ORIGINAL RESEARCH ARTICLE
Does a Hand Strength–Focused Exercise Program Improve
Grip Strength in Older Patients With Wrist Fractures
Managed Nonoperatively?
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A Randomized Controlled Trial
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Antony Nguyen, BMed, Mehr Vather, MBBS, Gobind Bal, MBBS, Donna Meaney, BAppSc, Megan White, BAppSc, MN,
Myles Kwa, BMed, and Jai Sungaran, BSc(Med), MBBS, FRACS(Orth), MASurg(Orth), FAOA
Objective: Distal radius fractures in the older population significantly
impair grip strength. The aim of the study was to investigate whether a
hand strength focused exercise program during the period of immobi-
lization for nonoperatively managed distal radius fractures in this pop-
ulation improved grip strength and quality of life.
Design: This is a single-center randomized controlled trial with
concealed allocation, assessor blinding, and intention-to-treat analysis.
Fifty-two patients older than 60 yrs who experienced distal radius frac-
tures managed nonoperatively with cast immobilization. The intervention
group (n = 26) received a home hand strength–focused exercise program
from 2 and 6 wks after injury while immobilized in a full short arm cast.
The control group (n = 26) performed finger range of motion exercises as per
protocol. Primary outcome was grip strength ratio of injured arm compared
with uninjured arm. Secondary outcome included functional scores of the
11-item shortened version of the Disabilities of the Arm, Shoulder
and Hand. Outcomes were measured at 2, 6, and 12 wks after injury.
Results: The intervention group significantly improved grip strength
ratio at both 6 and 12 wks (6 wks: 40% vs 25%, P = 0.0044, and
12 wks: 81% vs 51%, P = 0.0035). The intervention group improved the
11-item Disabilities of the Arm, Shoulder and Hand score at 12 wks; how-
ever, this was not statistically significant (25 vs 40, P = 0.066).
Conclusions: A hand strength–focused exercise program for elderly
patients with distal radius fractures while immobilized significantly
improved grip strength.
Key Words: Rehabilitation, Exercise, Wrist Fracture, Aged
(Am J Phys Med Rehabil 2020;99:285–290)
istal radius fractures are very common in the elderly pop-
D These
ulation with an incidence of approximately 20%.
fractures have a significant impact on patients’ lives
1
with a reduction in grip strength, range of motion (ROM), con-
fidence, and function.2–4
From the Liverpool Hospital, Liverpool, New South Wales, Australia (AN); Concord
Hospital, Sydney, New South Wales, Australia (AN, MV, GB, DM, MW, MK, JS);
and Royal North Shore Hospital, Sydney, New South Wales, Australia (GB, MK).
All correspondence should be addressed to: Antony Nguyen, BMed, PO Box 2231,
Carlingford Court, NSW 2118, Australia.
The research study was performed at Concord Hospital, NSW Australia.
Financial disclosure statements have been obtained, and no conflicts of interest have
been reported by the authors or by any individuals in control of the content of
this article.
Supplemental digital content is available for this article. Direct URL citations appear
in the printed text and are provided in the HTML and PDF versions of this article
on the journal’s Web site (www.ajpmr.com).
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0894-9115
DOI: 10.1097/PHM.0000000000001317
American Journal of Physical Medicine & Rehabilitation • Volume 99, Number 4, April 2020
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
Management of these injuries varies from center to center
with evidence for and against both operative and nonoperative
management. There have been many proponents of nonopera-
tive management for elderly patients with distal radius frac-
tures with some studies finding that radiographical outcomes
do not equivocate to clinical outcomes.5–8
In a meta-analysis in 2016, Chen et al.3 reported that the
main functional benefit of operative fixation compared with
nonoperative management in patients older than 60 yrs with
distal radius fracture was grip strength. There was no statistically
significant difference in other functional outcomes of patient-
reported scores, pain, or wrist ROM.3
When patients older than 60 yrs are managed nonoperatively,
they are immobilized in plaster or fiberglass cast for a period,
most protocols vary between 3 and 6 wks.9,10
This immobilization leads to significant decline in func-
tion and grip strength because of increased stiffness,
muscle wasting.11
For the elderly population who experienced a distal ra-
dius fracture and are managed nonoperatively, most rehabil-
itation programs have been incorporated to improve function
after immobilization.12
There is minimal literature investigating exercise pro-
grams or physiotherapy provided while a patient is
immobilized in a full cast. Nearly all exercise programs
studied in the literature are only after cast immobilization
has been removed.12
The authors performed a pilot study investigating grip
strength in an elderly population of patients older than 60 yrs
with distal radius fractures at 2 and 6 wks after injury. One ma-
jor finding was that patients older than 60 yrs who experienced
a distal radius fracture have poor grip strength when measured
at 2 and 6 wks after injury ranging from 0 to 5 kg. Most pa-
tients vocalized their concerns that they felt weak and unable
to perform activities of daily living.
