Sensorimotor Changes Following Distal Radius Fractures: Clinical Significance

Transcription

1 Sensrimtr Changes Fllwing Distal Radius Fractures: Clinical Significance Christs Karagiannpuls MPT, M.Ed, ATC, CHT, Ph.D ATI Physical Therapy OrthpaediCare Center 1200 Manr Drive, Chalfnt, PA 18914

2 Distal Radius Fracture Overview Metaphysial bne fx (Ring & Jupiter, 2007) Incidence sharply increases 50 years (4:1 rati) (Slgaard & Petersen, 1985) Lw-energy trauma (Chen and Jupiter, 2007) Strngest predictive factrs: Age and gender (Lippuner et al., 2009; Vgt et al., 2002; Singer et al., 1998). Lw-bne mineral density (Chen & Jupiter, 2007; Lippuner et al., 2009; Vgt et al., 2002)

3 Impairment Fllwing DRF Initial 12 weeks fllwing DRF interventin Critical perid fr treatment prgressin decisins Up t 50% functinal recvery Crrelated with physical impairment recvery Pain, AROM, grip strength (MacDermid et al., 2002; Karnezis & Fragkiadakis, 2002; Tremayne et al., 2002; Harris et al., 2005; Lucad et al., 2008). Delayed functinal return/cmplicatins frequently bserved: Sensry, muscle strength, recruitment, crdinatin deficits Sensri-mtr (SM) impairment is present Limited research t justify its assessment and treatment (Karagiannpuls, et al., 2013)

4 Prpriceptin Sensatins arising in the deep areas f the bdy cntributing t cnscius sensatins, pstural equilibrium, and jint stability Physilgist Charles Sctt Sherringtn 1906 Replaced by Sensri-Mtr cntrl in 1997 Delineate its prpriceptive rle n jint cntrl Describe prpriceptin is simply the afferent cnstituent f the sensri-mtr system Riemann & Lephart, 2002; Hagert, 2010

5 Sensri-Mtr Cntrl System Integrates peripheral afferent signals within CNS t prvide cnscius and uncnscius prpriceptive senses resulting in efferent respnses twards ptimal jint cntrl CNS Crtex & Cerebellum Sensry Prpriceptive input Skin-Jint-Ligament & Muscle Mtr Output (Riemann and Lephart, 2000; Hagert, JHT, 2010)

6 Sensri-Mtr Senses Riemann & Lephart, 2002; Prske & Gandevia, 2009; Hagert, 2010

7 Life-learned Sensri-Mtr Cntrl Develpment f uncnscius and cnscius senses derives frm early age via ur daily interactins and cnstant SM experiences frm surrundings

8 Uncnscius Sense Neurmuscular sense Cmplex autmatic SM jint functin Mediated by Incming feed-back afferent signals Centrally descending feed-frward mechanisms Cntrl functinal wrist AROM patterns Reciprcal & recurrent muscle inhibitin pathways Prvide wrist jint stability Synergistic and c-activatin muscle functins Preparatry and anticipatry cntrl

9 Cnscius Sense Incming sensry input Muscle spindle and skin receptrs Ascend t upper CNS centers Drsal clumn pathway Centrally prcessed and interpreted Cerebellum Primary sensry-mtr crtex Cnscius perceptin Precise jint mtin and psitin Optimal jint functin and cntrl

10 Cnscius Sense Kinesthesia: Ability t sense jint angle change r jint mtin Measured with visin blcked Detect smallest angle change that prmpts feeling f jint mtin Passive mtin, iskinetic dynammeter Jint Psitin Sense (JPS): Ability t sense jint psitin Measured with visin blcked Reprducing a specific jint angle f reference Gnimeter

11 Clinical Assessment Neurmuscular sense Cmplex interventinal instrumentatin Nt applicable fr daily clinical practice Cnscius Sense Kinesthesia Cmplex and expensive instrumentatin Jint Psitin Sense Simple instrumentatin Feasible in a busy clinical practice

12 Clinical Implicatins Wrist sensri-mtr impairment Frequently bserved in the clinic fllwing wrist trauma Sensibility deficit Muscle strength r recruitment difficulty Jint crdinatin deficit Delayed functinal return Integral gal f rehabilitatin strategies Treat the bserved sensri-mtr impairments Restre ptimal functin

13 Clinical Implicatins Sensri-mtr functin is critical fr ptimal jint cntrl and stability (Riemann and Lephart, 2002) Reasnable t assume that sensri-mtr impairment cntributes t functinal limitatins Clinical knwledge n sensri-mtr impairment and its assciatin with functin fllwing wrist trauma is imprtant t guide ur rehabilitatin paradigms

