ORIGINAL PAPER
Effects of aquatic exercises on upper limb physical function after a humeral shaft fracture – a time series analysis
1
Universidade Estadual de Londrina, Laboratory of Biomechanics and Clinical Epidemiology, PAIFIT Research Group, Londrina, PR, Brazil
Submission date: 2024-05-24
Acceptance date: 2025-02-28
Publication date: 2025-06-25
Corresponding author
Jefferson R. Cardoso
Universidade Estadual de Londrina, Laboratory of Biomechanics and Clinical Epidemiology, PAIFIT Research Group, Associated Graduate Program in Rehabilitation science UEL-Unopar, Av. Robert Kock 60, Londrina, PR, Brazil
Universidade Estadual de Londrina, Laboratory of Biomechanics and Clinical Epidemiology, PAIFIT Research Group, Associated Graduate Program in Rehabilitation science UEL-Unopar, Av. Robert Kock 60, Londrina, PR, Brazil
Hum Mov. 2025;26(2):91-101
KEYWORDS
TOPICS
ABSTRACT
Purpose:
Humeral shaft fractures account for 1.2% of all fractures in adults. Regardless of the treatment approach, the consequences of immobility can lead to decreased functional capacity in these individuals.
Methods:
This case report describes a 46-year-old male patient with a fracture of the greater tubercle and diaphysis of the humerus in the left limb (non-dominant) treated with 15 aquatic exercise sessions and five land-based sessions. The Disabilities of the Arm, Shoulder, and Hand Questionnaire (DASH) assessed physical function, Simulation Modeling Analysis (SMA) (autocorrelation, r, and significance) evaluated DASH measurements pre- and post-intervention, and the minimum clinically important difference (MCID) was reported. A MicroFet 2 HHD portable dynamometer measured muscle strength, while a manual goniometer assessed range of motion (ROM).
Results:
The MCID was reached in the DASH questionnaire, with an 18.3% improvement in physical function. The data analysed by SMA showed autocorrelation = –0.78, r = –0.87, and p = 0.01. There was an improvement in the ROM in all shoulder and elbow movements and an increase in the strength of the shoulder and elbow flexor muscles.
Conclusions:
Time series analysis with a slope of –2.25 each week predicted physical function. A score of zero on the DASH questionnaire indicated the absence of functional impairment and meant that the MCID was reached. Improvements in shoulder and elbow ROM and increased muscle strength were observed on the affected side.
Humeral shaft fractures account for 1.2% of all fractures in adults. Regardless of the treatment approach, the consequences of immobility can lead to decreased functional capacity in these individuals.
Methods:
This case report describes a 46-year-old male patient with a fracture of the greater tubercle and diaphysis of the humerus in the left limb (non-dominant) treated with 15 aquatic exercise sessions and five land-based sessions. The Disabilities of the Arm, Shoulder, and Hand Questionnaire (DASH) assessed physical function, Simulation Modeling Analysis (SMA) (autocorrelation, r, and significance) evaluated DASH measurements pre- and post-intervention, and the minimum clinically important difference (MCID) was reported. A MicroFet 2 HHD portable dynamometer measured muscle strength, while a manual goniometer assessed range of motion (ROM).
Results:
The MCID was reached in the DASH questionnaire, with an 18.3% improvement in physical function. The data analysed by SMA showed autocorrelation = –0.78, r = –0.87, and p = 0.01. There was an improvement in the ROM in all shoulder and elbow movements and an increase in the strength of the shoulder and elbow flexor muscles.
Conclusions:
Time series analysis with a slope of –2.25 each week predicted physical function. A score of zero on the DASH questionnaire indicated the absence of functional impairment and meant that the MCID was reached. Improvements in shoulder and elbow ROM and increased muscle strength were observed on the affected side.
REFERENCES (57)
1.
Bergdahl C, Ekholm C, Wennergren D, Nilsson F, Möller M. Epidemiology and patho-anatomical pattern of 2,011 humeral fractures: data from the Swedish Fracture Register. BMC Musculoskelet Disord. 2016;17:159; doi: 10.1186/s12891-016-1009-8.
