Presentation on theme: "Supervisor: Dr. Lynne Feehan"— Presentation transcript:
1 Supervisor: Dr. Lynne Feehan Does early mobilization have an affect on personal functioning post upper extremity fracture in older adults?A Systematic ReviewBy:Anja RobertsCaitlin EbbehojDorothy BerwickJessica McCartieKaya DownsKirsty ExnerRosemarie SancheSupervisor: Dr. Lynne Feehan
3 PurposeTo 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.
4 Introduction Description of upper extremity fracture Minimal-trauma, age-related or low energy fracturesPrecursor for skeletal fragility and increased risk for all types of subsequent osteoporotic fracturesgrowing public health problemprojected increasing incidence as the population ages(Bliuc, 2009; Centre, 2007; Cummings, 2002; Jones, 1994; Riggs, 1988; Cummings, 1985)
5 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)
6 Introduction Health care cost United States economic burden of osteoporosis estimated to be as high as $13.8 billion(Ray, 1997; Stone, 2003)Europe, the cost of osteoporotic fractures was estimated at 31.7 billion Euros(Kanis, 2005; Kanis, 2005; Tineke, 2007)
7 Introduction Associated morbidity & mortality Mortality increases following all major types of fragility fractures in older age groupsNon-hip, non-vertebral fractures associated with 29% of premature mortalityNon-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)
8 Introduction The Intervention SurgicallyOpen reduction with internal or external fixation, such as a plate, screw or pinNon-bridging external fixation = early motion of joints adjacent to the fracture site(Melendez, 1989)Bridging external fixation = motion not possible until the fixation device is removedKrishnan, 2003; Paksima, 2004)Non-surgicallyClosed reduction with additional stabilization or support (ie. plaster cast, dynamic splint)Removable sling or elastic bandage = early motionPlaster cast = immobilization
9 IntroductionImmobilization = 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 swellingreduces 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)
10 IntroductionImmobilization = no passive or active exercises for up to 3 weeksPotential consequences:muscle atrophypossible disuse osteoporosisadhesionsjoint stiffnessdecreased proprioception and kinesthesialong-term functional loss(Wright, 2008; Kannus, 2000; Buckwalter, 1995; Byl, 1999)
11 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)
12 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)
13 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 recoveryno definitive, high quality evidence to support practice recommendations post upper extremity fractures
14 Purpose: EPOCEXPOSUREactive motion of joints adjacent to a healing fracture introduced within the first 3 weeks post fracturePEOPLE45 years or older with any fracture within the upper extremityOUTCOMEimprove the quality and rate of physical functional recoveryCOMPARISONpeople treated with regional joint immobilization of greater than 3 weeks.
17 Methods: Search Strategy Main 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 collection
18 Methods: Study Selection Inclusion CriteriaExclusion Criteriagroups with a mean age of 45 or olderupper extremity fractureearly mobilization treatment intervention (< 3 weeks) to conventional or standard carehuman studiesavailable in full textin Englishrandomized control trialsquasi-randomized control trials,any pathological condition of the fracture site, excluding osteoporosisthey were taking corticosteroids or chemotherapy drugs
19 Methods Study Selection Last Search May 2010 Initial screen based on title and abstracttwo person independent reviewFull Text Review with inclusion criteria2 person independent review, 3rd reviewer if consensus could not be reached
20 Search Results Records identified through database searching: 80 Additional Records Identified from other sources: 46Records Screened 126Excluded : 7Full Text articles screened for eligibily: 119Full-text articles excluded, with reasons: 104Studies included in qualitative synthesis 15Studies included in quantitative synthesis 10Search Results
21 Methods: Study Selection Data Extraction FormCreated based onLocation of fractureIntervention groupsMethod of immobilization or mobilizationOutcome measuresPiloted on 7 studiesCompleted by one independent reviewer, verified by a 2nd reviewer, 3rd was brought in if there was any discrepancies
22 Methods: Quality Assessment Revised Downs and Black27 Criteria, consisting of four categories assessing:ReportingExternal validityInternal validity (bias)Internal validity (confounding) (Eng et al., 2007)All studies that met the inclusion criteria were usedRanked according to Level of Evidence:Level 1b: Individual RCT with Narrow CILevel 2b: Individual cohort study or low quality RCT(Oxford,2009)
23 Methods: Quality of Studies Revised Downs & Black Quality Assessment ToolMethodological criteria were independently assessed by two reviewersConsensus reached by discussionHigh Quality = 8 (score ≥ 21)Low Quality = 7 (score ≤ 20)
24 Methods: Data Analysis Studies with same outcome measureMeans reweightedScales standardizedEffect size calculatedStudies with different outcome measuresQualitative analysis3 time intervals for follow-upLess than 12 weeks, weeks, greater than 26 weeks
39 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)
40 Benefits of early motion Activity 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, 2009Different sx: ORIF (early) vs. CR w/ pin fixation (late) 1 week vs. 6 weeks
41 Benefits of early motion Body 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, 1999Same surgery: trans-styloid fixation 1wk vs. 6 wks in plaster cast
42 LimitationsProcess:Did not hand search conference proceedings or investigate ongoing studiesAuthors of unpublished studies were not contactedEnglish publications only
43 Limitations Evidence: Description of randomization Concealment of treatment allocationBlinding outcome assessors5 out of 15 studies excluded from quantitative synthesis due to lack of dataNon-standardized outcome measures2/15 studies with sample populations < 50Inability to conduct meta-analysis due to heterogeneityDifferent interventionsDifferent outcomes measures at different follow up times
44 Clinical 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 populationCommon 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…?
45 Future ResearchFocus on one or two common interventions, such as immobilization in a plaster cast versus early motion in a removable type of immobilization deviceUse 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
46 ConclusionThis 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.
47 Acknowledgements Dr. Lynne Feehan Charlotte Beck Kiran Bisra Dr. William Miller