

DESIGN

Cross-sectional study-

SETTING

Three acute-geriatric hospitals in and around Munich (Germany).

POPULATION

Patients aged 65 and over with confirmed joint contractures requiring rehabilitation care.

METHODS

The patients were asked to answer a questionnaire that comprised 124 categories of the ICF. Patients' problems in functioning were registered separately for each category. Data were collected through face-to-face interviews with patients and health professionals and from patients' medical records.

RESULTS

One hundred and fifty patients were eligible and agreed to participate. Mean age was 82.5 years (SD: 7.4), 64.8% of the patients were female. Problems in "muscle power functions" (95.9%) and "driving human-powered transportation" (89,6%) were those most frequently identified. 'Health services, systems and policies' (98,6%) was the most frequent environmental facilitator.

CONCLUSION

Aged persons with joint contractures experience high levels of disability. Specifically, mobility, participation restrictions and interactions with the environment emerged as important issues of our study.

CLINICAL REHABILITATION IMPACT

Mobility and support by others were frequently mentioned as aspects relevant for persons with joint contractures. These aspects have to be considered when assessing the impact of joint contractures.

[Important role of orthoses in the management of postburn scar contracture]

Joints involved in deep burn often result in joint contracture, limb dysfunction, psychological disorder, or even loss of living and working abilities. The management of post-burn joint contracture will directly orientate the functional recovery of the patients. Comprehensive intervention may prevent the contracture process of the affected joints. Orthoses application is an important measure and should be maintained throughout the whole process of burn care, from positioning the joints at the early stage to maintaining the range of joint motion at the late stage. Orthoses should be used on the premise of protecting the joint functions. In order to maintain the tissue tension while enhancing the joint mobility and muscle strength, the static orthoses and the dynamic orthoses are often alternately used. It is showed in clinical practice that orthoses are designed and applied on the basis that biomechanics will lead to a better outcome.

Systematic review of contracture reduction in the lower extremity with dynamic splinting

Introduction

Joint contractures are relatively common disorders that can result in significant, long-term morbidity. Initial treatment is non-operative and often entails the use of mechanical modalities such as dynamic and static splints. Although widely utilized, there is a paucity of data that support the use of such measures. The purpose of this systematic review was to evaluate the safety and efficacy of dynamic splinting as it is used to treat joint contracture in lower extremities, and to determine if duration on total hours of stretching had an effect on outcomes.

Methods

Reviews of PubMed, Science Direct, Medline, AMED, and EMBASE websites were conducted to identify the term ‘contracture reduction’ in manuscripts published from January 2002 to January 2012. Publications selected for inclusion were controlled trials, cohort studies, or case series studies employing prolonged, passive stretching for lower extremity contracture reduction. A total of 354 abstracts were screened and eight studies (487 subjects) met the inclusion criteria. The primary outcome measure was change in active range of motion (AROM).

Results

The mean aggregate change in AROM was 23.5º in the eight studies examined. Dynamic splinting with prolonged, passive stretching as home therapy treatment showed a significant direct, linear correlation between the total number of hours in stretching and restored AROM. No adverse events were reported.

Discussion

Dynamic splinting is a safe and efficacious treatment for lower extremity joint contractures. Joint specific stretching protocols accomplished greater durations of end-range stretching which may be considered to be responsible for connective tissue elongation.

Management of posttraumatic proximal interphalangeal joint contracture

Chronic flexion contracture of the proximal interphalangeal (PIP) joint presents a common yet challenging problem to hand surgeons. Over the years, multiple treatment modalities have been described for this problem, producing limited results. Nonoperative treatment using serial casting and splints should be tried before attempting open surgical release, which should be done in selected patients. The use of external fixation for treating PIP contracture has been encouraging and can be a useful alterative. This review provides an update on the current management of PIP joint contractures and presents a flowchart of treatment to aid decision making.

Management of mandibular deviation after mandibulectomy by simplified approach

Unfavourable sequelae from mandibular surgeries include malocclusion and temporomandibular joint dysfunction. The management of the situation before these complications arise is largely based on experience. This report presents a case where mandibular deviation is decreased through an additional row of teeth in the maxillary removable partial denture, and by decreasing scar contracture in the surgical site by means of a simple exercise.

Prevention and management of limb contractures in neuromuscular diseases

Limb contractures are a common impairment in neuromuscular diseases. They contribute to increased disability from decreased motor performance, mobility limitations, reduced functional range of motion, loss of function for activities of daily living, and increased pain. The pathogenesis of contractures is multifactorial. Myopathic conditions are associated with more severe limb contractures compared with neuropathic disorders. Although the evidence supporting the efficacy of multiple interventions to improve range of motion in neuromuscular diseases in a sustained manner is lacking, there are generally accepted principles with regard to splinting, bracing, stretching, and surgery that help minimize the impact or disability from contractures.

Electrical stimulation and splinting were not clearly more effective than splinting alone for contracture management after acquired brain injury: a randomised trial

QUESTION

Is electrical stimulation and splinting more effective than splinting alone for the management of wrist contracture following acquired brain injury?

DESIGN

A multi-centre randomised trial with concealed allocation, assessor blinding, and intention-to-treat analysis.

PARTICIPANTS

Thirty-six adults with first stroke or traumatic brain injury and mild to moderate wrist flexion contractures.

