Physiotherapy interventions & assessment of outcomes in distal radius fractures

Background and Aims Distal radius fractures account for 16% of all fractures seen in the United Kingdom. An estimated 71,000 adults sustained a distal forearm fracture in Britain in 2001. One of the key instruments for measuring change are patient reported outcome measures. The minimum clinically important difference (MCID) for the commonly used outcome measures is unknown for patients with a distal radius fracture. Many patients who sustain a distal radius fracture have symptoms and functional restrictions which persist beyond treatment. Following injury, physiotherapy advice is the main intervention, but we do not know if the way we provide this advice has an effect on outcomes. There is no evidence in support of providing physiotherapy advice to patients on video. The key aims of this thesis are to: 1. Determine the MCID in patients with distal radius fractures for three PROMs: (a)Disabilities of the Arm Shoulder and Hand (DASH) (b)Patient Evaluation Measure (PEM) (c) Patient Rated Wrist Evaluation (PRWE). 2. Assess the MYMOP as an outcome measure in patients with distal radius fractures. 3. Examine outcomes in patients with non-operatively managed distal radius fractures to assess three methods of delivery of therapy advice: (a)advice sheet (b) video (c) in person physiotherapy 4. Calculate the item costs of the three therapy interventions. Methods The aims were investigated by the use of two studies; the MCID Study and the Outcomes Study. The MCID Study was an observational study of 42 patients with distal radius fractures treated both surgically and non-surgically. It was designed to determine the minimum clinically important difference by means of an anchor based approach. The anchor was a 15 point bidirectional global rating of change scale. Participants were reviewed at two, six, twelve and twenty-four weeks making the MCID calculations time independent. Participants completed the MYMOP outcome measure over the same time- points to allow for it to be validated in distal radius fractures. The Outcomes Study was a single centre three arm randomised controlled trial with with 1:1:1 allocation to parallel groups using a superiority design with an additional equivalence analysis. It recruited 120 adult patients aged 18-70 with a non-operatively managed distal radius fracture. It was designed to inform a future larger study acting as a pilot. The participants allocated to the advice sheet were considered the active control and the participants allocated to video and in person physiotherapy were the two intervention groups. The primary outcome measure was the DASH score at six weeks after removal of plaster, with secondary outcomes of the PEM, range of movement and grip strength. The MCID for analysis was derived from the MCID study. The equivalence margin for the additional analysis was taken as half this value. MCID Study Findings The MCID for the DASH was calculated as 13.5 (AUC 0.75). The MCID for the PEM was calculated as 9.5 (AUC 0.68). The MCID for the PRWE was calculated as 13.5 to 15.5 (AUC 0.78 to 0.59). The MYMOP correlated strongly with the DASH, PEM and PRWE after six weeks. Analysis of patient important items generated by the MYMOP suggest that the DASH score has the highest content validity, though it also has the most redundant items. Outcomes Study Findings Nationally around 50% of patients are given an advice sheet and 40% are referred for in person physiotherapy after a distal radius fracture. With both an ‘as treated’ and ‘intention to treat’ analysis, video and in person physiotherapy failed to demonstrate superiority on the DASH score. However, on the DASH Work sub-scale in person physiotherapy demonstrated superiority over the other two interventions. There were insufficient participants to draw a conclusion of equivalence on this secondary analysis. Participants were very satisfied with all three interventions. The cost of providing an advice sheet is £0.34, video £1.36 and in person physiotherapy £66.21. Conclusion In patients who sustain a distal radius fracture which is managed non- operatively and in whom an uncomplicated recovery is expected; advice video and in person physiotherapy did not show superiority to advice sheet in returning a patient to daily function and reducing symptoms as measured by the DASH score twelve weeks after injury. Numbers recruited were insufficient to draw any conclusions about equivalence. However, in person physiotherapy appears to be superior in returning patients to normal function at work compared to advice sheet and advice video for those in employment at the time of injury, as measured by the DASH Work