Grip strength has been noted to be a marker of function
in elderly patients and given the poor grip strength in the pa-
tients who experience distal radius fractures and managed
nonoperatively with immobilization; this study endeavored
to find a way to attempt to improve this to improve quality
of life.13–15
The authors hypothesized that a 4-wk hand strength–focused
exercise program given to elderly patients with distal radius
fractures who were immobilized in a full cast between 2 and
6 wks will significantly improve patients’ grip strength and
therefore function in the short term.
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 Nguyen et al.
This is the first study in the literature to investigate a hand
strength–focused exercise program between 2 and 6 wks for
immobilized distal radius fractures managed in a full cast.
MATERIALS AND METHODS
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Study Design
This was a single-center prospective, parallel design,
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randomized controlled trial investigating whether a hand
strength–focused exercise program improved grip strength and
function in patients older than 60 yrs who experienced a distal
radius fracture managed nonoperatively. The study protocol
was approved by the local Human Research Ethics Committee
and registered on March 2016. This study conforms to all Con-
solidated Standards of Reporting Trials guidelines and reports the
required information accordingly (see Supplemental Checklist,
Supplemental Digital Content 1, http://links.lww.com/PHM/A890).
From June 2016 to June 2017, 52 patients were prospec-
tively enrolled. Patients underwent written informed consent.
Patients were enrolled to the study 2 wks after injury in the frac-
ture clinic. All data were recorded from patients at the clinic.
Inclusion Criteria
All patients older than 60 who experienced a distal radius
fracture that was managed nonoperatively were included in the
study. Patients who experienced a distal radius and ulnar frac-
ture were also included in this study.
Exclusion Criteria
Patients were excluded if they experienced bilateral distal
radius fractures, existing neurological condition, which has led
to weakness in the ipsilateral limb, previous distal radius frac-
ture in same arm, previous hand or wrist surgery in same
arm, had documented diagnosis of dementia by a geriatrician,
or were unable to follow instructions.
Hospital Protocol
At our center, patients with distal radius fractures man-
aged nonoperatively were immobilized in a below elbow dorsal
and volar plaster slab in the emergency department. If the frac-
ture was deemed as significantly displaced, the patient underwent
closed reduction before application of plaster.
The patients then presented at the fracture clinic 2 wks af-
ter initial injury. At this follow-up, the patient underwent radio-
graph and were changed to a below elbow full fiberglass cast.
Immobilization
It was integral to the study that every patient had a fiberglass
cast applied to allow for full flexion at the metacarpal phalangeal
joints of the fingers and full thumb movements.
The fiberglass cast extended to the distal palmar crease on
the volar surface and the metacarpal phalangeal joint on the
dorsal surface. After the cast was applied, the physiotherapist
ensured that all patients were able to flex their metacarpal pha-
langeal joints to 90 degrees, move the thumb, and were able to
touch each finger and thumb. If they were unable to perform
this because of the volar aspect of the cast being too distal,
the cast was trimmed to enable full flexion of the fingers.
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Volume 99, Number 4, April 2020
The thenar eminence was left free to enable thumb movements
in the cast.
Control
At 2 wks after initial injury, after fiberglass cast is applied,
our normal protocol is to give a patient information sheet with
general finger ROM exercises. They are instructed to perform
the exercises as tolerated for the following 4 wks. The patient is
then reviewed in the fracture clinic 6 wks after injury to remove
the full cast.
Once the cast is removed, the patient is given a general up-
per limb exercise sheet to improve strength in fingers and wrist
to be performed at home with no formal physiotherapy.
