Keywords
distal radius fracture - postoperative - proprioception - rehabilitation - sensorimotor
therapy
Although sensorimotor input is not easily defined, much study has been done to try
and understand sensorimotor pathways.[1]
[2] Specifically, proprioception has been studied extensively, prompting its use in
rehabilitation, most commonly to treat neurological and joint injuries.[3]
[4]
[5] Though many studies support proprioceptive training in the treatment and prevention
of ligamentous injuries, some controversy remains in regards to its effectiveness.[6]
[7]
[8]
While our understanding of proprioception in joints such as the knee or ankle has
been incorporated into rehabilitation and training techniques, our understanding of
wrist proprioception has only recently been elucidated and remains incomplete.[9]
[10]
[11] We are, therefore, still in the process of formulating ways to best evaluate proprioception
in the wrist, and are yet in preliminary stages of learning how to treat wrist ligamentous
injuries using proprioceptive training.[12]
[13]
[14]
The evaluation of wrist proprioception has been described using different methods,
most commonly, positioning of the injured wrist at different angles and then asking
the patient to mimic the angle with the intact wrist without the use of sight.[12]
[15]
[16] While this is a good test of joint position sense, most studies evaluate multiple
neurological functions, such as deep vibratory sensation and stereognosis.[9]
[17]
[18]
[19] Since all sensorimotor input is integrated centrally, we believe that rehabilitation
should include work on different aspects of sensorimotor function for optimal results.[20]
[21]
[22]
Our clinical impression is that patients following a significant period of immobilization
loose wrist and hand proprioceptive ability and require proprioception rehabilitation.
The reason for this deficiency in distal radius fractures has not been proven and
may differ in individual cases. It is possible that this stems from a central loss
due to immobilization and lack of sensory input, as described by Taube et al; however,
the fracture itself and the consequent surgery often involve damage to wrist joint
capsule, ligaments, and possibly other soft tissues, such as tendons and muscles.
This may impede sensory input from these structures but also motor output.[23]
[24]
This observation has been supported in some studies. Avanzino et al demonstrated that
in short-term (3 weeks) arm immobilization, maintenance of dynamic proprioceptive
inputs from muscle vibration prevent the hemispheric unbalance, induced by short-term
limb disuse.[25]
[26] Kavounoudias et al demonstrated the effect of sensory stimulation in offsetting
the effects of immobilization on functional magnetic resonance imaging.[27] We used an evaluation and treatment protocol that incorporates multiple sensorimotor
domains. This protocol has been employed in a series of patients following surgery
for open reduction and internal fixation (ORIF) of distal radius fractures (DRF) with
good functional recovery.[28]
The purpose of this study was to prospectively compare the clinical results of patients
following surgical treatment for DRFs, treated with a specific sensorimotor protocol
to those treated postoperatively without the protocol.
Patients and Methods
All consecutive adult patients treated surgically for a DRF were eligible for inclusion
in the study. Institutional review board (IRB) approval was obtained prior to study
commencement. Only patients treated with volar plating were included. All patients
were treated according to standard of care in therapy with postoperative orthotics,
active and passive exercises for the fingers while immobilized, and after removal
of the orthosis at 6 weeks, all began treatment for the wrist. Although some patients
could have started early range of motion of the wrist, for purposes of the study,
all patients were instructed to use an orthosis for a full 6 weeks. An evaluation
was not performed prior to surgery because the patients had an acute fracture and
it was deemed too painful to perform. Furthermore, evaluation in this situation might
yield unpredictable results. The patients were randomized prior to evaluation into
a group, treated according to standard of care with an added sensorimotor home protocol,
according to a list. The patients were instructed to perform the home protocol three
times a day for 15 minutes. IRB approval was obtained prior to the study commencement.
Sensorimotor evaluation was performed and documented in all patients during the first
couple of days post surgery: at 6 weeks (at the time of splint removal) and 3 months
following surgery. Since 48 patients (80%) had an ultrasound-guided regional block
for anesthesia, the initial evaluation was not performed immediately following surgery
but rather within the first 5 days of surgery when the effects of the anesthesia had
clearly worn off.
Patient information was collected including age, gender, hand dominance, injured hand,
occupation, background, disease–especially diabetes, and other neurological disease,
inflammatory disease, fracture type, and comminution according to the Arbeitsgemeinschaft
für Osteosynthesefragen (AO) classification, any complications, range of motion, and
grip strength at 6 weeks and 3 months.
