Effects of early manual therapy on functional outcomes after volar plating of distal radius fractures: A randomized controlled trial

Author Names

Tomruk, M; Gelecek, N; Basçi, O; Özkan, M.H

Reviewer Name

Abigail Reichow, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

 

Paper Abstract

We sought to investigate the effects of early manual therapy on functional outcomes in patients treated with volar plating of a distal radius fracture (DRF). This was a prospective, single-blinded, randomized controlled trial. Patients treated with volar plating of a DRF were randomly assigned to either Early Manual Therapy Group (EMTG, n = 19) or Standard Physiotherapy Group (SPG, n = 20). While SPG received standard physiotherapy, EMTG received standard physiotherapy plus Mulligan’s Mobilization with Movement technique two sessions a week, through 12 weeks. Function, pain intensity, range of motion, grip strength and the level of disability were assessed using the Patient Rated Wrist Evaluation (PRWE), Visual Analog Scale (VAS), goniometer, hand dynamometer and Disabilities of Arm, Shoulder and Hand (DASH) Questionnaire, respectively. Measurements were made at 3, 6, and 12 weeks postoperatively. Of the 54-screened patients, 39 met the inclusion criteria and were randomized. In total, 32 patients (EMTG, n = 15; SPG, n = 17) were analyzed. EMTG had significantly better DASH score and wrist flexion at 12 weeks, less pain and better PRWE total score, wrist extension, ulnar/radial deviation, supination and grip strength at all time points. Moreover, wrist flexion increased more with the addition of early manual therapy than standard physiotherapy alone (26.50 ± 13.19 versus 16.21 ± 16.06). The addition of early manual therapy to standard physiotherapy may contribute to better functional outcomes and be more effective in increasing wrist flexion in patients treated with volar plating of a DRF.

 

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

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

• Yes

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

• Yes

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

• Yes

4. Were study participants and providers blinded to treatment group assignment?

• Yes

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

• No

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

• Yes

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

• Cannot Determine, Not Reported, or Not Applicable

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

• Cannot Determine, Not Reported, or Not Applicable

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

• Cannot Determine, Not Reported, or Not Applicable

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

• Cannot Determine, Not Reported, or Not Applicable

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

• Yes

12. 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?

• Cannot Determine, Not Reported, or Not Applicable

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

• Yes

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

• Yes

1. Is the review based on a focused question that is adequately formulated and described?

2. Were eligibility criteria for included and excluded studies predefined and specified?

3. Did the literature search strategy use a comprehensive, systematic approach?

4. Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias?

5. Was the quality of each included study rated independently by two or more reviewers using a standard method to appraise its internal validity?

• No

6. Were the included studies listed along with important characteristics and results of each study?

7. Was publication bias assessed?

8. Was heterogeneity assessed? (This question applies only to meta-analyses.)

 

Key Finding #1

Implementing early manual therapy in addition to standard physical therapy interventions following volar plating produced better functional outcomes postoperatively when compared to standard physical therapy interventions as the sole treatment.

Key Finding #2

Patients who received early manual therapy combined with standard physical therapy interventions had significantly better DASH scores and wrist flexion range of motion 12-weeks post-operatively when compared to the group who received no manual therapy.

Key Finding #3

Patients who received early manual therapy combined with standard physical therapy interventions had lower pain, better self-reported wrist function, grip strength, and wrist extension, ulnar/radial deviation and supination range of motion at every check point when compared to the group who received no manual therapy.

 

Please provide your summary of the paper

This study was a randomized control trial that aimed to determine the efficacy of implementing early manual therapy in rehabilitation following volar plate surgery for distal radial fractures. 39 patients met the inclusion criteria and were split into two groups, early manual therapy (EMT, n=15) or standard physical therapy (SPT, n=17). The study was single-blinded. Subjects in the EMT group received standard physical therapy interventions with Mulligan’s Mobilization with Movement technique twice a week. Outcomes of wrist function (patient rated wrist evaluation), pain (visual analog scale), range of motion (goniometer), grip strength (hand dynamometer), and disability (Disabilities of Arm, Shoulder, and Hand Questionnaire) were assessed in both groups at 3-, 6-, and 12-weeks post op. There was no significant difference between the two groups at the start of the study with the exception of age (P=0.017). The study found that patients in the EMT group had significantly better disability scores and wrist flexion range of motion at the 12-week mark. Additionally, the EMT group had lower pain, better self-reported wrist function, grip strength, and wrist extension, ulnar/radial deviation and supination range of motion at every check point when compared to the SPT group who received no manual therapy.

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

The findings of this study are extremely clinically relevant in the outpatient orthopedic setting as distal radial fractures are among some of the most common fractures. Currently, volar plating as a method of open reduction internal fixation is the most frequent surgical treatment for this condition. Many patients experience higher levels of pain with range of motion following this procedure, delaying, and in some cases, limiting functional outcomes post-operatively. The Mulligans Mobilization with Movement technique is believed to help patients perform active range of motion with reduced pain as the therapist assists with proper positioning and tracking of the joint during movement. This study showed that utilizing this manual therapy technique in early rehabilitation of these patients was successful in improving pain and functional outcomes. This technique should therefore, be implemented in conjunction with standard physical therapy interventions when treating patients following volar plating for distal radius fractures.