Edited_Case Study Jared Barnes

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Jared Barnes
Applied Functional Science Movement Based Therapy in a 9yo 9-Year-Old Male
pPost Immobilization fFollowing FOOSH Distal Radius/Ulna Fracture: A Case
Study
By: Jared Barnes
Project paper submitted in partial fulfillment of the requirements of the course: PT 7243
Physical Therapy Program
Angelo State University
November 7, 2013

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ABSTRACT
Study Design: Case Study
Introduction: Distal radius and ulna fractures are the most common fractures seen in
children. Irreparable damage can occur if correct surgical and rehabilitation protocols are
not properly implemented. A relatively new intervention technique consisting of applied
functional science movement based therapy has become increasing popular in physical
therapy settings. Yet, both rehabilitation protocols following radius and ulna fractures as
well as the efficacy of a functional movement based therapy have not been studied
exclusively. This case study demonstrates the application of, and outcomes associated with
an applied functional science movement based intervention protocol that considers
disability and impairments associated with post immobilization after forearm fracture.
Case Description: An active prepubertal male following full arm cast immobilization for 12
weeks with percutaneous pinning associated with fracture was classified as having
decreased function with increase disability and impairments. Evaluation of this patient
included obtaining range of motion, gross muscle strength, grip strength, and disability of
the arm, shoulder, and hand on day one and day 10 of a 6-week physical therapy
intervention. The intervention included a functional movement based approach pioneered
by Gary Gray, PT and a rehabilitation protocol that consisted of optimizing healing and
function by incorporated movement in all three planes while simultaneously providing
proprioceptive input.
Results and Outcomes: All values taken for ROM at the elbow and wrist increased
significantly except for supination (p<.05). Grip strength doubled from initial evaluation to
discharge (8.17 -> 15.42kg). Manual muscle testing showed an increase in strength for all
musculature of the elbow and wrist to 4+ or greater. The disability of the arm, shoulder, and
hand questionnaire showed marked clinically significant decrease (28.33 -> 9.167). Effect
size of patient’s grip strength were R=.55, R=.99, and R=.92 for patient left at discharge
verses norms, left hand day 1 verses discharge, and left verses right at discharge
respectively.
Discussion: The results of this case study indicate that an applied science functional
movement based therapy appeared to be successful in reducing impairments and disability
associated with immobilization of a fractured distal radius and ulna in a prepubertal active
male. Applied science functional movement based therapy however appears to not be
successful at returning the patient’s grip strength to that of normal.
Key Words: distal radius ulna fracture, functional movement therapy, prepubertal
INTRODUCTION:
Distal radius and ulna fractures are the most common of all children long
bone fractures, accounting for approximately 40% of pediatric fractures. These
fractures are 3 times more likely to appear in boys than compared to girls.1
The
mechanism of injury usually occurs during a fall in which the wrist and fingers are

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Jared Barnes
extended to protect from bodily impact, and termed as a fall on out stretched hand
(FOOSH). If ground reaction forces through the hand, wrist, and forearm are
sufficient, a bowing of the forearm can occur. If the torque created from the bending
of the long bones of the radius and ulna is greater than the tensile strength of the
bone, a separating or facturefracture may take place .2
Fractures among the
epiphyseal plate of the radius can cause irreparable damage if correct surgical and
rehabilitation protocols are not properly implemented. Although extensive research
has been conducted over the surgical management of distal radius and ulna
fractures, there has been little attention applied to the rehabilitation that follows.
One study (Smith et al. 2004) identifies three interventions specifically following
volar-fixed plating, dorsal plating, and external fixation surgical treatments, yet
during a literature review, there appears to be no study for specific rehabilitation
following immobilization casting with percutaneous pinning in pediatric
populations.3
Studies (Wakefield et al. 2000, Wilcke et al. 2007, Pasila et al. 1974,
and Handoll et al. 2006) that have been conducted to determine weatherwhether
treat or no treat options are more beneficial following distal forearm fractures show
mixed results.4,5,6,7
The evaluation of the effects of a specific physical therapy
intervention following immobilization of distal radius and ulna fracture is essential
for determining its usefulness in a clinical setting.
Functional movement based therapy has become a widely used intervention
style for the prevention, rehabilitation, and performance enhancement in outpatient
physical therapy clinics in the United States Midwest and Southwest since its
development and implementation by Gary Gray, PT in the early 1990s. Applied

