Proximal humerus fracture rates will continue to increase with the aging population5-7,58 and the concomitant rise in osteoporosis.50 These fractures can cause prolonged and severe disability and often are underestimated when compared with hip fractures.25 This will increase the demands on health providers further, and some suggest that society faces an epidemic of fractures in the elderly population.21 Patients who have proximal humerus fractures often are in poor general health37 and have an increased risk of sustaining a future hip fracture.41 Most proximal humerus fractures are a result of minor trauma.57
The term rehabilitation is used in its widest sense and is defined as, “…restoration either of function or role (within the family, social network, or workforce).”54 The aim of rehabilitation should be to reestablish normal shoulder function,30 recognizing the functional interdependence of joints and soft tissues in the upper quadrant when treating dysfunction of the shoulder.4
The literature review will only include prospective studies for proximal humerus fractures in which conservative management and rehabilitation is advocated.52 Surgery is suggested for the more complex fractures,53 but in two retrospective reviews19,68 the authors found no difference in outcome between patients who had surgery or conservative treatment. This evidence suggests that rehabilitation may have a greater role in more complicated fractures; however, that is outside the scope of my study.
Specific evidence for proximal humerus fracture rehabilitation is sparse, which makes recommendations difficult. Research from other common shoulder problems and recently published data by the author33 are included in the rehabilitation section to make recommendations for proximal humerus rehabilitation.
How patients are rehabilitated is influenced by the referring surgeon, and any period of immobilization before rehabilitation will influence recovery. Immobilization remains central in the treatment of the proximal humerus fracture. Few authors 40,33 have investigated the optimum period of immobilization or when rehabilitation should start. I present unpublished survey findings for the United Kingdom (2002) on the use of immobilization and the timing of rehabilitation.
The effect of upper limb fractures on functional tasks continues for many years,48,66 especially in older patients. Long-term evaluation is needed to assess the efficacy of rehabilitation accurately. Most authors report evaluation should be 1 year or less43,45,51,56,59 after the fracture and only one set of authors call for a 2 year followup.40 Future long-term evaluation will identify problems still experienced by the patient and highlight the issues that must be considered when planning a rehabilitation program. My recommendations for proximal humerus fracture rehabilitation (and future research) ensure that the surgeon and therapist remain central to this process.
The primary aim of the literature review is to determine the optimum rehabilitation program for conservatively treated proximal humerus fractures based on current research evidence. Fundamental to this question is the role of immobilization in treating these fractures and the secondary aim is to establish if immobilization is necessary for these fractures before rehabilitation starts. The survey aims to establish current clinical practice in the rehabilitation of two part proximal humerus fractures in the UK. The objectives are: (1) Are patients routinely immobilized following a two-part proximal humerus fracture? (2) If, so for how long? (3) When are patients referred for rehabilitation?
MATERIALS AND METHODS
All prospective studies in the rehabilitation of proximal humerus fractures that were treated conservatively were included in the search. The following databases were included in the search strategy: Medline (1980-2005), Cinahl (1982-2005), PEDro (1990-2005), and the National Research Register (United Kingdom). The search was completed in February 2005. The search terms included: (1) humer*, (2) fract*, (3) proximal, (4) shoulder, (5) physiotherapy, (6) physical therapy, and (7) rehabilitation. From the search, eight studies33,36,40,43,45,56,59,67 were included in the review.
In 2002, 70% of hospitals in the UK with trauma and orthopaedic centers were sent questionnaires (Appendix 1). The questionnaire was completed by the senior physiotherapist working in proximal humerus fracture rehabilitation. A stratified random sample of each health region in the UK was obtained using random number tables. One hundred thirty-nine questionnaires were sent; 127 questionnaires were returned (response rate, 91%).
The general standard of the studies was low, with variable outcome points, unreliable outcome measures, and lack of detail regarding the rehabilitation programs.
The only authors43 who compared the use of electrotherapy in proximal humerus rehabilitation reported no difference in outcome at 6 months. Similarly, patients gained no benefit by self training and the addition of hydrotherapy56 compared with self training alone.
