Journal of Hand Therapy xxx (2017) 1e10

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Journal of Hand Therapy

journal homepage: www.jhandtherapy.org

Scientific/Clinical Article

Supervised physical therapy vs home exercise program for patients

with distal radius fracture: A single-blind randomized clinical study
Héctor Gutiérrez-Espinoza MD a, b, *, David Rubio-Oyarzún MD a, Cristian Olguín-Huerta MD a,
Rodrigo Gutiérrez-Monclus c, Sebastian Pinto-Concha d, Gonzalo Gana-Hervias e
a
Physical Therapy School, University of the Americas, Santiago, Chile
b
Physical Therapy Department, Clinical Hospital San Borja Arriaran, Santiago, Chile
c
Hand Team of Traumatology Institute of Santiago, Santiago, Chile
d
Physical Therapy Department, Clínica las Condes, Santiago, Chile
e
Adult Orthopedic Department, Clinical Hospital San Borja Arriaran, Santiago, Chile

a r t i c l e i n f o a b s t r a c t

Article history: Study Design: Randomized clinical study.

Received 7 July 2016 Introduction: Supervised physical therapy (PT) and home exercise programs (HEPs) are frequently used in
Received in revised form the rehabilitation of patients with distal radius fracture (DRF). However, there is no consensus as to
29 December 2016
whether unsupervised HEP provides comparable benefits to those achieved by supervised PT.
Accepted 6 February 2017
Purpose of the Study: To compare the improvements in pain and functional status between a supervised
Available online xxx
PT program and unsupervised HEP in DRF patients older than 60 years.
Methods: A total of 74 patients were randomized into 2 groups. One group received 12 sessions of su-
Keywords:
Distal radius fractures
pervised PT (n ¼ 37), and the other group followed an exercise program at home (n ¼ 37). Three eval-
Physical therapy modalities uations were performed, before the initiation of treatment, at 6-week, and 6-month follow-up. The study
Home exercise program conducted a statistical power analysis to detect an intergroup difference score of 15 points on the
Elderly Patient-Rated Wrist Evaluation (PRWE). The t-test or Mann-Whitney test was used, and it was set with a
Motor skill training significance level of .05.
Randomized clinical trial Results: The supervised PT group showed clinically significant differences in the total PRWE score at 6
weeks (17.67 points, P ¼ .000) in the PRWE function score (15.2 points, P ¼ .000) and in the PRWE pain
score (5.6 points, P ¼ .039). There was also a significant difference in the total PRWE score at 6-month
follow-up (17.05 points, P ¼ .000) in the PRWE function score (14.5 points, P ¼ .000) and in the PRWE
pain score (2.5 points, P ¼ .35).
Conclusions: A supervised PT program is more effective for improving function in the short- and medium-
term when compared with HEP in patients older than 60 years with DRF extraarticular without im-
mediate complications.
Level of Evidence: 1b
Ó 2017 Hanley & Belfus, an imprint of Elsevier Inc. All rights reserved.

Introduction reported a high incidence in white populations, mostly in pa-

Distal radius fracture (DRF) is one of the most common
musculoskeletal injuries, representing 15%-20% of total fractures
treated in emergency services.1,2 Epidemiologic studies have
Ethical approval: The Ethics Committee of the Servicio de Salud Metropolitano
Central in Chile approved the study protocol on January 20th 2011.
Conflicts of interest: The authors declare no potential conflicts of interest
regarding the research, authorship, and/or publication of this article.
* Corresponding author. Physical Therapy School, University of the Americas,
Echaurren Street 140, 3rd floor, Santiago, Chile 8320000. Tel.: þ569 92999298.
E-mail address: kinehector@gmail.com (H. Gutiérrez-Espinoza).
tients older than 60 years.3,4 In this age group, it is the second
most common type of fracture, after hip fractures,5,6 with
almost 4 times more injuries in women than men.7 DRFs in
patients have typically been treated conservatively with closed
reduction and plaster cast immobilization.8 However, this
method of treatment failed to maintain reduction and reported
redisplacement and malunion rates in over 50% of cases.9 The
age is one of the most significant risk factors for the loss of
reduction and secondary fracture displacement.10-12 Despite
this, the current evidence shows that in elderly patients,
the improvement in function is independent of the residual
deformity.13-20

