The Effect of Two Different Protocol in Wrist Joint Limitation After Distal Radius End Fractures
Condition: Distal Radius Fracture; Wrist Fracture
MeSH terms: Fractures, Bone; Radius Fractures; Wrist Fractures
Study type: Interventional

Summary: 
      Distal radius fractures are among the most common fractures treated by hand therapists. These
      patients are most conservatively treated with closed reduction and cast immobilization. Since
      there is an immobilization process after both treatments, a limitation in the range of motion
      of the joint occurs in patients. For this reason, most of the treatment models applied in
      rehabilitation are about restoring the range of motion of the joint. In general,
      kinesiophobia occurs due to joint limitation and pain. Loss of proprioception occurs in
      patients with mobility and desire as a result of kinesiophobia. By investigating the
      techniques used in rehabilitation, the more correct one for the patient can be selected.
      There is no clear result in the literature about which of the application methods is more
      effective. The aim of the study is to compare the effects of proprioceptive neuromuscular
      facilitation (PNF) based stretching and Mulligan mobilization on pain, proprioception (joint
      position sense), wrist functionality, muscle strength and kinesiophobia in patients with
      joint limitation after distal radius end fracture. Thirty-four individuals aged 18-65 who
      were referred to a physiotherapy and rehabilitation program after distal radius end fracture
      will be included in the study. Individuals will be randomized into two groups. In the study,
      algometer and Visual Analogue Scale (VAS) were used to evaluate the pain intensity of the
      patients, universal goniometer for the evaluation of the forearm and wrist joint range of
      motion, microFET®2 Digital Handheld Dynamometer for the evaluation of the strength of the
      wrist flexor and extensor muscles, ulnar and radial deviation muscles. device will be used.
      The functional use of the wrist of the individuals is using the patient-based wrist
      assessment questionnaire (Patient Graded Wrist Assessment PRWE), the sense of attachment
      position for proprioception, and the Tampa Kinesiophobia Scale (TKS) for kinesiophobia. In
      our study, an exercise program will be applied with a physiotherapist for 6 weeks, 2 days a
      week, 45 minutes. To the first group; In addition to the traditional treatment, Mulligan
      mobilization will be applied, and the second group will be applied to the PNF techniques,
      'hold-relax' in addition to the traditional treatment. It can be considerable that both
      techniques applied in our study may have positive effects on pain, kinesiophobia and
      proprioception.
    

Detailed description: 
      The wrist has a complex anatomy and consists of the following structures; bone, ligament,
      musculotendinous and neurovascular. The distal ends of the radius and ulna are radio-ulnar,
      radio-carpal and ulno-carpal; carpal bones form midcarpal joints among themselves (1).

      The ulna and radius bones articulate with the wrist bones on the distal side, thus providing
      bony integrity (2).

      The wrist joint is the joint region that is most exposed to trauma. Radius distal end
      fractures account for approximately 20% of fractures admitted to the emergency department and
      75% of all forearm fractures. (3).

      Distal radius fractures are very common, alone or in combination with other fractures and
      injuries. For example, in the United States there is an incidence of approximately 67 upper
      extremity fractures per 10,000 persons per year. Distal radius and ulna fractures account for
      approximately 25% of all fractures (4).

      Distal radius fractures can occur at any age, with a largely bimodal distribution based on
      age and gender; They are children under 18 and adults over 50 (5).

      The overall incidence of DR tip fractures occurring each year is increasing worldwide. For
      example, a 1998 study by Melton et al. of Rochester, Minnesota, USA documented a 17% increase
      in DR fractures between 1945 and 1994 (6). Direct trauma is less common in distal radius
      fractures.

      It occurs as a result of direct hitting and impact blows to the distal radius (7). Indirect
      trauma is more common. Individuals consciously or unconsciously position their elbows in
      extension, their forearms in pronation, and their wrists in dorsiflexion, and this position,
      which is defined as falling on an open hand, causes fractures (8). It is very important to
      determine both the type of fracture and the level of injury well. Thus, the treatment will be
      easier and the healing process will be accelerated (9).

