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Does Early Mobilization Have An Affect On Personal Functioning Post Upper Extremity Fracture in Older.. Berwick, Dorothy; Downs, Kaya; Ebbehoj, Caitlin; Exner, Kirsty; McCartie, Jessica; Roberts, Anja; Sanche, Rosemarie 2010

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A Systematic ReviewBy:Anja RobertsCaitlin EbbehojDorothy BerwickJessica McCartieKaya DownsKirsty ExnerRosemarie SancheSupervisor: Dr. Lynne FeehanOverviewPurposeIntroductionMethodsResultsDiscussionPurposeTo systematically review the current evidence and determine whether early mobilization improves physical functional outcomes when compared to immobilization in older adults with upper extremity fractures. IntroductionDescription of upper extremity fractureMinimal-trauma, age-related or low energy fracturesPrecursor for skeletal fragility and increased risk for all types of subsequent osteoporotic fractures growing public health problemprojected increasing incidence as the population ages (Bliuc, 2009; Centre, 2007; Cummings, 2002; Jones, 1994; Riggs, 1988; Cummings, 1985)		IntroductionIncidenceFractures of the humerus, forearm, and wrist account for one-third of the total incidence of fractures in older populations (Nguyen, 2001)							Non-hip and non-vertebral fractures = approximately 50% of all low-trauma fractures                                                                   (Bliuc, 2009)Caucasian women ( 65– 84 yrs) osteoporosis = approximately 70% of distal radius fractures and 50% of all other fractures (Melton, 1997; Stone, 2003)				IntroductionHealth care cost 1995 - United States economic burden of osteoporosis estimated to be as high as $13.8 billion (Ray, 1997; Stone, 2003)						2000 - Europe, the cost of osteoporotic fractures was estimated at 31.7 billion Euros (Kanis, 2005; Kanis, 2005; Tineke, 2007) IntroductionAssociated morbidity & mortalityMortality increases following all major types of fragility fractures in older age groupsNon-hip, non-vertebral fractures associated with 29% of premature mortality Non-hip and non-vertebral fractures are associated with more than 40% of all deaths(Bliuc, 2009)Greater percentage of mortality associated with increasing age (50-95yrs) post Colles’ fracture (Haentjens 2004)Within 5 years:individuals with a wrist fracture had a risk of a subsequent fracture of 17.9%after an initial non-vertebral fracture, nearly 1 in 5 patients sustained a subsequent non-vertebral fracture, and 1 in 3 died(Huntjens 2010) IntroductionThe InterventionNon-surgically Closed reduction with additional stabilization or support (ie. plaster cast, dynamic splint) Removable sling or elastic bandage =  early motionPlaster cast = immobilizationIntroductionImmobilization = no passive or active exercises for up to 3 weeks 		 likelihood of displacement of a fracture site after it has been reduced 	 further tissue damage, pain and swelling reduces complications such as deformity, functional problems and long-term pain (Nash, 2004). 						allows healing without extensive scarring and prevents secondary injuries (Kannus 2000) of a fracture site until it has healed leads to positive functional results (Boileau 2001)  	IntroductionImmobilization = no passive or active exercises for up to 3 weeks Potential consequences:muscle atrophy possible disuse osteoporosisadhesionsjoint stiffnessdecreased proprioception and kinesthesialong-term functional loss (Wright, 2008; Kannus, 2000; Buckwalter, 1995; Byl, 1999) IntroductionEarly mobilization = passive or active range of motion exercises within the first 3 weeksDecreases:swellingmuscle atrophydisuse osteoporosisadhesionjoint stiffnesslong-term functional loss (Dias, 1987; Allain, 1999; Abbaszadegan, 1989)	regenerates articular cartilagepromotes circulation and nutrition to the healing boneaids in the reduction of edema (Allain, 1999; Goslings, 1999)Improves soft tissue healing (Millet, 1995) IntroductionEarly mobilization = passive or active range of motion exercises within the first 3 weekssignificantly reduces pain in the short and long term (Hodgson, 2003; Liow, 2002; Allain, 1999; McAuliffe, 1987) earlier recovery of mobility and strengthfacilitates an earlier return to work (Feehan, 2004)decreases long-term disabilityensures a more rapid recovery of physical functioning (Millet 1995) IntroductionRecent systematic reviews:have looked at early mobilization post fracture in specific joints such as proximal humerus, distal radial, and