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functional science, as described by Gary Gray, is the interaction of anatomy,
biomechanics, and behavioral sciences that consist of the ideologies, approaches,
and techniques used for functional assessment, training, conditioning,
rehabilitation, and injury prevention of individuals in the field of physical therapy .8
Functional movement based therapy has been proven to yield positive
clinical results, yet during the time this article was written, no known study has
been conducted to determine the efficacy of its implementation in the physical
therapy realm, exclusively for pediatric populations. Also, no known study has
determined its usefulness following fracture of the distal radius and ulna. Therefore,
the intent of this paper is to reflect on the therapy, skills, techniques, and outcomes
of a 6-week long intervention provided to a 9-year-old patient, who sustained a
fractured distal radius and ulna. Concentration will focus on investigating whether
functional movement based therapy decreases the disabilities and impairments
seen after a forearm fracture. Lastly, the effect size of the patient’s functional grip
strength will be compared the norms of healthy individuals to determine the
efficacy of the applied functional movement based intervention.
CASE DESCRIPTION:
The patient used in this study is a 9-year-old male who sustained a left distal
radius/ulna fracture on 3/20/13 following a FOOSH injury while playing football at
school. The patient was placed in a long arm cast with percutaneous pinning of the
radius for 12 weeks, which was removed on 6/7/13 and cleared for PT. The patient
was evaluated and treated for PT on 6/18/13. The Ppatient is an active child

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participating in football, basketball, baseball, soccer, as well as summer camps and
youth groups for his church. Patient is right handed, has no pertinent past medical
history prior to the accident, no history of hospitalization and/or trauma, and has
not received PT prior to injury. Family history is also negative. The patient’s medical
status and candidacy for PT was determined to be good.
Examination:
The patient was referred by his overseeing doctor and was evaluated on
6/18/13. A full text evaluation can be found under Appendix 1. The patient was
with his father and had written consent to evaluate and treat. Examination of
subjective findings reveal difficulty with all left upper extremity (UE) elbow and
wrist movements with impairments during grasping, carrying objects, pushing, and
opening doors. The Ppatient also states decreased activity participation and
disability during sports related activities such as baseball, football, and basketball
post immobilization. The Ppatient reports pain since the accident to be the
following: worst 5/10, best 0/10, current 1/10. Patient states his goal is to play
sports again and participate in the baseball season starting August 10th
.
Objective findings show that the patient carries the left elbow and wrist in a
guarded position next to the body and presented in an over the counter, removable
wrist splint. Quick screens of neurological, integumentary, and cardiovascular
systems reveal no abnormal findings. The patient’s affected area had noticeable
atrophy to biceps, triceps, and wrist extensors and flexors, with scapular asymmetry
secondary to immobilization. There were no signs of inflammation or redness with
normal skin turgor and temperature.

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The tests and measures used for the patient are also used as outcome
measures, which are the following: Goniometry for range of motion (ROM), manual
muscle testing (MMT) for gross muscular strength, and hand held grip
dynamometer for functional grip strength. A study (Petherick et al. 1988) found the
university goniometry to have a interstater reliability of r=.91-.99 for joint ROM
with a Pearson product of .88-.97 for determining elbow flexion ROM.9
Therefore
goniometry will be the preferred method to determine the patient’s ROM. A study
(Fan et al. 2010) showed MMT to have an intraclass correlation coefficient of .98 and
a kappa .88 in detecting muscular weakness.10
Therefore MMT will be used to
determine gross muscular strength and weakness. The Disability of Arm, Shoulder,
Hand (DASH) index was used as an self- reported quality of life questionnaire and
outcome measure. It was found (Slobogean et al. 2010) to have an ICC of.93 and
moderate construct validity when compared to the EQ-5D, SF-6D, and HUI3 for
determining disability.11,24
Lastly, one study (Gerodimos 2012) found the reliability
of handgrip strength with use of a hand help grip dynamometer to have a ICC of .
88-.98 in prepubertal children and thus will be used as a determinant of functional
grip strength as well as norms for comparison.12
The hand held dynamometer is also
found (Mathiowetz et al. 1884) to be the gold standard in terms of validity for grip
strength.13
Results can be found under Range of Motion, Strength, Manual Muscle Tests
and DASH under Table 1. ROM was most decreased in supination, pronation, wrist
extension, and radial deviation as compared to the patient’s right unaffected UE.
Grip strength was found to be less than half of that of the right. MMT revealed

