Proximal humerus fracture rehabilitation. HODGSON, Steve A. Available from Sheffield Hallam University Research Archive (SHURA) at: http://shura.shu.ac.uk/20723/ This document is the author deposited version. You are advised to consult the publisher's version if you wish to cite from it. Published version HODGSON, Steve A. (2006). Proximal humerus fracture rehabilitation. Doctoral, Sheffield Hallam University (United Kingdom).. Copyright and re-use policy See http://shura.shu.ac.uk/information.html Sheffield Hallam University Research Archive http://shura.shu.ac.uk Learning and IT Services Collegiate Learning Centre I Collegiate Crescent Campus i I Sheffield S1G2BP j 101 853 270 6 r e f e r e n c e ProQuest Number: 10702821 All rights reserved INFORMATION TO ALL USERS The quality of this reproduction is dependent upon the quality of the copy submitted. In the unlikely event that the author did not send a complete manuscript and there are missing pages, these will be noted. Also, if material had to be removed, a note will indicate the deletion. uest ProQuest 10702821 Published by ProQuest LLC(2017). Copyright of the Dissertation is held by the Author. All rights reserved. This work is protected against unauthorized copying under Title 17, United States Code Microform Edition © ProQuest LLC. ProQuest LLC. 789 East Eisenhower Parkway P.O. Box 1346 Ann Arbor, Ml 48106- 1346 Proximal Humerus Fracture Rehabilitation Steve Hodgson A thesis submitted in partial fulfilment of the requirements of Sheffield Hallam University for the degree of Doctor of Philosophy WaiS'i:^§y August 2006 I. Declaration I hereby declare that, to my best knowledge and belief, it contains no material previously published or written by another person nor material which to a substantial extent has been accepted for the award of any other degree or diploma of the university or other institution of higher learning, except where due acknowledgement has been made in the text. Steve Hodgson 1 August 2006 II. Acknowledgements The idea for the study originated from a discussion with David Stanley who willingly gave up his time to consider the proposal and to give advice. His support, allowing his patients to enter the study, reading papers and passing comment, has been invaluable in the whole process. Inputting data and ensuring that the follow-up assessments were completed were both expertly managed by Julie Harris; her skill and dedication were crucial to the study and made the whole process easier. I would like to thank all the physiotherapists at the Northern General hospital who treated the patients and willingly contributed their time to help with the smooth running of the study. For their statistical advice I would like to thank Stephen Walters and Mike Grimley who never tired of my constant questioning and were always helpful with their comments. I would like to thank both Dr Sue Mawson and Dr John Saxton who supervised my dissertation for their constant support and encouragement. Finally, I would like to thank all the patients who willingly gave up their time to contribute to the study and whose only motivation was to help other people with a similar injury. Thank you. 3 III. Dedication This is dedicated to my children, Jenna and Helena, for asking why I still had to do homework at my age and to my parents for their constant support and encouragement. I would also thank Karen for helping keep my sanity during the final draft. 4 IV. Figures & Tables Figures Page Figure 1: Proximal humerus fracture 20 Figure 2: Fracture incidence by type of fracture 39 Figure 3: Exponential growth in PH fracture incidence 42 Figure 4: Incidence of PH fractures by gender 43 Figure 5: Age-specific annual incidence of PH fractures 45 Figure 6: Level of disability after a fracture grouped by age 73 Figure 7: Fall Direction with a Proximal Humerus fracture 81 Figure 8: Flow-chart (admission to entering study) 143 Figure 9: Patient Flow-chart at follow-up 179 Figure 10: Treatment sessions by group allocation 181 Figure 11: Constant shoulder score at 8 to 52 weeks 183 Figure 12: Regression Modelling Analysis CSS 185 Figure 13: Regression Analysis Modelling SF-36 (RLP) 191 Figure 14: Regression Analysis Modelling SF-36 (PF) 192 Figure 15: Regression Analysis Modelling SF-36 (P) 192 Figure 16: CSDQ scores for each question at two year follow-up 196 Figure 17: SF-36 Score (Pain) by gender 200 Figure 18: SF-36 Score (Physical Function) by gender 200 Figure 19: SF-36 Score (Pain) by level of deprivation. 201 Figure 20: SF-36 Score (PF) by level of deprivation. 