Resting injured limbs delays recovery: A systematic review

Deformity and other complications

Four studies found early mobilization reduced deformity: for angular displacement⁶¹ and radial shortening³² in Colles’ fractures; displacement of metacarpal fractures⁵⁸ and cosmetic deformity in radial fractures.⁴² Two studies were of high quality.^30,65 Ten trials reported no changes in deformity, no loss of fracture reduction, or any other complications with early mobilization of fractures.^{28,31,45,48,50,59,62-64,66} In contrast, for Colles’ fractures, significantly greater dorsal angulation⁶¹ and significant increases in radial tilt and decreased radioulnar joint space⁴⁹ were reported for mobilized wrists.

Patient preferences

Patients expressed preference for a brace following anterior cruciate ligament surgery because it helped reduce pain and swelling⁶⁷; they expressed preference for a cast following surgery for ankle fracture because it improved ability to perform everyday activities.²⁸

Patients with distal radius fractures preferred early treatment with a Tubigrip bandage and a back-slab instead of removable splints, which increased pain and decreased mobilization.⁵³ Generally, patients with fractures preferred rigid support immediately after the injury. Some also expected to have a traditional cast applied after learning their injured wrist was fractured.⁵³

Cost of treatment

Full economic evaluations were not usually satisfactorily undertaken in these clinical studies. The cost of early mobilization was more expensive than immobilization in some studies^8,23 but cheaper in others.^2,9,10,24,68 It is estimated that direct costs to the patient were lower for early mobilization because of the decreased loss of working time.^10,44,68,69

Adherence and supervision

Ten studies excluded patients who were unable to understand the nature of the treatment; had dementia; existing joint disease; drug abuse; alcohol problems; or difficulty with walking aids.^{28,31,38-41,45,46,49,69} Thus, many researchers have assumed that early mobilization requires greater patient responsibility. Some researchers have recommended applying casts for patients deemed “uncooperative” or “unlikely to be compliant,” despite their positive findings for early mobilization.^3,16

Although 10 trials employed physiotherapy or supervised mobilization sessions,^{25,26,28,29,40,41,46,65,70} 11 studies relied on self-controlled mobilization.^{27,30,31,38,39,42,44,45,48,49,52} In addition, some interventions (eg, braces) intrinsically required more supervision with their removal and reapplication than others (eg, functional casts or semirigid bandages).

Discussion

Early mobilization seems to decrease pain, swelling, and stiffness—at least in the short-term—and patients generally prefer it to immobilization. It results in earlier return—to work and to a greater range of motion, which is most significant within the first 2 months of the injury and can be maintained for up to 12 months for nonfracture injuries. Early mobilization does not increase cosmetic or radiological deformity for stable fractures, and patients experience fewer complications and residual symptoms. However, early mobilization may place greater demands on patients and require higher levels of understanding and responsibility, therefore making it unsuitable for some patients.

This systematic review of all upper- and lower-limb injuries, including fractures, consistently found in favor of early mobilization over rest. We acknowledge that the range of injuries reviewed is very limited. However, the clear benefits of mobilization indicated by this review suggest we need research in a wider range of injuries.

Similarly, it would be naïve to assume mobilization is better than immobilization in all circumstances. Harm must occur at some level of increased activity. In addition we know that pain and discomfort are often experienced by patients who demand immobilization (a “palliative” form of management). Finding the ideal level and type of activity must be undertaken empirically. Therefore more quality clinical trials are required to determine and evaluate the best regimens for early mobilization.

Newer studies will probably find that mobilization can be employed more often (and perhaps more vigorously) than we now advise. The best evidence at hand suggests the medical profession generally errs too conservatively on the side of immobilization.

Acknowledgments

Charlotte Nash did the searches, assembled and analysed the tables and wrote the first draft. Charlotte Nash and Sharon Mickan assessed the quality of all included studies and edited drafts. Paul Glasziou and Chris Del Mar initiated the question and edited drafts. This work was supported in part by a scholarship awarded by the Centre for General Practice, The University of Queensland, and funded by the Australian Commonwealth Department of Health and Ageing through the Primary Health Care Research, Evaluation and Development Strategy.

Corresponding author
Professor Chris B. Del Mar, Centre for General Practice, Faculty Heath Science and Medicine, Bond University, Gold Coast, Queensland 4229, Australia. E-mail: CDelMar@bond.edu.au.