EFFECTIVENESS OF RANGE OF MOTION EXERCISES IN IMPROVING RANGE OF MOTION IN
PATIENTS WITH POST-OPERATIVE OPEN REDUCTION INTERNAL FIXATION FOR PROXIMAL
PHALANGEAL FRACTURE
Ernn Gharend D. Elarco, Alliah Zaisa Colleen Glorioso
Department of Physical Therapy, College of Rehabilitation Sciences, De La Salle Medical and Health
Sciences Institute, City of Dasmariñas, Cavite, Philippines
_____________________________________________________________________________________
elarco.ernngharend.devela@gmail.com, glorioso.alliahzaisa.batingal@gmail.com
Date of Appraisal: September 26, 2022
_____________________________________________________________________________________
Clinical Bottomline:
● Constrained and unconstrained exercises are effective in improving range of motion, but both
interventions show no significant difference in improving range of motion.
Clinical Question:
What is the effectiveness of constrained range of motion exercises vs unconstrained range of motion
exercises in improving ROM in patients with post-operative open reduction internal fixation (ORIF) for
proximal phalangeal fracture?
Keywords: Range of Motion Exercise, Open Reduction Internal Fixation, Proximal Phalangeal Fracture
Table 1
Population
Middle-Aged Office Workers
Intervention
Unconstrained Range of Motion Exercises
Comparison
Constrained Range of Motion Exercises
Outcome
Improvement in Range of Motion
PubMed and EBSCO were utilized to locate and select the most updated evidence with regards to the
clinical question imposed. This is on the basis that the clinical question stated above is focused on the
effect of the intervention and outcomes of the said condition. Moreover, PubMed and EBSCOHost were
selected as the primary source of published evidence as it is able to provide up-to-date, full-text copies of
articles, with a reputation for being an online source of published articles.
Table 2
Search Strategy
Elements
Client Type
What Might Be Done
Intended Results
Office Workers
Range of Motion
Exercises
Increase Range of
Motion
Articles were filtered in the above mentioned data bases through a three-level screening process as
demonstrated by the yields, hits, retrieved and obtained. The number of articles that falls under the “yields”
pertains to the numbers of the articles found upon clicking the search button followed by filtering the given
articles through title screening, resulting in the number of eligible articles that may be shown under “hits”.
From the remaining articles, abstract screening was done and chosen articles will fall under “retrieved”. Out
of all the retrieved articles that passed from the title screening up until the abstract screening each will be
further evaluated to determine whether it will satisfy the inclusion and exclusion criteria that was set by the
researchers.
Search Terms
Table 3
Bracket A
Bracket B
Bracket C
Post-operative open reduction
internal fixation OR open
reduction internal fixation OR
ORIF
Range of Motion Exercises OR
ROM OR ROME
Proximal phalanx fracture OR
finger fracture OR fracture
Inclusion and Exclusion Criteria
To consider the article as included among evidences to be appraised, the article must be able to conform to
requirements set by the appraiser: (1) The article must be a randomized controlled trial (RCT), a systematic
review, or a meta-analysis, or a qualitative study, (2) must be in the English language, (3) within 10 years of
publication,
In the event that an article meets the requirements set forth by the appraiser but was not utilized for the
study, then the study may have one or more condition set under the exclusion criteria: (1) study participants
have not undergone ORIF, (2) fractures are not considered proximal phalangeal fracture, and (3) study
found is of lower level of evidence than randomised controlled trial.
Search Process
Table 4.1
PubMed Search Process
Search Terms
Yields
((Post-operative
31
open reduction
internal fixation
OR open
reduction internal
fixation OR ORIF)
AND (Range of
Motion Exercises
OR ROM OR
ROME)) AND
(Proximal phalanx
fracture OR finger
Hits
Retrieved
Obtained
1
1
1
fracture OR
fracture)
Miller, L., Crosbie, J., Wajon, A., & Ada, L. (2016). No difference between two types of exercise
after proximal phalangeal fracture fixation: a randomised trial. Journal of physiotherapy, 62(1),
12–19. https://doi.org/10.1016/j.jphys.2015.11.006
Table 4.2
ScienceDirect Search Process
Search Terms
Yields
Hits
Retrieved
Obtained
((Post-operative
open reduction
internal fixation
OR open
reduction internal
fixation OR ORIF)
AND (Range of
Motion Exercises
OR ROM OR
ROME)) AND
(Proximal phalanx
fracture OR finger
fracture OR
fracture)
3,197
1,442
1
1
Miller, L., Crosbie, J., Wajon, A., & Ada, L. (2016). No difference between two types of exercise
after proximal phalangeal fracture fixation: a randomised trial. Journal of physiotherapy, 62(1),
12–19. https://doi.org/10.1016/j.jphys.2015.11.006
Reason: Duplicate
Title of the Study
No difference between two types of exercise after
proximal phalangeal fracture fixation: a randomised
trial
Author
Lauren Miller, Jack Crosbie, Anne Wajon, Louise
Ada
Year Published
2015
Type of Evidence
Randomized Controlled Trial
Evidence Level
Level III Evidence
Purpose of the Study
To determine difference between synergistic wrist
and finger exercises with metacarpophalangeal joint
constrained, and finger exercises with the
metacarpophalangeal joint unconstrained
Sample/Participants
Consecutive cohort of 155 patients from Hand Clinic
at Sydney Hospital who have underwent ORIF of
any finger was screened
89 patients were excluded or declined or participate
in the study while 66 patients were categorized
based on the severity of their fracture and
complexity of the fixation used.
