Evidence-based rehabilitation after (peri-)articular fracture surgery
care, or rehabilitation, seems less systematically
documented and is often based on empirical, implicit
knowledge of the individual (para-)medical specialist
or therapist. Although aftercare is mentioned as being
very important in the treatment of patients with (peri-)
articular fractures, description of its exact content is
rare. To identify which physiotherapy/occupational
therapy protocols for the post-surgery treatment of
(peri-)articular fractures have been published and
to assess their quality, a systematic literature search
was performed. To enhance the clarity of this search,
3 types of (peri-)articular fractures were considered;
proximal humerus fractures, tibial plateau fractures,
and acetabulum fractures.
The aims of the current study were: (i) to assess
the availability of explicitly reported physiotherapy/
occupational therapy protocols or formal guidelines
describing rehabilitation following surgery of (peri-)
articular fractures of the proximal humerus, the ac-
etabulum and/or tibial plateau; and (ii) to critically
review the scientific evidence on the effectiveness of
(parts of) these protocols.
639
Two independent observers conducted the paper selection
in 2 steps:
1) Based on the papers’ title and abstract, first a global exclusion
cycle was performed, identifying papers that definitively did
NOT contain ANY indication AT ALL concerning a rehabili-
tation protocol or aftercare protocol, or an indication related
to fractures of the proximal humerus, acetabulum or tibial
plateau. Also, animal studies, model studies or single-case
descriptions were excluded. In case of any doubt, the paper
was not excluded in this phase of the selection procedure.
2) Next, based on the full text of the papers, documents were
evaluated with regard to 4 additional (sequential) criteria:
a) Is the term “aftercare”’ (or any equivalent term) mentio-
ned and specified in any way? (Y/N);
b) Are any treatment aims and treatment elements (e.g.
mobilization) mentioned? (Y/N);
c) Is any treatment content described in terms of nature and/
or time and/or intensity? (Y/N);
d) Are any decision rules and/or decision moments regarding
the provision of therapy described? (Y/N);
Papers were considered eligible if the answer to all 4 questions
mentioned above was “yes”. In case of inter-observer disagre-
ement, the paper was discussed by the 2 observers. Consensus
was reached in all cases.
Data extraction
METHODS
Data sources
A computerized search was conducted of all English, French,
German and Dutch scientific papers in MEDLINE (PubMed),
Cochrane databases, CINAHL, PEDro and Embase (Ovid).
Studies were collected up to November 2018. The following
Medical Subject Headings (MeSH) were used: (“Acetabulum”
OR (“Humerus” AND “Proximal”) OR (“Tibia” AND “Pla-
teau”)) AND “Fracture” AND (“Rehabilitation” OR “Physical
Therapy”) NOT “Infant” NOT “Pediatric” NOT “Animal” NOT
“Cadaver” NOT “Equipment Design” NOT “Case Report” NOT
“Legislation”.
Furthermore, a search for possible guidelines as to rehabi-
litation therapy content regarding aftercare following surgery
for (peri-)articular fractures was performed on a number of
stakeholder sites on the internet (in the domain of surgery and
traumatology: www.aofoundation.org; in the domain of medical
audit: www.diliguide.nl/richtlijnen/professionals; in the domain
of rehabilitation sciences: Dutch Paramedical institute (NPI):
www.paramedisch.org/doconline/portal.html; and clinical prac-
tical guideline domain: http://guidance.nice.org.uk, www.sign.
ac.uk, http://guidelines.gov, http://ww2.rch.org.au, https://www.
mja.com.au, http://www.evidence.nhs.uk). Finally, standard
textbooks covering issues related to the treatment of (peri-)
articular fractures, recommended by the Taskforce Trauma
Rehabilitation (Dutch: WTR) of the Dutch Society of Rehabi-
litation Medicine (Dutch: VRA), were checked.
Study selection
All papers identified by the search strategy were checked for
duplicates. A language check was also performed.
The results of the literature search are reported per fracture
location. First, the rehabilitation programmes are described in
general. Then, the content of the post-surgical rehabilitation
programmes is systematically described in the text and clas-
sified in a table according to: (i) ICF-level targeted (Function,
Activity, Participation) (5); (ii) time course (treatment phases,
i.e. time-delimited epochs within the rehabilitation process in
which the therapy is focused on one or more specific treat-
ment goals); (iii) goal(s) strived for; (iv) therapy dosage (i.e.
frequency, duration and intensity of therapy). Furthermore, the
programmes were assessed as to the availability of decision
rules determining the timing of the initiation of new therapy
elements, training specificity (i.e. whether aftercare focused on
the whole body (in general) or on a specific body region), and
whether protocols accommodate for adjustments to individual
patients’ needs. In addition, for evaluating the scientific evidence
as to the effectiveness of (parts of) the protocols identified,
the Van Tulder’s Quality assessment system was used (6). For
descriptive analysis, the Patients, Intervention, Comparison and
Outcome & Results (PICO) principle (7) was followed.
RESULTS
The initial literature search resulted in 664 papers.
Removal of duplicates resulted in 549 papers and, after
a language check, a further 54 papers were removed,
leaving 495 documents for assessment in step one.
Based on a global evaluation of the articles’ titles and
abstracts, 284 articles were excluded. Of the remain-
ing 211 papers, 80 remained after the assessment of
step 2. Next, 13 papers were excluded, because no
J Rehabil Med 51, 2019