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Department of Research,
School of Physiotherapy,
RK University, Rajkot,
Gujarat, India
Address for correspondence: Dr. Krupa Tank, Yogi Krupa, Shivam Park-1, B/H Amruta Hospital, Nr. Raiya Circle, 150 Feet Ring Road, Rajkot, Gujarat, India. E-mail: dr.krupatank@ gmail.com Submission: 25-04-2024 Revision: 01-08-2024 Accepted: 25-08-2024 Published: 16-10-2024 Department |
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Patel and Tank: Assistive devices used for reversible knee flexor contracture
| ultimately causing tightness and can lead to joint contracture.[6,7] Joint contracture is characterized by restriction in full ROM and occurs due to the shortening of periarticular connective tissues and muscles. Specifically, restriction in full extension of the knee is called a knee flexion contracture (KFC) or hamstring contracture.[7,8] The prevalence of flexion contracture (FC) of the knee in osteoarthritis (OA) is 32.4%.[9] There are mainly three types of joint contractures: myogenic, arthrogenic, and soft tissue. Myogenic, linked to muscle shortening, is common in neurological conditions or after prolonged immobility.[7,10] Atherogenic involves bone, cartilage, and joint capsule changes, often associated with pain in conditions such as OA.[10] Soft‐tissue contractures, related to scar tissue, occur with injuries such as burns.[11] All impair mobility significantly.[3,7] One study done on energy expenditure says that there will be a need for more energy when the knee persists in flexion during walking.[12,13] The quadriceps need to exert 22% more energy while the knee keeps in 15° of flexion and 50% more when the knee flexes to 30° of flexion.[13] There are various physiotherapy treatments available to treat reversible knee flexor contracture such as sustained stretch, vibration, and continuous passive motion (CPM).[4] Manual knee extension or with a manual therapy belt, heel prop exercise can also be beneficial to increase knee extension ROM.[14] Various mechanical devices exist for treating reversible knee flexor contracture such as static stretch devices,[15,16] advanced dynamic ROM splints,[17] and high‐intensity stretch mechanical therapy device ERMI Knee Extensionater.[15,18] The purpose of this literature is to explore the strong evidence for available assistive devices used to rehabilitate reversible knee flexor contracture. Aim The aim of the study was to find out the most appropriate, effective, user‐friendly mechanical device to treat reversible knee flexor contracture. Methodology A comprehensive narrative review was conducted utilizing PubMed, Google Scholar, and the physiotherapy evidence database to gather relevant literature up to April 2023, adhering to the scale for the assessment of narrative review articles checklist to ensure quality | and reliability. The search strategy involved the use of specific terms including “flexion contracture,” “hamstring contracture,” “knee flexion contracture,” “burn contracture,” “knee joint hypomobility,” “devices for reversible knee flexor contracture,” “rehabilitation,” and “physiotherapy to treat knee contracture.” The inclusion criteria were studies that focused on the physiotherapy treatment of reversible knee flexor contracture, were available in English, and provided full‐text access. Conversely, studies were excluded if they cantered on invasive or surgical treatment methods, were related to contractures caused by neurological involvement, focused on joints other than the knee, employed conventional rehabilitation methods, or were not available in full text or English. The study selection process began with an initial search that yielded 35,400 studies. After the first level of exclusion based on language, focus, and availability, 35,272 studies were excluded. This left 128 studies, which were then scrutinized further through abstract reviews to ensure relevance to the topic. Following a detailed full‐text review, an additional 121 studies were excluded because they focused on contractures due to neurological causes or did not incorporate mechanical devices for rehabilitation [As shown in Flowchart 1]. Ultimately, seven studies met all the inclusion criteria and were selected for detailed analysis. These studies provided insights into the noninvasive physiotherapy treatment of reversible knee flexor contracture using mechanical devices. The selected studies were meticulously analyzed to extract relevant data and identify key findings, aiming to present a comprehensive understanding of current practices and emerging trends in the physiotherapy treatment of reversible knee flexor contracture. This systematic approach ensures the robustness and reliability of the narrative review, contributing valuable knowledge to the field of physiotherapy and rehabilitation. |