2.
Oliver WM, Searle HKC, Ng ZH, Wickramasinghe NRL, Molyneux SG, White TO, et al. Fractures of the proximal- and middle-thirds of the humeral shaft should be considered as fragility fractures. Bone Joint J. 2020;102-B(11):1475–83; doi: 10.1302/0301-620X.102B11.BJJ-2020-0993.
3.
Mouraria GG, Mendonça BCN, Dias AL, Zogbi DR, Cruz MA, Etchebehere M. Epidemiological study of surgically treated humeral shaft fractures – a 10-year review. Acta Ortop Bras. 2022;30(6):e256500; doi: 10.1590/1413-785220223006e256500.
4.
Mattila H, Keskitalo T, Simons T, Ibounig T, Rämö L. Epidemiology of 936 humeral shaft fractures in a large Finnish trauma center. J Shoulder Elbow Surg. 2023;32(5):e206–15; doi: 10.1016/j.jse.2022.10.020.
5.
Smolle MA, Bösmüller S, Puchwein P, Ornig M, Leithner A, Seibert FJ. Complications in humeral shaft fractures – non-union, iatrogenic radial nerve palsy, and postoperative infection: a systematic review and meta-analysis. EFORT Open Rev. 2022;11;7(1):95–108; doi: 10.1530/EOR-21-0097.
6.
Schoch BS, Padegimas EM, Maltenfort M, Krieg J, Namdari S. Humeral shaft fractures: national trends in management. J Orthop Traumatol. 2017;18(3):259–63; doi: 10.1007/s10195-017-0459-6.
7.
Lode I, Nordviste V, Erichsen JL, Schmal H, Viberg B. Operative versus nonoperative treatment of humeral shaft fractures: a systematic review and meta-analysis. J Shoulder Elbow Surg. 2020;29(12):2495–504; doi: 10.1016/j.jse.2020.05.030.
8.
Yiğit Ş. What should be the timing of surgical treatment of humeral shaft fractures? Medicine. 2020;99(17):e19858; doi: 10.1097/MD.0000000000019858.
9.
Østergaard HK, Mechlenburg I, Launonen AP, Vestermark MT, Mattila VM, Ponkilainen VT. The benefits and harms of early mobilization and supervised exercise therapy after non-surgically treated proximal humerus or distal radius fracture: a systematic review and meta-analysis. Curr Rev Musculoskelet Med. 2021;14(2):107–29; doi: 10.1007/s12178-021-09697-5.
10.
Tiwari N, Patil S, Popalbhat R. Efficacy of physiotherapy rehabilitation for proximal femur fracture. Cureus. 2022;26;14(10):e30711; doi: 10.7759/cureus.30711.
11.
Bruzga B, Speer K. Challenges of rehabilitation after shoulder surgery. Clin Sports Med. 1999;18(4):769–93.
12.
Hardy EJO, Inns TB, Hatt J, Doleman B, Bass JJ, Atherton PJ, Lund JN, Phillips BE. The time course of disuse muscle atrophy of the lower limb in health and disease. J Cachexia Sarcopenia Muscle. 2022;13(6):2616–29; doi: 10.1002/jcsm.13067.
13.
White MJ, Davies CT. The effects of immobilization, after lower leg fracture, on the contractile properties of human triceps surae. Clin Sci. 1984;66(3):277–82; doi: 10.1042/cs0660277.
14.
Buckthorpe M, Pirotti E, Villa FD. Benefits and use of aquatic therapy during rehabilitation after acl reconstruction -a clinical commentary. Int J Sports Phys Ther. 2019;14(6):978–993.
15.
Cantarero-Villanueva I, Fernández-Lao C, Cuesta-Vargas AI, Del Moral-Avila R, Fernández-de-Las-Peñas C, Arroyo-Morales M. The effectiveness of a deep water aquatic exercise program in cancer-related fatigue in breast cancer survivors: a randomized controlled trial. Arch Phys Med Rehabil. 2013;94(2):221–30; doi: 10.1016/j.apmr.2012.09.008.