0894-1130/$ e see front matter Ó 2017 Hanley & Belfus, an imprint of Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.jht.2017.02.001
2 H. Gutiérrez-Espinoza et al. / Journal of Hand Therapy xxx (2017) 1e10
After the immobilization period, physical therapy (PT) is vitally
important, although its indications are not based on defined
criteria. PT is prescribed to reduce pain, restore range of motion
(ROM), and improve muscle strength and function.21 The thera-
peutic interventions that are used to achieve these aims can be
classified as active or passive interventions. Active interventions
refer to techniques where the patient is required to take an active
role in their rehabilitation, such as advice, a home exercise program
(HEP), or a program supervised by a physical therapist.22 Passive
interventions refer to techniques where the patient takes a passive
role during its application, such as massage, joint mobilization (JM),
and the use of physical agents such as ultrasound, hot pack, and
transcutaneous electrical nerve stimulation.22,23 In this respect, the
systematic review (SR) by Handoll et al24 concluded that the evi-
dence is insufficient to establish the effectiveness of the various
interventions used in the rehabilitation of adults with DRF in
improved function. However, active interventions, such as exercise
and advice, are most commonly used by physical therapists to treat
these patients. HEPs are the most frequently used exercise pre-
scription techniques.22-26
The study of Bruder et al22 showed that advice and home ex-
ercises were prescribed significantly more in patients with the
extraarticular type of DRF than in those with the intraarticular type
(P < .01) and in patients older than 50 years compared with
younger ones (P < .05). However, the current evidence has shown
controversial results regarding the effectiveness of a treatment
program conducted and supervised by a physical therapist vs the
one performed in adults with DRF at home. The SR by Gutiérrez
et al21 concluded that in medium term, the evidence is controver-
sial regarding whether a treatment program performed by a
physical therapist is more effective than an exercise program at
home in these patients. The SR by Valdes et al26 concluded that
available evidence was insufficient to support a home program or
supervised PT program as a superior method of treatment for
adults after a DRF without complications or presence of comor-
bidity. The results of the 2 randomized clinical trials (RCTs), con-
ducted in elderly patients with DRF treated conservatively, showed
only significant differences in favor of the supervised PT by
increasing the flexion-extension ROM and extension of the wrist,
respectively, in a short term,27,28 but there is no significant differ-
ences in pain or function.
By analyzing the information from published RCTs, some
methodological limitations in the selection criteria made the
generalization of the results of these studies difficult. For example,
patients across a wide range of ages, Krischak et al29 included pa-
tients aged between 18 and 76 years, and Valdes et al30 included
patients aged between 23 and 93 years. The SR by Diaz-Garcia
et al31 and Chen et al32 introduced a cutoff value for patients
older than 60 years when analyzing the evidence of different types
of treatment in elderly patients. Diaz-Garcia et al31 concluded that
despite worse radiographic outcomes associated with cast immo-
bilization, functional outcomes were no different from those of
surgically treated groups for patients aged 60 years and older. Chen
et al32 concluded that the current literature does not support the
theory that operative management can provide better clinical
outcomes in patients aged 60 years and older with DRF. Due to the
functional demands in this age group, the fracture reduction does
not appear to be as strongly associated with functional outcomes as
it does in younger patients.13,14,16,20 Other limitations were that the
studies lacked clarity as to specific interventions or treatments used
for home instruction or supervised therapy and provided limited or
no information related to the types, frequency, or duration of the
specific exercise or activity performed during treatment. Finally, no
study mentioned how these aspects might have affected their
conclusions and the extrapolation of their results.
The main objective of this RCT was to compare the improve-
ments in pain and functional status between supervised PT pro-
gram and unsupervised HEP in DRF patients older than 60 years
treated conservatively. The specific objectives were to compare the
effect of both treatments in the short (6-week follow-up) and
medium term (6-month follow-up) and to determine whether
there is a correlation between the acceptable DRF alignment eval-
uated by radiological criteria and the functional results.
Methods
This RCT was conducted in the PT department at the San Borja
Arriaran Clinical Hospital approved by the ethical committee in
Servicio de Salud Metropolitano Central in Chile. Between 2012 and
2015, 74 patients older than 60 years with an A3 extraarticular
multifragmentary DRF type, according to the AO/ASIF classification
system, were recruited.33 The diagnosis, performed by an ortho-
pedic surgeon, was based on the clinical presentation and radio-
logical studies. All patients were treated with closed reduction and
plaster cast immobilization for 6-7 weeks. At 4 weeks after
reduction, all patients underwent a radiological assessment to
evaluate the results of the closed orthopedic reduction. The study
was based on anteroposterior and lateral radiographs, where the
following extraarticular radiological parameters were measured:
radial inclination angle (normal, 21 -25 ), radial height (normal,
10-13 mm), volar angulation (normal, 7 -15 ), residual dorsal
angulation, and ulnar variance (normal, 0.7-1.5 mm).34 Subsequent
to cast removal, all patients were prescribed acetaminophen 500
mg every 8 hours for 7 days and were referred for PT.
Clinical assessment included administration of the Patient-
Rated Wrist Evaluation (PRWE) questionnaire to measure pain
and functions, dynamometer for measuring grip strength, visual
analog scale (VAS) for measuring pain intensity, and active ROM for
wrist flexion and extension.
Inclusion and exclusion criteria
The following patient inclusion criteria were applied:
 Patients older than 60 years who were forwarded from the
Department of Orthopedic Surgery. These patients had to be
diagnosed with an A3 extraarticular multifragmentary DRF type
according to the AO/ASIF classification system and treated
conservatively with closed reduction and plaster cast
immobilization.
 Informed consent accepted and signed by the subject.
The following patient exclusion criteria were applied:
 Patients treated with any type of surgical intervention for the
reduction and/or fixation of DRF (eg, volar plate, external fixa-
tion, and Kirschner wires).
 Patients with some degree of cognitive impairment with a score
less than 26 points on the Mini-Mental State Test (MMST).
 Patients with immediate complications after the removal of the
immobilization. Two diagnostics were performed by an ortho-
pedic surgeon, one evaluated carpal tunnel syndrome (CTS)
clinical history, using an examination in accordance with Bland’s
