Proximal humerus fracture rehabilitation.

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. 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. At the primary outcome point (16 weeks) Group A experienced less pain (p<0.01) and had greater shoulder function (p<0.001) 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 improvedshoulder 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%). 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. 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.