Scholarly article on topic 'Prescribed exercise programs may not be effective in reducing impairments and improving activity during upper limb fracture rehabilitation: a systematic review'

Prescribed exercise programs may not be effective in reducing impairments and improving activity during upper limb fracture rehabilitation: a systematic review Academic research paper on "Medical engineering"

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Journal of Physiotherapy
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{Exercise / "Upper limb" / Rehabilitation / Fracture / "Systematic review"}

Abstract of research paper on Medical engineering, author of scientific article — Andrea M Bruder, Nora Shields, Karen J Dodd, Nicholas F Taylor

Abstract Question What is the effect of exercise on increasing participation and activity levels and reducing impairment in the rehabilitation of people with upper limb fractures? Design Systematic review of controlled trials. Participants Adults following an upper limb fracture. Intervention Any exercise therapy program, including trials where exercise was delivered to both groups provided that the groups received different amounts of exercise. Outcome measures Impairments of body structure and function, activity limitations and participation restrictions. Results Twenty-two trials were identified that evaluated 1299 participants with an upper limb fracture. There was insufficient evidence from 13 trials to support or refute the effectiveness of home exercise therapy compared with therapist-supervised exercise or therapy that included exercise following distal radius or proximal humeral fractures. There was insufficient evidence from three trials to support or refute the effectiveness of exercise therapy compared with advice/no exercise intervention following distal radius fracture. There was moderate evidence from five trials (one examining distal radius fracture, one radial head fracture, and three proximal humeral fracture) to support commencing exercise early and reducing immobilisation in improving activity during upper limb rehabilitation compared with delayed exercise and mobilisation. There was preliminary evidence from one trial that exercise to the non-injured arm during immobilisation might lead to short-term benefits on increasing grip strength and range of movement following distal radius fracture. Less than 40% of included trials reported adequate exercise program descriptions to allow replication according to the TIDieR checklist. Conclusion There is emerging evidence that current prescribed exercise regimens may not be effective in reducing impairments and improving activity following an upper limb fracture. Starting exercise early combined with a shorter immobilisation period is more effective than starting exercise after a longer immobilisation period. Registration CRD42016041818. [Bruder AM, Shields N, Dodd KJ, Taylor NF (2017) Prescribed exercise programs may not be effective in reducing impairments and improving activity during upper limb fracture rehabilitation: a systematic review. Journal of Physiotherapy 63: 205–220]

Academic research paper on topic "Prescribed exercise programs may not be effective in reducing impairments and improving activity during upper limb fracture rehabilitation: a systematic review"

ímYSjíS; No. ol P.g,, 16

Journal of

PHYSIOTHERAPY

journal homepage www.elsevier.com/locate/jphys

Research

Prescribed exercise programs may not be effective in reducing impairments and improving activity during upper limb fracture rehabilitation: a systematic review

Andrea M Brudera, Nora Shields a,b, Karen J Dodda,c, Nicholas F Taylorad

a School of Allied Health, La Trobe University; b Department of Allied Health, Northern Health;c Victoria University; d Allied Health Clinical Research Office,

Eastern Health, Melbourne, Australia

ABSTRACT

Question: What is the effect of exercise on increasing participation and activity levels and reducing impairment in the rehabilitation of people with upper limb fractures? Design: Systematic review of controlled trials. Participants: Adults following an upper limb fracture. Intervention: Any exercise therapy program, including trials where exercise was delivered to both groups provided that the groups received different amounts of exercise. Outcome measures: Impairments of body structure and function, activity limitations and participation restrictions. Results: Twenty-two trials were identified that evaluated 1299 participants with an upper limb fracture. There was insufficient evidence from 13 trials to support or refute the effectiveness of home exercise therapy compared with therapist-supervised exercise or therapy that included exercise following distal radius or proximal humeral fractures. There was insufficient evidence from three trials to support or refute the effectiveness of exercise therapy compared with advice/no exercise intervention following distal radius fracture. There was moderate evidence from five trials (one examining distal radius fracture, one radial head fracture, and three proximal humeral fracture) to support commencing exercise early and reducing immobilisation in improving activity during upper limb rehabilitation compared with delayed exercise and mobilisation. There was preliminary evidence from one trial that exercise to the non-injured arm during immobilisation might lead to short-term benefits on increasing grip strength and range of movement following distal radius fracture. Less than 40% of included trials reported adequate exercise program descriptions to allow replication according to the TIDieR checklist. Conclusion: There is emerging evidence that current prescribed exercise regimens may not be effective in reducing impairments and improving activity following an upper limb fracture. Starting exercise early combined with a shorter immobilisation period is more effective than starting exercise after a longer immobilisation period. Registration: CRD42016041818. [Bruder AM, Shields N, Dodd KJ, Taylor NF (2017) Prescribed exercise programs may not be effective in reducing impairments and improving activity during upper limb fracture rehabilitation: a systematic review. Journal of Physiotherapy XX: XX-XX] © 2017 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

KEY WORDS

Exercise Upper limb Rehabilitation Fracture

Systematic review

Introduction

Upper limb fractures are common, and predicted to increase with an ageing population.1-3 Young adults typically sustain these fractures from high-energy traumas such as motor vehicle accidents, while older adults with osteoporotic changes sustain them from low-energy incidents such as a fall.4,5 Anyone who sustains an upper limb fracture will experience a period where they have difficulty participating in personal, occupational and sporting activities6 that may extend to 12 months beyond the time of fracture.7,8 Some difficulties may be associated with problems related to type or severity of fracture, or to complications such as complex regional pain syndrome. However, some issues may be related to the length and position of immobilisation, surgical treatment or patient-related factors such as age, gender and fear-avoidance behaviour.1,4,8-11 To address these problems and assist recovery, people are often referred for physiotherapy.12

Fracture management is centred on three principles: to reduce, to hold and to move.13 To address the move principle, therapists often prescribe exercise following upper limb fracture to help people return to pre-injury function.1,4'10'14,15 Exercise is structured physical activity that is performed with a goal, such as improvement in muscle strength and joint range of movement. Our previous version of this systematic review found preliminary and indirect evidence that conservatively managed distal radius and proximal humeral fractures may benefit from exercise, which is consistent with the theoretical benefits associated with movement.16 It was difficult to derive a definitive conclusion from that review because exercise was often received by both experimental and control groups, and in conjunction with other therapeutic interventions. The exercise programs were poorly described, preventing inferences about whether one type of program could be more effective in upper limb fracture rehabilitation. Two recently updated systematic reviews investigated treatment and rehabilitation after distal radius5 or proximal humeral fracture.4

ht:tp://dx.doi.org/10.1016/j.jphys.2017.08.009

1836-9553/© 2017 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons. org/licenses/by-nc-nd/4.0/).

These reviews concluded that there was insufficient evidence to recommend interventions during rehabilitation. It was recommended that advice and general instruction on mobilisation should be provided to all people following a distal radius fracture.5 Routine advice, education and exercise have also been recommended in proximal humeral rehabilitation.1

Given the uncertainty about the role of exercise in upper limb fracture rehabilitation, it is important that the original review,16 which had a search completed in 2011, is updated so that therapists have current evidence to inform decision-making. The importance of this review is further indicated by the predicted rise in upper limb fractures and subsequent demand on health services for cost-effective management and rehabilitation.4,7,1017 New trials evaluating exercise have been published since 2011, and a Template for Intervention Description and Replication (TIDieR)18 was published in 2014, which was expected to improve reporting of exercise programs in those subsequent trials. Improved reporting provides an opportunity to synthesise available research and better inform therapists about the types of exercise that should be prescribed following upper limb fracture.

Therefore, the research question for this systematic review update was:

What is the effect of exercise on increasing participation and activity levels and reducing impairment in the rehabilitation of people with upper limb fractures?

Method

This updated systematic review was based on the protocol previously described.16 To identify new trials, the same search strategy was used (see Appendix 1 on the eAddenda for full search strategy), but was limited between January 2011 and July 2016 in the following databases: CINAHL, MEDLINE, Embase, AMED, SPORT Discus, PubMed, PEDro and the Cochrane Central Register of Controlled Trials. Citation tracking of the included studies was also performed using manual reference list checks and Web of Science. Two reviewers independently examined study titles and abstracts to determine if they satisfied the eligibility criteria (Box 1). Where eligibility was not clear, the full text was obtained.

The data extracted from eligible trials were: trial design; age, gender and diagnosis of the participants; type and description of the exercise intervention; outcome measures; and summary data. Data were extracted by one reviewer using the form from the original review, and checked by a second reviewer. Where means

Box 2. Grading system used to describe the level of evidence reported in each trial.

++The trial reported strong or clear evidence that exercise therapy was effective.

