Volume 90, Issue 4 , Pages 537-544, April 2009
Physiotherapy After Volar Plating of Wrist Fractures Is Effective Using a Home Exercise Program
Article Outline
Abstract
Krischak GD, Krasteva A, Schneider F, Gulkin D, Gebhard F, Kramer M. Physiotherapy after volar plating of wrist fractures is effective using a home exercise program.
Objective
To determine the effect of 2 different postoperative therapy approaches after operative stabilization of the wrist fractures: treatment by a physical therapist with 12 sessions and an unassisted home exercise program.
Design
Randomized controlled cohort study.
Setting
Hospital-based care, primary center of orthopedic surgery.
Participants
Volunteers (N=48) with fractures of the distal radius after internal fixation with locking plates. There were 46 patients available for follow-up after exclusion of 2 participants due to physiotherapy sessions in excess of the study protocol.
Interventions
Not applicable.
Main Outcome Measures
Evaluation of grip strength using a Jamar dynamometer, range of motion (ROM), and Patient Related Wrist Evaluation (PRWE).
Results
After a 6-week period of postoperative treatment, the patients (n=23) performing an independent home exercise program using a training diary showed a significantly greater improvement of the functionality of the wrist. Grip strength reached 54% (P=.003), and ROM in extension and flexion 79% (P<.001) of the uninjured side. Ulnar and radial abduction was also higher in this group. In contrast, patients who were treated by a physical therapist achieved grip strength equal to 32%, and ROM in extension and flexion of 52% of the uninjured side. Patients who were performing the home training after operation recorded an improved wrist function with a nearly 50% lower value (P<.001) in the PRWE score.
Conclusions
In the postoperative rehabilitation of wrist fractures, instructions in a home exercise program are an effective alternative to prescribed physical therapy treatment.
Key Words: Fractures, bone, Rehabilitation
List of Abbreviations: AO, Arbeitsgemeinschft für Osteosynthesefragen, AP, anteroposterior, ORIF, open reduction and internal fixation, PNF, proprioceptive neuromuscular facilitation, PRWE, Patient Related Wrist Evaluation, ROM, range of motion
THE DISTAL RADIAL fracture is the most frequent of all fractures in trauma surgery.1 One of 6 fractures is of the distal radius.2, 3 Assuming that life expectancy continues to increase in western industrialized nations, the frequency of fractures to the wrist can be expected to increase by approximately 50% by the year 2030.4
The treatment of distal radial fractures has changed as a result of the experience gained through conservative treatments applied over the last 20 years. ORIF has moved to the forefront in order to maintain reduction and allow early functional treatment. The usage of locking plates has become the standard process used in the surgical treatment of distal radial fractures.5
Postoperative rehabilitation is an integral part of the complete concept for radial fractures treated through surgery, because there is an increased risk of long-term impairment due to the involvement of the wrist joint.6, 7 Functional restoration has a direct influence on the quality of life, as well as the duration of sick leave and laborer compensation, and therefore is of social economic interest. More than half the patients who sustain this injury are currently employed at the time they fracture their radius.8 In the median, patients with a distal radial fracture are off work from 67 days up to 20 weeks.9, 10 It is for this reason that postoperative therapy is critical in restoring functionality.11 Recommendations from professional organizations regarding the type, intensity, and duration of postoperative treatment do not exist; neither are there recommendations supported by studies regarding which patients might possibly benefit more or less from physical therapy.12 Therefore, it is incumbent on the treating surgeon to choose a postoperative treatment on a subjective basis, whereas the primary care system in Germany results in several doctors participating in determining and prescribing this treatment.
In this prospectively randomized study, the efficacy of 2 different postoperative rehabilitation approaches after the treatment of distal radial fractures through ORIF with locking plates was examined. We hypothesized that the treatment given by a physical therapist within the framework of a conventional prescription is more effective than an unassisted home exercise program.
Methods
Study Design
The study was approved by the local ethics committee (no. 46/06, 12.07.2006). All the patients were informed and confirmed their willingness to participate in the study by signature. Patients receiving surgical treatment of distal radial fractures at the center of surgery between July 2006 and November 2007 were candidates for the study. All the fractures were stabilized using a volar locking platea after open reduction.
