Treatment of limited shoulder motion using an elevation splint.

Treatment of Limited Shoulder Motion Using an Elevation Splint

This article describes the management of a patient with limited shoulder range of motion (ROM) by use of an elevation splint. The limited ROM was believed to be due to structural changes in the tissues surrounding the glenobumeral joint following a Magnuson-Stack repair for anterior glenobumeral instability. The patient's ROM plateaued approximately 6 months postoperatively and did not improve with a variety of physical therapy techniques. Use of an inexpensive, easily fabricated elevation splint was begun 8 months postoperatively, and subsequent improvements in ROM were observed. The rationale and suggestions for clinical use of the splint are discussed. [McClure PW, Flowers KR. Treatment of limited shoulder motion using an elevation splint. Phys Ther. 1992;72:57-62.]

Key Words: Orthotics/splints/casts, upper extremity; Shoulder joint; Splints; Upper extremity, shoulder.

Limited shoulder range of motion (ROM) is a common problem treated by physical therapists and can be the result of various pathologies.[1] We believe that proper treatment should be based on a clear understanding of the cause of limited ROM and have found it useful to classify causes of limited shoulder ROM into two categories. The first category is structural changes in the periarticular tissues. These changes would include shortening of capsule, ligament, or muscle as well as adhesion formation. These structural changes generally result from a combination of inflammation and immobilization.[2] The second category is problems not associated with a structural change in the periarticular tissues. Examples of these nonstructural problems are pain (and associated protective muscle contraction to prevent painful movements) and a loose body within the joint space.[3] This classification system is useful because it can form the basis for choosing a treatment strategy. Treatment of limited ROM attributable to structural changes, as we have defined them, should be geared toward applying tensile forces in an effort to cause elongation of the restricting tissues.[4] We believe that treatment of limited ROM believed to be attributable to nonstructural changes should be focused on relieving whatever problem is producing the limitation. For example, an acutely inflamed joint with associated pain and protective muscle action would most likely be treated with modalities oriented toward relieving pain.[5] In our practice, findings from the patient's history and physical examination that lead us to hypothesize passive range of motion (PROM) was limited as a result of structural changes are the following:

1. A history of trauma followed by

immobilization.[2] 2. A history of episodes of restricted

ROM persisting longer than 3

weeks.[2] 3. Loss of PROM in a capsular 

pattern.[6] (For the shoulder, the

greatest percentage of limitation of

lateral rotation followed by

abduction.) 4. A capsular end-feel.[6] (A capsular

end-feel is a firm halt to passive

movement with only a slight

degree of give to further force.) 5. No pain with resisted isometric 

contractions with the joint in a

neutral position.[6] The patient described in this case report was classified as having limited ROM secondary to structural changes. The purpose of this report is to describe the management of this patient by use of an easily fabricated and inexpensive shoulder elevation splint. Some authors[7-9] have suggested treatment approaches for limited shoulder ROM based on techniques that, according to their proponents, require the application of precise forces. These approaches require that a trained therapist apply the treatment. The forces therefore, are applied for relatively brief periods of time. When ROM is limited because of structural changes in periarticular tissues, the amount of time the joint is held at or near the end of ROM may be the critical factor that will influence outcome.[10] Basic science research suggests that periarticular tissues will remodel over time based on the forces applied to those tissues.[11-13] Clinical studies also suggest that treatment of limited ROM based on a lowload prolonged tensile stress regimen is more effective than treatments incorporating only brief periods of tensile stress.[14,15] The use of an elevation splint allows tensile forces to be applied to shortened, restricting tissues for relatively prolonged periods and therefore could facilitate appropriate remodeling.

Case Study

History

The patient was a 46-year-old woman employed as a medical assistant. She was also a dancer and choreographer for a competitive dance group. She had a 10-year history of chronic anterior glenohumeral dislocations. Her episodes of dislocation had become more frequent (three times in the year and a half preceding our treatment). Her primary activity limitation prior to surgery was inability to accomplish forceful, overhead movements because of pain and fear of dislocation. She was referred for physical therapy 6 weeks after surgery for recurrent anterior shoulder instability. The surgical procedure was a Magnuson-Stack procedure[16] in which the humeral attachment of the subscapularis muscle is moved both laterally and inferiorly. Prior to beginning physical therapy, the patient had been immobilized in a sling and swathe for the first 4 weeks postoperatively. At 4 weeks postoperatively, the patient began performing pendulum exercises for a few minutes, three times per day, but otherwise continued wearing a sling.