+ The trial reported moderate or limited evidence that exercise therapy was effective; or there were indications to support the effectiveness of exercise therapy.

0 The trial reported insufficient or no evidence to support or refute the effectiveness of exercise therapy; or exercise therapy was equally as effective as an alternative exercise therapy program that may have used different amounts of exercise (duration, frequency or intensity) or different method of administration.

- The trial reported that exercise therapy was harmful or less effective than no exercise, other therapy, or alternative exercise program.

and standard deviations of outcomes were not reported, data were estimated according to recommendations (see Appendix 2 on the eAddenda for statistical equations).19 Methodological quality of included trials was assessed independently by two reviewers using the PEDro scale.20 The completeness of intervention description for both intervention and control groups was assessed using the TIDieR checklist by two reviewers working independently.18 To ensure that each item was accurately assessed, sub-categories for items 3, 6 and 8 were used, which was similar to previous research.21 Cohen's kappa was calculated to assess the extent of agreement between reviewers for the PEDro scale and TIDieR checklist, where a kappa value > 0.75 was deemed an excellent level of agreement.22

Meta-analysis was conducted where at least two trials were considered clinically homogenous. Pooled analyses with random effects models to calculate standardised mean differences (SMD) and 95% confidence intervals were applied using Review Manager Version 5.3. Statistical heterogeneity was examined by the I2 statistic where a value of 0% indicated no observed heterogeneity, <25% was considered low heterogeneity and 100% indicated a completely heterogeneous sample.23 The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was used to assess the risk of bias between trials for each completed meta-analysis.24 A randomised, controlled trial was considered the highest level of evidence; however, this rating was downgraded if: PEDro scores were <6 for the majority of trials; there was greater than low levels of statistical heterogeneity between trials (I2 > 25%); there were large confidence intervals (ie, >0.8 SMD); and there was evidence of publication bias, as demonstrated by asymmetry of a funnel plot if >10 trials were included in the meta-analysis.25

In addition, a descriptive synthesis was completed, based on conclusions reported by each trial under the following headings: direct evidence of exercise therapy; indirect evidence of early exercise and early mobilisation; indirect evidence of comparison of different types of exercise therapy programs; and other. A grading system was used to describe the level of evidence reported in each trial,26 as shown in Box 2.

Results

Flow of studies through the review

The update identified a further 885 possible articles. Following removal of duplicates, screening of titles and abstracts, and citation tracking, 16 potentially relevant articles remained. After reapplication of inclusion criteria to full-text versions of the articles, nine were included27-35 and seven excluded.36-42 When added to the trials in the original review, 23 articles27-35,43-56 were

included; these comprised 22 separate trials27-35,43-45,47-56

because one article46 reported follow-up data (Figure 1).

Box 1. Inclusion criteria.

Design

• randomised or quasi-randomised controlled trial

• full-text publication

Participants

• humans

• reached skeletal maturity

• sustained any degree of upper limb fracture (scapula, clavicle, humerus, radius, ulna, carpal, phalanx)

Intervention

• any exercise therapy program

Outcome measures

• any outcome measure (classified by WHO 2001)

Comparisons

• exercise therapy program versus no exercise therapy program/placebo

• exercise therapy program plus other therapy versus other therapy

• exercise therapy program versus an alternative therapy program

• programs that compare different amounts of exercise (duration, frequency, intensity) or programs that compare different methods of administering exercise programs

SPÏÏYS-368; No. ol P,S« 16

Articles identified through electronic database search January 2011 to March 2016 (n = 885)

• EMBASE (n = 213)

• Sport Discus (n = 179) . MEDLINE (n = 161)

• Cochrane Central (n = 117)

• CINAHL (n = 107) . PubMed (n = 72)

• PEDro (n = 33)

• AMED (n = 3)

Articles identified through reference list checks and citation tracking (n = 0)

> Removal of duplicates (n = 130)

Articles screened by title and abstract (n = 755)

Articles excluded after screening titles and abstracts (n = 739)

Potentially relevant articles retrieved for evaluation of full text (n = 16)

Articles excluded after evaluation of full text (n = 7)

• exercise was not applied to the upper limb (n = 2)

• exercise was not the evaluated intervention (n = 4)

• study protocol only (n = 1)

Eligible articles identified (n = 9)

Articles from original review (n = 14)

Eligible articles included in review (n = 23) Eligible studies Included in review (n = 22)a

Figure 1. Flow of studies through the review.

aOne article reported follow-up data from a study that was already included.

Twenty-two trials were excluded for the following reasons: trial protocol only (n = 1);41 upper limb rehabilitation not evaluated (n = 2);36,37 exercise was not the intervention that was evaluated (n = 4);38-40,42 not (quasi-) randomised, controlled trials (n = 5);57-61 not in English (n = 1);62 published only as an abstract (n = 1);63 or insufficient information about the exercise therapy intervention (n = 8).64-71

Characteristics of the included trials

Quality

PEDro scores ranged from 2 to 8 out of 10, with a median score of 5 (Table 1). Cohen's kappa was 0.84 (95% CI 0.73 to 0.95), indicating excellent inter-rater agreement. Due to the nature of the interventions, no trial was able to blind participants and therapists. Thirteen trials blinded the assessor, seven used intention-to-treat analysis and ten concealed allocation.

Completeness of reporting

The completeness of intervention reporting was higher for the interventions than for the control group conditions. The percentage of studies that satisfactorily reported each item ranged from 0 to 80% for the intervention group (Figure 2) compared with 0 to 55% for the control group (Figure 3). The name of the intervention

(item 1) was the item most satisfactorily reported, while the intervention provider (item 5), how interventions were tailored (item 9), modified (item 10) or monitored irrespective of group (items 11 and 12) were poorly reported. Sufficient detail of the exercise program (including dosage) to allow replication (item 8) was satisfied in < 40% of studies for both groups. Cohen's kappa was 0.73 (95% CI 0.65 to 0.80) for the intervention group, indicating good inter-rater agreement, and 0.84 (95% CI 0.79 to 0.90) for the control group, indicating excellent agreement.

Participants

The 22 trials comprised 1299 participants aged 23 to 92 years, about 70% of whom were female (Table 2). Participants had sustained a distal radius fracture (15 trials), radial head fracture (one trial), or proximal humeral fracture (six trials) (Table 2).

Intervention

Four trials evaluated the effect of exercise following upper limb fracture by prescribing exercise to the intervention group only: one trial during fracture immobilisation period (first 5 weeks after fracture),30 and three trials after immobilisation (6 weeks after fracture)28'32'48 (Table 2).

In the remaining 18 trials,

29,30,34,35,44,45,49,51 -56

varying amounts

of exercise and advice were incorporated in both control and intervention groups. Five trials evaluated the introduction of exercise earlier in rehabilitation compared with delayed introduction: one following distal radius fracture,27 one following radial head fracture33 and three following proximal humeral frac-ture.43,47,50 Four trials evaluated the effects of supervised exercise in addition to a home exercise program compared with a home exercise program only following distal radius fracture.45,52-54 Eight trials examined the effect of therapy provided by an allied health professional that included supervised exercise plus a home exercise program compared with a home exercise program. Five of these eight trials examined physiotherapy,44,49,51,55,56 two examined occupational therapy,29,34 and one examined hand therapy.35 All trials except one investigated the effects of exercise training on the injured upper limb. A single trial examined the cross-education effect of completing a home strength training program of the non-injured arm following distal radius fracture.31

Outcome measures

All trials assessed at least one measure of impairment, 15 out of 22 trials assessed activity limitations, and seven out of 22 trials assessed participation restrictions (Table 2).

Effect of exercise versus no intervention

Distal radius fractures

There were no significant between-group within-session differences between participants who performed repetitive wrist extension during a 6-minute intervention period compared with the no-intervention control group after distal radius fracture.32

Radial head or proximal humeral fractures

There was no evidence to support or refute the benefit of exercise after radial head or proximal humeral fractures because no trials examined this intervention.

Effect of advice and exercise versus advice

Distal radius fractures

There was preliminary evidence that the addition of progressive exercise to advice provided no extra benefit on activity limitations or impairments compared with a program of advice following distal radius fracture.28 One trial found no difference between groups that received advice and exercise compared with advice only over three physiotherapy consultations on activity-focused primary outcome measures (Patient Rated Wrist Evaluation and

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Table 1

PEDro scores of methodological quality of studies included in systematic review update.

