Distal Radius Fracture Rehabilitation.

Distal radius fracture (DRF) is arguably the most common upper extremity fracture resulting from a fall accident. These clinical practice guidelines (CPG) were developed to guide all aspects of the management of DRF by physical therapists and other rehabilitation practitioners, such as certified hand therapists. This CPG employed a systematic review methodology to locate, appraise, and synthesize contemporary evidence while developing practice recommendations for determining the prognosis of outcomes, examination, and interventions while managing individuals with DRF. The quality of the primary studies found in the literature search was appraised using standardized tools. The strength of the available evidence for a particular practice domain (e.g., prognosis or intervention) was graded as strong, moderate, weak, or conflicting, where such gradings guided the level of obligation for each practice recommendation. Lastly, the CPG also provided the gaps in the evidence pool for the rehabilitation of DRF that future research efforts can address. J Orthop Sports Phys Ther 2024;54(9):CPG1-CPG78. doi:10.2519/jospt.2024.0301.

Impact of chronic wrist hypermobility on proprioception, strength, and functional performance in young adults.

BACKGROUND: Chronic joint hypermobility has been attributed to repetitive ligamentous microtrauma, benign joint hypermobility syndrome (BJHS), or genetic connective tissue disorders that lead to pain and functional impairment, especially among females. Chronic wrist hypermobility (CWH) prevalence, etiology, and effects on proprioception, strength, and function have yet to be established. PURPOSE: This pilot study aimed to determine the CWH prevalence among adults; its effects on proprioception, strength, and function; and whether these effects are gender based. STUDY DESIGN: This was a quasi-experimental cross-sectional study. METHODS: Ninety wrists (55 participants, mean age 27.46 years) with no wrist range of motion (ROM) restrictions or previous trauma for ≥6 months were screened for CWH based on an exploratory set of diagnostic criteria. Fifty-eight wrists (34 adults) were allocated to a CWH group, and 32 wrists (21 adults) were allocated to a healthy control group. Twenty-five CWH and 25 healthy control matched (gender, age, and handedness) participants were compared. Assessment included the active wrist joint position sense test, hand-held dynamometry for wrist extension and grip strength, and the patient-rated wrist evaluation for function. Testers were blinded to group allocation. RESULTS: A 64.4% CWH prevalence existed among CWH participants, who were mostly asymptomatic females (74%). Frequent etiologic factors were midcarpal (96.5%) and scapholunate (39%) instabilities and BJHS (37%), which was higher among females (30%) than males (8%). Independent t-tests showed statistically significant (p < 0.05) group differences in wrist proprioception, wrist isometric extension, grip strength, and function with moderate-high (0.41-0.75) effect size. No significant gender differences existed in proprioception and function. CONCLUSIONS: CWH is very prevalent among functional independent young adults with atraumatic midcarpal and intercarpal ligamentous laxities and BJHS. CWH prevails among women and adversely affects wrist proprioception, strength, and function. The study's specific CWH diagnostic criteria may be useful for clinicians to identify and timely manage impacted individuals by CWH.

Reliability and Validity of the ActivForce Digital Dynamometer in Assessing Shoulder Muscle Force across Different User Experience Levels.

