Problem: Flexion and extension
Mrs C has sustained a Colles’ fracture, an unexpected fall onto an outstretched hand (FOOSH) impacting on the distal radius with excessive force, both in the dorsal direction and along the axis of the radius (Altizer, 2008). She is presenting with pain and stiffness at the end of range for active and passive range of movement (ROM) of her right radio carpal (RC) joint, having been immobilised for 5 weeks in plaster of Paris (POP) (Gupta, 1991). Within the elderly population the radio-carpal joint is more exposed to mechanical injury, due to low bone density and less potential to regain the strained force. Studies have produced evidence on how the treatment of a Colles’ fracture causes stiffness after POP removal (Blakeney, 2010; Wahlström, 1982). The position of the wrist when immobilised appears to influence the response rate of the remodelling process where Mrs C is believed to be, causing muscle atrophy, which in turn reduces in muscle strength and endurance. A study conducted by Day et al (2000) found that approximately 3% of muscle strength is lost per day when immobilised. Further to this, the causes of these changes are a form of the lengthened muscle positions, by maximising in protein reduction and a decrease in the number of sarcomeres (Altizer, 2008). The effectiveness immobilisation has on the levels of glycogen and adenosine triphosphate (ATP) plays a part in lessening the capacity of oxidised fatty acids during muscle performance. Stiffness of the RC joint leads to the weakening of the joint contractures, further decreasing in tensile strength and thickness of the ligaments due to the increase in the connective tissue fibrosis forming, affecting the neighbouring muscles from ROM (Gupta, 1991). Cross-linking restricts regular gliding of connective tissue fibres and therefore limits movement contributing to joint stiffness, whereas increased movement activates the fibroblasts to speed up the healing process. Cross links of adhesions and collagen within the ligaments and joint capsule maybe the main extra-articular component limiting flexion and extension movements following joint immobilisation. As there is insufficient movement at the joint, synovial fluid is not produced causing the possibility of changes in the joint cartilage. Therefore, deficient weight bearing (WB) of bones and immobilisation of muscle stimulates demineralised bone, posing the risk of osteoporosis (Ellis, 2012).
Mrs C is displaying decreased flexion and extension at the radio-carpal joint, indicating a ROM test needs to be achieved. This involves the use of a goniometer device, which measures the degree of limitation of joint motion, both in active and passive ROM (Dos Santos et al, 2012). Measuring with a goniometer would present a change in movement compared to the other alternative joint, so comparing to the left wrist we would know Mrs C’s normal ROM, which according to Gebhard et al, (1993) this appears to be a positive test. An advantage of the goniometer is the simplistic way in assessing movement, without the use of a data process and is considerably low in cost, being ideal for clinical practice (Gajdosik and Bohannon, 1987). However, the down side to the device is the difficulty positioning and maintaining the arms to the joint, with some physiotherapists visually estimating without the use of a goniometer (Gebhard et al, 1993). Studies show the goniometer test to have greater intra-tester reliability than inter-tester reliability for wrist measurements. However, the test is found to have a low specificity (Dos Santos, 2012), due to the multiple joints and muscle cross over at the joint, limiting wrist movement.
Management: Joint mobilisations
Mrs C recently had her cast removed after a five week period, with a number of studies investigating to see whether accessory and physiological mobilisations has an effect after POP removal, indicating the stiffness and pain associated with injury. One article by Kay et al (2000) studied the effect of passive mobilisation following a Colles’ fracture. The study involved three weeks treatment of accessory mobilisations (grades 1-2) in both antero-posterior (AP and PA) directions of the wrist joint, progressing to end of range physiological movements (grades 3-4). The research underlines there was no beneficial differences between the control groups and effectiveness of treatment after 5 weeks (Taylor and Bennell, 1994; Kay et al, 1998). Inadequate evidence supported by a clinical trial by Taylor and Bennell (1994), again achieved no difference at the time of discharge from physiotherapy. However, the researchers concluded that the control group was not checked to see what healing stage the patients were currently at, making the results inaccurate for mobilisation.
A treatment of joint mobilisations twice a week proves to be favourable, by stimulating mechanoreceptors that limits transference of pain and improves the mobility of hypo-mobile joints after 8-10 weeks. An appropriate sample size to demonstrate 25% improvement was totalised at 80 participants, with 100 concluding the study, meeting the outcomes conveniently. It is crucial to have an understanding of the possible risk of bias with any research analysing the effectiveness of passive mobilisation, due to additional psychosocial circumstances influencing on the results, by the degree of physiotherapy contact. However, on the other hand joint mobilisations with AROM reduces pain, increases ROM and breaks down adhesions by structurally changing the surrounding structures, this prevents Mrs C from becoming hypo-mobile and experiencing unexpected muscle stimulation, which can cause tissue resistance and muscle spasms further weakening the wrist joint (Coyle and Robertson, 1998). This is significant for Mrs C as she struggles to grip for prolonged periods of time, and being active with her house chores, is a problem for stiffness and pain, with everyday use of her hands. Whilst numerous joint mobilisation studies show no remarkable breakthrough involving fractures of the distal radius, many prove to be advantageous to the reduction of pain and stiffness. A review by Heiser et al (2013) identifies this decline in the results, by expressing the significance of an individuals’ awareness of their pain relief and development. Mrs C’s awareness to recovery is fundamental during the remodelling process as stiffness maybe her personal measurement of the extremity of injury (Taylor and Bennell, 1994). If the joint mobilisations are performed correctly by the physiotherapist and the AROM exercises were well educated, this can give Mrs C confidence, independence, increase joint mobility and improve the extremity of her injury. This type of system can potentially minimise outpatient physiotherapy attendance by highlighting self-treatment (Kay et al, 2000). There is limited data on joint mobilisations (accessory and physiological) following a Colles’ fracture for the basis of miss conception of the subject, so overall more evidence is needed (Coyle and Robertson, 1998).