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How good are US and MRI in identifying thumb Stener lesion? Findings from a meta-analysis
Diagnostic accuracy of ultrasound and magnetic resonance imaging in detecting Stener lesions of the thumb: Systematic review and meta-analysis. Qamhawi, Z., et al. (2021) Level of Evidence: 2a Follow recommendation: 👍 👍 Type of study: Diagnostic Topic: Thumb Stener lesion – Ultrasound and MRI diagnostic This is a systematic review and meta-analysis assessing the usefulness of MRI and Ultrasound (US) in identifying Stener lesions of the thumb. Fifteen longitudinal studies were included in the review for a total of 423 participants. The quality of the studies included was assessed through the Quality Assessment of Diagnostic Accuracy Studies tool. Studies were included if participants had undergone US or MRI of their thumb following a thumb injury. The sensitivity and specificity of US and MRI was compared to surgical assessment of the lesion (gold standard) or clinical follow up. If a test is very sensitive and its result is negative, you can be more certain that the patient does not have the condition. If the test is specific and its result is positive, you can be more certain that the patient has the condition. The results showed that median time from injury to MRI and US was 6 and 9 days respectively (range 1-20). The time between in injury and surgery or clinical follow up varied greatly with a range from less than 2 weeks to 5 years. The sensitivity and specificity of MRI and US was beyond 90% suggesting that both investigations are useful for screening and diagnostic purposes. Unfortunately, not all participants from the studies underwent open surgery (gold standard) to assess the presence of a Stener lesion. This is therefore a limitation of the review as the pooled sensitivity and specificity are not drawn on true positive or negative. Clinical Take Home Message: Based on what we know today, US and MRI investigations may be useful for screening against, or making a diagnosis of Stener lesion in the thumb. The sensitivity and specificity of these imaging procedures have however been calculated against a mix of surgical (gold standard) and clinical assessment procedures rather than surgical findings alone. It is therefore possible that in the future, the real utility of these investigations may change. A previous non peer-reviewed study showed that the sensitivity of US imaging to identify Stener lesions of the thumb is quite low in a group of participants who all underwent surgery. Open Access URL: Abstract This study assesses the diagnostic accuracy of ultrasound and magnetic resonance imaging (MRI) in diagnosing Stener lesions of the thumb. MEDLINE, PubMed, Embase and Cochrane CENTRAL were searched for studies using ultrasound or MRI to detect Stener lesions following suspected thumb ulnar collateral ligament injuries. The reference standard was surgical exploration or clinical joint stability. Risk of bias was assessed using the Quality Assessment of Diagnostic Accuracy Studies tool. A random-effects bivariate meta-analysis was used to estimate pooled sensitivity and specificity. Forest plots were generated. Nine ultrasound (315 thumbs) and six MRI (107 thumbs) studies were included in meta-analysis (all high risk of bias). Pooled sensitivity and specificity for ultrasound were 95% and 94%, and for MRI were 93% and 98%. Both ultrasound and MRI demonstrate high diagnostic accuracy in detecting Stener lesions. Ultrasound is an appropriate first-line imaging modality.
US investigations for cubital tunnel syndrome?
Value of ultrasound in the management of cubital tunnel syndrome with associated space-occupying lesions. Yang, F., M. Li and Y. Qiu (2020) Level of Evidence: 4 Follow recommendation: 👍 👍 Type of study: Diagnostic Topic: Cubital tunnel – Ultrasound to screen for space occupying lesions This is a non-peer reviewed restrospective study assessing the usefulness of Ultrasound imaging (US) in identifying space occupying lesions causing cubital tunnel syndrome prior to surgical release. A total of 274 participants were included in the study. Only participants with symptoms of cubital tunnel syndrome, identified clinically, were included. US testing identified a space occupying lesion in 19 participants which was confirmed during surgical exploration. Only one case was missed by US assessment and identified at the time of surgery. This suggests the incidence of space occupying lesion in 7% of people presenting with cubital tunnel syndrome (consistent with what has been previously reported in the literature, which varies between 3% to 8%). On US imaging, the presence of these lesions was identified by hypo-echoic areas (low brightness) or the presence of nerve swelling just proximal to the space invading lesion (see picture below). Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message: Based on what we know today, US assessment may be useful for the identification of space occupying lesions responsible for cubital tunnel syndrome. These lesions are reasonably rare and you would expect to identify them in 1 client out of 10 or 1 out of 30 among those presenting with a cubital tunnel syndrome to your clinical practice. URL: Available through EBSCO Health Databases for PNZ members. No abstract available
Combined interventions for thumb OA: Are they superior to education alone?