The Evaluation
Testing included a panel of sensorimotor testing.[28] This included blinded sensory testing with Semmes–Weinstein monofilaments (Sammons
Preston, Bolingbrook, IL), static and moving 2-point discrimination, vibration, temperature,
the Moberg's pick-up test (timed), stereognosis, and proprioception.[29]
[30]
The testing for proprioception, as described, requires sensory input first, or an
afferent portion, and then, when bringing the opposite limb into the same position
there is a motor or efferent component. This test, therefore, involves both the involved
and the uninvolved side (as the afferent and efferent limbs of the movement). Since
we were unable to separate the components, we did not compare the involved to the
uninvolved side in proprioception. Furthermore, to simplify the analysis, all abnormal
values for proprioception were pooled and the analysis did not differentiate between
proprioception in individual fingers and the wrist.
Vibration was documented as normal or abnormal. Chronic regional pain syndrome (CRPS)
in its early stages was defined as patients seen in therapy with an increasing pain,
an unwillingness to move or work with the involved hand, and the very beginning of
trophic changes, such as a change in color. This was documented in the patient chart
by the treating therapist.
Therapeutic Protocol
Therapy sessions were performed (in both groups) once a week for about an hour. The
patients worked on movement, activities of daily living (ADL), and edema control as
well as orthosis adjustment as necessary. After 6 weeks, with removal of the orthosis,
the patients commenced work on the wrist with motion, both active and passive, and
gradual strengthening, as well as continuing work on ADL.
The home protocol has been described in [Table 1].[28] This protocol includes sensory stimulation, activities of daily living, performed
with eyes closed, and exercises to improve proprioception by first performing a task
with the uninjured wrist/hand, and then imitating it with the injured extremity. This
is done with eyes closed and corrected with eyes open. Furthermore, the patients used
mirror therapy and while the wrist was splinted, they imagined the wrist moving during
exercise. For those patients that had difficulty with imagination, the therapists
encouraged more mirror therapy to try and work on the wrist at a more “automatic”
level.[31]
Table 1
The home sensorimotor protocol
|
Home Protocol 15 min × 2 each day
|
|
•Sensory stimulation—each finger from distal to proximal with and without cream
|
|
•Flexion and extension—each finger active and passive using the uninjured hand—eyes
open and eyes closed
|
|
•Adduction and abduction fingers—eyes open and closed
|
|
•Mirror imaging of finger movement 1–5 flexion/extension abduction—eyes open and eyes
closed
|
|
•Stimulation of each finger with different textures (cotton. steel wool, toothbrush)—eyes
open and eyes closed
|
|
•Imagination with eyes closed wrist flexion/extension, radio–ulnar deviation and pro-supination
|
|
•Same movement—both wrists
|
|
•Activities of daily living (AOL)—eyes open and eyes closed
|
|
Dominant hand involved: write, eat, dress
|
|
Nondominant hand: eat, dress, grooming
|
Statistical Analysis
Analysis included the paired t-test or Mann–Whitney test to compare continuous outcome measures, such as range of
motion and grip strength between the two treatment groups. Fisher's exact test and
chi-squared test for categorical variables. McNemar's test was used for vibration
calculations (paired nominal data: abnormal/normal).
Results
Sixty patients were included in the study, 31 in the standard group and 29 in the
protocol group. The two groups did not differ in regards to patient or fracture characteristics.
[Table 2] describes the study population.
Table 2
Population characteristics
|
Test
|
Standard treatment group, n = 31
|
Protocol treatment group, n = 29
|
p-Value
|
|
Age, y (SD)
|
63.9 (17.0)
|
62.3 (18.0)
|
0.71
|
|
Gender = female n (%)
|
67.7
|
85.7
|
0.11
|
|
Hand dominance = right (%)
|
87.1
|
89.7
|
1.00
|
|
Dominant hand = injured hand (%)
|
41.9
|
51.7
|
0.46
|
|
Osteoporosis (%)
|
71.0
|
72.4
|
0.90
|
|
AO classification (C2, C3; %)
|
54.8
|
62.1
|
0.06
|
Abbreviation: AO, Arbeitsgemeinschaft für Osteosynthesefragen; SD, standard deviation.
Note: The two groups were comparable in regard to patient and fracture characteristics.
Both groups included approximately 70% of fragility fractures and most surgically
treated fractures were comminuted and intra-articular.