criteria.35 For suspected complex regional pain syndrome (CRPS),
the Budapest diagnostic criterion was used.36
Sample size hypothesis
Stata software (StataCorp. 2013, Stata Statistical Software:
Release 13; College Station, TX) was used to calculate the sample
 H. Gutiérrez-Espinoza et al. / Journal of Hand Therapy xxx (2017) 1e10
size. The initial data required were extracted from the RCT that was
conducted by Krischak et al.29 At the end of treatment (week
number 6), the group treated with HEP reported an average of 18.5
in the PRWE questionnaire with a standard deviation of 15.9 points.
Considering the studies of Sorensen et al37 and Walenkamp et al,38
a difference of at least 15 points was established as a minimal
clinically important difference for the group treated with super-
vised PT. Therefore, the authors of this study have proposed as an
experimental hypothesis that a reduction of at least 15 points on
the PRWE questionnaire should be observed in the group treated
with supervised PT compared with the home exercise group. To
detect this difference between the 2 treatments with an a ¼ 0.05
(probability of committing a type I error) and a statistical power of
95%, a minimum of 30 patients per group was required. We
considered adjusting the sample size for possible dropouts, a 20%
more patients on each group were recruited.
Randomization and blinding
The participants were randomly assigned to 1 of 2 groups
through a sequence of numbers generated by a computer program
before starting the selection process. The group assigned to each
patient was kept in a sealed envelope with the aim of concealing
the assignment from the investigator who was adjudicating the
admission of the subjects to the study (an orthopedic surgeon with
15 years of clinical experience).
The physical therapists and their patients, considering the na-
ture of the therapeutic interventions studied, could not be blinded.
However, the evaluator did not know to which group the subjects
were assigned when measuring the studied variables.
Interventions
The supervised PT program consisted of 15 minutes of active
wrist and hand exercises in a whirlpool at a temperature of 34 C.39
Then, JM was applied to the radiocarpal joint. During the first 2
weeks, participants received grade II or III of Maitland techniques,
at a dose of 1 cycle per second for 1 minute. In the remaining 4
weeks, sustained grade I gliding Kaltenborn method was per-
formed in both anteroposterior and posteroanterior directions, in a
neutral position with the distal radius stabilized. Treatment then
progressed to incorporate the end of range movement with the
mobilization grade II technique.40,41 The applied dose was left to
the discretion of the physical therapist but based on examined
findings and the patient’s tolerance.
Finally, exercises based on motor skill training were prescribed
to reorganize cortical plasticity and achieve motor learning.42-44
Three specific exercises were performed: (1) controlled grip
strength exercise with visual pressure biofeedback; (2) a reverse
dart-throwing exercise with precision of the first interosseous
space; and (3) a scapular retraction exercise. To avoid pain and
muscle fatigue, patients were doing short duration and low-
intensity exercises. The dose was 8-10 times for each exercise,
maintaining the task for 5 seconds with 10-30 seconds of rest in
between. The program consisted of 12 sessions, 2-3 times a week
and approximately 1-hour-long session (Fig. 1).
The other group received the HEP proposed by Krischak et al.29
Before the initiation of treatment, all patients received a 30-minute
consultation by a physical therapist, in which patients were
instructed to do the proper exercise at home. They were given a
printed document with a detailed description of the 6-week
treatment, which described the type of exercise, number of repe-
titions, intensity of the exercise, and workout rest time. The exer-
cises were grouped by week in accordance with the phases of
wound and fracture healing. During the first 2 weeks, the highest
3
priority was pain reduction and reduction of edema. After the
second week, passive exercises were introduced to stretch soft
tissues in patients. In addition, early active motions without resis-
tance were added to therapy to increase muscle activity, these ex-
ercises included finger stretching and spreading exercises, grip
strength exercises, forearm stretching, bending and stretching
elbow exercises, as well as abduction/adduction and external/in-
ternal rotation of the arm. Starting the second week, proprioceptive
neuromuscular facilitation stretching was performed as an exer-
cise. In the fifth week, dynamic muscle exercises with light resis-
tance were added. The treatment lasted 20-30 minutes, 2 times a
day.
At the end of the third week of treatment, a physical therapist
called the subjects on the phone to assess the level of adherence
and the presence of associated complications.
Measuring variables
Three evaluations were performed on both groups: the first
before the initiation of treatment, another at the end of week
number 6, and the third at the end of the follow-up after 6 months.
These assessments were performed by a physical therapist, not
associated with the research team, who had a Master’s Degree in
Manual Orthopaedic Therapy and more than 10 years of clinical
experience.
Primary outcome measures
Wrist/hand pain and function were evaluated by the PRWE
questionnaire, which is the specific instrument most frequently
used and recommended for evaluation of function in DRF pa-
tients,45,46 originally described by MacDermid.47 Initially, the pur-
pose of the questionnaire was to provide a valid and reliable tool for
measuring pain and wrist disability in patients with DRF.48 In 2004,
it was modified for additional use in the evaluation of hand pa-
thologies.49 The PRWE contains 2 subitems: the pain item contains
5 questions, and the function item has 10 questions; both using a
rating scale from 0 to 10 points. The final score ranges from 0 (no
pain/disability) to 100 (severe pain/disability).48 The PRWE has
proven to be a valid and reliable instrument in assessing pain-
reported and functional impairment outcomes for all patients
with DRF.50
Secondary outcome measures
A Jamar Dynamometer was used to test grip strength (Lafayette
Hydraulic Hand Dynamometer, Model J00105),51 and the mea-
surements were used as recommended by the American Society of
Hand Therapists.52 The participants were evaluated while seated,
with their arm placed to the side of the body; they had their
shoulders in neutral position, the elbow flexed to 90 , and the
forearm in neutral rotation. Then, patients were verbally instructed
to make tight fists with all their strength to hold that position for 4
seconds with their hands and then rest for 30 seconds on each set.
First, the unaffected side was evaluated and after that, the affected
side was evaluated. In both cases, the highest value obtained from 3
attempts was recorded.53 An adjustment of 6% between the force of
the dominant and nondominant side was made.54 The final result
was expressed as a percentage relative to the unaffected side. This
valid and reliable instrument serves as a reference standard for
evaluating the gripping function in patients with DRF.55-58
The VAS is a pain measurement scale, which is composed of a
