Evidence-based rehabilitation after (peri-)articular fracture surgery
thoughts for this protocol deviation (2, 8). However,
all authors seem to agree on the general therapy con-
tent and progression of the post-fracture rehabilitation
process, though the explicit arrangement into phases
is dissimilar. Based on this observation, the findings
of all 5 papers were combined, as presented below.
ICF – Body Functions and Structures level. According
to Moeckel et al. (9), the first phase of the selected
rehabilitation therapy programmes was aimed at
gaining full passive range of motion, i.e. improving
joint mobility, without compromising the stability of
the fixation. In the protocol of Handoll et al. (10), the
first phase was aimed at prevention of comorbidities
through, for instance, elbow, wrist and hand exercises,
and teaching sling application and axillary hygiene. All
other protocols strived for optimizing joint mobility
through pendulum exercises, passive forward eleva-
tion and passive external rotation, starting the first day
post-operatively. In the protocol of Handoll et al. (10)
these exercises were initiated in the second phase. The
surgeon defined during surgery (2, 9) or on the first
post-operative day (8), the range of motion constraints
during the exercises. In contrast to the other authors,
Compito et al. (8) stated that the patients should use
a sling for 6 weeks, except during therapy activities
(8). Patients receiving rehabilitation according to the
protocol of Handoll et al. (10) should wear a sling for
approximately 3 weeks, including during exercises.
When the patient feels safe, the sling can be removed
during exercises. According to Burton & Watters (1)
patients should warm-up by using a warm pack on
the shoulder. Patients receiving rehabilitation therapy
in accordance with the protocols of Cuomo et al. (2)
and Burton & Watters (1) had to repeat the exercises
4 times daily. Handoll et al. (10) advised therapists to
instruct patients to perform 5 repetitions, 3 times per
day, of all exercises in all phases. Compito et al. (8)
and Moeckel et al. (9) provided no information about
the training frequency and duration within this phase.
The therapy in the second phase showed a larger
variation across post-surgical therapy programmes.
Although in all papers the second phase was reported
to start at around the same time, i.e. approximately 6
weeks post-trauma, different clinical reasoning sub-
stantiating the start of phase 2 was used. The main
focus in this phase was the improvement in joint mo-
bility and strength. Overall, the second phase of the
physiotherapeutic/occupational therapeutic treatment
programme consisted of active assisted exercises and
strengthening or resistive exercises, though the exer-
cises were executed differently. In addition to these
exercises, stretching exercises were prescribed by
Burton & Watters (1) and Handoll et al. (10). Handoll
641
et al. (10) added isometric rotation exercises and closed
chain exercises. Due to insufficient information about
the therapy dosage, it was not possible to explore
whether therapy could improve endurance.
The third and last phase, starting approximately 3
months post-trauma, was mostly aimed at improving
the strength through resistive strengthening exercises.
Similar to the second phase, too little information was
provided to explore whether therapy aimed at improv
ing endurance. Except for the programme described
by Moeckel et al. (9), mobility was improved by using
stretching exercises. Exercises were not specified, e.g.
regarding movement plane. In contrast to the other
protocols, Burton & Watters (1) and Handoll et al.
(10) started out putting more emphasis on the needs of
the individual patient, by stating that aftercare should
continue “until functional gain reaches a plateau or
pre-injury levels” (1) or to continue strengthening ex-
ercises “appropriate to the patient’s premorbid activity
level” (10). In current rehabilitation therapy, this ap-
proach has been further developed into what is called
“’patient-centred” rehabilitation, in which individual
goal setting and patient-specific training regimes are
advocated. The duration of the full rehabilitation pro-
gramme varied from approximately 1 year (8, 9), to 1
year and 3 months (2). Handoll et al. (10) prescribed to
discharge patients when independent shoulder function
is achieved or if the therapist and patient do not observe
any improvement over several sessions.
Assessment rules based on patient characteristics
or on the progression of the fracture recovery seem
to be missing in most phases of the papers selected,
though Handoll et al. (10) state that the progression
of the rehabilitation process is dependent on certain
factors, e.g. stage of healing, and general health and
activity level. As a result, these papers only provided a
general roadmap instead of a protocol targeting after-
care at an individual level. Furthermore, no methods
to objectively monitor the rehabilitation progress were
mentioned. In addition, the papers only described the
physiotherapeutic/occupational therapeutic treatment
for fracture rehabilitation, disregarding possible other
physical or mental consequences of the fracture.
Moreover, none of the papers reported scientific
evidence on which the described physiotherapy/oc-
cupational therapy protocols were based. Furthermore,
only Handoll et al.’s research group (10) examined and
confirmed the effectiveness of their therapy protocol
(for methodological quality assessment, see below).
ICF – Activity level. In the second and third phase,
patients receiving therapy according to the protocol of
Handoll et al. (10) should progress functional activities
consistent with their abilities. However, no further
J Rehabil Med 51, 2019