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The International Classification of Functioning as an explanatory model of health after distal radius… Harris, Jocelyn E; MacDermid, Joy C; Roth, James Nov 16, 2005

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ralHealth and Quality of Life OutcomesssBioMed CentOpen AcceResearchThe International Classification of Functioning as an explanatory model of health after distal radius fracture: A cohort studyJocelyn E Harris†1,2, Joy C MacDermid*†3,4 and James Roth4Address: 1School of Rehabilitation Sciences, University of British Columbia, T325-2211 Wesbrook Mall, Vancouver, British Columbia, V6T 2B5, Canada , 2Rehabilitation Research Lab, GF Strong Rehab Centre, 4255 Laurel Street, Vancouver, British Columbia, V5Z 2G9, Canada , 3School of Rehabilitation Sciences, McMaster University, Institute of Applied Health Science, 1400 Main Street West, 4th Floor, Hamilton, Ontario, L8S 1C7, Canada  and 4Hand and Upper Limb Centre, St. Joseph's Health Centre, PO Box 5777, London, Ontario, N6A 4L6, CanadaEmail: Jocelyn E Harris - jocellen@interchange.ubc.ca; Joy C MacDermid* - macderj@mcmaster.ca; James Roth - James.Roth@sjhc.london.on.ca* Corresponding author    †Equal contributorsAbstractBackground: Distal radius fractures are common injuries that have an increasing impact on healthacross the lifespan. The purpose of this study was to identify health impacts in body structure/function, activity, and participation at baseline and follow-up, to determine whether they supportthe ICF model of health.Methods: This is a prospective cohort study of 790 individuals who were assessed at 1 week, 3months, and 1 year post injury. The Patient Rated Wrist Evaluation (PRWE), The Wrist OutcomeMeasure (WOM), and the Medical Outcome Survey Short-Form (SF-36) were used to measureimpairment, activity, participation, and health. Multiple regression was used to develop explanatorymodels of health outcome.Results: Regression analysis showed that the PRWE explained between 13% (one week) and 33%(three months) of the SF-36 Physical Component Summary Scores with pain, activities andparticipation subscales showing dominant effects at different stages of recovery. PRWE scoreswere less related to Mental Component Summary Scores, 10% (three months) and 8% (one year).Wrist impairment scores were less powerful predictors of health status than the PRWE.Conclusion: The ICF is an informative model for examining distal radius fracture. Difficulty in thedomains of activity and participation were able to explain a significant portion of physical health.Post-fracture rehabilitation and outcome assessments should extend beyond physical impairmentto insure comprehensive treatment to individuals with distal radius fracture.BackgroundIn 1980 the WHO [1] published a framework for classify-ing the consequences of disease. This classification systemincluded the domains of impairment, disability, andhandicap where a linear relationship was thought to existurement of health outcomes, specifically, the evaluationof disability, and handicap [2]. With increased applica-tion of the model it became apparent that the relationshipbetween the domains was not linear and other relevantcontributions to health (e.g., environmental, socio-demo-Published: 16 November 2005Health and Quality of Life Outcomes 2005, 3:73 doi:10.1186/1477-7525-3-73Received: 19 July 2005Accepted: 16 November 2005This article is available from: http://www.hqlo.com/content/3/1/73© 2005 Harris et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 9(page number not for citation purposes)between domains. This framework emphasized the multi-faceted nature of health and led to changes in the meas-graphic, and psychological has been ignored).Health and Quality of Life Outcomes 2005, 3:73 http://www.hqlo.com/content/3/1/73The WHO updated the framework to reflect emergingunderstanding of health. In 2001 the International Classi-fication of Functioning, Disability, and Health (ICF) waspublished [3,4]. It has three main domains, Body Struc-ture/Function, Activity, and Participation, that can beused to classify the impact of health. In this framework thedomains interact with each other (not necessarily in a lin-ear manner) and are influenced by both environmentaland personal factors [3]. Problem areas within thedomains are called impairment, activity limitation, andparticipation restriction. These terms decrease the nega-tive connotations associated with earlier terminology, i.e.,disability