Adding mobilisation with movement to exercise and advice hastens the improvement in range, pain and function after non-operative cast immobilisation for distal radius fracture: a multicentre, randomised trial

Effectiveness of mobilization with movement in patients operated for distal radius fracture: a single-blinded, randomized controlled study

OBJECTIVE

BACKGROUND: There are limited data on the use of Mulligan's mobilization with movement technique in patients who underwent surgery for distal radius fracture. AIMS: This study aimed to evaluate the effectiveness of adding Mulligan's mobilization with movement to the conventional exercise program for those who underwent open reduction and volar plate application due to distal radius fracture.

METHODS

This randomized controlled, single-blind study was conducted with 53 patients who had been operated on for distal radius fracture. The patients were divided into two groups, the mobilization with movement group and the control group. Patients in the mobilization with movement group were mobilized using Mulligan's mobilization with movement technique in addition to the rehabilitation program used in the control group. The degree of volar inclination and radial inclination were recorded. Radial height was measured in millimeters. Ulnar variance was recorded. Perimeter was measured using the Figure of Eight method. The range of motion of the joint was measured by goniometry. Hand grip strength was measured with Jamar® hand dynamometer, and pinch grip was measured with a pinch meter. The Patient-Rated Wrist Evaluation questionnaire was used to assess functionality.

RESULTS

There is no statistically significant difference identified between the groups (p>0.05). The intra-group changes in the data of the groups were found to be statistically significant in visual analog scale, range of motion, pinch grip, hand grip, and Patient-Rated Wrist Evaluation parameters (p<0.05). There was a statistically significant difference between the mobilization with movement group and the control group for pronation value and hand grip strength value in measurements (p<0.05).

CONCLUSIONS

XThe mobilization with movement had no additive effect on parameters other than hand grip strength and pronation.

Action observation intervention using three-dimensional movies improves the usability of hands with distal radius fractures in daily life-A nonrandomized controlled trial in women

OBJECTIVE

Prolonged immobilization of joints after distal radius fracture (DRF) causes cerebral disuse-dependent plasticity (DDP) and deterioration of upper extremity function. Action observation therapy (AOT) can improve DDP.

TRIAL DESIGN

This nonrandomized controlled trial (UMIN 000039973) tested the hypothesis that AOT improves hand-use difficulties during activities of daily living in patients with DRF.

METHOD

Right-handed women with volar locking plate fixation for DRF were divided into AOT and Non-AOT groups for a 12-week intervention. The primary outcome was difficulty in using the fractured hand, assessed with the Japanese version of the Patient-related Wrist Evaluation (PRWE). The secondary outcomes were range of motion (ROM) of the injured side and gap between measured ROM and patient-estimated ROM. The survey was administered immediately post operation and at postoperative weeks 4, 8, and 12. The AOT group used a head-mounted display and three-dimensional video during ROM exercises. The Non-AOT group used active ROM exercises alone. A generalized linear model (GLM) was used to confirm interactions and main effects by group and time period, and multiple comparisons were performed.

RESULTS

Thirty-five patients were assigned to the AOT group (n = 18, median age, 74 years) or the Non-AOT group (n = 17, median age, 70 years). In the GLM, PRWE Total, PRWE Specific, and PRWE Usual scores revealed interactions between groups and periods. The post-hoc test revealed that the PRWE Specific scores (z = 3.43, p = 0.02) and PRWE Usual scores (z = 7.53, p<0.01) were significantly lower in the AOT group than in the Non-AOT group at 4 weeks postoperatively, whereas PRWE Total scores (z = 3.29, p = 0.04) were lower at 8 weeks postoperatively.

CONCLUSIONS

These results suggested that AOT can improve hand-use difficulties in right-handed women after DRF surgery. AOT positively affects the motor imagery of patients with DRF and can reverse the patient's perceived difficulty in using the fractured hand during rehabilitation.

The effects of the addition of Mulligan mobilization with movement to exercise on elbow pain and function associated with lateral elbow tendinopathy

BACKGROUND

Mulligan mobilization with movement (MWM) and eccentric exercise (EE) have been shown to be effective for the treatment of chronic lateral elbow tendinopathy (LET). However, the addition of MWM to EE effects on LET remained unknown. The objective of the study was to determine the effects of adding of Mulligan mobilization with movement to eccentric exercise for the treatment of LET.

METHODS

In this quasi-experimental study, thirty participants with unilateral LET were assigned into two groups: 15 in MWM (received MWM + EE) (7 M and 8 F, mean age 36.8 ± 8.3 years) and 15 in EE (9 M and 6 F, mean age 46 ± 8.1 years). Both groups received education about painful activities and eccentric exercise, while the MWM group received MWM with the same eccentric exercise as the EE group. The visual analog scale (VAS) and the patient-rated tennis elbow evaluation (PRTEE) were used to assess pain and upper limb function, respectively, at baseline and at the end of 4 weeks. The data was analyzed using an independent t-test and a paired t-test.

RESULTS

There was no significant difference (p > 0.05) between groups at baseline. At the end of 4 weeks, significant and clinically meaningful improvements in pain and function were observed for both groups (p < 0.001); however, MWM group showed much better results in VAS (p < 0.001, d = 1.3) and PRTEE (p < 0.001, d = 5.2) CONCLUSION: This study showed that adding MWM to eccentric exercise resulted in enhanced pain reduction and improved function of the upper limb.

Distal Radius Fracture Rehabilitation

Distal radius fracture (DRF) is arguably the most common upper extremity fracture resulting from a fall accident. These clinical practice guidelines (CPG) were developed to guide all aspects of the management of DRF by physical therapists and other rehabilitation practitioners, such as certified hand therapists. This CPG employed a systematic review methodology to locate, appraise, and synthesize contemporary evidence while developing practice recommendations for determining the prognosis of outcomes, examination, and interventions while managing individuals with DRF. The quality of the primary studies found in the literature search was appraised using standardized tools. The strength of the available evidence for a particular practice domain (e.g., prognosis or intervention) was graded as strong, moderate, weak, or conflicting, where such gradings guided the level of obligation for each practice recommendation. Lastly, the CPG also provided the gaps in the evidence pool for the rehabilitation of DRF that future research efforts can address. J Orthop Sports Phys Ther 2024;54(9):CPG1-CPG78. doi:10.2519/jospt.2024.0301.

Comparison of supraclavicular block with infraclavicular block for distal arm surgeries: A meta-analysis of randomized controlled studies

BACKGROUND

Supraclavicular and infraclavicular nerve block are commonly used for the analgesia of distal arm surgeries, and this meta-analysis aims to compare their analgesic efficacy for distal arm surgeries.

METHODS

We searched several databases including PubMed, Embase, Web of Science, EBSCO, and Cochrane library databases, and selected the randomized controlled trials exploring the analgesic efficacy of supraclavicular block versus infraclavicular block for distal arm surgeries. This meta-analysis was conducted using the random-effect or fixed-effect model based on the heterogeneity.

RESULTS

Six randomized controlled trials were included in this meta-analysis. Compared with infraclavicular nerve block for distal arm surgeries, supraclavicular nerve block was associated with substantially reduced complete sensory block (odds ratio [OR] = 0.41; 95% confidence interval [CI] = 0.19-0.88; P = .02) and block performance time (standard mean difference [SMD] = -3.06; 95% CI = -5.82--0.31; P = .03), but had no effect on duration of analgesia (SMD = -0.15; 95% CI = -0.49-0.18; P = .36), time to sensory block (SMD = -0.41; 95% CI = -2.28-1.47; P = .67), vascular puncture (OR = 1.03; 95% CI = 0.11-10.05; P = .98) or adverse events (OR = 0.70; 95% CI = 0.12-4.04; P = .69).

CONCLUSIONS

Infraclavicular nerve block may be superior to supraclavicular nerve block for the analgesia of distal arm surgeries but needs increased block performance time.

The use of adhesive elastic tape for hand oedema control in patients with a wrist fracture treated in a cast: A pilot study

BACKGROUND

The adhesive elastic tape use is indicated for controlling oedema, although currently there is not the definitive evidence regarding its effectiveness. Wrist fractures are a frequent occurrence, often leading to oedema development in patients treated with forearm casts. This pilot study aims to investigate the effects of elastic tape in controlling hand oedema among patients with forearm casts for wrist fractures and the feasibility of a future randomized controlled trial.

METHODS

The study was conducted on adult patients with unilateral conservatively treated wrist fracture. The tape was applied to the intervention group after cast application, while the control group received the standard treatment. The circumference difference between baseline and the 7-day follow-up of both the 1st finger and the remaining 4 fingers merged together was evaluated. Ethical approval for the study has been obtained.

RESULTS

23 participants were enrolled. The intervention group showed a higher reduction in finger circumferences compared to the control group (median difference T1-T0 No tape vs Tape: 0 cm vs -0.2 cm for the 1st finger and 0.5 cm vs -0.5 cm for the remaining 4 fingers), although the changes were not statistically significant.

CONCLUSION

Although the number of enrolled patients was limited due to Covid-19 pandemic, the study results suggest a potential reduction in oedema after the use of adhesive elastic tape, justifying the needed of a future full-scale study. Given its low cost and ease of use, we believe that tape can be considered in clinical practice.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04683887.

Development of a robot-assisted reduction and rehabilitation system for distal radius fractures

Background: Closed reduction is the preferred treatment for distal radius fractures. However, it requires a multiple experienced medical staff and manually maintaining stable traction is difficult. Additionally, doctors cannot assess the reduction status of a fracture in real-time through radiographic images, which may lead to improper reduction. Furthermore, post-fracture complications such as joint adhesion, stiffness, and impaired mobility pose a challenge for the doctors. So it is necessary to optimize the treatment process of the distal radius fracture through technological means. Methods: A robot-assisted closed reduction and rehabilitation system, which could assist doctors throughout the entire process of reduction, fixation, and rehabilitation of distal radius fractures, was developed. A mechanical system, composed of two grippers and a cooperative robotic arm, was used to grasp and tract the affected limb. A doctor controlled the robot through a joystick console and Windows application program. A biplane radiographic device was integrated into the system, which is not only convenient for doctors to view radiographic images of the fracture at any time but also for them to select the rotation axis of the wrist on the images before reduction and rehabilitation. Important information including the anteroposterior and lateral radiographic data and force and position parameters during the reduction and rehabilitation process were displayed on a graphic user interface. Results: Experimental results showed that the proposed robotic system can meet the technical requirements for the reduction and rehabilitation of distal radius fractures, all the rotation angles could be achieved, a maximum force of more than 50 N could be achieved in all traction directions, and the error in selecting the wrist joint rotation axis line using radiographic images was less than 5 mm. Conclusion: The developed robot-assisted system was shown to be suitable for closed reduction and rehabilitation of distal radius fractures, contributing a potential improvement in the quality of the procedures.

The effectiveness of mobilization with movement on patients with mild and moderate carpal tunnel syndrome: A single-blinded, randomized controlled study

STUDY DESIGN

Single-blinded, randomized controlled study.

INTRODUCTION

Carpal Tunnel Syndrome (CTS) causes pain and loss of function in the affected hand. The mobilization with movement (MWM) technique is a manual therapy method applied to correct joint movement limitation and to relieve pain and functional disorders.

PURPOSE OF THE STUDY

This study aimed to examine the effectiveness of MWM technique on pain, grip strength, range of motion, edema, hand reaction, nerve conduction, and functional status in patients with CTS.

METHODS

A total of 45 patients enrolled in the study. The MWM group (n = 18) completed a 4-week combined conservative physiotherapy and MWM program, whereas the control group (n = 18) received only the 4 weeks of conservative physiotherapy. Pain severity according to the numerical rating scale was used as primary outcome.

RESULTS

We found an improvement within the subjects in resting pain (MWMG:5.1 ± 3.6 vs 1.1 ± 2.4, Effect Size (ES)=1.3; CG:4.5 ± 3.3 vs 1.0 ± 2.2, ES=1.1), in activity pain (MWMG:6.5 ± 3.7 vs 1.1 ± 2.4, ES=1.5; CG:4.8 ± 3.4 vs 2.2 ± 2.3, ES=1) and in night pain (MWMG:5.9 ± 3.2 vs 1.8 ± 2.5, ES=1.2; CG:5.3 ± 4.2 vs ± 2.3 ± 3.5, ES=0.9). For between the groups, a statistical difference was found for the activity pain, Disabilities of the Arm Shoulder and Hand Questionnaire score (MWMG:52.2 ± 23.8 vs 27 ± 24.7, ES=1.3; CG:47.0 ± 24.8 vs 41.5 ± 22.1, ES=0.2), Michigan Hand Outcomes Questionnaire (MHQ-1), (MWMG:44.4 ± 23.7 vs 74.7 ± 24.5, ES=1.3; CG:44.8 ± 17.4 vs 57.4 ± 21.7, ES=0.9) and MHQ-5 (MWMG:68.8 ± 13.1 vs 82.5 ± 11.5, ES=0.9; CG:63.4 ± 26.7 vs 59.3 ± 25.8, ES=0.1) parameters in favour of MWM group.

DISCUSSION

This study showed that MWM compared to conservative physiotherapy might be more effective in reducing perceived symptoms in mild and moderate CTS patients.

CONCLUSIONS

MWM produced a small benefit to recovery of activity pain and upper extremity functionality level outcomes of patients with mild to moderate CTS when added to a traditional CTS physical therapy program.

Wearable rehabilitation wristband for distal radius fractures

Background

Distal radius fractures are a common type of fracture. For patients treated with closed reduction with splinting, a period of rehabilitation is still required after the removal of the splint. However, there is a general lack of attention and low compliance to rehabilitation training during this period, so it is necessary to build a rehabilitation training monitoring system to improve the efficiency of patients' rehabilitation.

Methods

A wearable rehabilitation training wristband was proposed, which could be used in the patient's daily rehabilitation training scenario and could recognize four common wrist rehabilitation actions in real-time by using three thin film pressure sensors to detect the pressure change curve at three points on the wrist. An algorithmic framework for classifying rehabilitation training actions was proposed. In our framework, an action pre-detection strategy was designed to exclude false detections caused by switching initial gestures during rehabilitation training and wait for the arrival of the complete signal. To classify the action signals into four categories, firstly an autoencoder was used to downscale the original signal. Six SVMs were then used for evaluation and voting, and the final action with the highest number of votes would be used as the prediction result.

Results

Experimental results showed that the proposed algorithmic framework achieved an average recognition accuracy of 89.62%, an average recognition recall of 88.93%, and an f1 score of 89.27% on the four rehabilitation training actions.

Conclusion

The developed device has the advantages of being small size and easy to wear, which can quickly and accurately identify and classify four common rehabilitation training actions. It can easily be combined with peripheral devices and technologies (e.g., cell phones, computers, Internet) to build different rehabilitation training scenarios, making it worthwhile to use and promote in clinical settings.

Efficacy of cast immobilization versus surgical treatment for distal radius fractures in adults: a systematic review and meta-analysis

This articl e includes high-quality randomized controlled trials in recent years and updates the past meta-analysis. It has been proved that cast immobilization can achieve similar functional results, reduce economic burden in the long-term compared with surgery, and provide a basis for doctors to make treatment choices.

PURPOSE

The efficacy of conservative and surgical treatment of distal radius fractures (DRFs) in adults is still controversial. Recently, some high-quality randomized controlled trials (RCTs) evaluated the efficacy of both treatments. We hypothesized that treatment of DRFs with closed reduction and cast immobilization would achieve functional outcomes similar to surgery.

METHODS

This study is a systematic review and summary of RCTs comparing conservative and surgical management of DRFs from 2005 to March 2022. Patients were evaluated for functional and imaging outcomes and complications.

RESULTS

A total of 11 studies [1-11] included 1775 cases of DRFs. At 1-year follow-up, the cast group had lower mean differences (MDs) in DASH scores than the surgery group by - 2.55 (95% CI =  - 5.02 to - 0.09, P = 0.04); with an MD of 1.63 (95% CI = 1.08-2.45, P = 0.02), while the surgery group had a lesser complication rate than the cast group.

CONCLUSIONS

At 1-year follow-up, the lower DASH scores of the cast group showed advantages of this treatment, but the complication rate was higher than that of the surgery group. There was no massive distinction in other scoring methods.

Nonsurgical Management of Distal Radius Fractures in the Elderly: Approaches, Risks and Limitations

The elderly have conventionally been defined as individuals over the age of 65 and are projected to represent about 21% of the United States (US) population by the year 2030. Distal radius fractures (DRF) in particular are one of the most common fractures among elderly patients and their incidence continues to rise in part due to increased activity levels among the elderly, increased life expectancy, rising rates of obesity, changes to dietary habits, and the prevalence of osteoporosis. Although various treatment options exist for these injuries, nonsurgical treatment of distal radius fractures remains a mainstay among elderly patients with mounting evidence of its non-inferiority to surgical fixation in the literature. Here, we summarize the overall approach to nonsurgical treatment of distal radius fractures in the elderly population while examining its supporting data and highlighting potential risks and limitations to it.

A Randomized Trial Assessing the Muscle Strength and Range of Motion in Elderly Patients following Distal Radius Fractures Treated with 4- and 6-Week Cast Immobilization

BACKGROUND

There is no consensus among orthopedic surgeons as to the required period of cast immobilization in distal radius fractures in elderly patients. The purpose of this study was to assess muscle strength and range of motion symmetry in elderly patients after distal radius fractures with different periods of cast immobilization.

METHODS

This study evaluated 50 patients (33 women and 17 men), aged over 65 years, after cast immobilization treatment for distal radius fracture. The mean age at the beginning of treatment was 71 years. The mean duration of follow-up was 1 year and 3 months. The first subgroup (n = 24) comprised the patients whose fractures had been immobilized in a cast for 6 weeks, another subgroup (n = 26) comprised the patients with 4-week cast immobilization. We assessed: (1) muscle strength, (2) range of motion.

RESULTS

The mean grip strength in the treated limb was 71% and 81% of that in the healthy limb in the groups with 4-week and 6-week cast immobilization, respectively (p = 0.0432). The study groups showed no differences in the mean grip strength in the treated limbs or the mean grip strength in the healthy limbs. The mean treated limb flexion was 62° and 75° in the 4-week and 6-week immobilization groups, respectively (p = 0.025). The evaluated groups showed no differences in terms of any other range of motion parameters. The grip strength and range of motion values were significantly lower in the treated limb than in the healthy limb in both evaluated groups. Only the values of wrist radial deviation in the 6-week cast immobilization group showed no differences between the treated and healthy limbs.

CONCLUSION

Higher values of injured limb muscle strength and greater mean range of wrist flexion were achieved in the 6-week subgroup. Neither of the evaluated groups achieved a symmetry of muscle strength or range of motion after treatment. Full limb function did not return in any of the elderly distal radius fracture patients irrespective of cast immobilization duration.

The Unknown Prevalence of Postrandomization Bias in 15 Physical Therapy Journals: A Methods Review

OBJECTIVES

To determine the prevalence of prospective clinical trial registration and postrandomization bias in published musculoskeletal physical therapy randomized clinical trials (RCTs).

DESIGN

A methods review.

LITERATURE SEARCH

Articles indexed in MEDLINE and published between January 2016 and July 2020 were included.

STUDY SELECTION CRITERIA

Two independent blinded reviewers identified the RCTs using Covidence. We included RCTs related to musculoskeletal interventions that were published in International Society of Physiotherapy Journal Editors member journals.

DATA SYNTHESIS

Data were extracted independently for the variables of interest from the identified RCTs by 2 blinded reviewers. The data were presented descriptively or in frequency tables.

RESULTS

One hundred thirty-eight RCTs were identified. One third of RCTs were consistent with their prospectively registered intent (49/138); consistency with prospectively registered intent could not be determined for two thirds (89/138) of the RCTs. Four RCTs (8%)reported inconsistent results with the primary aims and 7 (14%) with the outcomes from the prospective clinical trial registry, despite high methodological quality (Physiotherapy Evidence Database [PEDro] scale score). Differences between prospectively registered and non-prospectively registered RCTs for PEDro scale scores had a medium effect size (r = 0.30). Two of 15 journals followed their clinical trial registration policy 100% of the time; in 1 journal, the published RCTs were consistent with the clinical trial registration.

CONCLUSION

Postrandomization bias in musculoskeletal physical therapy RCTs could not be ruled out, due to the lack of prospective clinical trial registration and detailed data analysis plans. J Orthop Sports Phys Ther 2021;51(11):542-550. Epub 21 Sep 2021. doi:10.2519/jospt.2021.10491.

Effectiveness of manual therapy in patients with distal radius fracture: a systematic review and meta-analysis

OBJECTIVE

To determine the effectiveness of manual therapy (MT) for functional outcomes in patients with distal radius fracture (DRF).