Evaluation

The patient's chief complaint was stiffness that limited her ability to move her arm. Pain was minimal and did not interfere with her ability to use the arm. She had a well-healed incision, and the area over the anterior aspect of the glenohumeral joint was slightly tender. Her shoulder PROM values are shown in the Table and are represented graphically in Figure 1. The end-feel[6] was capsular for all shoulder passive motions. There was no grossly observable muscle atrophy or swelling. Muscle performance was not assessed quantitatively. All major muscle groups around the shoulder, however, could resist moderate manual force without pain.

Treatment

Treatment initially consisted of moist heat applied for 20 minutes with the patient's arm slightly abducted and laterally rotated to her end range (ie, end of shoulder joint ROM). Ultrasound was given anteriorly for 5 minutes with the arm in the same position. The ultrasound was continuous, and the intensity was adjusted to tolerance, which ranged between 1.5 and 2.0 W/[cm.sup.2]. These modalities were applied to increase the compliance of the anterior tissues and were followed by an exercise program (Table), which consisted initially of pendulum exercises performed intermittently for 15 minutes. Exercise was followed by application of ice for 5 to 10 minutes to minimize inflammation resulting from exercise. The patient was instructed to perform her exercise program twice per day at home and to use heat before exercising and ice afterward whenever possible. She seemed to follow her exercise program as instructed. This was demonstrated by her ability to accurately reproduce the exercises as well as ask specific questions regarding the details of the exercise program. During the sixth to eighth postoperative weeks, the sling was worn only in situations posing significant risk of injury such as crowded public places. Sling use was discontinued after the eighth postoperative week. This basic routine was continued for 6 weeks. The exercise program was intensified, however, as the surgical repair matured. Initially, joint mobilization consisted of grade I and II anterior, posterior, and inferior glides at the glenohumeral joint and were progressed to grade IV mobilizations within 2 weeks.[7] The exercise program became more vigorous over time, as reflected in the Table, and the moist heat and ultrasound were eliminated from the program after 6 weeks of treatment. The heating modalities were also discontinued because they did not seem to make a difference in her ROM or her ability to exercise.

Results and Modification of Treatment

Because the patient's chief complaint was joint stiffness, PROM was considered the most important outcome measurement. Passive range of motion was recorded at least once a week, and there were no observable differences between active range of motion (AROM) and PROM. With the patient positioned supine, one therapist (PWM) used a large plastic goniometer to obtain ROM measurements, which were read to the nearest 5-degree increment. Lateral rotation was measured with the arm by the side, and abduction was measured with the arm in the plane of the scapula (ie, approximately 40 [degrees] anterior to the frontal plane).[17] This position is believed to most closely approximate the normal plane of arm elevation during functional activities. Medial rotation was not limited on observation and therefore was not measured goniometrically. Extension ROM was not assessed. No attempt was made to stabilize the scapula; therefore, measurements reflect shoulder-girdle ROM rather than glenohumeral motion. Based on observation, the limitation of ROM and subsequent gains in ROM occurred primarily at the glenohumeral joint. We have not assessed the reliability of the patient's shoulder PROM measurements. Riddle et al[18] reported high intratester reliability for shoulder PROM measurements. Gadjosik and Bohannon[19] point out that PROM measurements may be less consistent than AROM measurements because of the variability of the force applied by the tester. They also suggest, however, that repeated measurements by one tester (intratester reliability) are usually more reliable than measurements taken by multiple testers (intertester reliability). As shown in the Table and in Figure 1, the patient's ROM improved slowly in the first 3 months postoperatively, but her abduction ROM plateaued. From May 9 to August 11, there were no changes in either abduction or lateral rotation and only minimal gains in flexion. It should be noted that full lateral rotation is not expected following a Magnuson-Stack procedure. The patient understood this aspect of the procedure, but was not satisfied with her overhead motion and continued conscientiously with physical therapy and frequent home exercise. When she failed to make significant gains over this 3-month period, we searched for a way to increase the amount of tensile stress on her restricting tissues. We decided to institute a low-load, prolonged tensile stress program, using an elevation splint that we developed. As shown in the Table and Figure 1, the patient demonstrated observable increases in ROM within 2 weeks after instituting the use of the splint. The most dramatic changes were in abduction, but lateral rotation also improved. What encouraged us to report this case was the relatively long period in which there were no gains in ROM. We believe the gains in ROM could be largely attributed to the increased end-range time in the elevation splint. Therefore, we will describe the splint and its use in detail.

