CRITICALLY APPRAISED PAPER (CAP) CITATION AND DOI …

CRITICALLY APPRAISED PAPER (CAP)

CITATION AND DOI NUMBER: Knygsand-Roenhoej, K., & Maribo, T. (2011). A randomized clinical controlled study comparing the effect of modified manual edema mobilization treatment with traditional edema technique in patients with a fracture of the distal radius. Journal of Hand Therapy, 24, 184?194.

CLINICAL BOTTOM LINE:

The intended purpose of this study was to determine whether a modified manual edema mobilization (MEM) technique, when compared with a traditional edema treatment, would be more effective in terms of subacute hand and arm edema reduction, pain reduction, active range of motion (AROM), and activities of daily living (ADLs) over a 26-week period for patients after a fracture of the distal radius. The modified MEM technique massages MEM pump points (MPPs), followed by exercises in the segments just massaged, to reduce subacute edema. The purpose of massaging the MPP is to create a vacuum effect that clears large amounts of lymphatic fluids in affected areas. The results of the study indicate that no meaningful statistical differences occurred between the two groups regarding AROM, pain, or edema. The results do indicate statistically significant differences with favorable outcomes in edema, pain, and AROM between inclusion and the last follow-up in both groups. However, there is supportive evidence that individuals in the modified MEM treatment group received fewer edema treatments in comparison with individuals in the traditional edema group. This suggests that modified MEM may be equally effective with fewer treatments. Additionally, a statistical difference occurred between the two groups in ADL performance after 3 weeks, favoring the modified MEM group. Both the modified MEM and traditional edema treatments are satisfactory and have the ability to produce beneficial effects. Therefore, the modified MEM treatment can be used to treat subacute edema during rehabilitation. On the basis of the results of the study, a modified MEM treatment can be just as beneficial as traditional edema therapy, with fewer treatments, in treatment of patients with subacute hand or arm edema after a distal radius fracture to improve pain, edema, AROM, and performance of ADLs. Given this, if therapists choose to use this modified version rather than another technique, they should proceed with caution.

RESEARCH OBJECTIVE(S)

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List study objectives. To evaluate the effects of a modified MPP stimulation treatment in comparison with a traditional edema treatment technique in regard to subacute hand and arm edema reduction, pain reduction, AROM, and ADL performance for patients after a distal radius fracture

DESIGN TYPE AND LEVEL OF EVIDENCE: Level I: single blinded, randomized controlled clinical trial

SAMPLE SELECTION How were subjects recruited and selected to participate? Please describe. All participants were recruited by referral from the orthopedic department at Aarhus University Hospital in Denmark.

Inclusion Criteria 18 years of age Unilateral postdistal radius fracture treated with a plaster cast or internal or external fixation Subacute edema 4?10 weeks after trauma or surgery 60 mL in volume difference between the upper extremities

Exclusion Criteria Mental impairment preventing participation Infection Disease of internal organs Presence of lymphedema

SAMPLE CHARACTERISTICS N= (Number of participants taking part in the study): 30 #/ (%) Male: 8/(26%) #/ (%) Female: 22/(73%) Ethnicity: NR Disease/disability diagnosis: Distal radius fracture, Colles, n = 28 (94%) Distal radius fracture, Smith, n = 1 (3%) Not reported, n = 1 (3%)

INTERVENTION(S) AND CONTROL GROUPS Add groups if necessary

Group 1: Modified MEM treatment group

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Brief description of the intervention

The MEM treatment consisted of specific massage techniques, exercises, exercises during massaging, deep-diaphragm breathing, low-stretch bandage system (if needed), and a one-handed MEM home program.

"Participants started with deep diaphragmatic breathing, exercises starting proximally and ending distally, terminus stimulation (supraclavicular area), axillary stimulation starting on the uninvolved side, MEM to the trunk region, and MPP stimulation on the involved" upper extremity (p. 187). After each pump-point stimulation, flow massage was performed to the contralateral axillary region. Range of motion (ROM) exercises were performed after a segment had just cleared.