On initial evaluation, we found sensorimotor deficiencies in the injured hand in both
groups, when compared with the uninjured hand or established norms ([Tables 3] and [4]). The Disabilities of the Arm, Shoulder, and Hand (DASH) score for the group as
a whole was 67.14 (standard deviation [SD] = 22.7). The deficiencies were most pronounced
in the Moberg's pick-up test, stereognosis, and in proprioception ([Table 3]). There were significant differences between the two groups at initial evaluation
in static moving 2-point discrimination of the distal phalanx of the little finger
(0.02) and in the moving 2-point discrimination of the distal phalanx of the index
finger (0.05). There were no significant differences in sensation between the areas
innervated by the ulnar nerve and median nerves ([Table 4]). Temperature evaluation for both cold and hot sensation was normal at initial evaluation,
in both groups.
Table 3
Initial sensorimotor deficits-comparison between the two groups
|
Standard treatment group injured/noninjured, n = 31
|
Protocol treatment group injured/noninjured, n = 29
|
p-Value
|
|
Semmes–Weinstein distal phalanx thumb (mean)
median
|
1.08 (0.16)
1.00
|
1.09 (0.14)
1.00
|
0.91
|
|
Static 2 point distal phalanx thumb (mean)
median
|
1.12 (0.56)
1.00
|
1.12(0.33)
1.00
|
0.34
|
|
Moving 2 point distal phalanx thumb (mean)
median
|
1.12(0.55)
1.00
|
1.07(0.35)
1.00
|
0.66
|
|
Moberg's pick-up test eyes closed (s)
|
2.45 (1.01)
|
2.21 (0.79)
|
0.64
|
|
Moberg's pick-up test eyes open (s), SD
|
2.55 (1.10)
|
2.89 (1.85)
|
0.79
|
|
Stereognosis % abnormal (SD)
|
23 (85.2)
|
24 (82.8)
|
0.38
|
|
DASH score
|
72.9 (19.9)
|
61.4 (22.7)
|
0.06
|
|
Proprioception thumb involved, n (% abnormal)
|
12 (38.7)
|
10 (35.7)
|
0.65
|
|
Proprioception fingers all involved, n (% abnormal)
|
12 (40.0)
|
9 (40.9)
|
0.14
|
|
Proprioception wrist involved, n (% abnormal)
|
6 (19.4)
|
2 (7.4)
|
0.28
|
Abbreviation: DASH, disabilities of the arm, shoulder, and hand; SD, standard deviation.
Notes: DASH outcome questionnaire. There were no differences between our two groups
at initial evaluation (p-values), but there were significant deficiencies in sensorimotor testing in the group
as a whole.
Stereognosis and proprioception could not be compared with the uninjured side so were
documented as percent (%) abnormal results. The DASH score is listed as a number (0–100).
Table 4
Initial sensorimotor testing fingers
|
Standard treatment group, n = 30
|
Protocol treatment group, n = 29
|
p-Value (involved)
|
Standard treatment group injured/noninjured, n = 30
|
Protocol treatment group Injured/noninjured n = 29
|
p-Value injured/uninjured
|
|
Semmes–Weinstein distal phalanx index finger mean (SD)
median
|
3.42 (0.74)
3.61
|
3.50 (0.49)
3.61
|
0.25
|
1.06 (0.14)
1.00
|
1.08 (0.23)
1.00
|
0.15
|
|
Semmes–Weinstein distal phalanx little finger mean (SD) median
|
3.30 (0.44)
3.61
|
3.38 (0.57)
3.61
|
0.43
|
1.03 (0.15)
1.0
|
1.02 (0.09)
1.0
|
0.82
|
|
Static 2-point distal phalanx index finger mean (SD) median
|
0.67 (0.21)
0.60
|
0.70 (0.40)
0.50
|
0.46
|
1.20 (0.48)
1.0
|
0.97 (0.30)
1.0
|
0.10
|
|
Static 2-point distal phalanx little finger mean (SD) median
|
0.72 (0.3)
0.60
|
0.72 (0.4)
0.50
|
0.34
|
1.20 (0.30)
1.0
|
1.01 (0.30)
1.0
|
0.02
|
|
Moving 2-point distal phalanx index finger mean (SD) median
|
0.69 (0.21)
0.60
|
0.64 (0.27)
0.50
|
0.17
|
1.17 (0.40)
1.0
|
0.96 (0.27)
1.0
|
0.05
|
|
Moving 2-point distal phalanx little finger mean (SD) median
|
0.74 (0.29)
0.60
|
0.67 (0.31)
0.50
|
0.07
|
1.24 (0.49)
1.00
|
0.99 (0.34)
1.00
|
0.007
|
|
Vibration 256 Hz index finger (% normal)
|
75.0
|
86.7
|
1.0
|
–
|
–
|
–
|
|
Vibration 256 Hz little finger (% normal)
|
42.9
|
60.0
|
0.8
|
–
|
–
|
–
|
|
Vibration 30 Hz index finger (% normal)
|
81.8
|
81.3
|
1.0
|
–
|
–
|
–
|
|
Vibration 30 Hz little finger (% normal)
|
42.9
|
69.2
|
0.3
|
–
|
–
|
–
|
Abbreviation: SD, Standard deviation.
