Written by:
Samantha Marrah, MS, OTR/L
VHSF Fellow ‘22/’23
One of the most common upper limb injuries seen in hand therapy is a distal radius fracture (DRF). In the United States, the annual incidence is 25.4 per 10,000 patients over the age of 65 (Karl et al., 2015). Patients with this diagnosis may occupy up to 40% of an outpatient hand therapist’s caseload according to a survey study (Michlovitz et al., 2001).
Anecdotally, I have noticed that many older adult patients with a DRF also have postural issues. The reasons for poor posture are varied. Patients may develop kyphosis or hyperkyphosis due to numerous factors, including advanced age, degenerative disc disease, vertebral fractures, low bone mineral density, and muscle weakness (Kado et al., 2013). Poor posture may also be related to technology use. Increasing numbers of older adults are using smartphones, with 61% owning a smartphone in 2021 (Pew Research Center, 2021). Smartphone users often present with forward head posture (FHP), which has been associated with decreased proprioception in the cervical spine, which may negatively impact posture and balance (Tsantili et al., 2022).
Given that increased thoracic kyphosis in older adults is associated with future falls (van der Jagt-Willems et al., 2015), it is vitally important to address poor posture in older adult patients following a DRF, in addition to standard wrist rehabilitation.
What Can We Do to Address Poor Posture Following a DRF?
1. Address muscular weakness and mobility limitations
· If muscular weakness is determined to be the underlying cause of kyphosis, we can focus on targeted scapular stabilizer strengthening (e.g. lower trapezius, middle trapezius, rhomboids, etc.).
· Back extensor strengthening: Exercises targeting back extensor muscle strength may lead to modest kyphosis improvements (Bansal et al., 2014).
• Mobility limitations: To address adaptive shortening of anterior muscles (e.g. pectoralis minor), we can focus on stretching exercises such as the wall chest stretch, or the supine foam roller chest stretch.
2. Address dysfunctional scapular kinematics
· Patients with DRFs demonstrated dysfunctional scapular kinematics in one study,
including increased scapular internal rotation, anterior tilt, and upward rotation during arm elevation. These altered kinematics may potentially lead to secondary musculoskeletal disorders (Ayhan et al., 2015). Therefore, we must promote proper scapular positioning during early rehabilitation.
· Taping: The use of elastic taping was found to improve scapular kinematics following a DRF, improving scapular external rotation and posterior tilt during early rehabilitation (Turgut et al., 2017). Three strips of Kinesio tape were used with the following goals: to enhance elbow supination, control scapular position, and promote erect posture and proprioception (Turgut et al., 2017).
· Scapular exercise program: Improved arm function and reduced pain with movement were noted following a scapular exercise program for patients with DRFs (Gutiérrez-Espinoza et al., 2019). The program focused on improving scapular proprioception and strength. Exercises focused on the following muscles: lower trapezius, latissimus dorsi, rhomboid major, and teres major (Gutiérrez- Espinoza et al., 2019).
3. Postural Education (Postural Awareness Training)
· We can improve postural awareness in patients by providing sensory cues regarding postural alignment during exercises or simulated ADLs in the clinic (Pawlowsky et al., 2009).
· Use of a mirror in the clinic could provide visual feedback and improve postural awareness.
4. Ergonomics
• We can provide patient education regarding proper posture while using a smartphone, tablet, or laptop.
5. Physical Therapy(PT)Referral
• We can refer patients to PT for fall risk assessments, balance training, fall prevention education, and/or to evaluate spinal impairments.
6. Community Resources
· If a community-based fall prevention program exists, we can refer patients to it post-rehabilitation.
· Yoga interventions could also be useful to improve posture. A 12-week yoga intervention for women with hyperkyphosis, consisting of 4 series of modified poses targeting shoulders, spinal erectors, abdominals, and neck, demonstrated postural improvements which may be due to increased flexibility, strength, and attention to alignment (Greendale et al., 2002).
