Supervised physical therapy vs home exercise program for patients with distal radius fracture: A single-blind randomized clinical study

Abstract

Study Design

Randomized clinical study.

Introduction

Supervised physical therapy (PT) and home exercise programs (HEPs) are frequently used in the rehabilitation of patients with distal radius fracture (DRF). However, there is no consensus as to whether unsupervised HEP provides comparable benefits to those achieved by supervised PT.

Purpose of the Study

To compare the improvements in pain and functional status between a supervised PT program and unsupervised HEP in DRF patients older than 60 years.

Methods

A total of 74 patients were randomized into 2 groups. One group received 12 sessions of supervised PT (n = 37), and the other group followed an exercise program at home (n = 37). Three evaluations were performed, before the initiation of treatment, at 6-week, and 6-month follow-up. The study conducted a statistical power analysis to detect an intergroup difference score of 15 points on the Patient-Rated Wrist Evaluation (PRWE). The t-test or Mann-Whitney test was used, and it was set with a significance level of .05.

Results

The supervised PT group showed clinically significant differences in the total PRWE score at 6 weeks (17.67 points, P = .000) in the PRWE function score (15.2 points, P = .000) and in the PRWE pain score (5.6 points, P = .039). There was also a significant difference in the total PRWE score at 6-month follow-up (17.05 points, P = .000) in the PRWE function score (14.5 points, P = .000) and in the PRWE pain score (2.5 points, P = .35).

Conclusions

A supervised PT program is more effective for improving function in the short- and medium-term when compared with HEP in patients older than 60 years with DRF extraarticular without immediate complications.

Level of Evidence

1b

Introduction

Distal radius fracture (DRF) is one of the most common musculoskeletal injuries, representing 15%-20% of total fractures treated in emergency services.1, 2 Epidemiologic studies have reported a high incidence in white populations, mostly in patients older than 60 years.3, 4 In this age group, it is the second most common type of fracture, after hip fractures,5, 6 with almost 4 times more injuries in women than men.⁷ DRFs in patients have typically been treated conservatively with closed reduction and plaster cast immobilization.⁸ However, this method of treatment failed to maintain reduction and reported redisplacement and malunion rates in over 50% of cases.⁹ The age is one of the most significant risk factors for the loss of reduction and secondary fracture displacement.10, 11, 12 Despite this, the current evidence shows that in elderly patients, the improvement in function is independent of the residual deformity.13, 14, 15, 16, 17, 18, 19, 20

After the immobilization period, physical therapy (PT) is vitally important, although its indications are not based on defined criteria. PT is prescribed to reduce pain, restore range of motion (ROM), and improve muscle strength and function.²¹ The therapeutic interventions that are used to achieve these aims can be classified as active or passive interventions. Active interventions refer to techniques where the patient is required to take an active role in their rehabilitation, such as advice, a home exercise program (HEP), or a program supervised by a physical therapist.²² Passive interventions refer to techniques where the patient takes a passive role during its application, such as massage, joint mobilization (JM), and the use of physical agents such as ultrasound, hot pack, and transcutaneous electrical nerve stimulation.22, 23 In this respect, the systematic review (SR) by Handoll et al²⁴ concluded that the evidence is insufficient to establish the effectiveness of the various interventions used in the rehabilitation of adults with DRF in improved function. However, active interventions, such as exercise and advice, are most commonly used by physical therapists to treat these patients. HEPs are the most frequently used exercise prescription techniques.22, 23, 24, 25, 26

The study of Bruder et al²² showed that advice and home exercises were prescribed significantly more in patients with the extraarticular type of DRF than in those with the intraarticular type (P < .01) and in patients older than 50 years compared with younger ones (P < .05). However, the current evidence has shown controversial results regarding the effectiveness of a treatment program conducted and supervised by a physical therapist vs the one performed in adults with DRF at home. The SR by Gutiérrez et al²¹ concluded that in medium term, the evidence is controversial regarding whether a treatment program performed by a physical therapist is more effective than an exercise program at home in these patients. The SR by Valdes et al²⁶ concluded that available evidence was insufficient to support a home program or supervised PT program as a superior method of treatment for adults after a DRF without complications or presence of comorbidity. The results of the 2 randomized clinical trials (RCTs), conducted in elderly patients with DRF treated conservatively, showed only significant differences in favor of the supervised PT by increasing the flexion-extension ROM and extension of the wrist, respectively, in a short term,27, 28 but there is no significant differences in pain or function.

By analyzing the information from published RCTs, some methodological limitations in the selection criteria made the generalization of the results of these studies difficult. For example, patients across a wide range of ages, Krischak et al²⁹ included patients aged between 18 and 76 years, and Valdes et al³⁰ included patients aged between 23 and 93 years. The SR by Diaz-Garcia et al³¹ and Chen et al³² introduced a cutoff value for patients older than 60 years when analyzing the evidence of different types of treatment in elderly patients. Diaz-Garcia et al³¹ concluded that despite worse radiographic outcomes associated with cast immobilization, functional outcomes were no different from those of surgically treated groups for patients aged 60 years and older. Chen et al³² concluded that the current literature does not support the theory that operative management can provide better clinical outcomes in patients aged 60 years and older with DRF. Due to the functional demands in this age group, the fracture reduction does not appear to be as strongly associated with functional outcomes as it does in younger patients.13, 14, 16, 20 Other limitations were that the studies lacked clarity as to specific interventions or treatments used for home instruction or supervised therapy and provided limited or no information related to the types, frequency, or duration of the specific exercise or activity performed during treatment. Finally, no study mentioned how these aspects might have affected their conclusions and the extrapolation of their results.

The main objective of this RCT was to compare the improvements in pain and functional status between supervised PT program and unsupervised HEP in DRF patients older than 60 years treated conservatively. The specific objectives were to compare the effect of both treatments in the short (6-week follow-up) and medium term (6-month follow-up) and to determine whether there is a correlation between the acceptable DRF alignment evaluated by radiological criteria and the functional results.