Splint Fabrication 

A waist resting pad is first constructed from a 15.2-cm (6-in) square of thermoplastic material that is padded on one side (Fig. 2). Once softened in hot water, it is molded to the patient's waist just above the iliac crest. Likewise, a forearm trough is loosely molded to the patient's midforearm. Next, a rod is fashioned by cutting a section of an adjustable aluminum cane to an appropriate length. The most tedious step in fabrication is the attachment of thermoplastic wells, which will accept the rod on the resting pads. The wells are constructed by cutting two 10.2-cm (4-in) squares of thermoplastic material into cross-shaped pieces. One cross-shaped piece of thermoplastic material is softened in hot water and dried. The waist pad is spot heated with a heat gun and treated with bonding solvent. The hot, dry cross-shaped piece is molded into a well over one tip of the rod and attached to the waist pad. While it is still flexible, the well should be angled on the waist pad such that the rod points in the desired upward direction. Likewise, a second well is fabricated from the other thermoplastic cross-shaped piece and attached to the forearm trough on the other end of the rod. Finally, the belt is attached to the waist piece. The waist belt is fabricated from two pieces of 5.1-cm (2-in) web strap, which are joined by a buckle mechanism. Each piece is attached to the thermoplastic hip pad by a 5.1-X15.2-cm (2-X6-in) strip of thermoplastic material. This attachment is accomplished by bonding one end of the heated strip to the base, passing the free end through a metal loop (which is preattached to the web strap), and folding it back upon itself to complete the bonding. A list of the tools and materials required for fabrication is shown in the Appendix. The entire splint fabrication process should take about 1 hour to complete once the technique is mastered. The cost of the materials is approximately $25. The splint may be reused by subsequent patients with minor remolding and replacement of worn or soiled parts.

Splint Application

One of the advantages of the splint is the simple nature of its application. The waist resting pad is placed just above the iliac crest such that it will not migrate downward (Fig. 3). The belt is pulled snug and fastened. The forearm is lifted and placed into the forearm trough. Any adjustments in the length of the rod should be made without the forearm in the splint. The angle of the arm relative to the body should approximate the plane of the scapula (ie, 30 [degrees]-40 [degrees] anterior to the frontal plane).[17] The critical concern is that the shoulder come to rest at or near its available end range. The splint described can usually hold the arm in as much as 150 degrees of elevation. It may not be necessary, however, to maintain the joint in the absolute end-range position in order to increase ROM. Based on our experience, splinting a joint near end range may be better tolerated and just as therapeutic as splinting at the absolute end range.

Wearing Schedule and Dosage

The primary aim in our treatment of our patients is to maximize the amount of time spent at or near end range. This aim is based on the theory that lengthening of the restricting tissue is induced by moderate tensile stress and is directly proportionate to the total end-range time. We have found it useful to think of the total end-range time as the "dosage" of stress in much the same way "dosage" is used in regard to medication. The purpose of the elevation splint is to achieve a therapeutic amount of total end-range time. The initial length of wearing the splint was 30 minutes, for two to four sessions each day. This wearing time was increased to 60 minutes for four sessions per day, because no adverse reactivity was evident. We carefully monitored pain and ROM when using the elevation splint. Significantly increased pain or decreased ROM would have been considered a sign of inflammation, and the total end-range time would most likely have been reduced. If there were no appreciable changes in pain or ROM, the total end-range time would have been increased. Because ROM improved, we considered the amount of total end-range time appropriate. We decided, however, to increase the total end-range time to as much as 4 hours per day, because the patient did not report significant pain with use of the splint and she continued to demonstrate improved ROM.