Notes: The p-values relate to the comparison between the two groups (standard vs. protocol group
at initial evaluation). Semmes–Weinstein monofilaments test sensory detection thresholds.
Hz = hertz.
The values in bold are abnormal values. There were no significant differences between
the ulnar innervated fingers (little) and the median nerve innervated fingers (thumb
and index).
The significant differences between the groups at initial evaluation were in the ratio
of involved/uninvolved static and moving 2-point discrimination of the index finger
and the moving 2-point discrimination of the little finger. The standard group had
discrimination better than the treatment protocol group.
Vibration was documented as normal or abnormal. Vibration was also not compared with
the uninjured side but rather to normative values.
Vibration was abnormal in a large percentage of the population as a whole and did
not improve significantly with treatment. We observed that some of the patients had
increased vibration sense, which was most pronounced at initial evaluation. Out of
620 vibration measurements (including 30 and 256 Hz and all positions and patients)
128 documented increased sensitivity to vibration 20.6%.
There was no significant difference between the groups in range of motion (ROM) of
the fingers, thumb and wrist at the initial evaluation. Both treatment groups improved
from the 6-week evaluation to final evaluation at 3 months ([Table 5]). At 3 months, the protocol group had improved more than the standard treatment
group in all measured movements, but this difference was significant only in radial
and ulnar deviation ([Table 5]). Grip strength improved significantly in both groups.
Table 5
Wrist motion at 6 weeks and 3 months comparison between the groups
|
Standard rehabilitation 6 wk, n = 13
|
Standard rehabilitation 3 mo, n = 13
|
p-Value standard[a]
|
Protocol rehabilitation 6 wk, n = 10
|
Protocol rehabilitation 3 mo, n = 10
|
p-Value protocol[a]
|
p-Value (+)
|
|
Wrist ulnar deviation involved/uninvolved
|
0.60 (0.18)
|
0.66 (0.26)
|
0.50
|
0.47 (0.17)
|
0.79 (0.20)
|
0.002
|
0.02
|
|
Wrist radial deviation involved/uninvolvedb
|
0.63 (0.24)
|
0.71 (0.28)
|
0.52
|
0.54 (0.19)
|
0.89 (0.24)
|
0.001
|
0.04
|
|
Wrist flexion involved/uninvolved
|
0.39 (0.14)
|
0.67 (0.14)
|
0.003
|
0.39 (0.12)
|
0.76 (0.17)
|
0.001
|
0.30
|
|
Wrist extension involved/uninvolved
|
0.59 (0.18)
|
0.73 (0.11)
|
0.07
|
0.49 (0.38)
|
0.83 (0.17)
|
0.001
|
0.30
|
|
Wrist supination involved/uninvolved
|
0.68 (0.14)
|
0.73 (0.16)
|
0.40
|
0.65 (0.26)
|
0.85 (0.17)
|
0.02
|
0.18
|
|
Wrist pronation involved/uninvolved
|
0.99 (0.03)
|
1.00 (0.00)
|
0.30
|
0.85 (0.23)
|
0.99 (0.05)
|
0.04
|
0.30
|
Notes: (+) p-value refers to comparison of the groups in the amount of change from 0–3 mo. The
significant values are marked by bold facing.
a
p-value compares change from initial evaluation to evaluation at 3 mo within the group.
Most movements improved significantly between the 2 time periods (6 wk and 3 mo postsurgery)
in both groups.