Intervention
Our intervention comprised hand strength–focused 4-wk
home exercise program between 2 and 6 wks after injury with
exercises focused on improving grip strength. There were three
persons who created the exercise program: our hand surgeon,
hand therapist, and physiotherapist. The authors intended to
create a home exercise program, which was pragmatic, simple,
and reproducible. The exercise program consisted of three cat-
egories of gradual strengthening; finger ROM, isometric finger
strengthening exercises, and grip strength–focused exercises
using a soft rubber ball.
Once the patient was consented and randomized to the in-
tervention group, a physiotherapist explained the home exer-
cise program week by week to the patient. All patients were
given a rubber ball.
To determine compliance, every patient in the intervention
group was given a compliance checklist. For each exercise per-
formed, the patient would tick off the exercise as completed. If
there were any issues with completion or compliance of the ex-
ercise program, the patient would document the reasons.
Exercise Program
Week 1 – Finger ROM and Isometric Finger
Strengthening Exercises
The patient was instructed to perform finger ROM 20
times a day or if unable to reach this amount, as many as able.
Finger ROM exercises consisted of making a fist and extension
of fingers. This was a way to build confidence in the patient
and also to reduce stiffness.
The second exercise was isometric finger strengthening.
The patient was instructed to touch each of their fingers indi-
vidually to the thumb and to extend and flex the interphalan-
geal joints of each finger. They were asked to press their
finger and thumb together for 30 secs. One repetition was com-
pleted once the patient had sequentially pressed each finger
against the thumb for 30 secs each. This was performed daily,
5 times a day, and every day for a week.
Week 2 – Finger ROM and Introductory Hand
Strength Exercises With Rubber Ball
The ball was placed between the middle phalanx of the fin-
gers and the thumb tip. The patient was instructed to squeeze the
rubber ball as hard as they could while keeping the interphalan-
geal joints of the fingers and thumb straight 10 times. This was
© 2019 Wolters Kluwer Health, Inc. All rights reserved.
 Volume 99, Number 4, April 2020
first exampled by the investigator and then shown to the patient
with the patient asked to reproduce the movement with the ball
in the hand but without squeezing the ball.
This exercise was performed 5 times a day, every second
day for the week.
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The patient was also instructed to continue to perform
daily finger ROM exercises.
Week 3–4 – Finger ROM and Hand Strength
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Exercises With Rubber Ball
Week 3–4 consisted of week 2 exercises with the addition
of a third exercise. The patient was instructed to squeeze the
ball as hard as possible with the ball situated in the palm of
the injured hand 10 times. This exercise was performed 5 times
a day, every second day for the week.
At 6 wks after injury, the cast was removed and the patient
was given the same general home upper limb exercise sheet as
the control group with no formal physiotherapy.
Primary Outcome – Grip Strength
At 2, 6, and 12 wks, the grip strength was recorded. Grip
strength testing at 6 wks was measured before and removal of
cast. The average of those measurements was recorded. The ratio
of the grip strength of the injured hand to the normal hand was the
main outcome. The grip strength ratio reduced intersubject var-
iability.16 Grip strength was measured with a JAMAR hand
FIGURE 1. Randomization, allocation, and follow-up flow diagram. Randomization: 52 patients, allocation: 26 in each group, final 12-wk follow-up:
33 patients, and final statistical analysis: 48 patients. Four patients withdrew after randomization and 15 were lost to follow-up.
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Improved Strength After Wrist Fractures in Elderly
dynamometer (Lafayette Instrument Company) in kilograms.
The patient was positioned seated, with shoulders at 0 degree
of flexion; elbow 90 degrees of flexion, and the hand in neutral
position.17 Three measurements were taken and the average
was recorded.
Clear instructions regarding the use of the dynamometer
were communicated to the patient. No encouragement was
given to the patient to minimize measurement error.18 Three
measurements were taken and the average was recorded.
The final time point was 12 wks. This time point was in ac-
cordance with the aim of the study, to determine whether the
hand strength program improved outcomes in the short term.
Secondary Outcome – QuickDASH and Pain
The validated 11-item Disabilities of the Arm, Shoulder
and Hand (QuickDASH) score was used as a secondary out-
come and measured at 2, 6, and 12 wks. The score is between
0 and 100 with lower scores indicating better function.19,20
Pain scores were recorded using a visual analog scale of
0–10, with lower scores indicating less pain.
Radiographical Parameters
Plain radiographs were completed at 2- and 6-wk follow-up.
