Abstract
This study identified two factors associated with better occupational therapy outcomes after a distal radius fracture (DRF): early initiation of therapy and a higher number of occupational therapy sessions.
A distal radius fracture (DRF) is one of the most common fractures encountered in clinical practice, and its incidence is increasing (MacIntyre & Dewan, 2016; Nellans et al., 2012). DRF usually involves displacement of bone fragments and can result in complications such as deficits in range of motion and strength; complex regional pain syndrome; and significant problems with activities of daily living (ADLs), instrumental activities of daily living (IADLs), leisure, and work (Edwards et al., 2010; Nellans et al., 2012).
A Cochrane review examined the effects of the various rehabilitation interventions used as part of the management of these fractures in adults (Handoll & Elliott, 2015). Many of the interventions discussed are within the occupational therapy scope of practice (e.g., splints, education, and ADL training). All of the trials included were small, and most did not report on patient-reported outcome measures of function. (Keep in mind that patients with serious fractures, treatment-related complications, comorbidities, or poor function were excluded from many of these trials.) Handoll and Elliott (2015) rated the quality of available evidence as either low or very low and concluded that it is insufficient to establish the best form of rehabilitation. A systematic review consistently highlighted that the evidence for occupational therapy with adults with a DRF remains limited (Roll & Hardison, 2017), and few studies on DRFs were included in this review (N = 7). Moderate evidence suggests that early occupational therapy during immobilization leads to quicker recovery and that joint mobilization and exercise have positive outcomes after these fractures. This review found a paucity of evidence for occupation-based interventions and outcomes.
According to previous literature, relatively little is known about the specific outcomes of occupational therapy interventions after a DRF. More occupational therapy–led research is needed to establish an evidence-based practice. Additionally, a 2019 mapping review emphasized that research on rehabilitation with people with DRF (N = 18) primarily focuses on assessing the effects of exercise and patient education, with body functions and physiology being the most common outcome measures (Takata et al., 2019). None of the studies concerning DRF included in the Takata et al. (2019) review evaluated activity-based interventions. Consequently, our research analyzed the results of an occupational therapy intervention characterized by combining the use of activity and occupation with other therapeutic methods. To address another of the limitations discussed earlier, the primary outcome was self-rated functional status. Furthermore, we explored the factors of the intervention that contributed to the improvement among patients. Therefore, the main objective was to determine whether participation in an occupational therapy intervention improved performance of daily activities. Secondary objectives were to assess the effects on body functions and to examine the association between changes in outcome measures and the characteristics of the occupational therapy intervention.
Method
Design and Participants
The study was longitudinal, observational, and prospective. It was conducted at the Rehabilitation Service of the University Hospital of A Coruña (A Coruña, Spain), which is part of the National Health Service. The sampling method was consecutive for a 12-mo period in 2021 and 2022. All patients with a (radiologically diagnosed) unilateral DRF consecutively admitted to the occupational therapy ward were invited to participate. The eligibility criteria were as follows: (1) age 18 yr or older, (2) with a documented DRF as the main reason for referral to occupational therapy, and (3) with enough mental ability to understand the intervention procedures. Exclusion criteria were as follows: patients (1) with an unstable medical condition, (2) a significant secondary diagnosis involving the central nervous system, or (3) a fracture related to malignancy. Ethical approval was granted by the regional ethics committee. All participants provided written informed consent.
Intervention
The primary aim of the occupational therapy intervention was to regain the highest possible level of competent participation in desired daily activities. This outpatient intervention approach was multicomponent and included activities and techniques in a wide variety of domains, grouped into two categories: (1) adjunctive methods and (2) activity-based interventions. These domains are described in Tables A.1, A.2, and A.3 of the Supplemental Material (available online with this article at https://research.aota.org/ajot). Referral to occupational therapy was by a rehabilitation physician. All participants went through an individualized combination of interventions from all types of domains, adapted on a case-by-case basis, with the frequency determined by the therapist (typically two 45-min sessions/wk). The number of sessions was tailored to the recovery stage, individual priorities, and specific needs of each participant. An occupational therapist with extensive experience in the field of hand therapy conducted the entire intervention.
