Introduction

Orthopedics is a medical discipline focusing on the bones, joints, muscles, tendons, nerves, skeletal system, and limbs by diagnosing and managing musculoskeletal disorders, including interconnected soft tissues. Data from the Global Burden of Disease (GBD) shows that around 1.71 billion individuals worldwide experience orthopedic problems.1 This condition is also the main cause of disability throughout the world. Upper and lower extremity fractures are one of the main problems in orthopedic conditions, with approximately 436 million cases worldwide.2 The prevalence of upper and lower extremity fracture injuries in Indonesia reaches 5.5%.3

Upper and lower extremity fractures can cause damage to other organs of the body due to the risk of pressure from broken bones.4 This fracture conditions can be treated through orthopedic surgery that restores bone structure and function to normal. Orthopedic surgery aims to repair problems related to the skeleton, attachments, ligaments, and tendons.5 Patients with severe arthritis are often recommended to undergo total joint replacement surgery to improve range of motion.6 After undergoing orthopedic surgery, patients will usually spend time in the hospital for inpatient treatment before being allowed to go home to begin the recovery process.

During the recovery period, patients are asked to rest entirely and are immobilized so that the bone or joint that has been operated on remains in its position.7 Immobilization is done to reduce pain and swelling in the area of the surgical scar. The patient’s physical mobility is impaired due to immobilization due to movement restrictions such as bed rest or physical limits due to external equipment such as gips or skeletal traction. The time required for post-operative recovery or immobilization will vary depending on the type of surgery performed.8 Based on the data of gait rehabilitation in post-orthopedic surgery patients, patients can recover in a few weeks to months, such as 3 months to 6 months.9 The gait rehabilitation is assessed from the intensity and duration of physical activity, the number of steps (basic spatial and temporal gait), gait cycle, and step frequency, where the time of gait rehabilitation depends on the patient’s early mobilization activities.10

Generally, mobilization can be carried out 8 hours after surgery after ensuring that the patient is conscious or the limbs can be moved again after regional anesthesia.7 However, patient immobilization is often carried out for a long time, significantly reducing muscle strength associated with motor nerve function and central nervous drive and slowing the recovery process.11 This means most post-orthopedic surgery patients do not perform early mobilization because of the fear of pain in the surgical wound area when moved.12 In addition, the mobility of post-orthopedic surgery patients is also hampered by several medical devices installed in the body, such as infusions, catheters, nasogastric tubes, drainage tubes, monitor cables, and others.

Finally, most patients require full assistance for mobilization, such as getting out of bed and standing and walking. The necessary level of aid is closely related to length of stay in the hospital, mortality rate, and the risk of medical complications.13 Long-term immobilization can cause the risk of medical complications in the form of joint stiffness which can cause joint contractures, limited ligament movement, and muscle atrophy.6 Immobilization can also disrupt metabolic function, such as decreasing metabolic rate and fluid, electrolyte, and calcium imbalances.14

Therefore, post-orthopedic surgery patient requires maximum care to accelerate the post-operative recovery process and return of body function by providing early mobilization interventions. Early mobilization is a series of activities that begin after surgery, including light activities in bed to the ability to get out of bed, go to the bathroom, and leave the bed.14 Early mobilization performed by patients after orthopedic surgery has several risks in the form of hemodynamic instability, pain scale, and possible complaints of nausea or vomiting.6 However, early mobility is essential for post-orthopedic surgery patients to prevent prolonged healing, muscle stiffness, and limited post-operative movement.11 Early mobilization is a key component in physiological function because it is essential to maintaining independence. Early mobilization is by involving health workers in the process of guiding patients.15

Mobility is an important factor in maintaining the patient’s musculoskeletal function. Early mobilization can shorten the length of stay in the hospital, increasing patient mobility, and increasing patient satisfaction after surgery. Therefore, with the problem of the high number of orthopedic surgery cases for upper and lower fractures and the long immobilization time in post-orthopedic surgery patients, this literature review aims to determine early mobilization-based interventions that can be applied to adult patients after orthopedic surgery.