26 participants were categorized under the
experimental group while 30 were categorized under
the control group.
Intervention
First 6 weeks: one supervised session per week (40
mins) with home program
After 6 weeks: one supervised session per week (30
mins) until participant was discharged or decided to
withdraw
Control group performed unconstrained finger
exercises for 10 repetitions, 6 times a day. If wrist is
in neutral position, participants perform a sequenced
active finger movement consisting of five positions
(combined flexion extension movements).
Experimental group performed synergistic wrist and
finger exercises with constraint via removable
orthosis for 10 repetitions, 6 times a day.
Outcome Measures
Primary: active PIP extension, total active finger range
of motion, and strength
Secondary: Pain, activity limitation, participation
restrictions.
Data Analysis
Researchers set an expected achievable active PIP
extension of -27° based on two studies that
reviewed ROM after proximal phalanx ORIF, with
another 10° to 12° considered to be clinically
significant.
Clinical significance of the study was ascertained
through a mean between group difference of 95% CI
was computed for continuous outcomes and a risk
difference of 95% CI was computed for dichotomous
outcomes.
Participants’ data were analyzed based on allocation
in the group regardless of compliance to treatment.
Results
No significant between-group difference as to
improvement of active PIP extension, total active
finger ROM, pain, difficulty with specific hand
activity, or difficulty with usual hand activity for week
6.
No between-group difference as to improvement of
active PIP extension, total active finger ROM, pain,
difficulty with specific hand activity, or difficulty with
usual hand activity.
Conclusion
Both control and experimental groups improved
using the exercises, but no significant difference as
to effects of a 6-week treatment using synergistic
wrist and finger exercises with MCP constrained on
PIP extension, total active ROM, grip strength, pain,
and difficulty with hand activities than traditional
finger exercises with the MCP unconstrained.
Critical Appraisal (Miller et. al., 2016)
All contents of the obtained article were appraised using the CASP appraisal tool for systematic and
meta-analysis study, with findings documented below:
Questions
Yes/No
Comments
Section A: Is the basic study design valid for a randomised controlled trial?
Did the study address a clearly
focused research question?
Yes
The study focused itself in
determining if 6 weeks of
synergistic wrist and finger
exercises with the MCP joint
constrained via orthosis would
be more effective than
traditional finger exercises with
MCP joint unconstrained.
Was the assignment of
participants to interventions
randomised?
Yes
Were all participants who
No
entered the study accounted for
at its conclusion?
Section B: Was the study methodologically sound?
Were the participants ‘blind’ to
intervention they were given?
Were the investigators ‘blind’ to
the intervention they were
giving to participants?
Were the people
assessing/analysing outcome/s
‘blinded’?
No, No, Yes
The study used randomised,
parallel-group trial with
concealed allocation,
intention-to-treat analysis and
outcome assessors are all
blinded.
Researchers report a loss to
follow-up by week 12 and not
accounted for, mainly due to no
significant difference by week
12. The study was performed
with an intention-to-treat
analysis and although
participants continued to drop
until the conclusion, the study
still continued on.
Were the study groups similar
at the start of the randomised
controlled trial?
Yes
Apart from the experimental
intervention, did each study
group receive the same level of
care (that is, were they treated
equally?)
Yes
Patient inclusion criteria set by
the researchers
Section C: What are the results?
Were the effects of the
intervention reported
comprehensively?
Yes
Results were reported for each
group and per outcome
measure listed by researchers.
Was the precision of the
intervention or treatment effect
reported?
Yes
Confidence intervals used by
researchers are at 95% C (P <
0.05)
Do the benefits of the
experimental intervention
outweigh the harms and costs?
Can’t tell
The experimental intervention
was proven to be able to
improve ROM in patients who
have underwent ORIF, but its
costs may possibly outweigh
the benefits of the intervention.
No noted harm in the use of the
experimental intervention.
Can the results be applied to
your local population/in your
context?
Yes
Use of orthosis for constraining
movement may be applicable
for the local population
provided they are able to afford
the orthosis.
Would the experimental
intervention provide greater
value to the people in your care
than any of the existing
interventions?
No
The experimental intervention
involves using an orthosis for
constraining patient’s affected
finger. Expense in buying an
orthosis may not be ideal for
most patients in the local
setting.
TOTAL
7/11
Dimensions of
Evidence
Miller, L., Crosbie, J., Wajon, A., Ada,
L.
