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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.

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Presentation on theme: "A Systematic Review By: Anja Roberts Caitlin Ebbehoj Dorothy Berwick Jessica McCartie Kaya Downs Kirsty Exner Rosemarie Sanche Supervisor: Dr. Lynne Feehan."— Presentation transcript:

1 A Systematic Review By: Anja Roberts Caitlin Ebbehoj Dorothy Berwick Jessica McCartie Kaya Downs Kirsty Exner Rosemarie Sanche Supervisor: Dr. Lynne Feehan

2 Overview  Purpose  Introduction  Methods  Results  Discussion

3 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.

4 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)

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 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)

7 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)

8 Introduction The Intervention  Surgically Open reduction with internal or external fixation, such as a plate, screw or pin Non-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 removed Krishnan, 2003; Paksima, 2004)  Non-surgically Closed reduction with additional stabilization or support (ie. plaster cast, dynamic splint) Removable sling or elastic bandage = early motion Plaster cast = immobilization

9 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)

10 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)

11 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)

12 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)

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 recovery no definitive, high quality evidence to support practice recommendations post upper extremity fractures

14 Purpose: EPOC


16 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)

17 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

18 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

19 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, 3 rd reviewer if consensus could not be reached

20 Search Results 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

21 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 2 nd reviewer, 3 rd was brought in if there was any discrepancies

22 Methods: Quality Assessment  Revised Downs and Black  27 Criteria, consisting of four categories assessing: Reporting External validity Internal validity (bias) Internal validity (confounding) (Eng et al., 2007)  All studies that met the inclusion criteria were used  Ranked according to Level of Evidence: Level 1b: Individual RCT with Narrow CI Level 2b: Individual cohort study or low quality RCT (Oxford,2009)

23 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)

24 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


26 Study Selection 126 articles 15 relevant articles

27 Results: 15 Included Studies


29 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

30 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

31 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

32 Statistically Analyzed Outcomes





37 Adverse Events  257 out of 1,068 participants  most common: pin site infection malunion with surgical interventions parasthesia of radial & median nerve distributions


39 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 )

40 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

41 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

42 Limitations  Process: Did not hand search conference proceedings or investigate ongoing studies Authors of unpublished studies were not contacted English publications only

43 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

44 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

45 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

46 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.

47 Acknowledgements  Dr. Lynne Feehan  Charlotte Beck  Kiran Bisra  Dr. William Miller

48 Questions

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