IJTRR 2016; 5 (5):29-36

Original Research Article doi: 10.5455/ijtrr.000000179

International Journal of Therapies & Rehabilitation

E-ISSN
Research
2278-0343
http://www.scopemed.org/?jid=12

MAITLAND’S MOBLIZATION VERSUS CLOSED KINETIC CHAIN EXERCISES

AFTER COLLE'S FRACTURE FIXATION
Ola Ahmed Kamal, M.Sc1* ;Lilian Albert Zaky Ph.D2 ;Hassan Hamdy Abdelrahman Noaman, Ph.D3

1
Physical Therapist, Sohag General Hospital.
2
The Department of Musculoskeletal Disorders and its Surgery, Faculty of Physical Therapy, Cairo
University
3
The Department of Orthopedics, Faculty of Medicine, Sohag University

ABSTRACT

Background: The colle's fracture is the most common fracture site in the upper extremity; it causes functional
problems and disabling complications. Treatment of these common fractures and their dysfunctional sequalae
continues to challenge surgeons and therapists. Objective: The purpose of this study was to investigate effect of
Maitland's mobilization versus closed kinetic chain exercises after stable colle's fracture. Method: Thirty patients had
participated in this study. They were assigned randomly into two groups (Group A and Group B) with age ranged from
eighteen to fourty five years old. Group A consisted of 15 patients (15 females) received mitland's mobilization with
therapeutic ultrasound, group B consisted of 15 patients (15 females) received closed kinetic chain exercises with
therapeutic ultrasound for 3 times per week (12) sessions for 4 weeks. Patients were evaluated pre and post
treatment for their pain severity, function of the wrist joint, grip strength, wrist joint's ROM and proprioception at 20 ̊
wrist flexion, extension, radial and ulnar deviation. Result: The result revealed that there were significant differences
between both groups regarding the improvement in function, grip strength, range of motion of flexion, extension, radial
and ulnar deviation and there were no significant difference between both groups regarding the improvement in
function, grip strength, and joint position sense. Conclusion: Maitland's mobilization versus closed kinetic chain
exercises after stable colle's fractures no significant difference in improvement in function, grip strength, and joint
position sense, and Maitland's mobilization significantly improve wrist range of motion.

KEY WORDS: Colle's fracture, Maitland's mobilization, closed kinetic chain exercises,
Proprioception.