Study Eligibility criteria Random Concealed Groups similar Participant Therapist Assessor < 15% Intention-to-treat Between-group Point estimate and PEDro Score Total

were specified allocation allocation at baseline blinding blinding blinding dropouts analysis difference reported variability reported (0 to 10)

Agorastides et al (2007)43 N Y Y Y N N Y N N Y Y 6

Bertoft et al (1984)44 Y Y Y Y N N Y Y N N Y 6

Brehmer et al (2014)a27 Y Y N Y N N N Y N Y Y 5

Bruder et al (2016)a,28 Y Y Y Y N N Y Y Y Y Y 8

Christensen et al (2007)45 N Y Y Y N N N N N Y N 4

Filipova et al (2015)a29 Y Y N Y N N Y Y N Y Y 6

Hodgson et al (2003)47 N Y Y Y N N Y Y N Y Y 7

Hodgson et al (2007)46 N Y Y Y N N N Y N Y N 5

Kay et al (2008)48 Y Y Y Y N N Y Y Y Y Y 8

Krischak et al (2009)49 Y Y N Y N N N Y N Y Y 5

Kuo et al (2013)a30 Y Y Y Y N N Y Y N Y Y 7

Lefevre-Colau et al (2007)50 Y Y Y Y N N Y Y Y Y Y 8

Lundberg et al (1979)51 N Y N N N N N N N N Y 2

Maciel et al (2005)52 Y Y Y Y N N Y Y Y N Y 7

Magnus et al (2013)a31 Y Y N Y N N Y N N Y Y 5

Mitsukane (2015)a,32 Y Y N Y N N N Y Y N Y 5

Paschos et al (2013)a,33 Y Y N Y N N Y Y N Y N 5

Pasila et al (2000)53 Y Y N N N N N N N N Y 2

Revay et al (1992)54 N Y Y Y N N Y N N Y N 5

Souer et al (2011)a34 Y Y N Y N N N N Y Y Y 5

Valdes et al (2015f35 Y Y N Y N N N Y N Y N 4

Wakefield et al (2000)55 Y Y N Y N N Y Y Y Y Y 7

Watt et al (2000)56 N Y N Y N N Y N N Y Y 5

Y, yes; N, no. a Studies identified between 2010 and 2016.

JPHYS-368: No. of Pages 16 ARTICLE IN PRESS

Research

Yes ■ No

Figure 2. Percentage of included trials achieving each TIDieR item with the description of the experimental group intervention.

Percentage of trials achieving each TIDieR i t Applicable

Figure 3. Percentage of included trials achieving each TIDieR item with the description of the control group intervention.

QuickDASH), or impairment-based secondary measures (wrist range of movement, grip strength and pain).28

Radial head or proximal humeral fractures

There was no evidence to support or refute the benefit of advice and exercise compared with advice only after radial head or proximal humeral fractures, as no trials examined this.

Effect of advice and exercise versus no intervention

Distal radius fractures

Short-term reduction in pain and improvement in upper limb activity following conservatively managed distal radius fractures was found in one trial comparing a single session of advice and exercise compared with a no-intervention control group.48 Improvement in upper limb activity at 3 weeks (SMD 0.61, 95% CI 0.03 to 1.19), and reduced pain at 3 weeks (SMD 0.77, 95% CI 0.18 to 1.36) and 6 weeks (SMD 0.63, 95% CI 0.04 to 1.22) was found in favour of advice and exercise.48 No other significant between-

group findings were reported for the primary (wrist extension) and secondary outcomes measured at 3 or 6 weeks.48

Radial head or proximal humeral fractures

There was no evidence to support or refute the benefit of exercise combined with home advice after radial head or proximal humeral fractures because no trials examined this.

Effect of therapist-supervised exercise plus a home exercise program versus home exercise program alone

Distal radius fractures

A home exercise program may be just as effective as therapist-supervised exercise in addition to a home exercise program following conservatively managed distal radius fractures.16 None of the three trials reported any significant between-group differences for any outcome measure.45,52,53 Meta-analyses could not be conducted because, even though two trials carried out the intervention 6 weeks after removal of cast, they did not share any common outcome measure.45,52 The third trial implemented

Table 2

Summary of included studies (n = 23).

Design Participants

Intervention

Outcome measures

Agorastides et al (2007)43

Bertoft et al (1984)44

Brehmer et al

(2014)27

Bruder et al (2016)28

Filipova et al (2014)29

Christensen et al (2001)45

Hodgson et al (2003, 2007)47,46

Kay et al (2008)4

Krischak et al (2009)49

Kuo et al (2013)3

RCT n=49

Age (yr) = Con 67 (14); Exp 72 (12) Gender = 10 M, 39 F Diagnosis = Proximal humerus fracture Fx Type = Neer: 3-part: 9; 4-part: 39

RCT n = 18

Age (yr) = Con 66; Exp 62; [50 to 75] Gender = Not available Diagnosis = Proximal humerus fracture Fx Type = All had nondisplaced or slightly displaced

RCT n = 78

Age (yr) = Con 55.3 [27 to 83]; Exp

49.8 [21 to 72]

Gender = 21 M, 57 F

Diagnosis = Distal radius fracture

Fx Type = AO system: ea: 47; pa: 3; ca:

RCT N = 33

Age (yr) = Con 58 (18); Exp 51 (17)

Gender = 8 M, 25 F

Diagnosis = Distal radius fracture

Fx Type = AO system: ea: 19; pa: 14; ca:

RCT n = 61

Age (yr) = Con 58 (14.5); Exp 62 (14) Gender=13 M, 48 F Diagnosis = Distal radius fracture Fx Type = not provided

RCT n = 30

Age (yr) = Con 65.9 [57 to 79]; Exp 66.1 [46 to 82] Gender = 3 M, 27 F Diagnosis = Distal radius fracture Fx Type = Older Type I: 2; Type II: 11; Type III: 9; Type IV: 4; unclass: 3 RCT n = 86

Age (yr) = Con 69.6 (11.6); Exp 70.7 (12.5)

Gender = 6 M, 70 F

Diagnosis = Proximal humerus fracture Fx Type = Neer - group 1 RCT n = 56

Age (yr) = Con 55.8 (19.9); Exp 55.0 (20.3)

Gender=17 M, 39 F Diagnosis = Distal radius fracture Fx Type=AO system: ea-20; pa-8; ca-11 RCT n=48

Age (yr) = Con 53.7 (17.9); Exp 56 (11.1) Gender=16 M, 30 F Diagnosis = Distal radius fracture FxType = AO system: ea: 14; pa: 1; ca: 31

RCT n = 22

Age (yr) = Con 64.9 (7.6); Exp 59.3 (5.3)

Gender = 7 M, 15 F

Diagnosis = Distal radius fracture

Fx Type = Frykman I-III: 10; IV-VI: 11;

VII-VIII: 1

Exp=Advice and exercise program (supervised and HEP). Arm immobilised (sling) x 2 wks, then exercises commenced and progressed every 2 wks after commencement for 10 to 12 wks.

Con = Advice and exercise program (supervised and HEP). Arm immobilised (sling) x 6 wks, then exercises commenced and progressed every 2 wks after commencement for 10 to 12 wks. Exp = Exercise program (supervised and HEP), advice, passive joint mobilisation, commenced following immobilisation in sling 10 to 12 days post injury, 9 x over 10 to 12 wks.

Con = three sessions of instruction to perform same HEP as intervention group, 5 to 10 mins following immobilisation in sling 10 to 12 days post injury, 4 to 5 x/day. Exp = Exercise program (HEP) including AROM commenced 3 to 5 days from ORIF with HT. Commenced PROM and isometric strength exercises at 2 wks. Immobilised in splint for 4 wks from injury then introduced isotonic strength exercises.

Con = Exercise program (HEP) including same AROM exercises as Exp group commenced 3 to 5 days post ORIF with HT. Immobilised (splint) for 6 wks from injury then commenced same exercise program as Exp group. Exp = Exercise program (supervised by PT and HEP) and advice program commenced after removal of cast. Three sessions over 6 wks. Exercise program included progressive AROM, stretching and strengthening to be completed 3 x/ day. Advice program included advice on movement, return to work, leisure and sporting activities, swelling, skincare and pain management sleep strategies, and goal setting. Con = Same advice program as Exp group. Commenced after removal of cast. Three sessions over 6 wks. Exp = Exercise program (supervised by OT and HEP), In addition to the same PT program as con group. OT: 9 x 30 mins in 3 consecutive wks. Exercise program dosage not specified.

Con = Exercise program (supervised by PT and HEP), 20 min

galvanic baths. PT: 9 x 30 mins in 3 consecutive wks.

Exercise program dosage not specified.

Exp = Exercise program (supervised by OT and HEP), Heat,

advice commenced following removal of POP. OT: 2 x wk,

HEP 3 x/day; duration not specified.

Con = onesessionof instruction to perform same HEP (with

heat) as intervention group, 3 x/day; duration not specified.

Exp = Exercise program (supervised and HEP), advice. Immediate mobilisation and exercise program with PT (within 1 x wk of injury).