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decreased strength in the patient’s biceps, triceps, brachioradials, pronator teres,
wrist extensors, wrist flexors, and supinators.
Assessment and Goals:
The patient’s assessment was the following: “Patient is post immobilization
casted for left distal radius/ulna fracture. Patient shows decreased wrist ROM and
strength as well as decreased elbow strength impacting non dominant UE function-
patient continues relative protective phase.” Impairment problems included
difficulty carrying, moving, and handing objects for the elbow. For the hand,
problems were pulling, pushing, and catching objects. As for fine motor movement,
grasping and finger dexterity problems were identified. The patient’s function
limitations include decreased elbow and wrist ROM and strength. Disabilities were
noted as the inability to participate in hobbies and sport activities, which include
but not limited to swinging a bat, shooting a basketball, catching a football, ect. The
determined prognosis and rehab potential was “good with the plan of care (POC)
including 2-3 visits per week for 6 weeks.” The benefit statement was “the patient
will benefit from skilled PT to restore PLOF strength, ROM, and activity
participation.” The goals can be found in Appendix 1 under Short Term Goals and
Long Term Goals.
Evidence supporting the established prognosis and time frame include the
norms found under The Guide to Physical Therapist Practice 4G which state the
expected range of visits per episode of care to be 6-18 with a prognosis of “optimal
joint mobility, muscle performance, and range of motion and the high level of
functioning in home, work, and leisure environments” to be 3-6 months post

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fracture for those with impaired joint mobility, muscle performance, and range of
motion associated with fracture.14
Also, a study by Benson showed patients that
even underwent surgery following a distal radius fracture, had final outcome
measures after 6 weeks to be 91% of normal wrist extension, 85% normal flexion,
and grip strength 92% of that compared to contralateral side.15
Both references
support the timeline, established goals, and prognosis used for the patient.
Intervention:
The patient was progressed as seen fit by the therapist. A full list of
interventions provided and timeline can be found under Table 2. A functional
approach to therapy was taken as established and pioneered by Gary Gray PT,
focusing on movements in all three planes while simultaneously providing
proprioceptive input.8
Procedures provided can be broken down into 3 separate
intervention segments. Phase 1 includes a protective, stretching, motor control, and
fine movement restoration, and strengthening phase lasting ~2 weeks. Phase 2
consisted of a functional movement phase with mobilization with movement
(MWM), stretching, PNF, and elbow/wrist/scapular strengthening period with
resistance lasting ~2 weeks. Phase 3 included a return to activities functional
movement phase including continued increases of MWM, stretching, PNF,
wrist/elbow/shoulder/ scapular strengthening, and proprioceptive sport specific
activities lasting ~2 weeks. The patient received a moist heat pack at the beginning
of the session and ice pack ending the session.
Evidence supporting the use of the established POC for the patient can be
found exclusively from following the established POC guidelines in the article by

