Study methods quality and validity
Two authors independently scored the validity of each of the included 49 studies, meeting to discuss and resolve any disagreements. We relied on published data, without writing to authors to clarify or obtain information. Included studies were evaluated against 11 standard criteria.23 Each criterion was scored 0–2. However, the practical maximum possible score was 18 because it was impossible to blind patients or their caregivers to mobilization. We considered the quality of 16 studies scoring 11 to be high.
Results
Across the 49 eligible studies, the different interventions were well described and differentiated, and data collection methods were clearly explained. Duration of immobilization in a cast was described (if at all) from 10 days to 8 weeks. Mobilization strategies varied and included active exercise, orthoses, crutches, or bandages.
Study quality was poor in many respects: several did not include important demographic data (including age, sex, or the numbers randomized to control and experimental group). Most did not report data about the methods of randomization. Many studies used inadequate randomization methods, with only 5 reporting optimal methods. Loss to follow-up was addressed poorly (not described or intention-to-treat analysis was not used). Outcome assessment was not blinded (a serious shortcoming in view of the subjective assessment of some patient outcomes). Reporting of inclusion criteria was inadequate in a few studies.
Given these deficiencies, our discussion emphasizes conclusions supported by studies of high quality.
Reporting of the studies
We divided the 49 studies into 4 groups: lower-limb fractures, other lower-limb injuries, upper-limb fractures, and other upper-limb injuries (Table W, at www.jfponline.com). Each group was further divided into trials using some form of limb support (such as a brace, splint, or a short period of immobilization) or minimal or no support (bandage, crutches, or tape) in the early mobilization group.
Most studies used some form of dynamic treatment for the injured limb, with highest use in lowerlimb injuries (74%); 2 studies included both supported and unsupported mobilization.24-26 In studies of upper-limb fractures, support was used in 50%. In high-quality studies, 12 out of 16 studies used some support, but results were consistent with studies that did not. The smaller number of studies using minimal support makes comparison with supported mobilization difficult, but results suggest that supported mobilization may result in an earlier return to work or sport, whereas minimally supported patients achieved better composite scores and muscle strength. There was too much clinical heterogeneity to sensibly combine the results; however, we were interested to see whether mobilization was useful across a heterogeneous group of conditions.
Patient-centered outcomes
No study reported any significant improvement with rest on swelling and pain. To the contrary, 13 studies reported significant improvement with early mobilization compared with rest,16,17,27-37 and 9 studies reported enhanced patient satisfaction.16,30,36,38-43 High-quality studies that reported pain levels found no difference or favored early mobilization.25,26,30,31,39,44-51 This was significant in only 2 studies of lower-limb nonfractures.25,26,30 No study reported adverse patient opinion in an early mobilization regime,28,31,38,40,44-46,48,51-56 and patients appreciated their ability to use the affected limb.34,43,49
Functional outcomes
Ten studies measured global function, using composite scores including subjective and objective criteria—pain, stiffness, swelling, use of supports, and ability to climb stairs, play sport, work, and undertake activities of daily life (Table W). Seven studies reported significant improvements with early mobilization—after 6 months (6 studies),28,35,42,46,52,57 or 12 months (1 study).32 Four studies of high quality found significant benefit for early mobilization in composite scores, most of these for lower-limb fractures.46,47,52,54 Significantly more patients with acute ankle sprain, who were immobilized in a cast, sought medical and physiotherapy advice in the initial 3 weeks, compared with those mobilized early with a functional brace.50
Return to work and sport
Thirteen studies reported that early mobilization resulted in a significantly earlier return to work (about 30%–60% earlier),16,17,30,33,35,36,38-40,52,57-59 especially in lower-limb nonfracture injuries. In 1 study of ankle fractures, patients randomized to wear a cast reported better performance of daily activities at 6 weeks than those mobilized with crutches.28 Perhaps, this reflects practical difficulties associated with using crutches. Five studies of lower-limb injury reported an earlier return to sport,16,30,39,57,60 as did 3 studies of postoperative Achilles tendon repair30,39,60 and 2 of ankle ligament injury or sprains.16,57 Five studies reporting a significantly earlier return to work or sport were of high quality, as were all studies of lower limb injuries.25,26,30,39,46,52
Range of movement
Fourteen studies of upper- and lower-limb fractures reported significant improvements in range of movement. Significant differences in range of movement were typically observed within 13 weeks of the injury,12,27,29,34,38,42,45,46,49,52,61-64 although a few studies reported differences for longer periods. Similarly for lower-limb nonfractures, significantly better ranges of motion were found within short periods,25,33,37,39,43 and also after 12 months.30,39-41 Eleven studies reporting this outcome were of high quality,25,26,30,31,39,45,46,48-51,54 and 4 studies found significant benefit for early mobilization.25,26,30,46,49 The other 7 high-quality studies favored early mobilization, and 1 found no difference.45