title: Accelerated rehabilitation compared with a standard protocol after distal radial fractures treated with volar open reduction and internal fixation: a prospective, randomized, controlled study. The value of early mobilisation in the treatment of Colles' fractures. Therapist-supervised hand therapy versus home therapy with therapist instruction following distal radius fracture. Preventing functional loss during immobilization after osteoporotic wrist fractures in elderly patients: a randomized clinical trial Early mobilisation of Colles' fractures. A prospective trial. Do Colles’ fracture patients benefit from routine referral to physiotherapy following cast removal? Independent exercises versus physiotherapy in nondisplaced proximal humeral fractures. Early Functional Postoperative Therapy of Distal Radius Fracture with a Dynamic Orthosis: Results of a Prospective Randomized Cross-Over Comparative Study Physiotherapy after volar plating of wrist fractures is effective using a home exercise program. No difference between two types of exercise after proximal phalangeal fracture fixation: a randomised trial. Physiotherapy after fracture of the proximal end of the humerus. Comparison between two methods. Early mobilization in the treatment of Colles' fracture: a 3 year prospective study. [The importance of early exercise therapy in the treatment of Colles' fracture. A clinically controlled study]. Effect of exercises with weight vests and a patient education programme for women with osteopenia and a healed wrist fracture: a randomized, controlled trial of the OsteoACTIVE programme Efficacy of combined physical and occupational therapy in patients with conservatively treated distal radius fracture: randomized controlled trial Immediate mobilization compared with conventional immobilization for the impacted nonoperatively treated proximal humeral fracture. A randomized controlled trial. Cross-education for improving strength and mobility after distal radius fractures: a randomized controlled trial. Occupational therapy and Colles' fractures A progressive exercise and structured advice program does not improve activity more than structured advice alone following a distal radial fracture: a multi-centre, randomised trial. Comparison of Early Mobilization Protocols in Radial Head Fractures The role of physiotherapy and clinical predictors of outcome after fracture of the distal radius. Rehabilitation of two-part fractures of the neck of the humerus (two-year follow-up). Is progressive early digit mobilization intervention beneficial for patients with external fixation of distal radius fracture? A pilot randomized controlled trial An advice and exercise program has some benefits over natural recovery after distal radius fracture: a randomised trial. Early mobilisation for minimally displaced radial head fractures is desirable. A prospective randomised study of two protocols. A randomised clinical trial of activity-focussed physiotherapy on patients with distal radius fractures Early active mobilisation of volar plate avulsion fractures. A randomized clinical controlled study comparing the effect of modified manual edema mobilization treatment with traditional edema technique in patients with a fracture of the distal radius. Dynamic splints do not reduce contracture following distal radial fracture: a randomised controlled trial. Early versus late mobilization after hemiarthroplasty for proximal humeral fractures. Minimal clinically important differences of 3 patient-rated outcomes instruments. Rehabilitation after two-part fractures of the neck of the humerus. Rehabilitation After Immobilization for Ankle Fracture: The EXACT Randomized Clinical Trial. Immediate effects of repetitive wrist extension on grip strength in patients with distal radial fracture. A prospective randomized controlled trial comparing occupational therapy with independent exercises after volar plate fixation of a fracture of the distal part of the radius.
abstract: BACKGROUND There are relatively few studies in the literature that specifically evaluate accelerated rehabilitation protocol s for distal radial fractures treated with open reduction and internal fixation ( ORIF ) . The purpose of this study was to compare the early postoperative outcomes ( at zero to twelve weeks postoperatively ) of patients enrolled in an accelerated rehabilitation protocol  with those of patients enrolled in a st and ard rehabilitation protocol following ORIF for a distal radial fracture . We hypothesized that patients with accelerated rehabilitation after volar ORIF for a distal radial fracture would have an earlier return to function compared with patients who followed a st and ard protocol .  METHODS From November 2007 to November 2010 , eighty-one patients with an unstable distal radial fracture were prospect ively r and omized to follow either an accelerated or a st and ard rehabilitation protocol after undergoing ORIF with a volar plate for a distal radial fracture . Both groups began with gentle active range of motion at three to five days postoperatively . At two weeks , the accelerated group initiated wrist/forearm passive range of motion and strengthening exercises , whereas the st and ard group initiated passive range of motion and strengthening at six weeks postoperatively . Patients were assessed at three to five days , two weeks , three weeks , four weeks , six weeks , eight weeks , twelve weeks , and six months postoperatively . Outcomes included Disabilities of the Arm , Shoulder and H and ( DASH ) scores ( primary outcome ) and measurements of wrist flexion/extension , supination , pronation , grip strength , and palmar pinch . RESULTS The patients in the accelerated group had better mobility , strength , and DASH scores at the early postoperative time points ( zero to eight weeks postoperatively ) compared with the patients in the st and ard rehabilitation group . The difference between the groups was both clinical ly relevant and statistically significant . CONCLUSIONS Patients who follow an accelerated rehabilitation protocol that emphasizes motion immediately postoperatively and initiates strengthening at two weeks after volar ORIF of a distal radial fracture have an earlier return to function than patients who follow a more st and ard rehabilitation protocol . LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence Unilateral Colles ' fractures in 187 patients over the age of 55 years were studied in a r and omised prospect i ve trial : 97 fractures were minimally displaced and were treated either conventionally or in a crêpe b and age ; 90 displaced Colles ' fractures were reduced and of these 47 were treated conventionally while 43 were encouraged to mobilise the wrist in a cast which restricted extension . Early wrist movement hastened functional recovery and led to earlier resolution of wrist swelling . Discomfort was no greater than in patients who were treated conventionally . The bony deformity , which recurred irrespective of the method of treatment , was not adversely affected by early mobilisation PURPOSE To investigate whether there was a difference in Patient-Rated Wrist H and Evaluation ( PRWHE ) scores between patients with and without comorbidities who receive regular supervised therapy provided by a certified h and therapist ( CHT )  compared with patients who were provided with a home exercise program  