INTERVENTION

The experimental group received electrical stimulation to the wrist and finger extensor muscles for 1 hour a day over 4 weeks while the control group did not. Both groups wore a splint for 12 hours a day during this 4-week period.

OUTCOME MEASURES

The primary outcome was passive wrist extension measured with a 3Nm torque and with the fingers in extension. Secondary outcomes included passive wrist extension, wrist and finger extensor strength, wrist flexor spasticity, motor control of the hand, and Global Perceived Effect of Treatment, and perception of treatment credibility. Outcome measures were taken at baseline, at the end of the intervention period (4 weeks), and after a 2-week follow-up period (6 weeks).

RESULTS

At 4 and 6 weeks, the mean between-group difference (95% CI) for passive wrist extension was 7 degrees (-2 to 15) and -3 degrees (-13 to 7), respectively. Secondary outcomes were statistically non-significant or were of borderline statistical significance.

CONCLUSION

It is not clear whether electrical stimulation and splinting is more effective than splinting alone for the management of wrist contracture after acquired brain injury. Therapists' confidence in the efficacy of electrical stimulation for contracture management is not yet justified.

[Treatment of contracture of achilles tendon with minimally invasive achilles tendon lengthening and system rehabilitation]

OBJECTIVE

To investigate the safety and efficacy of minimally invasive achilles tendon lengthening and system rehabilitation for the treatment of contracture of achilles tendon.

METHODS

From January 2002 to December 2010, 27 patients (31 feet) with contracture of achilles tendon were treated with minimally invasive achilles tendon lengthening and system rehabilitation. There were 11 males and 16 females with an average age of 35.5 years (ranged 3 to 65 years). Right foot was in 13 cases, left foot was in 10 cases, both feet were in 4 cases. Course of disease was from 1 to 5 years with an average of 2.3 years. The cause of contracture included postoperative complication of tibia fractures treated with intramedullary nailing in 7 feet, sequelae of lower leg compartment syndrome in 11 feet, congenital talipes equinovarus in 13 feet (both feet in 4). Before operation, all the patients walked with limping, plantar flexion anomaly was from 15 degrees to 50 degrees with an average of 35.5 degrees. The strength of quadriceps muscle of thigh was grade V in 27 feet, grade IV in 4 feet, the strength of musculus triceps surae was grade V in 24 feet, grade IV in 7 feet.

RESULTS

All the patients were followed-up for 6-24 months with an average of 11.3 months. According to standard of Arner-Lindholm to evaluate function of ankle joint, 29 feet obtained excellent results and 2 feet good. No infection, re-rupture or re-contracture was found.

CONCLUSION

Minimally invasive achilles tendon lengthening and system rehabilitation in treating contracture of achilles tendon has advantage such as simple operation, less complication, lower recurrence rate, which is favourable for thoroughly rehabilitation of patients. But, the case in which the strength of quadriceps muscle of thigh or musculus triceps surae still less than grade III after preoperative rehabilitation care should not choose the method.

[The role of the continuous brachial plexus blockades in the treatment of the ulnar joints contractures in children with arthrogryposis]

There was evaluated the influence of continuous peripheral brachial plexus blockades, used in the structure of conservative treatment of the elbow joint contractures in children suffering from arthrogryposis. The quality of the blockades analgesic component during the active rehabilitation treatment was evaluated on the basis of clinical manifestations and scores of pain intensity on the visual-analogue scale. In all the studied patients due to the adequate blockade of pain impulses managed to achieve a state of comfort during surgical procedures. Obtained significant differences in the rate of blood flow volume at a blocked limbs in comparison with the healthy. Enumerated data made it possible to achieve positive results in the conservative treatment of elbow joints contractures.

[Functional outcome of posttraumatic elbow contractures]

INTRODUCTION

Posttraumatic elbow contractures can cause functional limitations and impairment of activities of daily living in children and adults. The aim of this study was to investigate the outcome and differences between posttraumatic elbow contractures in children and adults during rehabilitation.

MATERIAL AND METHODS

We analyzed 68 patients with posttraumatic elbow contractures, who had been admitted to the regional rehabilitation center and managed by procedures of physical therapy. All patients were divided into two groups: group A (34 children) and group B (34 adults). Mayo Clinic Performance Index for Elbow (MCPI) was measured at the beginning and at the end of the physical treatment for each patient.

RESULTS

Out of the study sample, 76.47% of children and 47.06% of adult patients had excellent score at the end of the therapy. The median of Performance index increased for both groups after the physical therapy and the differences were significantly high for both groups, children (t = 5.66, p < 0.001) and adults (t = 2.47, p < 0.001). MCPI at the discharge was significantly higher in the children than in the adults (t = 2.85, p < 0.05).

CONCLUSION

The results of our investigation have shown that the elbow function assessment in patients with posttraumatic elbow contractures (in regard to pain, motion, stability and sum of daily function) was better in children than in adults at discharge, after approximately 3 weeks of rehabilitation.

Correction of long standing proximal interphalangeal flexion contractures with cross finger flaps and vigorous postoperative exercises

PURPOSE

We reviewed the results of cross finger flaps after surgical release and vigorous postoperative exercises for long-standing, severe flexion contractures of the Proximal Interphalangeal (PIP) joints of fingers.

MATERIALS AND METHODS

In 9 patients, all contracted tissue was sequentially released and the resultant skin defect was covered with a cross-finger flap. The cause of the contracture was contact burn in 4, skin graft in 3, and a previous operation in 2. The mean followup period was 41.2 months.