16.
Yolgösteren E, Külekçioğlu S. The effectiveness of balneotherapy and thermal aquatic exercise in postoperative persistent lumbar pain syndrome. Int J Biometeorol. 2021;65(12):2137–45; doi: 10.1007/s00484-021-02176-z.
17.
Villalta EM, Peiris CL. Early aquatic physical therapy improves function and does not increase risk of wound-related adverse events for adults after orthopedic surgery: a systematic review and meta-analysis. Arch Phys Med Rehabil. 2013;94(1):138–48; doi: 10.1016/j.apmr.2012.07.020.
18.
Nash MR, Borckardt JJ, Abbasa A, Gray E. How to conduct and statistically analyze case-based time series studies, one patient at a time. J Exp Psychopathol. 2011;2(2):139–69; doi: 10.5127/jep.012210.
19.
Borckardt JJ, Nash MR. Simulation modelling analysis for small sets of single-subject data collected over time. Neuropsychol Rehabil. 2014;24(3–4):492–506; doi: 10.1080/09602011.2014.895390.
20.
Orfale AG, Araújo PM, Ferraz MB, Natour J. Translation into Brazilian Portuguese, cultural adaptation and evaluation of the reliability of the Disabilities of the Arm, Shoulder and Hand Questionnaire. Braz J Med Biol Res. 2005;38(2):293–302; doi: 10.1590/s0100-879x2005000200018.
21.
Jaeschke R, Singer J, Guyatt GH. Measurement of health status. Ascertaining the minimal clinically important difference. Control Clin Trials. 1989;10(4):407–15; doi: 10.1016/0197-2456(89)90005-6.
22.
Deyo RA, Diehr P, Patrick DL. Reproducibility and responsiveness of health status measures. Statistics and strategies for evaluation. Control Clin Trials. 1991;12(4):142–58; doi: 10.1016/s0197-2456(05)80019-4.
23.
van de Water AT, Shields N, Davidson M, Evans M, Taylor NF. Reliability and validity of shoulder function outcome measures in people with a proximal humeral fracture. Disabil Rehabil. 2014;36(13):1072–9; doi: 10.3109/09638288.2013.829529.
24.
Hannah DC, Scibek JS, Carcia CR. Strength profiles in healthy individuals with and without scapular dyskinesis. Int J Sports Phys Ther. 2017;12(3):305–13.
25.
Stratford PW, Balsor BE. A comparison of make and break tests using a hand-held dynamometer and the Kin-Com. J Orthop Sports Phys Ther. 1994;19(1):28–32; doi: 10.2519/jospt.1994.19.1.28.
26.
McClure PW, Michener LA, Sennett BJ, Karduna AR. Direct 3-dimensional measurement of scapular kinematics during dynamic movements in vivo. J Shoulder Elbow Surg. 2001;10(3):269–77; doi: 10.1067/mse.2001.112954.
27.
Trajković N, Kozinc Ž, Smajla D, Šarabon N. Interrater and intrarater reliability of the easyforce dynamometer for assessment of maximal shoulder, knee and hip strength. Diagnostics. 2022;12(2):442; doi: 10.3390/diagnostics12020442.
28.
Kolber MJ, Hanney WJ. The reliability and concurrent validity of shoulder mobility measurements using a digital inclinometer and goniometer: a technical report. Int J Sports Phys Ther. 2012;7(3):306–13.
29.
Crosbie J. Interrupted time-series analysis with brief single-subject data. J Consult Clin Psychol. 1993;61(6):966–74; doi: 10.1037//0022-006x.61.6.966. PMID: 8113497.
30.
Borckardt JJ, Nash MR, Murphy MD, Moore M, Shaw D, O’Neil P. Clinical practice as natural laboratory for psychotherapy research: a guide to case-based time-series analysis. Am Psychol. 2008;63(2):77–95; doi: 10.1037/0003-066X.63.2.77.
31.
