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ORIGINAL RESEARCH

Functional Electrical Stimulation Combined with Therapeutic Exercise in the Strengthening Phase of Rehabilitation of Distal Forearm Fractures Following Open Reduction Internal Fixation Surgery: a Randomized Controlled Trial
Levan Akhalkatsi1,ID, Marina Matiashvili1,ID, Valeri Akhalkatsi1,2,ID, Lela Maskhulia1,ID, Ketevan Sivsivadze1
Received: 1 Oct 2025; Accepted: 15 Oct 2025; Available online: 20 Oct 2025
References
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ABSTRACT

Background: Distal forearm fractures (DFF) are among the most common orthopedic lesions in adults, often significantly impairing upper limb function and reducing quality of life. Open reduction and internal fixation (ORIF) of DFF is the most widely used approach due to more favorable outcomes, underscoring the need for effective post-surgical rehabilitation. While standardized rehabilitation protocols exist, more effective approaches remain to be developed. The impact of functional electrical stimulation (FES) in rehabilitation management after ORIF surgery to improve muscle strength and prevent atrophy has not been sufficiently investigated.

Objectives: The objective of this study was to assess the impact of combining functional electrical stimulation with therapeutic exercise on the strengthening phase of rehabilitation of distal forearm fractures following open reduction internal fixation surgery.

Methods: 45 patients with DFFs that underwent ORIF participated in the study, which took place during weeks 6-8post-surgery (strengthening phase). Patients were first divided into two groups based on whether they used continuous passive motion (CPM) in the prior phase of rehabilitation (A-CPM group; B–no-CPM group). Consequently, the groups were further divided into two subgroups each: A1 and B1, receiving FES treatment focusing on grip strength and therapeutic exercise (TE), and A2 and B2, which underwent solely TE for the study period (3 weeks). All patients were assessed at the inception and end of the study for grip strength (GS), active range of motion of the wrist (AROM), and wrist function during activities of daily living (ADLs) using the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire.

Results: Statistical analysis of data revealed that even though all four groups demonstrated significant increase across all three measures at 3 weeks (p<0.05), the participants of A1 and B1groups experienced notably higher level of improvement with regards to GS and DASH scores (p<0.05), while the improvement in AROM was very similar in both pairings (A1 vs A2 and B1 vs B2, all p>0.05). Additionally, the comparison between the A1 and B1 groups showed that although the differences in GS changes were insignificant (p>0.05), the opposite was observed for AROM and DASH (p<0.05), with progress clearly greater in group A, which is directly linked to prior CPM use.

Conclusions: Using FES as an additional intervention during the strengthening phase of rehabilitation after ORIF in patients with DFFs may lead to increased muscle strength, improved wrist/hand function, and, therefore, improved activities of daily living. Further implementation of FES into various exercise programs may yield better outcomes in muscle strength, joint mobility, and function.

Keywords: Distal forearm fractures; functional electrical stimulation; open reduction internal fixation; rehabilitation; therapeutic exercise.

DOI: 10.52340/GBMN.2025.01.01.131

BACKGROUND

Distal forearm fractures (DFF), which encompass fractures of the distal radius and/or ulna, represent one of the most common orthopedic injuries in the adult population, as consistently demonstrated across multiple large-scale epidemiological studies, including the Swedish Fracture Register, regional population-based studies in Japan, and national analyses of upper extremity fractures in the United States. According to the above studies, DFFs constitute the majority of upper extremity fractures and account for over 16% of all fractures in adults. Notably, the incidence of DFFs is consistently and significantly higher in females across all studies. Additionally, while the majority of DFFs are attributed to distal radius fractures (DRF), isolated ulna fractures and combined distal ulna and radius fractures represent only a small fraction of these injuries.1-4

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Recent studies indicate a growing preference for open reduction and internal fixation (ORIF) in the treatment of DFFs, particularly DRFs, with its use in the USA rising from approximately 10% in 2012 to 15% in 2020. Similar trends have been reported internationally, especially among elderly patients.5-8 This shift is primarily attributed to shorter recovery periods and superior functional outcomes, including range of motion (ROM), DASH (Disabilities of the Arm, Shoulder and Hand) scores, and grip strength (GS), compared with non-surgical, cast/splint options.9,10 As DFFs remain among the most common orthopedic injuries in adults, the increased reliance on surgical management has consequently heightened the demand for postoperative rehabilitation.

