You are on page 1of 8

PHYST-671; No.

of Pages 8
ARTICLE IN PRESS

Physiotherapy xxx (2012) xxxxxx

Physiotherapy intervention practice patterns used in rehabilitation after


distal radial fracture
Andrea M. Bruder a, , Nicholas F. Taylor a,b , Karen J. Dodd a , Nora Shields a
a Department of Physiotherapy, La Trobe University, Victoria 3086, Australia
b Allied Health Clinical Research Office, Eastern Health, Victoria 3128, Australia

Abstract
Objectives To identify the type and frequency of interventions used by physiotherapists in rehabilitating patients after a distal radial fracture;
and, to examine whether any patient or therapist characteristics had an effect on the frequency of interventions administered.
Design Observational study.
Setting Four metropolitan outpatient physiotherapy departments.
Participants 14 physiotherapists reported on 160 distal radial fracture consultations.
Main outcome measures Physiotherapists recorded the type of interventions and time spent administering interventions during each distal
radial fracture consultation.
Results A combined site response rate of 70% was achieved (160/204). The most common interventions were exercise (155/160), advice
(144/160), passive joint mobilisation (88/160) and massage (60/160). Patient characteristics and physiotherapist experience had little impact
on the type and frequency of interventions reported by physiotherapists.
Conclusions Exercise and advice were the most frequently administered interventions for patients after a distal radial fracture irrespective of
physiotherapist or patient factors. During rehabilitation, these interventions aim to restore wrist mobility and are consistent with both fracture
management principles and a self management approach. Due to the routine use of exercise and advice there is a need for further research to
provide high quality evidence that these interventions improve outcomes in patients after a distal radial fracture.
2012 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.

Keywords: Rehabilitation; Physiotherapy; Distal radial fracture

Introduction lead to loss of every day function, people with distal radial
fractures are often referred to physiotherapy.
Physiotherapy interventions are frequently used to opti- The aims of physiotherapy after distal radial fracture are
mise recovery of function after a distal radial fracture. Every to restore full joint movement and functional ability [11].
year about 4 in 1000 women and 1 in 1000 men fracture their The interventions physiotherapists use to achieve these aims
distal radius [1,2], making this the most common upper limb may be classified as active or passive. Active interventions
fracture across all age groups [35]. These fractures may be refer to techniques such as exercise and advice, where the
classified as intra-articular or extra-articular, depending on patient is required to take an active role in their rehabili-
whether there is disruption of the joint surface or not. Both tation. Passive interventions refer to techniques where the
types of fractures can result in short and long-term impair- patient takes a passive role during its application, such as
ments such as loss of range of movement, pain, oedema, and passive joint mobilisation [12]. The content of the rehabilita-
muscle weakness [610], and because these impairments can tion program involves the physiotherapist using their clinical
reasoning skills to develop an individually tailored treatment
regime for each patient.
Corresponding author at: Department of Physiotherapy, La Trobe Uni- A rehabilitation program comprises one or more inter-
versity, Australia. Tel.: +61 3 9479 5853; fax: +61 3 9479 5768. ventions. The choice of which interventions are used comes
E-mail address: a.bruder@latrobe.edu.au (A.M. Bruder). from the physiotherapist making decisions about practice.

0031-9406/$ see front matter 2012 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.physio.2012.09.003

Please cite this article in press as: Bruder AM, et al. Physiotherapy intervention practice patterns used in rehabilitation after distal radial
fracture. Physiotherapy (2012), http://dx.doi.org/10.1016/j.physio.2012.09.003
PHYST-671; No. of Pages 8
ARTICLE IN PRESS
2 A.M. Bruder et al. / Physiotherapy xxx (2012) xxxxxx

