Effect of Cervicothoracic Mobilization in Distal Radius Fractures after Plaster Removal

Introduction: Distal Radius Fracture is one of the most common fractures in forearm. Chronic pain after these fractures could affect as much as 30% of patients. 22 to 39% incidence of Complex Regional pain Syndrome (CRPS) has been reported in patients with distal radius fractures. Spinal PA mobilization has generalized sympathoexcitatory effects, stimulate pain inhibitory descending pathways from Periaqueductal grey of brain and produce immediate hypoalgesia. Purpose: To see the effect of cervicothoracic mobilisation on pain, swelling and function over conventional therapy or control in these patients after plaster removal. Design: Experimental randomized controlled study Methodology: A total of 30 subjects (males-16,females-14) between the age group of 35 to 60 years with conservatively managed distal radius fractures meeting the inclusion and exclusion criteria were randomly divided into 3 groups. • GROUP A (experimental) 10 subjects received central PA mobilization of C7 to T3 spinous processes and conventional therapy including contrast bath and active and passive exercise. • GROUP B (conventional) 10 subjects received conventional therapy only. • GROUP C (control) 10 subjects received no treatment in fi rst week followed by home exercise (auto assisted active exercises) in the second week. Treatment was given daily 5 days a week for 2 weeks. Data collection: Measurements grip strength using dynamometer, swelling using volumeter, patient rated wrist evaluation scale, wrist ROM using goniometer and Heart rate were taken prior to the beginning of treatment (Pretest) and were repeated after completion of fi rst week (Post 1). Final measurements were taken on completion of second week (Post 2) Data analysis: The dependent variables were analysed using 3 X 3 ANOVA with repeated measures of the second factor. All pair wise post hoc comparisons were done using a 0.05 level of signifi cance. Results: At the end of 1st week as well as 2nd week both experimental and conventional groups showed signifi cantly better improvements in all the variables than control group. Experimental group was better than conventional group in all variables. Conclusion: This study showed that conventional physiotherapy has a role in the rehabilitation of patients with distal radius fracture after plaster removal in reducing swelling, pain and improving range of motion, strength and earlier return of function. However cervicothoracic mobilization has additional effects in all above mentioned variables. Research Article Effect of Cervicothoracic Mobilization in Distal Radius Fractures after Plaster Removal PP Mohanty*, Jaya Arora and Monalisa Pattnaik Swami Vivekananda National Institute of Rehabilitation Training and Research (SVNIRTAR), Olatpur, Bairoi, Cuttack, India Dates: Received: 16 November, 2016; Accepted: 07 December, 2016; Published: 08 December, 2016 *Corresponding author: PP Mohanty, Swami Vivekananda National Institute of Rehabilitation Training and Research (SVNIRTAR), Olatpur, Bairoi, Cuttack, India, E-mail:


Introduction
Distal Radius Fracture is one of the most common fractures of radius in forearm [1]. It is a common consequence of fall on outstretched hand, most often occurs in elderly due to osteoporosis and osteopenia.
An annual incidence of 36.8/10000 person years in women and 9/10000 person years in men has been estimated [2].
Citation: Mohanty  Considering these, goals of rehabilitation after distal radius fracture is to achieve complete and rapid recovery of ROM, strength, and function of wrist and hand. Typical treatment given for minimally or undisplaced fractures is immobilization in POP cast for 5 to 6weeks followed by rehabilitation period.
It has been observed that stable fractures with few or no complications reach maximum recovery at about 6 months after injury [5]. Thus it becomes a challenge for the therapist and patients to complete rehabilitation within a time frame that is not compatible with healing and functional recovery.
Reality is probable discharge from therapy before maximum functional improvement. The rationale for physiotherapy is that it addresses the most important principle of fracture management which is movement. Usual treatment after POP cast removal is ice, contrast bath, elevation of hand, active exercises, passive exercises, wax bath, strengthening exercises and functional activities.
Literature surrounding conservative management reveals confl icting results. It has been found that any infl ammation enhances excitability of primary afferent nociceptors (peripheral sensitization) which in turn increases the sensitivity of dorsal horn neurons (central sensitization). Decrease inhibitory input to spinal cord projecting neurons from higher centers like raphe nucleus, peri aquiductal grey area, also contributes to central sensitization. This causes secondary hyperalgesia [6].
Furthermore, experimental data suggests that sympathetic nervous system might control peripheral infl ammation and nociception activation, even subtle changes in pathophysiology can dramatically change the effect of SNS on pain that is descending inhibitory pathways change to facilitatory [7]. Also immobilization can result in sympathetic dysfunction [8].
An increasing number of studies hypothesize activation of central nervous system resulting in non-segmental hypoalgesia with activation of other neural pathways as potential mechanism of action [9]. In spite of frequent use of spinal manipulative techniques, their application has been largely based on clinical observation and hypothetical models rather than knowledge of physiological processes involved.
Cardinal feature of manual therapy technique applied to spine is that they supply very rapid onset analgesic affect. There is inhibitory effect of mobilization on spinal dorsal horn neurons [10]. Also mobilization has sympatho-excitatory effects, stimulate pain inhibitory descending pathways from PAG region of brain and produce immediate hypoalgesia in asymptomatic and symptomatic subjects that are specifi c to nociception stimulation [11].

