Advertisement

A modified-delphi study establishing consensus in the therapeutic management of posttrauamtic elbow stiffness

Published:January 12, 2022DOI:https://doi.org/10.1016/j.jht.2021.11.002

      Highlights

      • Web based modified Delphi study identifying expert consensus during 3 rounds.
      • Consensus was found in the following categories: examination procedures, therapeutic interventions, orthotic intervention considerations, contributing patient factors, and clinical decisions and rehabilitation challenges.
      • Findings of this study support the need for future high-level studies looking at effectiveness of recommended therapeutic interventions.

      Abstract

      Study Design

      : Web-based modified Delphi study.

      Background

      : Therapy is widely considered the first choice of treatment for posttraumatic stiffness of the elbow since loss of motion is a common sequela following traumatic elbow injuries. There is high variability in practice patterns for the management of the posttraumtic elbow.

      Purpose

      : The aim of this study is to identify the current therapeutic management of posttraumatic elbow stiffness using expert consensus.

      Methods

      : This study surveyed experts using a web-based 3 round modified Delphi method. Quantitative data and comments were collected during the first round. Questions with Likert scaling were used to identify consensus (defined as 75% agreement) with each statement and comment boxes enabled open-ended responses to gather expert opinion. Lack of consensus and data from comments guided the second-round of the survey. This process was repeated after Round 2 to develop the Round 3 survey. Consensus was achieved at Round 3 and no further rounds were needed.

      Results

      : Round 1 included 34 experts (response rate 20%), not all experts were able to continue through all rounds. Round 2 included 18 experts and Round 3 included 15 experts. Survey items were categorized as follows: examination procedures, therapeutic interventions, orthotic intervention considerations, contributing patient factors, and clinical decisions and rehabilitation challenges. Twenty-five percent of items achieved consensus after Round 1, 30% after Round 2 and 52% after Round 3. Although most participants agreed that orthotic intervention is critical to patient outcomes, there were conflicting thoughts about the orthotic design and wearing schedule.