Ola Ahmed Kamal

Photograph
Physical Therapist, Sohag General Hospital, Egypt

*Corresponding author
 IJTRR 2016; 5 (5):29-36
INTRODUCTION
COLLE'S fractures are a very
common extra-articular fracture (1). They occur when a
person falls on the palm of the hand with wrist in 40°-
90°of extensions (2). Typical fracture is localized at 1.5-
2.5 cm above wrist. Fractures below this level is
designated as low, while high fractures are situated
more than 4 cm above wrist (3). The management of
distal radial fractures depends on patient factors,
fracture patterns, and stability criteria. Stability criteria
can aid in assessing the risk for secondary fracture
displacement (4). Closed reduction with cast treatment
of all types of distal Radius fractures continues to be
the mainstay of treatment in our country. Intra or Extra-
articular malunited fractures have been shown to alter
function and patient satisfaction with the outcome of
treatment (5). This fracture can result in some
complications as persistent pain and loss of motion
accompanied by moderate effusion of the distal radius.
Increased angulation of distal radius can lead to
inability to grasp objects after plaster cast (6).
Impairment in range of motion and strength after distal
radius fractures may lead to difficulty with functional
task (7).
The Goal for rehabilitation after wrist
fractures is to achieve complete and rapid recovery of
ROM, strength (8) and to restore optimal function, which
can be complicated by long-term impairments and
functional deficits that prevail after radial fractures
management (9).
Ultrasound (US) has been a widely used and
accepted adjunct modality for the management of many
musculoskeletal conditions Therapeutic ultrasound is
the use of alternating compression and rarefaction of
sound waves for therapeutic benefit (10). Ultrasound is
tought to enhance blood flow, increase membrane
permeability and alter nerve conduction (11).
Ultrasound (US) has been reported to stimulate a wide
variety of subjective somatosensations in humans (12),
as well as EPs in response to painful ultrasonic stimuli.
Based on those observations and our previous ones
that US can directly stimulate central neurons (13)
Maitland’s exercises include application of
pressure and accessory oscillator movements to treat
stiffness. The aim is to restore the motion. This
technique includes 5 levels of grades. According to
Maitland’s concept, there will be activation of different
mechanoreceptors (14). One factor that is essential in
normalizing proprioception is to restore joint motion at
the level of innervation, since restored joint motion
improves proprioception (15). One way of restoring joint
motion is mobilization/ manipulation, which is suitable
since it can have an immediate and significantly
beneficial effect on proprioceptive feedback (16) and
result in plastic changes from sensorimotor integration
(17)
. Acute decreases in pain following manipulation may
allow more active participation in exercise and
functional retraining earlier in the rehabilitation process
(18)
. Since soft tissues also are richly innervated with
mechanoceptors, some soft tissues may also be useful
in normalizing proprioception (16).
CKC strengthened the muscle through co-
contraction, improved joint congruency, stability and
improved proprioception. Since the progressive
controlled weight bearing is a type of closed kinetic
chain exercise it helps in increasing the bone mineral
density of the fracture site, it decreased the period of
immobilization because of which secondary
complication like joint stiffness, decreased in muscles
strength are avoided and its promotes the co-
contraction of the muscle which help in facilitating the
joint approximation. Thus early rehabilitation of the
fracture is useful in terms of functional range of motion
and abilities of performing activities of daily living
(ADL).The muscles are strengthened through the CKC
exercises then it helps in achieving the early functional
range of motion. Functional range of motion is such
ROM which is necessary to do the normal physical
activities of daily living (19).
It hypothesized that there was no significant
difference between Maitland’s mobilization exercise
plus therapeutic ultrasound and closed kinetic chain
exercise plus therapeutic ultrasound on the wrist joint
range of motion, grip strength, proprioception, and
patient-rated wrist evaluation after colle's fracture.
MATERIALS AND METHODS
Thirty patients with stable colles’ fractures
collected from Sohag General Hospital and Hassan
Nomany Hospital treated conservatively with closed
reduction and casting and after removal of plaster cast
they involved in the study from November 2015 to April
2016. All patients were assigned randomly into two
groups; Group I (Maitland's mobilization), and Group II
(CKC).
Inclusion criteria:
For the Colle's fracture group, patients were enrolled in
the current study if they met all of the following criteria:
1) Patients group with radiological diagnosis of
post colle's fractures stiffness after 6 weeks.
2) Patients with limited ROM wrist.
Exclusion criteria:
Subjects of colle's fracture group were excluded if they
had:
3) Patient with Neuromuscular injuries.
4) The wrist or forearm motion deficits were
presented before the wrist injury to the degree
that it affected the patient's daily activity.
5) Patient with cardiac dysfunction.
6) Patient with renal dysfunction.
7) Osteopenia.
8) Previous colle's fracture.
9) Previous physiotherapy sessions for wrist.
10) Patient with both radius and ulna fractures.
Randomization method:
Each participant assigned a unique number.
These numbers were written on a piece of paper. The
paper has the same size otherwise the selected sample
will not be truly random. The pieces of paper were
placed in a container and thoroughly mixed with
strongly shaking the container. The numbers selected
by trusted physical therapist in the same hospital