Exclusion criteria
Surgically managed distal radius fracture, previous cervical thoracic surgery and spinal injuries, Diabetes, neurological diseases, frozen shoulder, malignancy, Rheumatoid arthritis, Peripheral nerve entrapment, cardio-vascular problems, Neck pain, any other contraindications of spinal mobilization.
Procedure: After fulfi lling the inclusion and exclusion criteria, all subjects were asked to fi ll the consent form, and then subjects were randomly allocated to: Before initiating treatment, subjects were assessed for baseline values of all the dependent variables such as grip strength by JAMAR dynamometer is a standardized instrument for grip testing [13], swelling by Volumeter, which is a valid instrument for measuring changes in hand size resulting from localized swelling [14], patient rated wrist evaluation is a 15 item questionnaire designed to measure wrist pain and disability in activities of daily living [15]. This allows patients to rate their levels of wrist pain and disability from 0 to 10 and consists of 2 subscales-Pain (0-no pain, 10 -worse ever) and Function-specifi c activities and usual activities. PULSE OXIMETER is a medical device that indirectly measures the heart rate and oxygen saturation of a patient' blood [16] and wrist ROM by goniometer, which is a valid instrument to measure wrist ROM [17] Citation: Mohanty  Therapy was started the day after the measurements were taken Group A: 10 subjects received conventional along with cervicothoracic mobilization. On each treatment session of cervicothoracic mobilization heart rate was measured before, during and immediately after mobilization to see the sympathetic changes. The baseline value of heart rate was taken after a stabilization period of 10 minutes.
• All patients were asked to lie down calmly for a period of 10 minutes in prone lying position required for mobilization. All patients were instructed not to take tobacco, alcohol or any other products of caffeine four hours before mobilization. After stabilization period pulse oximeter was attached to index fi nger of uninvolved extremity and baseline measures of heart rate were taken for 1 minute, then central PA mobilization was given over C7 spinous process for 2 minutes at a frequency of 2 Hz with amplitude as tolerated by patient with little discomfort and no pain.
Same procedure was repeated for T1, T2 and T3 spinous processes.
• Heart rate was continuously monitored during and immediately after intervention to see the sympathetic changes.
Group B: 10 subjects received only conventional treatment [18] such as contrast bath -fi rstly hand was immersed in warm water for 4 minutes then in cold water for 1 min. This sequence was repeated 5 times to provide a total treatment of 25 minutes and end with immersion in warm water.
Elevation of hand above elbow, elbow above heart level,

Data analysis
The dependent variables were analyzed using 3 X 3 ANOVA with repeated measures of the second factor. There was one between factor (Group) with three levels (Conventional along with cervico-thoracic mobilization, conventional alone and control group) and one within factor (time) with three levels (pre, post1, post2). All pair-wise post hoc comparisons were done using a 0.05 level of signifi cance.  to the end of fi rst week as well as second week. Conventional group showed signifi cant improvement in strength only from baseline to the end of fi rst week, while control group showed no signifi cant improvement in strength with time. At the end of fi rst week as well as second week both experimental and conventional groups showed signifi cant greater improvement of strength than control group. However at the end of second week experimental group was signifi cantly better than conventional group. Figure 3 illustrates improvement in scores of Patient Rated Wrist Evaluation Questionnaire over time to a greater extent in experimental group patients than patients in conventional group, while there was no change in control group.