Measures
Participants were assessed on admission to occupational therapy (Time 1 [T1]) and upon discharge after this intervention (Time 2 [T2]). Information was recorded for five domains: sociodemographic data, DRF characteristics, other hand-related health conditions, rehabilitation interventions, and outcome measures. Hospital medical records were reviewed. The following DRF characteristics were obtained: high- or low-energy injury, which hand was injured, surgical treatment, and concurrent distal ulna injuries. Regarding occupational therapy, the length of time from the fracture until the first session, the time elapsed since surgery, and the number of sessions attended were recorded. Additionally, the participants were asked to rate their degree of satisfaction with occupational therapy on a scale ranging from 0 (very dissatisfied) to 10 (very satisfied) at T2. Outcomes were functional status (primary) and body functions (secondary).
Primary Outcome
Cochin Hand Functional Disability Scale.
The Cochin Hand Functional Disability Scale (CHFS; Duruöz et al., 1996) was developed to assess a predefined set of common daily activities among patients with musculoskeletal conditions. This self-report scale consists of 18 questions. The participant is asked to assess the difficulty they have in carrying out these activities. Items are scored on a Likert scale ranging from 0 (no difficulty) to 5 (impossible). The total score is obtained by adding the scores for all items. The intrarater and interrater reliabilities were .97 and .96, respectively. The instrument has good convergent validity with general functional disability scales (Duruöz et al., 1996).
Patient-Specific Functional Scale.
The Patient-Specific Functional Scale (PSFS; Stratford et al., 1995) was developed to assess functional problems, primarily among individuals with musculoskeletal conditions. This widely used instrument has demonstrated adequate reliability. The intraclass correlation coefficient (ICC) was .97 (Stratford et al., 1995). Its concurrent validity was supported by a moderate correlation with an upper extremity functionality scale (.59; Hefford et al., 2012). The PSFS allows participants to identify activities that are personally relevant to them. Participants had to define their three main problems. Each participant was asked to identify a total of three important activities that they found difficult or impossible to perform. For each of three self-generated activities, the participants rated their degree of difficulty on a scale ranging from 0 (unable to perform the activity) to 10 (able to perform it at the same level as before the injury). An average of these three scores was used. To describe the main functional problems at baseline, we classified each of the chosen important activities into the following four categories: ADLs, IADLs, work, and leisure and social participation.
Secondary Outcomes
Grip Strength.
Hand grip strength was measured in kilograms of force following standardized procedures (Fess, 1992). The average of three measurements was recorded. Hand dynamometry is a valid and reliable test. This instrument has good intraobserver reliability, with ICC values of more than .8. Grip strength showed moderate correlations with upper extremity function scales among individuals with a DRF (Ziebart et al., 2021). Grip strength of the involved arm was compared with that of the opposite side. The grip strength fraction was presented as a percentage of the strength of the uninjured side.
Active Range of Motion.
Universal goniometers were used to measure range of motion of wrist flexion and extension, radial and ulnar deviation, and forearm supination and pronation in the injured limb. A standardized technique was used (MacDermid et al., 2015). With respect to the reliability of goniometric measurements of active wrist movements, the ICC values ranged from .78 to .90 (Horger, 1990).
Pain, Tingling, and Sleep.
These variables were assessed using three self-report items from the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) questionnaire (Beaton et al., 2005). The QuickDASH has a Cronbach’s α of more than .9 and good test–retest reliability (ICC > .9). Evidence of convergent construct validity was established (r ≥ .6 with pain and function measures; Beaton et al., 2005). Developed to measure upper limb physical function in people with musculoskeletal disorders, each item is graded on a 5-point Likert scale. For the pain and tingling items, severity is rated from 1 (none) to 5 (extreme); for the sleep difficulty items, it is rated from 1 (no difficulty) to 5 (so much difficulty that I can’t sleep).