and were regularly monitored . METHODS Fifty patients with a diagnosis of distal radius fractures and volar plate fixation were enrolled in a prospect i ve , r and omized clinical trial comparing those who received therapy under the supervision of a CHT with those enrolled in a home exercise program that was instructed and monitored by a CHT . The primary outcome measure ( PRWHE ) and secondary outcome measures , total arc of motion for wrist flexion and extension , supination and pronation , and grip strength , were assessed at 12 weeks . The primary outcome measure for both groups was also gathered at 6 months . RESULTS There were no statistically significant differences between the final scores of the PRWHE , wrist or forearm motion , pain , or grip strength between groups . Effect size calculations revealed that both groups experienced a large effect size for all outcomes . CONCLUSIONS Supervised clinic-based therapy is equally beneficial for patients without complications . Clinic-based therapy may be preferable for patients with noteworthy complications after a distal radius fracture with volar plate fixation . Patients with decreased finger motion and various comorbidities may benefit from therapy provided in a clinic under the supervision of a certified h and therapist . TYPE OF STUDY /LEVEL OF EVIDENCE Therapeutic II Background Distal radius fractures are among the most common fractures and account for approximately one-sixth of all fractures diagnosed . Therapy results after distal radius fracture , especially of elderly patients , are often suboptimal . The inevitable immobilization for several weeks leads to reduction in range of motion , deterioration of muscle strength , malfunction of fine motor skills as well as changes of motor and sensory representations in the brain . Currently , there are no strategies to counteract these immobilization problems . The overall aim of the study is to investigate the therapeutic potential of motor-cognitive approaches ( mental practice or mirror therapy ) on h and function after wrist fracture . Methods / Design This study is a controlled , r and omized , longitudinal intervention study with three intervention groups . One experimental group imagines movements of the fractured upper extremity without executing them ( mental practice ) . The second experimental group receives a mirror therapy program consisting of the performance of functional movement synergies using the unaffected forearm , wrist , and h and . The control group completes a relaxation training regime . Additionally , all patients receive usual care by the general practitioner . We include women aged 60 years and older having a distal radius fracture and sufficient cognitive function . All groups are visited at home for therapy sessions 5 times per week for the first 3 weeks and 3 times per week for weeks 4 to 6 . Measurements are taken at therapy onset , and after 3 , 6 and 12 weeks . The primary outcome measure will assess upper extremity functioning ( Patient-Rated Wrist Evaluation [ PRWE ] ) , while secondary outcome measures cover subjective wrist function ( Disabilities of the Arm and Shoulder ; [ DASH ] , objective impairment ( range of motion , grip force ) and quality of life ( EuroQol-5D , [ EQ5D ] ) . Discussion Results from this trial will contribute to the evidence on motor-cognitive approaches in the early therapy of distal radius fractures . Trial registration The trial is registered at Clinical Trials.gov with registration number NCT01394809 and was granted permission by the Medical Ethical Review Committee of the University of Tübingen in June 2011 The results of a prospect i ve controlled trial of early mobilisation of Colles ' fractures in the elderly are presented . Early mobilisation produced less pain and a stronger grip . It did not lead to any greater loss of reduction of the fracture . However , there was no significant improvement in the final range of movement of the wrist .  Immobilisation of the wrist for six weeks in plaster is extremely inconvenient for the elderly living alone and the patients greatly appreciated the reduction of this period of time to a minimum Abstract Colles ’ fracture patients who received physiotherapy  immediately following cast removal were compared with patients who received no active therapy following cast removal in a prospect i ve r and omised study . Patients who attended physiotherapy achieved significantly greater increases in wrist extension and grip strength after 6 weeks compared to patients who received no active therapy 42 patients with undisplaced , proximal humeral fractures were r and omly assigned into two groups in order to compare the results of instruction to the patient for independent exercises and conventional physiotherapy . No differences appeared between the groups subjectively or as regards functional parameters at 1 as well as at 3 months after the fracture and at a follow up more than 1 year later . As no disadvantage could be found instructions to the patients should in these cases be regarded as a satisfactory after-treatment Introduction This study was conducted according to GCP criteria as a prospect i ve r and omized cross-over study . The primary goal of the study was to determine clinical findings and patient satisfaction with postoperative treatment . 29 patients with a distal radius fracture that was surgically stabilized from volar and who met the inclusion criteria were enrolled over a 12-month period . Each patient r and omly received either a dorsal plaster splint or a vacuum-fit flexible but blocked orthosis applied postoperatively in the operating theatre to achieve postoperative immobilization . After one week all patients were crossed over to the complementary device maintaining the immobilization until end of week 2 . After week 2 both groups were allowed to exercise wrist mobility with a physiotherapist , in the orthosis group the device was deblocked , thus allowing limited wrist mobility . After week 4 the devices were removed in both groups . Follow-up exams were performed after postoperative weeks 1 , 2 , 4 and 12 . Results and Discussion Results were determined after week 1 and 2 using SF 36 and a personally compiled question naire ; after weeks 4 and 12 with a clinical check-up , calculation of ROM and the DASH Score . Comparison of the two groups showed a significant difference in ROM for volar flexion after 4 weeks , but no significant differences in DASH Score , duration of disability or x-ray findings . With regard to satisfaction with comfort and hygiene , patients were significantly more satisfied with the dynamic orthosis , and 23 of the 29 patients would prefer the flexible vacuum orthosis in future . Trial Registration German Clinical Trials Register ( DRKS ) OBJECTIVE To determine the effect of 2 different postoperative therapy approaches after operative stabilization of the wrist fractures :  treatment by a physical therapist with 12 sessions and an unassisted home exercise program . DESIGN R and omized controlled cohort study . SETTING Hospital-based care , primary center of orthopedic surgery . PARTICIPANTS Volunteers ( N=48 ) with fractures of the distal radius after internal fixation with locking plates . There were 46 patients available for follow-up after exclusion of 2 participants due to physiotherapy sessions in excess of the study protocol . INTERVENTIONS Not applicable . MAIN OUTCOME MEASURES Evaluation of grip strength using a Jamar dynamometer , range of motion ( ROM ) , and Patient Related Wrist Evaluation ( PRWE ) . RESULTS After a 6-week period of postoperative treatment , the patients ( n=23 ) performing an independent home exercise program using a training diary showed a significantly greater improvement of the functionality of the wrist . Grip strength reached 54 % ( P=.003 ) , and ROM in extension and flexion 79 % ( P<.001 ) of the uninjured side . Ulnar and radial abduction was also higher in this group . In contrast , patients who were treated by a physical therapist achieved grip strength equal to 32 % , and ROM in extension and flexion of 52 % of the uninjured side . Patients who were performing the home training after operation recorded an improved wrist function with a nearly 50 % lower value ( P<.001 ) in the PRWE score . CONCLUSIONS In the postoperative rehabilitation of wrist fractures , instructions in a home exercise program are an effective alternative to prescribed physical therapy treatment QUESTION Are 6 weeks of synergistic wrist and finger exercises with the metacarpophalangeal joint constrained in an orthosis ( constrained exercises ) more effective than traditional finger exercises with the metacarpophalangeal joint unconstrained ( unconstrained exercises ) after open reduction and internal fixation of a proximal phalangeal fracture in terms of impairment , activity limitation and participation restriction at 6 and 12 weeks ? DESIGN R and omised , parallel-group trial with concealed allocation , intention-to-treat analysis and blinded outcome assessors . PARTICIPANTS Sixty-six participants within 1 week of open reduction and internal fixation of proximal phalangeal fractures . INTERVENTION The experimental group carried out 6 weeks of synergistic wrist and finger exercises with the metacarpophalangeal joint constrained , whilst the control group carried out finger exercises with the metacarpophalangeal joint unconstrained , as part of a comprehensive rehabilitation program . OUTCOME MEASURES The primary outcomes were : active proximal interphalangeal joint extension of the injured finger , total active range of motion , and strength . Secondary outcomes were : pain , difficulty with specific h and activity and difficulty with usual h and activity . A blinded assessor measured outcomes at Weeks 1 , 6 and 12 . RESULTS By Week 6 , there were no significant between-group differences in improvement for : active proximal interphalangeal joint extension ( MD 2 deg , 95 % CI -3 to 7 ) ; total active finger range of motion ( MD 0 deg , 95 % CI -21 to 22 ) ; strength ( MD -2 kg , 95 % CI -8 to 4 ) ; pain ( MD 1/50 , 95 % CI -3 to 5 ) ; difficulty with specific h and activity ( MD 2/60 , 95 % CI -3 to 8) ; or difficulty with usual h and activity ( MD 0/40 , 95 % CI -4 to 3 ) . By Week 12 , there were also no significant between-group differences in any outcome . CONCLUSIONS Constrained and unconstrained exercises has similar effects after open reduction and internal fixation of proximal phalangeal fracture . REGISTRATION Australian New Zeal and Clinical Trials Registry ( ACTRN12610000294055 ) Two methods of physiotherapy after fracture of the proximal end of the humerus were compared . The study was design ed as a r and omized , controlled and single-blind trial . Twenty patients were assigned to two groups 10 - 12 days after the injury . One group was treated conventionally , the other received instructions in self-training with follow-up control of results .  Objective examination and subjective assessment were made at five intervals , up to one year after the injury . The greatest improvement in function was shown in both groups between 3 and 8 weeks . The patients deemed their daily life functions to be normal 8 weeks after the injury . The objective assessment was normal at later stages . No significant differences were found between the two groups in any of the tests . Instruction in self-training with control of results including objective assessment s are therefore an adequate method in the rehabilitation of these patients Ninety consecutive women with unilateral Colles ' fractures were r and omized into two different treatment groups . The control group was treated for 5 weeks in conventional short-arm , below the elbow plaster of Paris casts . The other group ( N = 45 ) was treated similarly in plaster casts for 3 weeks and then had flexible casting applied for the remaining 2 weeks which allowed for early joint mobilization . Functional recovery was assessed by measuring grip strength and joint mobility at intervals over the 3 years . Radiographic and overall assessment s were also made during 3 year course of study . Virtually all patients reported greater comfort after switching to the flexible casting . Mean grip scores and joint mobilities were higher at all time points with early mobilization , reaching levels of statistical significance at 6 months for grip score and at 3 months for joint mobility . By 3 years most differences between treatment groups had resolved . We found no evidence that early mobilization was detrimental to recovery . We conclude that early mobilization is a satisfactory treatment option for Colles ' fracture , and may , in fact , hasten functional recovery Forty patients participated in a study of the importance of early occupational therapy for the prognosis in stable Colles ' fractures . Seventeen patients were treated by an occupational therapist 1 - 3 days after the injury , and the need for appliances and home-care was estimated . Twenty-three patients completed the usual treatment . Five weeks after the injury , we found significantly ( p less than 0.05 ) better function of the h and in the 17 patients with early occupational therapy . This difference in function could not be found after 13 weeks . The rate of complications was the same in the two groups . The results indicate that contact with the occupational therapist shortly after the injury is valuable in patients with stable Colles ' fractures Background Exercise programmes have shown to be important for the prevention of fractures in patients with established osteoporosis . However , few studies have evaluated the effect of such programmes for women with low bone mineral density ( BMD ) ( osteoporosis or osteopenia ) who have already suffered a fracture . Studies have indicated that exercise programmes concentrating on muscular strength and dynamic balance have a positive effect on significant risk factors for falls such as quadriceps strength and balance . The aim of the present study was to assess the effect of a 6-month exercise programme and a patient education component ( OsteoACTIVE ) on quadriceps strength , BMD , dynamic balance , walking capacity , physical activity level and quality of life in postmenopausal women with osteopenia and a previous wrist fracture . Methods Eighty postmenopausal women with low BMD and a healed wrist fracture were r and omized to OsteoACTIVE ( n = 42 ) ( age 65.5 , range 51.2–79.2 years ) or patient education only ( control group ) ( n = 38 ) ( age 63.9 , range 52.7–86.8 years ) . Follow-up was conducted after 6 months ( end of intervention ) and 1 year . Outcome measures included quadriceps strength , BMD , dynamic balance , walking capacity , physical activity level and quality of life . Results Thirty-five participants ( 83 % ) completed the  OsteoACTIVE programme .  