The Centricity picture archiving and communication system was
used and all patients had a radiograph at the same center. The ra-
dial height, inclination, and volar tilt from the radiograph were
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 Nguyen et al. Volume 99, Number 4, April 2020

power of 90% with equivalent groups. To allow for a 20% loss

TABLE 1. Patient characteristics
to follow-up, 52 patients were included.
Control Intervention P
No. patients 26 22 Randomization and Blinding
Male/female 7/19 3/19 0.23
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Before starting the study, all 52 patients were randomized

Agea,b 80 (12) 79 (9) 0.77 using a random block randomization technique (http://www.
AO Fracture Classificationb,c randomization.com). The control group was assigned A, and
Type A 2 (8) 6 (23) 0.064 the intervention group assigned the character B. Once block
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Type B 4 (15) 3 (12) 0.86 randomization had occurred, the corresponding group of A or
Type C 19 (73) 13 (50) 0.31 B was written on 52 pieces of paper and assigned to 52 enve-
Missing data 1 (4) 0 (0) lopes each in sequential order 1–52.
a
Values are expressed as mean (SD). The envelopes were opened sequentially once the partici-
b
T test was used for comparison of age, and χ2 was used for sex and clas- pant had consented.
sification. A P value of less than 0.05 was considered significant. The investigator who performed the randomization was
c
Percentage in parenthesis. different to the person enrolling patients. Once the participant
was enrolled, the physiotherapist who was a different investiga-
measured at the 2- and 6-wk time point by the experienced hand tor would explain the exercise protocol for the control or inter-
surgeon. Fractures were classified according to the AO classification. vention group.
A different person then collected data at each stage of
follow-up. Participants were not blinded.
Complications
Complex regional pain syndrome (CRPS) was recorded as
a complication for patients as outlined by the Budapest criteria. Statistical Method
Data was analyzed using IBM SPSS Statistics Version 24.
An intention-to-treat analysis was performed on all participants
Sample Size originally assigned. Data were first tested for normal distribu-
Sample size was based on the main outcome of ratio of tion using the Shapiro-Wilk test. For comparison of means be-
grip strength of injured hand compared with uninjured hand. tween different groups with normal distribution, t test was
Based on a previous study, the minimum clinically important performed; otherwise, a Mann-Whitney U test was performed.
grip strength was described as a change in 19.5% of the ratio For intragroup comparisons, a paired t test was performed for
of injured arm compared with uninjured side.21 This equated normally distributed data; otherwise, a Wilcoxon test was per-
to a sample size of approximately 42 patients providing a formed. For comparison of proportion of complications, a χ2

TABLE 2. Clinical outcomes

Control Group Intervention Group 95% CI P a,b

Week 2 (n = 48)
Grip strengthc 2.0 (0 to 20.3) 2.5 (0 to 8.3) 0.14
Grip strength ratiod 8.5 (0 to 50) 12.9 (0 to 62.5) 0.12
QuickDASH 77.3 (29.5 to 93.2) 72.7 (29.5 to 88.6) 0.15
Pain 5 (0 to 10) 3 (0 to 6) 0.0061
Week 6 (n = 48)
Grip strengthc 4.3 (0 to 54.8) 7.2 (1.7 to 24.7) 0.032
Grip strength ratiod 25.0 (0 to 10.3) 40.2 (19.6 to 100) 0.0044
QuickDASH 48.9 (4.5 to 86.3) 42.0 (6.8 to 72.7) 0.19
Pain 3 (0 to 10) 3 (0 to 7) 0.57
Week 12 (n = 33)
Grip strengthc 10.0 (3.7 to 17.7) 12.2 (7.3 to 27.3) 0.18
Grip strength ratiod 51.0 (24.3) 81.0 (28.4) −49.38 to −10.68 0.0035
QuickDASH 39.9 (21.9) 25.4 (20.9) −1.01 to 29.93 0.066
Pain 2.0 (0 to 5) 0 (0 to 4) 0.046
a
Values are expressed as mean or median depending on distribution of data.
b
An independent 2-tailed t test was used for comparison between groups for normally distributed data; otherwise, Mann-Whitney U test was used. A P < 0.05 was
considered significant.
c
Grip strength was measured in kilograms.
d
Grip strength ratio is the percentage grip strength of the injured arm compared to uninjured arm.