Materials and Methods Study Design

The method used in reviewing this article is scoping review. The aim of a scoping review is to produce quality information in a shorter period of time by conducting a full quality assessment.16 There are 9 stages of article review carried out, namely formulating article review questions, formulating article search keywords, selecting criteria, identifying sources of information, determining article search strategies, article extraction, mapping and collecting articles, reporting the results of article analysis, and consultation with other competent.

Search Strategy

A literature search for review articles was conducted by the first author (PR) using four primers online databases: EBSCOhost, PubMed, Sage, and ScienceDirect. The selection criteria in this article search include inclusion criteria and exclusion criteria. The inclusion criteria for reviewing articles included post-orthopedic surgery patients, articles in the last 5 years (2019–2024), English language articles, articles with clinical trials and randomized controlled trials, and a focus on discussing early mobilization interventions. The exclusion criteria for this article review are articles with the type of literature review research. In searching for articles, the keywords “early ambulation”, “enhanced recovery after surgery”, “muscle strength”, and “orthopaedic nursing” were used. For each term verified by MeSH (Medical Subject Headings), synonyms are used to retrieve all possible relevant articles. In addition, the author uses the Boolean operators “AND” and “OR” to trim or expand the search results for various tenses. The following is the search algorithm for this article (Figure 1).

Figure 1 PRISMA flowchart.

Notes: PRISMA figure adapted from Page MJ, McKenzie JE, Bossuyt PM et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021; 372: n71. Creative Commons.17

Study Selection

The first author (PR) selected studies that met the eligibility criteria. Literature was chosen by removing articles from the last 5 years (2019–2024), duplicate articles, and articles that did not meet the inclusion criteria. The total number of articles obtained was 93151 articles. The articles were screened and 22 articles were found that met the criteria. Of this number, articles were screened in full text, and eight articles were obtained that could be analyzed. Four authors (PR, NZM, IY, and J) checked each complete text with the Joanna Briggs Institute (JBI) critical assessment checklist. Furthermore, the author (MK) as experts in nursing decides if there is a discrepancy in the selection results. We experienced no differences of opinion regarding the feasibility of the study.

The critical assessment consists of 13 questions for randomized control trial design articles and 10 questions for case-control studies.18 Each question consists of four response choices “yes”, “no”, “not applicable”, and “unclear”. Specifically, the authors calculated the critical appraisal score as the number of “yes” responses divided by the total number of “unclear”, “no”, and “yes” responses, excluding “not applicable” responses. Four authors eliminated any studies with a JBI score <70%. The results of the JBI that the majority of research was of good quality (>75%) (Table 1).

Table 1 JBI Critical Appraisal Results

Literature Identification and Mapping

The selection of literature used in this article review was based on the PRISMA method, and the author analyzed eight articles. Article analysis was done by compiling a matrix table consisting of the author’s name, title and year of the article; research purposes; research sample; types of research; orthopaedic surgery area; interventions/procedures; as well as research results.

Results

There are several early mobilization-based interventions to support the recovery process of patients after orthopaedic surgery, which were obtained from 8 articles, including 3 articles related to motion-based early mobilization interventions,19,22,24 1 article about early mobilization interventions based on Progressive Muscle Relaxation (PMR) training,20 2 articles about early mobilization interventions based on Weight Bearing,11,23 1 article about early mobilization interventions based on positioning,21 and 1 article about early mobilization interventions based on the Neuromuscular Electrical Stimulation (NMES) Application.25 The following is the analysis matrix for the articles reviewed (Table 2).

Table 2 Results of Article Analysis

Discussion

Early mobilization intervention can quickly restore patients’ everyday activities after orthopaedic surgery. The following are early mobilization-based interventions that can be applied to patients after orthopaedic surgery.

