Observational Study Medicine ®

OPEN

Manual passive rehabilitation program for

Abstract
Limitation of wrist range of motion (ROM) is a common complication of distal radius fractures (DRFs) in geriatric patients. The present
study aimed to evaluate the effectiveness of rehabilitation in the restoration of wrist ROM after geriatric DRF. Eighty-eight geriatric
patients with DRF, 59 women and 29 men aged 71.69 ± 6.232 years participated in the study. The time from wrist immobilization to
rehabilitation was 12.89 ± 5.318 weeks. Daily rehabilitation was performed 30 minutes a day for 8 weeks. Active wrist ROM was
measured before and at 2, 4, and 8 weeks after rehabilitation. Data were analyzed by the repeated measures multivariate analysis of
variance (MANOVA), one-way MANOVA, and analysis of variance (ANOVA). Repeated measures MANOVA suggested a significant
time effect for ROM (Wilks Lambda = 0.002, F = 7500.795, P < .001). Compared with before rehabilitation, each wrist ROM was
significantly improved at 2, 4, and 8 weeks after rehabilitation. The one-way MANOVA demonstrated that changes in ROM were
significantly different between groups (Wilks Lambda = 0.007, F = 559.525, partial eta square = 0.993, P < .001), indicating that
patients in the short-term stiffness group (3 months) had a significantly greater increase in ROM than patients in the long-term
stiffness group (>3 months). The results of this study suggest an 8-week daily rehabilitation program for geriatric patients with limited
ROM <3 months after DRF.
Abbreviations: AO = Arbeitsgemeinschaft fur Osteosynthesefragen, ANOVA = analysis of variance, DRF = distal radius fracture,
MANOVA = multivariate analysis of variance, ROM = range of motion, SPSS = Statistical Product and Service Solutions, STROBE =
strengthening the reporting of observational studies in epidemiology.
Keywords: distal radius fracture, range of motion, rehabilitation, wrist stiffness

Editor: Bo Liu.
Ethics approval: This study was approved by the Institutional Review Board of 1. Introduction
the Third Hospital of Hebei Medical University (#W2020-060-1).
Since the human species as a whole is growing older, medical
Consent to participate: The patients’ informed consent was waived due to the
services should be prepared to meet the needs of an older
retrospective nature of the study.
population.[1] In the elderly population, distal radius fracture
The study was supported by the Medical Scientific Research Foundation of
Hebei Province, China (20200986).
(DRF) is common, with an incidence between 200 and 1200 per
100,000 person-years.[2,3] In the geriatric population over
The authors have no conflicts of interest to disclose.
65 years, DRFs are the second most common fractures after
Availability of data and supporting materials section: The data were confidential.
hip fractures, and they account for almost one-fifth of all
The datasets generated during and/or analyzed during the current study are
fractures in this age group.[4,5] In the majority of patients, DRF
available from the corresponding author on reasonable request.
a
does not cause any limitations to daily activities; however,
Department of Pain Management, Third Hospital of Hebei Medical University,
b
Department of Orthopedic Surgery, Gaoyang County Hospital, c Department of
residual disability is not uncommon, especially in elderly
Orthopedic Surgery, Shijiazhuang People’s Hospital, d Department of Massage, patients.[6,7]
Third Hospital of Hebei Medical University, e Department of Traditional Chinese Many factors, including patients’ general health, the mecha-
Medicine, Third Hospital of Hebei Medical University, f Department of Orthopedic nism of injury, articular involvement, associated injuries, medical
Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, Hebei
comorbidities, and drug therapies, may affect the healing of DRF,
Providence, China.
∗ rehabilitation, and functional recovery of the upper extremi-
Correspondence: Bing Zhang, Department of Orthopedic Surgery, Third
Hospital of Hebei Medical University, 139 Ziqiang Road, Shijiazhuang, Hebei
ty.[7,8] Nonoperative treatment with a cast has been suggested as
050051, China (e-mail: zhangbingdr@[Link]). the primary treatment modality in patients aged over 65 years.[9]
Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc. Prolonged immobilization of the wrist joint in casts usually
This is an open access article distributed under the terms of the Creative makes early rehabilitation impossible in geriatric DRF. If
Commons Attribution-Non Commercial License 4.0 (CCBY-NC), where it is controlled mobilization is not initiated as early as fracture
permissible to download, share, remix, transform, and buildup the work provided healing permits, permanent stiffness, and residual disability may
it is properly cited. The work cannot be used commercially without permission
from the journal.
result, especially in geriatric patients.[10,11]
There is a plethora of literature regarding how to prevent wrist
How to cite this article: Zhang W, Wang L, Zhang X, Zhang Q, Liang B, Zhang
B. Manual passive rehabilitation program for geriatric distal radius fractures. complications in the management of DRFs.[12] No study has
Medicine 2021;100:3(e24074). detailed the management of wrist stiffness in geriatric patients
Received: 2 September 2020 / Received in final form: 2 December 2020 / with DRFs in the late rehabilitation process. Therefore, this study
Accepted: 2 December 2020 aimed to investigate the immediate short-term effects of the
[Link] passive rehabilitation method for improving wrist range of