Patients were excluded from the study if they were younger than 18 years, were uncooperative, lacked the cognitive capacity to participate in the study, lacked self-sufficiency in managing the requirements of daily life (eg, home care needed), had a psychiatric illness, had a bone disease responsible for the treated fracture (ie, bone metastasis, osteolysis), had a previous fracture near the wrist or carpal tunnel syndrome on the injured side, had inflammatory joint disease (ie, rheumatoid arthritis, gout), or had reflex sympathetic dystrophy.
One week after surgery, patients underwent their first examination (follow-up 1). A randomized selection process based on age was used to sort each patient into 1 of 2 postoperative programs. The randomized selection process based on age was done through block randomization. Each patient was placed in 1 of 3 blocks (age 18–44, 45–64, and >64y) before the randomization procedure. The study was not blinded. All measurements were done by the authors (G.D.K. and A.K.). Group A (home exercises) followed a regimen of exercises in home training; group B (therapist) received treatment by prescription in the practice of a physical therapist. Each patient was put in a splint after surgery for 2 weeks in order to ensure proper wound healing. The splint was removed for the therapy and put back on after the treatment.
After 6 weeks of rehabilitative treatment, a second follow-up examination (follow-up 2) was performed to determine the success of the respective postoperative therapies.
Types of Postoperative Therapy
Patients in group B received a prescription for a total of 12 sessions lasting 20 to 30 minutes each, over a 6-week period. All patients were free to choose their own therapist. The therapists were free to choose the type of therapy based on their own evaluation. As is general practice, the therapists were instructed to implement exercises that could be executed by the patients unassisted at home.
Patients in group A (home exercises) received detailed instructions and demonstrations in the home exercise program after the follow-up 1 examination. Patients were instructed in home exercises by the authors (G.D.K. and A.K), and received an exercise guidance booklet. The contents instructed the patients about the type of exercises, repetitions, intensity, training, and rest phases, as well as including a diary-type weekly plan (table 1). The details grouped 3 to 5 exercises in units requiring approximately 20 minutes. Each day called for 2 training units, to be performed once in the morning and once in the evening. Detailed descriptions and photographic illustrations were included for each of the exercises. The patients maintained a regular protocol of each exercise they performed, which was used to record information about compliance.
Table 1. Detailed Description of Home Program Exercises on a Weekly Schedule
| No. | Description | Figures | Frequency |
|---|---|---|---|
| Week 1 | |||
 1 | Making a fist: Extend fingers before making a fist. |  | 5×10 rep |
| 2 | Picking apples: Open your hand above your head and close it pulling your arm down. |  | 3×15 rep |
| Week 2 | |||
| 1 | Making a fist: Extend fingers before making a fist. |  | 5×10 rep |
| 2 | Waving: Hand rests on its edge (side of little finger), stabilize wrist. Slow flexion and extension movement. |  | 2×20 rep |
| 3 | Windshield wiper: Palm of the hand flat on table. Slowly abduct towards radius and ulna. |  | 2×20 rep |
| 4 | PNF technique: Make a fist while bending your arm over head, nose touching elbow. Slowly bring arm down to side of body, opening hand and extending elbow. |  | 2×20 rep |
| Week 3 | |||
| 1 | Make a fist, squeezing a soft foam ball for a few seconds. |  | 3×10 rep |
| 2 | Hand at edge of table: Slowly move hand towards you: (1) flexion, (2) extension, and (3) thumb pointing towards you. |  | 2×10 rep |
| 3 | Brushing teeth: Brush teeth as usual with injured arm. | — | 2×2 min |
| Week 4 | |||
| 1 | Making a fist, squeezing a soft foam ball for a few seconds. |  | 3×10 rep. |
| 2 | Waving: Hand rests on its edge (side of little finger), stabilize wrist. Slow flexion and extension movement. |  | 2×20 rep. |
| 3 | Windshield wiper: Palm of the hand flat on table. Slowly abduct towards radius and ulna. |  | 2×20 rep. |
