Adding mobilisation with movement to exercise and advice hastens the improvement in range, pain and function after non-operative cast immobilisation for distal radius fracture: a multicentre, randomised trial – Duke Center of Excellence in Manual and Manipulative Therapy

Author Names

Reid, S. A., Andersen, J. M., & Vicenzino, B.

Reviewer Name

Alli Shaw, SPT

Reviewer Affiliation(s)

Duke University DPT

Paper Abstract

Question: Does adding mobilisation with movement (MWM) to usual care (ie, exercises plus advice) improve outcomes after immobilisation for a distal radius fracture? Design: A prospective, multicentre, randomised, clinical trial with concealed allocation, blinding and intention-to-treat analysis. Participants: Sixty-seven adults (76% female, mean age 60 years) treated with casting after distal radius fracture. Intervention: The control group received exercises and advice. The experimental group received the same exercises and advice, plus supination and wrist extension MWM. Outcome measures: The primary outcome was forearm supi- nation at 4 weeks (immediately post-intervention). Secondary outcomes included wrist extension, flexion, pronation, grip strength, QuickDASH (Disabilities of Arm, Shoulder and Hand), Patient-Rated Wrist Evalua- tion (PRWE) and global rating of change. Follow-up time points were 4 and 12 weeks, with patient-rated measures at 26 and 52 weeks. Results: Compared with the control group, supination was greater in the experimental group by 12 deg (95% CI 5 to 20) at 4 weeks and 8 deg (95% CI 1 to 15) at 12 weeks. Various secondary outcomes were better in the experimental group at 4 weeks: extension (14 deg, 95% CI 7 to 20), flexion (9 deg, 95% CI 4 to 15), QuickDASH (211, 95% CI 218 to 23) and PRWE (213, 95% CI 223 to 24). Benefits were still evident at 12 weeks for supination, extension, flexion and QuickDASH. The experimental group were more likely to rate their global change as ‘improved’ (risk difference 22%, 95% CI 5 to 39). There were no clear benefits in any of the participant-rated measures at 26 and 52 weeks, and no adverse effects. Conclusion: Adding MWM to exercise and advice gives a faster and greater improvement in motion im- pairments for non-operative management of distal radius fracture. Registration: ACTRN12615001330538. [Reid SA, Andersen JM, Vicenzino B (2020) Adding mobilisation with movement to exercise and advice hastens the improvement in range, pain and function after non-operative cast immobilisation for distal radius fracture: a multicentre, randomised trial. Journal of Physiotherapy 66:105–112]

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT

Was the method of randomization adequate (i.e., use of randomly generated assignment)?

Was the treatment allocation concealed (so that assignments could not be predicted)?

Were study participants and providers blinded to treatment group assignment?

Were the people assessing the outcomes blinded to the participants’ group assignments?

Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?

Was there high adherence to the intervention protocols for each treatment group?

Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?

Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?

Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?

Key Finding #1

At week 4, the experimental group had on average 12 more degrees of supination compared to the control group. At week 12, the experimental group has on average 8 more degrees of supination compared to the control group.

Key Finding #2

At week 4 and 12, wrist flexion and extension range of motion were greater in experimental group compared to control groups.

Key Finding #3

Patient-reported outcome measures of the experimental group indicated improvement of all aspects of the PRWE and QUICKDash at week 4; however, this effect was no longer present by week 12.

Key Finding #4

Benefits from MWM were present at week 4 and 12; however, there was no statistical difference between outcomes of the experimental and control group at week 26 and 52.

Please provide your summary of the paper

Initial medical management of distal radius fractures involve immobilization of the wrist in a flexed, pronated, and ulnar deviated position for up to 6 weeks, resulting in stiffness and pain particularly with supination and extension. Limited evidence supports the use of joint mobilizations applied by the clinician. This study’s aim was to establish the efficacy of wrist extension and forearm supination mobilization with movement (MWM) techniques as part of a treatment plan for nonoperative management of distal radius fractures. A prospective, parallel, two-group randomized control trial was conducted with appropriate measures taken to ensure randomization and minimize bias. Appropriate exclusion criteria was incorporated. Baseline measurements of outcome measures (participant ratings of pain and disability, forearm and inter carpal supination range of motion, wrist flexion and extension range of motion, forearm pronation range of motion, grip strength, and a functional pouring task) were obtained, interventions were performed for 4 weeks, and outcomes were assessed at week 4, 12, 26, and 52. All participants performed range of motion exercises and were informed of other management strategies (i.e., controlling swelling, skin care, etc.). The experimental group received MWM techniques. The physiotherapist performed the technique on the patient during visits but also instructed patient on how to perform self-MWM technique. The researchers found that MWM techniques are an effective adjunct to exercise and education for management of nonsurgical distal radius fractures.

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.

Patients can expect to reach the same functional level regardless of whether a MWM technique was incorporated into their treatment plan; however, these improvements were reached quicker when MWM techniques were utilized.