References
Ayhan, C., Turgut, E., & Baltaci, G. (2015). Distal radius fractures result in alterations in scapular kinematics: a three-dimensional motion analysis. Clinical Biomechanics (Bristol, Avon), 30(3), 296–301. https://doi.org/10.1016/j.clinbiomech.2014.12.015
Bansal, S., Katzman, W. B., & Giangregorio, L. M. (2014). Exercise for improving age-related hyperkyphotic posture: a systematic review. Archives of Physical Medicine and Rehabilitation, 95(1), 129–140. https://doi.org/10.1016/j.apmr.2013.06.022
Candela, V., Di Lucia, P., Carnevali, C., Milanese, A., Spagnoli, A., Villani, C., & Gumina, S. (2022). Epidemiology of distal radius fractures: a detailed survey on a large sample of patients in a suburban area. Journal of Orthopaedics and Traumatology Official Journal of the Italian Society of Orthopaedics and Traumatology, 23(1), 43. https:// doi.org/10.1186/s10195-022-00663-6
Greendale, G. A., McDivit, A., Carpenter, A., Seeger, L., & Huang, M. H. (2002). Yoga for women with hyperkyphosis: results of a pilot study. American Journal of Public Health, 92(10), 1611–1614. https://doi.org/10.2105/ajph.92.10.1611
Gutiérrez-Espinoza, H., Araya-Quintanilla, F., Gutiérrez-Monclus, R., Cavero-Redondo, I., & Álvarez-Bueno, C. (2019). The effectiveness of adding a scapular exercise programme to physical therapy treatment in patients with distal radius fracture treated conservatively: a randomized controlled trial. Clinical Rehabilitation, 33(12), 1931–1939. https://doi.org/10.1177/0269215519866240
Kado, D. M., Huang, M. H., Karlamangla, A. S., Cawthon, P., Katzman, W., Hillier, T. A., Ensrud, K., & Cummings, S. R. (2013). Factors associated with kyphosis progression in older women: 15 years' experience in the study of osteoporotic fractures. Journal of Bone and Mineral Research: The Official Journal of the American Society for Bone and Mineral Research, 28(1), 179–187. https://doi.org/10.1002/jbmr.1728
Karl, J. W., Olson, P. R., & Rosenwasser, M. P. (2015). The Epidemiology of Upper Extremity Fractures in the United States, 2009. Journal of Orthopaedic Trauma, 29(8), e242–e244. https://doi.org/10.1097/BOT.0000000000000312
Michlovitz, S. L., LaStayo, P. C., Alzner, S., & Watson, E. (2001). Distal radius fractures: therapy practice patterns. Journal of Hand Therapy, 14(4), 249–257. https://doi.org/ 10.1016/s0894-1130(01)80002-8
Pawlowsky, S. B., Hamel, K. A., & Katzman, W. B. (2009). Stability of kyphosis, strength, and physical performance gains 1 year after a group exercise program in community-dwelling hyperkyphotic older women.Archives of Physical Medicine and Rehabilitation, 90(2), 358–361. https://doi.org/10.1016/j.apmr.2008.07.016
Pew Research Center. (2021). Mobile fact sheet.http://www.pewinternet.org/fact-sheet/ mobile/
Tsantili, A. R., Chrysikos, D., & Troupis, T. (2022). Text Neck Syndrome: Disentangling a New Epidemic. Acta Medica Academica, 51(2), 123–127. https://doi.org/10.5644/ ama2006-124.380
Turgut, E., Ayhan, C., & Baltaci G. (2017). Repositioning the scapula with taping following distal radius fracture: kinematic analysis using 3-dimensional motion system. Journal of Hand Therapy, 30(4): 477–482. https://doi.org/10.1016/j.jht.2017.07.001
van der Jagt-Willems, H. C., de Groot, M. H., van Campen, J. P., Lamoth, C. J., & Lems, W. F. (2015). Associations between vertebral fractures, increased thoracic kyphosis, a flexed posture and falls in older adults: a prospective cohort study. BMC Geriatrics, 15, 34. https://doi.org/10.1186/s12877-015-0018-z
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