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Does Early Mobilization Have An Affect On Personal Functioning Post Upper Extremity Fracture in Older.. Berwick, Dorothy 2011

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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 Register of Controlled Trials CINAHL EMBASE Medline Hand Searching • Reference Lists, Physical Therapy Personal Libraries 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 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 trials, any pathological condition 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     Full-text articles excluded, with reasons: 104       Studies included in qualitative synthesis 15 Studies included in quantitative synthesis 10 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 Rozental, 2009 • 1 compared same surgery Allain, 1999 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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