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Effect of early mobilisation on grip strength, pinch strength and work of hand muscles in cases of closed diaphyseal fracture radius-ulna treated with dynamic compression plating. PV Solanki, KP Mulgaonkar, SA RaoDepartment of Occupational Therapy, Seth G. S. Medical College and K. E. M. Hospital, Parel, Mumbai - 400 012, India., India
Correspondence Address: Source of Support: None, Conflict of Interest: None PMID: 0011015774
AIMS: The purpose of the study was to objectively determine the effects of early mobilisation in terms of grip strength and work of hand muscles in cases of closed diaphyseal fracture radius - ulna treated with dynamic compression plating. SUBJECTS AND METHODS: Fifty normal subjects and Twenty-one patients, (Eleven patients treated with early active and resistive goal directed mobilisation and Ten control group) were assessed for pinch strength and grip strength on Pinch Dynamometer and Jamar Dynamometer and work of hand muscles on Ergograph. Standardised positions of the equipments and patients were maintained throughout the study. RESULTS: Results showed highly significant reduction in performance in patients treated with early mobilisation as compared to normal subjects in their first assessment (Fourth week post operatively). These patients showed significant improvement in successive assessments (sixth & eighth post operative week) on exercising in between these assessments. CONCLUSIONS: There are significant effects on grip strength and work of hand muscles in patients treated with that early active and resistive goal directed mobilisation. Keywords: Adult, Bone Plates, Early Ambulation, Female, Fracture Fixation, Internal, Hand Strength, Human, Male, Muscle, Skeletal, physiology,Radius Fractures, surgery,Ulna Fractures, surgery,
Immobilisation being the modality of treatment in the initial phases of fracture healing might result in decreased functional output if prolonged[1]. In fractures of both bones of forearm immobilisation might cause muscle atrophy resulting in decreased hand muscle strength and endurance. Success in the management of forearm fracture means achievement of fracture union, restoration of elbow, forearm and wrist mobility, grip strength and endurance, in addition to regaining length, opposition and axial alignment. Early mobilisation seems to be a promising method in terms of regaining forearm rotation and hand muscle strength. Keeping this in mind it was decided to study the effect of active and resistive goal directed mobilisation on hand muscle strength and endurance by objective measurements. As reliable and valid evaluation of hand strength and endurance is of paramount importance to determine the effectiveness of surgical procedures.
The prospective study was conducted on fifty normal subjects and twenty-one patients. The subject chosen were in the age group of 20-40 years. Patients of either sex with closed diaphyseal fracture radius and ulna operated with dynamic compression plate were taken. They were divided into two groups. Group A consisted of eleven patients (nine males and two females). They were evaluated on dynamometers and ergograph in the fourth, sixth & eighth postoperative weeks and were treated with regular goal directed activity oriented active and resistive exercise regime in between. Group B consisted of ten patients (eight males and two females) who are evaluated in the eighth postoperative week. These patients formed the control group as they rarely participated in the active and resistive goal directed exercises and were not regular in their follow-ups. [Table - 1] Independent variables as age height, weight, length of long flexors, range of motion and muscle power were assessed but not analysed statistically. Dependent variables as grip strength, pinch strength (pad to pad, pad to lateral and tip to tip) and work of hand muscles before and after fatigue were assessed and analysed statistically. Subjects were tested on hand held Dynamometers (Jamar and Pinch Dynamometers) and Ergograph in a standardised position as suggested by the American Society of Hand Therapists i.e. seated in a straight back chair with feet flat on the floor, tested extremity held adducted against the body in neutral rotation, elbow flexed to 900 forearm in neutral position and wrist in extension[2],[3] .The subjects were asked to apply maximum force with the dynamometers. Three readings were taken and average was accepted. Ergograph A hand Ergograph is designed for measuring the work of hand muscles and hence it can also be used to assess the quantum of fatigue. It is a very sensitive machine and is characterised by a high measuring accuracy due to automatic graphic and quantitative registration of work of the hand muscles. It has recording calibration for the number of contractions and also for variation of tension. The resistance offered by Ergograph was kept constant for the control group and the non-affected extremity of patients i.e. 10 kgs and variable for affected extremity. After having prepared the device for the test, the subject was instructed to perform the task in a standardised method and was given the following instruction: “Please clamp the handle with palm in such a way that the tensioning part of the grip will shift to its dead end and then relax completely and then again clamp. So perform contractions at a constant speed to the rhythm of audiovisual metronome set at 1/sec”. The exercise in itself is a two count movement with the phase of contraction and relaxation being equal in the duration. The subject was asked to contract and relax as many times till the moment when the hand would be tired and would not be able to shift the tensioning part of the grip anymore. The results were recorded on the tape. According to the rise in fatigue process during continuous work of the hand the graphical recorder on the paper tape showed the deviation diagram of energy consumption and the meter showed quantitative evaluation of the work performance. The following dependent variables were measured from the raw data. The number of contractions before fatigue and the number of contractions after fatigue (Deviations of length less than 2/3rd of the total length of deviations as recorded graphically on the paper tape was considered as contractions after fatigue).
[Table - 2] shows comparison between normal subjects and first assessment (i.e. fourth post operative week) of patient Group A. It reveals highly significant reduction in grip strength and pinch strength, significant reduction in work of hand muscles before fatigue and non-significant results in work of hand muscles after fatigue in left fracture patients. Significant improvement in all the variables in second assessment (sixth week) of patient Group A as compared to their first assessment in Fourth week was seen [Table - 3] [Table - 4] shows highly significant improvement in grip strength, pinch strength and significant improvement in work of hand muscles before fatigue and non significant results in work of hand muscles after fatigue in Third assessment (eighth post operative week) of patient group A as compared to Second assessment (sixth post operative week) [Table - 5] shows comparison between third assessment (eighth week) of patient Group A and first assessment of patient Group B (eighth week). It shows highly significant difference in grip strength, pinch strength and work of hand muscles before fatigue and significant differences in work of hand muscles after fatigue.
The reduction in the performance in Group ‘A’ patients in their initial assessment, due to period of immobilisation and lack of goal oriented exercises with activities, is consistent with the study conducted by Hetlinger and Mueller in 1953. These studies have shown that in absence of any motor neuron lesion one week of rest may lead to 20% loss of initial strength level and another 20% decline in residual strength for each week of rest[4]. Significant improvement was observed in successive assessment during sixth and eighth post-operative weeks in patients Group A after an activity oriented exercise regime. Anderson et al[5] and Watson et al[6] stated that active mobilisation if started early shows better results in term of regaining forearm rotation and early union. Highly significant reduction in strength and endurance in control group patients as compared to patients treated with regular active and resistive mobilization shows that immobilisation has advantages only during first 2 stages of fracture repair & has deleterious effects if prolonged. Grace et al[7] has concluded better results with early mobilisation. Also Chapman et al[8] and Schemitsh et al[9] showed better results with early mobilisation without the need for post operative immobilisation by external means. Thus, the present study concludes that early active and resistive goal directed mobilisation has significant effects on grip strength and work of hand muscles. Ergograph and Dynamometers being an objective measure of evaluation has feed back effects on patients motivating them for better cooperation and performance. Since it was a pilot study and sample size being small further study is required.
We wish to thank the Dean, Seth G. S. Medical College and K. E. M. Hospital, Mrs. I. R. Kenkre, Professor and Head of Occupational Therapy School & Centre, Dr. V. J. Laheri, Head of Orthopaedic Department and Patients, without whose cooperation this study would not have been possible.
[Table - 1], [Table - 2], [Table - 3], [Table - 4], [Table - 5]
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