Mean adherence to OsteoACTIVE was 87 % ( range 48–100 % ) . Twenty-five participants ( 72 % ) met the a priori goal of 80 % adherence to the program . No adverse events were reported . There were no significant differences between the two groups over the 1-year follow-up for any of the outcome measures . Conclusion The OsteoACTIVE rehabilitation programme revealed no significant effect on quadriceps strength , BMD , dynamic balance , walking capacity or self-reported functional outcomes over the 1-year follow-up . Trial registration NCT01357278 at Clinical Trials.gov ( date of registration 2010 - 04 - 21 ) Summary Aim To evaluate the efficacy of combined physical and occupational therapy in comparison with physical therapy alone in patients with conservatively treated distal radius fracture . Methods Sixty-one participants , conservatively treated after a distal radius fracture , were included in a r and omized and single-blind trial . Group A had physical therapy only  ( n = 31 ) and group B had  physical and occupational therapy ( n = 30 ) . The assessment was performed three times : upon inclusion in the study in the first week after removal of the cast ( T1 ) , immediately after the end of the rehabilitation ( T2 ) , and 1 month after completing the rehabilitation ( T3 ) . The passive wrist range-of-motion , grip strength , and Disabilities of Arm , Shoulder and H and ( DASH ) score were used as rehabilitation outcomes . Results Rehabilitation outcomes were analyzed using two-way mixed analysis of variance . The effect of time was statistically significant ( p < 0.001 ) for all outcomes . The group ( therapy ) factor was statistically significant for grip strength only ( p = 0.038 ) . The interaction effect was statistically significant for rotation ( p = 0.034 ) and grip strength ( p = 0.021 ) . A comparison between time points T3:T1 showed statistically significant difference in grip strength in favor of group B 67 % ( 95 % CI 60–74 % ) versus group A 53 % ( 95 % CI 45–61 % ) , p = 0.024 . Conclusion The combined therapy result ed in a statistically significant increase of grip strength in comparison with isolated physical therapy in the period of 12–16 weeks after the fracture . This effectiveness was not confirmed with DASH score results BACKGROUND There have been few r and omized controlled trials evaluating nonoperative treatment of proximal humeral fractures . To investigate shortening the period of dependence , we assessed the feasibility and efficacy of early mobilization of the shoulder ( within three days after the fracture ) in comparison with those of conventional three-week immobilization followed by physiotherapy . METHODS We r and omly assigned seventy-four patients with an impacted proximal humeral fracture to receive early passive mobilization or conventional treatment . The primary outcome was the overall shoulder functional status ( as measured with the Constant score ) at three months . The secondary outcomes were the Constant score at six weeks and at six months , the change in pain ( on a visual analog scale ) , and the active and passive range of motion . RESULTS At three months and at six weeks , the early mobilization group had a significantly better Constant score than did the conventional-treatment group ( between-group difference , 9.9 [ 95 % confidence interval , 1.9 to 17.8 ] [ p = 0.02 ] and 10.1 [ 95 % confidence interval , 2.0 to 18.1 ] [ p = 0.02 ] , respectively ) and better active mobility in forward elevation ( between-group difference , 12.0 [ 95 % confidence interval , 1.7 to 22.4 ] [ p = 0.02 ] and 28.1 [ 95 % confidence interval , 7.1 to 49.1 ] [ p = 0.01 ] , respectively ) . At three months , the early mobilization group had significantly reduced pain compared with the conventional-treatment group ( between-group difference , 15.7 [ 95 % confidence interval , 0.52 to 30.8 ] [ p = 0.04 ] ) . No complications in displacement or nonhealing were noted . CONCLUSIONS Early mobilization for impacted nonoperatively treated proximal humeral fractures is safe and is more effective for quickly restoring the physical capability and performance of the injured arm than is conventional immobilization followed by physiotherapy OBJECTIVE To evaluate the effects of cross-education ( contralateral effect of unilateral strength training ) during recovery from unilateral distal radius fractures on muscle strength , range of motion ( ROM ) , and function . DESIGN R and omized controlled trial ( 26-wk follow-up ) . SETTING Hospital , orthopedic fracture clinic . PARTICIPANTS Women older than 50 years with a unilateral distal radius fracture . Fifty-one participants were r and omized and 39 participants were included in the final data analysis . INTERVENTIONS Participants were r and omized to st and ard rehabilitation ( Control ) or st and ard rehabilitation plus strength training ( Train ) . St and ard rehabilitation included forearm casting for 40.4±6.2 days and h and exercises for the fractured extremity . Nonfractured h and strength training for the training group began immediately postfracture and was conducted at home 3 times/week for 26 weeks . MAIN OUTCOME MEASURES The primary outcome measure was peak force ( h and grip dynamometer ) . Secondary outcomes were ROM ( flexion/extension ; supination/pronation ) via goniometer and the Patient Rated Wrist Evaluation question naire score for the fractured arm . RESULTS For the fractured h and , the training group ( 17.3±7.4 kg ) was significantly stronger than the control group ( 11.8±5.8 kg ) at 12 weeks postfracture ( P<.017 ) . There were no significant strength differences between the training and control groups at 9 ( 12.5±8.2 kg ; 11.3±6.9 kg ) or 26 weeks ( 23.0±7.6 kg ; 19.6±5.5 kg ) postfracture , respectively . Fractured h and ROM showed that the training group had significantly improved wrist flexion/extension ( 100.5 ° ±19.2 ° ) than the control group ( 80.2 ° ±18.7 ° ) at 12 weeks postfracture ( P<.017 ) . There were no significant differences between the training and control groups for flexion/extension ROM at 9 ( 78.0 ° ±20.7 ° ; 81.7 ° ±25.7 ° ) or 26 weeks ( 104.4 ° ±15.5 ° ; 106.0 ° ±26.5 ° ) or supination/pronation ROM at 9 ( 153.9 ° ±23.9 ° ; 151.8 ° ±33.0 ° ) , 12 ( 170.9 ° ±9.3 ° ; 156.7 ° ±20.8 ° ) or 26 weeks ( 169.4 ° ±11.9 ° ; 162.8 ° ±18.1 ° ) , respectively . There were no significant differences in Patient Rated Wrist Evaluation question naire scores between the training and control groups at 9 ( 54.2±39.0 ; 65.2±28.9 ) , 12 ( 36.4±37.2 ; 46.2±35.3 ) , or 26 weeks ( 23.6±25.6 ; 19.4±16.5 ) , respectively . CONCLUSIONS Strength training for the nonfractured limb after a distal radius fracture was associated with improved strength and ROM in the fractured limb at 12 weeks postfracture . These results have important implication s for rehabilitation strategies after unilateral injuries Abstract . In this r and omized trial , we enrolled 30 patients treated for a distal radius Colles ' type fracture . The fractures were reduced if necessary and fixed in a below-elbow plaster cast for 5 weeks . One group consisting of 14 patients received instructions for shoulder ; elbow and finger exercise and the other group consisting of 16 patients had occupational therapy . At 5 weeks , 3 and 9 months we