Prwe
There was a main effect for time F 2,54,0.05 = 164.120, p= 0.00 There was also a main effect for group F 2,27,0.05 = 20.402, p= 0.00 There was also a main effect for time X group interaction F 4,54,0.05 = 40.816, p=0.00 Tukeys HSD analysis showed that both experimental group and conventional group improved signifi cantly in PRWE scores from baseline to the end of fi rst week as well as second week. Control group did not improve signifi cantly with time. However at the end of fi rst week as well as second week experimental group showed signifi cantly greater improvement than other two groups. Similarly conventional group showed signifi cantly greater improvement than control group. Figure 4 illustrates improvement in fl exion range over time to a greater extent in experimental group patients as well as patients in conventional group than the patients in control group.

Flexion
There was a main effect for time F 2,54,0.05 = 92.273, p= 0.00 However, there was no main effect for group F 2,27,0.05 = 1.075, p= 0.355 There was also a main effect for time X group interaction F 4,54,0.05 = 18.677, p=0.00 Tukeys HSD analysis showed that both experimental and conventional group improved signifi cantly in fl exion range of motion from baseline to the end of fi rst week as well as second week. Patients in control group showed no signifi cant improvement with time. At the end of fi rst week as well as second week experimental group and conventional group were signifi cantly better than control group, while there was no signifi cant difference between experimental and conventional group. Figure 5 illustrates that there was improvement in extension range over time to a greater extent in experimental group than patients in conventional group, while there was no change in control group.

Extension
There was a main effect for time F 2,54,0.05 = 159.559, p= 0.00 There was also a main effect for group F 2,27,0.05 = 16.506, p= 0.00 There was also a main effect for time X group interaction F 4,54,0.05 = 62.594, p=0.00 Tukeys HSD analysis showed that experimental group improved signifi cantly in extension range of motion from baseline to the end of fi rst week as well as second week. Conventional group showed signifi cant improvement in extension only from baseline to the end of fi rst week, while control group showed no signifi cant improvement with time. At the end of fi rst week as well as second week experimental group showed signifi cant improvement than conventional and control group. Similarly conventional group is signifi cantly better than control group.