Data Analysis
The changes in the outcome measures, defined as the difference between the final score and the baseline, were calculated. The changes between T1 and T2 were tested for significance by means of paired-samples t tests for the normal variables and Wilcoxon’s signed-rank test for the other variables. Effect sizes for the t tests were calculated using Cohen’s d statistic: d > .8 is indicative of a large effect. The effect size (ES[r]) for Wilcoxon’s tests was calculated (Cohen, 1988): .10 constitutes a small effect; .30, a medium effect; and .50, a large effect. Additionally, the relationships between changes in outcome measures and two occupational therapy–related factors (time from fracture to occupational therapy and number of sessions) were tested using Spearman’s ρ or Pearson’s correlation coefficient, as appropriate. A correlation coefficient of .10 constitutes a weak relationship; .40, moderate; and .70, strong (Dancey & Reidy, 2007). Statistical analyses were conducted using IBM SPSS Statistics (Version 25.0). All tests used p < .05 (two-sided).
Results
During the studied period, 38 individuals with a DRF were admitted to occupational therapy. These individuals served as the participants in this study (ages 31–75 yr; 81.6% female). Table A.3 in the Supplemental Material presents descriptive information. Table 1 shows changes on the outcome measures.
Changes on Outcome Measures
Note. N = 38. ES = effect size; IQR = interquartile ratio; Mdn = median; QuickDASH = Quick Disabilities of the Arm, Shoulder, and Hand.
Wilcoxon’s signed-rank test unless otherwise noted.
n = 37; 1 participant did not complete this measurement because of severe pain.
Paired-samples t test; t(36) = −6.24.
Cohen’s d.
*p < .05.
Functional Status at Baseline
On the CHFS, the mean score was 33.13 points, representing difficulties in performing hand-related daily activities. On the PSFS, regarding the functional problems, the percentages of participants who selected at least one IADL, an ADL, a leisure or social participation activity, and a work activity were 89.5%, 60.5%, 26.3%, and 7.9%, respectively. For IADLs, the median number of activities chosen per participant was 2 (range = 0–3, interquartile ratio [IQR] = 1–2). For ADLs, the median was 1 (range = 0–2, IQR = 0–1).
Occupational Therapy
For all participants, occupational therapy was the only rehabilitation treatment provided during the study period. The mean duration of this intervention was 14.95 (SD = 7.98) sessions. After completing this intervention, the degree of satisfaction with occupational therapy was maximal (Mdn = 10, range = 5–10, IQR = 9–10).
Primary Outcome
CHFS Instrument
Statistically significant differences were found when comparing the CHFS scores obtained before and after the intervention. These changes reflect an improvement in functional status, with an ES(r) of >.6.
PSFS Instrument
There was a statistically significant change in PSFS score between T1 and T2. The score improved by 2.8 points, which corresponds to a decrease in participants’ difficulty with performing the daily activities they selected, with an ES(r) of >.5.
Secondary Outcomes
Grip Strength
One participant did not complete this measurement because of severe pain. The paired-samples t test showed a statistically significant change in the grip strength fraction from T1 to T2. This percentage increased by more than 20%. Cohen’s d exceeded a value of 1.
Active Range of Motion
Regarding the six wrist and forearm movements analyzed, Wilcoxon’s test showed a statistically significant increase in five; for two of these movements (wrist extension and flexion), the ES(r) was greater than .5. No significant change was found in pronation.
Pain, Tingling, and Sleep
Difficulty sleeping decreased significantly between T1 and T2. There was a statistically significant improvement in pain severity. For these two items, the ES(r) was greater than .4. For tingling, no significant change was found.
Relationships Between Changes in Outcome Measures and Occupational Therapy–Related Factors
Time From Fracture to Occupational Therapy
Table 2 shows the correlations between the changes on the outcome measures and the time elapsed between the DRF and the start of occupational therapy. Changes were significantly associated with the number of days between the fracture and the start of occupational therapy for three of the outcome measures studied: CHFS, grip strength, and pain. A shorter delay in the start of occupational therapy was associated with better outcomes in relation to functional status (CHFS), grip strength fraction, and pain severity.
Number of Occupational Therapy Sessions
The number of sessions was significantly associated with changes in four of the outcomes: grip strength and three movements (wrist extension, ulnar deviation, and radial deviation; see Table 2). The likelihood of achieving better outcomes was significantly higher among participants who attended more sessions.
Correlations Between the Changes in Outcome Measures and Occupational Therapy–Related Factors
Note. A dash indicates that the coefficient was not calculated, because the p value was not statistically significant (p > .05).
Changes in outcome measures were defined as the difference between the final score and the baseline score.
