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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 Jul 31, 2010

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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  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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