Efficacy of high intensity stretching in the treatment of elbow contractures: a retrospective
analysis
Samantha J Beckley PhDa, Shaun K Stinton PhDa, Maha Karim BSa, Thomas P Branch MDb
a ArthroResearch LLC, 441 Armour Place NE, Atlanta, GA, 30324, United States
b Ermi LLC, 2872 Woodcock Blvd. Suite 100, Atlanta, GA, 30341, United States
Address for correspondence:
Samantha Beckley, 441 Armour Place NE, Atlanta, GA, 30324, USA
Phone: +1 404-579-1546
Email: s.beckley@arthroresearch.com.
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Abstract
Background: Elbow contractures impair functional range of motion (ROM), affecting daily
activities and quality of life. High-intensity stretching (HIS) has shown efficacy in other joints
but remains unexplored for elbow contracture. This study evaluated the efficacy of a HIS device
in restoring elbow flexion and extension ROM.
Methods: A retrospective analysis included 67 patients prescribed a HIS device between October
2021 and August 2024. Patients had at least two ROM measurements documented in physical
therapy progress notes, with initial measurements recorded within 30 days of device delivery and
follow-up measurements at least 14 days later. The HIS device utilized the Patient Actuated
Serial Stretch protocol, with patients performing three 10-minute stretching sessions daily. Paired
t-tests compared initial and final ROM.
Results: Flexion improved significantly from 106.1° ± 20.6° to 121.4° ± 18.0° (gain: 15.3° ±
17.8°, p < 0.001), while extension improved from -29.7° ± 19.4° to -21.2° ± 16.9° (gain: 8.5° ±
15.8°, p < 0.001). Improvements were consistent across all demographics, including age, sex,
and motion loss severity. Patients with severe deficits (≤90° flexion or ≥50° extension loss)
achieved substantial gains, with flexion increasing by 26.2° and extension improving by 17.2°.
Most patients achieved functional ROM within two months, a timeline notably shorter than
traditional treatments.
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Conclusion: HIS is an effective treatment for elbow contractures, providing faster recovery and
potentially reducing the need for invasive interventions. Prospective studies are needed to
confirm these findings.
Keywords: Elbow; Motion Loss; Contracture, Mechanical Therapy; Non-operative Treatment
Introduction
The elbow is a hinge-like joint which can bend and straighten the arm while also contributing to
pronation/supination of the forearm. These motions allow for movement of the hand, making the
elbow crucial for activities of daily living (ADLs) such as reaching, grasping, and positioning the
hand to perform tasks like eating, personal hygiene, and writing. In a healthy joint, normal elbow
range of motion (ROM) spans from between -10 to 10 degrees in extension to 140-150 degrees
in flexion, and from 0 degrees to 80-90 degrees for both pronation and supination 1-4
. The elbow
ROM necessary to perform most ADLs is 30-130 degrees of flexion 5-7
. Deficits in elbow ROM
can lead to functional impairments, missed work, reduction in quality of life and mental health
issues, increased loading on the surrounding joints (shoulder and wrist), and increased usage of
healthcare resources 8-10
.
The elbow is prone to issues with stiffness due to its anatomy of congruent bones in a confined
space within the joint and the sensitivity of the joint to inflammation 2,3
. A substantial portion of
people who suffer elbow trauma will develop motion loss after injury or surgery with some
studies reporting motion loss in up to 56% of cases 2,3
. This motion loss can be due to the trauma
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itself, post-surgical complications, arthritis, heterotopic ossification, soft tissue contracture, or
prolonged immobilization and is defined as an elbow contracture 10
.
The first option for treatment of elbow contractures is generally physical therapy (PT). When PT
is not effective in reaching the ROM goals, other conservative modalities can be used in
conjunction with or following PT including: serial casting, dynamic splinting, and static
progressive stretch devices. These treatments have been shown to have varying degrees of
success in recovering lost ROM 11,12
. If these conservative methods fail to achieve the treatment
goals, motion restoring procedures or surgeries such as manipulation under anesthesia (MUA),
arthroscopic contracture release, and open contracture release are often the next step in
treatment. These procedures also have varied success rates while introducing the risk of serious
complications including fractures, heterotropic ossification, recurrent stiffness, pulmonary
embolism, nerve damage, infection, and complications related to anesthesia 10,13,14
.