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Patel and Tank: Assistive devices used for reversible knee flexor contracture
ResultsThis review article discusses the various devices for treating KFC resulting from different causes. The primary aim is to assess the effectiveness of available physiotherapeutic devices in treating contracture and determine their significance. Customized knee device A study done by McGrath et al. [19] on the treatment of FCs after TKA by using a customized knee device (CKD) is shown in Figure 1. This device made up using polyester‐based casting tape (Dynacast PII BSN Medical, Charlotte, NC) was utilized for brace fabrication. CKDs were constructed using a standardized method. Patients were positioned supine, and a stockinette was applied before marking the knee axis. Casting tape was wrapped around the thigh and lower leg, followed by shaping polycentric knee hinges. Additional layers of tape were added, and hooks were attached for elastic bands. Once dry, the cast was cut and trimmed. Patients were instructed on brace application and removal, wearing it only during stretching sessions. Some required recasting after 4–8 weeks customization takes 60–90 min. Forty‐seven patients with KFC >10° post‐TKA received conventional physiotherapy with no improvement. CKDs were then introduced alongside additional therapies including heat, mobilization, stretching, and electrical stimulation. CKD significantly improved knee ROM, knee society scores, and patient satisfaction, addressing contractures effectively in a short timeframe compared to other methods. Another study done by Bhave et al. [20] has supported CKDs as per Figure 1 for knee contractures after internal femoral lengthening. They conducted a retrospective cohort evaluation between 2002 and 2007. All patients underwent surgical iliotibial band release | From this cohort, patients who, despite treatment, had persistent KFC after isolated femoral limb lengthening were identified. Aknee flexor contracture was determined as a passive knee extension deficit of 10° or more. Thus, the final sample comprised 23 patients (27 limbs) undergoing femoral lengthening. Patients mobilized on postoperative day 1 with 50 lb weight bearing, gradually progressing to full weight‐bearing. Daily inpatient physical therapy sessions were followed by outpatient sessions five times a week on discharge, including joint mobilization, muscle stretching, neuromuscular electrical stimulation, and custom knee device application for KFC ≥10°. The following custom knee device protocol was advised: • Wear the CKD for 6–8 h daily at maximum tension, utilizing a TheraBand in a figure‐of‐eight configuration crossing the distal femur for knee extension support • Prop the heel with a pillow to encourage knee extension while sitting or lying down • Continue using the device for 1 h, twice daily, for an extra 2–3 weeks after achieving full extension to preserve correction. They have researched a correlation between the amount of limb lengthening and the occurrence of KFC. Individuals who underwent lengthening of 5–8 cm showed an average FC of 43°, while those with 4.9 cm or less of lengthening had a FC averaging at 30°. They have noticed KFC is common after femoral lengthening, regardless of the lengthening technique used. The study results indicated that combining a custom knee device with specialized physical therapy offers an affordable, noninvasive treatment option that proves effective for patients following femoral lengthening. Dynamic splint Finger and Willis[17] conducted a case report to describe the benefits of using dynamic splinting as an adjunct to physical therapy in reducing contracture and regaining full knee extension following a TKA. This patient was a 61‐year‐old male with FC of 20° following TKA. Physical therapy begins primarily 1 month postoperative. Modalities included galvanic stimulation + ice pack, kinesiotape for swelling, interferential current therapy, and electrical stimulation at home. Manual therapy involved myofascial release (anterior thigh release: 1 min hold; repeated three times), massage (kneading or petrissage and stripping), and joint mobilization (after swelling subsided). The |