and handicap [1]. Recently, studies have linkedoutcome measures to the ICF domains to better reflect allaspects of health, body function, activity, and participa-tion in musculoskeletal conditions [5-13]. With the emer-gence of this broader model of health, clinical researchhas started to focus on how ICF might explain health out-comes across a spectrum of health conditions [5-12].Distal radius fractures are the most common fracture [14].A 17% increase in incidence rate has been noted over thepast few decades [15]. In the United Kingdom 71, 000 per-sons will sustain a distal radius fracture each year with anincidence rate of 36.8/10,000 for women and 8.9/10,000for men [16]. Though distal radius fractures are foundwhich has been attributed to decreased bone mineral den-sity [16-18].Usually the majority of recovery from a distal radius frac-ture occurs within six months post fracture [19,20]. Untilrecently, descriptions of the clinical outcomes of distalradius fracture have focused on impairment, e.g., radio-graphic findings, range of motion, and strength. What aremissing from these studies are outcome measures thatevaluate an individual's ability to perform day-to-daytasks and engage in meaningful activities and roles.Recently studies have included broader outcome meas-ures that reflect performance in self-care, household,work, recreational, and social activities. These studiesshow that despite the fact that the majority of individualsreceive rehabilitation services, residual difficulty in work,sport, and leisure activities are reported [13,19,20].Studies addressing quality of life in individuals followingdistal radius fracture are few. Two cross-sectional studiesexamined the relationship between radiographic findingsand the Medical Outcomes Survey Short Form SF-36 [21]and SF-12 [22] (in long-term follow-up). Both studiesfound that radiographic findings did not correlate witheither the SF-36 or SF-12, and that patients' post-rehabili-tation scores were similar to those of the general popula-International Classification of Functioning (ICF) model applied to distal radius fractureFigure 1International Classification of Functioning (ICF) model applied to distal radius fracture. (Adapted from the World Health Organization, International Classification of Functioning, Disability, and Health training materials, Geneva, 2002). http://www3.who.int/icf/icftemplate.cfm?myurl=homepage.html&mytitle=Home%20Page.TablesHealth ConditionDistal Radius FractureBody Function/StructureImpairment:Deficit in anatomical structures or physiology e.g. pain,weakness, loss of dexterity.Measure UsedWOM, PRWE pain sub-scaleActivityActivity Limitation:Difficulty doing taskse.g. open a jar, turn ahandle, assemble partsMeasure UsedPRWE specific activity sub-scaleParticipationParticipation Restriction:Difficulty engaging in rolesand activities e.g. cleaning,gardening, grandparentMeasure UsedPRWE usual activity sub-scalePage 2 of 9(page number not for citation purposes)throughout the life span, women demonstrate an increasein incidence rate from age 50–70 (while men do not)tion. However, in the study by Fernandez and colleagues[21], men between the ages of 35–44 (physical compo-Health and Quality of Life Outcomes 2005, 3:73 http://www.hqlo.com/content/3/1/73nent score only) demonstrated a significant difference inSF-36 scores from their age-matched general populationnorm. It was suggested that this group represents a seg-ment of the population that has greater functionaldemand from both work and family life and thus thehealth impact of mild residual physical impairment wasgreater.In longitudinal studies that evaluated recovery from a dis-tal radius fracture it is clear that health is affected in theearly post-fracture period and that there is substantialrecovery. MacDermid and colleagues [20] reported SF-36scores that improved from the early post-fracture evalua-tion to a one-year evaluation for the Physical ComponentSummary Score (PCSS) (from 37–48) but found that theMental Health Summary Component Score (MCSS)remained within normal range throughout recovery (from51–53).One study evaluated the adjustment to distal radius frac-ture over a three month time frame [23]. This study usedscales that measure physical, emotional, social role func-Findings suggested that as time from fracture increases,scores in physical, emotional, and social role functionreflect adjustment to injury [23]. The authors suggestedthat during the early stages of recovery significant