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Zhang et al. Medicine (2021) 100:3 Medicine

motion (ROM) during a therapy session for geriatric patients Osteosynthesefragen (AO) fracture classification, and surgical or
with wrist stiffness after DRF. A secondary purpose of this study conservative intervention, are shown in Table 1.
was to determine if there were any differences in ROM change
between the short and long stiffness groups. A third purpose of 2.2. Rehabilitation process
this study was to determine the optimum duration of rehabilita-
tion for patients with short- and long-stiffness. All patients received pre-rehabilitation education. Patients were
informed that the rehabilitation program consisted of 4 parts:
superficial heat modalities, manual passive stretching training,
2. Methods forearm massage, and self-rehabilitation. During manual passive
The study was reported in accordance with the strengthening the stretching training, there were 15 to 20 seconds of pain that
reporting of observational studies in epidemiology (STROBE) needed to be tolerated as much as possible. The whole
guidelines. It was designed as a retrospective single-center study rehabilitation program took 30 minutes, once a day, for 8 weeks
and approved by the Institutional Review Board of the Third in the clinic and self-rehabilitation twice a day at home.
Hospital of Hebei Medical University (#W2020-060-1). Due to
the retrospective nature of our study, the requirement for 3. Superficial heat modalities
informed consent was waived.
Superficial heat modalities are commonly used for precondition-
ing joints to increase joint ROM during the mobilization stage
2.1. Inclusion and exclusion criteria after wrist fracture.[13] All patients had their arms placed in a hot
Between April 2017 and October 2019, patients who underwent water pot at 40 °C (104 °F) for 15 minutes before active
surgical or conservative treatment for acute DRFs and received rehabilitation. The entire forearm and hand were submersed to
rehabilitation carried out by the physical therapist, WZ, in our the level of the mid-upper arm, with the elbow flexed. This
hospital were included. Demographic characteristics and clinical pretreatment can accelerate blood circulation, soften tendons and
and follow-up information were obtained from the patients’ ligaments around the wrist joint, and reduce pain during active
medical records. Inclusion criteria were patients aged 60 years or rehabilitation.
older, definite diagnosis of DRF, wrist stiffness, receiving daily
rehabilitation for 8 weeks after DRF, and complete data available 4. Manual passive stretch training
in medical records. Exclusion criteria were pathological
(metastatic) or old fracture (>2 weeks since occurrence), open Manual passive stretch training included wrist extension, flexion,
fracture of the distal radius, concurrent fractures or disease in the radial deviation, pronation, and supination training. During the
contralateral forearm and wrist, serious medical comorbidities,
and incomplete medical records.
Eighty-eight patients were included in the final analysis in this
study. Relevant demographics, including time of immobilization
before active rehabilitation, age, sex, Arbeitsgemeinschaft fur