| 4 | Pressure and counter pressure: (1) Push with healthy hand against palm of injured hand, and (2) vice versa. |  | 2×10 rep. |
| 5 | Movement as above but without pressure, and fully flex and extend hand. |  | 2×10 rep. |
| Week 5 | |||
| All exercises of week 4 (1–5). | |||
| 6 | Water bottle: Same as in exercise 2 during week 3, while holding a bottle in your hand. |  | 2×10 rep. |
| Week 6 | |||
| 1 | Making a fist, squeezing a soft foam ball for a few seconds. |  | 3×10 rep. |
| 2 | Water bottle: Same as in exercise 2 during week 3, while holding a bottle in your hand. |  | 2×10 rep. |
| 3 | Stretching: Stretch injured hand towards total flexion and extension. |  | 3×1 min. |
| 4 | Making a fist, squeezing a tennis ball for a few seconds. |  | 3×10 rep. |
The exercises were grouped by week in accordance with the phases of wound and fracture healing. For the first 2 weeks, priority was given to pain reduction and reduction of postoperative edema.11 After the second week, passive exercises were introduced to stretch soft tissue. In addition, early active movements were added, without resistance, to increase muscle activity, including stretching and spreading fingers, making a fist, forearm stretching, and bending and stretching the elbow, as well as abduction/adduction and external/internal rotation of the arm.11, 13 Starting after the second week, exercises from the PNF technique were introduced. PNF activates motor function through stimulated proprioception induced by adequate facilitation.13 Stimulus is provided primarily by pull and pushing techniques. In the fifth week, dynamic muscle exercises against light resistance were increased.
Follow-up
During the postoperative examinations, general data and data concerning accompanying illnesses of the patients were collected. The fractures were grouped according to AO classification.14 The postoperative position of the joint was documented using standard radiographs (lateral and AP view): joint alignment (lateral view), radial inclination angle (AP view), and length of the radius (AP view).
Impairment was measured at both follow-up examinations (follow-up 1 and 2). The PRWE score was determined for each patient. The PRWE determines a subjective scoring of the functionality of the hand. The PRWE is a 15-item questionnaire that equally rates wrist-related pain and disability in functional activities. Scoring is performed on an 11-point scale (0, no issues or pain; 10, unable to perform or pain). Five questions require the patient to estimate pain at rest or during activities such as repeated motion or lifting. Functional items are divided into 2 categories: specific activities and activities of daily life. There are 6 specific tasks, such as turning a doorknob, cutting meat, and closing a button, and 4 categories of daily-life activities (self-care, work, household duties, recreation). The pain score is the sum of 5 items, with a worst score of 50. The disability score is the sum of 10 items, divided by 2. Thus, the total function on the PRWE scale ranges from 0 (normal wrist) to 150 (worst possible score). The PRWE is described in more detail elsewhere.15, 16 At the time of the follow-up 1 examination, the patients were requested to describe their PRWE status preceding the injury. At the time of the follow-up 2 examination, their current status was determined.
Grip strength was measured during both the follow-up 1 and 2 examinations by using a hydraulic hand strength measuring instrument.b The measurements were made in accordance with the recommendations of the American Society of Hand Therapists17: sitting in an upright position, feet flat on the ground, shoulders in neutral position, elbows flexed at 90°, forearm rotation neutral, and wrist extension between 0° and 30°. Three tests of maximum grip strength were performed, alternating between the injury-free and the injured hand, with a maximum of 4 seconds maintaining maximum grip force and 30 seconds of rest between the individual attempts. The injury-free hand was tested first and alternated thereafter. If the third value was the highest measured, a fourth measurement was made and, if necessary, additional measurements were made until the last measurement was not the highest.18, 19 The mean was taken of the 3 valid measures and recorded as the grip strength for the day of the examination.