without looking and after selection of the desired
numbers for each group, the assigned number put in
 IJTRR 2016; 5 (5):29-36
closed envelope and delivered to the researcher at
beginning of treatment
This study approved by the Ethical Committee of
Faculty of Physical Therapy, Cairo University. All
patients completed an informed consent form and
informed about the aim of the study without any
explanation to treatment.
Intervention:
Patients were assigned to one of two groups A and
B. All patients were received twelve treatment sessions.
All of them were received therapeutic ultrasound at an
intensity of 1.4 w/cm2 and frequency of 3 MHz for 6
minutes.
Group A received Maitland's mobilization plus
therapeutic ultrasound program in the form of:
A. Dorsal glide
The forearm was rested on a mat/table with the
hand just extending off the edge of the surface. The
researcher stabilizing hand grasps the patient's wrist
just proximal to the styloid processes to stabilize the
distal radioulnar joint. The mobilizing hand was placed
over the proximal carpal row. The mobilization was
involved moving the row of carpal bones dorsally to
promote wrist extension.
B. Ventral Glide
The forearm was rested on a mat/table with the hand
just extending off the edge of the surface. The
stabilizing hand was grasped the patient's wrist just
proximal to the styloid processes to stabilize the distal
radioulnar joint. The mobilizing hand was placed over
the proximal carpal row. The mobilization was involved
moving the row of carpal bones palmar to promote wrist
flexion
C. Radial glide (ulnar deviation)
Patient was sit with forearm supported on table.
Forearm was midline between supination or pronation.
The therapist stabilizing hand was grasped the patient's
distal radius and ulna. The table act as additional
stabilization for radius and ulna. The mobilizing hand
webspace was contacted the proximal carpal row
bones. The mobilizing hand was exerted distraction
force then was moved the proximal carpal row in medial
distraction to increase wrist adduction.
D. Ulnar glide (lateral deviation)
Patient was sit with forearm supported on table.
Forearm was midline between supination or pronation.
The therapist stabilizing hand was grasped the patient's
distal radius and ulna. The table act as additional
stabilization for radius and ulna. The mobilizing hand
web-space was contacted the proximal carpal row
bones. The mobilizing hand was exerted distraction
force then was moved the proximal carpal row in lateral
distraction to increase wrist abduction.
Group B received closed kinetic chain exercise plus
therapeutic ultrasound
A. Wall press:
Patient stood with feet shoulder width apart. The
arm was held directly out in front of the body at ninety
degree of elevation against the wall. Feet were
approximately two to three feet away from the wall. The
patient was asked to press on the wall and was asked
to keep pressing for thirty seconds.
B. The Ball Roll:
The subject kneeled on the floor with body
positioned over a ball. The elbow was kept straight and
the shoulder was flexed about ninety degrees. The
subject's upper body weight was position over the
upper extremity on the ball. The patient was balanced
the ball while rolling it in all planes of available motion
with his wrist for 30 seconds. Each week the time was
increased 5 seconds for progression.
CKC exercises were begun with 3 times each
time with 10 repetitions for each exercise and will be
progressed by two repetitions each week.
Outcome measures post radial fracture
The goal of any outcome measure is to
evaluate the improvement or detriment of a given
treatment of a condition, disease, or injury. In order for
a measure to be useful, it must be easily understood
and administered and have consistent reliability and
validity over a wide array of demo- graphic groups (20).
• Hand held dynamometer is considered to be a
reliable instrument in evaluating grip strength and is
used widely in rehabilitation it is used to measure the
force of flexor muscles of hand, generated during
gripping the dynamometer (21).
The patient-rated wrist evaluation score is a reliable,
valid measure of patient-rated pain and disability. It is a
patient self-rated, joint-specific questionnaire that
enquires about symptoms of the wrist and functional
limitations in relation to activities of daily living (ADL)
(22), (23)
.
Wrist and hand sensory dysfunction is important due to
its influence on optimal joint neuromuscular control and
stability during functional tasks. It can be tested via joint
position sense JPS method which tests the ability to
accurately reproduce a specific joint angle while vision
is blocked. (9). It can be quantified by using goniometer
and measure the absolute difference between the
target and the matching joint position sense accuracy
(24)
. It is reported that repositioning tests performed for
the upper extremities gave better results when the eyes
of the subjects were open than when they were closed
(25)
.
DATA ANALYSIS
The Independent variables were Maitland’s Mobilization
Technique and Closed kinetic chain exercises (CKC)
and dependent variable were Function, Hand Grip
Strength, ROM and wrist proprioception. Analyses were
performed using the SPSS statistical software package.
Paired‘t’ test were used for the measurement of pre-
testand post-test values of group A and B. Unpaired ‘t’
test were used to compare the post-test values of
Group B.P values ≤ 0.05 were considered significant.
RESULTS
In this study 30 patients (15 female and 15 female)
were assigned randomly into 2 groups; Group A (n=15)
their mean age was 36.13 ±8.5 years old. Group B
(n=15) their mean age was 36.53±5.75 years old (Table
1). The results at the end of the treatment program
revealed that Group A that received Maitland's
mobilization with therapeutic ultrasound showed a
greater statistical significant than Group B for ROM as
shown in (Table 2).
 IJTRR 2016; 5 (5):29-36