10-cm straight line, the left end indicates “no pain” (score of 0) and
the far right end indicates the “worst pain imaginable” (score of 10).
The patient was asked to draw a vertical line indicating the
magnitude of the pain experienced at the evaluation. It is a simple
4 H. Gutiérrez-Espinoza et al. / Journal of Hand Therapy xxx (2017) 1e10
Weeks DescripƟon
1-6 Whirlpool at 34 ° Celsius: acƟve wrist and
hand exercise.
1-3 Radio-carpal mobilizaƟon grade II or III
oscillatory technique by Maitland
3-6 Radio-carpal mobilizaƟon sustained
grade I A-P and P-A in neutral
posiƟon.
Progressed to incorporate radio-
carpal mobilizaƟon sustained grade II
at end of range by Kaltenborn.
1-6 Controlled grip strength exercise with
visual pressure biofeedback
Graduate control "reverse dart-
1-6
throwing with precision of the first
interosseous space.
1-6 Scapular retracƟon exercise.
Fig. 1. Detailed description of the supervised physical therapy program.
1-dimensional method that should be recommended to all patients
with DRF.59,60
A goniometer was used to measure active wrist flexion and
extension. The evaluation technique was ROM through a lateral
approach. Participants were evaluated in a sitting position to un-
cover their arms and to remove any accessories. This measure is
also recommended for included in the evaluation of all DRF
patients.60
In addition, before the beginning of the treatment, the cognitive
status of all patients was evaluated using the MMST, a test created
in 1975 by Folstein et al.61 This questionnaire is very well known,
and it is one of the most common examinations for performing a
brief standardized cognitive evaluation in elderly and it is used
extensively in clinical settings.62,63 There have been different ver-
sions and adaptations of this examination into Spanish, and
therefore sometimes, the validity and reliability can be ques-
tioned.63,64 The scores that patients with mild-to-moderate
cognitive impairment have in this questionnaire are influenced by
a number of sociodemographic variables, such as age and educa-
tional level.65,66 However, the cutoff scores are variables,67 we set
Figures Frequency
15 minutes for session.
One cycle per second for 1 minute.
Maintained glide for 30 seconds at 1
minute.
Pressure 5 seconds, 8 to 10 reps, and 10 to
30 seconds rest between reps.
Pressure 5 seconds, 8 to 10 reps, and 10 to
30 seconds rest between reps.
8 to 10 reps, and 10 to 30 seconds rest
between reps.
them at 26/27 in our study to make sure that patients could follow
simple commands and also could follow therapeutic indications for
their treatments.
Statistical analysis
All collected data were entered into the Excel for tabulation, and
the statistical analysis was performed using the Stata software
(StataCorp. 2013, Stata Statistical Software: Release 13; College
Station, TX). The quantitative variables are presented as means and
standard deviation and the qualitative variables as number and
percentage. To determine the statistical tests in the data analysis,
we first evaluated the normal distribution data with the Shapiro-
Wilk test. Then, to compare the initial baseline data of gender
and dominant side of the patient, the chi-squared test was used.
Student’s test (t-test) or the Wilcoxon test (Mann-Whitney) was
used for the remaining variables.
First, within each group, differences in the scores of total PRWE,
PRWE function, PRWE pain, grip strength, VAS, and active ROM
wrist flexion/extension were examined. Because 3 evaluations were
 H. Gutiérrez-Espinoza et al. / Journal of Hand Therapy xxx (2017) 1e10
conducted, analysis of variance (ANOVA) or Friedman test for
dependent samples was used. One-way ANOVA with repeated
measure was used with the time as independent variable. To
compare final results between each group, we used the t-test or
Mann-Whitney test for 2 independent samples; in both cases, a
significance level of 0.05 was set. After considering the sample size,
the confidence intervals of 95% for the differences in average be-
tween the 2 groups were calculated using the conventional
method.
The radiological parameters (dorsal angulation, radial inclina-
tion, and radial shortening) were analyzed as categorical variables
(within the acceptable and unacceptable parameters). The Mann-
Whitney test was used to determine the influence of the radio-
logical parameters on the functional results obtained with the total
PRWE questionnaire, this analysis was performed in 74 patients
that were included in the study, without considering an analysis
according to the type of treatment received. The chi-squared test
was used to determine whether correlation existed between the
acceptable DRF alignment evaluated by radiological criteria and the
functional results obtained with the total PRWE questionnaire.
Before conducting the study, researchers decided to conduct an
intention-to-treat statistical analysis; if data were lost, these pa-
tients would not be marginalized from the statistical calculation or
the resulting analysis.
Results
In this present study, researchers decided to conduct an
intention-to-treat statistical analysis, and it was not necessary
because no data were missing, the results of all patients were
included (Fig. 2). The results of the baseline characteristics of each
Fig. 2. Flow diagram of patients through phases of clinical study.
5
group are shown in Table 1. Patient age ranged from 60 to 75 years
with an average of 72.1 years for those in the supervised PT group
and 71.6 for those in the HEP group; 94.6 and 97.3% of the samples
were women, respectively. All were treated with closed reduction
and plaster cast following a 6.4- to 6.5-week immobilization period.
In terms of dominance, between 86.5% and 91.9% were affected on
the dominant side. In the supervised PT group, 6 patients did not
attend to 2 sessions of treatment due to health problems unrelated
to the DRF. In regard to complications associated with both treat-
ment protocols, at week number 3 of treatment, 4 patients in the
HEP group reported intense pain, which required a visit to the or-
thopedic surgeon to evaluate their condition. At the 6-month
follow-up, no patients in this group reported complications asso-
ciated with their treatment.
When analyzing the test for normality, VAS, grip strength, active
ROM wrist flexion, and extension rejected the analysis; this is the
reason why the nonparametric Mann-Whitney test was used to
make the comparison. The total PRWE score, PRWE function,
and PRWE pain presented normality in their distribution; therefore,
the t-test was used. None of the variables evaluated at the begin-
ning presented significant differences (all P values were greater
than .05).
The average values of the variables were evaluated at the
beginning of the study, at 6-week, and 6-month follow-up are
shown in Table 2. For data analysis of the total PRWE, PRWE
function, and PRWE pain variables, we used the 1-way ANOVA, and
Friedman test was used because the normality hypothesis was
rejected for all the other variables. An analysis was performed
within each group to compare with the initial data, at week number
6, both groups significantly improved in all the parameters that
were evaluated at the beginning (P < .05), except PRWE function in
6 H. Gutiérrez-Espinoza et al. / Journal of Hand Therapy xxx (2017) 1e10