Con = Exercise program (supervised and HEP), advice. Immobilised (collar and cuff sling) for 3 wks from injury then commenced exercise program with PT. Exp = one session of instruction to perform exercise program (HEP), advice, compression commenced after removal of POP.

Con = Usual care. No physiotherapy intervention (natural recovery).

Exp = Exercise program (supervised and HEP), advice, other interventions (at discretion of physiotherapist), commenced 1 wk post volar plating. 20 to 30 mins x 12 for

6 wks.

Con = Exercise program (detailed HEP and guidance booklet). Commenced 1 wk post volar plating. HEP 20 min x 2 x/day for 6 wks. Provided by a physician. Exp = Exercise program (supervised by OT and HEP), massage, passive stretches. Immobilised in external fixator. OT: 45 mins x three sessions/wk, 6 wks. Exercise program dosage not specified. After removal of fixator, regular rehabilitation commenced same as con group until 12 wks post-surgical fixation.

Con = Usual care (advice, wound care, basic exercises). Immobilised in external fixator (6 wks). After removal of fixator regular rehabilitation commenced until 12 wks post-surgical fixation.

Constant Shoulder Assessment Score, Oxford Score Follow-up = 24, 52 wks (from injury)

Shoulder ROM, isometric strength, subjective assessment ADL Follow-up = 3, 8,16, 24, 52 wks (from injury)

DASH, wrist AROM, grip strength

Follow-up = 3 to 5 days; 2, 3,4, 6, 8,12 wks, 6 mth (postop)

Activity section of PRWE, QuickDASH, pain section on PRWE, grip strength, AROM wrist extension, supination, flexion, PRWE Follow-up = 7 wks (post intervention), 6 mth

Wrist AROM, grip strength, DASH

Follow-up = end of rehab (8-12 wks after fracture); 1 mth after completion of rehab (12 to 16 wks after fracture)

Mod Solgaard and Werley Functional Score, grip strength Follow-up = 0, 7, 31 wks (from removal of POP)

Constant Shoulder Assessment Score, SF-36, Croft Shoulder Disability questionnaire Follow-up = 8,16 wks, 1 yr, 2yr (from injury)

Wrist ROM, grip strength, PRWE, QuickDASH Follow-up = 0, 3, 6 wks (from removal of POP)

Wrist ROM, grip strength, PRWE

Follow-up = 1, 7 wks (from injury)

Radiographs (radial inclination, radial height shortening and volar tilt), grip and pinch strength, Purdue pegboard test, manual ability measure-36, kinematic data of thumb and finger, maximal workspace of the thumb and finger, thumb and finger AROM Follow-up = 1, 3, 6,12 wks (after surgical fixation

SPÏÏYS-368; No. ol P,S« 16

Table 2 (Continued )

Design Participants

Intervention

Outcome measures

Lefevre-Colau et al RCT (2007)50

Lundberg et al (1979)51

Maciel et al

(2005)52

Magnus et al (2013)31

Mitsukane et al (2015)32

Paschos et al (2013)33

Pasila et al (1974)53 RCT

Revay et al (1992)54 RCT

n = 74

Age (yr) = Con 63.4 (17.5); Exp 63.2 (18.4)

Gender = 20 M, 54 F

Diagnosis = Proximal humerus fracture

Fx Type = Neer: 1-part: 34;

2-part: 16; 3-part: 24

n = 42

Age (yr)=Con and Exp 65 [30 to 89] Gender = 5 M 37 F

Diagnosis = Proximal humerus fracture Fx Type = Neer-group 1

n = 41

Age (yr) = Con-55.8 (19.4); Exp-55.7 (17.7)

Gender =10 M, 31 F

Diagnosis = Distal radius fracture

Fx Type=AO system: ea: 29; pa: 1; ca:

10 unclass: 1

n = 51

Age (yr) = Con 62.7 (10.2); Exp 63.3 (10) Gender = 51 F

Diagnosis = Distal radius fracture Fx Type = Not reported

n = 28

Age (yr)=Exp: 62 (13); Con: 64 (14) Gender = 9 M, 19 F Diagnosis = Distal radius fracture Fx Type = Not provided

n= 180

Age (yr) = Exp A: 37.9; Exp B: 35.3; Exp C: 36.7

Gender = 81 M, 99 F Diagnosis = Radial head fracture Fx Type=AO system: pa-180

n = 96

Age (yr)=Not specified

Gender = 7 M, 89 F

Diagnosis = Distal radius fracture

Fx Type = Older Type II: 9; Type III: 66;

Type IV: 18

n = 48

Age (yr) = Con and Exp: 62 Gender = 9 M, 39 F

Diagnosis = Proximal humerus fracture Fx Type = Neer: group 1

Exp = Exercise program (supervised and HEP), advice, ice, massage, passive joint mobilisation and sling between sessions (4 to 6 wks). Treatment commenced 72hrs post fracture. 2 hrs x 5 x/wk, frequency reduced over 3 mth. Con = Exercise program (supervised and HEP), advice, ice, massage, passive joint mobilisation, and sling between sessions (1 to 3 wks). Treatment commenced after immobilisation in sling for 3 wks. 2 hrs x 4 x/wk for 4 wks frequency reduced until 6 mth. Exp = Exercise program (supervised and HEP), advice, passive joint mobilisation. Immobilised in sling 1 wk then commenced physiotherapy 20 to 30 mins sessions, 1 - 2 x wk for 8 to 12 wks.

Con = two sessions of instruction to perform same HEP 5 to 10 mins, 4 to 5 x/day with advice. Immobilised in sling 1 wk. Exp = Exercise program (supervised and HEP), advice, manual therapy (if essential) commenced after removal of POP. Regular treatments for 6 x wks. Con = one to two sessions of instruction to perform same HEP as intervention group with advice. Commenced after removal of POP.

Exp = Exercise program of nonfractured limb (HEP designed by PT but provided by orthopaedic surgeon) during immobilisation period (6 wks) and the same clinic rehab program as con group. Dosage: 2 sets, 8 reps of max voluntary effort handgrip contractions (hold 3 secs) increasing to max 5 sets of 8 reps using handgrip trainers; 3 x/wk. Resistance progression monitored by telephone calls and at subsequent visits.

Con = Standard clinic rehab program (designed by PT but coached by orthopaedic surgeon across three visits). Immobilised for 6 wks (cast) and exercise program (HEP) including AROM exercises for neck, shoulder, elbow, fingers. Cast removed at 6 wks, introduced wrist AROM, 9 wks progressed to include strengthening exs. 12 wks encouraged to continue exercise. Dosage: all exercises to be completed 10 to 12 x/day. Duration not specified. Biweekly phone calls and asked how their wrist was feeling to match phone calls the Exp group received. Exp = one session of wrist exercise (supervised by OT) and typical OT program. Repeated wrist extension with isometric 3-sec holds at max extension then rested for 3 secs on affected side. Dosage: 10 reps in 1 minute, followed by 1 x minute rest. Repeat x 3 (30 reps total in 6 mins).

Con = one session of rest and typical OT program. Rest dosage: 6 mins. In additional to normal OT. Exp A = Immediate mobilisation from time of injury and active flex/ext exercises. No sup/pro exercises until 8th day from injury.

Exp B = Elbow immobilisation (sling) for the first 2 days from injury and no exercise. Mobilisation and active elbow flex/ext exercises for 5 days. Sup and pro allowed on 8th day of injury.

Exp C=Elbow immobilisation (half cast POP) for first 7 days from injury and no exercise. Mobilisation and active elbow ext/flex and sup/pron exercises commenced on 8th day from injury.

Written instructions and details of the protocol provided by physician in emergency department to all groups. Exp = Exercise program (supervised and HEP) and advice commenced during immobilisation period 1 to 12 wks (4 on average), discharge at discretion of treating physiotherapist.

Con = one session of instruction to perform same HEP and advice provided by physician.