Furthermore, evidence suggests that a substantial proportion of patients with distal forearm fractures (DFFs) seek rehabilitation services, with those undergoing ORIF significantly more likely to do so.11 The importance of post-surgical rehabilitation following DFFs is further corroborated in multiple studies that showcase the effectiveness of adequate rehabilitation in terms of significant progress with regards to range of motion, grip strength, and functional activity improvement, additionally highlighting the crucial role of rehabilitation across various stages of treatment, contributing to both short- and long-term recovery.12-14

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Standard rehabilitation protocol for DFFs (more commonly DRFs) as provided by American academy of orthopedic surgeons (AAOS) as well as the Academy of Hand and Upper Extremity Physical Therapy (AHUEPTA) and Academy of Orthopaedic Physical Therapy (AOPTA) entails a comprehensive therapeutic exercise (TE) and/or home exercise program (HEP) supervised by physical therapists (PTs). It is typically divided into three stages/phases: Protective Phase, Mobilization Phase, and Strengthening Phase. These phases focus on various goals, such as pain/edema management, prevention of soft-tissue contracture or adhesion development, early ROM recovery, muscle strengthening, and gradual return to functional activities.15,16 While therapeutic exercise remains the primary method of rehabilitation of the aforementioned pathological condition,17 contemporary approaches increasingly incorporate adjunctive modalities, such as electrical stimulation or mechanotherapy, to enhance recovery and improve clinical outcomes.

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The role of electrical muscle stimulation (EMS) in the rehabilitation process has always been controversial; however, its benefits in neurorehabilitation and in preventing muscle wasting during or following immobilization periods have been supported by multiple studies.18-21 Additionally, both EMS and functional electrical stimulation (FES) have demonstrated positive effects on muscle strength recovery and functional outcomes following various orthopedic or neurosurgical procedures, including anterior cruciate ligament reconstruction, total knee arthroplasty, and peripheral nerve surgeries.22-25 However, the effect of electrical stimulation on wrist function following orthopedic intervention, in particular, has not been sufficiently evaluated through scientific research. Given the widespread nature of DFFs and their significant impact on quality of life (QoL), establishing a more diverse, efficient, and comprehensive rehabilitation program to achieve better outcomes in activities of daily living (ADLs), improved strength, and faster recovery is a major priority and a challenge.

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The present study aimed to evaluate the effectiveness of functional electrical stimulation combined with therapeutic exercise during the strengthening phase of rehabilitation following open reduction and internal fixation surgery for distal forearm fractures.

METHODS

This single-center, randomized, controlled, interventional study with a parallel-group design was conducted between May 2023 and July 2025. Participants, aged 18 to 65 years, had undergone ORIF interventions for DFFs, using plates, screws, or intramedullary rods, and had already completed the protective (0 to 3 weeks) and mobilization (4 to 5 weeks) phases of rehabilitation, making the strengthening phase (6 to 8 weeks) the focus of the study. Naturally, the diagnosis of DFFs, as well as the degree of healing during follow-up assessment throughout the treatment period and the appropriateclassification of fractures according to the AO/OTA (Association of Osteosynthesis/Orthopedic Trauma Association) classification system - type A, B or C26,27 were performed and confirmed by radiographs takenin at least two standard projections (Posteroanterior, Lateral and/or Oblique). Patients with signs of notable soft tissue contractures due to delayed rehabilitation or significant pain due to inadequate, overly aggressive interventions were excluded from the study. Furthermore, patients with pathological fractures, infections, nerve damage, or other soft tissue lesions that required additional surgical interventions before the inception of rehabilitation were excluded as well. It is essential to note that patients selected for the study had completed previous stages of rehabilitation using two distinct methods: therapeutic exercise alone or therapeutic exercise aided by mechanotherapy, which involves the use of a continuous passive motion (CPM) device before starting exercise. This notable difference between the approaches led to differences in participants' range of motion and functional status, with patients who underwent additional CPM procedures showing, on average, better baseline outcomes. This particular circumstance led to an appropriate alteration in the randomization and allocation processes for participants.