Table 1
Demographic characteristics.
Characteristics Values
Gender (n, %)
Female 59 (67.05)
Male 29 (32.95)
Age (mean, SD), yr 71.69 (6.232)
Weeks immobilized (from fracture to rehabilitation), wks 12.89 (5.318)
Injury mechanism (n, %)
Slip fall 49 (55.68)
Fall >2 ft. 13 (14.77)
Hit injury 6 (6.82)
Unspecified 20 (22.73)
AO fracture type (n, %)
A 17 (19.32)
B 11 (12.50)
C 58 (65.91)
Dominance (n, %)
Figure 1. A 71-year-old female patient diagnosed with right distal radius-type
Right 76 (86.36)
C fracture after a slip fall. She underwent open reduction and internal fixation
Left 12 (13.64) and cast fixation for 2 weeks. The rehabilitation program started after 8 weeks
Fracture side (n, %) and the maximal active wrist flexion and extension were 12° and 20°,
Right 69 (78.41) respectively. (A) and (B) showing that preoperative and postoperative
Left 19 (21.59) anteroposterior and lateral radiographs, respectively. (C) and (D) showing
Intervention (n, %) method of manual passive wrist flexion and extension stretch training,
Surgery 73 (82.95) respectively. (E) and (F) showing that maximal active wrist flexion and extension
Conservation 15 (17.05) are 55° and 49°, respectively.

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Zhang et al. Medicine (2021) 100:3 [Link]

training, the patients were asked to lie in a supine position on the distal radioulnar joint and to avoid joint exudation and swelling,
examination bed. Figure 1 shows wrist extension training of a 65- the range of rotation training should be improved slowly. Based
year-old patient with wrist stiffness after DRF. on our experience, the recommended daily improvement of
rotation is between 5° and 10°. The final expected passive
pronation and supination were 110° and the active pronation and
4.1. Wrist extension training
supination would be 90°.
The affected upper limb was placed on the side of the body
naturally with the palm facing down. The palmer side of the distal
4.5. Outcome measurements
forearm was pressed and fixed on the bed as close as possible. The
affected hand was held by the palm, and the palmar muscle All patients had active ROM of their wrist measured before and
tendons were slowly stretched and pulled until the pain was at 3 consecutive follow-up visits, including 2, 4, and 8 weeks after
almost intolerable. The wrist joint was fixed in the maximum rehabilitation program was initiated. ROM was measured by the
extension position for 15 to 20 seconds, and a quick massage of same hand therapist with >10 years of experience. Active wrist
the forearm was performed subsequently. After repeating this ROM, consisting of wrist extension, flexion, radial deviation,
extension training 3 to 5 times, the palmar tendons were stretched ulnar deviation, pronation, and supination, were measured.
and the pain was relieved. The wrist extension angle would These measurements were taken before and at 2, 4, and 8 weeks
gradually increase, but no more than the maximum passive of rehabilitation, respectively. Measurement techniques for wrist
extension angle of the contralateral health wrist, which is usually flexion/extension and radial/ulnar deviation were completed as
between 90° and 100°. recommended by the American Society of Hand Therapists using
a standard goniometer.[14] For measurement of active forearm
rotation, the modified finger goniometer technique was used.[15]
4.2. Wrist flexion training
The affected upper limb was placed on the side of the body
4.6. Statistical analysis
naturally with the palm facing up. The dorsum of the distal
forearm was pressed and fixed on the bed as close as possible. The Statistical analysis was performed using IBM Statistical Product
affected hand was held by the dorsum, and the dorsal muscle and Service Solutions (SPSS version 23.0; Armonk, New York,
tendons were slowly stretched and pulled until the pain was NY). Repeated measures multivariate analysis of variance