CI indicates confidence interval.

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 Volume 99, Number 4, April 2020
test was used. A P value of 0.05 or less was considered
significant.
RESULTS
Figure 1 presents the flow of participants through the
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study. From June 2016 to June 2017, a total of 52 patients were
enrolled in the study. Forty-eight patients were included in the
analysis because of four patients withdrawing from the study
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after randomization. Twenty-six patients were included in the
control group and 22 patients were included in the intervention
group. Patient characteristics are reported in Table 1. Both
groups were comparable in sex and age, fracture classification,
and radiographical parameters. There was 100% compliance
with exercises in the intervention group.
At the final assessment, there were 15 patients (28%) lost
to follow-up with 33 patients completing the study. Ten pa-
tients did not want to continue to follow up in clinic once the
cast was removed. Two patients had moved interstate, one pa-
tient was overseas, and the final two patients, though contacted
regarding appointment, unfortunately did not follow up.
Primary Outcome
Grip Strength
The primary and secondary outcomes are reported in
Table 2. At 6- and 12-wk time points, patients in the interven-
tion group had significantly better grip strength than the con-
trol group. At 6 wks, the grip strength ratio was 40% in the
intervention group compared with 25% in the control group
(P = 0.0044) and grip strength ratio was 81% compared with
51% (P = 0.0035) at the final 12-wk time point.
Secondary Outcome
Functional Outcome
At the 6-wk time point, there was no significant difference
in median QuickDASH scores (P = 0.19). Although there was
a trend toward improved QuickDASH scores in the interven-
tion group at 12 wks, this was not statistically significant, 25
compared with 40, respectively (P = 0.066).
There was a significant improvement in VAS score for
pain at 12 wks for the intervention group 2 compared with 0
(P = 0.046); however, there was no difference at the 2- and
6-wk time points.
Radiographical Parameters
There was no significant difference between radial incli-
nation, height, and volar tilt in group B between 2 and 6 wks.
Adverse Events
There were three cases of CRPS in the control group
(11%). No patients in the intervention group were found to have
CRPS. This did not reach statistical significance (P = 0.10).
DISCUSSION
This was the first study in the literature to investigate a
hand strength–focused exercise program for patients who ex-
perienced distal radius fractures while they were immobilized
in a cast. This study found that a hand strength–focused
© 2019 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
Improved Strength After Wrist Fractures in Elderly
exercise program while immobilized between 2 and 6 wks sig-
nificantly improved grip strength at the 6 and 12-wk time points.
The authors initially hypothesized that a strengthening ex-
ercise program focused on improving hand strength would be
more effective than purely finger ROM exercises. Our program
was based on hand strength focused exercises in order to im-
prove grip strength.22
This was evident in our results where the grip strength ra-
tio of injured limb to uninjured limb significantly improved in
the intervention group compared with the control group at both
time points of 6 and 12 wks (40% vs 25%, P = 0.0044, and
81% vs 51%, P = 0.0035, respectively).
The most reproducible significant improvement of opera-
tive management in elderly patients experiencing distal radius
fractures was grip strength in the short term.3,23 Our findings
of improved grip strength at the 6 and 12-wk time points are
not only statistically significant but also clinically significant
as this provides evidence for nonoperative management of dis-
tal radius fractures in this population.
There was a trend toward improved functional outcomes in
the intervention group with QuickDASH 25 points versus 40
points (P = 0.066); although not statistically significant, it was a
clinically significant improvement. Some studies suggested a dif-
ference of 10 in the DASH score to be clinically significant.24,25
The pain scores were significantly better 3 mos after in-
jury in the intervention group. Both control and intervention
pain scores improved from 2 and 12 wks, making it difficult
to conclude whether this improvement was due to the exercise
program or pain improving over time. Causes of pain are mul-
tifactorial and the amount of analgesia the patient used at each
time point of review were not recorded. It was important to
note the pain scores to ensure that the exercise program did
not worsen pain in the intervention group.
There was no significant displacement of the distal radius
fracture in the intervention group between radial height, incli-
nation, and volar tilt. This finding was of importance as it
showed that a grip strength–focused exercise program did not
worsen functional or radiographical outcomes.
Complex regional pain syndrome is a devastating compli-
cation and is known to occur in distal radius fractures.26,27 It is
important to note that no patients in the intervention group ex-
perienced from CRPS at 12 wks compared with 11% of pa-
tients (3/26) in the control group, although this did not reach
statistical significance (P = 0.1).
