Early Passive Mobilization Research Articles

The association of early passive mobilization with intracranial pressure in the adult intensive care unit: A prospective, cohort study.

Early mobilization are key components of the ABCDEF Care Bundle and critical treatments to reduce acquired muscle weakness, delirium and prolonged intensive care unit (ICU) stay. This study aimed to determine whether routine early mobilization related to intracranial pressure in intensive care patients on mechanical ventilation, using optic nerve sheath diameter measurement (ONSD). This study was planned as a prospective, cohort study in the third-step adult ICU of a faculty hospital. The study included only patients who were intubated and followed up on a mechanical ventilator and were clinically stable. Passive range of motion (PROM) exercises were performed daily by the physiotherapists as part of routine care from the day of hospitalization. ONSD was assessed before, during and 10 min after PROM exercises. The study included 20 eligible patients out of the 142 who were evaluated upon admission to the ICU. The median age of the patients was 65 years, and nine (45%) of them were female. The analyses showed that there was no statistically significant change in ONSD during and at the end of the PROM (ONSD right eye p:.621, Partial η2: 0.025, ONSD left eye p:.935, Partial η2: 0.004). Similarly, there was no statistically significant change in haemodynamic parameters in during and at the end of the PROM (Heart beat p:.849, Partial η2: 0.009, Systolic Pressure p:.435, Partial η2: 0.043, Diastolic Pressure p:.128, Partial η2:0.103, Saturation p:.103, Partial η2: 0.113 and Respiratory rate p:.071, Partial η2:0.130). This study suggests that daily extremity physiotherapy exercises can be safely applied without causing increased intracranial pressure or haemodynamic instability in intensive care patients followed up on mechanical ventilation, including patients with vasopressor therapy. Early mobilization, including PROM, is considered safe in terms of intracranial pressure for intubated patients in the ICU.

The efficiency of Coban bandage on acute phase edema among patients undergoing a flexor tendon repair

Introduction: To evaluate the efficiency of 3M Coban self-adherent wrap application on early (1-4 weeks) edema among patients undergoing surgery following a flexor tendon injury in Zone V or distal.
 Material and Method: The study included 56 patients who had flexor tendon injuries. The patients were randomized into two groups by the computerized randomization method. Both groups were applied the "Modified Duran Protocol" (MDP) early passive mobilization exercises and "Retrograde Edema Massage". In addition, was applied 3M Coban self-adherent wrap to Group II. Finger circumferences was measured using a tape measure, and the pain intensity was evaluated with a visual analog scale (VAS). A goniometer was used to measure the joint range of motion (ROM), the Duruoz hand index (DHI) to evaluate functionality level, and the quality of life was investigated using the short form-36 (SF-36).
 Results: The results showed that was statistically significant differences in both groups compared to pre-treatment (p

Early passive mobilization increases vascular reactivity response in critical patients with sepsis: a quasi-experimental study

Early passive mobilization increases vascular reactivity response in critical patients with sepsis: a quasi-experimental study

Rehabilitación temprana de fracturas de radio distal con ortesis robóticas. Reporte de Casos

BackgroundRobotic exoskeletons are a new alternative to complement the functional rehabilitation processes of the wrist, facilitating early passive mobilization therapy after local traumatic events, with the purpose of maintaining or restoring joint range of motion while the tissues heal. The aim of the study is to present the results of early mobilization therapy in a passive robotic wrist orthosis. MethodsFour patients with distal radius fractures were selected, treated surgically with open reduction and internal fixation of distal radius fracture with volar plate locking system. Conventional physiotherapy and early mobilization with the PRO-Wix robotic orthosis was performed. Clinical monitoring of functionality (DASH scale), pain (VAS scale), joint mobility arches (goniometer), adherence and potential adverse events were carried out. Resultsall patients returned to their daily living activities after three weeks of rehabilitation. Recovery of normal wrist joint range of motion was achieved; decreased in pain intensity, functional recovery, adequate adherence to rehabilitation protocol and adverse events were also recorded. Discussionpreserving the joint anatomy as much as possible in specialized surgical intervention is the basis for starting early rehabilitation, and allowing the patient to tolerate passive mobilization with robotic orthoses. Further studies including a wide number of patients have to be conducted. Evidence LevelIV

Autonomous Patient-Controlled Mobilization Protocol After Flexor Tendon Repair: A Case Series.