almost intolerable. The wrist joint was fixed in the maximum (MANOVA)/Bonferroni test was conducted on the dependent
flexion position for 15 to 20 seconds, and a quick massage of the variables over time. If a significant time effect was found, a post-
forearm was performed subsequently. After repeating this 3 to 5 hoc Bonferroni test was conducted to evaluate whether the ROM
times, the wrist flexion angle would gradually increase, but the at each follow-up significantly differed from that before
final expected training result had to be no more than the rehabilitation. Improvement ROM was calculated by subtracting
maximum passive extension angle of the contralateral health the ROM before rehabilitation from that at each follow-up. The
wrist, which is usually approximately 90°. average change for each measurement was then calculated and
used as the dependent variable in the MANOVA. Once the
MANOVA was complete, several one-way analysis of variance
4.3. Wrist radial deviation training (ANOVA) were conducted to determine if there was a group
Since the wrist was required to be fixed in the ulnar deviation difference in ROM changes for each wrist measurement based on
position by a brace or cast after DRF, patients always suffered stiffness time (Group A 3 months and Group B >3 months).
from wrist stiffness at the ulnar deviation position. Therefore, The estimated marginal means for the change degree of each of
rehabilitation training aims to correct ulnar deviation to a neutral the measurements were also calculated along with 95%
position first, and then restore the range of radial deviation. The confidence intervals. Statistical significance was set at P < .05.
affected upper limb was fixed on the bed, and the hand was held
and pulled to the radial side until the pain was almost unbearable.
The wrist joint was fixed in this position for 15 to 20 seconds, and 5. Results
a quick massage of the forearm was performed subsequently. Table 2 shows the wrist ROM before and at 2, 4, and 8 weeks
Training was repeated 3 to 5 times. However, the final expected immediately after rehabilitation. Although the assumption of no
training result of the radial deviation angle refers to the univariate or multivariate outliers and multivariate normality
contralateral health wrist, which is usually around 25°. was not fully satisfied, the original data were preserved for
subsequent analysis. Since Mauchly test of sphericity was not
met, Greenhous–Geisser correction was applied. Repeated
4.4. Wrist rotation training measures MANOVA suggested a significant time effect for
The affected upper limb was placed on the side of the body ROM (Wilks Lambda = 0.002, F = 7500.795, P < .001). Com-
naturally with elbow flexion to 90°. The upper arm was pressed pared with before rehabilitation, each wrist ROM was
and fixed on the bed as close as possible to ensure that the elbow significantly improved at 2, 4, and 8 weeks after rehabilitation.
was neither lifted nor moved during training. The affected hand Table 3 shows the changes in ROM in patients with short- and
was held by the therapist with 2 hands, and forearm was long-term stiffness at 2, 4, and 8 weeks after rehabilitation. The
pronated and supinated, respectively, until the pain was almost one-way MANOVA demonstrated that changes in ROM were
unbearable. Patients experienced more intense pain during significantly different between groups (Wilks Lambda = 0.007,
rotation training than the other trainings; therefore, the patients’ F = 559.525, partial eta square = 0.993, P < .001), indicating that
painful faces should be carefully observed, and further rotation patients in the short-term stiffness group had a significantly larger
should be stopped immediately. To prevent ligament injury of the increase in ROM than patients in the long-term stiffness group.

