PHYST-671; No.

of Pages 8
ARTICLE IN PRESS

Physiotherapy xxx (2012) xxxxxx

Physiotherapy intervention practice patterns used in rehabilitation after

distal radial fracture
Andrea M. Bruder a, , Nicholas F. Taylor a,b , Karen J. Dodd a , Nora Shields a
a Department of Physiotherapy, La Trobe University, Victoria 3086, Australia
b Allied Health Clinical Research Office, Eastern Health, Victoria 3128, Australia

Abstract
Objectives To identify the type and frequency of interventions used by physiotherapists in rehabilitating patients after a distal radial fracture;
and, to examine whether any patient or therapist characteristics had an effect on the frequency of interventions administered.
Design Observational study.
Setting Four metropolitan outpatient physiotherapy departments.
Participants 14 physiotherapists reported on 160 distal radial fracture consultations.
Main outcome measures Physiotherapists recorded the type of interventions and time spent administering interventions during each distal
radial fracture consultation.
Results A combined site response rate of 70% was achieved (160/204). The most common interventions were exercise (155/160), advice
(144/160), passive joint mobilisation (88/160) and massage (60/160). Patient characteristics and physiotherapist experience had little impact
on the type and frequency of interventions reported by physiotherapists.
Conclusions Exercise and advice were the most frequently administered interventions for patients after a distal radial fracture irrespective of
physiotherapist or patient factors. During rehabilitation, these interventions aim to restore wrist mobility and are consistent with both fracture
management principles and a self management approach. Due to the routine use of exercise and advice there is a need for further research to
provide high quality evidence that these interventions improve outcomes in patients after a distal radial fracture.
2012 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.

Keywords: Rehabilitation; Physiotherapy; Distal radial fracture

Introduction
Physiotherapy interventions are frequently used to opti-
mise recovery of function after a distal radial fracture. Every
year about 4 in 1000 women and 1 in 1000 men fracture their
distal radius [1,2], making this the most common upper limb
fracture across all age groups [35]. These fractures may be
classified as intra-articular or extra-articular, depending on
whether there is disruption of the joint surface or not. Both
types of fractures can result in short and long-term impair-
ments such as loss of range of movement, pain, oedema, and
muscle weakness [610], and because these impairments can
Corresponding author at: Department of Physiotherapy, La Trobe Uni-
versity, Australia. Tel.: +61 3 9479 5853; fax: +61 3 9479 5768.
E-mail address: a.bruder@latrobe.edu.au (A.M. Bruder).
lead to loss of every day function, people with distal radial
fractures are often referred to physiotherapy.
The aims of physiotherapy after distal radial fracture are
to restore full joint movement and functional ability [11].
The interventions physiotherapists use to achieve these aims
may be classified as active or passive. Active interventions
refer to techniques such as exercise and advice, where the
patient is required to take an active role in their rehabili-
tation. Passive interventions refer to techniques where the
patient takes a passive role during its application, such as
passive joint mobilisation [12]. The content of the rehabilita-
tion program involves the physiotherapist using their clinical
reasoning skills to develop an individually tailored treatment
regime for each patient.
A rehabilitation program comprises one or more inter-
ventions. The choice of which interventions are used comes
from the physiotherapist making decisions about practice.

0031-9406/$ see front matter 2012 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.physio.2012.09.003