Despite many publications on rehabilitation after repair of flexor tendon injuries of the hand, there is no consensus as to which method is superior. It is clear that nonadherence to postoperative therapy adversely affects the outcome after flexor tendon surgery. In the context of a developing country, the most important factor associated with poor outcome is late onset of rehabilitation therapy. An autonomous rehabilitation program is proposed, with the use of a low-cost splint and based on an online illustrative video with the expectation to improve adherence and patient compliance, thus ensuring satisfactory outcome. Twenty-two consecutive digits of 14 patients after flexor tendon repair in zone II were included. Autonomous early passive mobilization physical therapy and splinting started shortly after surgery, supported by an online available video depicting prescribed exercises; follow-up was continued until postoperative week 20. Patients were evaluated regarding range of motion, grip strength, and the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) disability scale. Range of motion after 20 weeks according to the scoring system of the American Society of Surgery of Hand was excellent in 4, good in 11, and fair in 4 fingers. The mean total active motion score was 86% (95% confidence interval, 78%-93%). The mean grip strength at final follow-up was 86% of the contralateral hand. The mean QuickDASH score was 12.5 (2.3-31.8). This protocol achieves good results in range of motion and early return of function of the hand. We propose this simple, nonexpensive method to developing countries with less than optimal availability of health care.

Rehabilitación de fracturas del radio distal con órtesis robóticas

Introducción. El presente estudio es una serie de casos clínicos que describe los resultados de un tratamiento de fracturas del radio distal realizado en Manizales, Colombia, por el grupo de investigación F-CIBER-HAND y que integra el manejo quirúrgico de la fractura, la rehabilitación convencional y la rehabilitación con órtesis robóticas. Objetivo. Generar evidencia clínica (nivel III) sobre las ventajas de la movilización pasiva temprana con órtesis robóticas en la rehabilitación de pacientes posquirúrgicos de fracturas del radio distal. Materiales y métodos. Se seleccionaron 10 pacientes con fracturas del radio distal que presentaron limitación funcional de la muñeca después de dos semanas del posoperatorio; a los sujetos se les practicó terapia física y movilización pasiva con órtesis robótica PRO-Wix. Resultados. Los pacientes presentaron mejoría funcional de la muñeca según el cuestionario Disabilities of the Arm, Shoulder and Hand score, disminución de la intensidad del dolor según la escala visual analógica y recuperación del arco de movilidad articular según goniometría. Además, luego de tres semanas de rehabilitación retornaron a las actividades que realizaban antes de la fractura. Discusión. Es necesario realizar nuevos ensayos clínicos aleatorizados para poder determinar las ventajas de la movilización temprana con órtesis robóticas frente a la implementación exclusiva de la terapia convencional. Conclusiones. La movilización pasiva con órtesis robóticas complementa eficazmente la terapia física en pacientes posquirúrgicos de fracturas del radio distal y favorece la disminución del dolor, la recuperación del arco de movilidad articular y la funcionalidad.

A prospective study of functional outcome in displaced fractures of the proximal humerus managed surgically