202 Figure 21: SF-36 Score (RLP) by level of deprivation 202 5 Tables Table 1: Outcome variables 155 Table 2: CSDQ validation data 166 Table 3: Response rate 174 Table 4: Subjects’ baseline characteristics 176 Table 5: Complications reported over three years of the study 182 Table 6: Constant Shoulder Score difference (52 weeks) 184 Table 7: Constant shoulder score results up to one year 186 Table 8: Short form (SF-36) health survey 189 Table 9: Follow-up at one & two years 193 Table 10: Patient characteristics;at two years 194 Table 11: Shoulder disability (CSDQ) by group allocation 195 Table 12: Model output (binary logistic modelling) 197 Table 13: Regression modelling of SF-3 6 (Pain) 199 6 V. Abbreviations ADL Activities of Daily Living AO Arbeitsgemeinschaft fur Osteosynthesefragen BMC Bone Mineral Content BMI Body Mass Index BMD Bone Mineral Density P Bodily pain (SF-36) CSDQ Croft Shoulder Disability Questionnaire CSS Constant Shoulder Score CT Computerised Tomography CVA Cardiovascular Accident DoH Department of Health EQ EuroQoL GP General Practitioner/ General Practice ICC Intraclass correlation coefficient LLI Long term limiting illness M Million MS Musculoskeletal N Newtons (force) NHS National Health System OA Osteoarthritis PF Physical function (SF-36) PH Proximal Humerus POP Plaster of Paris RCT Randomised Controlled Trial RLP Role limitation-physical (SF-36) ROM Range of Movement RR Relative Risk SES Socioeconomic status SD Standard Deviation SDQ-NL Dutch Shoulder Disability Questionnaire SF-36 Short Form 36 Health Survey SPADI Shoulder Pain and Disability Index STHFT Sheffield Teaching Hospitals Foundation Trust SRQ Shoulder Rating Questionnaire UK United Kingdom USA United States of America WHO World Health Organisation 7 VI. Abstract Background The western world faces an explosion in the number of patients who will fracture their proximal humerus (PH) as a result of the rapidly changing demographics and the increase in osteoporosis. In 1998 there were 110 000 PH fractures in the United Kingdom (UK) and epidemiological studies indicate that the PH fracture incidence is increasing. Scant evidence exists to the optimum management and rehabilitation of these fractures and the aims of the study were to investigate the effect of an accelerated rehabilitation programme on patients’ recovery. Method A Randomised Controlled Trial (RCT) comparing two rehabilitation programmes (n=86) with patients who sustained two-part fractures of the proximal humerus was performed. Patients were randomised to receive immediate physiotherapy within one week (Group A) or delayed physiotherapy (Group B) after 3 weeks immobilisation. Assessment was at 8, 16 and 52 weeks with the Constant Shoulder Score (CSS), Short form generic health survey (SF-36) and Croft Shoulder Disability Questionnaire (CSDQ). Additional reassessment was undertaken at two years. Regression analysis modelling was conducted to identify the risk factors for developed long-term shoulder disability. Results At the primary outcome point (16 weeks) Group A experienced less pain (p<0.01) and had greater shoulder function (pO.OOl) compared to Group B. At 52 weeks the differences between the Groups had reduced. Overall, Group A experienced less pain as measured with the SF-36 (mean difference 486 Cl 83 to 889, p<0.01) and improved 8 shoulder function (mean difference in AUC 6.4 [95% Cl: 2.5 to 10.5], p< 0.002). At one year, shoulder disability (CSDQ) was 42.8% in Group A and 72.5% in Group B (p<0.01). By two years, shoulder disability in Group A remained unchanged (43.2%), but had reduced in Group B (59.5%). Discussion Immediate physiotherapy following a proximal humerus fracture results in faster recovery with maximal functional benefit being achieved at one year and requires fewer treatment sessions (9 versus 14 treatments, Group-A and B respectively). Delayed rehabilitation by three weeks shoulder immobilisation produces a slower recovery. The belief that patients make an excellent recovery after one year is questionable as 25 patients (33.5%) still reported considerable shoulder disability after two years of their injury. Gender (female), age and high levels of social deprivation were identified as risk factors for continued shoulder problems at two years after the fracture. Conclusions and recommendations This work suggests that patients who fracture their PH should not be immobilised before referral for physiotherapy as immediate referral to physiotherapy (within 1 week) results in faster recovery and less reported pain. Physiotherapy should be targeted towards those patients who are identified as having a greater risk of developing long-standing problems. Currently, a wide variation in PH fracture management exists in UK hospitals and implementing clinical care pathways will help target finite resources. 9 Contents Declaration I Acknowledgements II Dedication III List of Figures and tables IV Abbreviations V Abstract VI Chapter 1: Introduction 17 1.1 An ageing population: