PT GUIDE TO WRIST FRACTURE

A wrist fracture is a break in one of the bones near the wrist. In the United States, 1 out of every 10 broken bones diagnosed is a wrist fracture. Injury can occur as a result of a trauma, such as falling while playing sports or simply tripping when walking down a sidewalk. Children are susceptible to wrist fractures because of the high-risk sports they commonly play. A child may sustain a wrist fracture falling off a bike, playing football or soccer, or falling off playground equipment. Wrist fractures are also common in women after menopause, and frequently occur in the elderly population due to falls. A physical therapist can help individuals who have sustained a wrist fracture regain normal wrist motion, strength, and function, and learn how to prevent future fractures.

What Is Wrist Fracture?

A fracture is a crack or a break in a bone. Wrist fractures due to falls happen most often when people stretch the arm straight out to catch themselves as they fall. The wrist is made up of 8 small bones called carpal bones, and 2 bones in the forearm called the radius and the ulna. A wrist fracture is diagnosed when any of those bones breaks or cracks. The most frequently fractured bone is the radius, the bone in the forearm that is closest to the thumb.

There are 3 types of bone fractures:

• Type 1 – a "nondisplaced" fracture, where the bone is broken but is still in a normal position.
• Type 2 – a fracture where a fragment of bone is shifted from its normal position.
• Type 3 – the most serious type of fracture, with multiple breaks of the bone or bones.

Type 1 and 2 fractures usually are treated without surgery. Type 3 fractures, however, usually require surgery.

How Does it Feel?

A fractured wrist is usually painful and movement is affected. If you have sustained a wrist fracture, you may experience:

• Pain in the area of the fracture, which could be anywhere in the wrist, depending on which bone was affected. The pain can radiate from the wrist into the fingers, and even into the forearm.
• Swelling in the wrist and possibly in the hand, usually on the top surface of the wrist and hand.
• Tenderness to touch in the wrist.
• Difficulty and pain when moving the wrist or fingers      

How Is It Diagnosed?

An x-ray is the best way to diagnose a wrist fracture. If you have sustained a fall and are experiencing any of the symptoms mentioned above, you need to visit an emergency room, an urgent-care center, or your physician to get a complete diagnostic x-ray.

If a physical therapist suspects that you have a wrist fracture, the therapist may arrange for an x-ray and refer you to an appropriate physician. Your physical therapist can check for damage to other joints and muscles, and make sure that the nerves and blood vessels in your wrist, forearm, and hand have not been affected by the broken bone. In most cases, people with fractures visit a physician with a specialty in managing bones and joints (an orthopedist). Depending on the type of fracture, the physician might prescribe a cast or a sling to immobilize the area for a period of time until the fracture is healed. The amount of healing time varies, depending on the individual and the type of fracture, and can be anywhere from 4 to 10 weeks. If the fracture is severe, surgery will be required. The recovery time may be longer following surgery, depending on the severity of the injury.

How Can a Physical Therapist Help?

Your physical therapist will work with you following a wrist fracture to help you regain normal wrist motion, strength, and function, and will provide education and training to help you prevent future fractures.

While Your Wrist Is In a Cast or a Sling

While your bone heals, your arm will be in a cast or a sling to keep it still and promote healing. During that time, it is important to ensure that the arm does not get too stiff, weak, or swollen. Depending on the amount of activity that is allowed for your type of fracture, your physical therapist will prescribe gentle exercises to keep your shoulder, elbow, and fingers moving while you are in the cast or sling.

Most people with wrist fractures will slowly return to exercising the other arm and the legs, so that the rest of the body doesn't get out of shape while the fracture is healing. Your physical therapist can help you adapt your exercise program, so that you can maintain your overall strength and fitness without interfering with the healing of your wrist.

When the Cast or Sling Is Removed

After your cast or sling is removed, your wrist will most likely be stiff, and your arm will feel weak. Your physical therapist will examine your wrist, and select treatments to improve its function and restore strength to your arm.

Your rehabilitation will include treatments to:

Reduce Pain. Your physical therapist might use either warm or cold therapeutic treatments, or electrical stimulation, to help control pain or swelling in your wrist, hand, or arm.

Relieve Stiffness. Your physical therapist may use skilled hands-on techniques (manual therapy) to enable your joints and muscles to move more freely with less pain.

Increase Your Strength and Ability to Move. Physical therapists prescribe several types of exercises during recovery from a wrist fracture. Early on, your physical therapist can help you begin to gently move your elbow, using "passive range-of-motion" exercises. As your arm gets stronger, you can exercise it yourself without weights ("active range-of-motion" exercises). Once the bone is well-healed, you can begin to perform resistance exercises, using weights or elastic bands. In addition to prescribing range-of-motion and strengthening exercises, your physical therapist can help you retrain your muscles to react quickly when you need to protect yourself from a fall.

Get Back to Your Daily Activities. Your physical therapist will help you remain independent by teaching you how to perform your daily activities (eg, dressing, working on a computer, and cooking), even while wearing a cast or a sling. Once you can move your arm freely without pain, your physical therapist may begin adding activities that you were doing before your injury, such as using your arm for dressing, grooming, and housekeeping. Your physical therapist will design your individualized program based on an examination of your wrist, goals, level of physical activity, and general health.

Prepare for More Demanding Activities. Depending on the requirements of your job or the type of sports you play, you might need additional physical therapy tailored to meet specific demands. Your physical therapist will develop a specialized program to address your unique needs and goals.

Prevent Long-Term Disability. Everything your physical therapist prescribes for you will help prevent long-term disability by:

• Returning the arm to a strong level of fitness.
• Restoring full movement and strength in a safe manner, while healing occurs.
• Assessing the fracture to make sure that you can return safely to previous home and work activities.
• Guiding you to a safe return to sports and other physical activities. A return too early after a fracture may increase the risk of another fracture.
• Recommending protective equipment, such as wrist guards, for use during sports.

Can this Injury or Condition be Prevented?

In addition to helping individuals prevent long-term disability following a wrist fracture, physical therapists can help different at-risk populations prevent fractures.

• For the aging population, avoiding falls and other trauma is the best way to prevent fractures. Physical therapists are experts at determining your risk of falling, and can teach you how to perform balance exercises and take precautions to avoid falls. They also can perform work and home safety evaluations to make sure that your daily environment is safe.
• For postmenopausal women with osteoporosis leading to a higher risk of wrist fracture, a physical therapist can teach weight-bearing exercises to help build stronger bones. Your physical therapist also may refer you to a nutritionist for vitamin D supplements or other dietary changes to help make your bones stronger. Education in proper posture and body mechanics and joint protection techniques can be helpful in preventing strain on the wrist and arms.
• For children, wearing proper protective gear, such as wrist guards, can reduce the risk of a wrist fracture when playing certain sports. Making sure that playground equipment your child uses is safe and built on a soft surface can also reduce the risk of wrist fractures due to falls.

SELF-REFERRAL FOR BACK PAIN IS CHEAPER FOR OUR PATIENTS

Patients who receive care from self-referring physicians for the treatment of low back pain (LBP) are more likely to be referred for some form of physical therapy, but that's just part of the story. According to newly published research, LBP patients who are self-referred receive fewer physical therapy visits and more ineffective passive modalities than patients who aren't self-referred—and all at a higher overall cost. The state of Kansas accepts self-referral for physical therapy! 

In the study, researchers analyzed 158,151 LBP episodes in private health insurance claims records for nonelderly individuals enrolled in plans offered by Blue Cross Blue Shield of Texas. They found that physicians who "self-referred"—that is, referred their patients to a business with which they have a financial relationship—referred 26% of their patients to physical therapy. That rate was 16 percentage points higher than among non-self-referrals. Overall physical therapy was referred at a rate of 14%. 

But the higher rate of referrals doesn't tell the whole story, according to the study's authors, who analyzed what happened next—and how much it wound up costing. Results of the study were e-published ahead of print in the Forum for Health Economics and Policy (abstract only available for free). 

What they found was that the self-referred patients received, on average, 2 fewer physical therapy visits and 10 fewer 15-minute physical therapy service units compared with treatments by providers who did not self-refer. And when self-referred patients did receive physical therapy, they were treated differently from their non-self-referred counterparts, with an increased use of passive modalities such as hot and cold packs, mechanical traction, ultrasound, and electrical stimulation—approaches authors describe as "ineffective" in treatment of LBP.

Looking more closely at Healthcare Common Procedure Coding System (HCPCS) records, authors found that about 46% of physical therapy services rendered during non-self-referred episodes included individualized exercises to develop strength, endurance, range of motion, and flexibility, compared with a 31.5% rate among the self-referred episodes. Significant differences were also found in the use of dynamic activities designed to improve function, which occurred at a 6.7% rate for non-self-referred episodes but in only 4.2% of the self-referred episodes. Conversely, electrical stimulation accounted for almost 9% of the physical therapy services in self-referring episodes. Among the non-self-referred episodes, use of that passive modality was 1.4%.