RESULTS

The mean flexion contracture/further flexion in the joints were improved from 73.4/87.8 degrees to 8.4/95.4 degrees at the last follow-up. A mean of 19.5 degrees of extension was achieved with vigorous extension exercise after the operation. The mean gain in range of motion (ROM) was 79.4 degrees. Near full ROM was achieved in 3 cases. There were no major complications.

CONCLUSION

In severe flexion contractures with scarring of the PIP joints of fingers, cross finger flaps after sufficient release and vigorous postoperative exercise seems to be a reasonable option to obtain satisfactory ROM of the joints.

A new static progressive splint for treatment of knee and elbow flexion contractures

BACKGROUND

Knee and elbow flexion contractures are a frequent cause of ambulation and function problems that often require extensive rehabilitation. Traditional methods are of limited benefit in severe and fixed contracture. A new static progressive splint was developed from daily-use knee and elbow orthosis and a newly invented gradual telescopic rod, which is designed to provide low load, and gradual and prolonged stretching.

MATERIAL AND METHOD

The splint was used in ten cases (11 knees) of knee flexion contracture and three cases of elbow flexion contracture. There were multiple etiologies of contracture such as burn scar contractures, intra-articular fractures, septic arthritis, juvenile rheumatoid arthritis, and immobilization. The average timing of the contracture before splinting was 14.6 months (range, 2 to 36) in the knee group and 16.7 months (range, 6 to 30) in the elbow group.

RESULTS

The average initial extension was -53.6 degrees (range, -30 to -85) in the knee group and -70 degrees (range -65 to -80) in the elbow group. The average post treatment extension was -15 degrees (range, 0 to -30) in the knee group and -38.3 degrees (range, -30 to -45) in the elbow group. The average duration of treatment was 9.2 weeks (range, 4 to 16) in the knee group and 14 weeks (range, 11 to 20) in the elbow group. The most dramatic result was found in the patient who had burn scar flexion contractures of both knees for 20 months. The knee extensions increased from -60 and-85 degrees to full extension in four and 14 weeks after treatment, respectively. There were no recurrences or complications from the use of this splint. The patients were able to easily adjust the gradual telescopic rod themselves to provide the appropriate force for stretching.

CONCLUSION

The static progressive splint is a new, effective, and low cost method for treatment of knee and elbow flexion contracture from multiple etiologies. The excellent result was found in extra-articular contracture.

Non-surgical management of ankle contracture following acquired brain injury

BACKGROUND AND PURPOSE

The purpose of this study was to document the outcome of non-surgical management of equinovarus ankle contracture in a cohort of patients with acquired brain injury admitted to a specialist Neurosurgical Rehabilitation Unit.

METHODS

This prospective descriptive study examined all patients with a new diagnosis of moderate to severe acquired brain injury (Glasgow Coma Scale score </=12) admitted for rehabilitation over a 1 year period. Ankle dorsiflexion range and plantarflexor/invertor muscle activity were evaluated weekly during the period of hospitalization. Contracture was defined as maximal passive range of motion </= 0 degrees dorsiflexion, with the knee extended, on a minimum of two measurement occasions. Patients were retrospectively allocated to one of four treatment outcome categories according to ankle dorsiflexion range, type of intervention required and response to treatment.

RESULTS

Ankle contracture was identified in 40 of the 105 patients studied. Contracture resolved with a standard physiotherapy treatment programme, including prolonged weight-bearing stretches and motor re-education, in 23 patients. Contracture persisted or worsened in 17 of 40 cases, all of whom exhibited dystonic muscle overactivity producing sustained equinovarus posturing. Ten of 17 cases required serial plaster casting (+/- injection of botulinum toxin type A) in order to achieve a functional range of ankle motion. Remediation of ankle contracture was not considered a priority in the remaining seven patients due to the severity of their overall disability.

CONCLUSION

The incidence of ankle contracture identified in this population was considerably less than previously reported. Reduced dorsiflexion range was remediated with standard physiotherapy treatment in over half of the cases. Additional treatment with serial casting +/- botulinum toxin type-A injection was required to correct persistent or worsening contracture in one quarter of cases. Dystonic extensor muscle overactivity was a major contributor to persistent or progressive ankle contracture.

Therapeutic experience on multiple contractures in sclerodermoid chronic graft versus host disease

INTRODUCTION

A 25-year-old male underwent allogenic peripheral blood stem cell transplantation and developed sclerodermoid chronic graft versus host disease. He complained of limitation of motion of major joints and some difficulties with activities of daily living (ADL) performances.

DISCUSSION

He had been treated with physical and occupational therapies. After the rehabilitative managements, range of motion and ADL performances improved slightly.

CONCLUSION

Active and continuous multimodal rehabilitative treatment would be helpful in managing contracture and functional impairment and preventing the progression of the disease.