metacarpals(Feehan, 2004; Handoll, 2003; Handoll, 2008; Nash, 2004)each review suggests: inconsistent or insufficient evidence that early motion may improve short-term physical functional recoveryno definitive, high quality evidence to support practice recommendations post upper extremity fracturesPurpose: EPOCMethods: Search StrategyDatabasesOther FormsCochrane Central Register of Controlled TrialsCINAHL EMBASE Medline Hand Searching Reference Lists, Physical TherapyPersonal LibrariesClinical Expertise (Dr. Lynne Feehan; Clare Faulkner, IHT)Methods: Search StrategyMain Terms:aged, middle aged, aged 80 and over, upper extremity fracture, boneearly or immediate mobilization, exercise, physical therapy, range of motion, hand therapydelayed or late mobilizationactivities of daily living, self care, treatment outcome, recovery of function, quality of life, disability evaluation, data collectionMethods: Study SelectionInclusion Criteria	Exclusion Criteriagroups with a mean age of 45 or older upper extremity fractureearly mobilization treatment intervention (< 3 weeks) to conventional or standard carehuman studiesavailable in full text in Englishrandomized control trialsquasi-randomized control trials,any pathological condition of the fracture site, excluding osteoporosisthey were taking corticosteroids or chemotherapy drugsMethodsStudy SelectionLast Search May 2010Initial screen based on title and abstracttwo person independent reviewFull Text Review with inclusion criteria2 person independent review, 3rd reviewer if consensus could not be reachedRecords identified through database searching: 80Additional Records Identified from other sources: 46      Records Screened 126   Excluded : 7  Full Text articles screened for eligibily: 119   Full-text articles excluded, with reasons: 104    Studies included in qualitative synthesis 15Studies included in quantitative synthesis 10Methods: Study SelectionData Extraction FormCreated based on Location of fractureIntervention groups Method of immobilization or mobilization  Outcome measuresPiloted on 7 studies Completed by one independent reviewer, verified by a 2nd reviewer, 3rd was brought in if there was any discrepanciesMethods: Quality AssessmentMethods: Quality of StudiesRevised Downs & Black Quality Assessment ToolMethodological criteria were independently assessed by two reviewersConsensus reached by discussionHigh Quality = 8 (score ≥ 21)Low Quality = 7 (score ≤ 20)Methods: Data AnalysisStudies with same outcome measureMeans reweighted Scales standardizedEffect size calculatedStudies with different outcome measuresQualitative analysis 3 time intervals for follow-upLess than 12 weeks, 12-26 weeks, greater than 26 weeksStudy SelectionOutcome MeasurementsICF FrameworkPrimary outcome: Activity and Participation LimitationSF-12 & 36, Oxford, Constant Shoulder assessment, Croft disability score, DASH, Modified Neer Score Gartland & Werley, Modified Mayo wrist scoreSecondary outcomes: Body Function and StructureROM, pain, strengthQualitative Statistically significant findingsActivity and Participation Limitation: 5 studiesAbbaszadegan, Davis, Hodgson, Levefre-Colau & Rozental6 & 12 weeksearly motion group > late motion groupROM: 4 studies Abbaszadegan, Allain, Lefevre-Colau, Rozental6, 9 ,12 & 52 weeksearly motion group > late motion groupQualitative Statistically significant findingsGrip strength: 2 studies McAuliffe, Rozental6 & 52 weeksEarly motion group > late motion groupPain: 5 studies Abbaszadegan, Hodgson 2003, Kristiansen, Lefevre-Colau, McAuliffe8, 12 & 16 weeksearly motion group < late motion group Adverse Events257 out of 1,068 participantsmost common:pin site infectionmalunion with surgical interventionsparasthesia of radial & median nerve distributions Is early motion beneficial post upper extremity fracture?Differences in opinions exist as to the safety of early motion and its effectivenessAll 15 studies have a treatment group that allows early motion (7 surgically, 8 conservatively)Benefits of early motionActivity and participation benefitsEarly (<12 weeks) recovery of function, return to work and domestic abilitiesStudies that showed a clinically significant difference between groups:4 used removable types of immobilization (sling, elastic bandage) Hodgson 2003, Davis 1987 , Lefevre-Colau 2007, Abbaszadegan 19891 compared two different types of surgery  Rozental, 2009Benefits of early motionBody structure and function benefitsEarly (< 12 weeks) improvement in ROM, grip strength