SLR - January 2016 - Tyler Floyd

Title: Rehabilitation After Immobilization for Ankle Fracture. The EXACT Randomized Clinical Trial

Reference: Moseley AM, Beckenkamp PR, Haas M, Herbert RD, Lin CW. Rehabilitation After Immobilization for Ankle Fracture: The EXACT Randomized Clinical Trial. JAMA. 2015 Oct 6; 314(13): 1376-1385.
Reviewed By: Tyler Floyd, DPM
Residency Program: Bethesda Memorial Hospital, Boynton Beach, FL

Podiatric Relevance: Ankle fractures are a common finding in a foot and ankle surgeon’s office. Whether or not the ankle fracture needs surgical intervention, the patient will have a period of immobilization. A common practice is sending patients to physical therapy for a structural rehabilitation program once the patient is transitioned from the immobilized state. Due to the increasing costs for patients for additional treatment modalities, these modalities need to be evaluated for the efficacy. This study looks at uncomplicated ankle fractures that went through treatment processes that included immobilization. After the immobilization period the patient was then sent to a physical therapist for either a personalized rehabilitation program or just professional advice on what exercises to do. The study goal is to define which of these modalities was the most efficacious for the patient and is there a functional increase.

Methods: Study consisted of two groups in a pragmatic, randomized clinical trial. Participants were obtained from seven public hospitals in Sydney, Australia. Study included patients who had an isolated uncomplicated ankle fracture treated surgically or not, and immobilization removed the day of the recruitment to study. Participants were split into a group that had supervised exercise program and advice or to advice alone group. Outcomes were evaluated at one, three, and six-months follow-up. Primary outcomes were activity limitation measured by Lower Extremity Functional Scale (Range, 0 to 80; higher scores means better activity). Quality of life was also measured in quality-adjusted life-years (Range, 0 to 1; higher number equal better result).

Results: Study had 214 participants, 194 present at one-month follow-up, 173 present at three-month follow-up, and 170 present at six-month follow-up. Primary analysis shows that rehabilitation did not provide significant benefit over advice. Mean activity limitation increased from 30.1 (SD, 12.5) at baseline to 64.3 (SD, 13.5) at three months for the advice group and from 30.2 (SD, 13.2) to 64.3 (SD, 15.1) for the rehabilitation group. Mean quality of life increased from 0.51 (SD, 0.24) at baseline to 0.85 (SD, 0.17) at three months for advice and from 0.54 (SD, 0.24) to 0.85 (SD, 0.20) for the rehabilitation group. Similar results were seen at one and six months.

The authors concluded that there was no additional benefit in activity limitation or quality of life in patients who received advice alone versus a supervised exercise program for patients with an isolated uncomplicated ankle fracture. It is important to recognize that the advice alone group was also from a Physical Therapist. This was also in uncomplicated ankle fractures that were monitored very closely assuring patient compliance. There is a time and place for physical therapy and a personalized exercise program. In the more complicated ankle fractures, a tailored exercise program can definitely benefit the patient. At the extreme ages of children who have ankle fracture and are scared to put weight on it gait training and exercise program is a great way to build confidence to walk similar to pre-injury gait. Also, in the elderly, a personalized exercise program can have benefits on overall patient conditioning. On an uncomplicated ankle fracture, I will consider sending patient to at least one physical therapy session for demonstration and explanation of appropriate exercises and why they are important instead of routinely sending them for multiple sessions a week for an extended period of time. Like anything in medicine though this will have to be evaluated on a patient-to-patient basis.

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