Please cite this article in press as: Bruder AM, et al. Physiotherapy intervention practice patterns used in rehabilitation after distal radial
fracture. Physiotherapy (2012), http://dx.doi.org/10.1016/j.physio.2012.09.003
PHYST-671; No. of Pages 8
ARTICLE IN PRESS
2 A.M. Bruder et al. / Physiotherapy xxx (2012) xxxxxx
These decisions are supported by thorough assessment of the
patients presenting problems, the physiotherapists knowl-
edge about the best available evidence of effectiveness
of interventions, along with knowledge of the resources
available and their own professional expertise. The physio-
therapist will also take into account the patients personal
characteristics as well as their rights, values and preferences
[13]. This is known as evidence based practice. For evidence
based practice to be effective the physiotherapist needs skilled
clinical reasoning and sound professional judgement [14]. To
help facilitate evidence based practice, health models can be
used. The International Classification of Functioning frame-
work [15], and the Hypothesis Categories clinical reasoning
model that helps to assist in understanding the patient as
a person and their problem(s) [16], are examples of these.
Given these models are holistic and person centred, patient
characteristics are likely to influence which interventions
physiotherapists use in rehabilitation.
A previous study establishing therapy practice patterns
of hand therapists, occupational therapists and physiothera-
pists for distal radial fractures was completed in the United
States in 1998 [17]. In that study, 242 hand therapists were
surveyed about the treatment they provided during rehabili-
tation. The findings showed around 90% of therapists used
range of movement exercises and heat/cold modalities, while
more than 50% of therapists used compressive wraps, dexter-
ity exercises, ultrasound and soft tissue and joint mobilisation
[17]. Since this study, new evidence about the effectiveness
of some of these interventions has been published, and so it
is possible practice patterns have changed.
Since even after a course of rehabilitation some patients
report residual difficulties in work, sport and leisure activities
[18,19], it is important to identify the types of interventions
physiotherapists currently use as some of these may not be
supported by empirical evidence. This will allow conclusions
to be made about whether physiotherapy practice is informed
by current empirical evidence. Given these considerations,
the primary aim of this study was to identify the types and
frequency of interventions used by physiotherapists in reha-
bilitating patients after a distal radial fracture. The secondary
aim was to examine whether any patient or therapist char-
acteristics had an effect on the frequency of interventions
administered.
Methods
Design
An observational study was conducted including physio-
therapists working in four metropolitan public outpatient
departments over a four month period (November 2010
to February 2011). Physiotherapists reported data on dis-
tal radial fracture treatments they provided during the study
period.
Please cite this article in press as: Bruder AM, et al. Physiotherapy intervention practice patterns used in rehabilitation after distal radial
fracture. Physiotherapy (2012), http://dx.doi.org/10.1016/j.physio.2012.09.003
Participants
To be included, physiotherapists needed to have provided
rehabilitation to a patient with a distal radial fracture who
attended one of the four sites. Physiotherapists were clas-
sified as junior therapists if they had less than four years
experience or senior therapists if they had four or more years
of experience.
Outcome measure
Data were collected using two forms developed for the
study. These were a therapist questionnaire and a description
of treatment form (available from the corresponding author
on request). The therapist questionnaire asked the physio-
therapist to provide information on their age, gender, number
of years since gaining qualification and the country in which
they completed their physiotherapy training.
The description of treatment form comprised three sec-
tions. In the first section, physiotherapists were asked to
provide information about the patient including age, gen-
der, type of distal radial fracture, and if English was the
patients first language. In the second section, physiothera-
pists allocated each patient a code to allow the researchers
to document that patients rehabilitation during the study
period while ensuring patient anonymity. In the third sec-
tion, physiotherapists reported all interventions they used
during each consultation, and the time spent administering
each of those interventions. A list of potential interventions
were provided which were based on findings of a systematic
review [20] and the American Physical Therapist Associa-
tion [APTA] guide of physical therapy practice [21]. Advice
is recognised as a component of physiotherapy practice [22]
and for the purpose of this study includes recommenda-
tions and education on fracture protection and skin care,
reassurance and encouragement to resume graded activities
[23,24].
Procedures
The study was approved by the ethics committees at our
institution and relevant participating clinics. Physiotherapists
completed the therapist questionnaire at the commencement
of the study, and to maintain anonymity they assigned them-
selves a therapist code for use on the description of treatment
form.
The description of treatment form was completed by each
physiotherapist after every distal radial fracture consultation.
A consultation was defined as any therapeutic encounter with
the patient in the outpatient department.
At the end of the data collection period, the total number
of physiotherapy distal radial fracture treatments provided
during the study period was obtained from each department.
These data were obtained through manual record checks and
using health service patient administration systems.
PHYST-671; No. of Pages 8
ARTICLE IN PRESS
A.M. Bruder et al. / Physiotherapy xxx (2012) xxxxxx 3