Table (1): Demographic data of both groups.

Item Group A Group B t- value P value
Age (yrs) 36.8± 7.463 35.4± 6.22 0.249 0.418 (NS)
Data are expressed as mean ± SD
NS= Not Significant

Table (2): Comparison between the mean values of the variable in the two studied groups after treatment.
Items Group A Group B t-value P value
Function 10.2±1.923 12.2±3.492 -0.868 0.502 NS
Grip strength 13.8±2.049 14.2±3.114 -0.185 0.861 NS
Range of motion
Flexion (degree) 5±1.224 2.8±1.303 2.130 0.003 Significant
Extension (degree) 4.8±1.643 2.9±1.083 1.672 0.016 Significant
Radial deviation 2.05±0.570 1.15±0.335 2.356 0.014 significant
(degree)
Ulnar deviation 2.2±0.758 0.95±0.325 2.623 0.009
(degree) Significant
Proprioception
Flexion 0.264±0.276 0.53±0.379 -0.981 0.043 NS
Extension 0.33±0.33 0.39±0.276 -0.265 0.625 NS
Radial deviation 0.132±0.180 0.198±0.295 -0.33 0.272 NS
Ulnar deviation 0.266±0.434 0.332±0.408 -0.191 0.426 NS

Fig (1):post treatment values of function

Fig (2):Post treatment values of grip strength

 IJTRR 2016; 5 (5):29-36
Fig (3): Post treatment values of ROM
Fig (4): post treatment values at 20 ̊ wrist proprioception in both groups
DISCUSSION
This study was conducted to investigate the effect
of Maitland's mobilization combined with therapeutic
ultrasound versus closed kinetic chain exercises
combined with therapeutic ultrasound in the
rehabilitation after stable colle's fracture. We had
investigated the effect of Maitland's mobilization on
functional disability, grip strength, wrist ROM, and
proprioception at four target angles; at 20 ̊ wrist flexion,
at 20 ̊wrist extension, at 20 ̊ wrist radial and ulnar
deviation, and compared the results to those patients
who had received the closed kinetic chain exercises.
We had assessed function in the current study
using the patient- rated wrist evaluation questionnaire.
The Patient-rated Wrist Evaluation (PRWE) was
originally designed for the assessment of colle's
fracture and wrist injuries. Items were limited to 5 pain
questions and 10 function questions to permit a simple
scoring system. For answering each of questions, a 0
(no pain /no difficulty) – 10 (worst pain / unable to do)
scale was selected. The reason we've chosen this
questionnaire is that it achieves highest possible patient
acceptance, simplicity in scoring, and responsiveness
to change. The test- retest reliability of the PRWE was
high, and validity was also good as compared to other
questionnaires (26).
The PRWE was the functional outcome measure
used in the study of (27) to measure pain, activity
limitation and participation restriction. It was chosen its
qualities of validity, test- retest reliability,
responsiveness to change and being user friendly in
that it was easy to administer. A limitation in using this
scale was that it did not evaluate compensatory
mechanisms that the participants adopted in order to
perform activity and participate. Also, this scale does
not have a physical component of objective
measurement of activities. It could be argued that
compensatory strategies are not meaningful to the
practitioner rather than being of significance to the
person with a fracture of distal radius (27). The use of the
PRWE questionnaire in our study has been supported
by many other studies, like those of (26), (28), and (29),
who found it to be more efficient at detecting clinical
improvement, simpler for patients to complete, quicker
to administer, easier to score, and was simpler for both
themselves and their patients. This may explain why
they selected it for routine utilization.
According to the current results in this study,
there was a significant difference between patients in
group A who received Maitland's mobilization with
therapeutic ultrasound, and patients in group B who
received closed kinetic chain exercises regarding
 IJTRR 2016; 5 (5):29-36
improving wrist ROM, there was no significance
difference between patients in group A who received
Maitland's mobilization with therapeutic ultrasound, and
group B who received closed kinetic chain exercises on
function, grip strength, and wrist proprioception. A
similar study by (30) and (31) they statement that thermal
ultrasound used in concert with joint mobilizations was
an effective regimen aimed at restoring ROM in
hypomobile wrists postinjury or when immobilized after
surgery. Ultrasound also increased patient comfort
during the treatment and minimized posttreatment
soreness. Another study by (32) study who statement
that early mobilization of the wrist joint lead to increase
in both strength and movement without any
observational progression of residual deformity. (33)
report that applying mobilization early confirmed the
improvement in strength and pain.
Abd El-Latief (34)who statement that closed
kinetic chain exercise need more time and greater
range of motion in upper limb joints especially wrist joint
during quadruped and push up activities and active
range of motion has a little effect on recruitment of all
muscle fibers. Another study by (35) who statement that
closed kinetic chain with traditional physical therapy
program in the rehabilitation after fractures distal end of
radius, closed kinetic chain exercises didn't significantly
improve the proprioception of the wrist joint at the two
tested target angles (at 30 ̊ wrist flexion and at 30 ̊ wrist
extension) after four weeks of training in comparison to
traditional physical therapy program without CKC
exercises, but CKC exercises shown significant
improvement in grip strength, functional activities, and
increase in ROM of wrist flexion and extension, thought
radial and ulnar deviation didn't increase significantly.
Saad et al., (25), added the closed kinetic chain
exercises to the open kinetic chain exercises despite (36)
has found that the wrist proprioception was improved
only by open kinetic chain exercises but not by the
closed kinetic chain exercises because training with
closed kinetic chain exercises will add additional
benefits to the exercise program such as allowing the
mechanoceptors within the joints to be more aware and
responsive to static and dynamic stability at the joint
(37)
; the CKC activities facilitate the integration of
proprioceptive feedback coming from joint
mechanoceptors; and that the proprioceptive exercises,
especially in the closed kinetic chain, train the body to
use cocontraction of the muscles to produce stability,
thus protecting the healed soft tissue structures that
might be damaged by open chain exercises.
Studies are unfortunately lacking the effect of
proprioceptive training on different conditions of the
wrist joint, and up to the investigator knowledge, there's
are no study to show the effect of eight bearing
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It can be concluded that, Maitland's
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RECOMMENDATIONS
The results of the present study offered the need
for considering the following recommendations:
 Further studies are required to investigate the
effect of the weight bearing exercises like
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 Further similar comparisons including a larger
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joint at more target angles.
 Correlational study is required between
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Conflict of Interest: The authors declare that there is
no conflict of interest in this study. The manuscript has
been read and approved by authors.
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