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Smith. Although his protocol includes therapy post external fixation removal, the
POC can be adopted for those who only had closed reduction without external
fixation, such as the patient in this study. The following is an excerpt of his study:
Active, active-assisted, and passive ROM exercises are allowed for the uninvolved joints of the
shoulder, elbow, and wrist… Recognition and targeting by the therapist of this disabling problem with
active, active-assisted, and progressive passive motion of the forearm and digits are essential to
diminish long-term disability. After external fixator removal, the patient often will face considerable
stiffness of the radiocarpal and midcarpal joints in direct proportion to the degree of distraction, angle
of fixed positioning, and duration of fixation. Joint motion techniques are indicated with an emphasis on
extension, radial deviation, and supination. The patient should be instructed to perform these exercises
hourly during the daytime. Active, active-assisted, and progressive passive motion techniques are all
appropriate once the external fixator is removed. In those cases expected to be resistant, inclusion of
static progressive splinting for wrist extension, wrist flexion, and supination should be added at the time
of removal.3
As for the stretching protocol, support can be found in Dutton’s Orthopaedic
Examination, Evaluation, and Intervention book. It states that “an increase in
flexibility is achieved through a routine stretching program… with emphasis on
stretching the entire hand, forearm, and shoulder complex” for those with injuries to
the elbow and wrist. Dutton also states that stretching should follow the application
of heat.16
As for the fine motor movements and strengthening during phase 1,
Dutton states that gripping exercises using putty should be included as well as
concentric strengthening for the wrist should be initiated.16
Mobilization with
movement was adopted from Backstrom’s study of a patient with decreased wrist
ROM. She incorporated Mulligan’s maneuvers, which consisted of a sustained radial
glide of the proximal row of carpal bones and allowed full thumb and wrist motion

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to occur. Following 3 sets of 10 repetitions over 12 treatments in 2 months,
outcomes showed complete resolution of the condition.17
PNF movements in D1 and
D2 patterns can be supported by Khamwong’s study showing that a PNF group of
males post wrist extensor muscle damage had lesser deficits in sensory-motor
functions than compared to the control group.18
Dutton also states that PNF
techniques promote muscle groups to contract in the proper sequence for optimal
effectiveness and is the most applicable method for increasing ROM through muscle
lengthening.16
Also, a study by Fitzpatrick identified the importance of applied
proprioception input suggesting that two domains of muscular sense exist. One
consists of mapping the perceived objects length and weight with the other mapping
the perceived relations between hand and object.19
Both are equally important to
include during the neuromuscular re-education phase of rehabilitation. Gary Gray’s
basis for functional movement can best be supported from an article by Burton. It
explains the benefits of functional movement to overall cohesiveness between
muscles, joints, and neuromuscular system. Screening what functional movements
are most deficient must first take place followed by determining if the results are
considered a mobility or stability dysfunction. After which, the implementation of a
progressive functional movement based PNF innervation should be provided. It is
found that repeated PNF patterns increase coordination while promoting joint
stability and neuromuscular control.20
Alternative treatments were not considered
due to the focus of the study being solely on the effects of a specific treatment.
Modifications were made by therapist digression and patient tolerance.

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RESULTS AND OUTCOMES:
Reassessment took place on the patient’s 10th
visit, concluding 6 weeks of PT.
The same tests and measures were used as on the day of the initial evaluation.
Comparisons of the outcome measures can be made by examining Table 1. Largest
functional gains were increases in ROM during supination, wrist extension, and
radial deviation. Grip strength of the left UE was also dramatically increased to
almost double the amount compared to the findings during the evaluation. MMT
showed almost a full recovery of the left UE with all muscles tested exhibiting
increases in strength and presented to be either 4+ or 5/5. The DASH identifies
decreases in impairment and disability with scores significantly decreasing from to
28.333 to 9.167. Sorensen found that the minimal clinical important difference
(MCID) of the DASH is >10 points.21
The most identifiable decreases in impairment
and disability were in fact ones that were undocumented, which was motor control
and coordination using the non-dominate left hand. This was observed during L arm
plyometric ball toss and catch and during D1/D2 weighted movements and well as
the use of the left arm during activities of daily living. Changes in disability were
dramatically increased from being unable to swing a bat and throw a ball with the
left hand during initial exam to completing the task pain free with good form at
discharge.
The patient was discharged following the 10th
visit due to goals met and/or
patient request for discharge. The patient prognosis was determined to be good due
to the progressions seen and in the time frame in which they were made. Again, the
Guide states that full recovery for a fracture is approximately 3-6 months and in less