issues inroles, physical function, and adjustment to injury are evi-dent and should not be neglected during rehabilitation.Overall studies suggest that the impact of distal radiusfracture on physical and/or mental health abates by threemonths post injury and occurs to a greater extent withinthe physical health domain as compared to mental health.Although previous work has suggested that distal radiusfracture has an impact on overall health, these studieshave not focused on the extent to which health effects fitthe ICH health model. An understanding of how themodel applies to this common injury would assist thoseinvolved in planning or providing health services to cli-ents with these injuries. The purposes of this study were 1)to determine whether the ICF framework serves as anexplanatory model for distal radius fracture and 2) todetermine the impact of impairment, activity limitation,and participation restriction on physical and mentalhealth after distal radius fracture.MethodsThis study used a prospective cohort design. Patients withdistal radius fracture attending the Hand and Upper LimbCentre for primary care were identified by clinic lists andattending physicians. All identified patients were enrolledin the outcome evaluation process, unless they were una-ble to participate because of incompetence. Patients whofailed or were unable to comply with their scheduledappointments were contacted by phone to determinewhether they could reschedule their appointments. Theuniversity ethics review board approved the use of thisclinical outcomes database for this study.Patients completed standardized testing at one week, andat three and twelve months post fracture. Demographicdata was collected at the initial one-week post injury visit.The ICF was used as a conceptual model to frame thehealth outcome of distal radius fracture. We have outlinedthe model, adapted from the WHO, in Figure 1.Outcome measuresAll patients completed the Patient Rated Wrist Evaluation(PRWE) [24-26], and the SF-36 [27-29] at all 3 time pointsand the Wrist Outcome Measure (WOM) [30] at 3 and 12months. A research assistant verbally administered thequestionnaires (PRWE and SF-36) to patients who wereunable to read or write. When patients were unable tounderstand English sufficiently to answer, the question-naires were translated with the assistance of a bilingualTable 1: Sample characteristicsVariable DescriptionSex Male = 251Female = 539Dominant Hand Right = 90%Left = 10%Wrist Injured Right = 45%Left = 49%Mechanism of Fracture Fall on ice = 18%Other fall = 66%Other = 10%Energy of Fracture* Low = 69%Medium = 19%High = 6%Highest Level of Education Finished high school = 26%Finished college = 18%Finished university = 8%Finished graduate school = 4%Occupation at Injury† Retired = 27%Service = 13%Professional = 12%Occupational Demand§/P > Low = 57%Moderate = 24%High = 19%Had Physiotherapy 83%* Low = fall from a standing position, Medium = fall from a height, High = trauma† Top three occupations§Self-report of how much they used their hand at work; Low = low force, low repetition, Moderate = frequent repetition, intermittent force, High = high force, constant repetitionPage 3 of 9(page number not for citation purposes)tion, and meaning of injury, i.e., the SF-36, the EnforcedSocial Dependency Scale, and the Meaning of Illness scale.family member or friend. All questionnaires were admin-istered and scored according to the author's instructions.Health and Quality of Life Outcomes 2005, 3:73 http://www.hqlo.com/content/3/1/73An independent research assistant administered the WristOutcome Measure.The Wrist Outcome Measure is a composite impairmentscale with components that reflect range of motion(ROM), grip strength, and dexterity [30]. Range of motionmeasures were measured on the N-K computerized handevaluation system. A total score out of 30, scored by extentof attainment of normative values was given. Six wristmotions (extension/flexion [31], radial/ulnar deviation,pronation/supination [32]) and a gross finger flexionmeasure was summated. Grip strength was performedusing the NK Digit-grip device. The standard protocol rec-ommended by the American Society of Hand Therapistswas followed [33]. High reliability has been demonstratedfor this protocol and test instrument [34]. A grip strength(score out of 40) was determined as a ratio of the unin-jured hand with the injured hand and adjusting for dom-inance. Dexterity was measured using the checkers subtestof the Jebson's Hand Function