1. Supervisor: Dr. Lynne Feehan
Does early mobilization have an affect on personal functioning post upper extremity fracture in older adults?
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
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 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
EXPOSURE
active motion of joints adjacent to a healing fracture introduced within the first 3 weeks post fracture
PEOPLE
45 years or older with any fracture within the upper extremity
OUTCOME
improve the quality and rate of physical functional recovery
COMPARISON
people treated with regional joint immobilization of  greater than 3 weeks.

15. METHODS

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, 3rd 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
Search Results

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 2nd reviewer, 3rd 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, weeks, greater than 26 weeks

25. RESULTS

26. Study Selection
126 articles
15 relevant articles

27. Results: 15 Included Studies
Study
Type
Level of evidence n
Intervention
Abbaszadegan 1989
QRCT 2B 80
Elastic bandage vs cast (dist rad)
Agorastides 2007
RCT 59
hemiarthroplasty: 2 wks vs 6 wks (prox hum)
Allain 1999 60
trans-styloid k-wire fixation: 1 vs 6 wks (dist rad)
Atroshi 2006 38
non-briding vs bridging fixation vs (dist rad)
Davis 1987 1B 55
cast: 1 vs 4 wks (dist rad)
Hodgson 2003 86
sling: 0 vs 3 wks (prox hum)
Hodgson 2007

28. Results: 15 Included Studies
Study
Type
Level of evidence n
Intervention
Krishnan 2003
QRCT 1B 60
non-briding vs bridging fixation vs (dist rad)
Kristiansen 1989 2B 85
sling: 1 vs 3 wks (prox hum))
Lefevre-Colau 2007
RCT 74
sling: 0 vs 3 wks (prox hum)
Lozano-Calderon 2008
fixed angle volar plate: 0 vs 6 wks (dist rad)
McAuliffe 1987
108
cast: 3 vs 5 wks (dist rad)
McQueen 1996
120
cast vs external fixator (dist rad)
Rozental 2009 45
internal fixation vs percutaneous pinning (dist rad)
Stoffelen 1998 52
cast: 1 vs 3 wks (dist rad)

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

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

33. Statistically Analyzed Outcomes

34. Statistically Analyzed Outcomes

35. Statistically Analyzed Outcomes

36. 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

38. DISCUSSION

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
Different sx: ORIF (early) vs. CR w/ pin fixation (late) 1 week vs. 6 weeks

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
Same surgery: trans-styloid fixation 1wk vs. 6 wks in plaster cast

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
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 safe
No harm found after early motion interventions – minor adverse events and no diff. btw groups
From intro: low-impact fracture indicates possible start of osteop… can lead to secondary fractures…?

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