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than 18 visits for PT.14
When comparing results of ROM to the left and right on day
10, all are found to have no significant difference p<.05 except supination. As for
MMT results, there is no identified MCID so results will only be considered
meaningful if the grade increased from day 1 vs 10, which all muscles tested in the
patient, did. As mentioned, the DASH scores were greater than the MCID and are
also considered to be significant. Lastly, hand functional grip strength was used as
the ultimate identifier of recovery by comparing the patient’s results in terms of
effect size of right vs left at discharge, left day one vs discharge, and patient left at
discharge vs norms of male basketball players of the same age in a study by
Gerodimos.12
Comparisons of grip strength can be seen in Figure 1. The effect size
principle values as established by Portney for significance was used: >.2= small
statistical difference, >.5= moderate statistical difference, and >.8= large statistical
difference.22
There was found to be a large significant difference among left vs right
at discharge signifying that there was still marked decreased functional grip
strength of his left extremity when compared to his own relative strength. When
compared to the norms of a similar population and age, the patient’s values were
moderately significantly different although they fall within the 95% confidence
(19.78 kg ± 4.67) interval found in the study.12
Lastly, there was a large statistical
difference between the patient’s day 1 values vs his discharge values, denoting a
significant increase in strength.
DISCUSSION:
The results of this case study support there was a significant effect on the

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patient’s outcomes from the applied intervention. After comparing outcome
measures from day 1 vs discharge using significance levels, it was found that
increases in ROM, DASH scores, MMT, and grip strength all proved to be statistically
significant, except for supination ROM. Decreases in previously compromised
function, impairments, and disability were also noted. Post intervention data
comparison in Table 1 and Figure 1 reveal that the patient made both kinematic
and kinetic gains following immobilization. Increases in secondary function
unrelated to the aim of the case were also observed. Fine motor movements and
coordination of the injured extremity were increased. This was associated with
increased ability to perform functional tasks with the left hand during provided
interventions. It is possible that the gains in ROM, gross muscle strength, and grip
strength could have occurred spontaneously via natural bodily healing. Further
studies comparing treat vs non-treat options of functional movement therapy
should be conducted to observe the difference when comparing to a control
population of a conservative treatment. This is also a marked limitation of this
study. Comparisons could only be made to the patient’s own values to show
progression. Influence of prepubertal growth was not considered.
Although the primary intervention applied was functional movement based
therapy, viewing Table 2 shows alternative therapeutic approaches were
implemented. It is probable that the effects of non-functional movement based
therapy could have influenced the patient’s obtained values. This cross over effect
allows for type 1 error to occur, which this study was unable to determine. As
mentioned, the limitation of only including one subject in the study does not allow

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for comparison to a control group, which could be conducted to test for design error.
Future studies, again, that designate a specific functional movement intervention
group compared to other therapy options should be conducted to find true efficacy
of functional movement therapy.
When comparing the patient’s gains in functional grip strength to norms of a
similar population and age, there is a statistical discrepancy between the patient’s
outcomes vs the norms Figure 1. Since the intent of this study was also to discern if
the increases in functional grip strength were relative to healthy population norms,
it is interpreted that the patient did not recover fully. Even comparisons of the gains
seen in the left extremity to the patient’s healthy right at discharge were found to
have statistical discrepancy Figure 1. This proves that the patient did not fully
return to normal function when looking at own relative strength. It should be noted
that during testing of grip strength, no random selection of testing order was
implemented nor was the instrument calibrated before use. This allows for
decreased reliability and increased systematic error respectively, possibly providing
errant outcomes. Also, when determining patient grip strength compared to norms,
there are noted influencing factors. Relative grip strength in terms of kg grip
strength/ kg body mass would provide a more reliable comparison as body mass is
found to influence absolute grip strength.23
Post-hoc findings reveal that the average
body mass in the norms population used for comparisons was significantly different
than the subject in this case study (42.36± 10.12 kg vs 32.12 kg: p<.05).
This case report assessed an intervention style aimed at decreasing
impairments and disability. It is the first known study to assess the efficacy of

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applied science functional based movement therapy. It also is the first known study
to identify the use of a specific intervention during the rehabilitation following a
distal radius and ulna fracture. Although speculative, influence of factors such as
natural healing, systematic error, cross over, and intervention design error may
have allowed this subject to obtain and display skewed ROM, muscular strength,
DASH, and grip strength values. Future recommendations for studies should include
a randomized control trial with more participants of similar etiologies compared for
effectiveness of treatment.
CONCLUSION:
The results of this case study indicate that an applied science functional
movement based therapy appeared to be successful in reducing impairments and
disabilities associated with immobilization of a fractured distal radius and ulna in a
prepubertal active male. This was associated with increased ROM in the elbow and
wrist, increased strength in the elbow and wrist joint musculature, increased
functional grip strength, and decreased self-reported disability in the arm, shoulder,
and hand. Applied science functional movement based therapy however appears to
not be successful at returning the patient’s grip strength to that of normal.