These decisions are supported by thorough assessment of the Participants


patients presenting problems, the physiotherapists knowl-
edge about the best available evidence of effectiveness To be included, physiotherapists needed to have provided
of interventions, along with knowledge of the resources rehabilitation to a patient with a distal radial fracture who
available and their own professional expertise. The physio- attended one of the four sites. Physiotherapists were clas-
therapist will also take into account the patients personal sified as junior therapists if they had less than four years
characteristics as well as their rights, values and preferences experience or senior therapists if they had four or more years
[13]. This is known as evidence based practice. For evidence of experience.
based practice to be effective the physiotherapist needs skilled
clinical reasoning and sound professional judgement [14]. To Outcome measure
help facilitate evidence based practice, health models can be
used. The International Classification of Functioning frame- Data were collected using two forms developed for the
work [15], and the Hypothesis Categories clinical reasoning study. These were a therapist questionnaire and a description
model that helps to assist in understanding the patient as of treatment form (available from the corresponding author
a person and their problem(s) [16], are examples of these. on request). The therapist questionnaire asked the physio-
Given these models are holistic and person centred, patient therapist to provide information on their age, gender, number
characteristics are likely to influence which interventions of years since gaining qualification and the country in which
physiotherapists use in rehabilitation. they completed their physiotherapy training.
A previous study establishing therapy practice patterns The description of treatment form comprised three sec-
of hand therapists, occupational therapists and physiothera- tions. In the first section, physiotherapists were asked to
pists for distal radial fractures was completed in the United provide information about the patient including age, gen-
States in 1998 [17]. In that study, 242 hand therapists were der, type of distal radial fracture, and if English was the
surveyed about the treatment they provided during rehabili- patients first language. In the second section, physiothera-
tation. The findings showed around 90% of therapists used pists allocated each patient a code to allow the researchers
range of movement exercises and heat/cold modalities, while to document that patients rehabilitation during the study
more than 50% of therapists used compressive wraps, dexter- period while ensuring patient anonymity. In the third sec-
ity exercises, ultrasound and soft tissue and joint mobilisation tion, physiotherapists reported all interventions they used
[17]. Since this study, new evidence about the effectiveness during each consultation, and the time spent administering
of some of these interventions has been published, and so it each of those interventions. A list of potential interventions
is possible practice patterns have changed. were provided which were based on findings of a systematic
Since even after a course of rehabilitation some patients review [20] and the American Physical Therapist Associa-
report residual difficulties in work, sport and leisure activities tion [APTA] guide of physical therapy practice [21]. Advice
[18,19], it is important to identify the types of interventions is recognised as a component of physiotherapy practice [22]
physiotherapists currently use as some of these may not be and for the purpose of this study includes recommenda-
supported by empirical evidence. This will allow conclusions tions and education on fracture protection and skin care,
to be made about whether physiotherapy practice is informed reassurance and encouragement to resume graded activities
by current empirical evidence. Given these considerations, [23,24].
the primary aim of this study was to identify the types and
frequency of interventions used by physiotherapists in reha-
bilitating patients after a distal radial fracture. The secondary Procedures
aim was to examine whether any patient or therapist char-
acteristics had an effect on the frequency of interventions The study was approved by the ethics committees at our
administered. institution and relevant participating clinics. Physiotherapists
completed the therapist questionnaire at the commencement
of the study, and to maintain anonymity they assigned them-
selves a therapist code for use on the description of treatment
Methods form.
The description of treatment form was completed by each
Design physiotherapist after every distal radial fracture consultation.
A consultation was defined as any therapeutic encounter with
An observational study was conducted including physio- the patient in the outpatient department.
therapists working in four metropolitan public outpatient At the end of the data collection period, the total number
departments over a four month period (November 2010 of physiotherapy distal radial fracture treatments provided
to February 2011). Physiotherapists reported data on dis- during the study period was obtained from each department.
tal radial fracture treatments they provided during the study These data were obtained through manual record checks and
period. using health service patient administration systems.

Please cite this article in press as: Bruder AM, et al. Physiotherapy intervention practice patterns used in rehabilitation after distal radial
fracture. Physiotherapy (2012), http://dx.doi.org/10.1016/j.physio.2012.09.003
PHYST-671; No. of Pages 8
ARTICLE IN PRESS
A.M. Bruder et al. / Physiotherapy xxx (2012) xxxxxx 3