Becker BE. Aquatic therapy: scientific foundations and clinical rehabilitation applications. PM R. 2009;1(9):859–72; doi: 10.1016/j.pmrj.2009.05.017.
32.
Juvè Meeker B. Whirlpool therapy on postoperative pain and surgical wound healing: an exploration. Patient Educ Couns. 1998;33(1):39–48; doi: 10.1016/s0738-3991(97)00056-6.
33.
Kobayashi M, Watanabe Y, Matsushita T. Early full range of shoulder and elbow motion is possible after minimally invasive plate osteosynthesis for humeral shaft fractures. J Orthop Trauma. 2010;24(4):212–6; doi: 10.1097/BOT.0b013e3181c2fe49.
34.
Saltzman EB, Belay E, Federer AE, French R, Anakwenze O, Gage MJ, Klifto CS. Humeral intramedullary nail placement through the rotator interval: an anatomic and radiographic analysis. J Shoulder Elbow Surg. 2021;30(4):747–55; doi: 10.1016/j.jse.2020.07.044.
35.
Lopiz Y, Garriguez-Pérez D, Román-Gómez J, Scarano-Pereira JP, Ponz-Lueza V, García-Fernandez C, Marco F. Shoulder problems after percutaneous antegrade intramedullary nailing in humeral diaphyseal fractures using contemporary straight third-generation nail. J Shoulder Elbow Surg. 2023;32(11):2317–24; doi: 10.1016/j.jse.2023.04.012.
36.
Gracitelli MEC, Malavolta EA, Assunção JH, Matsumura BA, Kojima KE, Ferreira Neto AA. Ultrasound evaluation of the rotator cuff after osteosynthesis of proximal humeral fractures with locking intramedullary nail. Rev Bras Ortop. 2017;52(5):601–7; doi: 10.1016/j.rboe.2016.10.016.
37.
Lombardi I Jr, Magri AG, Fleury AM, da Silva AC, Natour J. Progressive resistance training in patients with shoulder impingement syndrome: a randomized controlled trial. Arthritis Rheum. 2008;59(5):615–22; doi: 10.1002/art.23576.
38.
Dickens VA, Williams JL, Bahmra MS. Role of physiotherapy in the treatment of subacromial impingement syndrome: a prospective study. Physiotherapy. 2005;91(3):159–64; doi:10.1016/j.physio.2004.10.008.
39.
Gebremariam L, Hay EM, van der Sande R, Rinkel WD, Koes BW, Huisstede BM. Subacromial impingement syndrome – effectiveness of physiotherapy and manual therapy. Br J Sports Med. 2014;48(16):1202–8; doi: 10.1136/bjsports-2012-091802.
40.
Desmeules F, Boudreault J, Dionne CE, Frémont P, Lowry V, MacDermid JC, Roy J-S. Efficacy of exercise therapy in workers with rotator cuff tendinopathy: a systematic review. J Occup Health. 2016;58(5):389–403; doi: 10.1539/joh.15-0103-RA.
41.
Steuri R, Sattelmayer M, Elsig S, Kolly C, Tal A, Taeymans J, Hilfiker R. Effectiveness of conservative interventions including exercise, manual therapy and medical management in adults with shoulder impingement: a systematic review and meta-analysis of RCTs. Br J Sports Med. 2017;51(18):1340–7; doi: 10.1136/bjsports-2016-096515.
42.
Dufournet A, Chong XL, Schwitzguébel A, Bernimoulin C, Carvalho M, Bothorel H, Lädermann A. Aquatic therapy versus standard rehabilitation after surgical rotator cuff repair: a randomized prospective study. Biology. 2022;17;11(4):610; doi: 10.3390/biology11040610.
43.
Brady B, Redfern J, MacDougal G, Williams J. The addition of aquatic therapy to rehabilitation following surgical rotator cuff repair: a feasibility study. Physiother Res Int. 2008;13(3):153–61; doi: 10.1002/pri.403.
44.