Exp = Exercise program (supervised hydrotherapy and HEP) and advice. Immobilised in for sling 1 wk, hydrotherapy 30min (max 20 sessions) and HEP 10 to 15min x 4 x/day Con = two sessions of instruction to perform same HEP, Immobilised in sling for 1 wk, HEP 10 to 15min x 4 x/day

Pain, shoulder ROM Follow-up = 6,12, 24 wks (from injury)

Pain (categorical), Shoulder ROM, Strength (grip and shoulder lifting power) Follow-up = 4,12 wks (from injury)

Wrist ROM, grip strength, PRWE

Follow-up = 0, 6, 24 wks (from removal of POP)

Grip strength, wrist AROM, PRWE

Follow-up = 1, 9,12, 26 wks (from injury)

Grip strength, pain (VAS) Follow-up = immediately after completing exercise/rest Isometric wrist ext strength Follow-up =10 mins after completing exercise/rest

Broberg and Morrey, ASES-E, pain, grip strength, pinch strength, elbow AROM Follow-up = 2nd, 3rd, 5th day, 1st, 2nd, 4th, 8th, 12th week, 6,12, 24 mth (from injury) X-ray= 1st, 4th, 12th week, 1st and 2nd year

Wrist ROM, grip strength, Oedema, subjective questions Follow-up = 5, 8, 12 wks (from injury)

Pain, shoulder ROM, subjective assessment of 9 ADL items and 4 functional tests measured ad modum Bertoft-Solem Follow-up = 4, 8, 12, 52 wks (from injury)

Souer et al (2011)34 RCT

n = 94

Age (yr)=Exp: 48.6; Con: 50.7 Gender = 33 M, 61 F Diagnosis = Distal radius fracture Fx Type = AO system: ea: 25, pa: 7; ca: 62

Exp = Exercise program (supervised by OT and HEP), formal OT. Content, frequency and duration of OT program at discretion of OT.

Con = one session of instruction by surgeon to perform exercise program (HEP) and advice. Dosage: at least 3 - 4 x/ day at least 30 mins.

Wrist AROM, grip strength, DASH, Pain, Pain-Gain, CES-D, PASS, PCS

Gartland and Werley, Mayo wrist score, Radiographic evaluation Follow-up = 3, 6 mth

Table 2 (Continued )

Design Participants

Intervention

Outcome measures

Valdes et al (2015)35

Wakefield et al (2000)55

Watt et al (2000)56 RCT

n = 50

Age (yr) = Exp: 28 to 81; Con: 23 to 92 Gender = 8 M, 42 F Diagnosis = Distal radius fracture Fx Type = Not provided

n = 96

Age (yr) = Con: 74 (9.1); Exp: 72 (9.8)

Gender = 9 M, 87 F

Diagnosis = Distal radius fracture

Fx Type = AO system: ea-35, pa-5, ca-26

n = 18

Age (yr) = Con: 77.3 (5.1); Exp: 74.4 (10.2)

Gender = 1 M, 27 F Diagnosis = Distal radius fracture Fx Type = Frykman I-III: 6; IV-VI: 5; VII-VIII: 7

Exp = Exercise program (supervised by HT and HEP). AROM and PROM exercises to wrist, forearm and digits, Passive Joint Mobilisation, Massage, Sensorimotor activities, stretches, Functional training. Dosage: 2 x 30 to 60 min HT per/wk (mean 16 visits). HEP same as control group. Con = Exercise Program (HEP). AROM and PROM exercises, Dosage: Wks 1 to 6: 5 exercises, 5 sets x 10 reps adding stretching exercises in Week 6. 2 x/day. Exp = Exercise program (supervised and HEP), advice and passive interventions (at discretion of physiotherapist)). HEP 3 x/day duration and frequency - discretion of physiotherapist

Con = 1 x Instructed to perform same HEP 3x/day

Exp = Exercise program (supervised and HEP), advice and passive joint mobilisation, attended ~5 times. Con = one session of instruction by orthopaedic surgeon to perform same HEP.

Wrist AROM Grip strength Pain (VAS) Oedema

Follow-up = 2,4,8,12 wks. Also 6mth for PRWE

Pain, wrist ROM, grip strength, scoring system to assessment of ADL; SF-36

Follow-up = 6, 12, 24 wks (from injury)

Wrist ROM, grip strength Follow-up = 0, 6 wks (from removal of POP)

ADL = activities of daily living, AO = Association for Osteosynthesis, AROM = active range of motion, ASES-E = American Shoulder and Elbow Surgeons-Elbow questionnaire, ca = complete articular, ASIF=Association for the Study of the Internal Fixation, CES-D = Center for Epidemiological Studies Depression Scale, on = control group, DASH = Disabilities of the Arm, Shoulder and Hand questionnaire, ea = extra-articular, Exp = experimental group, Fx = fracture, HEP = home exercise program, HT = hand therapist, ORIF=open reduction with external fixation, OT = occupational therapist, pa = partial articular, PASS = Pain Anxiety Symptoms Scale, PCS = pain catastrophising scale, PROM = passive range of motion, PT = physiotherapist, RCT=randomised, controlled trial, ROM = range of motion, POP = plaster of paris, PRWE = patient rated wrist evaluation, SF-36 = short form 36, VAS = visual analogue scale.

an exercise program to non-splinted joints during immobilisa-

tion.5

Radial head fractures

There was no evidence to support or refute the benefit of adding supervised exercise to a home exercise program after radial head fracture, as no trials examined this.

Proximal humeral fractures

The addition of physiotherapist-supervised aquatic exercise to a home exercise program may reduce upper limb activity and increase impairment in the short term after proximal humeral fractures compared with home exercise alone.16 Significant between-group differences in favour of the home exercise group were found in self-reported assessments and active shoulder abduction, flexion and internal rotation at 2 months, and active shoulder abduction and internal rotation at 3 months.54 No significant between-group differences were found at 1-year follow-up.54

Effect of starting exercise earlier after immobilisation versus delayed exercise

Distal radius fractures

Commencing a progressive range of movement and strength exercise program at 2 weeks may have short-term benefits in reducing activity limitations and impairments following surgical fixation after distal radius fracture.27 Evidence from one trial showed that regularly progressing exercises between 2 and 6 weeks postoperatively compared with commencing and progressing exercises after 6 weeks postoperatively had significantly lower (ie, improved) Disabilities of the Arm, Shoulder and Hand questionnaire (DASH) scores at each time point between 2 to 8 weeks (p < 0.05).27 There were statistically significant, and likely clinically relevant improvements,72 in DASH scores in favour of the early mobilisation group at 4 weeks (MD 10 points, 95% CI 3 to 17) and 6 weeks (MD 10 points, 95% CI 5 to 16).

(Protocol 1), a 48-hour delay in mobilisation (Protocol 2) and delayed mobilisation (after first 7 days) (Protocol 3). Range of movement was fully restored at the end of the third week after injury in the two early mobilisation groups (9 deg versus 5 deg versus 22 deg, p = 0.001, Protocol 1, 2 and 3, respectively) while a greater proportion of participants had significantly regained normal grip strength at the end of the first week in the early mobilisation groups.33 Furthermore, normal grip strength was restored in 98% of patients in the 48-hour delayed mobilisation group at 4 weeks after injury compared to 95% in each of the other

groups.33

Proximal humeral fractures

Conservatively managed proximal humeral fractures

Early mobilisation and exercises commenced within the first week of a conservatively managed proximal humeral fracture reduced pain in the short term and improved shoulder activity in the short-to-medium term compared with delayed mobilisation and exercises (Figure 4).16 Meta-analyses could not be conducted, as even though two trials compared early mobilisation within 1 week compared with delayed mobilisation at 3 weeks,47,50 one trial included other physiotherapy interventions in addition to exercise in both groups.50

Surgically managed proximal humeral fractures

Delaying mobilisation and exercises to 6 weeks following hemiarthoplasty for Neer 3-part and 4-part proximal humeral fractures was just as effective at improving shoulder function and range of movement compared with mobilisation and exercises commenced at 2 weeks (Figure 4).16 There were no significant between-group differences on the Constant Shoulder Assessment Score or Oxford Score; however, improvement was more evident in the late mobilisation group.43

Effect of exercise to the unaffected limb (including a home exercise program) versus a home exercise program

Radial head fractures

Preliminary evidence from one trial suggested that commencing mobilisation including exercises 48 hours after sustaining a simple radial head fracture increased range of movement, reduced pain, increased grip strength and achieved better functional outcomes in the short term.33 Paschos et al evaluated three protocols comparing immediate mobilisation including exercise

Distal radius fractures

There was preliminary evidence of improved fractured hand strength and range of movement after performing strength training of the unaffected side during immobilisation following a distal radius fracture (Figure 5).31 The intervention and control groups received the same standard rehabilitation program (including home exercises) supervised by an orthopaedic surgeon;

ímYSjíS; No. ol P.g,, 16

SMD (95% CI)

0 0.5 1

Conservative Management Hodgson et al (2003)46 n = 83

Pain (SF-36) 8wks 0.81 (0.36, 1.25)

Constant Shoulder Score 8 wks 0.13 (-0.31, 0.57)

Role Llmltatlon-phys (SF-36) 8 wks 0.60 (0.15, 1.03)

Pain (SF-36) 16 wks 0.60 (0.14, 1.04)

Constant Shoulder Score 16 wks 0.78 (0.32, 1.22)

Role Limitation -phys (SF-36) 16 wks 0.53 (0.08, 0.96)

