Investigating the effectiveness of stretching interventions on post-traumatic elbow stiffness: a systematic review.

Background: Post-traumatic elbow stiffness is a significant complication following traumatic elbow injury, with incidence up to 56%. A loss of 50% of elbow range-of-movement represents a total loss of 80% of upper limb function, a challenge for both patients and clinicians. There are no established guidelines for the physiotherapy management of elbow stiffness following traumatic injury. Understanding the best treatment for nonarthritic elbow stiffness and most effective rehabilitation for prevention of stiffness following trauma or surgery are two of the top 10 James Lind Alliance priorities for elbow conditions. The study investigates the effectiveness of clinical stretching interventions, either via hold-relax manual techniques or bracing, on post-traumatic elbow stiffness in previously healthy elbow joints. Methods: A systematic search of five databases was performed until July 2024. Search terms related to the condition and interventions were used, without limits on date, language, or design. Adults aged ≥18 years with post-traumatic elbow stiffness, investigating any clinical stretch intervention, were eligible. Chronic or overuse elbow injuries and studies assessing alternative conservative interventions were excluded. Outcomes studied were elbow range-of-movement, function, and pain. Two reviewers screened articles and independently rated the evidence using the Cochrane Risk of Bias and Joanna Briggs Institute critical appraisal tools. Data were extracted, tabulated, and narratively synthesized. Results: Nine studies were included, involving a total 312 participants. Three small randomized controlled trials investigated manual stretches using hold-relax stretch-reflex techniques in early post-traumatic elbow stiffness, with no adverse events reported. One randomized controlled trial and five retrospective case series studies investigated brace interventions in persistent post-traumatic elbow stiffness. Clinically important improvements were reported in elbow flexion and extension range-of-movement following both intervention types (hold-relax and bracing). Bracing interventions had more adverse events. Insufficient information was available regarding adherence to protocols. Heterogeneity and incomplete reporting prevented meta-analysis. Conclusion: Hold-relax interventions may be used for early post-traumatic elbow stiffness, with weaker evidence supporting bracing in persistent elbow stiffness. Limitations included the study risk of bias and number of participants, with larger, multicenter studies warranted to confirm and quantify the effect size.