There have been only two randomized control trials that
describe hand rehabilitation of distal radius fractures during
immobilization. Both did not use a hand strength–focused ex-
ercise program. One study by Gronlund compared an occupa-
tional therapy session 1–3 days after application of the plaster
to no therapy.28 The rehabilitation involved hand pumping ex-
ercises, finger, elbow, and shoulder active ROM and utilization
of appliances for home to improve hand therapy. They found a
significantly improved function in DASH score at 5 wks after
injury once plaster removed; however, no difference at 3 mos
after injury. This was contrasted to our results where we had
similar results in QuickDASH at 6 and 12 wks. This was most
likely due to their use of an occupational therapy program pre-
dominantly aimed at improving functional scores and out-
comes of the DASH score compared with our use of a hand
strength–focused exercise program for rehabilitation, where
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 Nguyen et al.
there was a significant improvement in grip strength at both 6
and 12 wks after injury. Important to note was 3 patients of
17 in the intervention group who experienced CRPS compared
with our study where no patients receiving the intervention ex-
perienced CRPS.28
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The other study investigating rehabilitation during immo-
bilization used an intervention comprised edema management,
active ROM for unaffected joints within 4 days of the fracture
compared with standard intervention starting after cast re-
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moval. They found a significant improvement in grip strength
4 wks after immobilization at approximately 3 mos after injury.
This study is different to ours, and given that they did not per-
form a hand strength–focused exercise program, there was not
a standard length of immobilization and it was also difficult to
generalize the result with a total of 17 participants.29
Limitations of this study included a large loss to follow-up of
29%, which may lead to significant bias. However, before starting
the study, it was decided to include all patients in data regardless
of loss to follow-up on the intention-to-treat analysis principle.
Although the study performed strict blinding and masking
of investigators, participants were unable to be blinded because
of the informed consent process and description of our normal
protocol of immobilized patients with distal radius fractures
between 2 and 6 wks.
The exercise program was cost-effective, pragmatic, and
reproducible to other centers with each stress ball only costing
AUD $1. The exercise compliance checklist was also simple
with all patients finding the checklist easy to follow.
Although rehabilitation after distal radius fractures has been
well described in the literature, there are no studies, which evaluate
a hand strength focused exercise program while immobilized.12
This randomized control trial is the first study, which in-
vestigated a home exercise program for elderly patients experi-
ence distal radius fractures while immobilized. Our findings
support a grip strength–focused exercise program for elderly pa-
tients with distal radius fractures while immobilized to improve
grip strength, function, and ultimately quality of life.
REFERENCES
1. Nellans KW, Kowalski E, Chung KC: The Epidemiology of Distal Radius Fractures.
Hand Clin 2012;28:113–25
2. Vergara I, Vrotsou K, Orive M, et al: Wrist fractures and their impact in daily living
functionality on elderly people: a prospective cohort study. BMC Geriatr 2016;16:11
3. Chen Y, Chen X, Li Z, et al: Safety and efficacy of operative versus nonsurgical management
of distal radius fractures in elderly patients: a systematic review and meta-analysis. J Hand
Surg Am 2016;41:404–13
4. Beumer A, McQueen MM: Fractures of the distal radius in low-demand elderly patients:
closed reduction of no value in 53 of 60 wrists. Acta Orthop Scand 2003;74:98–100
5. Arora R, Gabl M, Fau - Gschwentner M, et al: A comparative study of clinical and radiologic
outcomes of unstable colles type distal radius fractures in patients older than 70 years:
nonoperative treatment versus volar locking plating. J Orthop Trauma 2009;23:237–42
290 www.ajpmr.com
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
Volume 99, Number 4, April 2020
6. Cai L, Zhu S, Du S, et al: The relationship between radiographic parameters and clinical
outcome of distal radius fractures in elderly patients. Orthop Traumatol Surg Res
2015;101:827–31
7. Young BT, Rayan GM: Outcome following nonoperative treatment of displaced distal radius
fractures in low-demand patients older than 60 years. J Hand Surg Am 2000;25:19–28
8. Anzarut A, Johnson JA, Rowe BH, et al: Radiologic and patient-reported functional outcomes
in an elderly cohort with conservatively treated distal radius fractures. J Hand Surg Am
2004;29:1121–7
9. Christensen OM, Christiansen TG, Krasheninnikoff M, et al: Length of immobilisation after
fractures of the distal radius. Int Orthop. 1995;19:26–9
10. Vang Hansen F, Staunstrup H, Mikkelsen S: A comparison of 3 and 5 weeks immobilization
for older type 1 and 2 Colles’ fractures. J Hand Surg Br 1998;23:400–1
11. Dekkers M, Soballe K: Activities and impairments in the early stage of rehabilitation after
Colles' fracture. Disabil Rehabil 2004;26:662–8
12. Handoll HH, Elliott J: Rehabilitation for distal radial fractures in adults. Cochrane Database
Syst Rev 2015:CD003324
13. Michener SK, Olson AL, Humphrey BA, et al: Relationship among grip strength, functional
outcomes, and work performance following hand trauma. Work 2001;16:209–17
14. Di Monaco M, Castiglioni C, De Toma E, et al: Handgrip strength is an independent predictor
of functional outcome in hip-fracture women: a prospective study with 6-month follow-up.