Authors write that the use of exercise and dynamic activities "implies that [LBP] patients treated by non self-referring providers received skilled one-on-one care," and that "patients seen by self-referring providers received higher proportions of passive treatments." According to the authors, these passive treatments "can be easily performed by non physical therapists (medical assistants or technologists) in physicians' offices," and billed as physical therapy services under the "incident to" rule.

And what about overall cost? It turns out that fewer physical therapy sessions and a greater use of passive modalities doesn't wind up saving money—in fact, the LBP episodes addressed through self-referral averaged $889 in insurer-allowed costs, compared with $602 for non-self-referred episodes—a 49% difference. As for spending on individual physical therapy services, self-referral episodes averaged costs that were double non-self-referrals—an average of $144 for the self-referring provider, compared with $73 for the non-self-referring provider.

Results of the study not only inform physical therapist practice, but they help to clarify issues that have been at the heart of a policy debate over the reach of the Stark law, a law intended to prohibit referrals to a business that has a financial relationship with the referring provider under Medicare. That prohibition applies to most in-office ancillary services, but there a few exceptions: physical therapy is one of them. APTA has made elimination of these exceptions one of its public policy priorities.

The new study also fills in some of the gaps left in a 2014 report from the US General Accountability Office (GAO), which looked at self-referral for physical therapy across all health conditions under Medicare. That report found a higher rate of referral to physical therapy (and fewer physical therapist services received) among self-referred cases, but was limited in its scope. Authors of the new study cite a number of "deficiencies" in the report, including its focus only on elderly patients, and the lack of any analysis of the types and quality of physical therapist services rendered.

“The results of this study further confirm what APTA has firmly believed for years now,” said APTA President Sharon L. Dunn, PT, PhD, OCS, in an APTA news release. “Referral for profit leads to health care practices that benefit the provider and remove the focus from where it should be; the patient. APTA has long advocated for the elimination of referral for profit for physical therapist services from health care.” 

For their part, the study's authors keep the focus on the ways in which the quality of physical therapy services differ between self-referred and non-self-referred episodes.

"An important contribution of this study is the finding that the composition of physical therapy services rendered to [LBP] differs between self-referring and non self-referring practices," authors write. "The care provided by independent therapists is comprised of more active, hands on treatments which appear to be appropriate in light of empirical evidence showing that passive procedures are not effective treatments for LBP."

The study was funded in part by the Foundation for Physical Therapy and the National Institute on Aging.

UNDERSTANDING PAYMENT FOR PHYSICAL THERAPY

Physical therapists are professional health care providers who are licensed by the state in which they practice. You can check with your state agency overseeing physical therapy licensure to make sure that your physical therapist is licensed and in good standing or with the state's physical therapy chapter. The following are common questions and answers pertaining to payment and insurance for physical therapy services.

Does insurance cover physical therapy services?

Most insurance plans, including Medicare, workers’ compensation, and private insurers, pay for physical therapy services that are medically necessary and that are provided by or under the direction and supervision of a physical therapist.  Your physical therapist or your insurance company can tell you whether your insurance covers the recommended services and how much your out of pocket costs will be if there are any.

What if your physical therapist doesn’t participate in your insurance plan?

Most insurance companies, with the exception of Medicare and many HMOs, allow members to go "out of network" for health care services.  Going out of network means that you can choose to see a physical therapist who is not a participating provider with your insurance company. In most cases, the amount paid by the insurance company will be less, and you will be responsible for paying the difference between what the physical therapist charges and what the insurance company pays. Many patients choose to receive services out of network in order to see the physical therapist of their choice.  Your physical therapist can let you know in advance of your treatment what your out of pocket costs will be.

What if you don’t have insurance?

If you don't have health insurance that covers physical therapy services, you can still receive services from a physical therapist by paying for the services directly.   If cost is a barrier, you may want to ask your physical therapist to modify your program so that you can do more of your treatment on your own.  Ask about establishing a payment plan so that you can get the care that you need when you need it most.

Are there some services that physical therapists provide that are not covered by insurance?

Some physical therapists provide services that may not be covered by insurance plans. Examples of these services include fitness and wellness programs, sports performance enhancement, health education classes, and some prevention programs. Many individuals find these services to be of tremendous value and readily pay out of pocket for them.  Your physical therapist can let you know whether these services are covered by your insurance and can give you information about their cost in advance.