14 What we have been missing? Limited clinical research: Prevalence f SM deficit fllwing wrist trauma Bth cnscius and uncnscius senses Clinically meaningful SM assessment methds Instrument psychmetric prperties Assciatin between SM deficit and functin Optimal rehabilitatin methds twards SM deficit Influence f ther clinical factrs (pain, age, gender, bne quality) Influence f psych-scial factrs (anxiety, depressin)

15 Current Research Evidence A Descriptive Study n Wrist and Hand Sensri-Mtr Impairment and Functin Fllwing Distal Radius Fracture Interventin Karagiannpuls C, Sitler M, Michlvitz S, Tierney R. JHT, 26 (2013)

16 Primary Aim: T determine the magnitude f sensrimtr impairment fllwing DRF interventin 48 female participants 50 years 4 ATI Physical Therapy clinics Tested 8 weeks frm treatment initiatin

17 Dependent Variables Pain & Functin: PRWE questinnaire (MacDermid,1996) Mst respnsive functinal utcme measure fllwing DRF

18 Sensry Variables Sensibility Ten Test (Strauch et al., 1997) Simple instrumentatin Strng psychmetric prperties Mving light-tuch: equivalent skin dermatmes Verbal scale: = nrmal Cnscius Prpriceptin Active wrist JPS test High intra-tester reliability value (.85 ICC)

19 Active Wrist JPS Test Standardized prtcl: 1. Passive wrist psitining / memrizatin reference angle 2. Active relaxatin away frm reference angle 3. Active reprductin f reference angle Karagiannpuls et al., 2013

20 Active Wrist JPS Test Memrizatin f reference angle: 20 extensin Active reprductin Gnimetric assessment 2 trials Ttal scre based n abslute angle values Clinical example:

21 Mtr variables Surface EMG and Hand-Held Cmputerized Dynammeter Neurmuscular sense Ttal muscle recruitment WE, WF, FDS, FDI Muscle c-activatins WE/WF, WE/FDS, FDS/FDI Knwn synergistic activity during nrmal grasping Ttal grip frce prduced Over a 30-sec perid

22 Muscle Fatigue Knwn negative effect n cnscius prpriceptin (Hagert, 2010) Magnitude f grip frce decline ver time % value f the frce difference Between the peak and smallest frce prduced ver time

23 Study Results Significant and clinically meaningful differences between DRF and healthy cntrl grups SM variables: JPS Healthy = near 3 deg DRF = near 12 deg Muscle recruitment Ttal EMG activity: WE, WF, FDS, FDI Ttal grip frce Muscle fatigue Functin & pain TT JPS HC Surg Nsurg

24 Study Results Significant Crrelatins between SM variables Functin and Pain N crrelatin between SM variables and age

25 Study Results Ranking fr Clinical Meaningfulness and Crrelatin t Functin

26 Study Cnclusins Significant SM impairment prevails fllwing DRF Influenced by pain Assciated with sig functinal disability Active wrist JPS test mst clinically meaningful measure t assess wrist cnscius SM cntrl Simple gnimetric methd Easily reprduced in tday s clinical settings

27 Clinical Implicatins SM impairment assessment fllwing wrist trauma requires: Reliable, respnsive, and valid instrumentatin Hw varius patient factrs (e.g., pain) influence test psychmetric prperties Recent research evidence: 1. Active wrist JPS test is highly respnsive fllwing DRF Bth surgical and nn-surgical interventins Accurate t detect change within its specific clinical dmain ES, SRM, MDC, MCID values Hw influenced by pain Other cvariates: gender, age, hand dminance (Karagiannpuls et al., 2014 unpublished dissertatin wrk)

28 Current SM Rehabilitatin Evidence is limited fr wrist SM deficit interventins Prmising rehabilitatin methds exists Research evidence mainly frm ther jints Train cnscius and uncnscius senses Manual skills and techniques Clsed and pen chain active wrist ROM exercises Visual influence (mirrr therapy) Eccentric and cncentric exercises Ismetric: c-cntractin effect Perturbatin training: anticipatry cntrl

29 Cncluding Statement Significant SM impairment prevails fllwing DRF Clinically meaningful due t its strng assciatin with functin Active wrist JPS test is a reliable, respnsive, and clinically meaningful measure fr cnscius sensrimtr deficit Greatly influenced by pain levels fllwing DRF interventin Further clinical research is needed Substantiate the efficacy f current rehab methds Guide ur future wrist rehabilitatin paradigms