Background: The aim of the study is to evaluate the functional outcome of displaced fractures of the proximal humerus managed surgically.Methods: A prospective analysis of the functional outcome of 20 cases under surgically managed displaced proximal humeral fractures were undertaken in our hospital. The indications of the surgery were displacement to more than 1 cm and angulation of more than 45°. The patients were operated by the standard anterior deltopectoral approach, deltoid splitting or percutaneous procedure depending upon the type of fracture and bone quality. Results: The mean age of the patients was 44 years. The mode of injury was fall at ground level in 10(50%) patients, road traffic accident in 6(30%) patients, fall from height in 3(15%) patients, fall due to epilepsy in 1(5%) patients. Based on Neer’s sytem 10 patients (50%) had two part fractures, 5(25%) patients had 3 part fractures and 5(25%) had four part fractures. Greater Tuberosity fractures were the predominant type in 2 part fracture. Patients underwent the surgery on an average of 7.95 days after injury. The mean follow-up period in this study was 12.2 months. Conclusion: Displaced proximal humeral fractures when treated surgically produce less pain, less stiffness and greater range of motion. Earlier the surgery better are the results. Results are better with fractures than with fracture dislocations. Results are best when operative method results in stable fixation that allows early passive mobilization. Functional outcome of 2 part fractures is better than 3 part and 4 part fractures.

The Effect of Delay to Surgery on Major Complications after Primary Flexor Tendon Repair.

Background: Flexor tendon repair carries a significant risk for complications, which often leads to revision surgery. The purpose of this study was to assess the effect of different factors on the risk for major complications patients undergoing a primary end-to-end flexor tendon repair and early passive mobilization regimen (Kleinert protocol). Methods: Between January 2000 and September 2009, a total of 312 patients underwent a flexor tendon repair at out institution. We excluded patients whose injury was self-inflicted or secondary to a rheumatic disease or a fall leaving 187 patients with 325 injured tendons for the study. Results: 152 (81.7%) patients were male and 34 (18.3%) females. Mean age of the patients was 32.7 years (SD 14.4, range 11 to 73). The fifth ray was most commonly affected. The majority of the injuries were located in zone II. Median delay to surgery was 3 days. Complications were observed in 34 patients (18.2%). Univariable analysis showed that patient age, mechanism of injury, injured ray, delay to surgery between three and seven days, and greater suture thickness were associated with increased risk of complications. In the subsequent multivariable analysis, only the mechanism of injury and delay to surgery remained as significant risk factors for major complications. Conclusions: We conclude that complications after flexor tendon repair may be reduced by appropriate timing of the surgery. Delay to surgery lasting between three and seven days seems to be associated with increased risk for major complications.

Comparative study between early active and passive rehabilitation protocols following two-strand flexor tendon repair: can two-strand flexor tendon repair withstands early active rehabilitation?

BackgroundRestoration of full range of motion of digits as well as prevention of joint contracture following flexor tendon repair is a challenge. There is lack of solid evidence regarding the most suitable rehabilitation protocol following flexor tendon repair. This is owing to the limited number of studies comparing different rehabilitation protocols. Moreover, the present studies advocate a specific technique with no comparative group. Even the few controlled studies conducted vary in methods of repair and rehabilitation, and outcome assessment. To our knowledge, the only randomized controlled trial comparing early passive rehabilitation with early active rehabilitation is the one done by Trumble and colleagues in 2010, which was done on four-strand repaired tendon. These authors concluded that active rehabilitation program had better range of motion with less flexion contractures and greater satisfaction scores than those subjected to passive rehabilitation protocol.AimThis conclusion stimulated us to study the effect of early active mobilization versus early passive mobilization following two-strand repair.Patient and methodsWe conducted our study for 12 weeks comparing early active mobilization protocol ‘place and hold’ with early passive mobilization ‘modified Kleinert’ after standard two-strand modified Kessler repair in different hand zones.Results and conclusionWe concluded that early active mobilization had better tendon gliding and excursion even with the two-strand repair as active motion will decrease adhesion formation, with significant difference compared with the passive group. Moreover, there was no significant difference in the rupture rate and significant difference for combined tendon lag and flexion deformity owing to the tenodesis mobilization between both the groups.