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Patel and Tank: Assistive devices used for reversible knee flexor contracture
| exercise program targeted the ROM, strengthening, balance, and proprioception. A knee extension dynasplint (Dynasplint Systems, Inc. Severna Park MD, USA) shown in Figure 2 was used as a secondary intervention, prescribed for nightly wear because this device is generally worn at night while sleeping (6–8 h), which would yield an additional 42– 56 h per week in‐home therapy, tension was gradually increased every week. They found before the TKA, the patient had a maximal active ROM (AROM) of 5°. Post‐TKA, AROM decreased to 20°. After 2 months of physical therapy, AROM improved to 12° but still lacked full extension. Following 2 months of dynasplint use, the patient achieved full extension (AROM of 0°), avoiding the need for manipulation under anesthesia to reduce postoperative contracture. Static progressive stretch device One literature review was conducted by Bhave et al. [16] to treat knee stiffness using a static progressive stretch (SPS) device, as shown in Figure 3. The “total end‐range time” (TERT) principle suggests that gradually increasing the time spent at the end of a joint’s range can improve flexibility. This process allows tissues to adapt and lengthen safely. Applying gentle, prolonged force is effective, while sudden, intense force can lead to pain or injury. SPS devices are commonly bi‐directional and need one device for addressing motion in both directions. They apply a static load that is gradually adjusted, facilitating both relaxation and elongation of joint tissues. SPS braces are worn for up to 30 min, 2–3 times daily, significantly <8–12‐h duration of other treatments. | This review has more than 50 published systematic review, literature reviews, meta‐analyses, and randomized controlled trials which validate the effectiveness and safety of SPS for enhancing ROM, reducing stiffness, and alleviating pain. Large prospective data on SPS demonstrate a 90% increase in ROM, an 84% decrease in stiffness and swelling, and a 70% reduction in pain, with no complication or injury reported. Additional 13 studies focusing on patients with knee stiffness report impressive outcomes with SPS and a reduced need for manipulation under anesthesia or additional surgeries. They have noticed that SPS therapy has demonstrated significant benefits in various clinical trials. Despite lacking a standardized protocol, sessions lasting 5–30 min, up to three times daily, are recommended. Early utilization of SPS devices can yield better outcomes, especially within the first 12 weeks postinjury. Integrating SPS therapy into routine care can optimize ROM and function for patients with knee flexor contracture. Elite seat One case report on ACL reconstruction has been done by Biggs and Shelbourne.[21] This case report aims to describe the application of a knee extension device shown in Figure 4, in managing a patient with type 3 arthrofibrosis. A knee extension device was used in a home exercise regimen for this particular case. The patient was an 18‐year‐old female basketball player, with torn ACL and medial collateral ligament. They found the loss in knee extension is more problematic and causes more limitations than a loss of knee flexion. A knee extension device (Elite Seat, Kneebourne Therapeutics, Noblesville, IN) facilitated knee hyperextension with 10 min sessions, 3–4 times daily, complemented by exercises and gait training. By 8 months postsurgery, the patient resumed basketball, |
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Patel and Tank: Assistive devices used for reversible knee flexor contracture