Discussion

The efficacy of a low-load, prolonged stress treatment has been demonstrated for limited ROM at other joints.[15,20] We believe that the biological principle of tissues remodeling over time according to the amount of stress they receive can be applied to virtually all joints. Perhaps because of the relative technical difficulty in splinting the shoulder, this type of treatment has not been described. Rizk et al[14] found that low-load, prolonged stress treatment via a pulley-and-weight system was effective for increasing shoulder ROM. Their treatment, however, required the patient to be present in the clinic and to sit for prolonged periods. Our splint allows the patient to be ambulatory and relatively functional with the uninvolved arm. In our experience, patients often demonstrate significant gains in ROM with the amounts of end-range time used in the case described. More recalcitrant joints, however, have required as much as 12 to 16 hours of total end-range time per day. This splinting schedule may require the patient to sleep with the splint on, which can be accomplished by using pillows to support the arm appropriately. To facilitate patient compliance, we believe it is imperative that patients understand the purpose of the splint. Many patients are able to learn to monitor and adjust their total end-range time appropriately and can be given the responsibility of controlling their splinting schedule with guidance by the therapist. We have used this particular type of splint on only about 10 patients. We have much more experience with splinting other joints such as the elbows, knees, wrists, and digits. We believe the principles involved in determining wearing schedule and facilitating patient compliance are the same regardless of the joint involved. Our splint does not prevent motion at the scapulothoracic articulation. We have not observed scapulothoracic problems as a result of patients using the splint. We emphasize isolated glenohumeral motion and proper scapulohumeral rhythm during the active and passive exercise program, which helps to discourage an abnormal movement pattern of early, excessive scapulothoracic motion during arm elevation. We believe that if the arm is placed near end-range, the restricting tissue will come under appropriate therapeutic tensile stress. We typically monitor ROM three times per week until a therapeutic amount of total end-range time has been established. Thereafter, ROM may be monitored once a week. In cases of long-standing joint stiffness, visits may be scheduled at 2- or 3-week intervals. We chose to report this case because of the long plateau in ROM prior to use of the splint. This plateau seems to suggest that the increases in ROM were the direct result of spending increased amounts of time with the joint near the end range. Currently, we are more aggressive in the use of the splint and apply it earlier in the rehabilitation process. As with all treatments, success is dependent on appropriate patient selection. We do not recommend prolonged end-range stress via the use of an elevation splint for patients with acute inflammation. The indicators of acute inflammation that we use clinically are the following: resting pain, pain experienced before the limit of ROM is reached, pain referred below the elbow, and inability to sleep on the involved side.[6]

Summary and Conclusions

We have described the management of a patient with limited shoulder motion thought to be due to shortened periarticular tissues. Despite initial improvement with traditional techniques, the patient's improvement in ROM plateaued. Intervention with a splint designed to hold the shoulder near the end range of available motion seemed to cause appreciable increases in ROM. We conclude that use of a shoulder elevation splint may be useful in patients with limited ROM attributable to structural changes in the tissues surrounding the joint. Further study is necessary before any substantive claims can be made about the efficacy of this form of treatment.

Appendix. Materials and Tools Required for Splint Fabrication 2 15.2-cm (6-in) squares of thermoplastic material (waist and forearm pieces) 2 15.2-cm (6-in) squares of adhesive-backed foam padding (waist and forearm pieces) 2 10.2-cm (4-in) squares of thermoplastic material (cut into cross-shaped pieces to mold wells

that hold the adjustable rod) 2 5.1-x15.2-cm (2-x6-in) pieces of thermoplastic material (to hold the waist belt) 1 Velcro [R](a) waist belt (2 metal rings and buckle mechanism) 1 aluminum adjustable cane Bonding solvent (for thermoplastic material) Scissors, heat gun, hacksaw (a)Velcro USA Inc, PO Box 5218, 406 Brown Ave, Manchester, NH 03108. [Tabular Data Omitted]

PHOTO : Figure 1. Graph showing patient's range of motion versus time in postoperative weeks.