Test (score/15) [35]. A totalWrist Outcome Measure score out of 85 was devised fromthese scales. Further background and discussion on thedevelopment of an impairment rating score can be foundelsewhere [30].Patient Rated Wrist Evaluation is a 15-item questionnairethat equally rates wrist-related pain and disability in func-tional activities (see BMC reference for complete form)[19,24,25,36]. Scoring is done on an eleven-point scale(0–10) with zero being no issues or pain and 10 beingunable to do or severe pain. There are five questions thatrequire the individual to rate their pain doing activitiessuch as at rest, repeated motion, and lifting. Functionalitems are divided into two categories, specific and usualactivities. There are six specific tasks such as turning adoorknob, cutting meat, fastening a button, and fourusual activity categories, self-care, work, householdduties, and recreation. The PRWE can be divided intothree sub-scales, pain, specific activities, and usual activi-ties. The total of the combined scales is 100 (50 from pain,60 from specific, and 40 from usual). The psychometricproperties of this scale are excellent [19,24,25,36] and theThe SF-36 is a widely used health outcome measure. It iscomprised of eight scales and two summary scores [27-29,37]. There is a large database of normative data availa-ble through the Medical Outcomes Trust. The scale haseight sub-scales that portray various domains of health:physical function, physical role, bodily pain, vitality, gen-eral health, emotional role, mental health, and socialfunction. These sub-scales are scored out of a maximumscore of 100 (higher is better). The physical and mentalhealth component summary scores represent the twomain dimensions of health. These scores are calculated ina three-step process which involves weighting, transform-ing and aggregating the subscale scores to compute sum-mary scores scaled to a US population which representthese two distinct domains of health (US populationmean = 50). While the ICF model portrays health as a sin-gle concept with multiple, interacting contributors, theSF-36 separates physical and mental health. Since weexpected largely a physical effect of wrist fracture andbecause the SF-36 has been shown to be preferable toother general health measures for musculoskeletal disor-ders [38,39] we choose it to represent health status. Whilelesser effects were expected in mental health we decided toinclude both the Mental and Physical Component Sum-mary Scores as outcomes to determine the relative effectson both domains of health providing a more completepicture of overall health.Data analysisDescriptive statistics were calculated for the dependentvariables (SF-36 physical and mental health componentsummary scores) and independent variables (WOM totalscore, PRWE sub-scales pain, specific activities, and usualactivities). All data was inspected for assumption viola-tion by using histograms, box, and scatter-plots. Missingvalues were replaced using linear extrapolation. Missingvalues accounted for less than 5% of data points.Univariate analysis was completed to determine the rela-tionship between variables of interest and outcome varia-bles. Pearson's Correlation Coefficient was used todetermine the relationship between SF-36 physical andTable 2: Descriptive statistics for outcome measures at one week, three months, and one year post injury.Variable Time 1 Mean (SD) Time 2 Mean (SD) Time 3 Mean (SD)Wrist Outcome Measure (/85; 85 = best) N/A 59.6(8.9) 73.9(7.4)PRWE pain scale (/50; 50 = worst) 30.2(11.6) 17.0(10.4) 8.1(9.5)PRWE specific scale (/60; 60 = worst) 51.3(14.1) 19.4(15.0) 6.3(10.3)PRWE usual scale (/40; 40 = worst) 26.3(11.9) 11.4(12.5) 5.6(12.6)SF-36 physical health (US norm 50) 37.2(8.7) 43.7(8.9) 49.0(8.7)SF-36 mental health (US norm 50) 49.8(11.2) 51.5(9.8) 54.8(7.5)Page 4 of 9(page number not for citation purposes)patterns of recovery following a fracture have beendescribed using this scale [19,20].mental health summary scores and the PRWE pain, spe-cific, and usual activity scales, and the WOM total score.Health and Quality of Life Outcomes 2005, 3:73 http://www.hqlo.com/content/3/1/73Correlation was determined at time one (one week postinjury, time two (three months post injury), and timethree (twelve months post injury).Multivariate analysis was used to determine the explana-tory model for distal radius fracture health outcome attime one (one week post), two (three months post), andthree (twelve months post). Multiple