Spearman’s ρ unless otherwise stated.
Pearson correlation coefficient (r).
*Indicates significant finding (p < .05).
Discussion
Because the effects of occupational therapy among people with a DRF remain uncertain, the main contribution of this study was to quantify the outcomes in an outpatient rehabilitation service. Changes were quantified using effect sizes. Effect size is the magnitude of the impact of the treatment on an outcome measure (Peyton, 2005). We found evidence that this program was effective, revealing high satisfaction and significant improvements. Large improvements were found for the functional status scales (primary outcome), grip strength, and wrist extension and flexion movements. The improvements for which we found medium to large effect sizes are encouraging, suggesting a possible intervention effect on performance of daily activities and several body functions.
Comparisons between our findings and preexisting literature are complicated because of the considerable differences in the study samples and the heterogeneity of settings, interventions, and outcome measures (Handoll & Elliott, 2015; Roll & Hardison, 2017). Most previous studies have excluded people with serious injuries, complicated cases, or limited functional status (Handoll & Elliott, 2015). However, our research focused on the needs of the typical profile of occupational therapy outpatients in clinical practice, so it included a sample of individuals with marked motor impairments, severe pain, and difficulties in daily activities. More than half of the participants underwent surgery, which is usually necessary for unstable, comminuted, and intra-articular fractures (Aiello & Laseter, 2016). In addition to DRF, nearly 40% also had distal ulna injuries, which are associated with poorer health outcomes (MacIntyre & Dewan, 2016), and a high proportion had complex regional pain syndrome (Type 1; 18.4%) or other hand-related conditions.
Furthermore, although literature on DRFs prioritizes exercise interventions (Takata et al., 2019), to our knowledge this is the first longitudinal study to explore the results of a multicomponent occupational therapy strategy, characterized by combining supplementary techniques and activity-based interventions with a flexible protocol based on the interests and abilities of each individual. The hand therapy literature has postulated that graded use of meaningful activities and occupations optimizes the return to daily activities, because these meaningful activities increase the patient’s motivation and self-confidence and promote repeated, automatic, and naturally occurring movements of the injured hand, avoiding learned nonuse, which can improve stiffness, proprioceptive and strength deficits, and participation restrictions (Colaianni & Provident, 2010). In line with accumulated evidence on the treatment of orthopedic upper extremity conditions, we believe that the selection of interventions that focus on activity level may relatively explain our positive outcomes.
The use of patient-reported outcome measures of functional status was another strength of this study, combining self-assessment of a predefined set of activities (CHFS) with the selection of the most important functional problems for the participants (PSFS), which provided a comprehensive view of the primary outcome. At the baseline, IADLs were the most compromised occupations, followed by ADLs, consistent with a recent literature review that has revealed a paucity of studies on recovery with respect to daily activities in this population (Halim et al., 2021). On the PSFS, the notable improvement exceeded the minimally important difference established for people with upper extremity musculoskeletal conditions (Hefford et al., 2012). The positive impact on functional status was in line with the results of two studies on occupational therapy programs with conservatively treated women (Dahlqvist & Rosén, 2016; Nielsen & Dekkers, 2013). However, two trials did not find a significant functional improvement, although we should note that they exclusively analyzed exercise interventions supervised by occupational therapists (Filipova et al., 2015; Souer et al., 2011).
Regarding secondary outcomes, the improvement in grip strength identified in this study was faster than the typical recovery period established in the literature, which is between 6 mo and 1 yr after a DRF (Halim et al., 2021). In line with our findings, one study showed that focusing strengthening exercises on performing functional movements significantly increased grip strength in a sample of conservatively treated occupational therapy patients (Filipova et al., 2015). Although one scoping review indicated that range of motion is the most difficult body function to recover after a DRF (Halim et al., 2021), the findings showed an improvement in all the movements evaluated except pronation. Moreover, the wrist range of motion needed by the general population to perform most daily activities was achieved (Ryu et al., 1991). The greatest improvement was found in wrist extension, which is the movement most strongly associated with functional status in a longitudinal study of adults with a DRF (Yang et al., 2018). Because most patients commonly regain pronation quickly and easily (Aiello & Laseter, 2016), this movement already showed a normal range at baseline. Similar to previous research findings on occupational therapy (Nielsen & Dekkers, 2013), participants perceived significantly less pain after the intervention. However, a high proportion continued to have pain problems at the time of the final assessment. This result is consistent with previous literature, which has suggested that pain can persist beyond the first year (Roll & Hardison, 2017). Finally, the participants perceived significantly fewer sleep problems. No studies have been found that address the impact of occupational therapy in the sleep domain.