Efficacy of a combination of conservative therapies vs an education comparator on clinical outcomes in thumb base osteoarthritis: A randomized clinical trial. Deveza, L. A., et al. (2021). Level of Evidence: 1b Follow recommendation: 👍 👍 👍 👍 Type of study: Therapeutic Topic: Thumb osteoarthritis - Combined interventions vs self-management and joint protection This is a randomised, single-centre, double-blind, placebo controlled trial assessing the effectiveness of combined interventions vs self-management and ergonomics on pain and function in participants with thumb osteoarthritis (OA). Participants (N = 204) were included if they presented with thumb pain in half of the past month days, pain in 1st cmcj OA of at least 40 out of 100, Functional Index of Hand OA (FIHOA) of at least 6 out of 30, Kellgren-Lawrence grade 2 or higher on x-ray of the 1st cmcj. Participants were excluded if they had had hand surgery or cortisone injections in their hands in the last 6 months. Unfortunately, participants were not excluded if they had previously trialed interventions (e.g. splinting) which were being tested in the study (see full inclusion and exclusion criteria here). Effectiveness of intervention was assessed through pain (VAS) and function (FIHOA) at baseline, and 6 weeks. Participants and assessors were blinded to treatment allocation. Participants were randomised to either a 6 weeks combined interventions or educational program. The combined intervention program included education, joint protection advice, a neoprene splint (prefabricated neoprene worn for at least 4hrs during the day - see picture below), pain-free hand exercises (e.g. thumb opposition, pinch strengthening, grip strengthening) three times per week, and topical NSAIDs (n = 102). The education only program received education and joint protection advice alone (n = 102). Both groups attended 2 in person sessions (at baseline and at 2 weeks). The results showed that pain improved to clinically significant level in both group without differences between groups at the 6 weeks follow up. Function improved in both groups, however, there was a statistical and potentially clinically relevant difference between groups (favoring the combined interventions) at 6 weeks. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message: Based on what we know today, combined interventions for thumb OA do not provide greater pain-relief than education and joint protection in people with thumb OA. It is however possible that our clients could get some relevant improvements in hand function in the short term with a combined interventions approach. Considering that a recent large multi-crentred RCT found splinting to have no greater effect than a placebo splint in thumb OA, we may provide our clients with education, exercise, and topical NSAIDs alone. This would allow, to provide our clients with two sessions of hand therapy where we can progress exercises and reiterate key information (the price would be similar to one session of hand therapy + a splint). In addition, we may move away from joint protection programs for hand OA as these have not been shown to be effective in hand OA. Instead we could encourage joint motion for lotion, promote joint movement for amusement, and suggest meditation for elation. If this is not enough and clients want something passive (no exercises) that has been shown to have some effect (compared to placebo), although small, look at supplements for osteoarthritis. Also remember: keep smiling, your clients' pain will decrease! URL: Available through EBSCO Health Databases for PNZ members. Abstract IMPORTANCE: A combination of conservative treatments is commonly used in clinical practice for thumb base osteoarthritis despite limited evidence for this approach. OBJECTIVE: To determine the efficacy of a 6-week combination of conservative treatments compared with an education comparator. DESIGN, SETTING, AND PARTICIPANTS: Randomized, parallel trial with 1:1 allocation ratio among people aged 40 years and older with symptomatic and radiographic thumb base osteoarthritis in a community setting in Australia. INTERVENTIONS: The intervention group (n = 102) received education on self-management and ergonomic principles, a base-of-thumb splint, hand exercises, and diclofenac sodium, 1%, gel. The comparator group (n = 102) received education on self-management and ergonomic principles alone. Intervention use was at participants' discretion from 6 to 12 weeks. MAIN OUTCOMES AND MEASURES: Hand function (Functional Index for Hand Osteoarthritis; 0-30) and pain (visual analog scale; 0-100 mm) were measured at week 6 (primary time point) and week 12. An α of .027 was used at week 6 to account for co-primary outcomes. RESULTS: Of the 204 participants randomized, 195 (96%) and 194 (95%) completed follow-ups at 6 and 12 weeks, respectively; the mean (SD) age of the population was 65.6 (8.1) years, and 155 (76.0%) were female. At week 6, hand function improved significantly more in the intervention group than the comparator (between-group difference, -1.7 units; 97.3% CI, -2.9 to -0.5; P = .002). This trend was sustained at 12 weeks (-2.4 units; 95% CI, -3.5 to -1.3; P < .001). Pain scores improved similarly at week 6 (between-group difference, -4.2 mm; 97.3% CI, -11.3 to 3.0; P = .19). At week 12, pain reduction was significantly greater in the intervention group (-8.6 mm; 95% CI, -15.2 to -2.0; P = .01). There were 34 nonserious adverse events, all in the intervention group-mostly skin reactions and exercise-related pain exacerbations. CONCLUSIONS AND RELEVANCE: In this randomized clinical trial of people with thumb base osteoarthritis, combined treatments provided small to medium and potentially clinically beneficial effects on hand function but not pain. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry Identifier: ACTRN12616000353493.
