The effects of a three visit supervised physiotherapy exercise programme versus a six visit supervised physiotherapy exercise programme in children with supracondylar fractures without neurovascular injuries.
Background From the literature that has been reviewed for this study it is evident that there is a lack of research conducted investigating the value of early mobilization and exercise treatment of supracondylar fractures (SCF) in children. There has been no documented research conducted in South Africa on the frequency of physiotherapy treatment in children with SCF of the elbow joint or compliance of the child and parent/caregiver/guardian to a physiotherapy upper limb home exercise programme. Currently there is no set physiotherapy treatment protocol for SCF. Therefore this study attempts to investigate the effects of a supervised physiotherapy exercise programme in children with SCF and the compliance of the child to the home exercise programme monitored and conducted by the parent/caregiver/guardian. Aims and Objectives The primary aim of this study was to compare the effects of an exercise programme supervised by the researcher fortnightly (three visits) over a six week period to those who attended physiotherapy once per week (six visits) over a six week period. The secondary aim was to determine the compliance of the child supervised by the parent/caregiver/guardian at home with a physiotherapy home exercise programme over the 6 week period when not attending formal physiotherapy sessions at the hospital. The objectives used in the study was to determine pain, range of motion, activities of daily living and compliance of the physiotherapy exercise programme of flexion, extension supination and pronation movements at the elbow joint and soft tissue mobilization over three formal physiotherapy treatment sessions (3 visits) compared to six formal physiotherapy treatment sessions (6 visits) over the six week period. Study Design A randomised experimental design with a sample size of 50 children with SCF from three provincial hospitals in the eThekwini district was followed. The study population comprised of children between the ages of four to thirteen years presenting with SCF of the elbow joint in the participating hospitals. The children were randomly and equally assigned into two groups using a computer programme either into group A (intervention group) or group B (control group). The researcher was blinded to the groupings. The researcher performed the physiotherapy treatment programme consisting of six basic elbow exercises namely: flexion, extension, pronation and supination movements of the elbow joint (Appendix VI). Each of the exercises was conducted 20 times. Soft tissue mobilization was the other technique conducted where the researcher performed a passive stretch at the biceps muscle of the affected arm on the children during the formal physiotherapy sessions (Appendix VII). The stretch was repeated five times. Functional activities such as washing your face, eating and combing the hair (extension and flexion) as well as keying and un-keying a door (supination and pronation) are some of the basic activities one requires in life. These activities are only possible if there is 90%-100% full range of motion at the elbow joint. Group A received the physiotherapy regimen three times over a period of six weeks (first, third and sixth week) whereas group B received the same physiotherapy regimen of basic elbow exercises six times (once per week) over a six week period. Group A and group B were taught and requested to continue with the same basic elbow exercises performed in the hospital as a home programme where each exercise was performed 20 times three times a day. The parent/caregiver/guardian was taught how to record the relevant information on the record sheet (Appendix VI). This information was used to assess the compliance of the child with the home exercise programme supervised by the parent/caregiver/guardian. Data analysis The completed questionnaires consisting of the demographic data that was coded and was entered into an excel spreadsheet and descriptive statistics were performed using the Statistical Package for Social Sciences IBM SPSS version 20. The significance was set at p < 0.05. Baseline characteristics were compared between the two randomised groups using Pearson’s Chi Square Tests and the Fisher Exact Test. Data were described at each time point by group using non parametric descriptive statistics including median and interquartile range. Comparisons between groups were done at each time point using non parametric Mann- Whitney tests. Results The p value was identified to assess whether the effects of a) pain, b) range of motion, c) functional activities and d) compliance between the intervention group (three visit supervised physiotherapy exercise programme) and the control group (six visit supervised physiotherapy exercise programme) differed over time. A p value <0.05 was considered statistically significant. There was no evidence for a beneficial effect of the intervention group over the control group in terms of the differences in pain, range of motion and activities of daily living using the relevant assessment tools. In the intervention group there was a slight increase in flexion values at a non - significantly faster rate than those of the control group. There was however, significantly less compliance to the home exercise programme in the intervention group (three visits) compared to the control group (six visits). Conclusion The results of this study show that the condition of the children in the intervention group (three visit supervised physiotherapy exercise programme) improved with regards to pain, range of motion and function at the affected elbow at approximately the same rate as the children in the control group (six visit supervised physiotherapy exercise programme). Perhaps a more thorough illustration, demonstration and explanation of the purpose of the home exercises need to be communicated to the children and the caregivers in order to obtain a more positive response of the children to their compliance to the home exercise programme. Children presenting with supracondylar fractures without neurovascular injuries could possibly attend fewer formal physiotherapy sessions but comply with a home exercise programme which proved beneficial. Therefore children especially those from rural areas may spend less time attending formal physiotherapy sessions at public hospitals. The overall results will also be beneficial to the parent/caregiver/guardian as they will possibly spend less time away from work and will probably cut travel time and costs to bring the child to hospital.