Prescription of exercise after upper limb fracture is also consistent with the key principle of fracture management, movement (Adams and Hamblen, 1995), and adherence to prescribed

home exercise has been found to be TGF-beta inhibitor moderately-to-strongly associated with shortterm outcomes of impairment and activity after distal radius fracture (Lyngcoln et al 2005). Despite this there are currently no high quality trials that have evaluated the effects of exercise alone on rehabilitation outcomes. For this reason it is not possible to strongly advocate the routine use of exercise for all upper limb fractures. Having said that, there is preliminary evidence to support the role of exercise in the rehabilitation of specific upper limb fractures, which provides support for particular FG-4592 mouse protocols. Exercise and advice was found to be beneficial compared to no intervention in the short term in

the management of patients with a distal radius fracture (Kay et al 2008); early commencement of exercise was found to be beneficial in patients with conservatively managed proximal humeral fractures (Hodgson et al 2007, Lefevre-Colau et al 2007); and supervised exercise in addition to home exercise as part of physiotherapy was found to increase wrist range of movement in patients with conservatively managed distal radius fractures (Wakefield and McQueen, 2000, Watt et al 2000). In contrast, however, a program of supervised exercise in addition to home exercise was found to result in poorer short-term

outcomes of range of movement and upper limb activity after surgically managed distal radius fractures (Krischak et al 2009) and proximal humeral fractures (Revay et al 1992). One factor that makes interpretation of the results of this review difficult is the use of co-interventions in the designs of the included trials. Apart from one trial that found exercise and advice compared to no intervention beneficial (Kay et al 2008), all trials included exercise in both the intervention and control group, albeit with differences in the duration or number of supervised sessions. Further investigation with controlled trials that investigate exercise as the only intervention Rolziracetam versus a no-intervention control group is warranted to explore the role of exercise in upper limb fracture rehabilitation. The evidence demonstrating short- and medium-term improvement in upper limb function and reduced impairment with early commencement of exercise after fracture, is an example of how the use of co-interventions can make interpretation difficult (Hodgson et al 2003, Lefevre-Colau et al 2007). One explanation could be that the benefits may be attributable to exercising for a longer duration.