| achieving symmetrical full hyperextension and flexion within a year, demonstrating effective rehabilitation for type 3 arthrofibrosis. High‐intensity mechanical therapy Dempsey et al. [18] conducted a study on high‐intensity mechanical therapy with ERMI knee extension [As shown in Figure 5] after loss of knee extension. The ERMI Knee Extensionater employs a three‐point bending system with a rigid frame, contoured foam pad, and inflatable air cuff to enhance passive knee extension. In a study of 56 patients, significant improvements were observed after applying six sessions of 10-minute each with this device. Patients with KFCs showed an average 8° increase in extension, sustained over follow‐up, with treatment duration notably shorter than low‐load stretch methods. Torque production study In a study done by Uhl and Jacobs,[15] the purpose was to measure the torque applied by physical therapists during manual therapy, home therapy exercises, and three types of mechanical therapy devices. Torque is crucial in treating knee FC, impacting treatment efficacy. Limited data exist on typical treatment torque. Studies measured torque from various treatments: manual passive extension (68.0 ± 17.5 N m), ERMI knee extensionater (53.0 N m), prone hang exercises with shoes (10.0 N m) and weights (12.4 N m), and SPS devices (10.4 N m). Discussion and Conclusion This literature discussed different mechanical devices used for the FC of the knee. Devices such as SPS devices, dynamic splints, CKDs, ERMI knee Extensionater, and elite seat were discussed in conditions like FC after TKA, lengthening of the femur, arthroplasty, and ACL reconstruction. Moreover discussed the importance | of mechanical devices with positive results in treating KFC. A study was done on torque,[15] and they concluded that ERMI knee extension shows the highest torque production and can treat KFC more efficiently. A literature review by McElroy et al. [22] on Devices for the prevention and treatment of knee stiffness after TKA. They include SPS devices, CKD, and CPM and show positive results in contracture. A randomized control trial was conducted by Ibrahim et al. [23] to see the effect of the SPS device on a shoulder to treat adhesive capsulitis. They have concluded beneficial long‐lasting effects on ROM, pain, and functional outcome. A case report done by MacKay‐Lyons[24] supported the use of dynasplint on elbow FC. Fernandez‐Palazzi and Battistella[25] did a study on hemophilic patients comparing nonoperative treatments such as casting and de‐subluxation splints. Showing significant improvement by both treatment methods after 4 weeks. A case report was done by Jansen et al. [26] on a 67‐year‐old female with OA treated with nonsurgical treatment for 2 months and then went for surgery. After 3 weeks started with physiotherapy rehabilitation but lacked full knee extension and was stuck at 25° even after 3 months. At this point, 3 months after being discharged, the patient’s physical therapist introduced the use of a knee orthosis designed to provide progressive stretch and stress relaxation. The results show that in this particular patient use of 30 min of the device can be beneficial to increase ROM. There was another article supporting to SPS device by Costa et al. [27] used in 26 posttraumatic ankle stiffness patients for 10 weeks. The results show a patient‐directed treatment protocol using an SPS orthosis was an effective measure to treat ankle stiffness. FC, common and challenging to treat conservatively, can be managed with physical therapies. Conventional methods such as static stretching, hydrotherapy, and mobilization may lack consistent force application and often require additional manpower. |
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Patel and Tank: Assistive devices used for reversible knee flexor contracture
| Mechanical devices such as SPS devices, advanced dynamic ROM splints, and high‐intensity stretch devices such as the ERMI Knee Extensionater enhance FC treatment with time efficiency, consistent force, and improved rehabilitation outcomes. They also reduce therapist fatigue and allow for patient‐friendly, home‐based protocols. In conclusion, combining conventional physiotherapy with assistive devices reduces the burden on therapists and improves outcomes for patients with FCs. High‐torque devices like the ERMI knee Extensionater are particularly effective, offering consistent force and patient‐friendly application. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest. References 1. Gupton M, Imonugo O, Black AC, Launico MV, Terreberry RR. Anatomy, bony pelvis and lower limb, knee. InStatPearls [Internet] . StatPearls Publishing; 2023. 2. Hyodo K, Masuda T, Aizawa J, Jinno T, Morita S. Hip, knee, and ankle kinematics during activities of daily living: A cross‐sectional study. Braz J Phys Ther 2017;21:159‐66. 