Effects of physical therapy in the treatment of the posttraumatic elbow contractures in the children

Pediatric post-traumatic elbow contracture can occur as result of the various injuries of area of the elbow joint. The aim of the study was to investigate the effect of the physical therapy and rehabilitation on the range of the motion of the elbow joint in the post-traumatic elbow contractures in the childhood. We analyzed in this research 54 children (average age 9,4+/-3,15 years) that were treated because of posttraumatic elbow contractures. Kinesitherapy, occupational therapy and other procedures physical therapy are used in the management. Range of the motion of the elbow was measured at the beginning and the end of the therapy for every child. Functional outcome was presented in degree from 1 to 3 (Flynn). Satisfied result of the therapy at the discharge was in the 94, 45% of the children and 74, 07 % of the children had excellent result The difference in the grade at the beginning and the end of the therapy is statistically significant (t= 13,72, p<0,001). Significant improvement of the range of the motion in the elbow joint in the children with post-traumatic elbow contracture is attained by physical therapy.

Combined Iliazarov and Free Flap for Severe Recurrent Flexion–Contracture Release

This article discusses the treatment of recurrent flexion-contracture of the knee after circumferential burns involving the entire limb. A two-team approach to surgery is used: the orthopedic team widely excises the scar tissue and releases tendons, muscles, and adjacent soft tissue that limit joint movement. The microsurgery team covers the exposed popliteal neurovascular elements with a latissimus dorsi free flap. However, full range of the knee is still limited by the short neurovascular bundle. Therefore, the orthopedic team applies a circular hinged Iliazarov external-fixator-frame to achieve gradual correction, until full range of the knee is achieved. Intensive physiotherapy and continuing use of extension splints for additional 6 months until the scars are deemed stable compliment the treatment regimen and prevent the recurrence of contractures. Between the years 2002 and 2003, we treated four patients (totaling five knee joints) with recurrent severe flexion-contractures after circumferential burns of the entire lower extremity. A significant limitation was caused by the abnormal scarring, which left the patients confined to a wheelchair. In all our patients, previous attempts to release the flexion-contracture failed. With the aforementioned technique, within 3 months after the procedure, all patients were able to walk. We encountered one major complication (ie, drop foot). At follow-up, all patients enjoyed a full range of motion and were able to walk. The strength of our approach comes from combining a free muscle flap with an Iliazarov external fixation and a detailed postoperative rehabilitation plan.

Surgical treatment and customized rehabilitation for stiff knee arthroplasties

Treating patients who have arthrofibrotic or stiff knees after total knee arthroplasty can be difficult. Treatment with arthroscopic débridement, arthrolysis of adhesions with polyethylene spacer exchange, or complete revision arthroplasty often has led to less than optimal range of motion and functional outcomes. We used a combination of surgical arthrolysis and an intensive postoperative rehabilitation protocol, including functional bracing, to treat this condition. We then retrospectively reviewed 18 knees in 17 patients who had stiff knees after total knee arthroplasty with no other detectable clinical or radiographic abnormalities, at a mean followup of 30 months. Seventeen knees (94%) had gains in knee range of motion with a mean increased range of motion of 31 degrees. Although 16 of 17 patients had clinical improvement and were satisfied with the procedure, only (2/3) of the patients (12 of 18 patients) had excellent or good Knee Society objective scores. This combined surgical and rehabilitation method can lead to an increased range of motion. All patients improved clinically, but good functional results were less predictable. The authors think treatment of these difficult knees should be aimed at soft tissue operative releases supplemented by an intensive rehabilitation protocol.

LEVEL OF EVIDENCE

Therapeutic study, level IV (prospective study). See Guidelines for Authors for a complete description of levels of evidence.

Inpatient rehabilitation outcomes in primary and revision total knee arthroplasty patients

Inpatient rehabilitation is an effective means of improving physical function and independence following total knee arthroplasty (TKA). Revision TKA (TKAR) is becoming increasingly more prevalent and it is unclear if revision TKAR patients attain similar improvements following inpatient rehabilitation compared to primary TKA (TKAP) patients. This investigation compared functional outcomes following interdisciplinary inpatient rehabilitation in 286 TKAP and 138 TKAR consecutive male and female patients. Functional Independence Measure (FIM) scores improved from admission to discharge for the TKAP (81.6 to 110.5) and TKAR (74.4 to 101.4) groups (p = 0.015). TKAP patients had shorter length of stay (LOS) compared to TKAR (9.2 and 11.3). FIM efficiency (FIM/LOS) was greater for the TKAP compared to TKAR (3.6 and 2.6). Total hospital charges were 11,399 dollars and 13,407 dollars for the TKAP and TKAR groups, respectively. TKAP patients were more likely to be discharged home compared to the TKAR patients (97.6 vs. 78.3%). Both TKAP and TKAR patients demonstrate gains in FIM scores during inpatient rehabilitation. However, the amount of FIM efficiency is lower, and LOS and hospital charges are greater when comparing TKAR and TKAP. In addition, discharge disposition may be influenced by the type of TKA, primary and revision.

LEVEL OF EVIDENCE

Prognostic study, level II-1 (retrospective study). See Guidelines for Authors for a complete description of levels of evidence.

Twelve weeks of nightly stretch does not reduce thumb web-space contractures in people with a neurological condition: a randomised controlled trial

QUESTION

What is the effectiveness of 12 weeks of nightly stretch in reducing thumb web-space contracture in people with neurological conditions?

DESIGN

Assessor-blinded, randomised controlled trial.

PARTICIPANTS

Forty-four (one dropout)community-dwelling patients with a neurological condition (14 stroke, 7 traumatic brain injury, 23 spinal cord injury) who had uni or bilateral thumb web-space contractures (60 thumbs).

INTERVENTION

The experimental thumbs were splinted into a stretched,abducted position each night for 12 weeks. The control thumbs were not splinted.

