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
Non-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)
• 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: Search Strategy
Databases
 Cochrane Central
Register of Controlled
Trials
 CINAHL
 EMBASE
 Medline
Other Forms
 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
 any pathological condition of
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,
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
Search
Results
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
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
Study Selection
126 articles
15 relevant
articles
Results: 15 Included Studies
Study
Abbaszadegan
1989
Type
QRCT
Agorastides 2007 RCT
Level of
evidence
n
2B
80
2B
59
Allain 1999
QRCT
2B
60
Atroshi 2006
RCT
2B
38
Davis 1987
QRCT
1B
55
Hodgson 2003
RCT
2B
86
Hodgson 2007
RCT
2B
86
Intervention
Elastic bandage
vs cast (dist rad)
hemiarthroplasty:
2 wks vs 6 wks
(prox hum)
trans-styloid kwire fixation: 1 vs
6 wks (dist rad)
non-briding vs
bridging fixation
vs (dist rad)
cast: 1 vs 4 wks
(dist rad)
sling: 0 vs 3 wks
(prox hum)
sling: 0 vs 3 wks
(prox hum)
Results: 15 Included Studies
Study
Type
Level of
evidence
Krishnan 2003
QRCT
1B
60
Kristiansen 1989 QRCT
Lefevre-Colau
2007
RCT
2B
85
1B
74
Lozano-Calderon
2008
RCT
1B
60
McAuliffe 1987
QRCT
1B
108
McQueen 1996
QRCT
1B
120
Rozental 2009
QRCT
1B
45
Stoffelen 1998
QRCT
2B
52
n
Intervention
non-briding vs
bridging fixation
vs (dist rad)
sling: 1 vs 3 wks
(prox hum))
sling: 0 vs 3 wks
(prox hum)
fixed angle volar
plate: 0 vs 6 wks
(dist rad)
cast: 3 vs 5 wks
(dist rad)
cast vs external
fixator (dist rad)
internal fixation
vs percutaneous
pinning (dist rad)
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
 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, LefevreColau, 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
Standardized weighted mean
Activity and Participation Limitation
55
50
45
Early
Late
40
35
30
1
2
Follow-up (1=<12wks; 2=12-26wks; 3=>26wks)
3
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 Rozental, 2009
• 1 compared same surgery Allain, 1999
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 postfracture) 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