Data analyses Table 1


Characteristics of physiotherapists.
To be 95% confident that the confidence interval around Characteristic Number of
a proportion would be within 5% of the observed propor- physiotherapists
(n = 14)
tion, we estimated a sample of 140 completed description
of treatment forms were required [25]. This was calculated Age (yr), median (IQR) 33.5 (23 to 40)
Gender, n males (%) 7 (50)
based on the findings of previous research that exercises are Physiotherapy department location, n (%)
prescribed in 90% of consultations to patients after a distal Site 1 1 (7)
radial fracture [17]. Site 2 4 (29)
In this study, physiotherapy interventions were classified Site 3 4 (29)
as either active or passive. The decision to classify advice Site 4 5 (36)
Years of experience as a physiotherapist, n (%)
as an active intervention was made because advice typi- 0 to 3 yrs 6 (43)
cally involves the physiotherapist advising the patient to 4 to 7 yrs 2 (14)
re-commence using their upper limb during functional activ- 8 to 11 yrs 3 (22)
ities of daily living. 12 yrs 3 (22)
All analyses were completed using Predictive Analysis Total years of experience as a 7 (.8 to 11)
physiotherapist, median (IQR)
Software Version 18.0 (SPSS Inc., Chicago, IL, USA). The Location of physiotherapy education, n (%)
type and frequency of interventions used were analysed using Australia 12 (86)
descriptive and frequency statistics. To determine if there International 2 (14)
was a difference in the total time spent administering active
interventions compared to passive interventions, data were
some follow up consults. Seventy-five of 160 consultations
analysed using Wilcoxon Signed Ranks test. An alpha level
were classified as a first consult. The median initial consulta-
of p < 0.05 was regarded as statistically significant. The sec-
tion time was 28 minutes [IQR 20 to 40], including 5 minutes
ondary aims were analysed using Pearson Chi-Square or
[IQR 5 to 10] classified as assessment. The median follow-up
Fishers Exact test.
consultation time was 30 minutes [IQR 23 to 35], including
A sensitivity analysis was performed to check whether
5 minutes of assessment [IQR 5 to 8.5].
including a first consultation and a repeat consultation on the
same patient during the study period had any effect on the
results. The first consultation was defined as the first ther- Patients
apeutic encounter the physiotherapist had with each patient
during the study period. Seventy-five patients were treated over the 160 consulta-
tions. Typically, patients were female (52/75, 71%), aged over
51 years (56/75, 71%) and spoke English as their first lan-
Results guage (64/75, 85%) (Table 2). Thirty-nine patients received

Response rate Table 2


Characteristics of patients with distal radius fractures.

One hundred and sixty of 204 consultations provided to Characteristic Patients with
distal radius
patients with a distal radial fracture were reported, making a fractures (n = 75)
combined site response rate of 70%.
Age group, n (%)a
19 to 50 yrs 18 (24)
Participants 51 to 65 yrs 25 (33)
66 to 75 yrs 19 (25)
Fourteen physiotherapists with a median age of 33.5 years >75 yrs 12 (16)
[interquartile range (IQR) 23 to 40] participated. The median Gender, n males (%)a 22 (29)
English as first language, n (%)
years of physiotherapist experience was 7 years [IQR 0.8 to Yes 64 (85)
11] with 12 (86%) trained in Australia (Table 1). Six physio- No 11 (15)
therapists were classified as junior therapists. Type of distal radius fracture, n (%)
Intra-articular 32 (43)
Consultation Extra-articular 10 (13)
Dont know/did not report 33 (44)
Physiotherapy department where managed, n (%)
Fifty-one of 160 consultations were reported as initial con- Site 1 13 (17)
sults as they were the first therapeutic encounter the patient Site 2 8 (11)
had with a physiotherapist for rehabilitation of their distal Site 3 14 (19)
radial fracture. This is different to the first consultation dur- Site 4 40 (53)
a Missing data on one patient.
ing the study period which included all initial consults and

Please cite this article in press as: Bruder AM, et al. Physiotherapy intervention practice patterns used in rehabilitation after distal radial
fracture. Physiotherapy (2012), http://dx.doi.org/10.1016/j.physio.2012.09.003
PHYST-671; No. of Pages 8
ARTICLE IN PRESS
4 A.M. Bruder et al. / Physiotherapy xxx (2012) xxxxxx