Data analyses Table 1

Characteristics of physiotherapists.
To be 95% confident that the confidence interval around Characteristic Number of
a proportion would be within 5% of the observed propor- physiotherapists
(n = 14)
tion, we estimated a sample of 140 completed description
of treatment forms were required [25]. This was calculated Age (yr), median (IQR) 33.5 (23 to 40)
Gender, n males (%) 7 (50)
based on the findings of previous research that exercises are Physiotherapy department location, n (%)
prescribed in 90% of consultations to patients after a distal Site 1 1 (7)
radial fracture [17]. Site 2 4 (29)
In this study, physiotherapy interventions were classified Site 3 4 (29)
as either active or passive. The decision to classify advice Site 4 5 (36)
Years of experience as a physiotherapist, n (%)
as an active intervention was made because advice typi- 0 to 3 yrs 6 (43)
cally involves the physiotherapist advising the patient to 4 to 7 yrs 2 (14)
re-commence using their upper limb during functional activ- 8 to 11 yrs 3 (22)
ities of daily living. 12 yrs 3 (22)
All analyses were completed using Predictive Analysis Total years of experience as a 7 (.8 to 11)
physiotherapist, median (IQR)
Software Version 18.0 (SPSS Inc., Chicago, IL, USA). The Location of physiotherapy education, n (%)
type and frequency of interventions used were analysed using Australia 12 (86)
descriptive and frequency statistics. To determine if there International 2 (14)
was a difference in the total time spent administering active
interventions compared to passive interventions, data were
some follow up consults. Seventy-five of 160 consultations
analysed using Wilcoxon Signed Ranks test. An alpha level
were classified as a first consult. The median initial consulta-
of p < 0.05 was regarded as statistically significant. The sec-
tion time was 28 minutes [IQR 20 to 40], including 5 minutes
ondary aims were analysed using Pearson Chi-Square or
[IQR 5 to 10] classified as assessment. The median follow-up
Fishers Exact test.
consultation time was 30 minutes [IQR 23 to 35], including
A sensitivity analysis was performed to check whether
5 minutes of assessment [IQR 5 to 8.5].
including a first consultation and a repeat consultation on the
same patient during the study period had any effect on the
results. The first consultation was defined as the first ther- Patients
apeutic encounter the physiotherapist had with each patient
during the study period. Seventy-five patients were treated over the 160 consulta-
tions. Typically, patients were female (52/75, 71%), aged over
51 years (56/75, 71%) and spoke English as their first lan-
Results guage (64/75, 85%) (Table 2). Thirty-nine patients received

Response rate Table 2

Characteristics of patients with distal radius fractures.

One hundred and sixty of 204 consultations provided to Characteristic Patients with
distal radius
patients with a distal radial fracture were reported, making a fractures (n = 75)
combined site response rate of 70%.
Age group, n (%)a
19 to 50 yrs 18 (24)
Participants 51 to 65 yrs 25 (33)
66 to 75 yrs 19 (25)
Fourteen physiotherapists with a median age of 33.5 years >75 yrs 12 (16)
[interquartile range (IQR) 23 to 40] participated. The median Gender, n males (%)a 22 (29)
English as first language, n (%)
years of physiotherapist experience was 7 years [IQR 0.8 to Yes 64 (85)
11] with 12 (86%) trained in Australia (Table 1). Six physio- No 11 (15)
therapists were classified as junior therapists. Type of distal radius fracture, n (%)
Intra-articular 32 (43)
Consultation Extra-articular 10 (13)
Dont know/did not report 33 (44)
Physiotherapy department where managed, n (%)
Fifty-one of 160 consultations were reported as initial con- Site 1 13 (17)
sults as they were the first therapeutic encounter the patient Site 2 8 (11)
had with a physiotherapist for rehabilitation of their distal Site 3 14 (19)
radial fracture. This is different to the first consultation dur- Site 4 40 (53)
a Missing data on one patient.
ing the study period which included all initial consults and

Please cite this article in press as: Bruder AM, et al. Physiotherapy intervention practice patterns used in rehabilitation after distal radial
fracture. Physiotherapy (2012), http://dx.doi.org/10.1016/j.physio.2012.09.003
PHYST-671; No. of Pages 8
ARTICLE IN PRESS
4 A.M. Bruder et al. / Physiotherapy xxx (2012) xxxxxx