and decreased painStudies that showed a clinically significant difference between groups:5 used removable types of immobilization (sling,  elastic bandage) Lefevre-Colau, 2007; Hodgson 2003, Abbaszadegan,1989; Kristiansen, 1989; McAuliffe, 19871 compared two different types of surgery Rozental, 20091 compared same surgery Allain, 1999LimitationsProcess: Did not hand search conference proceedings or investigate ongoing studies Authors of unpublished studies were not contacted English publications onlyLimitations Evidence:Description of randomizationConcealment of treatment allocationBlinding outcome assessors5 out of 15 studies excluded from quantitative synthesis due to lack of dataNon-standardized outcome measures 2/15 studies with sample populations < 50Inability to conduct meta-analysis due to heterogeneity Different interventionsDifferent outcomes measures at different follow up timesClinical RelevanceEarly motion is safe and effective in improving a person’s activity and participation within the first 12 weeks of rehabilitationEarlier return to daily activities and work leading to an improved quality of lifeDecreased treatment time (costs)Decreased risk for a subsequent fracture in this older populationFuture ResearchFocus on one or two common interventions, such as immobilization in a plaster cast versus early motion in a removable type of immobilization device Use only valid and standardized activity and participation outcomes (SF-12 or DASH)Compare how early benefits (within twelve weeks post-fracture) of early motion intervention translates to earlier return to work, decreased risk for secondary fractures, and decreased costsConclusionThis review suggests that compared to the standard care or immobilization of greater than three weeks, early motion is effective in improving a person’s activity and participation, especially within the first 12 weeks of rehabilitation.AcknowledgementsDr. Lynne FeehanCharlotte BeckKiran BisraDr. William Miller Different sx: ORIF (early) vs. CR w/ pin fixation (late)  1 week vs. 6 weeks*Same surgery: trans-styloid fixation  1wk vs. 6 wks in plaster cast*Common theme found in studies was that there was no difference btw early and late, therefore cannot condemn early motion because adverse events were no diffferent btw groups, therefore it’s safeNo harm found after early motion interventions – minor adverse events and no diff. btw groupsFrom intro: low-impact fracture indicates possible start of osteop… can lead to secondary fractures…?* A Systematic Review By: Anja Roberts Caitlin Ebbehoj Dorothy Berwick Jessica McCartie Kaya Downs Kirsty Exner Rosemarie Sanche Supervisor: Dr. Lynne Feehan  Overview Purpose Introduction Methods Results Discussion  Purpose To systematically review the current evidence and determine whether early mobilization improves physical functional outcomes when compared to immobilization in older adults with upper extremity fractures.  Introduction Description of upper extremity fracture • Minimal-trauma, age-related or low energy fractures • Precursor for skeletal fragility and increased risk for  all types of subsequent osteoporotic fractures • growing public health problem • projected increasing incidence as the population  ages •  (Bliuc, 2009; Centre, 2007; Cummings, 2002; Jones, 1994; Riggs, 1988; Cummings, 1985)  Introduction Incidence • Fractures of the humerus, forearm, and wrist  account for one-third of the total incidence of fractures in older populations •  (Nguyen, 2001)  • Non-hip and non-vertebral fractures =  approximately 50% of all low-trauma fractures •  (Bliuc, 2009)   Caucasian women ( 65– 84 yrs) osteoporosis =  approximately 70% of distal radius fractures and 50% of all other fractures  (Melton, 1997; Stone, 2003)  Introduction Health care cost • 1995 - United States economic burden of osteoporosis estimated to be as high as $13.8 billion •  (Ray, 1997; Stone, 2003)  2000 - Europe, the cost of osteoporotic  fractures was estimated at 31.7 billion Euros   (Kanis, 2005; Kanis, 2005; Tineke, 2007)  Introduction Associated morbidity & mortality • Mortality increases following all major types of fragility  fractures in older age groups • Non-hip, non-vertebral fractures associated with 29% of premature mortality • Non-hip and non-vertebral fractures are associated with more than 40% of all deaths •  (Bliuc, 2009)  • Greater percentage of mortality associated with increasing  age (50-95yrs) post Colles’ fracture  (Haentjens 2004)  •  • Within 5 