Table 3
Frequency and time spent administering interventions by physiotherapists.
Types of interventions Frequency of all Frequency of Frequency of Time (minutes) Time (minutes)
interventions, interventions in interventions in per initial consult per follow up
n = 160 (%) initial consult, follow up consult, median, (IQR) consult median,
n = 51 (%) n = 109 (%) [range], n = 51 (IQR) [range],
n = 109
Active intervention
Advice to patient 143 (90) 49 (96) 94 (86) 5.0 (5 to 5) [0 to 20] 5.0 (3.5 to 5) [0 to 15]
Advice to family 12 (8) 7 (14) 5 (5) 0 (0 to 0) [0 to 5] 0.0 (0 to 0) [0 to 5]
Any advice 144 (90) 49 (96) 95 (87) 5.0 (5 to 10) [0 to 20] 5.0 (4.5 to 5) [0 to 15]
Functional training in self-care and home 19 (12) 8 (16) 11 (10) 0.0 (0 to 0) [0 to 5] 0.0 (0 to 0) [0 to 5]
management
Functional training in work, community 14 (9) 1 (2) 13 (12) 0.0 (0 to 0) [0 to 5] 0.0 (0 to 0) [0 to 5]
and leisure
Supervision of ROM/flexibility exercises 102 (64) 38 (75) 64 (59) 5.0 (0 to 10) [0 to 15] 2.0 (0 to 5) [0 to 10]
Supervision of strength exercises 54 (34) 12 (24) 42 (39) 0.0 (0 to 0) [0 to 10] 0.0 (0 to 5) [0 to 10]
Teaching a home exercise program 131 (82) 47 (92) 84 (77) 5.0 (5 to 5) [0 to 10] 5.0 (1 to 5) [0 to 10]
Any exercise intervention combined 155 (97) 51 (100) 104 (95) 10 (10 to 15) [4 to 20] 10.0 (5 to 10) [0 to 30]
Any active interventions combined 158 (99) 51 (100) 107 (98) 15.0 (15 to 20) [10 to 40] 15.0 (10 to 20) [0 to 40]
Passive interventions
Application of heat 16 (10) 3 (6) 13 (12) 0.0 (0 to 0) [0 to 10] 0.0 (0 to 0) [0 to 20]
Application of ice 2 (1) 0 (0) 2 (2) 0 0.0 (0 to 0) [0 to 10]
Application of elastic compression sleeve 44 (28) 20 (39) 24 (22) 0.0 (0 to 0) [0 to 10] 0.0 (0 to 0) [0 to 10]
(tubigrip)
Manual lymphatic drainage 0 0 0 0 0
Massage 60 (38) 16 (31) 45 (41) 0 (0 to 5) [0 to 10] 0.0 (0 to 5) [0 to 10]
Passive joint mobilisation 88 (55) 17 (33) 71 (65) 0.0 (0 to 5) [0 to 10] 5.0 (0 to 5) [0 to 20]
Prescription of assistive/adaptive devices 2 (1) 1 (2) 1 (1) 0.0 (0 to 0) [0 to 10] 0.0 (0 to 0) [0 to 10]
Use of electrotherapy modalities (e.g. 0 0 0 0 0
ultrasound)
Use of wax bath 0 0 0 0 0
Use of whirlpool bath 0 0 0 0 0
Any passive interventions combined 112 (70) 31 (61) 81 (74) 5.0 (0 to 10) [0 to 25] 6.0 (0 to 15) [0 to 40]

more than one consultation for rehabilitation of their distal Z = 5.834, p < 0.01]), and follow up consultations (median
radial fracture during the study period. difference 6 minutes [IQR 2 to 15; Z = 3.607, p < 0.01]).
No patient or therapist factor demonstrated a significant
effect on the frequency of active or passive interventions
Interventions (Table 4). However, advice was more frequently delivered to
patients with an extra-articular fracture compared to patients
Seventeen interventions were used during rehabilitation with an intra-articular fracture (p < 0.01), and to family mem-
(Table 3). Exercise was the most frequently used active bers of patients from a Non-English speaking background
intervention (97%, 155/160) followed by advice (90%, compared to family members where English was the patients
144/160). The most frequently used exercise prescription first language (p < 0.01). Exercise was more frequently pro-
techniques were teaching a home exercise program (82%, vided to patients aged greater than 50 compared to those aged
131/160) followed by supervision of range of movement 50 years and under (p < 0.05). In terms of physiotherapist
(ROM)/flexibility exercises (64%, 102/160) (Table 3). Func- characteristics, junior therapists more frequently provided
tional exercises that aimed to assist the patient to return to advice and taught a home exercise program to patients com-
work, community and leisure activities were used the least pared to senior therapists (p < 0.05, p < 0.01 respectively)
(9%, 14/160). Passive joint mobilisation (55%, 88/160), mas- (Table 5). Additionally, physiotherapists who trained interna-
sage (38%, 60/160) and application of an elastic compression tionally administered compression sleeves, heat and massage
sleeve (28%, 44/160) were the most frequently used passive more frequently than therapists trained in Australia (p < 0.01,
interventions. p < 0.01, p < 0.05, respectively).
Active interventions, advice and any form of exercise were
used in 99% (158/160) of consultations compared to pas-
sive interventions in 70% (112/160) of consults (Table 3). Sensitivity analysis
The time spent administering active interventions was signifi-
cantly longer compared to passive interventions during initial No differences were identified when comparing the
consultations (median difference 15.0 minutes, [IQR 5 to 20; type and frequency of interventions used during first

Please cite this article in press as: Bruder AM, et al. Physiotherapy intervention practice patterns used in rehabilitation after distal radial
fracture. Physiotherapy (2012), http://dx.doi.org/10.1016/j.physio.2012.09.003
PHYST-671; No. of Pages 8
fracture. Physiotherapy (2012), http://dx.doi.org/10.1016/j.physio.2012.09.003
Please cite this article in press as: Bruder AM, et al. Physiotherapy intervention practice patterns used in rehabilitation after distal radial