Table 3
Frequency and time spent administering interventions by physiotherapists.
Types of interventions Frequency of all Frequency of Frequency of Time (minutes) Time (minutes)
interventions, interventions in interventions in per initial consult per follow up
n = 160 (%) initial consult, follow up consult, median, (IQR) consult median,
n = 51 (%) n = 109 (%) [range], n = 51 (IQR) [range],
n = 109
Active intervention
Advice to patient 143 (90) 49 (96) 94 (86) 5.0 (5 to 5) [0 to 20] 5.0 (3.5 to 5) [0 to 15]
Advice to family 12 (8) 7 (14) 5 (5) 0 (0 to 0) [0 to 5] 0.0 (0 to 0) [0 to 5]
Any advice 144 (90) 49 (96) 95 (87) 5.0 (5 to 10) [0 to 20] 5.0 (4.5 to 5) [0 to 15]
Functional training in self-care and home 19 (12) 8 (16) 11 (10) 0.0 (0 to 0) [0 to 5] 0.0 (0 to 0) [0 to 5]
management
Functional training in work, community 14 (9) 1 (2) 13 (12) 0.0 (0 to 0) [0 to 5] 0.0 (0 to 0) [0 to 5]
and leisure
Supervision of ROM/flexibility exercises 102 (64) 38 (75) 64 (59) 5.0 (0 to 10) [0 to 15] 2.0 (0 to 5) [0 to 10]
Supervision of strength exercises 54 (34) 12 (24) 42 (39) 0.0 (0 to 0) [0 to 10] 0.0 (0 to 5) [0 to 10]
Teaching a home exercise program 131 (82) 47 (92) 84 (77) 5.0 (5 to 5) [0 to 10] 5.0 (1 to 5) [0 to 10]
Any exercise intervention combined 155 (97) 51 (100) 104 (95) 10 (10 to 15) [4 to 20] 10.0 (5 to 10) [0 to 30]
Any active interventions combined 158 (99) 51 (100) 107 (98) 15.0 (15 to 20) [10 to 40] 15.0 (10 to 20) [0 to 40]
Passive interventions
Application of heat 16 (10) 3 (6) 13 (12) 0.0 (0 to 0) [0 to 10] 0.0 (0 to 0) [0 to 20]
Application of ice 2 (1) 0 (0) 2 (2) 0 0.0 (0 to 0) [0 to 10]
Application of elastic compression sleeve 44 (28) 20 (39) 24 (22) 0.0 (0 to 0) [0 to 10] 0.0 (0 to 0) [0 to 10]
(tubigrip)
Manual lymphatic drainage 0 0 0 0 0
Massage 60 (38) 16 (31) 45 (41) 0 (0 to 5) [0 to 10] 0.0 (0 to 5) [0 to 10]
Passive joint mobilisation 88 (55) 17 (33) 71 (65) 0.0 (0 to 5) [0 to 10] 5.0 (0 to 5) [0 to 20]
Prescription of assistive/adaptive devices 2 (1) 1 (2) 1 (1) 0.0 (0 to 0) [0 to 10] 0.0 (0 to 0) [0 to 10]
Use of electrotherapy modalities (e.g. 0 0 0 0 0
ultrasound)
Use of wax bath 0 0 0 0 0
Use of whirlpool bath 0 0 0 0 0
Any passive interventions combined 112 (70) 31 (61) 81 (74) 5.0 (0 to 10) [0 to 25] 6.0 (0 to 15) [0 to 40]

more than one consultation for rehabilitation of their distal
radial fracture during the study period.
Interventions
Seventeen interventions were used during rehabilitation
(Table 3). Exercise was the most frequently used active
intervention (97%, 155/160) followed by advice (90%,
144/160). The most frequently used exercise prescription
techniques were teaching a home exercise program (82%,
131/160) followed by supervision of range of movement
(ROM)/flexibility exercises (64%, 102/160) (Table 3). Func-
tional exercises that aimed to assist the patient to return to
work, community and leisure activities were used the least
(9%, 14/160). Passive joint mobilisation (55%, 88/160), mas-
sage (38%, 60/160) and application of an elastic compression
sleeve (28%, 44/160) were the most frequently used passive
interventions.
Active interventions, advice and any form of exercise were
used in 99% (158/160) of consultations compared to pas-
sive interventions in 70% (112/160) of consults (Table 3).
The time spent administering active interventions was signifi-
cantly longer compared to passive interventions during initial
consultations (median difference 15.0 minutes, [IQR 5 to 20;
Z = 5.834, p < 0.01]), and follow up consultations (median
difference 6 minutes [IQR 2 to 15; Z = 3.607, p < 0.01]).
No patient or therapist factor demonstrated a significant
effect on the frequency of active or passive interventions
(Table 4). However, advice was more frequently delivered to
patients with an extra-articular fracture compared to patients
with an intra-articular fracture (p < 0.01), and to family mem-
bers of patients from a Non-English speaking background
compared to family members where English was the patients
first language (p < 0.01). Exercise was more frequently pro-
vided to patients aged greater than 50 compared to those aged
50 years and under (p < 0.05). In terms of physiotherapist
characteristics, junior therapists more frequently provided
advice and taught a home exercise program to patients com-
pared to senior therapists (p < 0.05, p < 0.01 respectively)
(Table 5). Additionally, physiotherapists who trained interna-
tionally administered compression sleeves, heat and massage
more frequently than therapists trained in Australia (p < 0.01,
p < 0.01, p < 0.05, respectively).
Sensitivity analysis
No differences were identified when comparing the
type and frequency of interventions used during first

Please cite this article in press as: Bruder AM, et al. Physiotherapy intervention practice patterns used in rehabilitation after distal radial
fracture. Physiotherapy (2012), http://dx.doi.org/10.1016/j.physio.2012.09.003
 PHYST-671; No. of Pages 8
fracture. Physiotherapy (2012), http://dx.doi.org/10.1016/j.physio.2012.09.003
Please cite this article in press as: Bruder AM, et al. Physiotherapy intervention practice patterns used in rehabilitation after distal radial

Table 4
Analysis of frequency of treatments of common interventions and patient characteristics.
Types of interventions Male patients, Female p value Aged 50 yrs, Aged > 50 yrs, p value Patients with Patients with p value NESB ESB patients, p value