OUTCOME MEASURES

Thumb web-space was measured as the carpometacarpal angle during the application of a 0.9 Nm abduction torque before and after intervention.

RESULTS

The mean increase in thumb web-space after 12 weeks was 1 deg (95% CI, -1 to 2).

CONCLUSION

Intensive stretch administered regularly over three months does not reduce thumb web-space contractures in neurological conditions.

A Modified Dynamic Mouth Splint for Burn Patients

The prevention and management of microstomia contracture is very important for the quality of life in a patient who has experienced facial burns. Mouth opening is important for speech, eating, dental hygiene, expression, social interaction, psychosocial well being, and administrating general anesthesia. Principles of scar management state a need for opposing horizontal, vertical, and circumferential forces for effective management of microstomia. At the Royal Brisbane and Women's Hospital, horizontal and circumferential stretch was provided well; however, a suitable vertical stretch component was required. After a literature review, we introduced and trialed a dynamic mouth splint. Subsequently, a modified dynamic mouth splint was developed. The presentation here of four case studies will demonstrate that the use of the splint in combination with current practice has improved mouth opening and consequently functional outcomes.

Feedback-Controlled and Programmed Stretching of the Ankle Plantarflexors and Dorsiflexors in Stroke: Effects of a 4-Week Intervention Program

OBJECTIVE

To investigate the effect of repeated feedback-controlled and programmed "intelligent" stretching of the ankle plantar- and dorsiflexors to treat subjects with ankle spasticity and/or contracture in stroke.

DESIGN

Noncontrolled trial.

SETTING

Institutional research center.

PARTICIPANTS

Subjects with spasticity and/or contracture after stroke.

INTERVENTIONS

Stretching of the plantar- and dorsiflexors of the ankle 3 times a week for 45 minutes during a 4-week period by using a feedback-controlled and programmed stretching device.

MAIN OUTCOME MEASURES

Passive and active range of motion (ROM), muscle strength, joint stiffness, joint viscous damping, reflex excitability, comfortable walking speed, and subjective experiences of the subjects.

RESULTS

Significant improvements were found in the passive ROM, maximum voluntary contraction, ankle stiffness, and comfortable walking speed. The visual analog scales indicated very positive subjective evaluation in terms of the comfort of stretching and the effect on their involved ankle.

CONCLUSIONS

Repeated feedback-controlled or intelligent stretching had a positive influence on the joint properties of the ankle with spasticity and/or contracture after stroke. The stretching device may be an effective and safe alternative to manual passive motion treatment by a therapist and has potential to be used to repeatedly and regularly stretch the ankle of subjects with spasticity and/or contracture without daily involvement of clinicians or physical therapists.

Figure-of-8 sling for prevention of recurrent axillary contracture after release and skin grafting

The axilla is a frequent site of adduction contracture after deep thermal injury, especially in burns in developing countries where the timely treatment of burns and the prevention of contracture are not possible for lack of appropriate services. Chronic contractures are difficult to treat, as large areas of wounds need to be covered with skin grafts or flaps. However, the most daunting aspect of adduction contracture is the maintenance of release after correction; this is often dealt with using long-term abduction splints, most of which are very uncomfortable. Our purpose here is to analyse our results with a simple figure-of-8 sling. A descriptive study was made covering a period of 10 years, comprising 40 cases of chronic extensive axillary contracture. All the cases were treated with simple release and skin grafting followed by a figure-of-8 sling. Preoperative limb abduction ranged from 0 degrees to 80 degrees; whereas, the postoperative range, at 1 year of follow-up, was from 140 degrees to 180 degrees. Hence, we conclude that the application of a figure-of-8 sling for axillary post-burn contractures is a safe, comfortable, easy and more compliant way of splintage with at least as reliable results as with other abduction splints.

Passive stretching does not enhance outcomes in patients with plantarflexion contracture after cast immobilization for ankle fracture: a randomized controlled trial

OBJECTIVE

To compare the efficacy of short- and long-duration passive stretches with a control treatment for the management of plantarflexion contracture after cast immobilization for ankle fracture.

DESIGN

Assessor-blinded, randomized controlled trial.

SETTING

Hospital physical therapy outpatient departments.

PARTICIPANTS

Adults with plantarflexion contracture (N=150) after cast immobilization for ankle fracture. All subjects were weight bearing or partial weight bearing.

INTERVENTIONS

Exercise only, exercise plus short-duration passive stretch, and exercise plus long-duration passive stretch. All subjects had a 4-week course of exercises. In addition, subjects in the short-duration stretch plus exercise group completed 6 minutes of stretching per day, and subjects in the long-duration stretch plus exercise group completed 30 minutes of stretching per day.

MAIN OUTCOME MEASURES

Lower Extremity Functional Scale and passive dorsiflexion range of motion with the knee bent and straight at baseline, and at 4 weeks and 3 months postintervention.

RESULTS

One hundred thirty-nine (93%) subjects completed the 4-week assessment and 134 (89%) subjects completed the 3-month assessment. There were no statistically significant or clinically important between-group differences for the primary outcomes.

CONCLUSIONS

The addition of passive stretching confers no benefit over exercise alone for the treatment of plantarflexion contracture after cast immobilization for ankle fracture.

