Rehabilitation
Many patients are referred to a rehabilitation provider following a DRF in order to optimise return to function.
The questions are divided into two sections with recommendations at the end and will consider how functional outcome after DRF is affected by:
- The impact of providing rehabilitation during the immobilisation period
- The impact of providing rehabilitation after definitive treatment implementation (surgically and non-surgically managed patients)
And then:
- The type of rehabilitation intervention
- The mode of rehabilitation delivery
- The discipline of the rehabilitation provider
Rehabilitation whilst in Cast
Introduction
The aim is to review whether rehabilitation provided during the casting period for patients with non-operatively managed DRFs impacted on patient reported and functional outcome.
Review Question
How does rehabilitation whilst in cast versus no rehabilitation affect functional outcome?
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Population
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Adults ≥16yrs of age who have sustained a distal radius fracture and managed non-operatively
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Intervention
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Rehabilitation during period in cast
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Comparison
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No rehabilitation
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Outcomes
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PROMs
Functional outcome
Complications
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Study Designs
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Meta-analyses, systematic reviews, RCTs, cohort studies
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Evidence
Three studies were examined for this question. Two studies were randomised controlled trials and were described and evaluated in the third study, a systematic review. View here.
Evidence Statement
Level 1:
There is insufficient evidence for or against any form of rehabilitation whilst the patient is being managed with wrist immobilisation (in cast or external fixator) after DRF.
Rehabilitation following definitive treatment of DRFs
Introduction
The aim is to review whether rehabilitation following definitive management (wrist immobilisation for non-surgically or surgically managed patients) impacted on patient reported or functional outcome when to compared to no rehabilitation provision.
Review Question – non-surgically managed patients
How does rehabilitation following cast removal versus no rehabilitation affect functional outcome?
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Population
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Adults ≥16yrs of age with a non-surgically managed DRF
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Intervention
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Rehabilitation following cast removal
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Comparison
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No rehabilitation
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Outcomes
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PROMs
Functional outcome
Complications
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Study Designs
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Meta-analyses, systematic reviews, RCTs, cohort studies
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Evidence
Three studies were examined for this question. Two studies were randomised controlled trials and were described and evaluated in the third study, a systematic review. View here.
Evidence Statement
Level 1:
There is insufficient evidence for or against any form of rehabilitation after removal of cast for patients with DRFs managed non-operatively.
Rehabilitation in surgically managed patients
Introduction
The aim is to review if there was any functional difference in these patients treated surgically with rehabilitation or without rehabilitation.
Review Question
How does rehabilitation versus no rehabilitation affect functional outcome?
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Population
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Adults ≥16yrs of age with a surgically managed DRF
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Intervention
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Rehabilitation
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Comparison
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No rehabilitation
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Outcomes
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PROMs
Functional outcome
Complications
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Study Designs
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Meta-analyses, systematic reviews, RCTs, cohort studies
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Evidence
No randomised controlled trials or cohort studies were found for this review question.
Evidence Statement
No evidence was found on the effect of rehabilitation provision on patient reported and functional outcome following surgical management of a DRF when compared to no rehabilitation provision.
Recommendation
Best Practice Point:
It is not uncommon for pain and oedema to occur following distal radius fracture whether treated non-operatively or operatively. Information regarding the signs and symptoms of common complications should be given along with a simple self-directed management plan. Patients should be provided with advice and education to manage pain and oedema, and to prevent loss of motion at the fingers, thumb, elbow and shoulder. Immobilisation casting should allow a full fist to be achieved with the fingers and the patient can be encouraged to use the injured limb whilst the wrist is immobilised for light functional activities, including self-care and tasks such as typing.
Patients who experience disproportionate levels of pain / oedema / loss of motion or delayed functional recovery should be referred to physiotherapy / occupational therapy after clinical assessment for further instruction and treatment.
Type of rehabilitation intervention, mode of delivery and discipline of deliverer
Introduction
The aim is to review if any particular type of intervention, mode in which rehabilitation was delivered, or the discipline of the provider influenced patient reported or functional outcome.
Review Question – Type of Intervention
Does any single rehabilitation intervention affect functional outcome more than any other rehabilitation intervention?