regression equationswere calculated using the SF-36 physical and mentalhealth summary scores as the dependent variables, andpatient characteristics, PRWE sub-scales and the WOM asthe independent variables as described in Figure 1. TheWOM was measured at three and twelve months but notat one week. It was felt that the variables of sex and age areknown to be related to health, so we controlled for ageand sex by blocked entry of these variables and then con-tinued with stepwise entry of the independent variables.Six stepwise regression models were built. Data wasinspected for assumption violation by examining box andscatter-plots of residuals against explanatory variablesfrom each model. Influential data points were examinedusing Cook's distance. The F to enter was 0.05 and the F toremove was 0.10. Statistical significance was set at 0.05 forall outcomes. All statistics was performed using SPSS 13.ResultsSample characteristicsThere was a total of 790 persons, mean age of 51.4 (SD =17.6, age range 18–91) in this study. The majority of thepeople in the study were female (68%). Descriptive char-can be found in Table 2. The mean score of the outcomemeasures improve at each follow up time period. At oneweek post injury scores demonstrate moderate to severeactivity limitation and participation restriction and theone-year measures demonstrate little activity limitation orparticipation restriction. The PRWE specific activity sub-scale showed the most change over time, from 51.3(severe limitation) to 6.3 (minimal limitation).Univariate analysisResults from the univariate analysis can found in Table 3.All PRWE sub-scales were correlated with SF-36 physicalhealth at one week, three, and twelve months post injury.At one week the sub-scale of usual activity demonstratedthe highest correlation (r = -0.31, p = 0.01), at three andtwelve months it was specific activity (r = -0.53, p = 0.01,r = -0.52, p = 0.01). Only usual activity was correlated withmental health (r = 0.09, p = 0.05) at one-week post injury.However, at three months all PRWE sub-scales were sig-nificantly correlated to physical health and at twelvemonths all independent variables (PRWE and WOM)were significantly correlated.Multivariate analysisAll regression results can be found in Tables 4, 5, and 6.The result from the forward stepwise regression model forSF-36 physical health at one-week post injury yielded aweakly predictive model where all PRWE sub-scales wereretained with an R2 = 0.13, p < 0.0001 for the full model(Table 4). Usual activity was most predictive and2 Table 3: Correlation results between outcome measures at one week, three months, and one year post injury.Variable PRWE pain PRWE specific PRWE usual SF-36 physical health SF-36 mental healthWrist Outcome MeasureTime 2 -0.27** -0.35** -0.20** 0.21** 0.07Time 3 -0.43** -0.46** -0.44** 0.32** 0.14**PRWE painTime 1 0.46** 0.44** -0.27** 0.05Time 2 0.75** 0.53** -0.50** -0.27**Time 3 0.79** 0.34** -0.50** -0.34**PRWE specificTime 1 0.48** -0.29** 0.01Time 2 0.57** -0.42** -0.23**Time 3 0.34** -0.52** -0.30**PRWE usualTime 1 -0.31** 0.09*Time 2 -0.42** -0.26**Time 3 -0.16** -0.10**SF-36 physical healthTime 1 -0.002Time 2 0.10**Time 3 0.13*** p = 0.05, **p = 0.01† Outcome variables are correlated with each variable at their respective time periods, i.e., time 1 with time 1, time 2 with time 2, etc.Page 5 of 9(page number not for citation purposes)acteristics of the sample can be found in Table 1. Sum-mary scores for the outcome measures at each time frameaccounted for R = 0.10 of the model. For SF-36 mentalhealth, minimal effects were observed with only PRWEHealth and Quality of Life Outcomes 2005, 3:73 http://www.hqlo.com/content/3/1/73usual activity retained within the model R2 = 0.01, p =0.04.The regression results for three-month post injury modelsyielded greater prediction form included variables (Table5). All PRWE sub-scales were retained in the SF-36 physi-cal health model with a total R2 = 0.33, p < 0.0001. PRWEspecific activity was most predictive and accounted for R2= 0.28 of the total model. Again at the three-monthmodel, SF-36 mental health was less explained by wristscores, but the independent variables PRWE pain andusual activity were retained, R2 = 0.10, p < 0.0001. PRWEpain accounted for the major effect, R2 = 0.08 of the totalmodel.The regression results for one-year post injury can befound in Table 6. At one year post injury the regressionmodel for SF-36 physical health showed that PRWE spe-cific and usual activity