ARTICLE IN PRESS
A.M. Bruder et al. / Physiotherapy xxx (2012) xxxxxx
n = 60 (%) patients, n = 51 (%) n = 108 (%) IA fracture, EA fracture, patients, n = 138 (%)
n = 99 (%) n = 59 (%) n = 31 (%) n = 22 (%)
Active intervention
Advice to patient 52 (87) 91 (92) 45 (88) 98 (91) 48 (81) 30 (97) 22 (100) 121 (88)
Advice to family 5 (8) 7 (7) 2 (4) 10 (9) 1 (2) 1 (3) 7 (32) 5 (4) **

Any advice 52 (87) 92 (93) 46 (90) 98 (91) 49 (83) 30 (97) 22 (100) 122 (88)
Any exercise 59 (98) 95 (96) 47 (92) 107 (99) * 57 (97) 29 (94) 22 (100) 133 (96)
Teaching a HEP 48 (80) 83 (84) 41 (80) 90 (83) 46 (78) 25 (81) 22 (100) 109 (79) *

Any active intervention 60 (100) 97 (98) 49 (96) 108 (100) 57 (97) 31 (100) 22 (100) 136 (99)
Passive interventions
Application of elastic 22 (37) 21 (21) * 9 (18) 34 (32) 12 (20) 3 (10) 12 (55) 32 (23) **

compression sleeve (tubigrip)

Hot pack 10 (17) 6 (6) 1 (2) 15 (14) * 4 (7) 2 (7) 0 (0) 16 (12)
Massage 30 (50) 30 (30) * 16 (31) 44 (41) 16 (27) 11 (35) 11 (50) 50 (36)
Passive joint mobilisation 35 (58) 52 (53) 27 (53) 60 (56) 33 (56) 19 (61) 7 (32) 81 (59) *

Any passive intervention 44 (73) 67 (68) 32 (63) 79 (73) 39 (66) 21 (68) 15 (68) 97 (70)
yrs, years; IA, intra-articular; EA, extra-articular; NESB, Non-English speaking background; ESB, English speaking background; HEP, home exercise program.
* p < 0.05.
** p < 0.01.

5
PHYST-671; No. of Pages 8
ARTICLE IN PRESS
6 A.M. Bruder et al. / Physiotherapy xxx (2012) xxxxxx

Table 5
Analysis of frequency of treatments of common interventions and therapist characteristics.
Types of interventions PT with <4 yrs PT with 4 yrs p value PT trained in PT trained internationally, p value
exp, n = 69 (%) exp, n = 88 (%) Australia, n = 97 (%) n = 60 (%)
Active intervention
Advice to patient 66 (96) 74 (84) * 88 (91) 52 (87)
Advice to family 0 (0) 12 (14) ** 2 (2) 10 (17) **

Any advice 66 (96) 75 (85) * 89 (92) 52 (87)

Any exercise 69 (100) 83 (94) 93 (96) 59 (98)
Teaching a HEP 65 (94) 63 (72) ** 85 (87) 43 (72) *

Any active intervention 69 (100) 86 (98) 95 (98) 60 (100)

Passive interventions
Application of elastic 11 (16) 32 (36) ** 14 (14) 29 (48) **

compression sleeve
(tubigrip)
Hot pack 4 (6) 12 (14) 4 (4) 12 (20) **

Massage 21 (30) 38 (43) 30 (31) 29 (48) *

Passive joint mobilisation 36 (52) 52 (60) 55 (57) 33 (55)

Any passive intervention 43 (62) 66 (75) 62 (64) 47 (78)
PT, physiotherapist; yrs, years; exp, experience; HEP, home exercise program.
* p < 0.05.
** p < 0.01.