measured the functional scores . There were no statistically significant differences between the groups at any time . It seems that for non-surgically treated patients with a distal radius fracture only instructions are necessary . Résumé . Etude r and omisée de 30 patients traités d'une fracture distale du radius de type Pouteaux-Colles . Les fractures furent réduites si nécessaire et fixées dans une manchette plâtrée durant 5 semaines . L'un des groupes était constitué de 14 patients qui avaient reçu des instructions d'exercices pour l'épaule , le coude et les doigts . L'autre groupe était constitué de 16 patients qui ont bénéficié d'une ergothérapie  . Une évaluation a été faite après 5 semaines , 3 et 9 mois . Il n'avait aucune différence significative entre les 2 groupes en aucune période . Il semble ainsi suffisant , dans les fractures distales du radius traitées orthopédiquement , d'instruire les patients en vue d'une autoréeducation QUESTION Does a program of exercise and structured advice implemented during the rehabilitation phase following a distal radial fracture achieve better recovery of upper limb activity than structured advice alone ? DESIGN A phase I/II , multi-centre , r and omised , controlled trial with concealed allocation , assessor blinding and intention-to-treat analysis . PARTICIPANTS Thirty-three adults ( 25 female , mean age 54 years ) following distal radial fracture managed in a cast . INTERVENTION The experimental intervention was a 6-week program of progressive exercise and structured advice implemented over three consultations by a physiotherapist . The control intervention was a program of structured advice only , delivered by a physiotherapist over three consultations . OUTCOME MEASURES The primary outcome was upper limb activity limitations , assessed by the Patient-Rated Wrist Evaluation and the shortened version of the Disabilities of the Arm , Shoulder and H and outcome measure ( QuickDASH ) . The secondary outcomes were wrist range of movement , grip strength and pain . All measures were completed at baseline ( week 0 ) , after the intervention ( week 7 ) and at 6 months ( week 24 ) . RESULTS There were no significant between-group differences in upper limb activity as measured by the Patient-Rated Wrist Evaluation at week 7 and week 24 assessment s ( mean difference -4 units , 95 % CI -10 to 2 ; mean difference 0 units , 95 % CI -3 to 3 , respectively ) , or QuickDASH at week 7 and week 24 assessment s ( mean difference -5 units , 95 % CI -16 to 6 ; mean difference 0.3 units , 95 % CI -6 to 7 , respectively ) . The secondary outcomes did not demonstrate any significant between-group effects . CONCLUSION The prescription of exercise in addition to a structured advice program over three physiotherapy consultations may convey no extra benefit following distal radial fracture managed in a cast . TRIAL REGISTRATION ACTRN12612000118808 . [ Bruder AM , Shields N , Dodd KJ , Hau R , Taylor NF ( 2016 ) A progressive exercise and structured advice program does not improve activity more than structured advice alone following a distal radial fracture : a multi-centre , r and omised trial . Journal of Physiotherapy62 : 145 - 152 ] Objectives : We compared 2 different protocol s of early mobilization with a protocol of delayed mobilization in patients with simple radial head fractures ( B2.1 type of Orthopaedic Trauma Association Classification ) . An attempt to correlate certain characteristics of the radial head fractures with outcome was made . Design : Prospect i ve r and omized comparative study . Setting : Level 1 trauma center . Patients / Participants : One hundred eighty consecutive patients were r and omly allocated into 3 different protocol s. Intervention : In the first group , immediate mobilization of the elbow joint was applied . In the second , a sling was used for 2 days and then active mobilization was introduced . The third protocol represented the control group where immobilization in a cast for 7 days before the mobilization was applied . Main Outcome Measurements : Broberg and Morrey score , The American Shoulder and Elbow Surgeons-Elbow score , visual analogue scale , and grip and pinch strength were evaluated . Results : The 2 protocol s introducing early mobilization result ed in better outcome compared with immobilization . The first protocol result ed in worse pain in the first 3 days . Range of motion , strength , and functional outcome was better in patients allocated to the second protocol . These differences were more evident in displaced fractures . A fragment displacement of more than 4 mm and an angulation of more than 30 degrees proved to impair outcome . Conclusions : Early mobilization of simple radial head fractures seemed to be a safe and an effective treatment option . It seems that a delay of 48 hours before early mobilization could be advantageous . Individualization of treatment in accordance to the characteristics of fracture could be a decisive factor for outcome . Level of Evidence : Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence The capacity for physiotherapy to improve the outcome after fracture of the distal radius is unproven . We carried out a r and omised controlled trial on 96 patients , comparing conventional physiotherapy with a regime of home exercises .  The function of the upper limb was assessed at the time of removal of the plaster cast and at three and six months after injury . Factors which may predict poor outcome in these patients were sought . Grip strength and h and function did not significantly differ between the two groups . Flexion and extension of the wrist were the only movements to improve with physiotherapy at six months ( p = 0.001 ) . Predictors of poor functional outcome were malunion and impaired function before the fracture . These patients presented with pain , decreased rotation of the forearm and low functional scores at six weeks . Our study has shown that home exercises are adequate rehabilitation after uncomplicated fracture of the distal radius , and routine referral for a course of physiotherapy should be discouraged . The role of physiotherapy in patients at high risk of a poor outcome requires further investigation The 2-year results of a r and omized , prospect i ve , controlled trial of minimally displaced proximal humeral fractures treated either by immediate physiotherapy ( group A ) or after 3 weeks of immobilization ( group B ) are reported . At 1 year shoulder disability , as measured with the Croft shoulder disability question naire , was found in 42.8 % of patients in group A and 72.5 % in group B ( P < .01 ) . By 2 years , shoulder disability in group A remained unchanged ( 43.2 % ) but had reduced in group B ( 59.5 % ) . This difference was not statistically significant . Immediate physiotherapy after a minimally displaced proximal humeral fracture results in faster recovery , with maximal functional benefit being achieved at 1 year . Delayed rehabilitation by 3 weeks of shoulder immobilization produces a slower recovery , which continues for at least 2 years after the time of injury Objective : To investigate whether progressive early digit mobilization result ed in better outcomes for h and stiffness and related functional results , as well as the effects on the bone healing process . Design : Prospect i ve , pilot r and omized controlled trial . Setting : A university hospital in southern Taiwan . Participants : Twenty-two patients with distal radius fracture r and omized into two groups : early digit mobilization or control .  