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Population
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Adults ≥16yrs of age or older with a DRF
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Intervention
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Any rehabilitation intervention
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Comparison
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Any other rehabilitation intervention
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Outcomes
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PROMs
Functional outcome
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Study Designs
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Meta-analyses, systematic reviews, RCTs, cohort studies
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Evidence
Six papers were identified for this question. Five papers reported randomised controlled trials and one was a systematic review. One of the randomised controlled trials was included in the systematic review. The remaining five studies and the systematic review can be viewed here.
Evidence Statement
Level 1:
There is insufficient evidence to suggest any one rehabilitation intervention is superior to any other rehabilitation intervention to restore function following an acute DRF.
Review Question – Mode of Delivery
Does any form of rehabilitation delivery affect functional outcome more than any other form of rehabilitation delivery?
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Population
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Adults ≥16yrs of age who have sustained a DRF
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Intervention
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Any one form of rehabilitation
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Comparison
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Any other form of rehabilitation
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Outcomes
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PROMs
Functional outcome
Complications
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Study Designs
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Meta-analyses, systematic reviews, RCTs, cohort studies
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Evidence
Seven studies were reviewed for this question. Of these, five were randomised controlled trials and two were systematic reviews. All of the randomised controlled trials were reported in the systematic reviews can be viewed here.
Evidence Statement
Level 1:
There is insufficient evidence that formal physiotherapy or occupational therapy is more likely to restore function versus a home exercise or group programme in patients that have sustained uncomplicated DRFs.
Review Question – Discipline of Provider
Does provision of rehabilitation by any one health discipline affect functional outcome more than any other health discipline?
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Population
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Adults ≥16yrs of age who have sustained a DRF
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Intervention
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Rehabilitation provided by any one health discipline
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Comparison
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Rehabilitation provided by any other health discipline
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Outcomes
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PROMs
Functional outcome
Complications
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Study Designs
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Meta-analyses, systematic reviews, RCTs, cohort studies
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Evidence
No randomised controlled trials or cohort studies were found for this review question.
Evidence Statement
There is no evidence that rehabilitation provided by one health professional over another affects patient reported outcome or function following a DRF.
Recommendations On Type of Rehabilitation Intervention, Mode Of Delivery And Discipline Of Deliverer
Patients who identify with ongoing pain, limited range of movement and/or inability to return to function should be referred for rehabilitation. Rehabilitation should be delivered by a health care specialist with the appropriate level of knowledge and skills to address the various problems that can arise following distal radius fracture, ranging from loss of finger motion to reduced strength to complex regional pain syndrome. Choice of intervention should consider the patient’s roles and responsibilities as well as physical impairments. Education and rehabilitation programmes should be delivered in a timely manner and in a variety of forms to suit the patient’s specific needs.
References:
REHABILITATION WHILST IN CAST
Back
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Study
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Intervention/ comparison
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Patients
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Outcomes
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Comments
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Handoll et al. (2015)
Cochrane systematic review
Systematic Review
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Early therapeutic intervention vs occupational therapy vs cyclic pneumatic soft tissue compression vs digit mobilisation programme vs pulsed electromagnetic field therapy vs cross-education programme vs no intervention
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Six studies
(Challis et al 2007; Cooper et al 2001; Gronlund et al 1990; Kuo et al 2013; Lazovic et al 2012; Magnus et al 2013)
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DASH
Modified Gartland & Werley
Grip strength
Pinch grip
ROM
Dexterity
Finger movement
Complications and cast problems
Referral to hand therapy
Use of appliances and home help
Oedema
Participant satisfaction
MAM-36
Fracture displacement
PRWE
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Unable to combine data to perform meta-analysis; participants tending to be without serious fracture or treatment-related complications or pre-existing comorbidities or functional deficits; all studies of low methodological quality; very low quality evidence
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REHABILITATION FOLLOWING DEFINITIVE TREATMENT OF DRFs
Back
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Study
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Intervention/ comparison
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Patients
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Outcomes
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Comments
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Handoll et al (2015)
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Physiotherapy & home exercise programme vs
Physiotherapy vs occupational therapy vs occupational therapy & continuous passive motion vs pulsed electromagnetic field therapy vs ice with / without pulsed electromagnetic field vs passive mobilisation vs intermittent pneumatic compression vs ultrasound vs whirlpool vs dynamic wrist extension splint
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(Bache 2001; Basso 1998; Cheing 2005; Christensen 2001; Jongs 2012; Kay 2008; Maciel 2008; Rozencrawaig 1996; Svensson 1993; Taylor 1994; Toomey 1996; Wakefield 2000
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PRWE
QuickDASH
Grip strength
ROM
Thumb motion
Web span
Complications / adverse events
Participant satisfaction
Compliance
Request / referral for physiotherapy / occupational therapy
Levine score
ADL
Modified Gartland & Werley
Pain
SF-36
Number of sessions
Duration of therapy
Time to achieve independence
Cost
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Unable to combine data to perform meta-analysis; participants tending to be without serious fracture or treatment-related complications or pre-existing comorbidities or functional deficits; all studies of low methodological quality; very low quality evidence
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TYPE OF INTERVENTION
Back
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Study
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Intervention/ comparison
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Patients
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Outcomes
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Comments
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Bache et al.