Earlier studies recommended a correcting adjustment of 10% for the dominant hand regardless of right- or left-side dominance.20 Subsequent research determined that while the normal grip strength of the dominant hand in right-handed people is higher, the same is not true for left-handed people, who have equal strength in both hands.21, 22 Therefore, as recommended by the latter authors, a 10% adjustment was only made for the right hand in patients with right-hand dominance. The results of the injury-free hand served as the base value for both examination days, while the measurement of the injured hand was drawn as a percentage indexed value of the mean for the healthy hand.
ROM was documented for both the healthy and the injured hand using a commercially available goniometer23; extension and flexion of the wrist, ulnar and radial abduction of the wrist, and pronation and supination were measured. ROM was calculated from the values of the opposing directions. Because there are interindividual differences in mobility, the ROM of the healthy hand was defined as the initial value and set empirically with a value of 100%. Then, a relative degree of mobility, in percentage terms, was calculated for the injured hand. As the values of the opposing side were measured in each of the postoperative examinations (follow-up 1 and 2), the mean was calculated as the ROM for the healthy extremity.
Statistics
Analysis was done using the Software StatView.c The data were first structured descriptively: for constant interval-scaled variables by mean, SD, frequency, maximum, and minimum; for nominal- and ordinal-scaled variables by absolute and relative frequency.
Differences between the semistatistical scores were analyzed using the nonparametric Mann-Whitney U test. Correlation analysis was done using a regression analysis, followed by a Fisher transformation determining the P value. Because of the low-frequency level, the Fisher exact test was used, which delivers the results as a conditional probability. The level of significance for every comparison was set below .05 (P<.05). The measure for effect size was Cohen d, which is a measure of standardized differences between means, expressed in terms of SD units.24 Cohen24 roughly defined an effect size of 0.2 as small, that of 0.5 as medium, and that above 0.8 as large.
Box-plot diagrams are not uniformly defined and therefore require a more exact description. StatView defines the upper and lower borders of the box as the first and third quartile, respectively. Therefore, 50% of the data points lie within the box. The lower and upper whiskers represent the tenth and ninetieth percentile, respectively. The dots above and below the whiskers show the maximum and minimum values.
For the evaluation of grip strength and ROM, the results of both examinations of the healthy hand were taken in average and set empirically at 100% as the reference value. The results of the measurements of the injured hand from each postoperative examination (follow-up 1 and 2) were then calculated in relation to this value.
Results
Patient Data
A total of 48 patients with distal radial fractures were included in the study. Two participants (1 of each group) had to be excluded because they received additional physiotherapy sessions. Thus, the randomized groups each consisted of 23 patients. Patients in group A (8 men, 15 women) had a mean age of 53.7±17.9 (18–76) years, while patients in group B (8 men, 15 women) were 56.0±11.1 (26–73) years. There were no significant differences in age or sex between the 2 groups. The distribution between the injured and dominant hands is shown in table 2. The results of the Fisher exact test showed no significant differences in the distribution on the side injured or on the dominant side injured.
Table 2. Distribution of the Injured Side in Relation to the Dominant Hand
| Group | No. Total | Dominant Side Injured | Side | |
|---|---|---|---|---|
| Right | Left | |||
| A (Home program) | 23 | 8(35) | 9 | 14 |
| B (Physiotherapist) | 23 | 11(48) | 11 | 12 |
The distribution of the accompanying illnesses is shown in table 3. There were no significant differences between the randomized groups with respect to the severity of the fractures by AO classification (table 4). The percentage of C fractures was identical in both groups (61%). One B fracture was treated in group A, while there were 3 B fractures in group B. The remainders of the fractures were grade A according to the AO classification. Radiographically, there were no significant differences in the postoperative alignment of the joints (table 5).