Interventions : The intervention group received 45 minutes per treatment session and three sessions per week until the external fixator was removed 6 weeks after fracture . The control group received usual home programmes . After removing fixators , both groups received regular rehabilitation programmes until 12 weeks after surgery . Main measures : H and strength , dexterity and functional outcomes were obtained using a dynamometer , Purdue pegboard and self-report assessment , respectively , and X-rays of the distal radius were taken to reveal bone healing 1 , 3 , 6 and 12 weeks after surgery . A motion tracking system measured various kinematic parameters . Results : The recovery rates between the groups showed statistically significant differences in both thumb workspace ( 81.55 % vs. 69.54 % , P = 0.04 ) and finger workspace ( 89.22 % vs. 59.97 % , P = 0.03 ) 12 weeks after injury . However , no statistical differences were found in finger dexterity , strength and self-reported outcomes . The radiographic assessment showed no significant differences between the groups for radial inclination , radial height and volar tilt throughout the examinations . Conclusions : The findings suggest that early rehabilitative intervention for digits is applicable for distal radius fracture treatment , and does not produce additional bone deformities QUESTION Does an advice and exercise program improve outcome for adults following distal radius fracture ? DESIGN R and omised trial with concealed allocation , assessor blinding , and intention-to-treat analysis . PARTICIPANTS Fifty-six patients whose fracture had been managed with pins and /or cast . INTERVENTION The experimental group received a physiotherapist-directed program of advice and exercises . The control group did not receive any physiotherapy intervention . OUTCOME MEASURES The primary outcome was wrist extension ( measured with a goniometer ) . Secondary outcomes were the other wrist ranges of motion ( measured with a goniometer ) , grip strength ( measured with a dynamometer ) , pain , and activity limitations ( measured with question naires ) . These outcomes were measured initially , then three and six weeks later . Participants also rated their satisfaction with physiotherapy intervention at Week 6 . RESULTS No difference was found between groups for the primary outcome of wrist extension ( mean difference 6 deg , 95 % CI -3 to 14 ) , nor for the secondary outcomes of other range of motion data and grip strength . The difference between groups for pain was -16 points out of 100 ( 95 % CI -27 to -5 ) at Week 3 , and -14 points ( 95 % CI -25 to -3 ) points at Week 6 , and for activity was -13 points out of 100 ( 95 % CI -24 to -2 ) at Week 3 ; in favour of the experimental group . The experimental group was also more satisfied with the amount of physiotherapy intervention . CONCLUSION An advice and exercise program provided some additional benefits over no intervention for adults following distal radius fracture We compared two protocol s of early mobilisation for minimally displaced radial head fractures through a single-blinded , prospect i ve r and omised trial . Sixty patients were r and omly allocated to either immediate active mobilisation or 5-day delay before active mobilisation was commenced . Patients were review ed at 7 days , 4 weeks and 3 months after injuries . A blinded observer assessed each patient . All fractures united by the third month . At the end of 7 days , the mobilisation group had less pain ( visual analogue scale ( VAS ) 6 versus 7.6 , P=0.002 ) ; greater flexion ( mean 112 versus 98 degrees , P=0.0004 ) ; greater strength in supination ( P<0.001 ) and better elbow function ( Morrey Score : 54 versus 43 , P=0.005 ) . By the fourth week , both groups were comparable in all parameters and improvement continued into the third month . Mean limit of extension at the third month were 2.3 degrees in the immediate mobilisation group and 1.8 degrees in the delayed group ( NS ) . All had excellent function on the basis of the Morrey Score . Immediate mobilisation did not adversely affect the outcome ; the patients had less pain and better elbow function at 1-week post-injury . Pain , ranges of movement and function were similar by the fourth week post-injury Introduction : Physiotherapy is considered by some authorities to be an important aspect of management in patients following distal radius fractures . There is evidence of improvement in impairment with physiotherapy ; however , there is no evidence to support early return of functional activity . Traditional physiotherapy management has focussed on improving impairment ; however , there are no trials with emphasis on skill acquisition via motor re-learning principles . Material s and methods : Forty-one participants with conservatively managed distal radius fractures were studied in a r and omised , single-blinded , prospect i ve trial . Two treatment options were compared : exercise and advice versus activity-focussed physiotherapy with measurement periods of 6 weeks after removal of cast and follow-up at 24 weeks . Results : Participants allocated to the exercise and advice group consulted a physiotherapist an average of 0.9 ( SD 0.4 ) times , while the participants allocated to the more intensive activity-focussed group consulted with physiotherapy a mean of 4.4 ( SD 2.3 ) times . At both 6 and 24 weeks there were no significant differences between the groups for change in impairment ( as measured by grip strength , range of motion of wrist flexion and extension and pain intensity ) , activity limitation and participation restriction , as measured by the Patient-Rated Wrist Evaluation ( PRWE ) .  Exercise and advice given by a physiotherapist were equally as effective as  activity-focussed physiotherapy  in recovery both at 6 and 24 weeks . Conclusion : The results suggest that after removal of cast from fracture of distal radius , patients may routinely require no more than a single session of advice and exercise provided by a physiotherapist This is a prospect i ve follow up of 190 consecutive cases of volar plate avulsion fractures . A st and ard management regimen of immediate , active movement was followed in all cases and physiotherapy was rarely required . Of the 190 patients , 162 were followed up for at least one year . An excellent or good outcome was achieved in 98 per cent . Patients presenting more than three weeks from injury had a worse outcome . The size and displacement of the avulsed fragment did not affect the outcome . For the stable joint , early active mobilisation with minimal or no splintage provides a good result STUDY DESIGN R and omized controlled clinical trial . INTRODUCTION Manual edema mobilization ( MEM ) is a method of edema reduction based on the lymphatic system 's ability to drain and resolve subacute edema . PURPOSE OF THE STUDY To investigate the effect of a modified MEM approach and compare it with a traditional edema technique in patients with subacute h and /arm edema after a distal radius fracture . METHOD The patients were r and omized into one of two treatment groups : a group that received traditional edema treatment and a group that received