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Table 1
6/18/13- Day 1
7
/
3
0
/
1
3
-
D
a
y
1
0
Right Left Right Left
ROM
Supination 95 45 98 84
Pronation 88 75 90 88
Wrist Extension 66 38 65 63
Wrist Flexion 68 62 67 65
Radial Deviation 30 22 30 30
Ulnar Deviation 34 34 35 35
MMT
Biceps 5/5 4-/5 5/5 5/5
Triceps 5/5 4/5 5/5 5/5
Brachioradialis 5/5 4/5 5/5 5/5
Pronator Teres 5/5 4-/5 5/5 4+/5
Wrist Extensors 5/5 4/5 5/5 4+/5
Wrist Flexors 5/5 4/5 5/5 4+/5
Supinator 5/5 4-/5 5/5 4+/5
Grip Strength
Best attempt 17.24 kg 8.17 kg 17.69 kg 15.42 kg
DASH
Total 28.333 9
.
1
6

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Table 2
Reps Sets Duration Resistance
Phase 1 (6/18/13-7/2/13)
Moist Heat Pack 7 minutes
Soft Tissue Massage 5 minutes
Laser lv 4 5 minutes
Wall wrist extension/flexion
stretches 8 1 20 seconds
Rice bucket exercise 8 minutes
Theraband putty wrist strength 8 minutes white
Cold ice pack 10 minutes
Phase 2 (7/3/13-7/16/13)
Soft Tissue Massage 5 minutes
Laser lv 4 5 minutes
Mulligans Mobs 10 3 5 seconds
PNF UE D1/D2 stretches 15 2 1 lb
Scapular band protraction 15 2 purple
Scapular band retraction 15 2 purple
Planks 4 1 30 seconds
UE matrix* 15 2 2 lbs
Phase 3 (7/17/13-7/30/13)
Mulligans Mobs 10 3 5 seconds
PNF D1/D2 stretches 15 2 2 lb
Scapular band protraction 15 2 pink
Scapular band retraction 15 2 pink
Planks 4 1 30 seconds
UE matrix* 15 2 2 lbs
LE matrix* with overhead B UE
reach 15 2 2 lbs

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Angled Swiss ball pushups 15 2
Ball throw and catch into
trampoline 7 minutes 1 lb
L handed ball catch 5 minutes 2 lbs
Wrist rolls 3 2 1 lb
Bicep curls 15 2 2 lbs
Supination stretch 4 1 20 seconds
4 lb
hammer
Weighted bat swing 15 2
32
ouncesoz
* as described by Gary Gray’s “The Matrix” video
Figure 1
ES Effect Size
d/c Discharge
* information taken from study by Gerodimos22