Table 3. Descriptive Listing of the Recorded Accompanying Illnesses
| Accompanying Illness | Group A | Group B |
|---|---|---|
| None | 7(30) | 6(26) |
| Musculoskeletal disease | 14(61) | 9(39) |
| Heart disease | 1(4) | 2(9) |
| Pulmonary disease | 1(4) | 2(9) |
| Diabetes mellitus | 0 | 5(22) |
| Prosthesis | 0 | 0 |
| Vascular disease | 9(39) | 2(9) |
| Neurologic disease | 5(22) | 2(9) |
| Carcinoma | 1(4) | 2(9) |
| Others | 10(43) | 9(39) |
Table 4. Distribution of the Observed Frequency of the Class of Fractures According to AO
| AO Classification | Group A | Group B |
|---|---|---|
| A2 | 2(9) | 4(17) |
| A3 | 6(26) | 2(9) |
| B1 | 0 | 0 |
| B2 | 0 | 1(4) |
| B3 | 1(4) | 2(9) |
| C1 | 2(9) | 8(35) |
| C2 | 9(39) | 4(17) |
| C3 | 3(13) | 2(9) |
Table 5. Position of the Joints in the First Radiographs of the Wrists in Both Planes: Radial Inclination, Alignment, and Length of the Radius
| Postoperative Radiograph | Group A | Group B |
|---|---|---|
| Radial inclination, AP (°) | 16.7±6.0(3–28) | 17.3±7.8(5–33) |
| Alignment, lateral (°) | 0.4±8.2(−12–22) | 2.9±8.7(−8–22) |
| Radial length, AP (mm) | 0.9±1.8(−3–4) | 0.2±1.7(−2–4) |
Twenty patients in group A documented their compliance with the exercise guidance booklet; 97% of exercises were documented as “done.” Three patients did not return their booklet to the examiners. All patients in group B received 12 documented sessions of physical therapy.
The PRWE scores of both groups showed a virtually identical starting value before the fracture (table 6). A large difference was recorded in the functional scores after the postoperative treatment. Group A showed a nearly 50% lower value than group B. The difference was significant (P<.001) and corresponded to a large effect size (Cohen d=1.18).
Table 6. PRWE Scores Before the Accident (Data Gained During Follow-up 1) and at Follow-Up 2
| PRWE | Before Accident (Ascertained FU1) | After Accident (FU2) |
|---|---|---|
| A (Home program) | 1.1±5.2(0–25) | 18.5±15.9(2.5–56) |
| B (Physiotherapist) | 0.5±2.3(0–11) | 36.1±13.9(10.5–61) |
Grip strength relative to the opposing healthy side is shown in figure 1. Both groups showed a distinctly lower level at the postoperative examination (follow-up 1). After 6 weeks, patients in group A showed a mean grip strength that was 54% of the starting base value, while those in group B only recorded a grip strength that was 32% of the starting base value. This difference was significant (P=.003), and a large effect size difference was calculated (Cohen d=1.14).
Fig 1.
Recorded grip strength, using the Jamar dynamometer, as a percentage of the healthy side (empirically 100%) as measured in both follow-up examinations, follow-up 1 and follow-up 2 (box plots: upper and lower borders of box, first and third quartile, respectively; horizontal line inside box, median; lower and upper whiskers, tenth and ninetieth percentile, respectively; dots above and below whiskers, maximum and minimum values, respectively). Abbreviations: FU1, follow-up 1; FU2, follow-up 2.
The ROM in the healthy hand showed no notable difference between the 2 groups. The mobility of all patients at the time of the first follow-up (follow-up 1) was markedly reduced. The results of the ROM of extension and flexion are shown in figure 2. After an interval of 6 weeks from treatment, group A achieved a ROM that was 79% of the uninjured side, while group B only achieved 52%. The difference was significant (P<.001), corresponding to a large difference in effect size (Cohen d=1.35). The results recorded for ulnar and radial abduction are shown in figure 3. At the time of the follow-up 2 examination, group A reached a ROM that was 70% of the healthy side, while group B showed a significantly lower ROM of 59% of the healthy side (P=.013), corresponding to a medium difference in effect size (Cohen d=0.71). The results recorded for pronation and supination are shown in figure 4. Both groups achieved a high level of motion after the postoperative treatment, without a significant difference between the 2 groups.
Fig 2.
ROM of wrist extension and flexion as a percentage of the healthy side (empirically 100%) as measured in both follow-up examinations, follow-up 1 and follow-up 2 (box plots: upper and lower borders of box, first and third quartile, respectively; horizontal line inside box, median; lower and upper whiskers, tenth and ninetieth percentile, respectively; dots above and below whiskers, maximum and minimum values, respectively). Abbreviations: FU1, follow-up 1; FU2, follow-up 2.