Fear of movement and its effects on hand function after tendon repair

After tendon injuries, it has been observed clinically that patient-reported disability is more severe than the patient's actual performance. This is thought to result from a fear of movement (kinesiophobia) after surgery. The aim of this study was to investigate the presence of kinesiophobia in this patient population and its effects on the clinical outcomes. Patients (n=118) with tendon repairs were included. All the participants received early passive mobilization and were assessed at the end of the 8th week. Grip and pinch strengths were measured and the Nine-Hole Peg Test (9HPT) was conducted. Patients also filled out the Michigan Hand Outcomes Questionnaire (MHOQ) and Tampa Scale for Kinesiophobia (TSK). Patients were divided according to their kinesiophobia: Group 1 with low kinesiophobia (TSK<37) and Group 2 with high kinesiophobia (TSK≥37). The groups were compared on the assessed parameters. Fifty-nine percent of the patients had a high kinesiophobia level. The performance-based test results were similar between the groups (P>0.05). Patient-reported MHOQ and TSK scores were significantly lower in the high kinesiophobic group (P=0.001 and P=0.000, respectively). Patients with tendon repairs often develop kinesiophobia, which may contribute to difficulty when starting to re-use their hand in daily life. None of the objective results were affected by this fear of movement–only patient-reported disability. Clinicians should be aware that clinical outcomes may be affected by the patient's kinesiophobic thinking and must be cautious during treatment.

Evidence based post-operative treatment of flexor tendons

Flexor Tendon injuries require surgical repair and intensive therapy post-operatively for optimal outcomes. “The repair technique is important but it is the way the tendon is managed afterwards that determines the outcome” ([1], page 112). Multiple protocols exist for the post-operative rehabilitation of tendon injuries. Currently four main options for post-operative treatment are utilized: immobilization, early passive mobilization, early active-passive mobilization and earlyactive mobilization. Early protected movement has been shown to decrease adhesion formation and stimulate tendon healing [2]. It is well established that protected early movement of the tendon results in a better outcome than immobilization [3-5]. There is less risk of tendon rupture with early passive motion protocols, but an increased risk for decreased range of motion in the final outcome, in comparison to early active motion protocols [6]. “The goal of tendon repair and rehabilitation is to achieve a normally gliding and functioning tendon.”([1], p 115). To achieve this goal the surgeon, the therapist and the patient must work closely together. The surgeon must create a repair that is strong enough to withstand the rehabilitation phase. The therapist must have a thorough understanding of: tendon anatomy, the mechanical limitations of the repair, the healing process and the biomechanical forces at work during the healing process. Additionally the therapist must understand the tendon’s response to the chosen treatment and continually adjust the treatment accordingly. The patient too must participate in the treatment; this requires that the patient receives sufficient instruction that allows him or her to understand the injury and participate in the subsequent rehabilitation process. In many clinics, flexor tendon rehabilitation is protocol driven; a standard post-operative protocol is implemented routinely for flexor tendon injury cases. This approach may work well when the patient meets the standard inclusion criteria. However when the patient does not meet the criteria for the prescribed protocol for post-operative treatment, treatment of acute flexor tendon injuries can be a challenge and if not adjusted for may result in less than optimal outcomes. “Functional outcomes do not depend on following a prescribed protocol, but on progressing each patient individually with the available evidence-based information and on observation of the individual’s healing process” [7]. There is ample evidence available to guide therapists and physicians in clinical decision making when patient characteristics do not fit the protocol. A review of evidence that supports and guides the therapist’s clinical decision making in rehabilitation of the flexor tendon will be presented. Options for clinical situations such as: delayed initiation of post-operative treatment, concomitant injuries and or conditions that require rest vs. movement, patients that cannot follow complex treatment programs and other clinical scenarios that require an adapted approach to obtain an optimal outcome, will be discussed.

Rehabilitation following zone II flexor tendon repairs.

