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Arch Orthop Trauma Surg (1997) 116:373-375 © Springer-Verlag 1997 
G. V. Oskarsson • A. H ja l l • P. Aaser 
Physiotherapy: an overestimated factor in after-treatment 
of fractures in the distal radius? 
Received: 23 May 1996 
Abst ract Supervis ion by physiotherapists, starting 4 -6 
weeks after cast removal, was compared with self-training 
in 110 patients treated for Col les' fracture. The patients 
guided by physiotherapists were all satisfied with the 
treatment, but no functional advantages could be dis- 
cerned when compared with self-training. 
Introduction 
Conscientious training after the conventional 4- to 6-week 
treatment for Col les' fractures is imperative to regain ac- 
ceptable wrist function. The benefit of systematic training 
supervised by physiotherapists, as compared to self-train- 
ing, is however uncertain and debatable. A small number 
of studies has been publ ished in recent years concerning 
this issue with somewhat divergent conclusions. The aim 
of this study is by no means to discredit the excel lent 
work done by physiotherapists, but to emphasize that 
good function can be achieved by motivation and careful 
instructions given by the surgeon for self-training. We 
considered randomizat ion impossible because of the gen- 
eral predi lection of people for physiotherapy, and we fur- 
thermore found it unacceptable not to be able to advise as- 
sistance by a physiotherapist in certain cases. 
Materials and methods 
The effect of training supervision by physiotherapists was studied 
in 110 patients treated for Colles' fracture at the Surgical Depart- 
ment, Bmrum Hospital, during 1989. The mean patient age was 58 
years and the male/female ratio was 17/83 (Fig. 1). The fractures 
were classified into Frykman's eight classes (Table 1) [3]. 
Treatment followed conventional methods, i.e. immobilisation 
in cast for 4 or 6 weeks. Reduction, when required, was carried out 
under local anaesthesia (haematoma block). 
Following initial treatment, all patients were instructed in self- 
training of the fingers, elbow and shoulder. The importance of this 
G. V. Oskarsson (N~) . A. Hjall • P. Aaser 
Surgical Department A, Rikshospitalet, N-0027 Oslo, Norway 
e~ 
E 
z 
40- 
35- 
30- 
25- 
20- 
15. 
10. 
• Males 
F1 Females 
5. i 
O' 
25-34 35-44 45-54 55-64 
Age groups 
Fig. 1 Age and sex distribution among the 110 patients included 
in the study 
m 
m "1 
65-75 
Table 1 Influence of physio- 
therapy versus fracture classes 
in a total of 110 patients suf- 
fering from a fracture of the 
distal radius. (Ph+: patients 
guided (Ph-: not guided) by 
physiotherapists 
Frykman Ph+ Ph- 
class 
I 11 23 
II 10 24 
III 4 6 
IV 6 6 
V 1 2 
VI 5 7 
VII 1 1 
VIII 2 1 
Total 40 70 
was urged upon them, and written instructions were given. After 
cast removal, these factors were emphasised again, and mobilisa- 
tion of the wrist instructed carefully (flexion, extension, adduction, 
abduction, and rotatory movements). 
Referral to physiotherapy was not given routinely, but the pa- 
tients' requests were as a rule followed, and those with severe stiff- 
ness were advised to seek such help. The referrals were given at 
the 10-week follow-up (4-6 weeks after cast removal). Conse- 
374 
quently, a total of 40 patients (31 women and 9 men, Table 1) were 
supervised by physiotherapists between weeks 10 and 35, 
Measurements and evaluations were carried out at 10 and 35 
weeks. Function was estimated as grip strength (MGS) and wrist 
movement score (WMS). WMS was found by measuring dorsal 
and volar flexion, pronation and supination with a standard go- 
niometer, and the results given as a percentage of the WMS on the 
unaffected side. MGS was measured with a vigorimeter, and the 
results given as percentage of the expected value, i.e. as measured 
on the uninjured arm. The non-dominant arm was considered 15% 
weaker than the dominant one [5]. 
Pain and discomfort in the first 2 days after cast removal were 
registered at the 10-week follow-up. Patients guided by a physio- 
therapist were asked whether they considered that physiotherapy 
had improved their function or not. 
For statistical analysis we used Student's t-test and regression 
analysis. P < 0.05 was regarded as significant. No randomization 
was carried out as stated in the introduction. To obtain comparable 
groups to represent both those who were supervised by a physio- 
therapist and those who were not, we paired patients with the same 
score (+ 2%) at 10 weeks. We thus studied the effect of physio- 
therapy on WMS in 29 pairs and evaluated the effect on MGS in 
33 pairs. 