Mean
Interpretation
Hierarchy Level
2
2.5 = 3
Fair Level
Methodological
Quality
7/11
6.5 = 7
Fair Quality
Statistical
Precision
P < 0.05
-
Strong Evidence
-
-
Effect Size
Week 1
Active ROM
PIP extension:
Cohen's d
=0
Glass's delta = 0
Hedges' g = 0
Total extension:
Cohen's d = 0.256865
Glass's delta = 0.285714
Hedges' g = 0.255059
Week 6
Active ROM
PIP extension:
Cohen's d = 0.099504
Glass's delta = 0.111111
Hedges' g = 0.098782
Total extension :
Cohen's d = 0.264887
Glass's delta =0.255814
Hedges' g = 0.265598
Grip strength (kg)
Pain (PRWHE)(0 to 50):
Cohen's d 0.181818
Glass's delta = 0.181818
Hedges' g = 0.181818
Activity limitations
Difficulty with specific hand activity
(PRWHE)(0 to 60):
Cohen's d = 0.196116
Glass's delta = 0.16666
Hedges' g = 0.19897
Participation restrictions
Difficulty with usual hand activity
(PRWHE)(0 to 40):
Cohen’s d =0.166667
Glass’s delta = 0.166667
Hedges’ g = 0.166667
Week 12
Active ROM
PIP extension:
Cohen's d = 0.332182.
Glass's delta = 0.363636.
Hedges' g = 0.330164.
Total extension:
Cohen's d = 0.394791
Glass's delta = 0.410256
Hedges' g = 0.393714
Grip strength (kg)
Pain (PRWHE)(0 to 50):
Cohen's d = 0.086874
Glass's delta = 0.083333
Hedges' g = 0.087155
Activity limitations
Difficulty with specific hand activity
(PRWHE)(0 to 60):
Cohen's d = 0.333333
Glass's delta = 0.333333
Hedges' g = 0.333333
Participation restrictions
Difficulty with usual hand activity
(PRWHE)(0 to 40):
Cohen's d = 0
Glass's delta = 0
Hedges' g = 0
Relevance
3
3
High Relevance
Hierarchy of Evidence
Very High Level 1: Meta-analysis/Systematic Review
High Level Level 2: RCTs
Fair Level Level 3: Non-RCT/Quasi-Experimental Trial
Low Level Level 4: Observational Study
Very Low Level Level 5: Case Study
Methodological Quality
8-10 High Quality
4-7 Fair Quality
0-3 Low Quality
Statistical Significance
P ≤0.05 Strong Evidence
P>0.05 Weak Evidence
Effect Size
Test
Relevant Effect Size
Threshold
Standardized Mean Difference
Hedges’ g
Small
Medium
Large
0.20
0.50
0.80
Relevance
0 – No relevance (not relevant to population, intervention used, outcome measure used)
1 – Low Relevance (relevant to one criterion of the three)
2 – Fair Relevance (relevant in two of the three criteria)
3 – High Relevance (relevant to population, intervention used, outcome measure used)
Conclusion and Recommendation
Summary of the Results
The first article concludes that there is no significant difference between the use of constrained and
unconstrained exercises in improving postoperative range of motion in patients who have recently
underwent open reduction internal fixation of a proximal phalangeal fracture. There is improvement in the
range of motion of patients who have undergone both exercise programs, but not so much difference
between them to make one a much more viable option than the other, which may suggest that the
exercises are still beneficial to the patient.
Overall, researchers have shown that range of motion exercises, whether constrained or
unconstrained, are effective in improving range of motion in patients who have underwent open reduction
internal fixation of a proximal phalangeal fracture. Follow-ups during the 6th and 12th weeks show
improvement in patient’s ROM.
Implications to Practice
One notable implication to practice is that patients who have underwent ORIF are commonly
referred to physical therapy for rehabilitation. Allowing more viable interventions for treatment can help
improve the flexibility of physical therapists in the treatment of patients.
Implications to Research
Future researchers should focus on comparison of various interventions fracture due to the low
number of studies that discusses its effectiveness and use for patients who have recently underwent ORIF
to treat proximal phalangeal fracture. More research should also be used to determine whether constrained
exercises really do place more stress than unconstrained exercises, and how can it be improved to be
offered as a possible intervention to improve range of motion. Comparison should also be done towards
other interventions, with a major difference in the overall program. This may help in increasing the
significance of interventions being tested and open more options to therapists during treatment sessions.
Clinical Decision
In conclusion, ROM exercises may be used in the treatment of patients who had recently
underwent open reduction internal fixation (ORIF) surgical procedure for proximal phalangeal fracture to
improve patient’s Range of Motion.
References:
Miller, L., Crosbie, J., Wajon, A., & Ada, L. (2016). No difference between two types of exercise after
proximal phalangeal fracture fixation: a randomised trial. Journal of physiotherapy, 62(1), 12–19.
https://doi.org/10.1016/j.jphys.2015.11.006
Appendix A: Search Process