Table 4
Analysis of frequency of treatments of common interventions and patient characteristics.
Types of interventions Male patients, Female p value Aged 50 yrs, Aged > 50 yrs, p value Patients with Patients with p value NESB ESB patients, p value

ARTICLE IN PRESS
A.M. Bruder et al. / Physiotherapy xxx (2012) xxxxxx
n = 60 (%) patients, n = 51 (%) n = 108 (%) IA fracture, EA fracture, patients, n = 138 (%)
n = 99 (%) n = 59 (%) n = 31 (%) n = 22 (%)
Active intervention
Advice to patient 52 (87) 91 (92) 45 (88) 98 (91) 48 (81) 30 (97) 22 (100) 121 (88)
Advice to family 5 (8) 7 (7) 2 (4) 10 (9) 1 (2) 1 (3) 7 (32) 5 (4) **

Any advice 52 (87) 92 (93) 46 (90) 98 (91) 49 (83) 30 (97) 22 (100) 122 (88)
Any exercise 59 (98) 95 (96) 47 (92) 107 (99) * 57 (97) 29 (94) 22 (100) 133 (96)
Teaching a HEP 48 (80) 83 (84) 41 (80) 90 (83) 46 (78) 25 (81) 22 (100) 109 (79) *

Any active intervention 60 (100) 97 (98) 49 (96) 108 (100) 57 (97) 31 (100) 22 (100) 136 (99)
Passive interventions
Application of elastic 22 (37) 21 (21) * 9 (18) 34 (32) 12 (20) 3 (10) 12 (55) 32 (23) **

compression sleeve (tubigrip)


Hot pack 10 (17) 6 (6) 1 (2) 15 (14) * 4 (7) 2 (7) 0 (0) 16 (12)
Massage 30 (50) 30 (30) * 16 (31) 44 (41) 16 (27) 11 (35) 11 (50) 50 (36)
Passive joint mobilisation 35 (58) 52 (53) 27 (53) 60 (56) 33 (56) 19 (61) 7 (32) 81 (59) *

Any passive intervention 44 (73) 67 (68) 32 (63) 79 (73) 39 (66) 21 (68) 15 (68) 97 (70)
yrs, years; IA, intra-articular; EA, extra-articular; NESB, Non-English speaking background; ESB, English speaking background; HEP, home exercise program.
* p < 0.05.
** p < 0.01.

5
PHYST-671; No. of Pages 8
ARTICLE IN PRESS
6 A.M. Bruder et al. / Physiotherapy xxx (2012) xxxxxx

Table 5
Analysis of frequency of treatments of common interventions and therapist characteristics.
Types of interventions PT with <4 yrs PT with 4 yrs p value PT trained in PT trained internationally, p value
exp, n = 69 (%) exp, n = 88 (%) Australia, n = 97 (%) n = 60 (%)
Active intervention
Advice to patient 66 (96) 74 (84) * 88 (91) 52 (87)
Advice to family 0 (0) 12 (14) ** 2 (2) 10 (17) **

Any advice 66 (96) 75 (85) * 89 (92) 52 (87)


Any exercise 69 (100) 83 (94) 93 (96) 59 (98)
Teaching a HEP 65 (94) 63 (72) ** 85 (87) 43 (72) *

Any active intervention 69 (100) 86 (98) 95 (98) 60 (100)


Passive interventions
Application of elastic 11 (16) 32 (36) ** 14 (14) 29 (48) **

compression sleeve
(tubigrip)
Hot pack 4 (6) 12 (14) 4 (4) 12 (20) **

Massage 21 (30) 38 (43) 30 (31) 29 (48) *

Passive joint mobilisation 36 (52) 52 (60) 55 (57) 33 (55)


Any passive intervention 43 (62) 66 (75) 62 (64) 47 (78)
PT, physiotherapist; yrs, years; exp, experience; HEP, home exercise program.
* p < 0.05.
** p < 0.01.