Background: Currently available hand-held dynamometers (HHD) offer a more objective and reliable assessment of muscle force production as compared to a manual muscle test (MMT). Yet, their clinical utility is limited due to high cost. The ActivForce (AF) digital dynamometer is a new low-cost HHD with unknown psychometric properties, and its utilization may benefit clinical practice. Hypothesis/Purpose: This study aimed to determine the AF intra- and inter-tester reliabilities, standard error of measurement (SEM), minimal detectable change (MDC), and criterion validity for assessing shoulder isometric force as compared to the microFET2 (MF2) across testers with different experiences. Design: Descriptive observational study. Methods: A convenience sample of 29 healthy adults were assessed twice by each of three testers (two experienced clinicians and a novice PT student) on shoulder external rotation (ER), internal rotation (IR), and forward elevation (FE) using both the AF and MF2 devices. Tester, HHD, and shoulder motion assignment orders were randomized. All testing was performed in a standardized seated position. ER and IR were tested with the shoulder fully adducted. FE was tested at 45° at the scapular plane. All testing and rest periods between testers and tested motions were standardized and monitored via a stopwatch. Results: Both devices had high intra- [ ER (.95-.98), IR (.97 - .99), FE (.96 - .99)] and inter-tester [ ER (.85-.96), IR (.95 - .97), FE (.88 - .95)] intraclass correlation coefficient (ICC) with comparable intra- (1.68-1.80) and inter-tester (2.36-2.98) SEM, and intra- (4.64-4.97) and inter-tester (6.50-8.24) MDC values across all motions. Tester experience did not affect these values. High (.89-.93) statistically significant Pearson correlations were found between HHDs for all shoulder motions. Conclusion: Both the AF and MF2 HHDs were found to have high reliability levels across all shoulder motions regardless of tester clinical experience. The AF was also found to be valid for measuring shoulder isometric force production compared to the criterion standard device, the MF2. Its low-cost and electronic accessibility features may promote better compliance for clinicians using dynamometry to objectively assess and store muscle force data in a cost-effective manner. Level of Evidence: 3.

The effect of muscle fatigue on wrist joint position sense in healthy adults.

STUDY DESIGN: Pretest and posttest experimental study. INTRODUCTION: The effect of muscle fatigue on wrist joint position sense (JPS) has yet to be determined. PURPOSE OF THE STUDY: The primary aim was to determine whether muscle fatigue affects wrist JPS in healthy adults. The secondary aims were to compare the effect of muscle fatigue on younger and older adults JPS and determine the association between JPS rate of change and total muscle fatigue (TMF) rates postexercise. METHODS: Forty male and female healthy adults were assigned into younger (18-40 years) and older (41-65 years) groups. Preexercise and postexercise testing consisted of active wrist JPS, handgrip, and wrist extensor strength assessments. Muscle fatigue was induced via a calibrated gripper and wrist extension dumbbell exercises. Dependent variables were the JPS rate of change (ie, preexercise and postexercise), TMF rate (ie, grip and wrist extension average strength decline), and Borg Rating of Perceived Exertion scale scores. RESULTS: Postexercise wrist JPS test scores were significantly higher than preexercise. Exercises induced statistically significant TMF rates and Borg Rating of Perceived Exertion scores among all participants. No statistically significant age-group differences on JPS rate of change, and TMF rate was found. A statistically significant mild correlation (r = 0.425) existed between JPS rate of change and TMF rates. DISCUSSION: Postexercise fatigue significantly impairs wrist JPS in both younger and older adults. On average, an 18% muscle strength decline led to 215% wrist JPS deficit. CONCLUSIONS: Significant wrist proprioception deficits persist for ≤5 min following exertional exercises, regardless of age level.

Reliability and accuracy of the brachial plexus neurodynamic test.

STUDY DESIGN: Observational study. INTRODUCTION: The brachial plexus neurodynamic test (BPNT), based on previous neurodynamic tests, is considered a clinically meaningful tool to objectively assess brachial plexus extensibility. This novel test's psychometric properties have yet to be determined. PURPOSE OF THE STUDY: The primary study aim was to assess the inter- and intrarater reliability and accuracy of the BPNT, which biases the median nerve and brachial plexus, among clinicians of various professional experience levels and geographic US regions. The secondary study aim was to determine if professional experience or geographic region affects the accuracy levels of this test. METHODS: In phase 1, inter-rater reliability and accuracy was determined. About 307 participants attending neural mobilization conferences and courses were instructed in the BPNT and asked to score 7 different videos of 14 possible test levels. In phase 2, intrarater reliability was determined via scoring the same test videos twice. RESULTS: High inter-rater intraclass correlation coefficient (range, 0.98-0.99) and accuracy (range, 0.88-0.94) levels were determined for all clinical experience levels and geographic regions. Intrarater intraclass correlation coefficient values were high (range, 0.96-1.0) among all participants. One-way analysis of variance indicated no significant differences on test accuracy based on professional clinical experience (F = 0.104; P = .958) and geographic region (F = 0.416; P = .416) among all 307 participants. DISCUSSION: Excellent inter- and intrarater reliability and accuracy levels may allow clinicians to correctly identify BPNT positions regardless of their professional experience or geographic location. CONCLUSION: The BPNT can reliably and accurately quantify outcomes in neural mobility scoring.