Table 1
Baseline characteristics of patients with DRF in both treatment groups

Baseline characteristics Supervised PT group, N ¼ 37 HEP group, N ¼ 37 P value

Gender, female (number, %) 35/37, 94.6% 36/37, 97.3% .347a
Age (y), mean (SD) 72.10 (7.44) 71.62 (7.83) .680b
Immobilization time (wk), mean (SD) 6.54 (0.90) 6.48 (0.90) .834b
Fractured dominant hand (number, %) 32/37, 86.5% 34/37, 91.9% .560a
Radial inclination (degrees), mean (SD) 13.6 (5.3) 14.3 (2.6) .782b
Radial height (mm), mean (SD) 3.5 (2.6) 4.1 (1.9) .613b
Volar angulation (degrees), mean (SD) 7.4 (8.6) 9.2 (10.3) .228b
Dorsal angulation (degrees), mean (SD) 15.7 (7.1) 14.2 (9.3) .351b
Ulnar variance (mm), mean (SD) 2.5 (3.4) 2.1 (3.6) .127b
Total PRWE (0-100 points), mean (SD) 68.08 (8.29) 68.56 (11.40) .834c
PRWE function (0-50 points), mean (SD) 40.2 (8.6) 38.4 (6.8) .538c
PRWE pain (0-50 points), mean (SD) 30.2 (4.9) 29.5 (6.7) .453c
VAS (cm), mean (SD) 6.08 (0.98) 5.81 (1.07) .275b
Active ROM wrist flexion (degrees), mean (SD) 31.75 (5.02) 35.00 (13.07) .274b
Active ROM wrist extension (degrees), mean (SD) 38.51 (6.33) 34.59 (9.15) .071b
Grip strength (%), mean (SD) 27.29 (11.09) 26.6 (13.33) .657b

DRF ¼ distal radius fracture; HEP ¼ home exercise program; PRWE ¼ patient-rated wrist evaluation; PT ¼ physical therapy; ROM ¼ range of motion; SD ¼ standard deviation;
VAS ¼ visual analog scale.
a
P value: obtained with the chi-square test.
b
P value: obtained with the Mann-Whitney test for independent samples.
c
P value: obtained with the t-test for independent samples.