Motion-Based Early Mobilization Intervention

Limited Range of Motion (ROM) is one factor that can influence patients’ functional status after orthopaedic surgery, such as Total Knee Arthroplasty (TKA). Patient dissatisfaction after limited ROM and post-operative pain caused TKA in 90.6% of patients.26 Therefore, early strengthening of ROM and modulation of pain can accelerate normal mobilization and reduce the patient’s length of stay in the hospital.21 Rehabilitation carried out by patients after orthopaedic surgery, such as TKA, focuses on reducing pain, restoring the ability to flex by 90 degrees, and ROM with full extension.27 However, to carry out daily life activities, such as going up or down stairs, at least 110 degrees of flexion is required.

Research results show that pain reduction, increased mobility function, and patient satisfaction are effectively obtained by implementing early mobilization through a combination of a structured exercise program with manual therapy, including joint and soft tissue mobilization.21 The results of other studies show that early mobilization can significantly reduce the incidence of anxiety, pain, nausea and vomiting after 24 hours of surgery.22 The hospital stay is shorter after providing early mobilization intervention through movement after rehabilitation.

Other studies say most patients benefit significantly from motion-based early mobilization after surgery.28 In orthopaedic cases, distal radius fractures are frequent, and fixation is carried out in the form of volar plating. Indications for early mobilization for distal radius fractures include significant radial (>3 mm), extension (beyond neutral), loss of radial inclination (>5 degrees), and articular incongruity or instability.29 Motion-based early mobilization that can be carried out after surgery includes functional movements, such as flexion-extension, radial, ulnar deviation, and pronation-supination, as well as strengthening movements, such as grip strength, Appositional Pinch Strength (APS) and Oppositional Pinch Strength (OPS)); Disabilities of the Arm, Shoulder and Hand (DASH); Patient-Rated Wrist Evaluation (PRWE); and Pain Visual Analog Scale (VAS).19

Motion-based early mobilization carried out on patients requires supervision by health workers, such as nurses or therapists. In the first 14 days after surgery, the patient undergoes ROM on the finger and thumb and then performs functional movements and strengthening movements.30 By carrying out motion-based early mobilization, patients after orthopaedic surgery can recover their movement within 6 weeks compared to patients without early mobilization, where within 6 weeks, they have just removed the cast and cannot move normally.19 Other studies show that movement as an early mobilization intervention provides a faster recovery time of 1–2 months.21 Patient recovery and return to normal activities are faster because early mobilization can improve pain control, outcome scores, and movement.

Early Mobilization Intervention Based on Progressive Muscle Relaxation (PMR)

Progressive Muscle Relaxation (PMR) is the easiest technique given to patients in the form of physical and mental relaxation.31 PMR intervention is a type of early mobilization after orthopaedic surgery that can reduce anxiety, regulate neuromuscular activity, release muscle tension, and reduce the overall pain sensation because pain stimuli’s transmission is blocked and pain perception is changed.32 One of the orthopaedic cases where PMR can be performed is Total Knee Arthroplasty (TKA).20 In previous studies, a complementary modality in early mobilization, combining PMR with guided and mental imagery, can improve pain, mobility, and muscle strength in patients with various disorders.6,11,23

When carrying out early mobilization in the form of PMR, patients will be advised to carry out standard physiotherapy starting on post-operative day 1 (POD1), which takes place twice daily and lasts 30 minutes.20 Standard physiotherapy includes active assistance (ROM), isometric and isotonic strengthening exercises, gait training, functional exercises for transfer, and walking. Patients are given rest for 10 minutes before continuing with PMR exercises to prevent the disturbing effects of turning off the lights, not wearing tight clothing, and minimizing the urgency of urinating and defecating.

Early mobilization in the form of PMR is carried out during POD1 to POD3 (around 30 minutes) according to the PMR audio recording instructions that the Psychologists Association has prepared. The audio recording was accompanied by low-pitched background music and the sound of water which was listened to by the patient using an audio player using headphones in a supine position in bed and performing PMR exercises supervised by a physiotherapist to get used to the intervention.33 After the PMR activity, the patient will be assessed regarding the level of pain, knee range of motion, and knee oedema (using the Numeric Pain Rating Scale (NPRS) and goniometer); knee strength (using a handheld dynamometer flexing the hip at 90 degrees and knee at 60 degrees); knee function score (using the Hospital for Special Surgery (HSS) knee score); functional activity and walking speed level (using the Iowa Level of Assistance Scale (ILAS) and Timed Up and Go (TUG) test); hospital anxiety and depression scale (using the Hospital Anxiety and Depression Scale (HADS)); and the Tampa Kinesiophobia scale (using the Tampa Scale for Kinesiophobia (TSK)).20