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A total of 45 participants (10 males, 35 females; mean age 50.82±9.34 years; range 30–65) met the inclusion criteria and were enrolled in the study. Based on their prior rehabilitation method, participants were initially assigned to two groups: Group A (CPM group, n=23) and Group B (no-CPM group, n=22). Each group was then subdivided into two subgroups: A1 and B1 received functional electrical stimulation in addition to therapeutic exercise, while A2 and B2 received therapeutic exercise alone during the 3-week study period. Participants were allocated to their appropriate subgroup using stratified randomization to minimize the impact of sociodemographic factors on study outcomes. Stratification was based on age (30–45 and >45 years) and sex (male and female), yielding four strata. Randomization within each stratum ensured balanced allocation across subgroups: A1 (n=12, mean age 51.08±8.51), A2 (n=11, mean age 51.91±9.82), B1 (n=11, mean age 49.91±7.65), and B2 (n=11, mean age 50.36±10.998). The study flowchart is presented in Figure 1. All assessments and data collection were performed by the same physical therapist to ensure consistency, while the principal investigator remained blinded to group assignments to minimize bias.

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FIGURE 1. Study design flowchart

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Informed consent, written and oral, was obtained from each patient before they participated in this study. The study had previously been submitted and approved by the university's Ethics Committee for Research (â„–2-2023/103).

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The participants, having completed the protection and mobilization phases of post-ORIF DFF rehabilitation before the study period, entered the strengthening phase (i.e., weight-bearing phase), which lasted 3 weeks. The strengthening phase includes a therapeutic exercise program designed to return the patient to weight-bearing ADLs gradually. The rehabilitation program during this phase typically encompasses isometric and isotonic strengthening exercises, grip strengthening, resistance exercises (using hand grippers, putties, or exercise balls), functional activities, and weight-bearing exercises with low- to medium-weight loads.

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All participants underwent an identical, previously described therapeutic exercise program provided by the AAOS. The patients attended physical therapy sessions 5 days per week, once per day, for a total of 15 sessions in 3 weeks. These sessions lasted approximately 45 minutes. In addition, identical HEPs were designed for all patients to be performed at home throughout the 3-week study period. These HEPs, similarly to the exercises above, focused on increasing ROM, wrist/hand strength, and improving overall ADLs via specific functional activities. Patients were instructed to perform the home exercises twice a day. However, patients in subgroups A1 and B1 also received functional electrical stimulation (FES) during their therapeutic exercise sessions. Because FES is a variation of EMS that uses the same type of electrical current but combines it with light exercise or functional activity, FES procedures were integrated into the rehabilitation sessions to aid grip-strength exercises using exercise balls. This same exercise was also applied to the A2 and B2 subgroups, although without electrical stimulation.

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FES procedures were performed with the "Restorative Therapies XCITE" device, which provided stimulation to the flexors as well as the extensors of the digits/fingers with separate channels for both stimulation areas. The parameters of stimulation were as follows: Frequency - 50Hz, Pulse width – 150µs, Amplitude/Intensity – 20-30 mA. The resistive exercise ball used for grip strengthening in all groups was a soft ball from a set of hand strengthening exercisers by "HandmasterPlus". Overall, the duration of this strengthening exercise was 20 minutes across all groups, regardless of electrical stimulation.

All participants were assessed at two stages of the study: an initial assessment (Pre-Intervention) conducted before the start of the strengthening phase, 5 weeks after surgery, and a follow-up assessment (post-Intervention) 8 weeks after surgery. The aim was to evaluate and measure the effects of the above interventions on wrist/hand strength and overall function during the strengthening phase of the rehabilitation process.

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As FES procedures primarily focused on enhancing muscle strength, the therapeutic exercise was generally directed toward improving ADLs. Grip Strength (GS) and the DASH questionnaire were defined as the primary outcome measures for the present study. The Camry EH101 Digital Hand Dynamometer was used to measure grip strength, as its validity has been recognized in existing research due to its reliability and accuracy.28 The DASH is a standardized, self-report tool used to assess the impact of arm, shoulder, or hand problems on ADLs, work, and social functioning. The score is calculated from a 30-item questionnaire that evaluates a patient's ability to perform upper-limb activities and the severity of related symptoms. Each item is rated on a 1 to 5 scale, and the final score is converted to a 0 to 100 scale, with higher scores indicating a more severe functional deficit. It is important to note that the DASH questionnaire is widely recognized as one of the most reliable patient-rated outcome measurement tools for upper extremity assessment.29,30