consultations (75/160) to all consultations (160/160) during
the study period.
Discussion
Active interventions were used in almost all distal
radial fracture consultations regardless of physiotherapist or
patient characteristics. Physiotherapists also spent more time
administering active interventions compared to passive inter-
ventions. The use of active interventions such as teaching a
home exercise program and providing advice, are consistent
with the promotion of patient independence through the use
of a self management approach [26]. A growing body of evi-
dence indicates that self management programs can provide
benefits in participants knowledge, symptom management,
self-management behaviours, self-efficacy and aspects of
health status [27]. These programs are usually aimed at giv-
ing patients with chronic illnesses the knowledge and skills
to manage their conditions [28]. However, these self manage-
ment skills could also be applied to patients with acute and
sub-acute conditions. Skills in decision making and taking
action seem appropriate in distal radial fracture rehabilita-
tion, as patients report residual difficulties in work, sport and
leisure activities even after a course of rehabilitation [18,19].
Developing positive health behaviours during the rehabilita-
tion phase may also help to increase patient adherence with
prescribed exercise programs [29].
Exercise was the most frequently used active interven-
tion, a finding consistent with previous research [17]. Our
results show physiotherapists spent more time administer-
ing exercise, particularly teaching a home exercise program,
in both initial and follow up consultations than all other
interventions. The use of exercise in distal radial frac-
ture rehabilitation is consistent with theory proposing that
movement is one of the key principles of fracture manage-
ment [30]. Furthermore, there is evidence to support using
exercise in improving patient outcomes for many other health
conditions that physiotherapists treat [31], suggesting it may
also be a useful intervention in this population. Despite this,
there are no high quality trials that have investigated the effect
of a course of exercise on rehabilitation outcomes after dis-
tal radial fracture [32]. There is a need for future research to
examine the effect of exercise as the manipulated variable in
a randomised controlled trial for patients after a distal radial
fracture. Such a trial is needed to provide evidence to support
the current common practice of exercise prescription in this
population.
Passive joint mobilisation [12] was the most frequently
used passive intervention which reflects previous research
[17]. It appears that even though evidence published since
the late 1990s does not support the use of passive joint
mobilisation in distal radial fracture rehabilitation [3234],
therapy practice patterns have not changed. This is unlike
the use of ultrasound, which was used routinely by over
50% of surveyed hand therapists in 1998 [17] but was not
used by any physiotherapists in our study. Physiotherapists
may rationalise that the use of passive joint mobilisation is
warranted to assist with wrist mobilisation when the fracture
is intra-articular. Our analysis suggests there was no rela-
tionship between the use of passive joint mobilisation and
whether the fracture involved the wrist joint or not. It is pos-
sible that physiotherapists may use passive joint mobilisation
as, if effective, immediate benefits in joint range of move-
ment can be seen after its use [34]. Seeing this immediate
improvement in movement would provide positive reinforce-
ment to the therapist and the patient. However, any short-term
benefits, if indeed they exist, do not translate to longer term
rehabilitation outcomes [33,34]. It is also possible that phy-
siotherapists believe they have not fulfilled their rehabilitative