Ongoing clinical and basic research has improved understanding of flexor tendon mechanics and physiology for surgical repair and rehabilitation after a zone II flexor tendon repair. Yet, the ideal surgical repair technique that includes sufficient strength to allow safe immediate active motion of the finger, without excessive repair stiffness, bulk or rough surfaces resulting in excessive resistance to flexion, does not exist. After optimizing the repair, the surgeon and therapist team must select a rehabilitation plan that protects the repair but helps to maintain tendon gliding. There are 3 types of rehabilitation programs for flexor tendon repairs: delayed mobilization, early passive mobilization, or an early active mobilization. No guideline for rehabilitation should be followed exactly. Many factors influence therapy decisions, including repair technique, associated tendon healing, passive versus active range of motion, edema, and tendon adhesions. These factors can assist in guiding rehabilitation progression and promote functional range of motion, safely mobilize the repaired tendon(s) and prevent gapping, rupture, and adhesions.

Primary Flexor Tendon Repair in Zones 1 and 2: Early Passive Mobilization Versus Controlled Active Motion

To compare early passive mobilization (EPM) with controlled active motion (CAM) after flexor tendon surgery in zones 1 and 2. We performed a retrospective analysis of collected data of all patients receiving primary flexor tendon repair in zones 1 and 2 from 2006 to 2011, during which time 228 patients were treated, and 191 patients with 231 injured digits were eligible for study. Exclusion criteria were replantation, finger revascularization, age younger than 16 years, rehabilitation by means other than EPM or CAM, and missing information regarding postoperative rehabilitation. This left 132 patients with 159 injured fingers for analysis. The primary endpoint was the comparison of total active motion (TAM) values 4 and 12 weeks after surgery between the EPM and the CAM protocols. The analysis of TAM measurements under the rehabilitation protocols was conducted using t-tests and further linear modeling. We defined rupture rate and the assessment of adhesion/infection as secondary endpoints. There was a statistically significant difference between the TAM values of the EPM and the CAM protocols 4 weeks after surgery. At 12 weeks, however, there was no significant difference between the 2 protocols. Older age and injuries with finger fractures were associated with lower TAM values. Rupture rates were 5% (CAM) and 7% (EPM), which were not statistically different. This study showed a favorable effect of CAM protocol on TAM 4 weeks after surgery. The percent rupture rate was slightly lower in the patients with CAM than in the patients with EPM regime. Further studies are required to confirm our results and to investigate whether faster recovery of TAM is associated with shorter time out of work. Therapeutic III.

Biomechanical Characteristics of Suture Anchor Implants for Flexor Digitorum Profundus Repair

To determine strength and failure characteristics of 2 suture anchors used to repair simulated flexor digitorum profundus avulsions during passive mobilization protocol simulation. We simulated avulsion of the flexor digitorum profundus tendon in 30 distal phalanges from fresh-frozen human cadavers. Repair was performed with a 1.3× 3.7 mm Micro-Mitek suture anchor (3-0 Orthocord suture) and a 2.2× 4.0-mm Corkscrew suture anchor (2-0 FiberWire suture). All specimens were loaded cyclically from 2 to 15 N at 5 N/s for a total of 500 cycles. Samples were tested to failure at the completion of 500 cycles. Load at failure, load at first noteworthy displacement (> 2 mm), elongation of the system, gap formation at the tendon-bone interface, and the mechanism of failure were assessed. Suture failure at maximum load was the prevalent failure mechanism in both groups. No statistically significant difference in elongation of the tendon-suture complex was observed. The Corkscrew suture anchor showed a significantly superior performance in load to failure, load at first significant displacement, and gap formation at the tendon-bone interface. The significantly higher load capacity at first displacement (> 2 mm) and the significance of a lower gap formation at the repair site seem to be the most relevant clinical parameters. Based on this concept, the Corkscrew anchor may be superior biomechanically to the Micro-Mitek when considering an early passive mobilization protocol. The choice of an appropriate implant may influence the postoperative mobilization protocol and thereby improve currently reported success rates. Defining a biomechanically superior implant will provide an essential basis for further studies in flexor tendon repair research.