years: • •  individuals with a wrist fracture had a risk of a subsequent fracture of 17.9% after an initial non-vertebral fracture, nearly 1 in 5 patients sustained a subsequent non-vertebral fracture, and 1 in 3 died •  (Huntjens 2010)  Introduction The Intervention Non-surgically • Closed reduction with  additional stabilization or support (ie. plaster cast, dynamic splint) •  Removable sling or elastic bandage = early motion  •  Plaster cast = immobilization  Introduction Immobilization = no passive or active exercises for up to 3 weeks  •  likelihood of displacement of a fracture site after it has been  reduced •  further tissue damage, pain and swelling  • reduces complications such as deformity, functional problems  and long-term pain •  (Nash, 2004).  • allows healing without extensive scarring and prevents  secondary injuries  •  (Kannus 2000)   of a fracture site until it has healed leads to positive functional  results    (Boileau 2001)  Introduction Immobilization = no passive or active exercises for up to 3 weeks • Potential consequences: • muscle atrophy • possible disuse osteoporosis • adhesions • joint stiffness • decreased proprioception and kinesthesia • long-term functional loss •  (Wright, 2008; Kannus, 2000; Buckwalter, 1995; Byl, 1999)  Introduction  Early mobilization = passive or active range of motion exercises within the first 3 weeks • Decreases: • • • • • •  swelling muscle atrophy disuse osteoporosis adhesion joint stiffness long-term functional loss •  (Dias, 1987; Allain, 1999; Abbaszadegan, 1989)   regenerates articular cartilage  promotes circulation and nutrition to the healing bone  aids in the reduction of edema   (Allain, 1999; Goslings, 1999)  • Improves soft tissue healing •  (Millet, 1995)  Introduction Early mobilization = passive or active range of motion exercises within the first 3 weeks  significantly reduces pain in the short and long term   (Hodgson, 2003; Liow, 2002; Allain, 1999; McAuliffe, 1987)  • earlier recovery of mobility and strength • facilitates an earlier return to work •  (Feehan, 2004)   decreases long-term disability  ensures a more rapid recovery of physical functioning   (Millet 1995)  Introduction Recent systematic reviews: • have looked at early mobilization post fracture in specific  joints such as proximal humerus, distal radial, and metacarpals •  (Feehan, 2004; Handoll, 2003; Handoll, 2008; Nash, 2004)  • each review suggests: • inconsistent or insufficient evidence that early motion  may improve short-term physical functional recovery • no definitive, high quality evidence to support practice  recommendations post upper extremity fractures  Purpose: EPOC  Methods: Search Strategy Databases  Other Forms  Cochrane Central  Hand Searching • Reference Lists, Physical Therapy Personal Libraries  Register of Controlled Trials CINAHL EMBASE Medline  Clinical Expertise (Dr.  Lynne Feehan; Clare Faulkner, IHT)  Methods: Search Strategy Main Terms: aged, middle aged, aged 80 and over, upper extremity fracture, bone early or immediate mobilization, exercise,  physical therapy, range of motion, hand therapy  delayed or late mobilization activities of daily living, self care, treatment  outcome, recovery of function, quality of life, disability evaluation, data collection  Methods: Study Selection Inclusion Criteria  Exclusion Criteria   groups with a mean age of   any pathological condition  45 or older  upper extremity fracture  early mobilization treatment intervention (< 3 weeks) to conventional or standard care  human studies  available in full text  in English  randomized control trials  quasi-randomized control  of the fracture site, excluding osteoporosis  they were taking corticosteroids or chemotherapy drugs  Methods Study Selection Last Search May 2010 Initial screen based on title and abstract • two person independent review Full Text Review with inclusion criteria 2  person independent review, 3rd reviewer if consensus could not be reached  Records identified through database searching: 80  Additional Records Identified from other sources: 46      Records Screened 126     Excluded : 7  Full Text articles screened for eligibily: 119  Methods: Study Selection Data Extraction Form  Created based on  Location  of fracture  Intervention groups  Method of immobilization or mobilization  Outcome measures Piloted on 7 studies Completed by one independent reviewer,  verified by a 2nd reviewer, 3rd was brought in if there was any discrepancies  Methods: Quality Assessment  