Lundberg et al45 and Solem-Bertoft et al59 compared conventional physical therapy with independent exercises and reported no difference between groups at 12 months. Both were small studies (n = 42 and n = 20, respectively) with no reliable outcome measure, but their results do challenge the assumption that all patients need referral for physical therapy.
Authors of two studies have compared different periods of immobilization before starting physical therapy.40,33 Researchers40 comparing 1 or 3 weeks of immobilization reported no difference between groups at 12 months, but those immobilized for only 1 week reported less pain during the first 3 months. This observation is supported by Young and Wallace,67 who found that patients starting physical therapy earlier had better shoulder function and required fewer treatment sessions. The only authors who compared no immobilization with immobilization for 3 weeks33 before physical therapy found that the patients starting treatment within 1 week of their fracture reported less pain and greater shoulder function at 16 weeks and 1 year.
The only authors to investigate the role of joint mobilization36 in the rehabilitation of proximal humerus fractures found that patients regained full shoulder function with 1 month of the injury by the use of joint mobilization. This was a small study (n = 14) and did not include a control group, but the authors' findings suggest that adding joint mobilization to a rehabilitation program can help regain shoulder movement.
Of the 127 centers surveyed, 73 (57%) always used immobilization and 26 (20%) sometimes immobilized proximal humerus fractures. The period of immobilization varied from 1 to 7 weeks. The most common period of immobilization was 3 weeks (55%). There were 103 centers (81%) that routinely refer patients for physical therapy. Most were referred (105 patients, 88%) within 3 weeks (Appendix 2).
From the available evidence it is only possible to reach certain conclusions about the optimum rehabilitation program for proximal humerus fractures. The overall quality of the studies is poor and “…there is insufficient evidence from randomized trials to determine which interventions are most appropriate.”29 Increasingly, authors of shoulder rehabilitation studies favor programs based on advice, exercise, and joint mobilization4,10 This work is included to develop an approach for proximal humerus fracture rehabilitation.
There is no evidence for the inclusion of electrotherapy in rehabilitation programs specifically to proximal humerus fractures,43 other shoulder conditions,61-63 or for pain relief.26 The passive nature of electrotherapy might actually slow recovery when a more active, engaging approach is required.11 Patients with rotator cuff disease who are treated with an exercise-based approach improved considerably despite having a failed physical therapy program that included electrotherapy.10 The use of hydrotherapy56 in proximal humerus fracture rehabilitation produced no improvement in shoulder function, but more research is needed to test the efficacy of hydrotherapy. Several authors26,43,61 failed to support the use of electrotherapy in a range of shoulder problems; its value in proximal humerus fracture treatment is questionable.
Therapeutic exercise and joint mobilization are axiomatic to physical therapy practice, but most interventions in shoulder pain are limited to electrotherapy. In two systematic reviews of interventions for shoulder pain,61,31 only six studies that included exercise or mobilization met the inclusion criteria out of a possible 51 trials. Exercise is not used exclusively in research programs because it is combined with education, advice, pain control and a graded home exercise program.10,28
When exercise was compared with surgery in the treatment of rotator cuff disease,10 the results in both groups were superior to the placebo group. The exercise program aimed to normalize neuromuscular patterns and a graded increase in resistance to the rotator cuff and scapular stabilizing muscles. Exercise was equally effective as surgery at 2.5-year followup.10 More people in the exercise group remained at work (80% versus 59%), suggesting that patients maintained their exercise program.10 Patients given a supervised exercise program for shoulder pain32 had better improvement at 6 months compared with those who were given an injection, but they also had fewer consultations with their general practitioner. From this evidence it seems that exercise programs give the patient greater control of his or her condition and promote independence.
