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

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 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

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 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.

METHODS

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

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

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 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)

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

RESULTS

Study Selection 126 articles 15 relevant articles

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

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)

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

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  

Statistically Analyzed Outcomes

Statistically Analyzed Outcomes

Statistically Analyzed Outcomes

Statistically Analyzed Outcomes

Statistically Analyzed Outcomes

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

DISCUSSION

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

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

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 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…?

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

Questions