Key Points
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Current evidences show no significant difference of clinical outcomes between patients treated with versus without additional physiotherapeutic intervention, but high-quality studies are lacking.
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Patient education and exercise (so-called home exercise program) seems sufficient after distal radius fracture (DRF) based on current evidence, suggesting that there is no need to prescribe a routine supervised physiotherapy session for all patients.
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The subgroup who would obtain significant benefit from supervised physiotherapy session has not yet been identified. Future studies should aim to identify for whom this costly intervention is needed.
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Earlier rehabilitation after surgery leads to early recovery and return to work at short-term follow-up.
Case 1
A 56-year-old homemaker presented to the emergency department with a displaced extra-articular distal radius fracture (DRF). Closed reduction and immobilization with a sugar-tong splintwas achieved. Reduction was subsequently maintained via 5-week cast immobilization ( Fig. 1 ). Is exercise prescribed by a therapist required for this patient during cast immobilization or after cast removal?
Case 2
An 86-year-old woman presented to emergency department with DRF. An orthopedic resident attempted closed reduction and applied a sugar-tong splint, but loss of reduction was observed at the first outpatient visit. Thus, we decided to perform open reduction and internal fixation because of her high activity before injury, which appeared to achieve acceptable reduction and stable fixation of the fracture fragments ( Fig. 2 ). Would there be any benefit of early start of mobilization and physiotherapy in this patient?
Importance of the Problem
DRF is a very common injury. Nonoperative treatment with a cast remains the most popular treatment for stable fracture. However, surgical treatment has been increasingly adopted as a reliable modality since the volar locking plate (VLP) was introduced as a robust implant. Although many studies have focused on immobilization methods or surgical approaches, little attention has been given to rehabilitation protocols during or after those definitive treatments. However, achieving successful outcomes requires both sound definitive treatment and timely appropriate rehabilitation. Rehabilitation prevents fracture-related complications and optimizes functional recovery to maintain activities of daily living. Despite rehabilitation being critical to the final prognosis of DRF, sufficient evidence of its application and efficacy is lacking. This issue will become increasingly important because of the predicted increase in the number of affected patients and demand for cost-effective healthcare.
Main Question
What is the effect of rehabilitation protocols (home exercise program [HEP] versus supervised physiotherapy session [SPS]) on functional outcome after DRF, and when should they be initiated?
Current Opinion
HEP and SPS are the two most frequently prescribed forms of rehabilitation. HEP consists of basic education and advice including fracture protection, cast care, and edema control as well as instructions to engage in progressive exercise at home. This is the simplest and most cost-effective form of rehabilitation after DRF. This measure is the minimal intervention usually provided to patients during or after immobilization, and many randomized controlled trials (RCTs) adopted HEP to the control group. In contrast, SPS consists of exercises performed in specific places, such as a hospital under the supervision of a physiotherapist or other medical personnel, for a certain period. Although it is assumed that patients who receive early structured physiotherapy achieve a faster recovery, it is unclear whether SPS is truly beneficial over natural recovery or HEP.
Finding the Evidence
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Cochrane search: “distal radius fracture”
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Pubmed (Medline): (“radius fractures” [Mesh] OR distal radius fracture*[tiab]) AND (“rehabilitation” OR “exercise” OR “physiotherapy” OR “occupational therapy” OR “mobilization” OR “training” OR “edema” OR “glove” OR “PEMF” OR “mirror”)
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Manual review of eligible articles (especially systematic reviews and metaanalyses)
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Articles (at least abstracts) not published in English, French, or German were excluded.
Quality of Evidence
Level I:
Systematic reviews/metaanalyses: 5
Randomized trials: 28
Level II:
Randomized trials with methodological limitations: 1
Level III or IV: 2
Findings
After a certain immobilization period, limited range of motion (ROM), weak grip strength, pain, and swelling or edema are typical indications for rehabilitation. Extensive rehabilitation intervention is frequently required to reduce pain, restore ROM, and improve muscle strength and function. According to Waljee et al., 20.6% of patients received either physical or occupational therapy (OT) after DRF. Patients who underwent open reduction and internal fixation (ORIF) were more likely to receive formal physiotherapy than patients who received nonoperative treatment. Furthermore, patients who undergo ORIF were referred to a physiotherapist sooner than those who receive other management are. Bruder et al., who performed an observational study of 14 physiotherapists, reported that most common interventions prescribed by surgeons were exercise (97%), advice (90%), passive joint mobilization (55%), and massage (38%).