Fig 3.
ROM of ulnar and radial abduction as a percentage of the healthy side (empirically 100%) as measured in both follow-up examinations, follow-up 1 and follow-up 2 (box plots: upper and lower borders of box, first and third quartile, respectively; horizontal line inside box, median; lower and upper whiskers, tenth and ninetieth percentile, respectively; dots above and below whiskers, maximum and minimum values, respectively). Abbreviations: FU1, follow-up 1; FU2, follow-up 2.
Fig 4.
ROM of pronation and supination as a percentage of the healthy side (empirically 100%) as measured in both follow-up examinations, follow-up 1 and follow-up 2 (box plots: upper and lower borders of box, first and third quartile, respectively; horizontal line inside box, median; lower and upper whiskers, tenth and ninetieth percentile, respectively; dots above and below whiskers, maximum and minimum values, respectively). Abbreviations: FU1, follow-up 1; FU2, follow-up 2.
Discussion
This prospectively randomized study investigated the effect of 2 different postoperative therapy concepts after the surgical treatment of distal radial fractures. After a 6-week period of postoperative treatment, the patients performing an independent home exercise program using a training diary showed a significantly greater improvement of the functionality of the wrists (PRWE, grip strength, ROM extension and flexion, ulnar and radial abduction).
The postoperative treatment of fractures receiving surgical therapy generally targets the avoidance of complications and the optimal possible recovery of functionality and the performance of daily tasks.25 The starting point for beginning physical therapy after surgical treatment was investigated by Gronlund et al.26 They found that for 17 patients, as opposed to 23 others, who received postoperative physical therapy directly, there was a significantly better functioning of the hand and recommended, based on their results, an early start to postoperative treatment.
Study Limitations
When comparing our results with the data in the literature, it should be noted that follow-up in our investigation was only short-term (6 weeks), and long-term results are not available, which we consider a limitation of our study. Randomized studies examining the effect of physical therapy on surgically treated distal radial fractures have not been published. Several studies have been published on this subject following conservatively treated distal radial fractures. Watt et al27 showed that patients with distal radial fractures who completed a 6-week home exercise program after removal of their casts, had a poorer ROM and grip strength than patients receiving treatment from a therapist. After a 6-month period, Wakefield and McQueen28 were able to document a better range of mobility in extension and flexion after treatment by physical therapists, beyond which there were no other significant differences between the 2 groups. After a period of 3 months (6 months after surgery), the authors found that there were no significant differences between the groups. The ROM did not correlate to the functionality score, leading the authors to conclude that extension and flexion do not influence hand functionality.
Other studies were not able to prove that there was an advantage to after-treatment given in a physical therapy practice. Maciel et al29 were unable to detect any significant effect of a postoperative physical therapy treatment on the functionality of the hand, pain, or the PRWE score after periods of 6 and 24 weeks. The PRWE was originally described by MacDermid et al16 as a tool for quantifying wrist pain and disability in patients with distal radial fractures. The PRWE has been identified as the most responsive measurement for evaluating outcomes of patients with distal radial fractures when compared with other measurements (including Disabilities of the Arm, Shoulder and Hand score, Brigham and Women's carpal tunnel questionnaire, and the Gartley and Werley score).30 The authors confirmed a good reliability and responsiveness of the PRWE, and a fair validity.30
In a prospective study, Taylor and Bennell31 investigated the effect of passive exercise treatment on conservatively treated distal radial fractures, which after a median of 4.5 weeks showed no significant improvement beyond that from active motion therapy. Other authors found no difference in the functional results between patients doing exercises without direction and those receiving professional after-treatment from therapists.32
A remarkable finding in all the studies in which a directed home exercise program and professional treatment from a physiotherapist were researched, is the low frequency of treatment in the visits to the therapist. The median number of therapy sessions in the study by Pasila and Sundholm33 was 4 units (minimum 1, maximum 12); by Bache et al,34 3 units (minimum 1, maximum 16); by Wakefield and McQueen,28 3 units (minimum 1, maximum 22); by Watt et al,27 5 units; and by Maciel et al,29 4.4 units. Therefore, the number of treatments received by the patients in all available studies was far below the level achieved in the patients participating in this study, each of whom was examined after 12 treatment sessions by a physical therapist.