3. Tariq H, Collins K, Tait D, Dunn J, Altaf S, Porter S. Factors associated with joint contractures in adults: A systematic review with narrative synthesis. Disabil Rehabil 2023;45:1755‐72. 4. Kumar R, Kaushal K, Kaur S. Role of physiotherapy in post‐operative knee stiffness: A literature review. AUJMSR 2020;2:31‐5. 5. Pua YH, Ong PH, Chong HC, Yeo W, Tan C , Lo NN. Knee extension range of motion and self‐report physical function in total knee arthroplasty: Mediating effects of knee extensor strength. BMC Musculoskelet Disord 2013;14:33. 6. Holavanahalli RK, Helm PA, Kowalske KJ, Hynan LS. Effectiveness of paraffin and sustained stretch in treatment of shoulder contractures following a burn injury. Arch Phys Med Rehabil 2020;101:S42‐9. 7. Kisner C, Colby LA, Borstad J. Therapeutic Exercise: Foundations and Techniques. Philadelphia, Pennsylvania: F.A. Davis; 2017. p. 1117. 8. Campbell TM, Trudel G, Laneuville O. Knee flexion contractures in patients with osteoarthritis: Clinical features and histologic characterization of the posterior capsule. PM R 2015;7:466‐73. 9. Campbell TM, McGonagle D. Flexion contracture is a risk factor for knee osteoarthritis incidence, progression and earlier | arthroplasty: Data from the osteoarthritis initiative. Ann Phys Rehabil Med 2021;64:101439. 10. Wong K, Trudel G, Laneuville O. Noninflammatory joint contractures arising from immobility: Animal models to future treatments. Biomed Res Int 2015;2015:848290. 11. Klingshirn H, Müller M, Beutner K, Hirt J, Strobl R, Grill E, et al. Implementation of a complex intervention to improve participation in older people with joint contractures living in nursing homes: A process evaluation of a cluster‐randomised pilot trial. BMC Geriatr 2020;20:270. 12. Haller JM, Holt DC, McFadden ML, Higgins TF, Kubiak EN. Arthrofibrosis of the knee following a fracture of the tibial plateau. Bone Joint J 2015;97‐B:109‐14. 13. Su EP. Fixed flexion deformity and total knee arthroplasty. J Bone Joint Surg Br 2012;94:112‐5. 14. Shah N. Increasing knee range of motion using a unique sustained method. N Am J Sports Phys Ther 2008;3:110‐3. 15. Uhl TL, Jacobs CA. Torque measures of common therapies for the treatment of flexion contractures. J Arthroplasty 2011;26:328‐34. 16. Bhave A, Sodhi N, Anis HK, Ehiorobo JO, Mont MA. Static progressive stretch orthosis‐consensus modality to treat knee stiffness‐rationale and literature review. Ann Transl Med 2019;7:S256. 17. Finger E, Willis FB. Dynamic splinting for knee flexion contracture following total knee arthroplasty: A case report. Cases J 2008;1:421. 18. Dempsey AL, Branch TP, Mills T, Karsch RM. High‐intensity mechanical therapy for loss of knee extension for worker’s compensation and non‐compensation patients. Sports Med Arthrosc Rehabil Ther Technol 2010;2:26. 19. McGrathMS, MontMA, SiddiquiJA, Baker E, BhaveA. Evaluation of a custom device for the treatment of flexion contractures after total knee arthroplasty. Clin Orthop Relat Res 2009;467:1485‐92. 20. Bhave A, Shabtai L, Ong PH, Standard SC, Paley D, Herzenberg JE. Custom knee device for knee contractures after internal femoral lengthening. Orthopedics 2015;38:e567‐72. 21. Biggs A, Shelbourne KD. Use of knee extension device during rehabilitation of a patient with Type 3 arthrofibrosis after ACL reconstruction. N Am J Sports Phys Ther 2006;1:124‐31. 22. McElroy MJ, Johnson AJ, Zywiel MG, Mont MA. Devices for the prevention and treatment of knee stiffness after total knee arthroplasty. Expert Rev Med Devices 2011;8:57‐65. 23. Ibrahim M, Donatelli R, Hellman M, Echternach J. Efficacy of a static progressive stretch device as an adjunct to physical therapy in treating adhesive capsulitis of the shoulder: A prospective, randomised study. Physiotherapy 2014;100:228‐34. 24. MacKay‐Lyons M. Low‐load, prolonged stretch in treatment of elbow flexion contractures secondary to head trauma: A case report. Phys Ther 1989;69:292‐6. 25. Fernandez‐Palazzi F, Battistella LR. Non‐operative treatment of flexion contracture of the knee in haemophilia. Haemophilia 1999;5 Suppl_1:20‐4. 26. JansenCM, WindauJE, BonuttiPM, BrillhartMV. Treatment of a knee contracture using a knee orthosis incorporating stress‐relaxation techniques. Phys Ther 1996;76:182‐6. 27. Costa CR, McElroy MJ, Johnson AJ, Lamm BM, Mont MA. Use of a static progressive stretch orthosis to treat post‐traumatic ankle stiffness. BMC Res Notes 2012;5:348. |