After a proximal humerus fracture, changes in the neuromuscular patterning of the shoulder are common because stiffness in the glenohumeral joint results in compensatory movement in the shoulder girdle. Research has identified excessive scapular vertical movement in patients recovering from unilateral upper-limb disorders.3 Early restoration of normal neuromuscular shoulder patterning is paramount in preventing secondary problems and this can be achieved by verbal instruction.3 Furthermore, the exercise program should address the contribution of the entire body to the control of the shoulder28 as part of the kinetic chain model.49
When joint mobilization is used to accelerate shoulder movement after proximal humerus fractures,36 11 of 14 patients achieved 90° of abduction within the first treatment session (all started rehabilitation within 14 days after injury). All patients had full active flexion by 27 days.36 This suggests that mobilization might limit the effects of shoulder stiffness. Not all proximal humerus fractures require joint mobilization, but certain patients might benefit from this approach. No authors have evaluated the addition of joint mobilization with proximal humerus fractures. Authors of one study4 suggested combined treatment (mobilization plus exercise) showed better improvement in pain and strength compared with exercise alone. Likewise, in shoulder impingement syndrome,18 improvements have been reported in pain and range of motion with the addition of joint mobilization. These are relatively small studies with limited followup, but the results suggest that the addition of joint mobilization to an exercise program gives added benefits. Patients with proximal humerus fractures might benefit from this approach.
Immobilization for pain relief1,8 or to allow the head and shaft to move as one52 often is recommended for the treatment of proximal humerus fractures before starting rehabilitation. The period of immobilization is about 3 weeks, but immobilization for up to 7 weeks or longer is not uncommon. Patients who were immobilized for 3 weeks before starting physical therapy33 had more pain and reported slower recovery of shoulder function when compared with patients who had immediate physical therapy. From this evidence, immobilization for 3 weeks or longer provides no benefit to the patient and only delays the rehabilitation process. Its routine practice must be questioned.
In the survey, only 20% (26 of 127 patients) of patients' did not have immobilization routinely, but no clear indication was given for the selection of patients who did not need immobilization. Considerable variation existed between and within hospitals. The variation in treating proximal humerus fractures was evident from the survey and highlights the lack of research evidence when making clinical decisions.29 The survey was completed by the physical therapist and only represents an overall representation of all proximal humerus treatment in one trauma center. This represents a limitation in the survey and a more detailed evaluation of practice is needed.
Authors of two studies not included in the literature review have reported that less time spent in a sling seemed to correlate with speed of recovery and restoration of function.17,39 However, Kristiansen et al40 found no difference in outcome between 1 or 3 weeks of immobilization, although their measure of shoulder function remains untested. Hodgson et al33 measured a difference in outcome between immediate and delayed physical therapy but used a range of outcome measures that gave a more in-depth evaluation of shoulder function, pain, and general health status.
Early referral to physical therapy without immobilization seems to accelerate recovery by reducing pain and shoulder stiffness, which contribute to long-term functional loss. Fear of pain will affect behavior and neuro- muscular function.65 Limiting immobilization will reduce this fear if the patient learns to move the limb with early rehabilitation. Shoulder function will be limited further if patients develop chronic pain because this reduces agonist muscle activity and increases antagonist muscle activity.44 Concerns that early movement across the fracture site could increase complication rates1,8 were unfounded with 43 patients having immediate graded return of shoulder movement,31 but larger studies are required to provide a definitive answer. Early resumption of activity is promoted for the restoration of function12 and connective tissue consistently responds better to early movement than immobilization.2,34,35 Rehabilitation should begin immediately for most patients. Immobilization might be necessary in more complex fractures, especially if vascular structures are compromised because avascular necrosis is not uncommon in these types of fractures.8 There is some evidence that short periods of immobilization are acceptable29; however, it is mostly unnecessary and only delays recovery.33,29
No authors have included an economic evaluation of the different rehabilitation approaches. If patients benefit from immediate rehabilitation there should be associated cost-benefits as patients return to function faster and have less long-term disability. More research is needed to support this idea.
The survey results suggest that most proximal humerus fractures are routinely referred to physical therapy, but some authors report that physical therapy makes no difference to patient outcome.45,59 However, these authors reported on relatively small studies and detailed measures of shoulder function were not included in the assessment.45,59 Their findings must be viewed with some caution.