Two factors were associated with better outcomes: early initiation of therapy and a higher number of occupational therapy sessions. The strength of the relationships ranged between weak and moderate. Significant differences were found in changes in grip strength, pain, and functional status, based on the delay in starting occupational therapy. These results in favor of early intervention are consistent with the conclusions of a systematic review of occupational therapy studies (Roll & Hardison, 2017). Similarly, a meta-analysis has shown that early initiation of movement after open reduction and internal fixation leads to significant improvements in the domains of functional status, strength, and pain (Ghaddaf et al., 2021). However, this is the first study to confirm a significant relationship between an increased number of sessions and greater recovery of grip strength and of some active movements after a DRF. The structured and repeated practice of therapeutic activities, with an individualized graduation according to parameters such as the objects required or the level of difficulty and resistance, seems to be key to improving these objectively evaluated study variables.
Limitations
We noted several limitations. The sample size was relatively small, thus reducing the statistical power of the calculations and increasing the risk of not detecting significant associations. Additionally, potentially important factors, such as type of fracture (e.g., extra- or intra-articular and comminution) and comorbidity, were not recorded. The participants were recruited using a nonrandom technique from a single rehabilitation center. Therefore, our outcomes may not be generalizable to the overall population of people with a DRF. Because referral was based on the rehabilitation physician’s clinical judgment, in the context of public health care services, the results may be more representative of adults with a specific needs profile characterized by a greater need for rehabilitation interventions and more severe functional limitations. Last, it is not known whether the positive effects extended beyond the period studied.
Although this study has its limitations, we believe that its findings provide a great deal of information as a basis for further research. Future replications should include a larger sample of participants and more facilities. A recommended step is to validate these results through a large-scale intervention trial, including a comparison group, random sampling procedures, and long-term monitoring. In addition to the total number of sessions, future research should also explore the influence on outcomes of other factors related to occupational therapy (e.g., frequency and number of days between the first and last session) to provide more information on the ideal intensity and optimal dosage of intervention for this population. Another recommendation for future studies is to analyze the impact of personal factors related to therapists, such as education, degree of specialization, or years of professional experience.
Implications for Occupational Therapy Practice
This study has the following implications for occupational therapy practice: ▪ An outpatient occupational therapy intervention that integrates adjunctive methods and activity-based interventions has the potential to provide positive outcomes for people with a DRF in the areas of return to independent competence in daily activities and body functions, so occupational therapy services are suggested to mitigate functional problems and impairments resulting from these fractures. ▪ Two intervention-related factors significantly increase the effectiveness of occupational therapy after a DRF: early initiation of therapy and a higher number of sessions. Consideration of these factors should be present in the decision-making process related to the planning of occupational therapy programs in clinical settings.
Conclusion
Although the effectiveness of this intervention approach remains to be tested in a controlled clinical trial, the findings extend the evidence base for this occupational therapy practice. This longitudinal study showed clinically and statistically significant improvements on almost all outcome measures. Our research supported the proposition that these occupational therapy services have an important role to play after a conservatively or surgically treated DRF in terms of returning to daily activities and reducing impairments in body functions. The results may be useful in developing more effective strategies by identifying two factors associated with better recovery: Earlier intervention and a higher number of occupational therapy sessions are likely to further improve these outcomes.
Supplemental Material
Supplementary material for Functional Changes After Occupational Therapy Among Individuals With a Distal Radius Fracture: A Longitudinal Study
Supplementary material, sj-pdf-1-aot-10.5014_ajot.2023.050218.pdf for Functional Changes After Occupational Therapy Among Individuals With a Distal Radius Fracture: A Longitudinal Study by Iván De-Rosende-Celeiro and Jorge Juan Fernández-Barreiro in The American Journal of Occupational Therapy
References
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