Is median nerve gliding impaired in people with cervical radiculopathy?
Excursion of the median nerve during a contra-lateral cervical lateral glide movement in people with and without cervical radiculopathy. Thoomes, E., R. Ellis, A. Dilley, D. Falla and M. Thoomes-de Graaf (2021) Level of Evidence: 3b Follow recommendation: 👍 👍 Type of study: Aetiologic, Prognostic Topic: Cervical radiculopathy - Median nerve gliding This is a case-control study assessing differences in median nerve gliding in participants with and without cervical radiculopathy during a contralateral cervical lateral glide. A total of 40 participants were included in the study. Cervical radiculopathy was diagnosed through clinical examination through a positive upper limb neurodynamic test (ULNT of median/ulnar/radial nerve) and/or Spurling's test and confirmed through MRI. Controls were participants who did not present with neck/arm pain and had a negative Spurling's or ULNT tests. Median nerve gliding was assessed just proximal to the wrist and elbow through an ultrasound machine. The contralateral cervical lateral glide was performed within a pain-free range and the amount of movement was recorded by a machine in which the head was positioned. The results showed that there was no difference in the amount of pain free contralateral cervical lateral glide between cervical radiculopathy and healthy participants. In other words, the range of movement was similar. There was a significant difference in the amount of median nerve gliding between the participants with and without cervical radiculopathy. In particular, healthy participants had a median glide of 2-3.5 mm vs 0.5-1.2 mm in participants with cervical radiculopathy. This difference resolved after three months. During these three months, the cervical radiculopathy was treated conservatively with exercises, manual therapy, nerve glides, and medications. Unfortunately, we are not sure whether these intervention contributed or not to the improvement in medial nerve glide recovery because no wait and see group with radiculopathy was included in the study. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article.
Clinical Take Home Message: Based on what we know today, clients with cervical radiculopathy present with reduced median nerve gliding in the upper limb compared to healthy controls. It is possible that these impairments may contribute to pain and functional deficits. Currently, there is no evidence supporting the use of specific neural mobilisation interventions for upper limb nerve related pain and active range of movement and resistance exercises for the neck may suffice to provide clinically significant improvements. URL: Available through EBSCO Health Databases for PNZ members. Abstract Background: A segmental, contra-lateral cervical lateral glide (CCLG) mobilization technique is effective for patients with cervical radiculopathy (CR). The CCLG technique induces median nerve sliding in healthy individuals, but this has not been assessed in patients with CR. Objective This study aimed to 1) assess longitudinal excursion of the median nerve in patients with CR and asymptomatic participants during a CCLG movement, 2) reassess nerve excursions following an intervention at a 3-month follow-up in patients with CR and 3) correlate changes in nerve excursions with changes in clinical signs and symptoms. Design Case-control study. Methods: During a computer-controlled mechanically induced CCLG, executed by the Occiflex™, longitudinal median nerve excursion was assessed at the wrist and elbow with ultrasound imaging (T0) in 20 patients with CR and 20 matched controls. Patients were re-assessed at a 3-month follow-up (T1), following conservative treatment including neurodynamic mobilization. Results: There was a significant difference between patients and controls in the excursion of the median nerve at both the wrist (Mdn = 0.50 mm; IQR = 0.13–1.30; 2.10 mm (IQR = 1.42–2.80, p < 0.05)) and elbow (Mdn = 1.21 mm (IQR = 0.85–1.94); 3.49 mm (IQR = 2.45–4.24, p < 0.05)) respectively at T0. There was also a significant increase in median nerve excursion at both sites between T0 and T1 in those with CR (Mdn = 1.96, 2.63 respectively). Wilcoxon Signed-Ranks Test indicated median pre-test ranks (Mdn = 0.5, 1.21; Z = - 3.82, p < 0.01; Z = −3.78, p < 0.01 respectively) and median post-test ranks. There was a strong correlation between improvement in median nerve excursion at the elbow at T1 and improvement in pain intensity (r = 0.7, p < 0.001) and functional limitations (r = 0.6, p < 0.01). Conclusion: Longitudinal median nerve excursion differs significantly between patients with CR and asymptomatic volunteers at baseline, but this difference is no longer present after 3 months of conservative physiotherapy management. Improvement in nerve excursion correlates with improvement in clinical signs and symptoms.