Another conservative option that may prevent the need for motion restoring procedures in
patients that are struggling to achieve their ROM goals is high intensity stretching (HIS). A HIS
device can provide increased efficacy in treating ROM deficits compared to physical therapy
alone or compared to low intensity stretch devices 15-18
. Using a HIS device has been shown to be
effective in other joints 16,18,19,20
, but this is the first study investigating the use of a HIS device for
treatment of elbow contractures.
Therefore, the purpose of this study was to evaluate the efficacy of a HIS device in treating
elbow joint contractures. We hypothesized that a HIS device would effectively address motion
loss, thereby aiding patients in restoring functional ROM.
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Methods
Study Population
The study qualified for exemption from institutional review board review, and a waiver of
authorization was secured before initiation. A retrospective review was conducted for 293
patients who were prescribed a HIS device (the Ermi Elbow Flexionater+; Figure 1) for motion
loss due to joint stiffness (elbow contracture) between October 2021 and August 2024. Patient
records were retrieved from an internal database, which included details such as ROM
measurements, measurement dates, device delivery and retrieval timelines, medical insurance
information, and clinician and physical therapist notes (with corresponding ICD-10 codes).
Flexion and/or extension ROM measurements were collected from PT progress notes. Patients
included for analyses in the study had two or more ROM values of the same type measurements
recorded from the PT notes. The initial range of motion measurement was required to be
documented within 30 days of device delivery, while the subsequent measurement had to be
recorded at a minimum interval of 14 days following the initial assessment.
HIS Device Protocol
A HIS device is typically prescribed when a patient experiences a plateau in motion recovery
following a minimum of four weeks of physical therapy. During this period, standard therapy is
often continued alongside device usage. Patients included in this study had likely failed to
achieve the elbow flexion and/or extension range of motion (ROM) goals established by the
treating clinician. These goals were determined based on factors such as the type of injury or
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surgical procedure, contralateral elbow ROM, and patient-specific characteristics including age
and sex.
The HIS device utilizes the Patient Actuated Serial Stretch (PASS) protocol to address deficits in
elbow flexion and extension ROM. Patients were instructed to use the device three times per day,
each session comprising 10 minutes of active stretching into maximum tolerable flexion or
extension using the hydraulic system, followed by a 10-minute rest period, and concluding with
an additional 10 minutes of stretching. During the active stretch intervals, patients were directed
to achieve a level of discomfort just below their pain threshold, allowing for gradual, controlled
elongation of soft tissues.
PT Measurements
Physical therapists documented ROM measurements in clinic progress notes. A goniometer was
used to measure movement, with the acromion process, lateral epicondyle of the humerus, and
radial styloid process serving as bony landmarks. Both active (AROM) and passive (PROM)
ROM were recorded; however, only AROM data are reported, as these measurements were the
most commonly documented and are more applicable to ADLs.
Outcomes of interest
The outcomes used for the purpose of the study included ROM measurements and the number of
days between the first and last measurement taken.
Statistical analysis
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Paired t-tests were conducted to compare initial and final ROM measurements. Results are
reported as mean ± standard deviation, with statistical significance defined at α < 0.05. All
analyses were performed using GraphPad Prism software (version 10.4.1).
figure 1 here
Figure 1. The high intensity stretch (HIS) device used for flexion stretching (left) and extension
stretching (right).
Results
After excluding patients that were missing PT notes and had fewer than two flexion/extension
measurements within the required timeframe, a total of 67 patients were included in the analysis.
On average, patients were 48.8 ± 12.6 years old, 56.7% were male, 3% did not report their sex
and 50.7% were treating the left elbow. The most common conditions treated based on patients’
ICD-10 codes included joint stiffness (34.3%), fractures (23.9%) and pain (13.4%).
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Initial and last recorded ROM measurements, motion gains and the days between the device
delivery date and last recorded ROM from PT notes are shown in Table 1.
Table 1. Measurements from physical therapy notes for active range of motion.
n Initial Last Recorded Gains P-Value
Days from Delivery to
Last Measurement
Flexion 64 106.1 ± 20.6 121.4 ± 18.0 15.3 ± 17.8 <0.001 58.1 ± 34.7
Extension 64 -29.7 ± 19.4 -21.2 ± -16.9 8.5 ± 15.8 <0.001 57.3 ± 33.7
Within this dataset, males (n = 37) demonstrated an improvement in flexion from an initial
102.7° ± 19.9° to 117.8° ± 19.4° (p < 0.001), while females (n = 25) improved from 111.8° ±
21.4° to 127.5° ± 14.8° (p < 0.001). For extension, males (n = 38) improved from -29.1° ± 18.7°
to -19.6° ± 18.2° (p < 0.001), and females (n = 24) improved from -29.8° ± 20.8° to -22.5° ±
14.8° (p = 0.031).