Pain (SF-36) 52 wks Constant Shoulder Score 52 wks

0.13 (-0.31, 0.57) 0.29 (-0.15, 0.72)

Role Limitatlon-phys (SF-36) 52 wks 0.13 (-0.31, 0.56)

Lefevre-Colau et al (2007)50 n = 64 Constant Shoulder Score 6 wks Change of Pain Intensity 6 wks Difference in Abd ROM 6 wks Difference In Flex ROM 6 wks Constant Shoulder Score 12 wks Change of Pain Intensity 12 wks Difference in Abd ROM 12 wks Difference In Flex ROM 12 wks Constant Shoulder Score 24wks Change of Pain Intensity 24 wks Difference in Abd ROM 24 wks Difference In Flex ROM 24 wks

Hodgson et al (2007)46 n = 86 Insufficient data to calculate SMD

Surgical Management

Agorastides et al (1999)43 n = 49 Constant Shoulder Score 24 wks Oxford Score 24 wks Constant Shoulder Score 52 wks Oxford Score 52 wks

0.61 (0.10, 1.11) 0.10 (-0.39, 0.59) 0.60(1.10, 0.10) 0.67 (1.17, 0.16) 0.62 (0.12, 1.12) 0.51 (0.00, 1.00) 0.52, (1.01, 0.01) 0.59(1.08, 0.08) 0.47 (-0.03, 0.96) 0.01 (0.50, -0.48) 0.36 (0.85, -0.14) 0.28 (0.77, -0.22)

-0.07 (-0.63, 0.50) -0.23 (-0.79, 0.34) ■ -0.19 (-0.75, 0.38) -0.31 (-0.87, 0.26)-

Favours delayed exercise and mobilisation

Favours early exercise and mobilisation

SMD (95% CI)

Figure 4. Standardised mean difference (95% CI) of effect of early exercise and mobilisation compared with delayed exercise and immobilisation after proximal humeral fracture. Abd = abduction, Flex = flexion, Phys = physical domain, ROM = range of motion, SF-36 = short form 36.

SMD (95% CI)

Conservative Management

Magnus et al (2013)31

Grip strength-fractured side 9 wks 0.16 (-0.47, 0.79) Grip strength-nonfractured side 9 wks 0.69 (0.02, 1.32)

Forearm sup-pro 9 wks 0.07 (-0.56, 0.70)

Wrist flex-ext ROM 9 wks -0.16 (-0.78, 0.48)

PRWE questionnaire 9 wks 0.32 (-0.32, 0.95)

Grip strength-Fx side 12 wks 0.84 (0.16, 1.47)

Grip strength-non Fx side 12 wks 1.06 (0.37, 1.71)

Forearm sup-pro 12 wks 0.86 (0.18, 1.50)

Wrist flex-ext ROM 12 wks 0.82 (0.15, 1.46)

PRWE questionnaire 12 wks 0.27 (-0.37, 0.90)

Grip strength-Fx side 26 wks 0.52 (-0.13, 1.15)

Grip strength-non Fx side 26 wks 0.67 (0.01, 1.30)

Forearm sup-pro 26 wks 0.42 (-0.22, 1.05)

Wrist flex-ext ROM 26 wks -0.07 (-0.70, 0.56)

PRWE questionnaire 26 wks -0.20 (-0.83, 0.44)

Favours home exercise Favours unaffected limb exercise and home exercise

SMD (95% CI)

Figure 5. Standardised mean difference (95% CI) of exercise to the unaffected limb including a home exercise program compared to a home exercise program after distal radius fracture. Ext = extension, Flex = flexion, Fx = fracture, Pro = pronation, PRWE = patient rated wrist evaluation, ROM = range of motion, Sup = supination.

however, the intervention group also performed a progressive strength training program of their nonfractured limb throughout the trial period.31 The strength training commenced once the fracture was immobilised and continued throughout the follow-up period (26 weeks). There was no significant between-group difference on activity measures.31

Radial head or proximal humeral fractures

There was no evidence to support or refute the benefit of adding strength exercise of the unaffected limb to a home exercise program after radial head or proximal humeral fractures because no trials examined this.

Effect of a therapy program versus a home exercise program

In this section 'therapy' refers to a rehabilitation program provided by a physiotherapist, occupational therapist or hand therapist that typically included advice, a program of supervised and home exercises, joint and/or soft tissue mobilisation and electrotherapy.

Distal radius fractures during immobilisation

There was preliminary evidence from one trial that commencing a supervised progressive phalanx exercise program during immobilisation after distal radius fracture significantly improved recovery rates in thumb workspace (82 versus 70%, p = 0.04) and finger workspace (89 versus 60%, p = 0.03) at 12 weeks from injury.30 Kuo et al evaluated the effectiveness of a progressive digit exercise program supervised by an occupational therapist and completed until the external fixator was removed 6 weeks after distal radius fracture.30 Patients randomised to the comparison group received a home exercise program targeted at maintaining range of movement of the shoulder and elbow joints during immobilisation.30 Both groups received the same rehabilitation program supervised by an occupational therapist after 7 weeks.30 No additional benefit was found on hand strength, finger dexterity or functional outcomes during immobilisation or at any other time period after the fixator was removed.30

Conservatively managed distal radius fractures

The addition of therapy (which could include components of supervised exercise, advice, passive joint mobilisation and electrotherapy) provided by a physiotherapist to a home exercise program after conservatively managed distal radius fractures may improve wrist range of movement and grip strength in the short term (Figure 6).55,56 However, the effect on grip strength was not demonstrated in a meta-analysis combining two trials comparing

Figure 7. Standardised mean difference (95%CI) of effect of therapy program on grip strength (kgs) compared with a home exercise program at 12 weeks post distal radius fracture immobilisation.

physiotherapy including supervised exercise and a home exercise program compared with a home exercise program (d = 0.55,95% CI, -0.65 to 1.75, I2 = 79%) (Figure 7).55,56 A detailed forest plot is presented in Figure 8 (see eAddenda for Figure 8). The level of evidence for this meta-analysis was downgraded by two to low, due to 50% of included trials scoring < 6 out of 10 on the PEDro scale and results of I2 > 25% suggesting heterogeneity between trials.

Surgically managed distal radius fractures

Adding therapy (including supervised exercise) to a home exercise program after surgically managed distal radius fractures had no additional benefit in reducing impairment or increasing upper limb function in the short-to-medium term (Figure 9).34,35,49 Krischak et al reported that 12 sessions of therapy provided by a physiotherapist over 6 weeks may actually reduce upper limb function, and increase impairment in the short term when compared with home exercise alone.29 These trials commenced mobilisation 2 weeks after volar plating for distal radius fracture. Patients randomised to the comparison group in two trials received detailed instructions and a home exercise program.35,49 Therapy was consistent with usual practice and included supervised exercise. Two of three trials assessed impairments at 12 weeks, which allowed meta-analyses.34,35 The first meta-analysis did not demonstrate any effect of therapy including supervised exercise plus a home exercise program on pain at 12 weeks following distal radius fracture (d = 0.07, 95% CI -0.26 to 0.40, I2 = 0%] (Figure 10).34,35 A detailed forest plot is presented in Figure 11 (see eAddenda for Figure 11). The second did not demonstrate any

Figure 6. Standardised mean difference (95% CI) of effect of a therapy program compared to a home exercise program after conservatively managed distal radius fracture. ADL = activities of daily living, Ext = extension, Flex = flexion, ROM = range of motion.