Comparison between early active and passive mobilization programs after hand flexor tendon repair in zone II

ObjectiveThe objective of this study was to study the efficacy of an early active mobilization program in comparison with passive mobilization on the range of motion (ROM) and grip strength after flexor tendon repair in zone II.Patients and methodsThe Modified Kessler technique, followed by a contin

Rehabilitation After Surgery Repair of Flexor Tendon Injuries of the Hand with Kleinert early Passive Mobilization Protocol

Rehabilitation after surgery repair of flexor tendon injuries of the hand remains challenging and requires experienced professionals and interdisciplinary approaches. The aim of this study was to evaluate rehabilitation results after surgery repair of flexor tendon injuries in the hand with the early passive mobilization--Kleinert protocol. In this retrospective case-series study rehabilitation results of flexor tendon injuries in the hand with the early passive mobilization--Kleinert protocol were evaluated in 35 patients, treated in the Orthopaedic Clinic University Clinical Centre of Kosovo between December 2007 and November 2008. Patients had unilateral injuries on right hand without associated injuries. Patients were divided in three groups: patient with injury of FPL (n = 15), patient with injury of FDP and FDS dig. I-V (n = 10) and patient with injury of FDP and FDS dig.II (n = 10). Patients were included in a rehabilitation program using the Kleinert-early passive mobilization protocol. Functional evaluation was made using the mean improvement on MCP, PIP and DIP joints motion, mean functional are of motion (FAM) and total active motion (TAM) scoring system of The American Society of Surgery of Hand. The functional outcomes were analyzed by Paired t-test, and One way Analysis of Variance, while the mean TAM score were compared using the Wilcoxon Matched-Pairs Signed-Ranks test with significance set at p < 0.05. About 67% of patients with FPL injuries achieved excellent range TAM score, and about 22% of patients with FDS&FDP injuries achieved excellent and 74% good range of total active motion. With earlier performed primary surgical tendon repair followed by Kleinert-early passive mobilization protocol may achieves satisfactory functional results for any flexor tendon injuries in zones I-IV of the hand.

Shoulder stiffness and rotator cuff repair

Shoulder stiffness is a frequent complication of surgical repair of rotator cuff tears. Post-operative stiffness negatively affects surgical outcomes leading to a substantial comorbidity and to the failure of surgical treatment. Also, a stiff shoulder could commonly be concomitant with an rotator cuff tear (RCT). We performed a comprehensive search of CINAHL, Embase, Medline and the Cochrane Central Registry of Controlled Trials, from inception of the database to 31 July 2011. Sixteen articles published in peer-reviewed journals were included in this comprehensive review. The management of shoulder stiffness is still controversial. The role of rehabilitation programs (standard versus early passive mobilization) after RCT repair on the development of stiffness is not clear, while the role of arthroscopic capsular release for post-operative stiffness is better defined, although a threshold of decreased the range of movement for which capsular release is advised has not been identified. Several factors have been identified to predispose the development of shoulder stiffness. There is also evidence in favor of surgical management of RCTs even when accompanied by shoulder stiffness, and there are strong evidences that arthroscopic capsular release is reliable and effective in managing shoulder stiffness. The post-operative rehabilitation protocol remains controversial. We are still far from definitive guidelines for the management of pre- and post-operative stiffness, and prospective double-blinded randomized clinical trials are needed to obtain evidence allowing to establish a reliable and effective management plan for shoulder stiffness.