METHODS

An electronic search was performed in the Medline, Central, Embase, PEDro, Lilacs, CINAHL, SPORTDiscus, and Web of Science databases. The eligibility criteria for selecting studies included randomized clinical trials that included MT techniques with or without other therapeutic interventions in functional outcomes, such as wrist or upper limb function, pain, grip strength, and wrist range of motion in patients older than 18 years with DRF.

RESULTS

Eight clinical trials met the eligibility criteria; for the quantitative synthesis, six studies were included. For supervised physiotherapy plus joint mobilization versus home exercise program at 6 weeks follow-up, the mean difference (MD) for wrist flexion was 7.1 degrees (p = 0.20), and extension was 11.99 degrees (p = 0.16). For exercise program plus mobilization with movement versus exercise program at 12 weeks follow-up, the PRWE was -10.2 points (p = 0.02), the DASH was -9.86 points (p = 0.0001), and grip strength was 3.9 percent (p = 0.25). For conventional treatment plus manual lymph drainage versus conventional treatment, for edema the MD at 3-7 days was -14.58 ml (p = 0.03), at 17-21 days -17.96 ml (p = 0.009), at 33-42 days -15.34 ml (p = 0.003), and at 63-68 days -13.97 ml (p = 0.002).

CONCLUSION

There was very low to high evidence according to the GRADE rating. Adding mobilization with movement and manual lymphatic drainage showed statistically significant differences in wrist, upper limb function, and hand edema in patients with DRF.

Do Better Postoperative Radiological Findings Predict Better Long-Term Functional Outcomes in Adults with a Displaced Distal Radius Fracture?

Purpose: The purpose of this study was to analyze the relationship of early radiological outcomes and longterm function in postoperative distal radius fracture patients. Methods: This was prospective cohort research, with information including sex, age, patient satisfaction, Gartland and Werley Score, and radiographic score. The statistics, including correlation analysis, ROC Curve, and multivariable binary Logistic Regression, were analyzed in SPSS. Results: In the entire 135 patients, 48 were male, 87 were female. ROC curve showed longterm Gartland and Werley Score, and early radiographic scores have an association to a certain extent with a Spearman correlation coefficient of 0.196 (p = 0.023) and an AUC of 0.639 (ROC Curve, p = 0.017). Patient satisfaction was mainly determined by the statistical modeling of 4.096×(palmar flexion−dorsiflexion)−4.378× (pronation−supination)−5.754 (Multivariable Binary Logistic Regression). Conclusion: Long-terms functional outcomes of postoperative distal radius fracture patients are not only influenced by radiographic score. Patient satisfaction is mainly concerning palmar flexion and pronation–supination of the wrist.

Comparison of rehabilitation interventions in nonoperatively treated distal radius fractures: a randomized controlled trial of effectiveness

AIMS

Following cast removal for nonoperatively treated distal radius fractures, rehabilitation facilitated by advice leaflet and advice video were compared to a course of face-to-face therapy.

METHODS

Adults with an isolated, nonoperatively treated distal radius fracture were included at six weeks post-cast removal. Participants were randomized to delivery of rehabilitation interventions in one of three ways: an advice leaflet; an advice video; or face-to-face therapy session(s). The primary outcome measure was the Disabilities of the Arm, Shoulder and Hand (DASH) score at six weeks post intervention and secondary outcome measures included DASH at one year, DASH work subscale, grip strength, and range of motion at six weeks and one year.

RESULTS

A total of 116 (97%) of 120 enrolled participants commenced treatment. Of those, 21 were lost to follow-up, resulting in 30 participants in the advice leaflet, 32 in the advice video, and 33 face-to-face therapy arms, respectively at six weeks of follow-up. There was no significant difference between the treatment groups in the DASH at six weeks (advice leaflet vs face-to-face therapy, p = 0.69; advice video vs face-to-face therapy, p = 0.56; advice leaflet vs advice video, p = 0.37; advice leaflet vs advice video vs face-to-face therapy, p = 0.63). At six weeks, there were no differences in any secondary outcome measures except for the DASH work subscale, where face-to-face therapy conferred benefit over advice leaflet (p = 0.01).

CONCLUSION

Following cast removal for nonoperatively treated distal radius fractures, offering an advice leaflet or advice video for rehabilitation gives equivalent patient-reported outcomes to a course of face-to-face therapy. Cite this article: Bone Joint J 2021;103-B(6):1033-1039.