SMD (95% CI)

Krlschak et al (2 0 0 9)43 n = 46 Grip strength 6 wks Wrist Flex/Ext ROM 6 wks PRWE 6 wks

Valdes et al (2015)35 n = 50 PRWE 6 mo Total wrist ROM 3 mo Total forearm ROM 3 mo Pain 3 mo

Grip strength (lb) 3 mo

Soueretal (2011)34 n = 94 Wrist flex-ext arc 3 mo Wrist flexion 3 mo Wrist extension 3 mo Wrist radial dev 3 mo Wrist ulnar dev 3 mo Forearm pro 3 mo Forearm sup 3 mo Grip strength (kg) 3 mo Pinch strength (kg) 3 mo Pain (points) 3 mo DASH (points) 3mo MAYO wrist score 3 mo Gartland & Werley 3 mo Wrist flex-ext arc (deg) 6 mo Wrist flexion (deg) 6 mo Wrist extension (deg) 6 mo Wrist radial dev (deg) 6 mo Wrist ulnar dev (deg) 6 mo Forearm pro (deg) 6 mo Forearm sup (deg) 6 mo Grip strength (kg) 6 mo Pinch strength (kg) 6 mo Pain (points) 6 mo DASH (points) 6 mo MAYO wrist score 6 mo Gartland & Werley 6 mo

-1.70 (-2.35, -1.00) <• -0.95 (-1.54. -0.32) -1.18 (-0.53, -1.78) -

-0.10 (-0.65, 0.46) -0.28 (-0.83, 0.29) -0.06 (-0.62, 0.50) -0.07 (-0.63, 0.49) -0.02 (-0.58, 0.54)

-0.31 (-0.71, 0.10) -0.20 (-0.61, 0.20) -0.23 (-0.64, 0.17) 0.00 (-0.40, 0.40) 0.00 (-0.40, 0.40) 0.00 (-0.40, 0.40) -0.24 (-0.64, 0.17) -0.53 (-0.93, -0.11) -0.21 (-0.61, 0.20) 0.13 (-0.27, 0.54) 0.02 (-0.39, 0.42) -0.30 (-0.70, 0.11) 0.00 (-0.40, 0.40) -0.54 (-0.95, -0.12) -0.30 (-0.71, 0.11) -0.58 (-0.99. -0.16) -0.27 (-0.67, 0.14) -0.75 (-1.16, -0.32) 0.00 (-0.40, 0.40) -0.65 (-1.06, -0.23) -0.33 (-0.73, 0.08) 0.30 (-0.11.0.70) 0.12 (-0.28, 0.53) 0.15 (-0.26, 0.55) -0.39 (-0.79, 0.03) 0.16 (-0.25, 0.56)

Favours home exercise Favours therapy

SMD (95% CI)

Figure 9. Standardised mean difference (95% CI) of effect of a therapy program compared to a home exercise program after surgically managed distal radius fracture. DASH = Disabilities of the Arm, Shoulder and Hand questionnaire, Dev = deviation, Ext = extension, Flex = flexion, Pro = pronation, PRWE = patient-rated wrist evaluation, ROM = range of motion, Sup = supination.

effect of therapy including supervised exercise plus a home exercise program on grip strength at 12 weeks following distal radius fracture (d = 0.07, 95% CI -0.26 to 0.40, I2 = 43%) (Figure 12). A detailed forest plot is presented in Figure 13 (see eAddenda for

Figure 13). The level of evidence for this meta-analysis was downgraded by two to low, due to 50% of included trials scoring < 6 out of 10 on the PEDro scale and results of I2 > 25% suggesting heterogeneity between trials.

Figure 10. Standardised mean difference (95%CI) of effect of therapy program on pain compared with a home exercise program at 12 weeks post distal radius fracture.

Figure 12. Standardised mean difference (95%CI) of effect of therapy program on grip strength (lb) compared with a home exercise program at 12 weeks post distal radius fracture.

SMD (95% CI)

Bertoft et al (1984)44 n = 18

Pain (hand on neck) 3 wks 0.45 (-0.51, 1.37)

Pain (hand in back) 3 wks 1.07 (0.03, 2.00)

Sh AROM-hand on neck 3 wks -0.30 (-1.22, 0.65)

Sh AROM-hand in back 3 wks -0.67 (-1.59, 0.32) •

Pain (hand on neck) 8 wks -0.19 (-1.11, 0.75)

Pain (hand in back) 8 wks 0.63 (-0.35, 1.55)

Sh AROM-hand on neck 8 wks 0.45 (-0.51, 1.37)

Sh AROM-hand in back 8 wks -0.32 (-1.24, 0.63)

Pain (hand on neck) 16 wks 0.18 (-0.78, 1.13)

Pain (hand in back) 16 wks 0.20 (-0.76, 1.15)

Sh AROM-hand on neck 16 wks 0.27 (-0.68, 1.19)

Sh AROM-hand in back 16 wks -0.50 (-1.42, 0.46)

Pain (hand on neck) 24 wks 0.22 (-0.81,1.22)

Pain (hand in back) 24 wks -0.13 (-1.14, 0.89)

Sh AROM-hand on neck 24 wks -0.23 (-1.15, 0.72)

Sh AROM-hand in back 24 wks -0.15 (-1.07, 0.79)

Lundberg et al (1979)51 n = Grip Strength 4 wks Grip Power 4 wks Sh Flex AROM 4 wks Sh Flex PROM 4 wks Grip Strength 12 wks Grip Power 12 wks Sh Flex AROM 12wks Sh Flex PROM 12 wks

0.34 (-0.27, 0.95) 0.47 (-0.15, 1.08) -0.02 (-0.63, 0.59) 0.35 (-0.27, 0.95) -0.20 (-0.81, 0.41) -0.25 (-0.86, 0.36) 0.20, (-0.41, 0.80) 0.38 (-0.24, 0.99)

Favours home exercise Favours therapy SMD (95% CI)

Figure 14. Standardised mean difference (95% CI) of effect of physiotherapy including supervised exercise and a home exercise program compared to a home exercise program after proximal humeral fractures. AROM = active range of motion, PROM = passive range of motion, Sh = shoulder.

Proximal humeral fractures

There may be no benefit of adding supervised exercise to a home exercise program as part of a course of therapy provided by a physiotherapist compared with a home exercise program after conservatively managed proximal humeral fractures (Figure 14).44,51 Two trials found no difference between these interventions on any impairment or activity measure.44,51 Both trials commenced treatment after sling removal.

Effect of occupational therapy (including physiotherapist-supervised exercises) versus physiotherapist including supervised exercises only

Distal radius fractures

There was preliminary evidence that the addition of therapy provided by an occupational therapist to a physiotherapist-supervised

exercise program may result in short-term improvements in impairment after distal radius fracture (Figure 15).29 One trial examined a course of therapy provided by an occupational therapist that included supervised functional exercises that were different to the physiotherapy range of movement and strength exercise program performed by both intervention and comparison groups. There was significant short-term improvement in grip strength in favour of the group receiving additional occupational therapy. No significant differences were found on activity measures such as the Disabilities of Arm, Shoulder and Hand questionnaire.

Radial head and proximal humeral fractures

There was no evidence to support or refute the benefit of adding occupational therapy to a physiotherapy program including supervised exercises after radial head or proximal humeral fractures, as no trials examined this.

SMD (95% CI) -1

-0.5 0 0.5 1 1.5

Filipova et al (2014)29 Wrist flex-ext ROM 8 wk Forearm sup-pro 8 wk Grip strength (%) 8 wk DASH (points) 8 wk

-0.24 (-0.76, 0.28) -0.35 (-0.86,0.18) 0.82 (0.28, 1.35) 0.33 (-0.19, 0.84)

Wrist flex-ext ROM (deg) 12 wk -0.06 (-0.58, 0.45) Forearm sup-pro (deg) 12 wk -0.10 (-0.61, 0.42) Grip strength (%) 12 wk 0.96 (0.40, 1.49)

DASH (points) 12 wk 0.47 (-0.06, 0.98)

Favours PT Favours OT and PT

SMD (95% CI)

Figure 15. Standardised mean difference (95% CI) of effect of occupational therapy including physiotherapy and supervised exercise compared to physiotherapy including supervised exercises after conservatively managed distal radius fracture. DASH = Disabilities of the Arm, Shoulder and Hand questionnaire, Ext = extension, Flex = flexion, OT = occupational therapy intervention, Pro = pronation, PT = physiotherapy intervention, ROM = range of motion, Sup = supination.

Adherence to an exercise program

Four of 22 trials reported adherence to either supervised exercise or prescribed home exercise programs. Adherence was only reported for both groups (70% attended the supervised exercise sessions) in one trial,50 and the control group (97% rated the home exercise program as being completed) in one trial.49 The intervention group adherence was reported in three trials as: 54% for participants completing at least 70% of prescribed exercise,28 85% completing their exercises at least once a day,48 to 94% completing at least one training session/week.31

Adverse events

(one distal radius fracture,27 one radial head fracture,33 three proximal humeral fractures43,47,50) to support commencing exercise early and reducing immobilisation in improving activity during upper limb rehabilitation compared with delayed exercise and mobilisation. There was insufficient evidence from 13 trials29,30 34,35,44,45,49 51-56 to support or refute the effectiveness of home exercise therapy compared with therapist-supervised exercise or therapy that included exercise following distal radius or proximal humeral fractures. There was preliminary evidence from one trial31 that exercise to the non-injured arm during immobilisation might lead to short-term benefits on increasing grip strength and range of movement following distal radius fracture.