The sensorimotor tests improved from initial evaluation to final evaluation at 3 months,
in both groups. The difference in improvement was significantly better (larger) in
the protocol treatment group as compared with the standard treatment group in Semmes–Weinstein
testing of the wrist (p = 0.03), static 2-point discrimination in the index (p = 0.03), and little fingers (p = 0.008).
Moberg's pick-up testing with eyes open and closed improved significantly (p = 0.02, p = 0.05), only in the protocol group. Stereognosis improved in the protocol group
from 24% with an abnormal test at initial evaluation to 0% at 3-month evaluation,
while the standard group improved from 14 to 0%. At 6 weeks, there were 0% abnormal
tests in the protocol group and 6% in the standard treatment group.
Although no patients developed full blown chronic regional pain syndrome (CRPS), there
were four cases of documented initial signs and symptoms of CRPS. All of these were
in the standard treatment group.
The DASH score improved significantly in the protocol group only p = 0.00. At 3 months, the mean was 33.7 (22.0) in the standard group and 21.3 (17.4)
in the protocol group.
Proprioception deficits were pronounced at initial evaluation and remained high at
6 weeks and at 3 months, though there was consistent improvement in all, but the wrist
parameters. At 6 weeks there was a trend toward significance in wrist proprioception
between the two groups. Both groups had increased proprioception deficits, when compared
with the initial evaluation, but the protocol group had less of an increase: the standard
group had 10 patients (55.6%) with abnormal testing, the protocol group had eight
patients (28.6%) with abnormal results p = 0.07. There were no other significant differences in improvement between the two
groups at 3 months ([Table 6]).
Table 6
Proprioception testing at initial evaluation, 6 weeks and 3 months postoperative comparison
between the groups
|
Standard rehabilitation initial (n = 31)
|
Standard rehabilitation 3 mo
|
Protocol rehabilitation initial (n = 29)
|
Protocol rehabilitation 3 mo
|
p-Value
|
|
Proprioception thumb involved n (% abnormal)
|
12 (38.7)
|
9 (20.0)
|
10 (35.7)
|
11 (16.7)
|
0.65
|
|
Proprioception fingers all involved n (% abnormal)
|
12 (40.0)
|
7 (24.1)
|
9 (40.9)
|
5 (33.3)
|
0.14
|
|
Proprioception wrist involved n (% abnormal)
|
6 (19.4)
|
3 (20)
|
2 (7.4)
|
1 (4.5)
|
0.28
|
Note: All finger measurements were used for proprioception of fingers. p-Value evaluates the difference from 0 to 3 months between the two groups (protocol
and standard treatment groups). There were no significant associations.
The treating therapists had a (unmeasured and likely biased) sense that patients treated
with the protocol had better overall function and earlier use of both hands for everyday
function.
Discussion
This study found significant initial sensorimotor deficits in a population of patients
being treated in therapy following ORIF of DRF. The use of a protocol aimed at improving
sensorimotor function seemed to improve function faster than standard postoperative
therapy. This was demonstrated objectively in multiple measured functional scores.
The improvement in sensorimotor testing at 3 months in the treated group is in tandem
with the results of sensorimotor re-education.[32]
[33]
We did not find a significant improvement in proprioception, despite using a protocol,
aimed at treating proprioceptive loss. On the contrary, we saw a trend toward increase
in wrist proprioception deficit at 6 weeks. This evaluation was performed following
6 weeks of wrist immobilization (for all patients) and despite treatment, the impairment
increased in both groups. This increase may be explained by a longer period of immobilization.
Since at initial evaluation, patients had variable and much shorter periods of immobilization
prior to surgery and consequent testing, it is possible that further restriction increased
the deficits.
We did see a weak trend toward better proprioception (less of an increase in deficit)
using the protocol. Although this may support its use in rehabilitation, we were unable
to prove its effectiveness. We also do not know, how long the immobilization or sensory
deprivation needs to be present to cause a clinically measureable loss in the wrist.
Furthermore, at 3 months the deficit improved and there was no difference between
the two treatment groups, so in summary, the clinical importance of this protocol
in improving proprioception remains unclear and this study does not support its use.
Part of the difficulty, we encountered, was in our ability to understand and then
evaluate and treat proprioception. Our evaluation of proprioception consisted of first
positioning the uninjured hand and then having the patient bring the injured side
to the same position with eyes closed. The same was then done moving the injured hand
first. As stated, since we could not compare sides, it is possible that we were not
evaluating proprioception correctly. Although evaluating the uninjured side and injured
side separately is certainly a distinct evaluation, we were unsure as to how these
evaluations contrasted because both tests for proprioception (first moving the injured
side, first moving the uninjured side) required input and output from both sides.