      Fracture healing has been studied in different phases by the researchers. As it is generally
      known, it consists of three phases; Inflammatory phase, Repair phase, Remodeling phase
      (10-13).

      All these processes require prostaglandins and bone stimulants, which are binding factors.
      (14,15). According to Wolf's law, skeletal mass and strength are variable according to load
      distribution (16). It has been observed that compressive axial loads stimulate periosteal
      callus formation. Shearing and tensile forces have been shown to inhibit union (17).

      Displacement, deformation and loads at the fracture site affect the behavior of bone cells,
      tissue structure, and thus healing. (18).

      The primary goals of treatment are to control edema and pain, and to restore normal range of
      motion to the patient (19). Restoring joint play in patients with resistant joint stiffness
      will be important in gaining joint range of motion (ROM). Joint mobilization techniques can
      be used for this purpose (20,21). Movement mobilization (MWM) technique unique to Mulligan
      Concept, which is one of the mobilization techniques, can be applied safely and effectively
      in both musculoskeletal and nervous system diseases. Mulligan Concept is functional
      restoration, techniques are applied in functional positions to improve the daily functions of
      patients (22).

      Stretching, which is a frequently applied method for gaining ROM, can be added to the
      exercise program as long as fracture healing allows, and by obtaining the opinion of the
      surgeon with the radiographic findings. In the literature, it has been reported that passive
      stretching lasting 30 seconds has positive effects on ROM gain when performed repeatedly
      during the day (23). One of the stretching techniques, Proprioceptive Neuromuscular
      Facilitation (PNF) based stretching, which is based on the neurophysiological mechanisms of
      reciprocal innervation and post-isometric relaxation, is one of the active stretching
      applications that improves mobility, movement control and joint coordination. (24,25).

      The consequences of traumatic wrist lesions contribute to proprioceptive and motor control
      deficits observed in both the acute and post-acute period (26). The aim of rehabilitation
      after distal radius end fracture is to restore joint mobility and functionality, reduce pain
      and edema, increase muscle activity through active movement, and train proprioception (27)

      Adding mobilization and PNF hold-loose technique to the traditional treatment program may be
      beneficial in terms of pain, proprioception, muscle strength and kinesiophobia after distal
      radius end fracture, but it is not known which method will improve more in this patient
      group. (28).

      The aim of the study is to compare the effects of proprioceptive neuromuscular facilitation
      (PNF) based stretching and Mulligan mobilization on pain, proprioception (joint position
      sense), wrist functionality, muscle strength and kinesiophobia in patients with joint
      limitation after distal radius end fracture.
    

Intervention name(s): Exercise; PNF Technique; Mulligan Mobilization
Intervention type(s): Other; Other; Other
Intervention description(s): It is important for the therapist to organize a home exercise program to provide edema and pain control. The exercise program should be specific and clear to the patient. The exercise program will be taught to the patient and given as a home program; While the limb is in the agonist pattern, the patient is instructed to perform isometric contractions for 5-8 seconds against maximum resistance without movement at the limiting point. After maximum isometric contraction, the patient is instructed to actively relax.Participants in the second group will be applied 10 repetitions of isometric contractions for 8 seconds at the limitation points of the movement with the PNF techniques, the hold and relax active movement technique in the direction of wrist flexion and extension.; In thw Mobilization with movement technique; the patient is expected to perform painless ROM. After obtaining painless movement in the patients participating in the study, this application will be applied to the patient with the painless active movement technique in 10 repetitions and 2-3 sets. Rest time between sets will be 15-20 seconds. Patients will be taught self-mobilization to ensure the continuity of painless movement. Self-mobilization will be applied by the patient at home with 10 repetitions every two hours (29).
Other intervention name(s): Traditional Exercise Program
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: Randomized Controlled Clinical Trial
Masking: Single (Participant)
Primary purpose: Treatment
Keywords: Distal Radius Fractures; Joint Limitation; Mulligan Mobilization; PNF Technique; Proprioception