Responsiveness of the active wrist joint position sense test after distal radius fracture intervention.

STUDY DESIGN: Prospective cohort study. INTRODUCTION: The active wrist joint position sense (JPS) test has been determined to be a clinically useful test for assessing wrist sensorimotor (SM) status after distal radius fracture (DRF). Its responsiveness is yet to be determined. PURPOSE OF THE STUDY: Primary study aim was to determine the active wrist JPS test responsiveness to detect change in wrist SM status at 8 and 12 weeks after DRF treatment intervention. Secondary aims were to compare group (nonsurgical, surgical, high, and low pain) test responsiveness; compare pain-level group participants test scores; determine the relationship between test minimal clinically important difference (MCID) value and function; compare functional outcomes across assessment times; and determine the Patient Global Impression of Change Scale intrarater reliability. METHODS: A total of 33 male and female participants were tested at baseline, 8, and 12 weeks after nonsurgical (n = 13) and surgical (n = 20) DRF treatment interventions. Distribution-based analysis encompassed both group- (ie, effect size, standardized response mean) and individual-based (ie, minimum detectable change) statistical indices. Anchor-based analysis determined the MCID value by linking test scores to the Patient Global Impression of Change Scale. RESULTS: The active wrist JPS test is highly responsive based on effect size (8 weeks = 1.53 and 12 weeks = 2.36) and standardized response mean (8 weeks = 1.57 and 12 weeks = 2.14). Statistically significant minimum detectable change values were 4.28° and 4.94° at 8 and 12 weeks, respectively. Clinically meaningful MCID values were 5.00° and 7.09° at 8 and 12 weeks, respectively. Between treatment type and pain-level group responsiveness levels were not significantly different. High-pain participants demonstrated significantly greater JPS deficit. Test MCID values and function were significantly associated. DISCUSSION: This is the first study to determine the active wrist JPS test responsiveness as reflected by its group- and individual-based statistical indices following DRF surgical and non-surgical interventions among low- and high-pain level participants. The statistical analysis approach, which was used to determine the aforementioned variables of the active wrist JPS test, is consistent with current research. This study's strengths included its design, methodology, and statistical approach. The study findings must be interpreted, however, within the content of several methodological limitations. CONCLUSIONS: The active wrist JPS test was determined to be highly responsive to detect wrist SM status change at 8 and 12 weeks regardless of treatment type or pain level. Clinicians can use this test with confidence to measure clinically meaningful SM impairment after DRF treatment. LEVEL OF EVIDENCE: 2b.

Rehabilitation strategies for wrist sensorimotor control impairment: From theory to practice.

UNLABELLED: This clinical review discusses the organization, neuroanatomy, assessment, clinical relevance, and rehabilitation of sensorimotor (SM) control impairment after wrist trauma. The wrist SM control system encompasses complex SM pathways that control normal wrist active range of motion and mediate wrist joint neuromuscular stability for maintaining joint function. Among various known assessment methods of wrist SM control impairment, the active wrist joint position sense test is determined to be a clinically meaningful and responsive measure for wrist SM control impairment after wrist fracture. Wrist trauma may involve significant soft tissue injury (ie, skin, ligament, muscle), which could disrupt the generation and transmission of adequate proprioceptive input from wrist mechanoreceptors, thus leading to significant joint SM impairment. Various clinical examples of wrist trauma (eg, distal radius fracture, scapholunate joint injury) along with known prognostic factors (eg, pain) that may influence wrist SM control impairment recovery are discussed to illustrate this point. This article proposes promising rehabilitation strategies toward restoring wrist joint conscious and unconscious SM control impairments, integrating current research evidence with clinical practice. These strategies require more rigorous evaluation in clinical trials. LEVEL OF EVIDENCE: 5.