(2000)
PRCT
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Advice and exercise vs Advice, exercise and physiotherapy
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Adults (n=98)
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ROM
Function (Levine scale)
Grip strength
Pain (VAS)
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A trend towards improvements with physiotherapy group but no significant findings
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Brehmer et al. (2014)
PRCT
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Standard exercise vs Early resistance and passive exercise
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Adults (n=78)
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DASH
Active ROM
Grip strength
Pinch strength
X-ray
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Immediate ROM and strengthening at two weeks gives earlier return to clinically relevant function
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Jongs et al. (2012)
PRCT
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Routine care plus dynamic wrist extension splint vs Routine care (exercises and advice)
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Adults (n=40)
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Passive wrist extension
PRWHE
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Conducted on patients already presenting with flexion contracture
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Handoll
(2015)
Cochrane systematic review)
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Routine physiotherapy vs home programme vs pulsed electromagnetic field therapy & ice vs ice vs modified manual oedema mobilisation vs manual oedema mobilisation
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3 studies (Watt et al 2000; Cheing et al 2005; Knygsand-Roenhoej et al 2011)
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Grip strength
ROM
Number of physiotherapy / occupational therapy sessions
Adverse events
Oedema
ADL
Canadian Occupational Performance Measure
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Unable to combine data to perform meta-analysis; participants tending to be without serious fracture or treatment-related complications or pre-existing comorbidities or functional deficits; all studies of low methodological quality; very low quality evidence
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Magnus et al. (2013)
PRCT
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Strength training (contralateral hand) vs Standard home programme
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Adults (n=39)
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Grip strength
ROM
PRWHE
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Greater grip strength and ROM at 12 weeks but not at 26
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MODE OF DELIVERY
Back
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Study
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Intervention/ comparison
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Patients
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Outcomes
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Comments
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Handoll
(2015)
Cochrane systematic review)
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Supervised physiotherapy or occupational therapy vs galvanic bath & exercise session vs home programme
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5 studies (Bighea et al 2013; Brehmer et al 2014; Krischak et al 2009; Pasila et al 1974; Souer et al 2011)
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Grip strength
Pinch strength
ROM
Number of physiotherapy / occupational therapy sessions
Return to work
PRWE
DASH
Mayo wrist score
Pain
Complications / adverse events
Change to treatment
Compliance
Cost
Fracture alignment & healing
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Unable to combine data to perform meta-analysis; participants tending to be without serious fracture or treatment-related complications or pre-existing comorbidities or functional deficits; all studies of low methodological quality; very low quality evidence
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Valdes et al. (2014)
Systematic review
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Home exercise programme vs 1:1 OT / PT
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7 studies (Christensen et al 2000; Kay et al 2000; Krischak et al 2009; Maciel et al 2005; Souer et al 2011; Wakefield & McQueen 2000; Watt et al 2000)
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PRWE
DASH
Gartley & Werley score
Mayo score
ROM
Thumb motion
Grip strength
Pinch strength
Pain
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All studies included methodological flaws; studies excluded participants with complex presentations; insufficient evidence to support one form of therapy deliver over another
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