accounted for a total R2 = 0.28, p <0.0001, with specific activity accounting for the majorityof the model, R2 = 0.25. The regression model for SF-36mental health one year post injury showed that onlyPRWE pain was retained and accounted for a total R2 =0.08, p < 0.001.DiscussionThis study determined that the ICF framework is sup-ported when evaluating the impact of distal radius frac-ture on health because impairment, activity limitationsand participation restrictions, individually and in combi-nations, were related to self-reported physical health sta-tus as measured on the SF-36. Statistically significantmodels for SF-36 physical and mental health were found.The models for SF-36 physical health were strong with thePRWE accounting for 13% (one week), 33% (threemonths), and 28% (one year) of the variance. Models forSF-36 mental health demonstrated weak relationshipswith the PRWE accounting for 1% (one week), 10% (threemonths), and 8% (one year) of the variance. This studyconfirms previous work that a distal radius fracturemainly affects the physical domains of health, although itThe ICF framework is advantageous as the inclusion ofaspects relating to the injury, the individual and the envi-ronment provide a broader view of how health interven-tions might be undertaken. In the past the focus ofoutcome for distal radius fracture has been impairmentbased (e.g., radiographic data, strength, and range ofmotion). However, studies have shown that impairmentis not necessarily the best method to measure outcome asit does not always reflect activity and or participationrestrictions [13,22,40]. We measured health by self-reportallowing us to capture early and late health effects. ThePRWE sub-scales were able to explain a significant portionof the SF-36 physical health score at all time periods.When examining the areas measured by the PRWE sub-scales this indicates that problems in areas such as pain,dexterity, lifting, work, household duties, recreation, andself-care after fracture do contribute to overall physicalhealth. However, there were differences in the magnitudeof the models and the most prevalent sub-scale betweenthe time periods suggesting that impairment, activity, andparticipation have different health impacts at differenttime points in recovery from distal radius fracture.The regression equations at one-week explained relativelylittle of the health impact of the fracture. This may havebeen because PRWE scores are consistently very poor atthis point across all patients [19], and variations in healthstatus were not well reflected at this point. For example,many patients would be immobilized providing a com-mon restriction on specific activities like lifting or gettingup from a chair. The PRWE usual activity focused on abil-ity to do usual activities and was significant, althoughaccounting for only 10% of the variance of the physicalhealth model (R2 = 0.13) at one-week post injury. Thissub-scale evaluates perform their usual self-care, work,household duties, and recreational activities (i.e., partici-pation). This suggests that there is more variability in abil-ity to participate in usual activity, than is observed on thespecific activities subscale and these variations impactedon health status. This is in agreement with qualitativestudies where clients emphasized the impact of distalTable 4: Multiple regression results for SF-36 Physical Health one week post injuryVariable R2 Standardized Beta P valueSF-36 Physical Health Summary Scale, Total Model R2 = 0.13, p < 0.0001PRWE usual* 0.10 -0.19 0.0001PRWE specific 0.12 -0.15 0.0001PRWE pain 0.13 -0.12 0.003* Independent variable scores are from one-week post injuryPage 6 of 9(page number not for citation purposes)does suggest that pain levels and mental health are alsorelated.radius fracture on work and household activities [41,42].It is worth noting that issues with pain and inability to doHealth and Quality of Life Outcomes 2005, 3:73 http://www.hqlo.com/content/3/1/73specific activities were not unimportant at this time asthey were rated as being at high levels of limitation. Giventhat participation in usual activity was related to earlyhealth status it might be worthwhile to provide somefocus on methods to adapt to limitations in the early stageof fracture treatment. Individuals might benefit from edu-cational materials that outline expected activity limita-tions and possible adaptations to maximize their abilityto perform common tasks of daily life.SF-36 physical health scores