consultations (75/160) to all consultations (160/160) during movement is one of the key principles of fracture manage-
the study period. ment [30]. Furthermore, there is evidence to support using
exercise in improving patient outcomes for many other health
conditions that physiotherapists treat [31], suggesting it may
Discussion also be a useful intervention in this population. Despite this,
there are no high quality trials that have investigated the effect
Active interventions were used in almost all distal of a course of exercise on rehabilitation outcomes after dis-
radial fracture consultations regardless of physiotherapist or tal radial fracture [32]. There is a need for future research to
patient characteristics. Physiotherapists also spent more time examine the effect of exercise as the manipulated variable in
administering active interventions compared to passive inter- a randomised controlled trial for patients after a distal radial
ventions. The use of active interventions such as teaching a fracture. Such a trial is needed to provide evidence to support
home exercise program and providing advice, are consistent the current common practice of exercise prescription in this
with the promotion of patient independence through the use population.
of a self management approach [26]. A growing body of evi- Passive joint mobilisation [12] was the most frequently
dence indicates that self management programs can provide used passive intervention which reflects previous research
benefits in participants knowledge, symptom management, [17]. It appears that even though evidence published since
self-management behaviours, self-efficacy and aspects of the late 1990s does not support the use of passive joint
health status [27]. These programs are usually aimed at giv- mobilisation in distal radial fracture rehabilitation [3234],
ing patients with chronic illnesses the knowledge and skills therapy practice patterns have not changed. This is unlike
to manage their conditions [28]. However, these self manage- the use of ultrasound, which was used routinely by over
ment skills could also be applied to patients with acute and 50% of surveyed hand therapists in 1998 [17] but was not
sub-acute conditions. Skills in decision making and taking used by any physiotherapists in our study. Physiotherapists
action seem appropriate in distal radial fracture rehabilita- may rationalise that the use of passive joint mobilisation is
tion, as patients report residual difficulties in work, sport and warranted to assist with wrist mobilisation when the fracture
leisure activities even after a course of rehabilitation [18,19]. is intra-articular. Our analysis suggests there was no rela-
Developing positive health behaviours during the rehabilita- tionship between the use of passive joint mobilisation and
tion phase may also help to increase patient adherence with whether the fracture involved the wrist joint or not. It is pos-
prescribed exercise programs [29]. sible that physiotherapists may use passive joint mobilisation
Exercise was the most frequently used active interven- as, if effective, immediate benefits in joint range of move-
tion, a finding consistent with previous research [17]. Our ment can be seen after its use [34]. Seeing this immediate
results show physiotherapists spent more time administer- improvement in movement would provide positive reinforce-
ing exercise, particularly teaching a home exercise program, ment to the therapist and the patient. However, any short-term
in both initial and follow up consultations than all other benefits, if indeed they exist, do not translate to longer term
interventions. The use of exercise in distal radial frac- rehabilitation outcomes [33,34]. It is also possible that phy-
ture rehabilitation is consistent with theory proposing that siotherapists believe they have not fulfilled their rehabilitative

Please cite this article in press as: Bruder AM, et al. Physiotherapy intervention practice patterns used in rehabilitation after distal radial
fracture. Physiotherapy (2012), http://dx.doi.org/10.1016/j.physio.2012.09.003
PHYST-671; No. of Pages 8
ARTICLE IN PRESS
A.M. Bruder et al. / Physiotherapy xxx (2012) xxxxxx 7