For the first session, MEM was performed at the trunk region and sometimes included pump-point stimulation to the elbow region. Subsequent sessions used MEM to the trunk and pump points distal to the wrist. Contingent on the patient's clinical picture, MEM to the hand region was performed.

The specific massage technique "consist[ed] of light skin traction that move[d] the skin in a `U' pattern" (p. 187) to facilitate movement of lymphatic fluid. This technique began proximal to distal and was then followed by the reverse pattern to stimulate the movement of lymph back through the affected area. The massage was supplemented with ROM movements. Sessions then concluded with distal to proximal exercises, breathing exercises, and terminus stimulation.

Participants were required to wear an Isotoner open-finger glove at all times, except when receiving massage or undertaking personal hygiene. Participants were also required to perform home MEM exercises and participate in a functional training program at home. ROM and strengthening interventions were provided on a case-bycase basis.

How many

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participants in the

group?

Where did the intervention take place?

Treatment took place at Aarhus University Hospital's Department of Occupational Therapy. Additionally, therapy occurred in the home through prescribed home exercise programs.

Who Delivered? How often?

All patients received the modified MEM from the principal investigator (OT, CLT).

All sessions lasted 30 min. Sessions occurred three times a week for the first 4 weeks, then twice a week for 2 weeks. Home exercises were not reported.

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For how long?

After the initial 6 weeks, treatment was continued as needed. Home exercises were not reported.

Group 2: Traditional edema treatment group

Brief description of the intervention

Participants received traditional edema treatment in the form of elevation, compression, and functional training. A Coban wrap was used to compress the patient's digits and "proximal to the wrist." Participants were instructed to play shoulder-high solitaire, receive Flowtron intermittent compression, and wear an Isotoner open-finger glove during the night.

Patients were also required to perform a home program for edema and mobility. ROM and strengthening interventions were provided on a case-by-case basis.

How many

15

participants in the

group?

Where did the intervention take place?

Treatment took place at Aarhus University Hospital's Department of Occupational Therapy. Additionally, therapy occurred in the home through prescribed home exercise programs.

Who Delivered? How often?

All patients received the traditional edema treatment from an experienced occupational therapist.

All sessions lasted about 30 min. Sessions occurred three times a week for the first 4 weeks, then twice a week for 2 weeks. Home exercises were not reported.

For how long?

Solitaire play above shoulder height was at least 10 min. Flowtron intermittent compression system was administered for 20 min. After the initial 6 weeks, treatment was continued as needed. Home exercises were not reported.

Intervention Biases: Check yes, no, or NR and explain, if needed.

Contamination:

YES NO NR

Comment:

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Co-intervention:

YES NO NR

Comment: Pain perception could have been skewed by prescribed pain medication given to patients. Both groups received regular therapy for ROM and strengthening on a case-by-case basis. These biases would tend to favor a lack of differences between treatment groups.

Timing:

YES NO NR

Comment: The natural course of the body healing could have been an influential factor over the study's 26-week duration. This could have contributed to a lack of differences between treatment groups.

Site:

YES NO NR

Comment:

Use of different therapists to provide intervention:

YES NO NR

Comment: The principal investigator was responsible for administering all care to only the modified MEM group, which might have influenced the results of the treatment group. A different occupational therapist was solely responsible for the traditional edema group.

MEASURES AND OUTCOMES

Complete for each measure relevant to occupational therapy:

Measure 1: Subacute edema

Name/type of measure used: What outcome was measured?

Is the measure reliable? Is the measure valid? When is the measure used?

Volumeter

Subacute edema. The standardized volumeter protocol by the American

Society of Hand Therapists was followed, but with two modifications

made: cooler water temperatures (23?24?C) and a standing position

during the assessment.

YES

NO

NR

YES

NO

NR

Inclusion and at Weeks 1, 3, 6, 9, and 26

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