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Additionally, ROM assessment was included as a secondary outcome measure. Although the methods described above do not necessarily focus on increasing ROM, adequate active range of motion (AROM) has a significant impact on overall function, underscoring the importance of its inclusion. Furthermore, the TE and HEPs that all participants underwent included activities focused on ROM improvement, making ROM an inherent part of the study. AROM assessment was conducted using a Prestige Medical goniometer that conforms to the ISOM (International Standards of Measurement) measurement standards. Wrist goniometry/AROM measurement was performed using the active movement arc, which refers to the sum of two opposite movements of a joint —in this case, flexion and extension of the wrist.

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All in-clinic measurements and interventions were performed and overseen by the same physical therapist to ensure consistency. All statistical analyses were conducted using IBM SPSS Statistics for Windows, Version 26.0 software (Armonk, NY: IBM Corp, USA).​

RESULTS

The initial evaluation of the statistical data shows negligible differences between groups A1 and A2, and B1 and B2, in terms of age and gender distribution, making these groups comparable sociodemographically. Furthermore, progress across all outcome measures from pre-intervention to post-intervention has been clearly demonstrated in all groups; however, the statistical significance of this improvement warrants further investigation (Tab.1).

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TABLE 1. Socio-demographic and clinical characteristics of participants, with a detailed description of pre- and post-intervention mean values across all outcome measures

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Abbreviations: AROM, active range of motion; DASH, disabilities of the arm, shoulder, and hand; GS, grip strength; SD, standard deviation.

Initially, the Shapiro-Wilk test was conducted to assess baseline comparability and the normality of data distribution for all outcome measures. The results of the Shapiro-Wilk test indicated that the distributions of all variables, except the DASH scores, within Group A1 met the assumption of normality. Due to this outcome, parametric tests such as the Paired-samples T-test and the one-way analysis of variance (ANOVA), followed by Tukey's HSD post hoc test to identify pairwise group differences, were applied to assess differences within and between groups. On the other hand, the Wilcoxon Signed-Rank test and the Kruskal-Wallis test with pairwise comparisons were used to compare DASH scores in Group A1. Findings were considered significant at an alpha level of p<0.05 for all analyses/data.
 

The comparison of all parameters at baseline showed no statistically significant differences between group A1 and A2, or between B1 and B2 (all p > 0.05), confirming that the groups were homogeneous at the start of the intervention. Additionally, the comparison of post-intervention data with the pre-intervention means showed clear and significant improvement in all groups (very low p-values) (Tab.2).

TABLE 2. Baseline comparability and statistical significance of progress across all outcome measures

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Abbreviations: AROM, active range of motion; DASH, disabilities of the arm, shoulder and hand; GS, grip strength.

​To assess the effect of FES on the abovementioned outcome measures (GS, DASH, AROM), improvement rates within the groups were analyzed and compared using the one-way ANOVA with Tukey's HSD for parametric variables and the Kruskal–Wallis test for nonparametric variables (Tab.3).

 
TABLE 3. Comparison of improvement between groups across all outcome measures
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Abbreviations: AROM, active range of motion; DASH, disabilities of the arm, shoulder, and hand; GS, grip strength.

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The p-values for GS and DASH were extremely low in both comparison cases (A1 with A2 and B1 with B2), with the improvement levels significantly higher in the groups under number 1, underscoring that the improvement rates among these groups were vastly unequal. Contrary to this discovery, the p-values for AROM comparisons between A1/A2 and B1/B2 were 0.921 and 0.971, respectively, indicating that the differences between the appropriate groups were not statistically significant. In addition, both groups that underwent FES procedures (A1 and B1) were compared to evaluate the potential combined effect of CPM and FES on all key outcome measures (Tab.4). The data show a statistically significant impact in group A1 for AROM and DASH scores (p<0.000 in both cases). In contrast, the improvement rates of GS seem very similar across groups (p=0.361).

