The Effect of Two Different Protocol in Wrist Joint Limitation After Distal Radius End Fractures

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.

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.

Eligibility Criteria:
Inclusion Criteria:

* To be directed to the physiotherapy program after distal radius fracture between the ages of 18-65,
* Having signed the Informed Consent Form
* Patients with good cooperation level

Exclusion Criteria:

* Being illiterate of reading and writing
* Having another orthopedic, neurological and cardiovascular problem
* Pre-existing complex regional pain syndrome
* Having had an operation involving the ipsilateral upper extremity in the last 6 months