Heron SR, Woby SR, Thompson DP. Comparison of three types of exercise in the treatment of rotator cuff tendinopathy/shoulder impingement syndrome: a randomized controlled trial. Physiotherapy. 2017;103(2):167–73; doi: 10.1016/j.physio.2016.09.001.
45.
Torres-Ronda L, Del Alcázar XS. The properties of water and their applications for training. J Hum Kinet. 2014;44:237–48; doi: 10.2478/hukin-2014-0129.
46.
Allegrone J, Green II J, Nicoloro D, Heislein DM, Eisemon EO, Edgar T. Savidge ET, Hariri S, Rubash HE. Physical rehabilitation after total hip arthroplasty. In: Magee DJ, Zachazewski JE, Quillen WS, Manske RC. Pathology and Intervention in Musculoskeletal Rehabilitation. 2nd ed. Elsevier; 2016, pp. 692–712; doi: 10.1016/B978-0-323-31072-7.00019-1.
47.
Watkins J, Mathieson I. The pocket podiatry guide: functional anatomy. 1st ed. Elsevier; 2009; doi: 10.1016/B978-0-7020-3032-1.X0001-7.
48.
Radák Z. Skeletal muscle, function, and muscle fiber types. In: Radák Z. The Physiology of Physical Training. 1st ed. Elsevier; 2018:15–31; doi: 10.1016/B978-0-12-815137-2.00002-4.
49.
Krzysztofik M, Wilk M, Wojdała G, Gołaś A. Maximizing muscle hypertrophy: a systematic review of advanced resistance training techniques and methods. Int J Environ Res Public Health. 2019;16(24):4897; doi: 10.3390/ijerph16244897.
50.
Plotkin D, Coleman M, Van Every D, Maldonado J, Oberlin D, Israetel M, Feather J, Alto A, Vigotsky AD, Schoenfeld BJ. Progressive overload without progressing load? The effects of load or repetition progression on muscular adaptations. PeerJ. 2022;10:e14142; doi: 10.7717/peerj.14142.
51.
Jones EJ, Bishop PA, Woods AK, Green JM. Cross-sectional area and muscular strength: a brief review. Sports Med. 2008;38(12):987–94; doi: 10.2165/00007256-200838120-00003.
52.
McKendry J, Stokes T, Mcleod JC, Phillips SM. Resistance exercise, aging, disuse, and muscle protein metabolism. Compr Physiol. 2021;11(3):2249–78; doi: 10.1002/cphy.c200029.
53.
Nunes EA, Stokes T, McKendry J, Currier BS, Phillips SM. Disuse-induced skeletal muscle atrophy in disease and nondisease states in humans: mechanisms, prevention, and recovery strategies. Am J Physiol Cell Physiol. 2022;1;322(6):C1068–84; doi: 10.1152/ajpcell.00425.2021.
54.
Mattos F, Leite N, Pitta A, Bento PCB. Effects of aquatic exercise on muscle strength and functional performance of individuals with osteoarthritis: a systematic review. Rev Bras Reumatol. 2016;56(6):530–42; doi: 10.1016/j.rbr.2016.06.007.
55.
Dai S, Yuan H, Wang J, Yang Y, Wen S. Effects of aquatic exercise on the improvement of lower-extremity motor function and quality of life in patients with Parkinson’s disease: a meta-analysis. Front Physiol. 2023;14:1066718; doi: 10.3389/fphys.2023.1066718.
56.
Zhou WS, Mao SJ, Zhang SK, Xu H, Li WL. Effects of aquatic exercises on physical fitness and quality of life in postmenopausal women: an updated systematic review and meta-analysis. Front Public Health. 2023;11:1126126; doi: 10.3389/fpubh.2023.1126126.
57.
Heywood S, McClelland J, Mentiplay B, Geigle P, Rahmann A, Clark R. Effectiveness of aquatic exercise in improving lower limb strength in musculoskeletal conditions: a systematic review and meta-analysis. Arch Phys Med Rehabil. 2017;98(1):173–86; doi: 10.1016/j.apmr.2016.08.472.
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