Discussion
The overall results showed that experimental group improved signifi cantly with time in all the variables at the end of 1 st week as well as 2 nd week. Conventional group also improved signifi cantly with time in PRWE and fl exion range of motion from baseline to the end of 1 st week as well as 2 nd week. However strength and extension range in this group improved only at the end of 1 st week, while control group showed no change.
At the end of 1 st week as well as 2 nd week both experimental and conventional groups showed signifi cantly better improvements  can be seen within 46 to 72 days post injury and this plays a decisive role in the genesis of chronic regional pain syndrome I [19]. Chir Nazadov in 1996 has discussed about algodystrophy being a severe complication of distal radius fractures and in 2007 has said that early recognition and immediate commencement of effective therapy gives a real chance of recovery, thereby prevention of the condition is a reasonable approach [20,21]. Preliminary fi ndings in healthy subjects have suggested that limb immobilization may give rise to pain, change in skin temperature and sensitivity [8]. Signifi cant reduction in swelling. In our experimental group suggests the underlying neurophysiological effects of cervicothoracic mobilization which was given only to these patients. As the sympathetic supply to upper limb stem from upper thoracic spinal segments T2-T5, hence the corresponding spinous processes C7,T1,T2,T3 were mobilized [12]. Mobilization of cervicothoracic spine resulted in increased sympathetic activity as shown by 15% increase in heart rate which was measured continuously on pulse oximeter on day to day basis. Vincenzino et al who found 10.5 % increase in heart rate during spinal mobilization [24]. Decrease in skin blood fl ow is in accordance with the study of Sterling et al who found decrease in skin temperature occurs with cervical spinal mobilization [25]. Daniel et al., in 2004 has shown that generalized exercise induced more hypoalgesia than isometric grip exercise in normal subjects. The results of the study suggested that hypoalgesia was more with generalized exercise group who demonstrated more sympathoexcitation as compared with local exercise group [26]. Decrease in swelling can also be attributed to the fact that manual therapy results in transient increase in EMG, decrease in muscle inhibition and stimulation of muscle spindle evoking a monosynaptic excitatory potential in all the alpha motor neurons of the same muscle [27]. Hence there is facilitation of muscle activity resulting in decrease in swelling.
Thirdly there is also direct mechanical effect of mobilization stimulating mechanoreceptors [28]. There is constant sensory input in a rhythmic pattern which goes to the dorsal horn and then to brainstem fi nally to cortex. This results in reduction  of sensitization as well as pain perception. Decrease in pain reduces muscle inhibition and facilitates activity, thus reducing swelling. Conventional group showed signifi cantly better reduction in swelling than control but showed improvement to a lesser extent than experimental group. This can be explained by the fact that though active movements are important to aid venous drainage thereby reduction of swelling but strong muscular contractions and full joint ROM is necessary to accelerate drainage [29] and also severe pain inhibits the patient's ability to exercise the hand, so natural pumping action of hand is sacrifi ced permitting increased edema and fi brosis [30]. There was no change in control group because no treatment was given.

Patient rated wrist evaluation questionnaire
Findings of the study showed signifi cant reduction in PRWE scores in both Experimental and conventional group at the end of 1 st week as well as at the end of 2 nd week than control group. However experimental group showed signifi cantly better reduction in PRWE than conventional group both at end of 1 st and 2 nd week. Improvement in both experimental and conventional group with time can be attributed to the fact that conventional protocol was given to both groups under supervision which included contrast bath, active and passive exercises, strengthening exercises that simulated functional activities of wrist and hand. Patients in both experimental and conventional group were encouraged regularly to increase the hand usage for all ADL from the day of commencement of treatment. Early wrist motions provide functional improvement in wrist and hand functions according to a study by Roumen et al. 1991 [36]. The improvement of scores of PRWE can also be attributed to the improvement in Strength and Range of motion in both experimental and conventional groups. As demonstrated by Taylor et al., in august 2001 that in distal radius fracture patients there were strong and signifi cant correlation between grip strength and functional tasks. Signifi cantly greater improvement in experimental group can be attributed to greater reduction in swelling and greater improvement in extension range of motion and strength [37]. While in control group since no treatment was given there was no change in PRWE due to over cautious behavior of patients there may be functional neglect present that is refusal either conscious or unconscious to use the affected hand. Development of functional neglect in patients can be attributed to fear of pain caused by active movements or a changed body image as the patient regards the hand as sick therefore not useful.

Range of motion
There was signifi cant improvement in fl exion Range of motion in experimental group at the end of 1 st week and 2 nd week than control group. however there is no signifi cant difference in fl exion ROM between conventional and experimental group .as the plaster cast is applied with wrist in 20 degrees of fl exion and ulnar deviation [38], so the restriction in fl exion range was less in both groups at the baseline, hence the residual defi cit in range was gained easily with the effect of common conventional protocol given to both groups.
There was statistically signifi cant improvement in extension range of motion in experimental group at the end of 1 st week as well as 2 nd week than conventional and control group, similarly conventional group is better than control group. In all patients pain was more during extension than fl exion, this is due to the fact that as we move towards extension, wrist is moving towards closed pack position which causes joint approximation and pain [39]. Due to signifi cant better reduction of pain and swelling and improvement of strength in experimental group, extension improved more in this group.
Conventional group is better than control group as regarding fl exion and extension range of motion as the exercise protocol was given only to the former.

Conclusion
This study showed that conventional physiotherapy has a role in the rehabilitation of patients with distal radius fracture after plaster removal in reducing swelling, pain and improving