Home Exercise Program

Current evidence is insufficient to answer the question of whether supervised hand therapy leads to different outcomes as compared to an independent home exercise program following surgical or non-surgical treatment of a distal radius fracture (DRF). There were only a few studies that met the inclusion criteria and even those had some important shortcomings. After expanding the number of studies, issues with the experiments included risk of bias, lack of homogeneity regarding injury severity, variable ages, and low prevalence of post-fracture complications. One high (Gutierrez Espinoza et al, 2017) and six moderate quality studies (Valdes et al, 2015; Souer et al, 2011; Oken et al. 2011; Krischak et al, 2009; Maciel et al. 2005; Wakefield et al, 2000) were included and appraised. One found a benefit to supervised therapy 3 weeks after injury or surgery (Oken et al. 2011), and one (Gutierrez Espinoza et al, 2017) at 6 weeks and at 6 months. In contrast, one study (Krischak et al, 2009) favored independent exercises at 6 weeks, and 4 found no difference between supervised and independent exercises (Valdes et al, 2015; Souer et al, 2011; Maciel et al. 2005; Wakefield et al, 2000). 

Risks and Benefits of Implementation

It is possible that a subset of people recovering from distal radius fractures might benefit from supervised hand therapy, and experience more rapid return to function with decreased total societal costs. For those that independent exercises are sufficient, we can preserve health care resources and minimize cost and time burden for patients recovering from distal radius fractures through independent exercises.

Outcome Importance

A rule prohibiting supervised therapy after distal radius fractures might limit access for a subset of people who stand to benefit. We might conclude that—to date--routine supervised hand therapy does not seem to provide a benefit on average.

Cost Effectiveness/Resource Utilization

We currently lack sufficient evidence to determine if there are circumstances in which supervised therapy limits patient and societal costs. 

Acceptability

There is a risk that surgeons might feel this statement restricts their ability to ask for help from expert colleagues when a patient’s recovery from distal radius fractures is delayed or difficult.  There is a risk 

that hand therapists will feel the summary of the evidence undervalues their contributions to the recovery of some people recovering from distal radius fractures.

Feasibility

Implementation of this summary is feasible to the extent that it does not become an all or none policy and that we continue to investigate factors that facilitate recovery and utilize supervised hand therapy for those subset(s) of patients where clinical benefit can be demonstrated.

Future Research

More and better evidence is needed to determine when supervised hand therapy benefits people recovering from DRF. Most importantly, further research is needed to determine prognostic criteria that would allow for proper patient selection. Thus, research should be invested in establishing a classification system for DRF patients sub-categorization based on their rehabilitation needs, while considering all contextual factors that may limit their recovery potential.