Please cite this article in press as: Bruder AM, et al. Physiotherapy intervention practice patterns used in rehabilitation after distal radial
fracture. Physiotherapy (2012), http://dx.doi.org/10.1016/j.physio.2012.09.003
PHYST-671; No. of Pages 8
ARTICLE IN PRESS
A.M. Bruder et al. / Physiotherapy xxx (2012) xxxxxx
role until they have placed their hands on the patient, or
delivered a manual technique [35,36]. Further investigation is
needed to understand why physiotherapists select particular
interventions and how they apply best available evidence.
The interventions implemented by physiotherapists in dis-
tal radial fracture rehabilitation were primarily impairment
focused, including range of movement and strength exercises
and passive joint mobilisation to improve range of move-
ment. The aims of physiotherapy in distal radial fracture
rehabilitation are to restore maximum movement and func-
tional ability [11]. Functioning encompasses body structure
and function, activities and societal participation which are
domains of the World Health Organisations, International
Classification of Functioning framework [15]. Physiothera-
pists may use impairment based interventions in distal radial
fracture rehabilitation on the assumption that reducing wrist
impairment will transfer to an increase in upper limb activity.
There is limited evidence to support the association between
an impairment in grip strength and activity levels; however,
there does not appear to be a consistent association between
wrist range of movement and activity [37]. A lack of asso-
ciation between reducing impairment of body structure and
function, and improvement in activity and disability has been
observed in other populations [38,39]. Further investigation
of the effects of an exercise program on distal radial fracture
rehabilitation outcomes may also include activity-focused
exercises and tasks that may be more specific to achieving
improvements in activity.
The type and frequency of interventions reported by phy-
siotherapists for patients after a distal radial fracture seemed
to be affected little by patient presentation or physiotherapist
experience. There were no differences in the frequency of
active and passive interventions used for patients with respect
to these characteristics. Some differences were seen in the
frequency of individual interventions when related to phy-
siotherapist and/or patient factors. However, the magnitude
of these differences was small and not likely to be clinically
significant. The relative invariance in the content of rehabil-
itation may suggest therapists use treatment routines rather
than evidence based practice to develop an individually tail-
ored treatment regimen specific to the patient problem. It
would be expected that the decision to use particular interven-
tions would be influenced by the therapists knowledge and
clinical experience, empirical clinical evidence and patients
own characteristics which would result in a greater variability
in the types and frequency of interventions used. However,
this was not found in our study. It is also possible the classifi-
cation we used during data collection did not provide enough
detail about the specifics of individually tailored treatment
regimens.
A limitation of this study was the inclusion of some
observations on the same patient for first consultations
and follow-up consults. This was based on the assumption
that interventions administered to the same patient would
change between each consultation. Our sensitivity analy-
sis found no difference between the type and frequency of
Please cite this article in press as: Bruder AM, et al. Physiotherapy intervention practice patterns used in rehabilitation after distal radial
fracture. Physiotherapy (2012), http://dx.doi.org/10.1016/j.physio.2012.09.003
7
interventions used on the first consult compared to all con-
sultations. Another limitation is that our response rate was
relatively low, but was consistent with the general consen-
sus that a response rate of 70% or above is necessary to
ensure that the observations of our sample is sufficiently rep-
resentative of the population [40]. A final limitation of the
description of treatment form was that we did not collect data
related to outcome measures therefore are not able to corre-
late the degree of functional impairment with both number
of treatments provided and type of treatments provided.
Conclusion
Active interventions, including exercise and advice, were
the most frequently administered interventions for patients
after a distal radial fracture irrespective of physiotherapist or
patient factors. Although the common use of exercise in distal
radial fracture rehabilitation is consistent with the principles
of fracture management and principles of self management,
there is a need for further research to provide high quality
evidence that this intervention improves outcomes in patients
with a distal radial fracture.
Acknowledgements
We would like to acknowledge our team of associate
investigators Paula ONeil and Edmund Leahy from North-
ern Health and Mark Guerra and Vincent Man from Eastern
Health, for their help in carrying out the study.
Ethical approval: Human Research Ethics Committee of
La Trobe University, Faculty of Health Sciences, Ref. No.
FHEC10/185; Eastern Health Research and Ethics Commit-
tee, Ref. No. LR21/1011; Northern Health Research and
Ethics Committee, Ref. No. CC41/10.
Conflict of interest: The authors declare no conflicts of inter-
est.
References
[1] ONeil TW, Cooper C, Finn JD, Lunt M, Purdie D, Reid DM, et al. Inci-
dence of distal forearm fracture in British men and women. Osteoporos
Int 2001;12(7):5558.
[2] Van Staa TP, Dennison EM, Leufkens GM, Cooper C. Epidemiology
of fractures in England and Wales. Bone 2001;29(6):51722.
[3] Larsen CF, Lauritsen J. Epidemiology of acute wrist trauma. Int J
Epidemiol 1993;22(5):9116.