We, therefore, analyzed them as separate tests (not as compared with each other: involved/uninvolved).
In general, it is not completely clear, what neurological pathways are involved in
wrist proprioception and it is possible that this study was unable to demonstrate
differences between the treatment protocols not only because we were underpowered,
but also because our testing is inadequate to evaluate true function.[34]
[35] Karagiannopoulos et al evaluated active joint position sense and found it to be
sensitive to change following DRF.[36]
Many of the sensorimotor tests do not take into account differences in side dominance.
Recently, studies have demonstrated that hand dominance has a profound effect on the
results of the DASH score.[37]
[38] The inability to compare with norms related to hand dominance might have affected
our results. Further study is necessary to clarify the effect of hand dominance on
other functional tests.
Vibration testing demonstrated increased sensitivity to vibration in over 20% of the
patients at initial evaluation. Furthermore, this test did not seem to change in either
treatment group. Some studies have discussed the use of vibration as treatment for
edema, but it is possible that the occurrence of edema (as in the postoperative state)
actually affects sensitivity to vibration.[39] Mridha et al evaluated the effect of fluid in the tissues on mechanical pulse wave
propagation.[40] It is not clear, why the sense of vibration remained abnormal throughout the period
of the study. Further study is necessary to better understand the relevance of vibration
in the healing upper extremity.
Temperature was normal throughout the period of the study, possibly because it is
logical that immobilization would have no effect on temperature input (sensation).
DRF are the most common cause of CRPS in the upper extremity.[41]
[42] The beginning of, or tendency toward CRPS was more common in the standard therapy
group. No patients actually developed CRPS. This may be due to very detailed follow-up
and aggressive therapy, when CRPS was suspected. Though, this study was not aimed
at evaluation CRPS development and clearly, we were underpowered for this evaluation,
we believe that this treatment protocol has the potential to prevent the development
of CRPS, since essentially, we are connecting the brain to the limb at a very early
stage of recovery. The treating therapists had the impression that the patients treated
with the protocol had better and earlier return to function and again, though this
was not substantiated using most of the tests, it is possible that our testing is
lacking, and not that the differences do not exist.
To date, prevention of CRPS rests on our ability to diagnose and treat it early, perhaps,
we can prevent its occurrence altogether using this or similar protocols.[43]
[44] Further study is necessary to evaluate the utility of our protocol in CRPS.
Limitations: Assessment of outcomes after hand and wrist surgery is important to be
able to improve results and to communicate regarding our treatment of wrist conditions.
While we have clear radiographic guidelines (such as intra-articular step-off in distal
radius fractures), evaluating true functional outcome is difficult. Partially at least,
the difficulty stems from the effect of multiple variables, not all of them easily
measured on hand and wrist function. Furthermore, function itself is composed of multiple
components, some of them difficult to quantify and qualify. Outcomes, following surgery
for DRF, will be dependent on the quality of surgical correction, the postoperative
therapeutic protocol, and the patient's adherence to it, as well as patient characteristics.[35]
[45] As stated, though we felt that patients being treated with the sensorimotor protocol
improved faster, the difference was not statistically significant in many of the parameters
that were evaluated. The observation by the treating therapists that patients used
their hands faster and better needs to be examined scientifically and systematically.
Our minimal significant findings may be due to the complexity of function and its
evaluation, that is, though we measured a relatively wide range of functions, we did
not encompass some important aspects of function that were indeed influenced by the
protocol but were not included in our testing. There are some studies that have shown
minimal association between functional tests, such as the DASH score and wrist flexion
and true function.[46] We believe a better test/s of function should be devised to incorporate both hands
in the task/s as well as to take into account sensory (afferent) function and motor
(efferent) function, while correcting for patient-related factors such as anxiety.
It is also possible that we were underpowered to detect some of the differences.
In summary, we trialed a treatment protocol based on sensorimotor input. This study
supports its use in DRF. Our clinical impression was that it promoted a significant
improvement in functional outcome, though there was a discrepancy between the perceived
function and our outcome measures. We believe, this protocol may also have the potential
to improve our rehabilitation of other injuries and conditions including CRPS. More
study is necessary to better evaluate its utility, and to better understand sensorimotor
neurological processes in the wrist, and how to evaluate them.