In other research, it is said that with the PMR approach, all anxiety and depression experienced by patients will experience modulation of neurosympathetic and neuroendocrine responses.34 PMR activities with standard physiotherapy can provide better short-term effects on pain, kinesiophobia, and muscle strength compared to standard physiotherapy. Therefore, PMR can be easily implemented as part of patient rehabilitation after TKA surgery because it uses a simple technique that is easy for patients to carry out and is safe and cheap.

Weight Bearing-Based Early Mobilization Intervention

Lower extremity fracture sufferers can undergo surgical or non-operative treatment based on the level of fracture experienced. Based on the principles of handling orthopaedic cases according to the Arbeitsgemeinschaft für Osteosynthesefragen guideline, in fracture conditions that require surgery, standard post-operative care is usually given, including non-weight-bearing and immobilization for six weeks.35 Research regarding the feasibility of early weight-bearing has been carried out in recent years in fracture cases undergoing surgery. Weight-bearing is placing body weight on the injured leg. Early weight-bearing (EWB) or Permissive Weight-Bearing (PWB) is carried out by instructing the patient to apply weight-bearing according to the patient’s tolerance to accelerate union and increase bone strength.11

The EWB action is carried out without limiting the percentage of body weight but uses indicators for the appearance of clinical symptoms, such as pain or swelling. Based on standards, immobilization or non-weight bearing must be done for six weeks. However, early mobilization with non-weight bearing two weeks after surgery provides better results 12 weeks after surgery, such as reducing stiffness and pain and improving general function and activity. Daily life and quality of life.23 This is in accordance with other studies showing that non-weight bearing interventions can provide effective results if carried out two weeks after surgery, then given partial loading for 10 weeks and full loading for 12 weeks.36

Positioning-Based Early Mobilization Intervention

Post-operative positioning-based early mobilization of the knee limb is a simple and cost-effective intervention to prevent excess blood loss and increase range of motion. Early healing and increasing range of motion are important points in post-operative patients because they can reduce swelling in the knee. There is research that shows by comparing three different positions, namely in group A, 50 degrees of hip flexion and 90 degrees of knee flexion for six hours after surgery, in group B, 30 degrees of flexion and 45 degrees of knee flexion for six hours after surgery, and in group C The operated knees were straightened after surgery. The results showed that group A was better than groups B and C.37

Another study showed that post-orthopaedic surgery patients who underwent positioning could significantly minimize total and hidden blood loss, drain volume, and haemoglobin.38 This is because TKA management with post-operative flexion has been proven to increase the patient’s range of motion and prevent excessive post-operative blood loss. This is in accordance with other research, which states that positioning can also improve knee range of motion function, speed up post-operative return time, reduce knee swelling one day after surgery, and increase patient satisfaction.39

Early Mobilization Intervention Based on Neuromuscular Electrical Stimulation Application

Electrical stimulation, known as Neuromuscular Electrical Stimulation (NMES), applies electrical stimulation to the percutaneous periphery, which can produce skeletal muscle contractions.25 The aim of NMES is to strengthen muscles, especially in conditions of long immobilization, maintain muscle mass, and train muscles selectively. The NMES therapy system is controlled by a home-based application, a convenient device combining digital health technology with home-based NMES clinical rehabilitation technology. When installed with NMES, patient-reported outcomes are the patient’s pain and activity levels, which are sent to the cloud portal for review by the provider. Patients use the device for one-week post-surgery and continue for up to 12 weeks.