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Zhang et al. Medicine (2021) 100:3 Medicine

Table 2
Wrist ROM before and after rehabilitation (standard deviation in bracket).
Wrist ROM, °
Wrist motion N Before 2 weeks 4 weeks 8 weeks
Extension 88 13.9 (3.948) 20.15 (6.158) 36.4 (7.844) 43.91 (6.219)
Flexion 88 21.74 (6.066) 28.65 (8.358) 39.44 (7.342) 44.95 (6.87)
Radial deviation 88 –9.61 (2.838) –5.73 (3.548) 5.75 (5.34) 9.76 (4.144)
Ulnar deviation 88 18.42 (1.952) 20.56 (1.523) 22.16 (0.883) 24.32 (1.18)
Pronation 88 17.31 (4.637) 24.97 (7.656) 36.19 (8.501) 44.77 (9.456)
Supination 88 21.88 (3.575) 30.68 (5.686) 38.74 (6.926) 43.43 (7.474)
N = number of case; ROM = range of motion.

The partial eta-squared for the analysis was 0.993, indicating that for therapeutic stretching,[19] which was adopted in this study.
99.3% of the variance in ROM was explained by the term The results of the current study suggest that passive rehabilitation
stiffness. When assessing individual motions, except ulnar can effectively improve wrist ROM in geriatric patients with
deviation, patients with short-term stiffness showed a greater DRF.
improvement in wrist extension, flexion, radial deviation, Our rehabilitation program is based on a biopsychosocial
pronation, and supination than those in the long-term stiffness model. The present study confirmed the effectiveness of manual
group, at 2, 4, and 8 weeks after rehabilitation. passive stretching in the recovery of wrist ROM. However, the
ANOVA was conducted to determine if there were differences almost unbearable pain involved limits its application. A study
in ROM change among the 3 follow-up periods in the short- and found greater functional improvement in the treatment of anxiety
long-term stiffness groups, respectively. In each ROM, there and depression.[20] In the process of our rehabilitation process,
were significantly different changes at 2, 4, and 8 weeks after patients are given psychological treatment to relieve anxiety and
rehabilitation in short- and long-term stiffness. depression. Patient education is also given to increase patients’
awareness of the rehabilitation process and their confidence in the
outcome. In addition, after passive stretch training, forearm
6. Discussion
massage was administered to relieve pain and provide psycho-
The fracture of the distal radius, the most common fracture of the logical comfort.
arm in geriatric patients, would heal; however, incomplete The present study found that wrist ROM improved continu-
functional recovery can lead to significant functional conse- ously during the 8-week rehabilitation process, and the changes
quences.[10,11,16] Patients with DRF are often referred for hand in ROM were greater in patients with short-term stiffness than in
therapy to achieve rapid recovery, strength, ROM improvement, those with long-term stiffness. Our results suggest that rehabili-
and long-term disability reduction.[17] Although there are many tation should be started as early as possible, which is consistent
magnitudes of wrist rehabilitation, the changes in ROM are quite with previous studies. Various studies on early active motion
different. A moderate-quality randomized control trial found that have shown beneficial results, but no one protocol is clearly
core-strengthening activities did not benefit hand-related out- superior to another.[21,22] There is no consensus on the duration
comes in wrist rehabilitation.[18] Superficial heat modalities, such of rehabilitation. Based on our data, the rehabilitation effect at 8
as therapeutic whirlpool and hot packs, can achieve a small gain weeks was better than that at 4 weeks in both groups. Therefore,
in ROM; therefore, they are often used to precondition the joint it recommends a full 8-week rehabilitation course.

Table 3
Changes of ROM after rehabilitation (standard deviation in bracket).
Change of wrist ROM, °
Group Direction 2 weeks 4 weeks 8 weeks
a
A Wrist extension 8.29 (4.229) 27.68 (5.868) 33.42 (6.488)a,b
Wrist flexion 9.32 (4.777) 21.84 (5.065)a 26.61 (4.175)a,b
Radial deviation 4.45 (2.009) 17.5 (4.065)a 20.58 (3.422)a,b
Ulnar deviation 2.21 (0.875) 3.63 (1.422)a 5.87 (2.28)a,b
Pronation 10.74 (6.181) 24.13 (6.347)a 32.5 (5.646)a,b
Supination 11.34 (6.274) 21.05 (5.317)a 26.47 (5.931)a,b
∗ ∗ ∗
B Wrist extension 4.05 (1.541) 15.32 (5.822)a, 24.95 (4.81)a,b,
∗ ∗ ∗
Wrist flexion 4.08 (1.923) 12.37 (4.327)a, 19.26 (5.51)a,b,
∗ a,∗ a,b,∗
Radial deviation 3 (1.065) 11.55 (2.501) 16.95 (2.731)
Ulnar deviation 2.13 (1.018) 3.74 (1.571)a 6.08 (1.992)a,b
∗ ∗ ∗
Pronation 4.61 (2.626) 13.11 (3.667)a, 20.21 (4.557)a,b,
∗ a,∗ a,b,∗
Supination 8.45 (6.310) 17.74 (8.120) 26.71 (8.084)
Group A: stiffness time 3 months; Group B stiffness >3 months. ROM = range of motion.
a
Symbol indicates a statistically significant difference from change of wrist ROM at 2 weeks.
b
Symbol indicates a statistically significant difference from change of wrist ROM at 4 weeks.
∗
Symbol indicates a statistically significant difference from change of wrist ROM in Group A.

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