Patients aged 60 years and older (n = 16) improved in flexion from 101.6° ± 16.5° to 116.8° ±
16.5° (p < 0.001), while those under 60 years (n = 48) improved from 107.7° ± 21.7° to 123.0° ±
18.3° (p < 0.001). For extension, older patients improved from -32.3° ± 19.1° to -19.9° ± 14.6°
(p < 0.001), while younger patients improved from -28.9° ± 19.6° to -21.6° ± 17.7° (p = 0.006).
Among patients with severe motion loss (≤90° of active flexion at the initial measurement; n =
11), flexion increased from 73.9° ± 17.1° to 100.1° ± 23.1° (p = 0.013). For those with severe
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extension deficits (≤-50° of active extension deficit; n = 12), extension improved from -57.6° ±
11.1° to -40.4° ± 14.7° (p < 0.001).
Discussion
The most important finding from this study is that high intensity stretching is an effective
treatment modality for patients with elbow contractures as shown by the gains in ROM for elbow
flexion and extension in this population. These gains are consistent for all types of patients
regardless of age, sex, or the severity of motion loss.
PT and low intensity stretch devices (dynamic and static splints) have variable results in treating
elbow contractures. Low intensity devices have been shown to produce motion gains in patients
with moderate motion loss, but may not be effective in patients with more severe motion loss 21
.
Complaints with the comfort of wearing lower intensity devices have also been reported 22
. Only
63% of SPS patients reached a functional ROM after treatment 23
. Treatment with dynamic or
static splinting could take 6 to 12 months to see significant results 24
.
Motion restoring procedures have been shown to have limited efficacy in treating elbow
contractures. One study reported that only 55% of patients gained motion after MUA while 27%
of patients saw no change and 18% which lost motion 25
. The same study reported transient
sensory ulnar neuropathies in 18% of patients. In another study, 16.7% of MUA patients went on
to require subsequent open contracture release surgery 26
. It has also been shown that if an MUA
is performed more than 3 months after the initial surgery, the MUA does not reliably increase
elbow motion 27
. After arthroscopic or open contracture release surgery, 80% of patients achieve
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functional ROM (between 30 and 130 degrees), but mobility acquired by surgery may be lost in
many cases 10
.
The results of this study show that patients treated with the HIS device reach a ROM level where
they would avoid motion restoring procedures and be able to perform most or all ADLs. While
the last recorded flexion is lower than the level reported for some ADLs, this was not the final
ROM at the end of treatment. The last recorded measurement is generally taken prior to the last
month of treatment and the patient would generally have additional gains with additional days of
treatment. The device was in the patient’s home for more than a month after the last recorded
measurement 81% of the time. The average final recorded flexion is already sufficient to perform
all ADLs reported in the study by Vasen et al. 28
. The last recorded flexion for HIS patients in the
study was high enough to perform ADLs in 63% of patients (120 degrees or above). Since this
was not the final flexion at the end of treatment, additional patients would likely reach the 120
degree mark by the end of treatment. The last recorded flexion was at least 115 degrees in 73%
of patients. This success rate is higher than the 63% rate of functional motion recovery reported
in SPS devices and nearly equivalent to the success rate after surgical procedures without the
added risks. The average time between measurements for HIS patients was less than 2 months,
so functional ROM was achieved in a much shorter timeframe than in the 6-12 months of
treatment time reported for lower intensity devices. HIS devices have also been shown to
maintain motion gains over time 18
. HIS is an attractive treatment modality compared to other
available options because it has improved outcomes compared to lower intensity stretch devices
and to PT alone and it avoids the risks and costs associated with any surgical procedure 15-18
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The limitations of this study are the same as seen in any retrospective study such as missing
information, lost followups, and no control group. While there is not a control group, the data
from this population could be compared to the natural history of recovery after traumatic elbow
contractures using healthcare claims data in the future.
Conclusion
We believe that high intensity stretching should be considered as a treatment option in
appropriate patients prior to performing an MUA or more invasive surgery because the data from
this study show that high intensity stretching will likely be able to prevent the more aggressive
treatment and the associated costs and risks by allowing for functional range of motion recovery
in the majority of patients in less than two months of treatment.
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