Proximal humeral fracture and shoulder artroplasty: Rehabilitation treatment

The proximal humeral fractures need a specific and specialist rehabilitation approach for their treatment, both for conservative or after shoulder artroplasty surgical implant. There are many factors that may influence the final recovery of the patient; the localization of the fracture (intra or extra capsular fracture), its size, the extent of the trauma, the general clinical conditions of the patient, the quality of the shoulder tissue and its personal ability to heal, the rehabilitative tecniques used, patient motivations and psicological aspects and how much time the patient have got to spend to follow the rehabilitation project to reach specific functional goals. The ROM deficit is the more common complication after proximal humeral fracture. The causes may be lack of articular congruence (stabilized meccanical rigidity without pain) or retraction of the capsulo ligament structures (changeable tissutal rigidity with pain). In most clinical situations (except prosthesis) an early passive articular mobilization in a safe range of motion (reduced ROM, on a scapular plane and avoiding rotations) will be usefull, postponing active mobilization and muscolar reinforce when there will be a safe clinical and radiological heal of the fracture or the prosthesis implant will be stable. The rehabilitation treatment of the patient that underwent surgical procedure of prosthesis implant (total shoulder arthroplasty, endoprosthesis, reverse shoulder arthroplasty, resurfacing prosthesis) needs in any case to avoid manual traction of the gleno humeral articulation or articular pompages, manual stabilizzation of the scapula, and in the first post surgery month to save humerous from rotations. In the end the clinical monitoring of many parameters (range of motion, muscolar force and endurance, coordinated skills, sportive gesture, daily living activity and functionality) using validated clinical tests (isokinetic and isometric tests, aerobic and anaerobic thereshold, scale to evaluate the functionality and the state of psychological health) will permit to understand if and at wich level the functional goals have been reached and will allow to observe far off the functional outcome.

Importance of Early Passive Mobilization following Double Free Gracilis Muscle Transfer

The tendinous portion of the transferred muscle following double free gracilis muscle transfer for reconstruction of prehensile function in complete paralysis of the brachial plexus has a tendency to adhere to the surrounding bed and thus impede active finger motion despite powerful contraction of the muscle per se. The purpose of this study was to evaluate the effectiveness of early postoperative passive mobilization of the tendon to prevent its adhesion and the need for tenolysis. Of 34 patients who underwent double free gracilis muscle transfer technique, the initial 19 patients (group 1) underwent the conventional postoperative management consisting of 6 weeks of immobilization, and the following 15 patients (group 2) had early passive mobilization. Postoperative active range of motion of elbow and finger joints and the incidence of tenolysis were reviewed. Early passive mobilization technique in group 2 negated the need for tenolysis of the transferred muscle, whereas 10 of 38 transferred muscles in group 1 required tenolysis to improve finger motion. Before tenolysis, there was a significant difference of total active finger motion between group 1 and group 2, although there was no significant difference in the total active finger motion between group 1 and group 2 after tenolysis. Early passive mobilization in the postoperative period, consisting of tendon compression at the elbow and assisted resistance exercises of finger and wrist joints, can prevent postoperative adhesion and improve tendon excursion and motion of the free transferred muscle.

Immediate Mobilization Compared with Conventional Immobilization for the Impacted Nonoperatively Treated Proximal Humeral Fracture

There have been few randomized controlled trials evaluating nonoperative treatment of proximal humeral fractures. To investigate shortening the period of dependence, we assessed the feasibility and efficacy of early mobilization of the shoulder (within three days after the fracture) in comparison with those of conventional three-week immobilization followed by physiotherapy. We randomly assigned seventy-four patients with an impacted proximal humeral fracture to receive early passive mobilization or conventional treatment. The primary outcome was the overall shoulder functional status (as measured with the Constant score) at three months. The secondary outcomes were the Constant score at six weeks and at six months, the change in pain (on a visual analog scale), and the active and passive range of motion. At three months and at six weeks, the early mobilization group had a significantly better Constant score than did the conventional-treatment group (between-group difference, 9.9 [95% confidence interval, 1.9 to 17.8] [p = 0.02] and 10.1 [95% confidence interval, 2.0 to 18.1] [p = 0.02], respectively) and better active mobility in forward elevation (between-group difference, 12.0 [95% confidence interval, 1.7 to 22.4] [p = 0.02] and 28.1 [95% confidence interval, 7.1 to 49.1] [p = 0.01], respectively). At three months, the early mobilization group had significantly reduced pain compared with the conventional-treatment group (between-group difference, 15.7 [95% confidence interval, 0.52 to 30.8] [p = 0.04]). No complications in displacement or nonhealing were noted. Early mobilization for impacted nonoperatively treated proximal humeral fractures is safe and is more effective for quickly restoring the physical capability and performance of the injured arm than is conventional immobilization followed by physiotherapy.