Role of HEP
HEP can be the minimum requirement for effective rehabilitation; however, there is a paucity of evidence of its true effectiveness. Just one RCT by Kay et al. compared an HEP group with a group received no instruction or intervention after cast or pin fixation. No significant intergroup difference was found regarding wrist ROM at 6 weeks. However, in terms of a decrease in pain visual analog scale score and increase in functional activity (Patient Rated Wrist Evaluation [PRWE] score), the HEP group showed superior outcomes at 3 and 6 weeks. In addition, patient satisfaction was higher in the HEP group. The authors concluded that HEP with advice provides some benefit over natural recovery without formal intervention.
Role of SPS
The need for additional SPS has been under debate for DRF rehabilitation. In at least three RCTs, SPS showed more favorable outcomes than HEP. Watt et al. compared the effect of SPS and HEP after cast removal in 18 patients, and those treated with SPS showed significant increases in wrist extension and grip strength at 6 weeks. Accordingly, a recent study by Gutiérrez-Espinoza et al. demonstrated that SPS was more effective than HEP in patients older than 60 years; in fact, the SPS group showed better results in terms of PRWE score at 6 weeks and 6 months. Gronlund et al. studied the effect of early OT in 40 patients treated with a cast for stable Colle’s fracture. A better functional score according to Gartland classification was found in OT group at 5 weeks but not at 9 weeks or 3 months. In terms of wrist ROM and complication rate, the two groups were similar at 3 months. Based on these findings, they concluded that early OT during immobilization has a favorable short-term effect on the recovery of hand function.
However, a larger number of studies including nine RCTs do not support those favorable effects of SPS. Pasila et al. investigated the effect of early SPS started during cast immobilization in 96 patients. At 3 months’ follow-up, there were no significant differences in hand strength or ROM between the SPS and HEP groups. These findings were repeated in several RCTs comparing the effects of HEP and SPS in patients given nonoperative treatment ( Table 1 ). The same conclusion was drawn from studies including RCTs of patients treated with a VLP ( Table 1 ). Fig. 3 shows representative forest plots that demonstrate no difference in PRWE scores between the SPS and HEP groups at 6 weeks and 6 months. However, the data in each study are not reliable because of extreme study heterogeneity such as wide variations in interventions, timing, and measurement tools.
| Author | Year | Number of Patients | Treatment Method | Time of Evaluation | Outcome Measured |
|---|---|---|---|---|---|
| Studies showing superior effect of SPS over HEP | |||||
| Watt | 2010 | 18 | Cast | 6 weeks | Extension, grip strength |
| Gutiérrez-Espinoza | 2017 | 74 | Cast | 6 weeks and 6 months | ROM, grip strength, pain, PRWE |
| Gronlund | 1990 | 40 | Cast | 5 weeks, 9 weeks, and 5 months | Modified functional score |
| Studies showing similar effects of SPS and HEP | |||||
| Kay | 2000 | 40 | Cast or pin | 6 weeks | ROM, grip strength, pain |
| Wakefield | 2000 | 66 | Cast | 3 months and 6 months | ROM, grip strength, pain |
| Christensen | 2001 | 30 | Cast | 5 weeks, 3 months, and 9 months | ROM, grip strength, pain, DASH |
| Maciel | 2005 | 41 | Cast | 6 weeks and 6 months | ROM, grip strength, pain, PRWE |
| Bruder | 2016 | 33 | Cast | 7 weeks and 6 months | PRWE, DASH |
| Valdes | 2015 | 50 | VLP | 3 months | ROM, grip strength, pain, PRWE |
| Studies showing superior effect of HEP over SPS | |||||
| Krischak | 2009 | 48 | VLP | 6 weeks | ROM, grip strength, PRWE |
| Souer | 2011 | 94 | VLP | 3 months and 6 months | ROM, grip strength, pain, Mayo wrist score, DASH |
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