      Conclusions

      : The findings of this web-based modified Delphi study helped to establish a current body of knowledge using expert consensus to guide practice and identify specific questions that can be studied in future clinical studies on posttraumatic elbow stiffness.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Journal of Hand Therapy
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Everding NG
        • Maschke SD
        • Hoyen HA
        • Evans PJ.
        Prevention and treatment of elbow stiffness: a 5-year update.
        J Hand Surg Am. 2013; 38: 2496-2507
        • Zheng W
        • Chen S
        • Song J
        • Liu J
        • Fan C.
        The influence of body mass index on outcome of open arthrolysis for post-traumatic elbow stiffness.
        J Shoulder Elbow Surg. 2017; 26: 809-814
        • Zhang D
        • Nazarian A
        • Rodriguez E.
        Post-traumatic elbow stiffness: Pathogenesis and current treatments.
        Shoulder Elbow. 2018; 12: 38-45
        • Bruno RJ
        • Lee ML
        • Strauch RJ
        • Rosenwasser MP.
        Posttraumatic elbow stiffness: evaluation and management.
        J Am Acad Orthop Surg. 2002; 10: 106-116
        • Chuinard C.
        The stiff elbow.
        Current Orthop Pract. 2008; 19: 602-607
        • Monument MJ
        • Hart DA
        • Salo PT
        • Befus AD
        • Hildebrand KA.
        Posttraumatic elbow contractures: targeting neuroinflammatory fibrogenic mechanisms.
        J Orthop Sci. 2013; 18: 869-877
        • Morrey BF.
        The posttraumatic stiff elbow.
        Clin Orthop Relat Res. 2005; : 26-35
        • Aldridge 3rd, JM
        • Atkins TA
        • Gunneson EE
        • Urbaniak JR.
        Anterior release of the elbow for extension loss.
        J Bone Joint Surg Am. 2004; 86: 1955-1960
        • Viveen J
        • Doornberg JN
        • Kodde IF
        • et al.
        Continuous passive motion and physical therapy (CPM) versus physical therapy (PT) versus delayed physical therapy (DPT) after surgical release for elbow contractures; a study protocol for a prospective randomized controlled trial.
        BMC Musculoskelet Disord. 2017; 18: 484
        • Vardakas DG
        • Varitimidis SE
        • Goebel F
        • Vogt MT
        • Sotereanos DG.
        Evaluating and treating the stiff elbow.
        Hand Clin. 2002; 18: 77-85
        • Jones V.
        Conservative management of the post-traumatic stiff elbow: a physiotherapist's perspective.
        Shoulder Elbow. 2016; 8: 134-141
        • Murphy M
        • Black NA
        • Lamping DL
        • et al.
        Consensus development methods, and their use in clinical guideline development.
        Health Technol Asses. 1998; 2: 1-100
        • Keeney S
        • Hasson F
        • MH P
        Consultign the oracle: ten lessons from using the Delphi technique in nurisng research.
        J Adv Nurs. 2006; 53: 205-511
        • Sim G
        • Fleming J
        • Glasgow C.
        Mobilizing orthoses in the management of post-traumatic elbow contractures: A survey of Australian hand therapy practice.
        J Hand Ther. 2020; (SO894-1130(20)30014-4)
        • Marinelli A
        • Bettelli G
        • Guerra E
        • Nigrisoli M
        • Rotini R.
        Mobilization brace in post-traumatic elbow stiffness.
        Musculoskelet Surg. 2010; 94: S37-S45
        • Lindenhovius AL
        • Jupiter JB.
        The posttraumatic stiff elbow: a review of the literature.
        J Hand Surg Am. 2007; 32: 1605-1623
        • Veltman ES
        • Doornberg JN
        • Eygendaal D
        • van den Bekerom MP.
        Static progressive versus dynamic splinting for posttraumatic elbow stiffness: a systematic review of 232 patients.
        Arch Orthop Trauma Surg. 2015; 135: 613-617
        • Birinci T
        • Razak Ozdincler A
        • Altun S
        • Kural C
        A structured exercise programme combined with proprioceptive neuromuscular facilitation stretching or static stretching in posttraumatic stiffness of the elbow: a randomized controlled trial.
        Clin Rehabil. 2018; 33: 241-252
        • Paul R
        • Chan R.
        Nonsurgical treatment of elbow stiffness.
        J Hand Surg Am. 2013; 38: 2002-2004
        • MacDermid JC
        • Tottenham V.
        Responsiveness of the Disability of Arm, and Shoulder, and Hand (DASH) and the Patient-Rated Wrist/Hand Evaluation (PRWHE) in Evaluating Change after Hand Therapy.
        J Hand Ther. 2004; 17: 18-23
        • MacDermid JC
        • Tottenham V.
        Responsiveness of the disability of the arm, shoulder, and hand (DASH) and patient-rated wrist/hand evaluation (PRWHE) in evaluating change after hand therapy.
        J Hand Ther. 2004; 17: 18-23
        • Doornberg JN
        • Ring D
        • Fabian LM
        • Malhotra L
        • Zurakowski D
        • Jupiter JB.
        Pain dominates measurements of elbow function and health status.
        J Bone Joint Surg Am. 2005; 87: 1725-1731
        • MacDermid JC.
        Outcome evaluation in patients with elbow pathology: Issues in instrument development and evaluation.
        J Hand Ther. 2001; 14: 105-114
        • Vincent JL
        • MacDermid JC
        • King JW
        • Grewal R
        The Patient-Rated Elbow Evaluation and the American Shoulder and Elbow Surgeons- Elbow form capture aspects of functioning that are important to patients with elbow injuries.
        J Hand Ther. 2020; (SO894-1130(20)30026-0)
        • Davila SA
        • Johnston-Jones K
        Managing the stiff elbow: operative, nonoperative, and postoperative techniques.
        J Hand Ther. 2006; 19: 268-281
        • Brinsden MD
        • Carr AJ
        • Rees JL.
        Post-traumatic flexion contractures of the elbow: operative treatment via the limited lateral approach.
        J Orthop Surg Res. 2008; 3: 39
        • Muller AM
        • Sadoghi P
        • Lucas R
        • et al.
        Effectiveness of bracing in the treatment of nonosseous restriction of elbow mobility: a systematic review and meta-analysis of 13 studies.
        J Shoulder Elbow Surg. 2013; 22: 1146-1152
        • Sodhi N
        • Khlopas A
        • Vaughn MD
        • et al.
        Manufactured Brace Modalities for Elbow Stiffness.
        Orthopedics. 2018; 41: e127-e135
        • Fedorczyk J
        • Whitten M.
        Therapeutic Management of Fractures, Dislocations, Traumatic Instability, and Stiffness of the Elbow.
        in: Skirven Osterman Fedorczyk Amadio Feldscher Shin Rehabilitaion of the Hand and Upper Extremity. Vol. 1, Philadelphial, PA7th ed. Elsevier, 2021: 928-948
        • Blackmore S.
        Splinting for Elbow Injuries and Contractures.
        Atlas Hand Clin. 2001; 6: 21-50
        • Flowers KR.
        A proposed decision hierarchy for splinting the stiff joint, with an emphasis on force application parameters.
        J Hand Ther. 2002; 15: 158-162

      JHT Read for Credit

      Quiz: # 846

      Record your answers on the Return Answer Form found on the tear-out coupon at the back of this issue or to complete online and use a credit card, go to JHTReadforCredit.com. There is only one best answer for each question.
      • # 1.
        How many rounds were needed to reach consensus?
        • a.
          10
        • b.
          1
        • c.
          2
        • d.
          3
      • # 2.
        To be included as a so-called expert, a therapist had to treat a minimum of ______ traumatic elbow patients in a year
        • a.
          5
        • b.
          25
        • c.
          10
        • d.
          100
      • # 3.
        Commonly encountered clinical issues included
        • a.
          reactive flares to interventions
        • b.
          reluctance to wearing splints
        • c.
          altered esthetics secondary to limited ROM
        • d.
          insurance company's declining reimbursement for therapy
      • # 4.
        The experts agreed that the chief intervention was
        • a.
          manual therapy
        • b.
          orthotic wearing
        • c.
          physical agent modalities
        • d.
          therapeutic exercise
      • # 5.
        The Modified Weeks Test was the most commonly identified tool for assessing orthotic intervention
        • a.
          false
        • b.
          true
      When submitting to the HTCC for re-certification, please batch your JHT RFC certificates in groups of 3 or more to get full credit.