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TABLE 4. Comparison of improvement between Groups A1 and B1 for assessment of the combined effect of functional electrical stimulation (FES) and continuous passive motion (CPM)

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Abbreviations: AROM, active range of motion; DASH, disabilities of the arm, shoulder, and hand; GS, grip strength.​

DISCUSSION

The current randomized controlled study presents the results of a rehabilitation plan for distal forearm fractures following open reduction internal fixation surgery, comparing an established, standard rehabilitation program with an approach combining therapeutic exercise and functional electrical stimulation throughout the strengthening phase.

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Firstly, it is essential to note that both approaches used and evaluated in this study led to statistically significant improvements across all outcome measures in all four groups and did not exacerbate pain, which would have led to more extended rehabilitation periods and decreased efficacy or poorer overall outcomes. During the strengthening phase of rehabilitation, improving muscle strength and ADLs becomes a greater priority, and, as a result, achieving higher grip strength and better functional outcomes, as measured by DASH scores, can be invaluable. The data from the current study indicate that combining specific therapeutic exercise programs with functional electrical stimulation to improve grip strength can yield statistically significant and clinically impactful results. These results are bolstered by the significantly higher degree of GS improvement observed in both groups A1 and B1 compared to A2 and B2, respectively. Furthermore, given that the baseline mean parameters in the B1 groupwere significantly lower than those of A1 group(especially with regards to AROM), the levels of improvement were still similar, which underlines not only the positive impact of functional electrical stimulation on grip strength at the aforementioned stage of rehabilitation, even in cases of relatively limited functional parameters, but also indicates a possible combined effect of increased AROM and FES on primary outcome measures for patients with distal forearm fractures.

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Similar differences were observed in DASH scores across the two group pairings, suggesting a potentially significant impact of FES on ADLs and overall quality of life. However, it is imperative to consider the fact that FES in this study was solely utilzed to aid with therapeutic exercise that specifically targeted grip strength, which implies that the significantly higher level of improvement of the parameter mentioned above within groups A1 and B1 may have been caused by the indirect and positive effect of better grip strength rather than a direct impact of FES on ADLs.The data concerning AROM presented above clearly demonstrate no significant differences in improvement between groups, which is not surprising, since all interventions aimed at increasing the range of motion were identical across groups. The only exception to this finding was observed in the comparison between the A1 and B1 groups, which can be explained by the fact that the baseline AROM parameters in these two groups were not comparable due to prior CPM procedures in group A1.

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The findings of the present study are consistent with prior research on the use of adjunct therapeutic modalities, such as electrical stimulation, in the rehabilitation of distal forearm fractures. Factor et al. demonstrated a significant improvement in grip strength at 6 weeks postoperatively in patients receiving pulsed electromagnetic field (PEMF) therapy following ORIF, indicating that electrical stimulation can facilitate functional gains and reduce muscle atrophy in post-surgical patients. Likewise, Reischl et al. showed comparable benefits using neuromuscular electrical stimulation (NMES) during immobilization in non-operatively managed fractures, with patients achieving significantly higher grip strength at both 8 and 12 weeks compared to control groups.31,32 These results suggest that electrical stimulation can serve as a valuable additional tool to strengthen rehabilitation protocols, supporting the clinical relevance of the presented FES-based intervention.

CONCLUSIONS

In conclusion, the incorporation of functional electrical stimulation into the strengthening phase of rehabilitation following ORIF interventions of distal forearm fractures showcased statistically and clinically significant improvements and better overall outcomes in terms of grip strength, as well as DASH scores, when compared with standard rehabilitation protocols involving sole use of therapeutic exercise, indicating superior hand control and improved performance of activities of daily living, and therefore, better quality of life. However, no significant benefit was found regarding increased active range of motion or wrist mobility, as FES was used exclusively as an adjunctive modality to improve muscle strength, mainly in the finger flexor and extensor groups. These exact findings imply additional benefits of implementing FES in other physical exercises targeting different muscle groups or different objectives altogether, such as improving the range of motion.

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Given the statement above, further studies with long-term follow-up and a wider range of patients are required to improve understanding of the use of FES for the rehabilitation of distal forearm fractures and for patients undergoing orthopedic surgical interventions.

AUTHOR AFFILIATION

1 Department of Physical Medicine, Tbilisi State Medical University, Tbilisi, Georgia;

2 Tbilisi State Medical University Sports Medicine and Rehabilitation Clinical Center, Tbilisi, Georgia.

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