the HEP group (P ¼ .24). At 6-month follow-up, the supervised PT
group showed significant changes in the reduction of their total
PRWE score, PRWE function, grip strength improvement, and active
ROM increases for wrist flexion and extension. The VAS (P ¼ .400)
and PRWE pain (0.086) variables did not show significant
changes. In contrast, at the end of the follow-up, the HEP group
showed significant changes in the total PRWE score, PRWE pain,
and VAS (P < .05).
Treatment effects are shown in Table 3, which compares the final
values between both groups at the 6-week and 6-month follow-ups
(Fig. 3). When comparing the results between both treatments at
week 6, significant differences were observed favoring the super-
vised PT group. Examining the results of the total PRWE question-
naire, the difference was statistically and clinically significant with
17.67 more points (P ¼ .000) for the experimental group, confirming
our experimental hypothesis at the beginning of the study. The other
differences were PRWE function, 15.2 points (P ¼ .000); PRWE pain,
5.6 points (P ¼ .039); VAS, 1.78 cm (P ¼ .000); wrist active ROM
flexion, 12.29 (P ¼ .000); wrist active ROM extension, 20.27
(P ¼ .000); and grip strength, 21.21% (P ¼ .000). At the end of the
6-month follow-up, differences favoring the supervised PT group
were observed again in all variables studied. For the total PRWE
questionnaire, the clinically and statistically significant difference
remained at 17.05 points (P ¼ .000). The other differences shown in
the study were PRWE function, 14.5 points (P ¼ .000); PRWE pain,
2.5 points (P ¼ .35); VAS, 0.97 cm (P ¼ .000); for wrist active ROM
flexion,17.70 (P ¼.000); for wrist active ROM extension, 19.05 ; and
finally, for grip strength, 25.81% (P ¼ .000). Confidence intervals
confirm the hypothesis that the supervised PT treatment obtained
better results than the HEP in patients with DRF.

Table 2
Summary of results that evaluate the response to treatment within each group

Outcome Baseline, mean (SD) 6 wk, mean (SD) P valuea 6 mo, mean (SD) P valueb
Total PRWE
Supervised PT group 68.08 (8.29) 27.94 (9.26) <.001c 15.75 (6.16) <.001c
HEP group 68.56 (11.40) 45.62 (15.80) <.001c 32.81 (14.21) <.001c
PRWE Function
Supervised PT group 40.2 (8.6) 20.2 (4.6) <.001c 8.4 (3.2) <.001c
HEP group 38.4 (6.8) 35.4 (10.2) .024c 25.6 (13.5) .073c
PRWE pain
Supervised PT group 30.2 (4.9) 14.1 (8.2) <.001c 10.1 (4.5) .086c
HEP group 29.5 (6.7) 19.3 (7.6) .001c 12.9 (5.8) .001c
VAS
Supervised PT group 6.08 (0.98) 1.27 (0.90) <.001d 0.94 (0.88) .400d
HEP group 5.81 (1.07) 3.05 (1.76) <.001 d 1.91 (1.01) .001d
Active ROM wrist flexion
Supervised PT group 31.75 (5.02) 61.35 (8.94) <.001d 71.08 (4.87) <.001d
HEP group 35.00 (13.07) 49.05 (15.08) <.001d 53.37 (15.59) .618d
Active ROM wrist extension
Supervised PT group 38.51 (6.33) 71.08 (6.25) <.001d 77.02 (2.48) <.001d
HEP group 34.59 (9.15) 50.81 (18.20) <.001d 57.97 (15.78) .122d
% Grip strength
Supervised PT group 27.29 (11.09) 66.35 (9.40) <.001d 78.64 (7.23) <.001d
HEP group 26.62 (13.33) 45.13 (18.98) <.001d 52.83 (21.16) .211d

HEP ¼ home exercise program; PT ¼ physical therapy; PRWE ¼ patient-rated wrist evaluation; ROM ¼ range of motion; SD ¼ standard deviation; VAS ¼ visual analog scale.
a
P value difference between baseline and the sixth week.
b
P value difference between the sixth week and sixth month.
c
P value: obtained with parametric ANOVA test for dependent samples.
d
P value: obtained with the nonparametric test for dependent samples: Friedman test.
 H. Gutiérrez-Espinoza et al. / Journal of Hand Therapy xxx (2017) 1e10 7