Adverse events were not systematically reported. Two trials explicitly reported no serious adverse events related to the

Discussion

intervention;2

one of these trials reported wrist pain as a

minor adverse event.28 One trial reported complications but these were related to surgical treatment.43 Six trials reported problems such as complex regional pain syndrome or post-traumatic carpal tunnel syndrome at initial assessment,29,34,48 1 week postoperative33 or during the rehabilitative period.27,29,34,35 One trial reported that one patient in the experimental group sustained a tendon rupture of the affected side requiring surgical management.27

Descriptive synthesis

There was insufficient evidence from three trials2

support or refute the effectiveness of exercise therapy compared with advice/no exercise intervention following distal radius fracture (Table 3). There was moderate evidence from five trials

There was insufficient evidence to support exercise as a therapeutic intervention that increases participation and activity, and reduces impairment following upper limb fracture compared with no intervention or advice. Therapists regularly prescribed exercise after distal radius fracture;14,15 exercise was recommended in distal radius fracture treatment guidelines,73 yet only three trials attempted to directly evaluate its effect.28,48,32 These trials found that exercise had no benefit on improving participation or activity levels in the medium-term, and only short-term benefits for pain and activity levels at 3 weeks following cast removal for conservatively managed distal radius fractures. These findings were similar to results from a randomised clinical trial that found no difference in activity limitations or quality of life between a program of supervised exercise and advice compared with advice only for people after ankle fracture.74 No randomised, controlled trial has evaluated the effect of exercise compared

Table 3

Summary conclusions on exercise therapy effectiveness from randomised, controlled trials.

Intervention

Conclusion

Direct evidence of exercise therapy Bruder et al (2016)28 Kay et al (2008)48 Overall result

There is insufficient evidence to support or refute the effectiveness of exercise therapy compared with advice/no exercise intervention

Indirect evidence of comparison of different types of exercise therapy programs Bertoft et al (1984)44 Christensen et al (2007)45 Filipova et al (2015)29 Krischak et al (2009)49 Kuo et al (2013)30 Lundberg et al (1979)51 Maciel et al (2005)52 Pasila et al (2000)53 Revay et al (1992)54 Souer et al (2011)34 Valdes et al (2015)35 Wakefield et al (2000)55 Watt et al (2000)56 Overall result

There is insufficient evidence to support or refute the effectiveness of home exercise therapy, compared with therapist-supervised exercise or therapy including exercise

Indirect evidence of early exercise and early mobilisation Agorastides et al (2007)43 Brehmer et al (2014)27 Hodgson et al (2003)47 Hodgson et al (2007)a,46 Lefevre-Colau et al (2007)50 Paschos et al (2013)33 Overall results

Commencing exercise therapy and early mobilisation is effective, compared with delayed exercise and mobilisation.

Others

Magnus et al (2013)31 - exercise to noninjured arm Mitsukane (2015)32 - repetitive wrist extension within session Overall result

There is preliminary evidence to support the use of exercise performed on the noninjured arm.

+ = Moderate or limited evidence that exercise therapy was effective, or there were indications to support the effectiveness of exercise therapy.

0 = Insufficient or no evidence to support or refute the effectiveness of exercise therapy, or exercise therapy was equally as effective as an alternative exercise therapy program that may have included difference amounts of exercise (duration, frequency or intensity), or different method of administration. - = Exercise therapy was harmful or less effective than no exercise, other therapy, or alternative exercise program. a Follow-up trial.

with a no-intervention control group in the rehabilitation of any other upper limb fracture, despite its frequent therapeutic use.

Thirteen trials indirectly evaluated exercise by comparing therapist-supervised exercise or therapy that included exercise with home exercise to find no additional benefit to increasing activity levels or reducing impairment in the short-to-medium term. Two trials (one distal radius fracture, and one proximal humeral fracture) found that therapy including exercise may significantly reduce activity levels and increase impairment in the short term when compared with home exercise alone;49,54 however, poorer outcomes were not consistent in similar trials.

Exercise has been demonstrated to be beneficial in many areas of physiotherapy practice including musculoskeletal conditions.75 However, the growing body of evidence (now 22 independent trials) suggests that exercise in the form that it has been prescribed is not effective in making changes that cannot be achieved by moving the arm in everyday living. One explanation could be that the typical dose of exercise prescribed in the included trials may have been insufficient to remodel soft tissues and achieve benefit over and above what can be achieved through normal use. For example, many programs required participants to exercise three times a day, completing a relatively small number of repetitions with no reference to intensity.35,49 Current evidence of stretching to create long-lasting soft tissue structural adaptation suggests that prescription of 30 minutes per day may be required to increase joint range of movement and improve soft tissue extensibility, which are commonly problematic following upper limb fracture.76 Similarly, to improve muscle strength, exercises specific to the target muscles action should be selected, performed at an intensity that corresponds to 60 to 70% of 1-repetition maximum and progressed between 2 to 10% to ensure that the neuromuscular system is continuously challenged.77 Therefore, it is possible that current exercise prescription may be insufficient in terms of duration, intensity, repetition or progression to cause structural changes to increase joint range of movement, muscular length or muscular strength.

One theme that emerged from this review was the positive effect on increasing participation and activity levels and reducing impairment when exercise was started early and combined with a shorter immobilisation period. Indirect evidence from five trials found significant improvements in favour of people who commenced early mobilisation and exercise after surgically treated distal radius fractures and conservatively managed simple radial head and proximal humeral fractures. Early movement is a priority in fracture management, as it helps to reduce the likelihood of a recurring pain cycle, swelling and unresolved oedema that may thicken into scar tissue around joints and cause joint stiffness, contracture and tendon adhesions.78 These symptoms, in addition to physical changes that limit movement and function in a joint, have been called the 'fracture (cast) disease'.78 Definitive conclusions about the effect of early exercise alone are difficult to make, as this approach was always combined with shorter immobilisation. Given this, it is uncertain what effect reducing immobilisation alone would have in improving activity and participation levels compared with movement through performing prescribed exercises. Preliminary evidence from one trial suggested that people following distal radius fracture who were surgically managed, permitted to move their injured arm one week post-operatively and received the same physiotherapy rehabilitation program compared with people who were immobilised for 5 weeks in a cast had significantly better function and greater activity.79

Applying the TIDieR checklist has highlighted the poor reporting of intervention conditions for both the intervention and control group. The items most poorly described (Figures 2 and 3) were: intervention provider, amount of intervention provided (number of sessions/schedule/duration/intensity), tailoring/modification of the intervention and lack of homogenous monitoring of adherence to interventions. These findings are consistent with a review that found the reporting of physiotherapy interventions in trials to be poor.21 Lack of comprehensive

reporting and monitoring of interventions make it difficult for therapists to incorporate exercise into practice and unfair to make assumptions about exercise effectiveness if it is unclear whether people adhered to the protocol. Additionally, if adherence is not monitored and reported consistently between studies, inferences about different exercise programs cannot be made. Future research should investigate the best methods to accurately monitor and report exercise program adherence.

The findings of this updated review are consistent with two recently updated systematic reviews that concluded insufficient evidence to support exercise prescription following distal radius or proximal humeral fractures.4,5 This updated review adds to the literature by focusing on exercise for any upper limb fracture, and includes nine recently published trials.

Consistent with our original review, the strengths of this update include a comprehensive search strategy. All trials were assessed independently for quality and for completeness of intervention reporting. The GRADE system was used to ensure that meta-analyses results were not over interpreted. A limitation of this review might be the method used to perform the descriptive synthesis. However, the consistent pattern across relevant studies that examined a similar question increases confidence in this approach to synthesis.

There is emerging direct and indirect evidence that current prescribed exercise regimens after upper limb fracture may not be effective in reducing impairment and increasing activity. Commencing mobilisation and exercise after shorter immobilisation may be beneficial, but it remains uncertain whether the benefit is due to reducing the immobilisation period or starting exercise earlier.

What is already known on this topic: Upper limb fractures are common. During recovery after a fracture, people experience difficulty participating in personal, occupational and sporting activities. Physiotherapists often prescribe exercise following upper limb fracture to help people return to pre-injury function. A previous systematic review found preliminary and indirect evidence that conservatively managed distal radius and proximal humeral fractures may benefit from exercise, but the conclusion about the effect of exercise was not definitive.

What this study adds: An update of the existing review found nine newtrials, generating data on 22 trials altogether. Despite the additional evidence, current prescribed exercise regimens were notclearlyshown to be effective in reducing impairments and improving activity following an upper limb fracture. However, starting exercise early combined with a shorter immobilisation period was more effective than starting exercise after a longer immobilisation period.

eAddenda: Appendix 1 and 2 and Figures 8, 11 and 13 can be found online at: http://dx.doi.org/10.1016/jjphys.2017.08.009 Ethics approval: Not applicable as this is a systematic review. Competing interests: Nil. Source of support: Nil. Acknowledgements: Nil. Provenance: Not invited. Peer reviewed. Correspondence: Andrea Bruder, School of Allied Health, La Trobe University, Australia. Email: A.bruder@latrobe.edu.au

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