Lundberg and Svenungson-Hartwig45 highlight the problem of what constitutes physical therapy. Both groups had contact with a physical therapist for advice and to recommend a home exercise program. Only one group came to the physical therapy department for joint mobilization and supervised exercises. Physical therapy in the rehabilitation of the proximal humerus fracture is a complex intervention that is based on advice and a home exercise program, aiming to give the patient control of their recovery. Education is important for any rehabilitation program because it reinforces active coping strategies for daily functioning.11 Patients remain fearful of a return to normal activities after a fracture and positive messages help to strengthen their role in rehabilitation.11 Joint mobilization and supervised exercises are only required when patients are not making the anticipated progress and additional help is needed. Many patients will only need advice and monitoring, requiring minimal input from a physical therapist. Other patients with a high risk of developing long-term shoulder problems will need additional input and extended treatment.
Many authors report51,53,40 that patients make an excellent recovery after the fracture, but the evidence is conflicting. Wildner et al66 reported patients with upper-limb fractures have ongoing problems up to 4 years after the initial injury. Patients examined at 1 year who had initial 3-week immobilization33 only achieved 82% return of shoulder function compared with their healthy shoulder. The long-term effects of a proximal humerus fracture are considerable and continue to impact on the patient and their caretakers for many years. Further long-term evaluation is needed to assess treatment efficacy in the proximal humerus fracture fully.
Referring all patients with proximal humerus fractures to physical therapy might not be the best policy. Targeting certain vulnerable groups might maximize recovery against a single program that lacks specificity and fails to meet individual requirements. Patients routinely should be given advice, education, and an exercise program.
The rehabilitation program is based on available evidence and the protocol used in the Sheffield study33 for early restoration of shoulder function. Rehabilitation consists of education, exercise, and joint mobilization (if necessary). Three phases of rehabilitation are described (Appendix 3): early (first 2 weeks), intermediate (2-8 weeks), and later (≥ 8 weeks).33
Early rehabilitation aims are restoring normal shoulder patterns and educating the patient about the benefits of early movement and maintaining their home exercise program. The patient is encouraged to move his or her arm and to prevent compensatory movement in the shoulder girdle. Fear avoidance is limited by reducing the reliance on the sling and promoting early movement. Electrotherapy is not used and joint mobilization is only used if the patient is not achieving 90° abduction within the first three sessions. If necessary, passive movement is applied.36 The head of the head of humerus is moved passively while keeping the fracture site stable. Many patients only require advice and a home exercise program at this stage. They will require monitoring but do not need to attend a center for physical therapy. Pain control is maintained with medication and heat or cold, depending on the patient's preference.
Progression to the intermediate stage is based on the patient's pain levels and functional ability. At no stage are patients encouraged to push through pain, because this might place unacceptable stresses across the fracture site. Physiologic movement is increased and light functional exercises that do not exacerbate pain are encouraged. Proprioceptive exercises are given to improve shoulder control and closed-chain exercises are started in the seated position and placing the hand on the wall (scapular plane). Closed-chain exercises are progressed by balancing the hand on a ball against the wall. Activation of lateral rotation is started against gravity (side lying). Medial rotation is achieved by pressing the hand onto the stomach but preventing inappropriate activation of pectoralis major. These both are progressed by the use of light weights or a resistance band.
During later rehabilitation, active and resisted exercise is increased to regain full shoulder functional activity. The sling usually is discarded by this stage. If joint contractures persist, passive stretching is started in a controlled manner.
Disability increases with age60 and sustaining a proximal humerus fracture increases the risk of having a hip fracture 11% to 16%41 compared with a control population. Proximal humerus fractures are a result of minor trauma,57 and the fall commonly is forward and directly onto the shoulder.55 Patients' inability to break their falls with the upper limb is characteristic of proximal limb fractures and represents a considerable loss in neuromuscular control mechanisms. The risk of future fracture is highest within the first 2 years of the injury,66 and many patients with more complex problems will require a range of professionals to prevent further injury. The increased risk of future osteoporotic fractures must be recognized in this group, and fall prevention programs should be incorporated into long-term evaluation and treatment.