role until they have placed their hands on the patient, or interventions used on the first consult compared to all con-
delivered a manual technique [35,36]. Further investigation is sultations. Another limitation is that our response rate was
needed to understand why physiotherapists select particular relatively low, but was consistent with the general consen-
interventions and how they apply best available evidence. sus that a response rate of 70% or above is necessary to
The interventions implemented by physiotherapists in dis- ensure that the observations of our sample is sufficiently rep-
tal radial fracture rehabilitation were primarily impairment resentative of the population [40]. A final limitation of the
focused, including range of movement and strength exercises description of treatment form was that we did not collect data
and passive joint mobilisation to improve range of move- related to outcome measures therefore are not able to corre-
ment. The aims of physiotherapy in distal radial fracture late the degree of functional impairment with both number
rehabilitation are to restore maximum movement and func- of treatments provided and type of treatments provided.
tional ability [11]. Functioning encompasses body structure
and function, activities and societal participation which are
domains of the World Health Organisations, International
Conclusion
Classification of Functioning framework [15]. Physiothera-
pists may use impairment based interventions in distal radial
Active interventions, including exercise and advice, were
fracture rehabilitation on the assumption that reducing wrist
the most frequently administered interventions for patients
impairment will transfer to an increase in upper limb activity.
after a distal radial fracture irrespective of physiotherapist or
There is limited evidence to support the association between
patient factors. Although the common use of exercise in distal
an impairment in grip strength and activity levels; however,
radial fracture rehabilitation is consistent with the principles
there does not appear to be a consistent association between
of fracture management and principles of self management,
wrist range of movement and activity [37]. A lack of asso-
there is a need for further research to provide high quality
ciation between reducing impairment of body structure and
evidence that this intervention improves outcomes in patients
function, and improvement in activity and disability has been
with a distal radial fracture.
observed in other populations [38,39]. Further investigation
of the effects of an exercise program on distal radial fracture
rehabilitation outcomes may also include activity-focused
exercises and tasks that may be more specific to achieving Acknowledgements
improvements in activity.
The type and frequency of interventions reported by phy- We would like to acknowledge our team of associate
siotherapists for patients after a distal radial fracture seemed investigators Paula ONeil and Edmund Leahy from North-
to be affected little by patient presentation or physiotherapist ern Health and Mark Guerra and Vincent Man from Eastern
experience. There were no differences in the frequency of Health, for their help in carrying out the study.
active and passive interventions used for patients with respect Ethical approval: Human Research Ethics Committee of
to these characteristics. Some differences were seen in the La Trobe University, Faculty of Health Sciences, Ref. No.
frequency of individual interventions when related to phy- FHEC10/185; Eastern Health Research and Ethics Commit-
siotherapist and/or patient factors. However, the magnitude tee, Ref. No. LR21/1011; Northern Health Research and
of these differences was small and not likely to be clinically Ethics Committee, Ref. No. CC41/10.
significant. The relative invariance in the content of rehabil-
itation may suggest therapists use treatment routines rather Conflict of interest: The authors declare no conflicts of inter-
than evidence based practice to develop an individually tail- est.
ored treatment regimen specific to the patient problem. It
would be expected that the decision to use particular interven-
tions would be influenced by the therapists knowledge and References
clinical experience, empirical clinical evidence and patients
own characteristics which would result in a greater variability [1] ONeil TW, Cooper C, Finn JD, Lunt M, Purdie D, Reid DM, et al. Inci-
in the types and frequency of interventions used. However, dence of distal forearm fracture in British men and women. Osteoporos
this was not found in our study. It is also possible the classifi- Int 2001;12(7):5558.
[2] Van Staa TP, Dennison EM, Leufkens GM, Cooper C. Epidemiology
cation we used during data collection did not provide enough
of fractures in England and Wales. Bone 2001;29(6):51722.
detail about the specifics of individually tailored treatment [3] Larsen CF, Lauritsen J. Epidemiology of acute wrist trauma. Int J
regimens. Epidemiol 1993;22(5):9116.
A limitation of this study was the inclusion of some [4] Rennie L, Court-Brown CM, Mok JYQ, Beattie TF. The epidemiology
observations on the same patient for first consultations of fractures in children. Injury 2007;38:91322.
[5] Sanders KM, Seeman E, Ugoni AM, Pasco JA, Martin TJ, Skoric B,
and follow-up consults. This was based on the assumption
et al. Age- and gender-specific rate of fractures in Australia: a popula-
that interventions administered to the same patient would tion based study. Osteoporos Int 1999;10:2407.
change between each consultation. Our sensitivity analy- [6] Atkins RM. Aspects of current management: complex regional pain
sis found no difference between the type and frequency of syndrome. J Bone Joint Surg Br 2003;85(8):11006.

Please cite this article in press as: Bruder AM, et al. Physiotherapy intervention practice patterns used in rehabilitation after distal radial
fracture. Physiotherapy (2012), http://dx.doi.org/10.1016/j.physio.2012.09.003
PHYST-671; No. of Pages 8
ARTICLE IN PRESS
8 A.M. Bruder et al. / Physiotherapy xxx (2012) xxxxxx