Medicine (Baltimore) 2015;94:e542
15. Fischer A, Spiegl M, Altmann K, et al: Muscle mass, strength and functional outcomes in
critically ill patients after cardiothoracic surgery: does neuromuscular electrical stimulation
help? The Catastim 2 randomized controlled trial. Crit Care 2016;20:30
16. Beumer A, Lindau TR: Grip strength ratio: a grip strength measurement that correlates
well with DASH score in different hand/wrist conditions. BMC Musculoskelet Disord
2014;15:336
17. Fess: ASHT Clinical Assessment Recommendations, 2nd ed. Chicago, American Society of
Hand Therapists; 1992
18. Jung MC, Hallbeck MS: The effects of instruction, verbal encouragement, and visual
feedback on static handgrip strength. Proc Hum Factors Ergon Soc Annu Meeting
1999;43:703–7
19. Gummesson C, Ward MM, Atroshi I: The shortened disabilities of the arm, shoulder and hand
questionnaire (QuickDASH): validity and reliability based on responses within the full-length
DASH. BMC Musculoskelet Disord 2006;7:44
20. Tsang P, Walton D, Grewal R, et al: Validation of the QuickDASH and DASH in patients
with distal radius fractures through agreement analysis. Arch Phys Med Rehabil 2017;
98:1217–22.e1
21. Kim JK, Park MG, Shin SJ: What is the minimum clinically important difference in grip
strength? Clin Orthop Relat Res 2014;472:2536–41
22. Kozin SH, Porter S, Clark P, et al: The contribution of the intrinsic muscles to grip and pinch
strength. J Hand Surg Am 1999;24:64–72
23. McCamley C, Tamblyn P, Kimber C, et al: Fractures of the distal radius: a randomized
controlled trial of 180 patients comparing volar locking plates and alternative fixation
methods. J Trauma Treat 2016;5:308
24. Gummesson C, Atroshi I, Ekdahl C: The disabilities of the arm, shoulder and hand (DASH)
outcome questionnaire: longitudinal construct validity and measuring self-rated health change
after surgery. BMC Musculoskelet Disord 2003;4:11
25. Wilcke MK, Abbaszadegan H, Adolphson PY: Wrist function recovers more rapidly after
volar locked plating than after external fixation but the outcomes are similar after 1 year. Acta
Orthop 2011;82:76–81
26. Crijns TJ, van der Gronde BATD, Ring D, et al: Complex regional pain syndrome after distal
radius fracture is uncommon and is often associated with fibromyalgia. Clin Orthop Relat Res
2018;476:744–50
27. Ratti C, Nordio A, Resmini G, et al: Post-traumatic complex regional pain syndrome: clinical
features and epidemiology. Clin Cases Miner Bone Metab 2015;12(suppl 1):11–6
28. Grønlund B, Harreby MS, Kofoed R, et al: [The importance of early exercise therapy in the
treatment of Colles' fracture. A clinically controlled study]. Ugeskr Laeger 1990;152:2491–3
29. Cooper A: Early therapeutic intervention following fractured distal radius. Paper
presented at: Chartered Society of Physiotherapy Annual Congress and Exhibition.
Birmingham, MA, August 10, 2004
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