The results of another study showed that TKA patients using NMES could increase quadriceps strength, as evidenced by a 13% increase in quadriceps strength post-operatively in the first three weeks.40 Patients using NMES had a lower mean length of stay of 1.79 days. Research reports that the use of NMES can significantly increase quadriceps muscle strength.41 Another different study in which post-TKA patients showed no difference in changes in ROM after using NMES.42 These results are based on other studies that show no significant differences in knee flexion or extension in patients treated with NMES at six weeks or six months post-operatively.43 This is due to the need for consistency in carrying out other early mobilization interventions to obtain optimal results.

Implications for Multidisciplinary Practice and Future Research

Early mobilization intervention in post-orthopedic surgery patients has many benefits to accelerate the recovery process. In implementing comprehensive interventions, a coordinated multidisciplinary practice approach is certainly needed from various health care providers, such as orthopedic surgeons, nurses, physiotherapists, nutritionists, and others. All health care providers need to implement health team collaboration in designing a care plan that focuses on appropriate early mobilization intervention for post-orthopedic surgery patients. Every health worker has an important role in the success of the early mobilization intervention process in patients.

Doctors together with nurses and physiotherapists can collaborate to determine and implement early mobilization techniques that are appropriate to the patient’s condition, especially nurses as providers of nursing care can also always monitor the patient’s condition and nutritionists can help the recovery process through appropriate nutritional intake. In addition, all health workers also need to collaborate to manage the pain of patients after orthopedic surgery effectively so that early mobilization interventions can be implemented optimally. That way, multidisciplinary collaboration related to early mobilization interventions for patients after orthopedic surgery can accelerate the return of muscle function in patients and minimize symptoms felt after surgery.

Currently, research focusing on the effectiveness of various types of early mobilization interventions in post-orthopedic surgery patients is still very limited. Therefore, multidisciplinary collaboration needs to be implemented optimally. Thus, for further research, the author suggests that researchers can increase the number of participants and reach more post-orthopedic surgery patients due to fractures in the extremity and non-extremity areas so that a broader review can be conducted using the meta-analysis method.

Strengths and Limitations

This scoping review has strengths and limitations. First, this article has yet to be able to integrate the results through meta-analysis due to the limited data presented from the included studies. Second, this review only used a systematic search of four major databases because specific research articles related to early mobilization interventions in post-orthopaedic surgery patients due to extremity fractures are pretty rare, so the scope is limited. Third, regarding the sample size, we did not include studies with a minimum number of patients because existing research articles related to the topic are very limited. However, the critical appraisal analysis results with JBI showed >75% for all studies analyzed.

Conclusion

Early mobilization benefits patients after orthopaedic surgery by increasing the range of motion, reducing pain, and reducing hospital stay. Early mobilization interventions that can be applied include motion interventions, which have the fastest recovery time, namely six weeks after surgery; PMR interventions, which can reduce pain and increase the effects of muscle strength and kinesiophobia in the short term; weight-bearing interventions which can reduce stiffness and pain as well as improving quality of life and daily activities in the 12 weeks post-surgery, positioning interventions that can reduce post-operative blood loss and increase patient range of motion, as well as NMES interventions for patients who receive prolonged immobilization to increase muscle strengthening. Of the five interventions, motion-based early mobilization and PMR showed better results than other interventions as seen from the faster recovery time to range of motion, namely six weeks after surgery. In addition, both interventions are easy to implement as part of safe and inexpensive patient rehabilitation because the techniques used are simple.

Nurses and other healthcare providers can utilize the results of this literature review as additional information to assess and follow training related to how to provide early mobilization interventions that are appropriate for post-orthopaedic surgery patients. Nurses, as providers of nursing care, are expected to be able to implement one of the early mobilization interventions for patients after orthopaedic surgery to accelerate the return of the patient’s muscle function and minimize the symptoms felt after surgery. Early mobilization in post-orthopaedic surgery patients can benefit for hospitals by shortening recovery time and hospitalization. As for further research, it is hoped that it can further improve the results of specific studies related to other effective early mobilization interventions for post-orthopedic surgery patients and a broader review can be carried out using the meta-analysis method for maximum results.

Acknowledgments

All authors would like to thank Universitas Padjadjaran, Sumedang, West Java, Indonesia, for facilitating the database for this study.

Disclosure

The authors report no conflicts of interest in this work.

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