Table 3 chi-squared correlation coefficient was 0.102 (P ¼ .750). As such,

Comparison of the final results between groups little or no correlation between the 2 variables has been shown, and
Outcome Effect of 95% CI difference P value there is no significant relationship between the radiological results
treatment,a between groups and functional results in the medium-term timeframe for patients
mean (SD) with DRF treated conservatively.
Total PRWE
6 wk 17.67 (19.70) 23.70 to 11.64 <.001b
Discussion
6 mo 17.05 (15.53) 22.17 to 11.93 <.001b
PRWE function
6 wk 15.2 (10.6) 21.5 to 12.6 <.001b This RCT compared the clinical effectiveness of 2 treatment
6 mo 14.5 (12) 20.9 to 11.4 <.001b programs in patients with DRF older than 60 years treated
PRWE pain conservatively. For 6-week and at 6-month follow-up, the patients
6 wk 5.6 (8.1) 2.1 to 10.9 .039b
6 mo 2.5 (4.1) 1.2 to 6.3 .35b
performed a supervised PT program, consisting of hydrotherapy,
VAS manual therapy, and an exercise program based on motor skill
6 wk 1.78 (2.13) 2.43 to 1.13 <.001c training. The supervised PT program showed a clinical and signif-
6 mo 0.97 (1.38) 1.41 to 0.53 <.001c icantly greater improvement in wrist function compared with a
Active ROM wrist flexion
detailed HEP as described by Krischak et al.29
6 wk 12.29 (18.54) 18.06 to 6.52 <.001c
6 mo 17.70 (17.02) 23.11 to 12.28 <.001c The optimal treatment for elderly patients with DRF has been
Active ROM wrist extension very controversial,13,31,32,68,69 since malunion or redisplacement in
6 wk 20.27 (19.03) 26.64 to 13.89 <.001c these patients does not necessarily translate into unsatisfactory
6 mo 19.05 (15.89) 24.37 to 13.73 <.001c functional outcomes. In addition, many patients have satisfactory
% Grip strength
6 wk 21.21 (19.90) 28.20 to 14.22 <.001c
functional results despite an imperfect reduction or malunion.13-20
6 mo 25.81 (22.50) 33.22 to 18.40 <.001c The lack of association between the radiographic results and
functional outcomes in patients older than 60 years could be
CI ¼ confidence interval; PRWE ¼ patient-rated wrist evaluation; ROM ¼ range of
motion; SD ¼ standard deviation; VAS ¼ visual analog scale. related to lower functional demand in the upper extremity that is
a
Difference between the final values of PT supervised group and HEP group. thought to be associated with aging.14 Some authors propose that
b
P value: obtained with t-test for independent samples. categorizing elderly patients into low-demand and high-demand
c
P value: obtained with Mann-Whitney test for independent samples. groups may improve the therapeutic management of DRF.68,69
These patients have been treated conservatively with closed
reduction and plaster cast immobilization,8 although this method
Based on the study of Grewal et al,17 “unacceptable alignment”
of treatment has reported redisplacement rates in over 50% of the
was considered > 10 of dorsal angulation, < 15 radial inclination,
cases.9 However, variable rates have been reported in secondary
and  3 mm for positive ulnar variance. According to these criteria,
displacement due to the disparity of the criteria used for its defi-
only 14 patients (10.3%) of all 74 patients in the study had an
nition and the lack of consensus regarding the radiological indices
acceptable alignment of the fracture at the beginning of both
and range of values that determine an acceptable DRF reduc-
treatment protocols. The presence of DRF malalignment in patients
tion.70,71 The recent meta-analysis of the studies published by
did not influence the results in the reports in terms of function; the
Walenkamp et al72 may partly explain our findings because the
total PRWE score (P ¼ .542) was not significantly different when
only significant predictors of secondary DRF displacement are fe-
comparing the patients with unacceptable alignment, also the
male gender, age > 60-65 years, and dorsal comminution. Despite
the suboptimal results for fracture alignment based on the radio-
logical criteria, our sample of patients demonstrated no correlation
between “acceptable alignment” and the functional outcomes
evaluated with the total PRWE questionnaire. These findings are
similar to those reported by Grewal et al17 that in 65-year-old pa-
tients and older, the presence of malalignment of the distal radius
did not influence patient reports related to pain and disability
neither in the PRWE (P ¼ .224) nor the disability of arm, shoulder
and hand (DASH) (P ¼ .386). In addition, others studies have shown
that elderly, patients with physically nondemanding lifestyles
tolerate residual deformity well.14,16,18,19
With respect to complications after DRF, for reasons of ethical
consideration in our study, we excluded 1 patient with CTS and 4
patients with suspected CRPS. A review of the literature revealed
that there is a great amount of variability in complication data re-
ported.73,74 The study of Shauver et al75 showed that the probability
in complications in elderly patients with DRF treated with cast
immobilization was 0.15 and in the immediate complications of CTS
and CRPS was 0.12. Waljee et al showed that in the United States,
from a total of 46,754 patients over 65 years with DRF, 2,395 pa-
tients, equivalent to 5.1%, presented immediate complications, such
Fig. 3. Graphic PRWE from the baseline to end of follow-up for both groups (95% CI). as CTS or CRPS.76 MacDermid et al77 affirmed that patients without
The graphic compares the total PRWE scores of both groups; at baseline, there is no complications require less professional clinical supervision than
significant difference, at 6 weeks was observed that the supervised PT group has 17.67 those with complications immediately after DRF. These consider-
points less than HEP group (P ¼ .000), and at 6 month, follow-up there was a statis-
tically significant difference between groups 17.05 points in favor the group receiving
ations are relevant to Valdes et al, who concluded in their SR that
PT supervised. CI ¼ confidence interval; HEP ¼ home exercise program; PRWE ¼ patients with DRF who equally benefited from a supervised PT
patient-rated wrist evaluation; PT ¼ physical therapy. program and a HEP were those without immediate complications
8 H. Gutiérrez-Espinoza et al. / Journal of Hand Therapy xxx (2017) 1e10
after the removal of the immobilization.26 Importantly, the results
of our study cannot be extrapolated to patients with complications,
based on anecdotal clinical experience, suggesting that patients
who present with complications require heightened clinical
expertise and direct supervision for improved functional results.30
Our results are not concordant with other RCTs published in the
literature.27-30 Krischak et al29 and Valdes et al30 found no signifi-
cant differences in the PRWE questionnaire in the short and me-
dium term, respectively. Wakefield et al27 found no differences in