at three months and one-yearpost injury were explained to a greater extent by variationsin the PRWE. The PRWE sub-scale of specific activityexplained between 25% (model R2 = 0.28) and 28%(model R2 = 0.33) of the variance, replacing usual activityas the prominent variable. At three months post injury thecast has been removed and rehabilitation is underway andpatients may be variable in their inability to do specifictasks that require pain-free wrist motion or strength. Self-reported wrist/hand activity limitations and participationrestrictions explained a significant portion of overall phys-ical health scores indicating that the wrist injury has a sub-stantial impact on overall health in a manner that isconsistent with the view of health portrayed in ICF. Com-posite wrist impairment rating had minimal additionalinfluence on the models accounting for between 1% and3% additional variance in health. This is in agreementwith the studies that found that impairment was not agood indicator of function [13,21,22,30,40]. Physicalimpairment contributes to activity limitation, however,there is not a direct relationship.Though the PRWE sub-scales accounted for a significantportion of the SF-36 physical health score (13%-33%),there are obviously other influencing factors that remainunexplained. We were unable to address a broad spectrumof potentially useful variables given database limitations.place environment; rehabilitation, surgery, socio-economic status, etc., should be included.Physical and mental health domains have been seen asdistinct domains of health according to SF-36 develop-ment and validation. This was also true in this studywhere the correlation between the physical and mentalcomponent summary scores was very low (r<0.10). Nei-ther physical impairments, activities limitations nor par-ticipation restrictions were strongly predictive of SF-36mental health scores. This is consistent with the view thatdistal radius fracture primarily affects physical health. ThePRWE pain sub-scale accounted for slight variation in SF-36 mental health scores. Pain however, has not beenshown to significantly impact recovery of distal radiusfracture [43,44]. In fact in a study by Bialocerkowski [42],clients with wrist disorders were asked to explore difficul-ties post injury and pain was not mentioned. Insteadissues with household duties, work demands, recreation,and fine motor skills were identified. Because regressionreveals associations, it is not clear whether higher painlowers mental health, or if those with poorer mentalhealth experience more pain.In describing rehabilitation following distal radius frac-ture, the importance of a staged approach has been sug-gested [45-47]. This study would support a stagedapproach as the mediators of physical health vary overtime. In the early phases where immobilization and frac-ture healing limit motion and activity, the ability to per-form usual activities is important. In addition to thecustomary attention to pain management, rehabilitationshould also include compensatory strategies or aids asrequired to assist individuals complete their usual activi-ties. In the rehabilitative phase where ability to performspecific tasks plays a larger role, remediation of impair-ment, incorporation of client driven goals and activity-Table 5: Multiple regression results for SF-36 Physical and Mental Health three months post injuryVariable R2 Standardized Beta P valueSF-36 Physical Health Summary Scale, Total Model R2 = 0.33, p < 0.0001*PRWE specific† 0.28 -0.27 0.0001PRWE pain 0.31 -0.23 0.0001PRWE usual 0.33 -0.15 0.0001SF-36 Mental Health Summary Scale, Total Model R2 = 0.10, p < 0.0001§PRWE pain 0.08 -0.18 0.0001PRWE usual 0.10 -0.17 0.0001* Excluded variable Wrist Outcome Measure† Independent variable scores are from three months post injury§Excluded variables Wrist Outcome Measure, PRWE specificPage 7 of 9(page number not for citation purposes)More complex models are needed to explore the remain-der of the variance and additional concepts such as work-based rehabilitation [48] are needed. Finally, the impor-tance of participation is highlighted in these models andHealth and Quality of Life Outcomes 2005, 3:73 http://www.hqlo.com/content/3/1/73suggests that participation in usual self-care, household,work, and recreation, must be maximized to restore phys-ical health. It has been demonstrated that even afteradjusting for age and comorbidity patients more than 65years of age who sustain a wrist fracture have a 57% 