Adjustable aesthetic aeroplane splint for axillary burn contractures

Managing axillary burns with an Aeroplane Splint has been known for its effectiveness for years. However, poor compliance in using the various models of currently available aeroplane splints leads to an inadequate outcome, because of the discomfort produced not only in wearing but also while ambulating within the community. In developing countries like India the biggest barrier to environmental accessibility is the presence of multiple permanent structures like narrow thoroughfares, entry/exit sites of public transport, and narrow aisles. These pose a challenge to rehabilitation professionals while prescribing large splints. An attempt to target these problems was made by Manigandan et al, but aeroplane splints, even the one described by them does not deal with the major problem of aesthetic appeal as identified by many of our patients. Accordingly this article presents a new model of the aeroplane splint with innovative changes, focussing on aesthetic appeal while maintaining all the benefits of the splint described by Manigandan et al.

[Surgical management of orthopedic problems in adult patients with cerebral palsy]

OBJECTIVES

We evaluated the results of surgical treatment for orthopedic problems in adult patients with cerebral palsy.

METHODS

Nine adult patients with cerebral palsy (4 females, 5 males; mean age 22 years; range 19 to 29 years) were managed surgically to lessen pain, correct deformities and contractures, and enhance their mobilization potential. Seven patients underwent bilateral multiple-level tendinous and/or musculotendinous release procedures involving the lower extremities, of whom two patients underwent additional triple arthrodesis, and one patient underwent extension osteotomy in the knee. One patient was treated with proximal femoral and distal tibial derotation osteotomies and bilateral hamstring release for knee flexion contractures. Finally, one patient was treated with posterior fusion with instrumentation for thoracolumbar scoliosis. Before surgery, four patients were community ambulators, and one patient could walk only with the aid of bilateral crutches. Four patients with total body involvement could not walk, but they could sit without support except for one patient with scoliosis. The mean follow-up was 25 months (range 8 to 49 months).

RESULTS

On final evaluations, eight patients could walk without support, and one patient who could not sit preoperatively managed to sit without support. Three patients developed bilateral, five patients developed unilateral superficial skin wounds at the back of the heels associated with cast/brace use, and deep wound infection was encountered in the patient with scoliosis. All the wounds healed with early debridements and antibiotic therapy, together with the modifications made in cast/brace applications, without the need for implant removal.

CONCLUSION

Surgical treatment of orthopedic problems in adult patients with cerebral palsy is of substantial importance in enhancing their sitting and walking capacities, and in restoring their community-based relations and activities.

The effect of selective tibial neurotomy and rehabilitation in a quadriplegic patient with ankle spasticity following traumatic brain injury

Ankle spasticity following brain injury leads to abnormal posture and joint contracture; making standing or walking impossible. This study investigates the efficacy of selective tibial neurotomy (STN) and intensive rehabilitation in a patient who suffered ankle spasticity after brain injury. This case describes a 37-year-old man whose traumatic brain injury (TBI) resulted in severe right ankle spasticity and contracture. He was unable to stand due to severe right ankle spasticity and contracture. Intensive rehabilitation and STN allowed him to walk without brace at 6 months and run at 12 months after STN. STN is an effective procedure to resolve localized spasticity of the ankle and it may be considered as a management strategy after local injection to alleviate ankle spasticity and/or contracture prior to orthopaedic surgery.

Paediatric rehabilitation in a developing country--India in relation to aetiology, consequences and outcome in a group of 459 burnt children

Age, aetiology of burn, percentage body surface area burnt and post-burn sequelae have a direct relationship to the rehabilitative necessity in burnt children in a developing country--India. In spite of the gross disfigurements and sequelae, only adolescent children required psychosocial rehabilitation. These are the results following a retrospective analysis of 459 paediatric burn patients in Madras, India.

[The treatment of deformity of axillary scar contracture after burns]

OBJECTIVE

To explore the best methods to repair the deformity of axillary scar contracture after burns.

METHODS

Ninety cases in 78 patients with axillary scar contracture after burns from January 1998 to January 2002 were analyzed. According to the severity of the deformity and its influence on the function of the shoulder joint. 46 cases suffered from mild degree axillary scar contracture, 26 cases with moderate and 18 with severe degree. The deformities of axillary scar contracture were repaired by Z plasty (18 cases), five-flap plasty (14 cases), skin graft (23 cases), Z plasty and skin graft (14 cases), transfer of scapular skin flaps (5 cases), lateral throatic skin flaps (4 cases) and scar flaps (12 cases), respectively. Exopexy, anti-scar drug and functional exercises were applied postoperationally.

RESULTS

All the flaps were survived with first intention, except for necrosis of the split skin graft occurring in 4 cases. The function and configuration in all the cases were satisfactory after 6 months to 4 years follow-up.

CONCLUSION

Appropriate methods should be chosen to restore the function and configuration of the shoulder joint and improve patients' living condition according to the size, degree of the deformity of axillary scar contracture after burns.