a modified MEM treatment . All patients were examined for edema , active range of motion ( AROM ) , pain , and activities of daily living ( ADL ) . The number of edema sessions and the number of all sessions were counted . RESULT No statistically significant changes were observed in edema reduction , AROM , pain , and ADL at six and nine weeks between the treatment groups . A statistically significant improvement was observed in ADL after three weeks after inclusion ( p=0.03 ) in the modified MEM group compared with the control group . Furthermore , fewer edema treatment sessions were needed ( p=0.03 ) in the modified MEM group . At six weeks , we observed a difference between the two groups ' needs for further edema treatment ( p=0.04 ) . CONCLUSION Neither the traditional nor the modified MEM treatment program was superior in terms of edema reduction , although the modified MEM result ed in fewer sessions to decrease subacute h and /arm edema compared with using traditional edema reduction techniques in patients after distal radius fracture . LEVEL OF EVIDENCE 1 QUESTION Do dynamic splints reduce contracture following distal radial fracture ? DESIGN Assessor-blinded , r and omised controlled trial . PARTICIPANTS Forty out patients with contracture following distal radial fracture . INTERVENTION The control group received routine care consisting of exercises and advice for 8 weeks . In addition to routine care , during the day the experimental group received a dynamic splint , which stretched the wrist into extension but allowed intermittent movement . OUTCOME MEASURES The primary outcomes were passive wrist extension and the Patient Rated H and Wrist Evaluation ( PRHWE ) . The secondary outcomes were active wrist extension , flexion , radial deviation , and ulnar deviation , and the performance and satisfaction items of the Canadian Occupational Performance Measure ( COPM ) . All outcomes were measured at commencement , at the end of 8 weeks of treatment , and at 12 weeks ( ie , 1 month follow-up ) . RESULTS The mean between-group difference for passive wrist extension and PRHWE at 8 weeks were 4 deg ( 95 % CI -4 to 12 ) and -2 points ( 95 % CI -8 to 4 ) , respectively . The corresponding values at 12 week follow-up were 6 deg ( 95 % CI 1 to 12 ) and 2 points ( 95 % CI -5 to 9 ) . There were no sufficiently important between-group differences for any of the secondary outcome measures at 8 or 12 weeks . CONCLUSION It is unclear whether dynamic splints following distal radial fracture have therapeutic effects on passive wrist extension or PRHWE , but they clearly do not have any therapeutic effects on active wrist extension , flexion , radial or ulnar deviation , or on the performance or satisfaction items of the COPM . The ongoing use of dynamic splints following distal radial fracture is difficult to justify . TRIAL REGISTRATION ACTRN12608000309381 This r and omized controlled trial compares 2 mobilization regimens after  shoulder hemiarthroplasty for acute 3- and 4-part fractures . The aim was to establish whether the length of immobilization plays a role in the functional outcome , tuberosity healing , and subsequent range of motion . The same prosthesis and surgical technique were used . We recruited 59 patients into the study ; 31 were r and omized to early ( 2 weeks ) mobilization and 28 to late ( 6 weeks ) mobilization .  Greater tuberosity migration was assessed with a series of radiographs , and the functional outcome was assessed with the Constant Shoulder Assessment and Oxford shoulder scores . Of the patients , 49 ( mean age , 70 years ) met the inclusion criteria and were followed up for 12 months . Greater tuberosity migration occurred in 3 cases in the early mobilization group and once in the late mobilization group ( P > .10 ) . There was no significant difference in the Constant Shoulder Assessment and Oxford scores between the 2 groups . Although there was a decreased incidence of tuberosity migration in the group undergoing late mobilization , this was not statistically significant PURPOSE Patient-rated instruments are increasingly used to measure orthopedic outcomes . However , the clinical relevance of modest score changes on such instruments is often unclear . This study was design ed to define the minimal clinical ly important differences ( MCIDs ) of the Disabilities of the Arm , Shoulder , and H and ( DASH ) , QuickDASH ( subset of DASH ) , and Patient-Rated Wrist Evaluation ( PRWE ) question naires for atraumatic conditions of the h and , wrist , and forearm . METHODS We prospect ively analyzed 102 patients undergoing nonoperative treatment for isolated tendinitis , arthritis , or nerve compression syndromes from the forearm to the h and . By phone , patients completed the DASH , QuickDASH , and PRWE at enrollment and at 2 weeks ( n = 78 used in the analysis ) and 4 weeks ( n = 24 used in the analysis ) after initiating treatment . Patients reporting clinical improvement each contributed a single data point categorized as no change ( n = 41 ) , minimal improvement ( n = 30 ) , or marked improvement ( n = 31 ) via a vali date d anchor-based approach . We calculated the MCID as the mean change score for each outcome measure in the minimal improvement group . RESULTS The MCID ( 95 % confidence interval ) for the DASH was 10 ( 5 - 15 ) . The MCID for the QuickDASH was 14 ( 9 - 20 ) . The MCID was 14 ( 8 - 20 ) for the PRWE . The MCID values were significantly different from changes in these outcome measures at times of either no change or marked improvement . The MCID values positively correlated with baseline outcome measure scores to a greater degree than final outcome measure scores . CONCLUSIONS Longitudinal changes on the DASH of 10 points , on the QuickDASH of 14 points , and on the PRWE of 14 points represent minimal clinical ly important changes . We recommend application of these MCID values for group-level analysis when conducting research and interpreting data examining groups of patients as opposed to assessing individual patients . These MCID values may provide a basis for sample size calculations for future investigation using these common patient-rated outcome measures . TYPE OF STUDY /LEVEL OF EVIDENCE Diagnostic III We undertook a prospect i ve , controlled trial which compared two rehabilitation programmes for 86 patients who sustained two-part fractures of the proximal humerus . Patients were r and omised either to receive immediate physiotherapy within one week ( group A ) or delayed physiotherapy after three weeks of immobilisation in a collar and cuff sling ( group B ) . At 16 weeks after the fracture , patients in group A had less pain ( p < 0.01 ) and had greater shoulder function ( p < 0.001 ) than those in group B. At 52 weeks , the differences between the groups had reduced . Although group A still had greater shoulder function and less pain , there was no statistical difference when compared with group B. By analysis of the area under the curve , an overall measure up to the 52-week period , group A experienced less pain as measured by the SF36 general health question naire and had improved shoulder function . Our results show that patients with two-part fractures of the proximal humerus who begin immediate physiotherapy , experience less pain . The gains in shoulder function persist at 52 weeks which suggests that patients do not benefit