7-yearsurvival rate, as compared to 71% for the comparative USpopulation [49]. One possible contributor to this prob-lem can be reduced participation in an active lifestyle thatincreases risk for additional health problems. Addressingparticipation during fracture rehabilitation may haveshort-term and longer-term health benefits.ConclusionThe ICF model is useful in framing the health effects of adistal radius fracture that has implications for optimalmanagement of distal radius fractures. Self-reportedhealth measures should provide insight into the impair-ment, activity limitations and participation restrictionsthat result from a distal radius fracture. These aspects ofhealth can be addressed at different phases of fracturemanagement and rehabilitation to provide optimal phys-ical health recovery.Authors' contributionsJM formed the original study design and clinical database,obtained the ethics approval and obtained database fund-ing. JH and JM developed the research question andplanned statistical analyses. JH conducted statistical anal-yses and drafted the manuscript. JR enrolled, treated andevaluated patients in this study and contributed to thedesign of evaluation procedures, study equipment andpersonnel funding. All authors approved the final studyprotocol, contributed to interpretation of the study resultsand participated in revisions of the manuscript. Allauthors read and approved the final manuscript.AcknowledgementsThis project was supported by the New Investigator Award, Canadian Insti-tute of Health Research (JCM), and Doctoral Research Award, Canadian Institute of Health Research, and a Canadian Institute of Health Research Training Fellowship in Quality of Life Research in Rehabilitation, sponsored by the Institute of Musculoskeletal Health and Arthritis (JEH).References2. Garratt A, Schmidt L, Mackintosh A, Fitzpatrick R: Quality of lifemeasurement: bibliographic study of patient assessed healthoutcome measures.  BMJ 2002, 324:1417.3. International Classification of Functioning, Disability andHealth.  World Health Organization; 2003. 4. Grimby G, Smedby B: ICF approved as the successor of ICIDH.J Rehabil Med 2001, 33:193-194.5. Cieza A, Brockow T, Ewert T, Amman E, Kollerits B, Chatterji S,Ustun TB, Stucki G: Linking health-status measurements to theinternational classification of functioning, disability andhealth.  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Jebson RH, Taylor N, Trieschmann RB, Trotter MJ, Howard LA: Anobjective and standardized test of hand function.  Arch PhysMed Rehabil 1969, 50:311-319.36. MacDermid JC, Richards RS, Donner A, Bellamy N, Roth JH:Responsiveness of the short form-36, disability of the arm,shoulder, and hand questionnaire, patient-rated wrist evalu-ation, and physical impairment measurements in evaluatingrecovery after a distal radius fracture.  J Hand Surg [Am ] 2000,25A:330-340.37. Ware JEJ: Conceptualization and measurement of health-related quality of life: comments on an evolving field.  ArchPhys Med Rehabil 2003, 84:S43-S51.38. Beaton DE, Bombardier C, Hogg-Johnson SA: Measuring health ininjured workers: a cross-sectional comparison of five generichealth status instruments in workers with musculoskeletalinjuries.  Am J Ind Med 1996, 29:618-631.39. 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Fujii K, Henmi T, Kanematsu Y, Mishiro T, Sakai T, Terai T: Frac-tures of the distal end of radius in elderly patients: a compar-ative study of anatomical and functional results.  J Orthop Surg45. Distal Radius Fracture:  Practice Guidelines.  Chicago, Il, Amer-ican Society of Hand Therapists; 1998. 46. Laseter GF, Carter PR: Management of distal radius fractures.J Hand Ther 1996, 9:114-128.47. MacDermid JC: Hand therapy management of intra-artiocularfractures with open reduction and pi plate fixation: A thera-pist's perspective.  Techniques in Hand and Upper Extremity Surgery2004, 8:219-223.48. Maciel JS, Taylor NF, McIlveen C: A randomised clinical trial ofactivity-focussed physiotherapy on patients with distal radiusfractures.  Arch Orthop Trauma Surg 2005, 125:515-520.49. Rozental TD, Branas CC, Bozentka DJ, Beredjiklian PK: Survivalamong elderly patients after fractures of the distal radius.  JHand Surg [Am ] 2002, 27:948-952.yours — you keep the copyrightSubmit your manuscript here:http://www.biomedcentral.com/info/publishing_adv.aspBioMedcentralPage 9 of 9(page number not for citation purposes)(Hong Kong ) 2002, 10:9-15.

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