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References
1
Waters M, Mih A "Distal radius and ulna fractures." Fractures in children.
Philadelphia (PA): Lippincott Williams & Wilkins (2001).
2
Short W, Palmer A, Werner, et al. A biomechanical study of distal radial fractures.
The Journal of hand surgery. 1987; 12(4): 529-534.
3
Smith, D. Brou, K. Henry, M. “Early active rehabilitation for operatively stabilized
distal radius fractures.” Journal of Hand Therapy. 2004 March; 17(1): 43-49.
4
Wakefield A, McQueen M. "The role of physiotherapy and clinical predictors of
outcome after fracture of the distal radius." Journal of Bone & Joint Surgery, British
Volume. 2000; 82(7): 972-976.
5
Wilcke, Maria KT, Hassan Abbaszadegan, and Per Y. Adolphson. "Patient-perceived
outcome after displaced distal radius fractures: a comparison between radiological
parameters, objective physical variables, and the DASH score." Journal of Hand
Therapy. 2007; 20(4): 290-299.
6
Pasila M, Karaharju E, Lepistö P. "Role of physical therapy in recovery of function
after Colles' fracture." Archives of physical medicine and rehabilitation. 1974; 55.3:
130.
7
Handoll H, Madhok R, Howe T. "Rehabilitation for distal radial fractures in adults."
Cochrane Database System Rev 3 (2006).
8
Gray G, Gray D. “Functional Training Defined.” IDEA Fitness Journal. December
2009: 7(12)
9
Petherick M, Rheault W, Kimble S, et al. “Concurrent Validity and Intertester
Reliability of Universal and Fluid-based Goniometers for Active Elbow Range of
Motion.” Physical Therapy. 1988; 68:966-969.
10
Fan, E. Ciesla, D. Needham, D. “Inter-rater reliability of manual muscle strength
testing in ICU survivors and simulated patients.” Intensive Care Med. 2010 June;
36(6): 1038-1043.
11
Slobogean G, Noonan V, O'Brien P. "The reliability and validity of the Disabilities of
Arm, Shoulder, and Hand, EuroQol-5D, Health Utilities Index, and Short Form-6D
outcome instruments in patients with proximal humeral fractures." Journal of
shoulder and elbow surgery. 2010; 19(3): 342-348.
12
Gerodimos, V. “Reliability of Handgrip Strength Test in Basketball Players.” J Hum
Kinet. 2012 March; 31: 25-36.
13
Mathiowetz, Virgil, et al. "Reliability and validity of grip and pinch strength
evaluations." The Journal of hand surgery. 1984; 9(2): 222-226.
14
Guide to Physical Therapist Practice. 2nd
Edition. American Physical Therapist
Association. 2003.
15
Benson, L. Minihane,K. Stern, L. et al. “The Outcome of Intra-Articular Distal
Radius Fractures Treated With Fragment-Specific Fixation.” Journal of Hand
Therapy. 2006 October; 31(8): 1333-1339.
16
Dutton’s Orthopaedic Examination, Evaluation, and Intervention. 3rd
Edition.
McGraw Hill.
17
Backstrom K. “Mobilization with movement as an adjunct intervention in a patient
with complicated De Quervain’s tenosynovitis: a case report.” Jour of Ortho and
Sports Physical Therapy. 2002;32(3):86–97.

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Khamwong, P.Pirunsan, U. Paungmali, A. “A prophylactic effect of proprioceptive
neuromuscular facilitation (PNF) stretching on symptoms of muscle damage
induced by eccentric exercise of the wrist extensors.” J Bodywork Movement
Therapy. 2011 October; 15(4): 507-516.
19
Fitzpatrick, P. Carello, C. Turvey, M. “Eigenvalues of the inertia tensor and
exteroception by the ‘muscular sense’.” Neuroscience. 1994 May: 60(2); 551-568.
20
Burton, L. Brigham, H. “Proprioceptive Neuromuscular Facilitation: The
Foundation of Functional Training” Screening. 2013 July.
21
Sorensen A, et al. "Minimal Clinically Important Differences of 3 Patient-Rated
Outcomes Instruments." The Journal of hand surgery (2013).44 22
Portney L, Watkins
M. “Foundations of Clinical Research: Applications to practice. Pearson Education
Inc. 3rd
Ed. Upper Saddle River, NJ. 2009.
23
Gale C, Martyn C, Cooper C, Sayer A. Grip strength, body composition, and
mortality. International Journal of Epidemiology. 2007: 36(1); 228-235.
24
MacDermid, J. Richards, R. Donner, A. et al. “Responsiveness of the Short Form-36,
Disability of the Arm, Shoulder, and Hand Questionnaire, Patient- Rated Wrist
Evaluation, and Physical Impairment Measurements in Evaluating Recovery After a
Distal Radius Fracture.” Journal of Hand Surgery. March 2000: 25(2); 330-340.