PHOTO : Figure 2. Attachment of adjustable aluminum rod to the waist resting pad using a cross-shaped piece of thermoplastic material.

PHOTO : Figure 3. Subject wearing shoulder elevation splint.

References

[1]Neviaser JS. Adhesive capsulitis and the stiff and painful shoulder. Orthop Clin North Am. 1980;11:327-333. [2]Akeson W, Amiel D, Abel M, et al. Effects of immobilization on joints. Clin Orthop 1987;219:28-37. [3]Neviaser RJ, Neviaser TJ. The frozen shoulder diagnosis and management. Clin Orthop 1987;223:59-64. [4]Flowers KR, Michlovitz St. Assessment and management of loss of motion in orthopedic dysfunction. Postgraduate Advances in physical Therapy. 1988;2-8:1-11. [5]Michlovitz SL. Cryotherapy: the use of cold as a therapeutic agent. In Michlovitz SL, ed. Thermal Agents in Rehabilitation Philadelphia Pa: FA Davis Co; 1986:87-90. [6]Cyraix J. Textbook of Orthopedic Medicine, Volume I: Diagnosis of Soft Tissue Lesions. 6th ed. Baltimore, Md: Williams & Wilkins; 195. [7]Maitland GD. Peripheral Manipulation. 2nd ed. London, England: Butterworth & Co (Publisher) Ltd.; 1977. [8]Kaltenborn FM. Mobilization of the Extremity Joints Oslo, Norway: Olaf Noris Bokhandel; 1980. [9]Mennell JM. Joint Pain. Boston, Mass: Little, Brown & Co Inc; 1964. [10]Brand P. Clinical Mechanics of the Hand. St Louis, Mo: CV Mosby Co; 1984:68. [11]Arem AJ, Madden JW. Effects of stress on healing wounds: intermittent noncyclical tension. J Surg Res. 1976;20:93-102. [12]Williams PE, Goldspink G. Changes in sarcomere length and physiological properties in immobilized muscle. J Anat. 1978;127:459-468. [13]Warren CG, Lehmann JF, Koblanski JN. Heat and stretch procedures: an evaluation using rat tail tendon. Arch Phys Med Rehabil. 1976;57:122-127. [14]Rizk TE, Christopher RP, Pinals RS, et al. Adhesive capsulitis: a new approach to its management. Arch Phys Med Rehabil. 1983;64:29-33. [15]Light KE, Nuzik S. Personius W, Barstrom A. Low-load prolonged stretch vs high-load brief stretch in treating knee contractures. Phys Ther. 1984;64:330-333. [16]Miller LS, Donahue JR, Grood RP, et al. The Magnuson-Stack procedure for treatment of recurrent glenohumeral dislocations. Am J Sports Med. 1984;12:133-137. [17]Johnston TB. The movements of the shoulder joint: a plea for the "plane of the scapula" as a reference for movements occurring at the humeroscapular joint. Br J Surg. 1937;25:252-260. [18]Riddle DL, Rothstein JM, Lamb RL. Goniometric reliability in a clinical setting: shoulder measurements. Phys Ther. 1987;67:668-673. [19]Gadjosik RL, Bohannon RW. Clinical measurements or range of motion: review of goniometry emphasizing reliability and validity. Phys Ther. 1987;67:1867-1872. [20]Hepburn GR. Case studies: contracture and stiff joint management with Dynasplint. Journal of Orthopaedic and Sports Physical Therapy. 1987;8:498-504.

PW McClure, MS, PT, OCS, is Assistant Professor, Department of Orthopedic Surgery and Rehabilitation, Hahnemann University, MS 502, Broad and Vine Sts, Philadelphia, PA 19102 (USA). Address all correspondence to Mr. McClure. KR Flowers, BA, PT, ASHT, is Director, Valley Forge Hand Rehabilitation, Phoenixville Hospital, 140 Nutt Rd, Phoenixville, PA 19460.