[7] Belsole RJ, Hess AV. Concomitant skeletal and soft tissue injuries. Design of a randomized controlled trial. BMC Musculoskelet Disord
Orthop Clin North Am 1993;24(2):32731. 2003;4:18.
[8] Cooney WP, Dobyns JH, Linscheid RL. Complications of Colles frac- [25] Wild C, Seber G. Chance encounters: a first course in data analysis and
tures. J Bone Joint Surg Am 1980;62(4):139. inference. New York: John Wiley & Sons; 2000.
[9] Handoll HH, Madhok R. Conservative interventions for treating distal [26] Newsom S, Steed L, Mulligan K. Self-management interventions for
radial fractures in adults (review). Cochrane Database Syst Rev 2003:2. chronic illness. Lancet 2004;364:152337.
[10] Weinstock TB. Management of fractures of the distal radius: therapists [27] Barlow J, Wright C, Sheasby J, Turner A, Hainsworth J. Self-
commentary. J Hand Ther 1999;12:99102. management approaches for people with chronic conditions: a review.
[11] World Confederation for Physical Therapy. Description of Physical Patient Educ Couns 2002;48:17787.
Therapy. Declarations of principle and positions statement revised and [28] Lorig KR, Halsted RH. Self-management education: history, def-
re-approved at the 17th General Meeting of WCPT, June 2011. London inition, outcomes and mechanisms. Ann Behav Med 2003;26(1):
2011. 17.
[12] Hengeveld E, Banks K, editors. Matilands peripheral manipulation. [29] Barron CJ, Klaber Moffett JA, Potter M. Patient expectations of phys-
4th ed. Edinburgh: Butterworth Heinemann; 2005. iotherapy: definitions, concepts, and theories. Physiother Theory Pract
[13] Edwards I, Jones M, Carr J, Braunack-Mayer A, Jensen GM. Clin- 2007;23(1):3746.
ical reasoning strategies in physical therapy. Phys Ther 2004;84: [30] Adams JC, Hamblen DL. Outline of orthopaedics. 12th ed. Edinburgh:
31235. Churchill Livingston; 1995.
[14] Jones MJ, Grimmer K, Edwards I, Higgs J, Trede F. Challenges in apply- [31] Taylor N, Dodd K, Shields N, Bruder A. Therapeutic exercise in
ing best evidence to physiotherapy practice. Internet J Allied Health Sci physiotherapy practice is beneficial: a summary of systematic reviews
Pract 2006;4:3. 20022005. J Physiother 2007;53:716.
[15] World Health Organisation. ICF: international classification of func- [32] Bruder A, Taylor NF, Dodd KJ, Shields N. Exercise reduces impair-
tioning, disability and health. Geneva: WHO; 2001. ment and improves activity in people after some upper limb fractures:
[16] Jones M, Rivett D. Introduction to clinical reasoning. In: Jones M, a systematic review. J Physiother 2011;57:7182.
Rivett D, editors. Clinical reasoning for manual therapists. Oxford: [33] Kay S, Haensel N, Stiller K. The effect of passive mobilisation fol-
Butterworth-Heinemann; 2004. p. 324. lowing fractures involving the distal radius: a randomised study. J
[17] Michlovitz SL, LaStayo PC, Alzner S, Watson E. Distal radial fractures: Physiother 2000;46(2):93101.
therapy practice patterns. J Hand Ther 2001;14(4):24957. [34] Taylor NF, Bennell KL. The effectiveness of passive joint mobilisation
[18] MacDermid JC, Richards RS, Roth JH. Distal radius fracture: a prospec- on the return of active wrist extension following Colles fracture: a
tive outcome study of 275 patients. J Hand Ther 2001;14(2):15469. clinical trial. NZ J Physiother 1994;22(1):248.
[19] MacDermid JC, Roth JH, Richards RS. Pain and disability reported [35] Jette AM, Delitto A. Physical therapy treatment choices for muscu-
in the year following a distal radius fracture: a cohort study. BMC loskeletal impairments. Phys Ther 1997;77:14554.
Musculoskelet Disord 2003;4:24. [36] Pinkston D. Evolution of the practice of physical therapy in the United
[20] Handoll HH, Madhok R, Howe TE. Rehabilitation for distal radial States. In: Scully RM, Barnes MR, editors. Physical therapy. Philadel-
fractures in adults. Cochrane Database Syst Rev 2006:3. phia: JB Lippincott Co.; 1989. p. 230.
[21] American Physical Therapy Association. Who are physical therapists, [37] Tremayne A, Taylor NF, McBurney H, Baskus D. Correlation of impair-
and what do they do? (a guide to physical therapist practice). Phys Ther ment and activity limitation after wrist fracture. Physiother Res Int
2001;81(1):39. 2002;7(2):909.
[22] The Chartered Society of Physiotherapy. The physiotherapy frame- [38] Keysor JJ, Jette AM. Have we oversold the benefit of late-life exercise?
work [Internet]; 2011. Available from: http://www.csp47.co.uk/ J Gerontol A Biol Sci Med Sci 2001;56A(7). M412-M23.
framework/content/welcome [03.08.12]. [39] Van Baar ME, Assendelft EJ, Dekker J, Oostendorp RA, KBijlsrna JW.
[23] Kay S, McMahon M, Stiller K. An advice and exercise program has Effectiveness of exercise therapy in patients with osteoarthritis of the
some benefits over natural recovery after distal radius fracture: a ran- hip or knee: a systematic review of randomized clinical trials. Arthritis
domised trial. J Physiother 2008;54(4):2539. Rheum 1999;42:13619.
[24] Stewart MJ, Maher CG, Refshauge KM, Herbert RD, Bogduk N, [40] Patel MX, Doku V, Tennakoon L. Challenges in recruitment of research
Nicholas M. Advice or exercise for chronic whiplash disorders? participants. Adv Psychiatr Treat 2003;9:22938.

Available online at www.sciencedirect.com

Please cite this article in press as: Bruder AM, et al. Physiotherapy intervention practice patterns used in rehabilitation after distal radial
fracture. Physiotherapy (2012), http://dx.doi.org/10.1016/j.physio.2012.09.003