A fracture of the wrist is an injury that results in the loss of function for the entire affected extremity. Patients frequently have a tendency to disassociate the injured extremity from their body (make the best of it, doctor).35 Therefore, the call for taking responsibility for the after-treatment is an alternative medical concept, in order to engage the patient directly in the medical treatment and postoperative therapy. The informed patient realizes that success and failure depend on the patient's own motivation and reliability, and neither the surgeon nor therapist can be solely responsible for the results. A presupposition here is that the patient is to be informed during a comprehensive consultation about the rationale for, and details of, the home exercise program, clarifying that (1) the self-directed treatment can only succeed when one can be assured that the patient performs it concomitant with the treating physician's intentions, and (2) the establishment of a basis of trust is primary to following through with an alternative treatment concept, without which it cannot be successful.
Lyngcoln et al36 studied patients with distal radial fractures to determine the effect of patient reliability on the performance of physical therapy. They were able to show that of all the exercises, those diligently performed and documented in the study using an exercise diary, were the most important factor in regaining functionality of the hand. In order to ensure that this study was correctly executed, in addition to a comprehensive consultation, each of the exercises was demonstrated, and the patients received a home exercise diary with instructions and commented exercises as well as pictorials.
It is known that educational status and cognitive level influence the commitment towards participation in research studies.37, 38, 39, 40 Patients in group B (physiotherapy, self-reliant) were only required to make and attend the appointments with a therapist. Taking personal responsibility was therefore of little importance. By contrast, the home exercise program of group A required an understanding of the urgency of the after-treatment, as well as motivation and endurance in performing the exercises.
While regaining functionality of the hand is primarily of personal and medical interests, it also has economic implications. Within the framework of an outpatient physical therapy, patients incur costs resulting from the product of the treatment fee and the number of treatments. In general, a physiotherapist practice charges approximately 18 € for a 20- to 30-minute session. Therefore, the expense of a prescription for 6 sessions of therapeutic exercises alone is 108 €. Furthermore, the cost for transportation may not be insignificant, depending on the distance involved. Independent of the expense, there is a burden placed on the patient as a result of the postoperative treatment at a physical therapist's practice. Each session requires travel to and from the practice, to which there may well be waiting room time added. Wittemann et al10 enumerated the sum of the costs of injury during the time of disablement for patients with small hand injuries, to which the authors included distal radial fractures, to be 7700 €.
A possibly important factor for the better outcomes of patients in group A could be the higher level of exercise intensity. If one calculates the intensity in terms of hours trained per week, the physiotherapy group had 1 hour per week of training versus 4.6 hours per week for the home exercise group, assuming that the training book instructions were followed. For economic reasons, a similarly high level of exercise intensity in an outpatient physical therapy practice, considering the good clinical results of the patients in group A, is not justified.
The individual constitution of the patient, possible clinical complications and fracture type, accompanying illnesses, and other circumstances can make it unfeasible to have the patient responsible for carrying out a home exercise program. For example, patients with dementia, depression, or lack of motivation, as well as those with amblyopia or cognitive impairment, are not candidates for a home exercise program.
Conclusions
The hypothesis that patients performing postoperative rehabilitation therapy after surgical treatment of wrist fractures would have poorer development of hand functionality after 6 weeks has to be rejected. We conclude that instructions in a home exercise program using a booklet with guidance is a valid alternative to prescribed physical therapy.
Suppliers
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No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the authors or on any organization with which the authors are associated.
Trial registration number: The study was been approved by the local Ethics Committee (no. 46/06, 12.07.2006).
PII: S0003-9993(09)00004-5
doi:10.1016/j.apmr.2008.09.575
© 2009 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.
Volume 90, Issue 4 , Pages 537-544, April 2009