Developing rehabilitation programs that maximize upper limb function after a proximal humerus fracture is crucial because of the increasing elderly population. It is important to minimize the period before rehabilitation starts, to inform the patients about their roles in the process, and to inform them why movement is important. Reducing or stopping any period of immobilization requires trust between the referring surgeon and the therapist because there are concerns about aggressive exercise leading to fracture displacement and malunion.8 Synovial joints require movement to maintain homeostasis, and the fracture relies on the stimulus of movement13,27,38 to optimize the repair process.
The risk of a future hip fracture is higher after a proximal humerus fracture, and the mortality rate9 is increased in this group of patients. Problems persist for many years after the fracture66 as with other shoulder problems.23,46,64 Patients do not recover spontaneously and many continue to live with chronic pain.44 Pain in one area of the body is a risk factor for developing pain in other areas of the body.22 After a proximal humerus fracture, patients learn to live with limitations in their upper-limb function and to rely on caregivers for support.47 The sudden onset of shoulder problems resulting from a fracture can cause greater loss of function when compared with a gradually increasing problem in which the patient has time to adapt.24 With a normal elderly population comprising approximately 21% to 34% of patients with shoulder problems,14-16 proximal humerus fractures will only increase this percentage. Immediate rehabilitation that targets vulnerable groups offers the best approach for limiting future problems.
Patients with proximal humerus fractures often have poor neuromuscular status,37 and this is a risk factor for developing this type of fracture.42 Any rehabilitation program must recognize these differences and tailor the program to the patients' needs. Some patients only require advice, an exercise program, and monitoring for a short period. Others need more long-term, structured rehabilitation that necessitates greater input from a therapist and possibly other professional groups.
The author thanks Julie Harris for her help in conducting the United Kingdom survey.
APPENDIX 1. FRACTURED PROXIMAL HUMERUS QUESTIONNAIRE
This questionnaire concerns the treatment of the minimally displaced (Neer type 1 classification) fractured proximal humerus with patients older than 40 years in your hospital.
Please indicate overleaf if you would like to receive a copy of the findings.
- Are patients who fracture their proximal humerus (minimally displaced fractures or Neer type 1) routinely immobilized in your hospital?
If these patients are immobilized, how long is this period?
- If sometimes, please clarify:__________________________________
Do patients receive physical therapy after the fracture?
- (If period varies please state the most common period of immobilization and the range, eg, 4 weeks, range 3-8 weeks).
- Period of immobilization ___________ weeks
- Range of possible immobilization _____________ weeks
How long after their fracture do patients have their first physical therapy contact (including initial clinic assessment if applicable)?
Any other comments. (Please continue overleaf if necessary).
- If sometimes, please clarify:_______________________________________
APPENDIX 2. FRACTURED PROXIMAL HUMERUS QUESTIONNAIRE RESULTS
APPENDIX 3. REHABILITATION PROGRAM FOR PROXIMAL HUMERUS FRACTURES
Early Rehabilitation (injury to 2 weeks)
- Educate the patient regarding the benefits of early movement
- Prevent inappropriate shoulder movement patterns
- Passive accessory movements to the shoulder, within pain limit
- Passive shoulder abduction and lateral rotation aiming for 90° abduction within the first three sessions
- Teach the patient gravity assisted pendular exercises to do at home.
- Pain control with heat or ice
Intermediate Rehabilitation (2 to 8 weeks)
- Supervised passive shoulder exercises in supine (flexion and lateral rotation)
- Light functional exercises without causing pain exacerbation.
- Increase passive physiologic movements (not into resistance) to full range.
- Proprioceptive exercises (closed chain and open chain).
Late Rehabilitation (8 weeks or more)
- Active exercise against gravity.
- Isometric muscle work to strengthen rotator cuff muscles.
- Reduce use of sling and encourage functional exercises.
- Passive stretching if soft tissue contractions persist.
Discharge when independent function is regained.
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