from immobilisation before beginning physiotherapy IMPORTANCE The benefits of rehabilitation after immobilization for ankle fracture are unclear . OBJECTIVES To determine the effectiveness of a supervised exercise program and advice ( rehabilitation ) compared with advice alone and to determine if effects are moderated by fracture severity or age and sex . DESIGN , SETTING , AND PARTICIPANTS The EXACT trial was a pragmatic , r and omized clinical trial conducted from December 2010 to June 2014 . Patients with isolated ankle fracture presenting to fracture clinics in 7 Australian hospitals were r and omized on the day of removal of immobilization . Of 571 eligible patients , 357 chose not to participate and 214 were allocated to rehabilitation ( n = 106 ) or advice alone ( n = 108 ) , with 194 ( 91 % ) followed up at 1 month , 173 ( 81 % ) at 3 months , and 170 ( 79 % ) at 6 months . There were no withdrawals attributed to adverse effects . Recruitment terminated early on December 31 , 2013 ( planned enrollment , 342 ; actual , 214 ) , because funding was exhausted . INTERVENTIONS Supervised exercise program and advice about self-management ( rehabilitation ) ( individually tailored , prescribed , monitored , and progressed ) or advice alone , both delivered by a physical therapist . MAIN OUTCOMES AND MEASURES Primary outcomes were activity limitation assessed using the Lower Extremity Functional Scale ( score range , 0 - 80 ; higher scores indicate better activity ) , and quality of life assessed using the Assessment of Quality of Life ( score range , 0 - 1 ; higher scores indicate better quality of life ) , measured at baseline and at 1 , 3 ( primary time point ) , and 6 months . RESULTS Mean activity limitation and quality of life at baseline were 30.1 ( SD , 12.5 ) and 0.51 ( SD , 0.24 ) , respectively , for advice and 30.2 ( SD , 13.2 ) and 0.54 ( SD , 0.24 ) for rehabilitation , increasing to 64.3 ( SD , 13.5 ) and 0.85 ( SD , 0.17 ) for advice vs 64.3 ( SD , 15.1 ) and 0.85 ( SD , 0.20 ) for rehabilitation at 3 months . Rehabilitation was not more effective than advice for activity limitation ( mean effect at 3 months , 0.4 [ 95 % CI , -3.3 to 4.1 ] ) or quality of life ( -0.01 [ 95 % CI , -0.06 to 0.04 ] ) . Treatment effects were not moderated by fracture severity or age and sex . CONCLUSIONS AND RELEVANCE A supervised exercise program and advice did not confer additional benefits in activity limitation or quality of life compared with advice alone for patients with isolated and uncomplicated ankle fracture . These findings do not support the routine use of supervised exercise programs after removal of immobilization for patients with isolated and uncomplicated ankle fracture . TRIAL REGISTRATION anzctr.org.au Identifier : ACTRN12610000979055 OBJECTIVE To evaluate the immediate effect of repetitive wrist extension on grip strength in patients with distal radial fracture . DESIGN Interventional study . SETTING Patients who were admitted to a hospital department of occupational therapy . PARTICIPANTS Consecutive patients with a unilateral distal radial fracture ( N=28 ) . INTERVENTION Each patient was r and omly allocated to either the experimental group ( n=14 ) or the control group ( n=14 ) . The experimental group performed 30 repetitive wrist extensions with maximal isometric contraction of the extensors of their affected h and s during a 6-minute intervention period , whereas the control group did not perform the exercise . MAIN OUTCOME MEASURES Grip strength was measured just before and after the intervention period . Pain during grip strength measurements was also quantified using the visual analog scale . Wrist extension strength was measured 10 minutes after the grip strength measurement . RESULTS Grip strength increased immediately after repetitive wrist extension in the experimental group , but it remained the same in the control group . Visual analog scale scores indicated that pain was relieved only in the experimental group . However , pain was unrelated to strength production . CONCLUSIONS The intervention used in this study might be useful during physical examination to reveal the potential grip strength of patients . The intervention may also be an effective warm-up training procedure in preparation for conventional grip-strengthening exercises BACKGROUND The effect of formal occupational therapy on recovery after open reduction and volar plate fixation of a fracture of the distal part of the radius is uncertain . We hypothesized that there would be no difference in wrist function and arm-specific disability six months after open reduction and volar plate fixation of a distal radial fracture between patients who receive formal occupational therapy and those with instructions for independent exercises .  METHODS Ninety-four patients with an unstable distal radial fracture treated with open reduction and volar locking plate fixation were enrolled in a prospect i ve r and omized controlled trial comparing exercises done under the supervision of an occupational therapist with surgeon-directed independent exercises . The primary study question addressed combined wrist flexion and extension six months after surgery Secondary study questions addressed wrist motion , grip strength , Gartl and and Werley scores , Mayo wrist scores , and DASH ( Disabilities of the Arm , Shoulder and H and ) scores at three months and six months after surgery . RESULTS There was a significant difference in the mean arc of wrist flexion and extension six months after surgery ( 118 ° versus 129 ° ) , favoring patients prescribed independent exercises . Three months after surgery , there was a significant difference in mean pinch strength ( 80 % versus 90 % ) , mean grip strength ( 66 % versus 81 % ) , and mean Gartl and and Werley scores , favoring patients prescribed independent exercises . At six months , there was a significant difference in mean wrist extension ( 55 ° versus 62 ° ) , ulnar deviation ( 82 % versus 93 % ) , mean supination ( 84 ° versus 90 ° ) , mean grip strength ( 81 % versus 92 % ) , and mean Mayo score , favoring patients prescribed independent exercises . There were no differences in arm-specific disability ( DASH score ) at any time point . CONCLUSIONS Prescription of formal occupational therapy does not improve the average motion or disability score after volar locking plate fixation of a fracture of the distal part of the radius
target: There was preliminary evidence from one trial that exercise to the non-injured arm during immobilisation might lead to short-term benefits on increasing grip strength and range of movement following distal radius fracture .
  There is emerging evidence that current prescribed exercise regimens may not be effective in reducing impairments and improving activity following an upper limb fracture .
  Starting exercise early combined with a shorter immobilisation period is more effective than starting exercise after a longer immobilisation period .
background: QUESTION What is the effect of exercise on increasing participation and activity levels and reducing impairment in the rehabilitation of people with upper limb fractures ?
  Bruder AM , Shields N , Dodd KJ , Taylor NF ( 2017 ) Prescribed exercise programs may not be effective in reducing impairments and improving activity during upper limb fracture rehabilitation : a systematic review .