Methods: Quality of Studies Revised Downs & Black Quality Assessment Tool • Methodological criteria were independently assessed by two reviewers • Consensus reached by discussion • High Quality = 8 (score ≥ 21) • Low Quality = 7 (score ≤ 20)  Methods: Data Analysis Studies with same outcome measure • Means reweighted • Scales standardized • Effect size calculated Studies with different outcome measures • Qualitative analysis  3 time intervals for follow-up • Less than 12 weeks, 12-26 weeks, greater than 26 weeks  Study Selection  Outcome Measurements ICF Framework Primary outcome: Activity and Participation  Limitation SF-12 & 36, Oxford, Constant Shoulder  assessment, Croft disability score, DASH, Modified Neer Score Gartland & Werley, Modified Mayo wrist score  Secondary outcomes: Body Function and  Structure ROM, pain, strength  Qualitative Statistically significant findings Activity and Participation Limitation: 5 studies • Abbaszadegan, Davis, Hodgson, Levefre-Colau & Rozental 6 & 12 weeks early motion group > late motion group ROM: 4 studies  Abbaszadegan, Allain, Lefevre-Colau, Rozental 6, 9 ,12 & 52 weeks early motion group > late motion group  Qualitative Statistically significant findings Grip strength: 2 studies McAuliffe, Rozental 6 & 52 weeks Early motion group > late motion group Pain: 5 studies Abbaszadegan, Hodgson 2003, Kristiansen, Lefevre-Colau, McAuliffe 8, 12 & 16 weeks early motion group < late motion group  Adverse Events 257 out of 1,068 participants most common: • pin site infection • malunion with surgical interventions • parasthesia of radial & median nerve distributions     Is early motion beneficial post upper extremity fracture? Differences in opinions exist as to the safety of  early motion and its effectiveness All 15 studies have a treatment group that allows  early motion (7 surgically, 8 conservatively)  Benefits of early motion Activity and participation benefits • Early (<12 weeks) recovery of function, return to  work and domestic abilities  Studies that showed a clinically significant  difference between groups: • 4 used removable types of immobilization  (sling, elastic bandage)  Hodgson 2003, Davis 1987 , Lefevre-Colau  2007, Abbaszadegan 1989  • 1 compared two different types of surgery Rozental, 2009  Benefits of early motion Body structure and function benefits • Early (< 12 weeks) improvement in ROM, grip strength and decreased pain Studies that showed a clinically significant  difference between groups: • 5 used removable types of immobilization  (sling, elastic bandage)  Lefevre-Colau, 2007; Hodgson 2003, Abbaszadegan,1989; Kristiansen, 1989; McAuliffe, 1987  • 1 compared two different types of surgery 2009  • 1 compared same surgery  Allain, 1999  Rozental,  Limitations Process: Did not hand search conference proceedings or  investigate ongoing studies Authors of unpublished studies were not contacted English publications only  Limitations  Evidence: • Description of randomization  Concealment of treatment allocation  Blinding outcome assessors  5 out of 15 studies excluded from quantitative synthesis  due to lack of data  Non-standardized outcome measures  2/15 studies with sample populations < 50  Inability to conduct meta-analysis due to heterogeneity  Different interventions  Different outcomes measures at different follow up times  Clinical Relevance Early motion is safe and effective in improving a  person’s activity and participation within the first 12 weeks of rehabilitation Earlier return to daily activities and work leading to an improved quality of life Decreased treatment time (costs) Decreased risk for a subsequent fracture in this older population  Future Research Focus on one or two common interventions, such  as immobilization in a plaster cast versus early motion in a removable type of immobilization device Use only valid and standardized activity and participation outcomes (SF-12 or DASH) Compare how early benefits (within twelve weeks post-fracture) of early motion intervention translates to earlier return to work, decreased risk for secondary fractures, and decreased costs  Conclusion This review suggests that compared to the standard  care or immobilization of greater than three weeks, early motion is effective in improving a person’s activity and participation, especially within the first 12 weeks of rehabilitation.  Acknowledgements Dr. Lynne Feehan Charlotte Beck Kiran Bisra Dr. William Miller  

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