Table 2 Mean grip strength (MGS) and wrist movement score 
(WMS) compared between the two main groups, i.e. those attend- 
ing formal physiotherapy (Pt+) and those who did not (Pt-) 
Pt+ (95% CI) Pt- (95% CI) P 
(n = 40) (n = 70) 
MGS 10 weeks 40.9 (33.9-47.9) 53.7 (48.1-59.2) 0.007 
MGS 35 weeks 71.8 (66.2-77.3) 80.9 (77.0-84.8) 0.009 
Gain 30.9 (25.4-36.0) 27.2 (23.4-32.0) 0.4 
WMS 10 weeks 70.5 (65.8-75.1) 80.4 (77.6-83.1) 0.0002 
WMS 35 weeks 85.3 (81.8-87.1) 90.9 (89.2-92.5) 0.002 
Gain 14.8 (11.9-19.5) 10.5 (8.6-12.5) 0.01 
% 
35 w 
75 ° 
Mean 
Kip strength 
• • • O• • OI, O O00013DOL XDs.~ 
• 0 • ,,,. ~" " Y O 
O ,& . O • ~" ~" A ,~ 
.- - / • -o *'o 
/ • • o 
6 o~ • • 
50] o • • 
• Pt + ~ ••• (~=& not matched) 
& Pt • • • (o-o o not matched) 
2's s'o i5 % 
lOw 
gO00 
Fig. 2 Regression analysis of mean grip strength (MGS), compar- 
ing the physiotherapy treated group (Pt+) and those who were not 
(Pt-). The scatter diagram shows the distribution of MGS coordi- 
nates between 10 and 35 weeks (n = 110). A total of 33 matched 
pairs. Unmatched coordinates symbolized by open circles and tri- 
angles 
Table 3 Distribution of the matched pair sample into classes ac- 
cording to Frykman 
Frykman WMS (n = 58) MGS (n = 66) 
class 
Pt+ Pt- Pt+ Pt- 
I 9 7 10 10 
II 7 11 10 10 
III 3 2 3 2 
IV 3 3 4 3 
V 1 1 1 2 
VI 3 3 3 5 
VII 1 1 0 0 
VIII 2 1 2 1 
Total 29 29 33 33 
% 
35 w 
75- 
50 
25 
Mean 
wrist movement score 
• ° "° o" o 
,~ ~ '~ '~O • O I O• J~ A 
A 
A 
I , • 
i , 
Pt + ~ •A• (A*,~ not matched) 
Pt • • • (o o o not matched) 
5'0 is % ' 
10w 
Fig. 3 Regression analysis of mean wrist movement score (WMS), 
comparing the Pt- and Pt+ groups. The scatter diagram displays 
the distribution of WMS coordinates between 10 and 35 weeks (n 
= 110). A total of 29 matched pairs. Unmatched coordinates sym- 
bolized by open circles and triangles 
Table 4 Wrist function compared between groups consisting of 
matched pairs from each of the two pooled samples, i.e. those at- 
tending formal physiotherapy (Pt+) and those who did not (Pt-). 
Figures in percent as compared with the uninjured wrist 
Pt+ Pt- P 
MGS (33 pairs) 
At 10 weeks 44.36 44.52 NS 
At 35 weeks 74.42 78.30 NS 
Gain 30.06 33.78 NS 
WMS (29 pairs) 
At 10 weeks 75.13 75.05 NS 
At 35 weeks 88.71 89.17 NS 
Gain 13.58 14.12 NS 
Results 
From the pat ients ' sel f -assessment, the mean pain score 
registered at i0 weeks for those supervised by physiother- 
apists was 6.0 + 2.6 and for those who were not, 4.6 + 2.3 
(P = 0.009). Of the former, 93% judged the physiotherapy 
to have been effective when asked. 
At 35 weeks, the loss of MGS amongst those guided 
by a physiotherapist was 28.2% and amongst those who 
were not, 19.1% (P = 0.009) (Table 2, pooled patient sam- 
ple). A similiar difference was noted at 10 weeks. On re- 
gressional analysis of the same patient material, compar- 
ing the regression lines for gain in strength in the 25-week 
period, we found no difference between those supervised 
by physiotherapists andthose who were not. 
When studied in matched pairs (Fig. 2, Table 3), the re- 
gression lines had identical slopes, and no difference was 
found. Patients in Frykman class 1 immobilized for 4 
weeks had a somewhat smaller loss of MGS at 10 weeks 
than those immobilized for 6 weeks. Otherwise, no differ- 
ence could be ascribed to the immobilization time. 
Mean WMS differed significantly between the groups 
before referral to physiotherapy (Table 2), and the gain in 
WMS was significantly greater amongst those who were 
supervised by physiotherapists. 
When studied in matched pairs (Fig. 3, Table 4), the 
groups were found to be identical. No difference in WMS 
at 10 or 35 weeks could be ascribed to the different im- 
mobilization times. 
375 
patients in our study referred for physiotherapy had a 
greater loss of function than those who were not. At 35 
weeks, we found, as might be expected, a statistically sig- 
nificant, but spurious effect on the WMS, while the MGS, 
which seems a better indicator than WMS of hand func- 
tion [4], had not significantly improved. In comparable 
groups, however, i.e. matched pairs, the regimes were 
found to give identical results. This, of course, does not 
completely exclude the possibility that better results could 
have been achieved if supervision by a physiotherapist 
had been started earlier, e.g. as part of the initial treat- 
ment, but that has been found by Pasila [7] to be value- 
less. Physiotherapy cannot be expected to counterbalance 
unsatisfactory primary treatment or complications caused 
by a compound and difficult fracture [6]. The present re- 
sults indicate that self-training is just as effective as sys- 
tematic guidance by a physiotherapist for achieving opti- 
mal functioning. 
Placebo effects may be valuable, but could possibly be 
obtained at a lesser cost. It seems fair to conclude that fol- 
lowing the typical distal radius fracture, only patients with 
severe stiffness and those who for any reason cannot exe- 
cute their self-training programme should be referred to a 
physiotherapist. 
Discussion 
Reports on the objective effects of physiotherapy on the 
regaining of wrist function after a fracture of the distal ra- 
dius seem rare. On the other hand, some authors [1, 2] 
have emphasised the positive effect of a short immobilisa- 
tion period and early training. 
The majority of patients supervised by physiothera- 
pists were content, even if their wrist function was excel- 
lent before they began, and the gain was trivial. This 
merely seems to demonstrate a placebo effect. 
Although thoroughly instructed at all consultations, 
some patients seemed unable and/or unwilling to carry out 
their exercises. There are no data on this patient compli- 
ance. One may assume, however, that those who wanted 
guidance by a physiotherapist at 10 weeks had been more 
hesitant than the others to execute the self-training pro- 
gramme given to them at the clinic. 
Indisputably, an amelioration caused by physiotherapy 
can only be expected when function is reduced, and those 
References 
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