[4] Rennie L, Court-Brown CM, Mok JYQ, Beattie TF. The epidemiology
of fractures in children. Injury 2007;38:91322.
[5] Sanders KM, Seeman E, Ugoni AM, Pasco JA, Martin TJ, Skoric B,
et al. Age- and gender-specific rate of fractures in Australia: a popula-
tion based study. Osteoporos Int 1999;10:2407.
[6] Atkins RM. Aspects of current management: complex regional pain
syndrome. J Bone Joint Surg Br 2003;85(8):11006.
PHYST-671; No. of Pages 8
ARTICLE IN PRESS
8 A.M. Bruder et al. / Physiotherapy xxx (2012) xxxxxx
[7] Belsole RJ, Hess AV. Concomitant skeletal and soft tissue injuries.
Orthop Clin North Am 1993;24(2):32731.
[8] Cooney WP, Dobyns JH, Linscheid RL. Complications of Colles frac-
tures. J Bone Joint Surg Am 1980;62(4):139.
[9] Handoll HH, Madhok R. Conservative interventions for treating distal
radial fractures in adults (review). Cochrane Database Syst Rev 2003:2.
[10] Weinstock TB. Management of fractures of the distal radius: therapists
commentary. J Hand Ther 1999;12:99102.
[11] World Confederation for Physical Therapy. Description of Physical
Therapy. Declarations of principle and positions statement revised and
re-approved at the 17th General Meeting of WCPT, June 2011. London
2011.
[12] Hengeveld E, Banks K, editors. Matilands peripheral manipulation.
4th ed. Edinburgh: Butterworth Heinemann; 2005.
[13] Edwards I, Jones M, Carr J, Braunack-Mayer A, Jensen GM. Clin-
ical reasoning strategies in physical therapy. Phys Ther 2004;84:
31235.
[14] Jones MJ, Grimmer K, Edwards I, Higgs J, Trede F. Challenges in apply-
ing best evidence to physiotherapy practice. Internet J Allied Health Sci
Pract 2006;4:3.
[15] World Health Organisation. ICF: international classification of func-
tioning, disability and health. Geneva: WHO; 2001.
[16] Jones M, Rivett D. Introduction to clinical reasoning. In: Jones M,
Rivett D, editors. Clinical reasoning for manual therapists. Oxford:
Butterworth-Heinemann; 2004. p. 324.
[17] Michlovitz SL, LaStayo PC, Alzner S, Watson E. Distal radial fractures:
therapy practice patterns. J Hand Ther 2001;14(4):24957.
[18] MacDermid JC, Richards RS, Roth JH. Distal radius fracture: a prospec-
tive outcome study of 275 patients. J Hand Ther 2001;14(2):15469.
[19] MacDermid JC, Roth JH, Richards RS. Pain and disability reported
in the year following a distal radius fracture: a cohort study. BMC
Musculoskelet Disord 2003;4:24.
[20] Handoll HH, Madhok R, Howe TE. Rehabilitation for distal radial
fractures in adults. Cochrane Database Syst Rev 2006:3.
[21] American Physical Therapy Association. Who are physical therapists,
and what do they do? (a guide to physical therapist practice). Phys Ther
2001;81(1):39.
[22] The Chartered Society of Physiotherapy. The physiotherapy frame-
work [Internet]; 2011. Available from: http://www.csp47.co.uk/
framework/content/welcome [03.08.12].
[23] Kay S, McMahon M, Stiller K. An advice and exercise program has
some benefits over natural recovery after distal radius fracture: a ran-
domised trial. J Physiother 2008;54(4):2539.
[24] Stewart MJ, Maher CG, Refshauge KM, Herbert RD, Bogduk N,
Nicholas M. Advice or exercise for chronic whiplash disorders?
Available online at www.sciencedirect.com
Please cite this article in press as: Bruder AM, et al. Physiotherapy intervention practice patterns used in rehabilitation after distal radial
fracture. Physiotherapy (2012), http://dx.doi.org/10.1016/j.physio.2012.09.003
Design of a randomized controlled trial. BMC Musculoskelet Disord
2003;4:18.
[25] Wild C, Seber G. Chance encounters: a first course in data analysis and
inference. New York: John Wiley & Sons; 2000.
[26] Newsom S, Steed L, Mulligan K. Self-management interventions for
chronic illness. Lancet 2004;364:152337.
[27] Barlow J, Wright C, Sheasby J, Turner A, Hainsworth J. Self-
management approaches for people with chronic conditions: a review.
Patient Educ Couns 2002;48:17787.
[28] Lorig KR, Halsted RH. Self-management education: history, def-
inition, outcomes and mechanisms. Ann Behav Med 2003;26(1):
17.
[29] Barron CJ, Klaber Moffett JA, Potter M. Patient expectations of phys-
iotherapy: definitions, concepts, and theories. Physiother Theory Pract
2007;23(1):3746.
[30] Adams JC, Hamblen DL. Outline of orthopaedics. 12th ed. Edinburgh:
Churchill Livingston; 1995.
[31] Taylor N, Dodd K, Shields N, Bruder A. Therapeutic exercise in
physiotherapy practice is beneficial: a summary of systematic reviews
20022005. J Physiother 2007;53:716.
[32] Bruder A, Taylor NF, Dodd KJ, Shields N. Exercise reduces impair-
ment and improves activity in people after some upper limb fractures:
a systematic review. J Physiother 2011;57:7182.
[33] Kay S, Haensel N, Stiller K. The effect of passive mobilisation fol-
lowing fractures involving the distal radius: a randomised study. J
Physiother 2000;46(2):93101.
[34] Taylor NF, Bennell KL. The effectiveness of passive joint mobilisation
on the return of active wrist extension following Colles fracture: a
clinical trial. NZ J Physiother 1994;22(1):248.
[35] Jette AM, Delitto A. Physical therapy treatment choices for muscu-
loskeletal impairments. Phys Ther 1997;77:14554.
[36] Pinkston D. Evolution of the practice of physical therapy in the United
States. In: Scully RM, Barnes MR, editors. Physical therapy. Philadel-
phia: JB Lippincott Co.; 1989. p. 230.
[37] Tremayne A, Taylor NF, McBurney H, Baskus D. Correlation of impair-
ment and activity limitation after wrist fracture. Physiother Res Int
2002;7(2):909.
[38] Keysor JJ, Jette AM. Have we oversold the benefit of late-life exercise?
J Gerontol A Biol Sci Med Sci 2001;56A(7). M412-M23.
[39] Van Baar ME, Assendelft EJ, Dekker J, Oostendorp RA, KBijlsrna JW.
Effectiveness of exercise therapy in patients with osteoarthritis of the
hip or knee: a systematic review of randomized clinical trials. Arthritis
Rheum 1999;42:13619.
[40] Patel MX, Doku V, Tennakoon L. Challenges in recruitment of research
participants. Adv Psychiatr Treat 2003;9:22938.