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Appendix 1
Date of Initial Examination: 06/18/2013
Date of Birth: 01/17/2005
Injury/Onset Date/Change of Status Date: New Injury, R ulna fx
Diagnosis: 813.4 Fracture of radius and ulna, lower end, closed
Visit No.: 1: Treatment Diagnosis: 813.4 Fracture of radius and ulna, lower end, closed
Subjective
Treatment Side: Left
History of Present Condition/Mechanism of Injury: Pt is post L distal radius/ulna fx following
FOOSH accident on 3/20/13. Pt was playing football with friends during time of incident. Pt out of
cast since 6/7/13 and cleared for PT.
Primary Concern/Chief Complaint: Pain during wrist movements, most notably in extension,
radial deviation and supination with marked decreases in ROM and strength secondary to
immobilization.
Prior Level of Function: baseball, football, basketball
Current Functional Limitations: Carrying, Moving & Handling Objects: Hand & Arm Use: Pulling
Objects, Pushing Objects, Catching; Fine Hand Use: Grasping, unable to participate in hobbies and
sport activities.
Pain Location: L wrist
Pain Scale: Worst: 5 Best: 0 Current: 1
Aggravating Factors: grasping, carrying objects, pushing
General Health: Good
Home Health Care: No
Medical History: No Known Significant PMH To Affect Treatment
Diagnostic Testing/Imaging: positive for distal radius and ulna fx with healing
Mental Status/Cognitive Function Appears Impaired? No
Patient Goals: play sports again
Objective
Patient/Parent/Guardian Consent Yes
Chaperone Present Yes, Father
Inspection Pt carries wrist in a guarded position with noticeable swelling
Handedness Right
Cast/Splint Yes, Prefab splint
Complaints with use No
Pt instructed to wear wrist splint throughout the day
Posture Scapular Asymmetry
Muscular Asymmetries Pt L UE shows atrophy secondary to immobilization
Muscle Guarding Mild
Muscle Atrophy biceps, triceps, and wrist extensors and flexors
Elbow AROM Right Left
Supination 95° 45 °
Pronation 88° 75 °
Wrist AROM Right Left
Extension 66° 38°
Flexion 68° 62°
Radial Deviation 30 ° 22°
Ulnar Deviation 34° 34°
Strength

22
Grip / Pinch Right Left
Repeated Grip 40.00, 35.00, 35.00 || 20.00, 15.00, 15.00
Average 36.67 || 16.67
Manual Muscle Tests
Right Left
Biceps 5/5 4-/5
Triceps 5/5 4/5
Brachioradialis 5/5 4/5
Pronator Teres 5/5 4-/5
Wrist Extensors 5/5 4/5
Wrist Flexors 5/5 4/5
Supinator 5/5 4-/5
Palpation
Pt has mild swelling to L wrist with no edema or warmth. Pt also states there is no tenderness with
palpation. Palpable tenderness or increased muscular tone noted.
Assessment
Assessment/Diagnosis: Pt is post immobilization casted for L distal radius/ulna fx. Pt shows
decreased wrist ROM and strength as well as decreased elbow strength impacting non dominant UE
function- patient continues relative protective phase.
Patient Demonstrates Compliance with Prescribed HEP
Rehab Potential: Good
Contraindications to Therapy: None
Patient Problems:
- Pain
- decreased wrist and elbow ROM
- decreased wrist and elbow strength
Short Term Goals:
1: (1 Visit) | Goal Met | Pt will be independent with HEP and stretching protocol
Long Term Goals:
1: (4 Weeks) | 0% | Pt will have PLOF wrist and elbow strength as compared to R UE
2: (6 Weeks) | 0% | Pt will report no pain during wrist and elbow movements
3: (6 Weeks) | 0% | Pt will have PLOF wrist and elbow ROM as compared to R UE
4: (6 Weeks) | 0% | Pt will have < 10% functional grip strength difference R:L
5: (6 Weeks) | 0% | Pt will be able to fully swing a bat painfree
Plan
Frequency: 2-3 times a week
Duration: 6 weeks
Plan: Begin Plan as Outlined
Treatment to be provided:
Procedures
Therapeutic Exercises (ROM, Strength, Stability), Neuromuscular Rehabilitation
(Balance/Proprioception Training, Muscle Re-Education, Coordination), Manual Therapy (Soft Tissue
Mobilization, Joint Mobilization, Muscle Energy Techniques)
Modalities
To Improve (Pain Relief, Decrease Inflammation, Increase Blood Flow), Laser (Cold Laser),
Cryotherapy (Ice Pack), Hot Packs2

Edited_Case Study Jared Barnes

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