Tissue Flossing Technique on Post Traumatic Elbow Stiffness.
Condition: Elbow Stiffness
Study type: Interventional

Summary: 
      The purpose of this research is to determine the effect of tissue flossing technique on
      post-traumatic elbow stiffness, Pain and ROM. A randomized control trial was conducted at
      Pakistan ordinance factory (POF) Hospital Wah Cantt, Pakistan. The sample size was 36
      calculated from G-power. 6 participants were excluded from the study and remaining 30
      participants were divided into two groups, each having 15 participants. The study duration
      was six months. Sampling technique was applied was Non probability Convenience Sampling
      technique for recruitment and group randomization using random selection of participants.
      Both post-traumatic and post-operative male and female participants of aged 18-45 years with
      flexion <120° and loss of extension >30°. Tools used in this study are Liverpool elbow Score
      Questionnaire (LES), Goniometer and Visual Analogue Scale (VAS). Data was analyzed through
      SPSS version 23.
    

Detailed description: 
      Post traumatic or operative stiffness at elbow is quite common problem causes higher level of
      impairments in daily living activities i.e. use of mobile or computer, personal hygiene,
      dressing, eating, cooking that requires higher degree of elbow range of motion and adversely
      effects the quality of life (1).

      The common reason of stiffness in elbow is trauma with rates ranging from 3% to 20% (1).
      Incidence of (PTES) is increased up to 56% after elbow trauma (2). Simultaneously radial head
      and elbow injuries increase incidence rate up to 90%, and 5-10% patients are effected by PTES
      even with an isolated injury to the radial head (3). Another study shows that exact incidence
      of elbow stiffness is not known but elbow injuries causes stiffness in approximately 12% of
      patients (1). Elbow stiffness causes can be categorized as traumatic, atraumatic and
      congenital (4).

      Patients with well reduced and stabilized fracture are also suffer for soft tissue and
      capsule thickening leads to range of motion limitation. Stiff elbow has thickened capsule
      with high level of myofibroblast. This causes alteration in the auto-regulation of (TGF-β)
      transforming growth factor-beta. The influence of myofibroblasts is increased in initial
      period after trauma but deficient in chronic stiffness (>5 months) (4).

      Treatment depends upon the cause of stiffness, stiffness time, severity of stiffness and
      involved movement of elbow (5). Treatment include CPM (continuous Passive motion),
      manipulation, stretching, active and passive exercises, mobilization, passive resistance
      exercises, passive mobilization with movements and PNF (proprioceptive neuromuscular
      facilitation technique) (6, 7). Physiotherapy is commonly used treatment both for prevention
      of post traumatic elbow stiffness and regain motion after surgery (7). Factors effecting PTES
      consist of patients and characteristics of fracture and treatment of fracture causes
      stiffness, pain, instability and functional limitations of elbow (4).

      Clinically according to the severity, elbow stiffness is classified as very severe ( flexion/
      extension arc <30), severe ( 30-60), moderate ( 61-90), minimal ( >90) (8). Diagnosis depends
      upon history, imaging and physical examination. Plain radiographs are useful to see joint
      congruity, osteophytes and myositis mass (6).

      Different studies have been conducted to show influence of tissue flossing on ROM, majority
      of these studies have shown positive effects on range of motion (9).

      A systematic and evidence based search of relevant literature was performed by utilizing
      Google Scholar as Search engine and the Key words used were Elbow stiffness, Tissue Flossing,
      Post- Operative elbow stiffness. The purpose of the Literature review is to find out the
      pre-existing literature regarding the Tissue flossing effects.

      In 2017 kiefer et al, conducted a pilot study on the tissue flossing effects and glenohumeral
      flexibility and concluded that flexibility in posttest is significantly increased (10).

      In 2020 Kaneda et al. conducted an experimental research on tissue flossing effect and
      stretching on calf muscles in which 20 healthy young men participated and concluded that prep
      and post changes in dorsiflexion was significantly increase with flossing compare to rest
      (11).

      Although enough researches have not been conducted in disease population but some studies
      have shown its beneficial effect in reducing pain and improve range of motion in diseases
      population (12, 13).

      In 2017, Borda and Selhorst conducted a case study on 14 years old female with chronic pain
      with 8/10 intensity of Achilles tendinopathy and only two session with tissue flossing shows
      improvement in pain with 0/10 and disability during sports (12).

      In 2018, weber et al. conducted a study on 14 years old male soccer player with
      Osgood-Schlatter's disease and concluded that there is significant improvement on muscle
      functions and pain with nine weeks flossing intervention plan (13).

      In 2020 by Marco et al. a pilot study was conducted on five young male athletes with knee
      pain and shows significant improvement on knee pain and jump performance with flossing
      technique (14).

      In 2017 a research was conducted on twelve elite healthy tennis players in which floss band
      wrapped with 50% stretch on elbow joint and perform 6 passive exercises in three mints and
      concluded that there is significant improvement in elbow range of motion in floss band group
      (15).

      In 2019, Stevenson conducted a research on 5 male athletes who had stiffness, tightness, heel
      pain or calf pain and concluded that there was a significant difference between floss group
      and control group (16).

      In 2020, Kielur and powden perform systematic review and meta-analysis in which 6 articles
      were enrolled and concluded that floss band is an effective method for endurance, strength
      and physical functions (17)
    

Intervention name(s): Tisue Flossing Technique
Intervention type(s): Other
Intervention description(s): Experimental Group (Tissue Flossing + conventional therapy) Tissue Flossing involved active and passive movement with elbow wrapped with a floss band made from latex rubber (7m x 2 inch) Floss band was wrapped around the elbow (distal to proximal) using 25% overlapping pattern with an elongation stretch of 25%. During treatment the compression of floss band was measured with modified sphygmomanometer by placing cuff under floss band (which is applied on muscle) and note the pressure on manometer.
Control Group (Conventional Therapy) Conventional therapy was applied for 23 minutes for both groups which include hot pack for 10 minutes, PNF (hold-relax with agonist contraction): It started with a gentle stretch of bicep muscle for 10 seconds followed by isometric contraction for 6 seconds then the patient tried to flex their elbow and the therapist also assisted.
Other intervention name(s): Conventional Physical therapy
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Outcomes Assessor)
Primary purpose: Treatment
Keywords: Tissue Flossing, Postoperative elbow stiffness