Stiffness after total knee arthroplasty

Postoperative stiffness is a debilitating complication of total knee arthroplasty. Preoperative risk factors include limited range of motion, underlying diagnosis, and history of prior surgery. Intraoperative factors include improper flexion-extension gap balancing, oversizing or malpositioning of components, inadequate femoral or tibial resection, excessive joint line elevation, creation of an anterior tibial slope, and inadequate resection of posterior osteophytes. Postoperative factors include poor patient motivation, arthrofibrosis, infection, complex regional pain syndrome, and heterotopic ossification. The first steps in treating stiffness are mobilizing the patient and instituting physical therapy. If these interventions fail, options include manipulation, lysis of adhesions, and revision arthroplasty. Closed manipulation is most successful within the first 3 months after total knee arthroplasty. Arthroscopic or modified open lysis of adhesions can be considered after 3 months. Revision arthroplasty is preferred for stiffness from malpositioned or oversized components. Patients who initially achieve adequate range of motion (>90 degrees of flexion) but subsequently develop stiffness more than 3 months after surgery should be assessed for intrinsic as well as extrinsic causes.

Management of An Unusual Extreme Extension Contracture of the Wrist

An extreme extension contracture of wrist with dorsal contracture of fingers 15 years after burn injury is described. Shortening of extensor tendons, secondary lengthening of flexor tendons, contracted wrist joint capsule, unusual dislocation of carpals, dorsal dislocation of metacarpophalangeal joints of fingers, and provision of sufficient amount of good-quality skin were some of the issues that had to be addressed in treatment. The contracture was released, the carpals and metacarpophalangeal joint dislocations were corrected and fixed with K wires, and the resulting defect was covered with a sheet split-thickness skin graft. An exercise program was designed that consisted of isotonic, isokinetic, and isometric resistance exercises and passive, active, and active-assistive range of motion exercises. These exercises were pursued with the intention of increasing dynamic strength, endurance, and overall functional recovery of the flexor muscles by exploiting the immature nature of early scar tissue. The resultant enhanced flexor muscle power from exercises along with the dynamic splint helped in lengthening of extensor tendons, wrist joint capsule, and split-thickness skin graft. It also helped in resisting the recontracting tendency, with further recovery of good range of wrist and fingers movements, obviating the need of tendon-lengthening surgery and flap coverage. One and half years of follow up didn't show any sign of recontracture, and the patient was able to perform his routine activities. Postburn wrist contractures of such magnitude have been seldom described. Emphasis is put on simple contracture release and a postoperative exercise program.

Optimal daily total end range time for contracture: resolution in hand splinting

Reduced passive range of motion (PROM) of the joints of the hand is a common sequela of traumatic upper limb injury. Although mobilizing splinting is a common modality used by hand therapists to improve PROM, limited empirical evidence is available to guide therapist prescription. This study investigated the importance of the timing of splint application per 24-hour period, daily total end range time (TERT), via a prospective sequential clinical trial. A total of 43 subjects with joint contractures of the hand after traumatic upper limb injury were randomly allocated to one of two splint programs. Subjects in group A used their splint for less than 6 hours per day, and subjects in group B used their splint for 6 to 12 hours per day. Daily TERT was recorded by subjects in a splint diary. Passive torque range of motion (TROM) was used to measure the extent of contracture resolution over four weeks of splinting. High intrarater, interrater, and test-retest reliability of the TROM technique was established for this sample (intraclass correlation coefficients 0.993 to 0.998). Sequential analysis showed a statistically significant preference for group B, daily TERT of 6 to 12 hours per day (p < 0.05). Pretreatment joint stiffness (p = 0.162) and joint type (p = 0.463) did not influence final TROM significantly. These findings help to provide some controlled data from which therapists may base future prescription (dose) of daily TERT.

The assessment and management of the stiff elbow

Posttraumatic loss of elbow motion can cause substantial disability, limiting the ability to put one's hand in the volume of a sphere in space. Although a number of conditions can lead to loss of motion, a greater understanding of the functional anatomy of the elbow has led to advances in surgical management. Elbow stiffness has been classified in a number of ways, but the consistent feature is capsular contracture. Treatment of the stiff elbow begins with clinical evaluation of elbow stiffness and identification of indications for surgical intervention. Techniques of open and arthroscopic elbow contracture release are evolving. Assessment and management of elbow contracture associated with heterotopic ossification, and treatment of distal humerus nonunion should be done early to restore elbow motion.

[Nonoperative treatment of ischemic contractures of forearm and hand]

The acute compartment syndrome of the forearm and hand leads to severe muscle necrosis and nerve damage if the diagnosis is not recognized. The resulting ischemic contractures and paralyses require a distinctive regime of therapy. Therefore,physiotherapy and occupational therapy are of main importance. In mild cases exclusively nonoperative treatment is possible. The goal is to exercise the function of the remaining muscles, mobilize the joints, and stretch muscle scars. Severe forms need surgery. To reach the best starting point for the operation, extensive preoperative active and passive exercises as well as splint therapy are required. Postoperatively, this regime has to be continued to retain a favorable outcome. The treatment approach is demonstrated with a case report.

A multi-purpose, self-adjustable aeroplane splint for the splinting of axillary burns

External splinting has been acknowledged for many years as a useful approach for preventing and correcting burn contractures. Though this practice could be traced back many centuries, there is still a dearth of knowledge regarding a good splint to serve these purposes for axillary burns. The newly designed multi-purpose, self-adjustable aeroplane splint presented in this report helps in various ways, such as improving compliance, and positioning during preoperative, postoperative and rehabilitative phases of axillary burn management. It acts as a splint that provides circumferential pressure for scar management, provides prolonged stretch to contracted tissue and acts as a serial cast in increasing the shoulder range. Most of all, it is very much user-friendly, thus enhancing compliance and giving a good outcome in axillary burns.