A descriptive study on wrist and hand sensori-motor impairment and function following distal radius fracture intervention.

STUDY DESIGN: Descriptive cross-sectional design. INTRODUCTION: Wrist and hand sensori-motor impairment have been observed after distal radius fracture (DRF) treatment. This impairment and its relationship to function lack research. PURPOSE OF THE STUDY: The primary aim of this exploratory study was to determine the magnitude of wrist and hand sensori-motor impairment following surgical and non-surgical treatment among older patients following DRF. Secondary aims were to determine the relationship between wrist and hand sensori-motor impairment with function and pain as well as the relationships among wrist and hand sensori-motor impairment and function and age following DRF. METHODS: Ten Test (TT), active joint position sense (JPS), electromyography (EMG), computerized hand-grip dynamometer (CHD), and the Patient-Rated Wrist Evaluation (PRWE) were used to assess twenty-four female participants 8 weeks following DRF treatment and their 24 matched-control healthy counterparts on wrist and hand sensibility, proprioception, muscle recruitment, grip force, muscle fatigue, and functional status. RESULTS: Participants following DRF demonstrated significantly (p < .05) greater sensory (i.e., JPS, TT), and motor (i.e., EMG, CHD) deficits than their control counterparts. A significantly higher functional deficit (i.e., PRWE) also existed among participants following DRF than the control group. Participants following surgical and non-surgical DRF treatment were found to be statistically different only on total grip force. Group differences on JPS and total grip force revealed the strongest effect size with the highest correlations to PRWE. EMG and muscle fatigue ratio group differences revealed a weaker effect size with a fair degree of correlation to PRWE. Pain significantly correlated with sensori-motor function. Age did not correlate with any measured variable. CONCLUSIONS: Significant wrist and hand sensori-motor impairment and functional deficits among older females 8 weeks following DRF surgical and non-surgical interventions were revealed. JPS and total grip force were the most clinically meaningful tests for assessing the sensori-motor status as well as explaining functional disability and pain levels for these patients. LEVEL OF EVIDENCE: 2c.

Reliability of 2 functional goniometric methods for measuring forearm pronation and supination active range of motion.

STUDY DESIGN: Test-retest reliability study. OBJECTIVES: To determine intra- and intertester reliability of the hand-held pencil (HHP) and the plumbline goniometer (PLG) methods for measuring active forearm pronation and supination motions in individuals with and without injuries. BACKGROUND: The distal forearm method has been considered the gold standard for measuring forearm pronation and supination motion. The HHP and PLG, however, are 2 more functional methods for measuring forearm motions, though limited information on the psychometric properties of these tests is currently available. METHODS AND MEASURES: Intra- and intertester reliability of the HHP and PLG methods were determined in 40 subjects of convenience (20 injured and 20 noninjured). Two testers performed 3 repeated measurements for each motion and method on all subjects. Intraclass correlation coefficients (ICC3,1 for intratester reliability, ICC2,3 for intertester reliability) and standard error of measurements (SEMs) were determined. RESULTS: The ICCs for the measurements of pronation and supination using the HHP and PLG methods were high (range, 0.86-0.98) for individuals with and without injuries, with the reliability for the PLG method being equal or slightly greater than the HHP method for the majority of pronation and supination measurements. Intratester ICCs were higher (SEMs were conversely lower) than intertester ICCs for nearly all measurements. The ICC values were generally the same or higher for individuals with injuries compared to individuals without injuries. CONCLUSIONS: The HHP and PLG are highly reliable methods for measuring functional forearm pronation and supination. Because plumbline goniometers are not commercially available and the instrumentation for the HHP method is readily accessible, clinicians should consider the latter as their method of choice for measuring functional forearm pronation and supination.