the functional activities evaluated in the short and medium term
between both groups. Finally, the RCT of Watt et al28 did not use any
specific instruments to evaluate function. Some clinical and
methodological differences might explain this disparity. With
respect to the patient selection criteria, we included only one
subtype of fracture; the other RCTs included several types of DRF
(combined both intraarticular and extraarticular DRF).27-29 or did
not report the type.30 This was to ensure that the clinical condition
studied was as homogeneous as possible and that the variability
associated with the different degrees of injury complexity would
not influence the final results of each group. Regarding age, only the
studies of Wakefield et al27 and Watt et al28 reported age similar to
our average (72 and 74 years). The patients in the RCTs of those
studies were treated with closed reduction and plaster cast
immobilization, unlike those of Krischak et al29 and Valdes et al30
who were treated with volar plate surgery. Concerning the super-
vised PT treatment, these studies only provided general de-
scriptions27,28,30 or none at all because such treatment remained at
the discretion of the physical therapists.29 Wakefield et al27 and
Watt et al28 did not report dosage, whereas Krischak et al29 and
Valdes et al30 conducted twice-weekly sessions with a total of 12
and 16 sessions overall. With respect to the HEP, only the RCT of
Krischak et al29 described the types of exercises and their repeti-
tions in detail.
In our supervised PT program, all patients began with 15 mi-
nutes of active wrist and hand exercises in a whirlpool, we used
thermoneutral water immersion (34 C), which decreases the ac-
tivity of the sympathetic nervous system, and when combined with
the effects of hydrostatic pressure, helps reduce edema and pain
perception.39 In addition, performing active movements in a pain-
free ROM, and in a comfortable environment for the patient, de-
creases associated reactive and/or evasive behavior as a means of
self-protection, thereby reducing the apprehension of movement in
the affected area.
Then, JM was performed; these manual therapy techniques
were used to increase ROM and to decrease pain.78 JM is the most
frequent passive intervention used in rehabilitation for patients
with DRF,22 although the SR by Heiser et al78 reported that oscil-
lating and/or sustained techniques only have moderate evidence of
short-term pain reduction and improvement in ROM of the wrist.
Usually, patients older than 60 years present with osteoporosis or
other bone health problems; this condition is a relative contrain-
dication to JM, depending on the intent and direction of move-
ment.79 Despite these RCTs in elderly patients, they did not report
problems with pain tolerance related to techniques or dosage. Kay
et al41 reported only 1 patient who left his study because he found
the technique of mobilization uncomfortable. Coyle et al40 reported
no related complications to JM techniques. In our study, 3 patients
reported mild discomfort when performing the sustained grade II
Kaltenborn gliding techniques, and in these cases, dosage was
adjusted. JM was used following the example of Coyle et al in
which, using a “cross-over” methodological design, they showed
that both techniques improved active ROM and reduced pain,
depending, however, on the time of the application of each tech-
nique. During the first 2 weeks of treatment, when pain levels are
high, the oscillatory techniques are better tolerated and more
effective in increasing wrist active ROM. From week number 3,
when pain levels are lower, mainly at rest, the sustained gliding
techniques are more effective.40
Although the primary therapeutic objective of PT should be the
improvement of function, short- and long-term studies have shown
that the physical impairments more commonly reported in DRF
patients are in active ROM and grip strength.80 Despite these
findings, current evidence supports sensorimotor system alter-
ations as the most clinically relevant impairment after fracture.81
These deficits have been suggested to result from cortical reorga-
nization, which would be influentially associated with persistent
and recurrent pain42,82 and have been significantly correlated with
poor results in reported functionality and disability.77 The gradual
reintroduction of functional activity using therapeutic exercise
with a focus on graduated corticomotor retraining is founded on
the neurophysiology of motor learning.42 The conscious and
voluntary learning of specific motor skills, such as control of
scapular retraction, gradual wrist prehensile activity, and subtle
manual skills require precision, decreasing the fear of the perceived
threat of pain, reducing local rigidity, and modifying the cortical
representation of the musculature affected by trauma.42,44,82
In our study, we decided to incorporate an evaluation using the
MMST as a criterion for the sample selection and to thereby ensure
that patients in both groups possessed a cognitive level that
allowed them to follow simple commands and therapeutic in-
dications. However, the level of adherence in the HEP group was
only assessed through a telephone call after the third week of
treatment. This is an important limitation of our study because
Lyngcoln et al83 found a significant correlation between adherence
to HEP and short-term clinical outcomes in DRF patients, who were
treated conservatively. This is a very important aspect to consider
when prescribing or indicating PT to elderly patients with DRF.
In addition, our RCT presents some limitations. One important
limitation was the exclusion of patients with immediate compli-
cations subsequent to the removal of the immobilization. Despite
contemplating a short- and medium-term follow-up, the long-term
(after 1 year) effectiveness of therapeutic interventions remains
important to determine. In addition, the blinding of the physical
therapists and patients was not achievable given the nature of the
interventions studied. Finally, all these considerations must be
examined when attempting to extrapolate the results of our study
to DRF patients younger than 60 years, with immediate complica-
tions, with intraarticular fractures and/or subjected to any type of
surgical intervention. There should be more research in terms of
evaluating the effectiveness of the supervised PT program proposed
in these patients.
Conclusion
A supervised PT program is effective in the short and medium
term, showing a clinically and statistically significant increase in
function. This treatment also reduces pain and improves wrist ROM
compared with a HEP in patients older than 60 years with DRF
extraarticular AO/ASIF type 3 without immediate complications.
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