Mechanical therapy for loss of knee flexion

We hypothesized that adding home mechanical therapy to traditional physical therapy by a physical therapist would significantly reduce the need for surgical management of loss of knee flexion after surgery or injury. From 1990 to 1999, we followed up on 34 patients who added home mechanical therapy after failure of physical therapy alone. Thirty-one (91.2%) of these patients regained functional flexion (defined as flexion to 115 degrees) after 6.7 weeks. After surgery, these patients had waited a mean of 23.6 weeks before starting home mechanical therapy. Over the course of this therapy, mean knee flexion progressed from 70.8 degrees to 130.6 degrees. Only 2 patients in this study required surgical manipulation. We conclude that a home mechanical therapy program will reduce the need for surgical management of loss of knee flexion.

Evaluation of serial casting to correct equinovarus deformity of the ankle after acquired brain injury in adults

OBJECTIVE

To determine the potential short-term benefit of serial plaster casting in the management of equinovarus deformity associated with acquired brain injury.

DESIGN

Prospective uncontrolled interventional trial.

SETTING

Inpatient rehabilitation facility in Australia.

PARTICIPANTS

Sixteen patients (19 limbs) with equinovarus deformity or deteriorating ankle range of motion associated with severe plantarflexor and invertor muscle overactivity underwent serial plaster casting over an 18-month period.

INTERVENTIONS

Below-knee plaster casts were reapplied weekly to increase joint range and muscle extensibility.

MAIN OUTCOME MEASURES

Precasting goniometric measures of maximal ankle dorsiflexion range (in knee extension and flexion) were compared with 4 subsequent test occasions (after initial cast, midpoint of casting, after final cast, 1 wk after removal). The amount and type of assistance required to perform a standardized wheelchair-to-bed transfer before and 3 months from commencement of casting were also compared.

RESULTS

Subjects who underwent the serial casting regimen had significantly improved ankle range (knee flexed mean, 18 degrees; knee extended mean, 16 degrees; P<.0001); 13 subjects reduced their need for transfer assistance (P<.0015).

CONCLUSION

Serial casting appears to be effective, at least in the short term, in reducing the equinovarus deformity that occurs after acquired brain injury. Greater ankle mobility was associated with improved transfer independence in the majority of subjects.

Splinting the hand in the functional position after brain impairment: a randomized, controlled trial

OBJECTIVE

To evaluate the effects of 4 weeks of hand splinting on the length of finger and wrist flexor muscles, hand function, and pain in people with acquired brain impairment.

DESIGN

Randomized, assessor-blinded trial.

SETTING

Rehabilitation center in Australia.

PARTICIPANTS

Twenty-eight adults with acquired brain impairment, all within 6 months of the first injury. There was 1 withdrawal.

INTERVENTIONS

Subjects in both experimental (n=17) and control (n=11) groups participated in routine therapy-motor training for upper-limb use and upper-limb stretches-5 days a week. The experimental group also wore an immobilizing hand splint in the functional position (10 degrees -30 degrees wrist extension) for a maximum of 12 hours each night for the duration of the 4-week intervention period.

MAIN OUTCOME MEASURES

The length of the wrist and extrinsic finger flexor muscles was evaluated by measuring the torque-controlled range of wrist extension with the fingers extended. Functional hand use was evaluated with the Motor Assessment Scale. Pain was evaluated with a visual analog scale.

RESULTS

The effects of splinting were statistically nonsignificant and clinically unimportant. At follow-up, estimates of treatment effects slightly favored the control group: range of motion at the wrist favored controls by 2 degrees (95% confidence interval [CI], -7.2 degrees to 3.2 degrees ), function favored controls by 0.2 points (95% CI, -2.7 to 2.3), and pain favored the experimental group by 1cm (95% CI, -4.6 to 2.2).

CONCLUSIONS

An overnight splint-wearing regimen with the affected hand in the functional position does not produce clinically beneficial effects in adults with acquired brain impairment.

Splinting programme for patients with burnt hand

Splintage is commonly used in conjunction with pressure therapy to tackle the contracted scars, make it supple and thus minimise dysfunction. A static or dynamic splint can provide valuable therapy that goes beyond any treatment session. The patient's active participation in the splint programme can facilitate early recovery. A good splinting design and wearing regime often depends on the therapist's understanding and integration of visco-elastic properties in soft tissues, maturation process of hypertrophic scars and mechanical principles in splinting. Different types of splints serve different functions at different stages of rehabilitation. A suitable and efficient application of splints can minimise most of the corrective surgical intervention and alleviate psychological trauma. This article attempts to highlight the clinical rationale and special considerations when applying different splintage on burns patients with upper limbs involvement.

Management of stiff hand: an occupational therapy perspective

Joint stiffness, resulting from a variety of complications after hand injuries, remains a common problem. Prolonged swelling, scar formation and shortening of soft tissue after prolonged period of immobilisation are the major causes leading to the loss of joint range of motion. Treatment used to improve the joint stiffness should be integrative and problem-focused. Pressure therapy, active and passive mobilisation through remedial activities and corrective splinting should be started as soon as problems arise. Applying low-load stress through prolonged periods of time onto the shortened tissue at its maximum tolerable range is the main principle in restoration of passive joint range of motion. The greater the joint limitation becomes, the longer the time the splint should be applied. Therapists should understand the process of tissue healing and different functions of splints before a correct and effective splint can be prescribed properly.