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Better results with independent exercise vs. formal therapy after volar plating
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 David C. Ring |
The results of a level 1 study show superior wrist function in patients who performed surgeon-directed independent exercises after volar plating for distal radius fracture than those who had formal occupational therapy.
“Three months after, the patients who did independent exercises were statistically better, and we were looking for a large effect size so a reasonably large difference [was seen] in pinch, grip, and Gartland and Werley scores,” David C. Ring, MD, PhD, said during his presentation 2011 Annual Meeting of the American Society for Surgery of the Hand. “Then, at 6 months, the patients who did their exercises independently were better on just about everything.”
Ring and colleagues studied two groups of about 45 patients who underwent open reduction and locked volar plating for distal radius fractures, and were randomized to independently perform exercises directed by a surgeon or perform exercises supervised by an occupational therapist.
The investigators used combined wrist flexion and extension at 6 months as their primary outcome and results in grip and pinch strength, Mayo wrist, DASH and Gartland and Werley scores at 3 months and 6 months as secondary outcomes.
In addition to finding better results for patients who performed independent exercises, Ring, who is also an Orthopedics Today Editoral Board member, noted that predictors of final flexion and extension included group designation, patient age and and ulnar variance.
Reference:
- Souer S, Ring DC, Buijze GA. A prospective randomized controlled trial comparing occupational therapy with independent exercises after volar plate fixation of a fracture of the distal radius. Paper #17. Presented at the 2011 Annual Meeting of the American Society for Surgery of the Hand. Sept. 8-10. Las Vegas.
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In this excellent, randomized study, Dr. Ring and his colleagues determined that patients who followed a surgeon-directed rehabilitation protocol had superior wrist function to those who underwent the more conventional occupational therapy. Enlisting patients' participation in their recovery seems to improve the results. However, the increased time commitment to teaching patients therapy may be challenging. Although many patients can rehabilitate with surgeon instruction, some will continue to benefit from formal occupational therapy. It will have to be individualized, patient by patient.
— Barry P. Simmons, MD
Brigham & Women’s Hospital
Boston
David Ring and his colleagues have been leaders in conducting prospective randomized trials in upper extremity research. This study adds another Level I outcome to their productivity.
Volar locked plating of the distal radius fracture has improved outcomes in unstable fractures. It has allowed an earlier return to function. Post operative wrist motion or wrist immobilization for up to six weeks has not shown a significant difference at one year.
Similarly this study, presented at the recent ASSH meeting in Las Vegas, showed that formal therapy versus independent exercises did not alter the six month outcome. I would agree with these conclusions with some caveats.
These caveats are that the published paper will need to describe the exact protocols used by the independent and formal therapy groups. Also the presentation mentions that the physician as a critical should pay increased attention to “painful stretches” as a critical part of recovery. Is such a comment referring to that patient who may not be reaching appropriate goals. It is imperative following the early treatment of any distal radius fracture that the patient have near full digital motion. Disproportionate pain or stiffness is an absolute indication for concern and for possible evaluation for nerve dysfunction or pain syndromes. It is an area where formal therapy may help identify a developing problem as well as treat it.
— A. Lee Osterman, MD
Orthopedics Today Editorial Board member