Can activity trackers make your clients...physically fit, physically, physically, physically fit?
Do smartphone applications and activity trackers increase physical activity in adults? Systematic review, meta-analysis and metaregression. Laranjo, L., et al. (2020). Level of Evidence: 1a- Follow recommendation: 👍 👍 👍 Type of study: Preventative, Therapeutic Topic: Activity tracker - Physical activity This is a systematic review and meta-analysis assessing the effectiveness of activity trackers effect on physical activity in healthy adults. Thirty-five RCTs were included in the systematic review, for a total of 7,454 participants. Twenty-eight studies were included in the meta-analysis and they were assessed through the Risk of Bias criteria recommended by the Cochrane Review Group. The overall strength of evidence was assessed through the GRADE approach ("low", "very low", "moderate", "high"), which has also been suggested by the Cochrane group for systematic reviews. The addition of activity tracker devices (associated with mobile apps allowing quantification of physical activity) was compared to general exercise (without activity tracker devices). Efficacy of intervention was assessed through measures of physical activity (e.g. daily step counts). The assessment time points varied significantly, and they ranged from 1.5 to 10 months, after baseline assessment (average follow up time was 13 weeks). Low to moderate quality evidence showed that activity trackers increase the average number of steps by 1,850 (95% CI: 1,247 to 2,457). The addition of text reminders and personalised messages appeared to have a beneficial effect, however, the size of improvements is hard to quantify. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message: Based on what we know today, activity trackers appear to significantly increase the level of physical activity in healthy adult clients. You can be 95% confident that your clients will walk between 1,247 to 2,457 steps/day more if they get an activity tracker. These improvements are important considering that an extra 2,000 steps can reduce mortality by 5% in our sedentary clients (see picture below and previous synopsis). Several of our older clients such as those with distal forearm/wrist fractures may particularly benefit by being given such activity trackers as they are 5 times more likely to have another fracture in the following year compared to their healthy peers. Several activity trackers are available (e.g. Fitbit). Currently in NZ the Nymbl mobile app has been sponsored by ACC for older adults and it can be used to keep our active and reduce their risk of falls. The picture above is from the article by Saint-Maurice et al. (2020). URL: Available through EBSCO Health Databases for PNZ members. Abstract Objectives: Objective To determine the effectiveness of physical activity interventions involving mobile applications (apps) or trackers with automated and continuous self-monitoring and feedback. Design: Systematic review and meta-analysis. Data sources: PubMed and seven additional databases, from 2007 to 2020.Study selection Randomised controlled trials in adults (18–65 years old) without chronic illness, testing a mobile app or an activity tracker, with any comparison, where the main outcome was a physical activity measure. Independent screening was conducted. Data extraction and synthesis: We conducted random effects meta-analysis and all effect sizes were transformed into standardised difference in means (SDM). We conducted exploratory metaregression with continuous and discrete moderators identified as statistically significant in subgroup analyses. Main outcome measures: Physical activity: daily step counts, min/week of moderate-to-vigorous physical activity, weekly days exercised, min/week of total physical activity, metabolic equivalents. Results: Thirty-five studies met inclusion criteria and 28 were included in the meta-analysis (n=7454 participants, 28% women). The meta-analysis showed a small-to-moderate positive effect on physical activity measures (SDM 0.350, 95% CI 0.236 to 0.465, I2=69%, T2=0.051) corresponding to 1850 steps per day (95% CI 1247 to 2457). Interventions including text-messaging and personalisation features were significantly more effective in subgroup analyses and metaregression. Conclusion: Interventions using apps or trackers seem to be effective in promoting physical activity. Longer studies are needed to assess the impact of different intervention components on long-term engagement and effectiveness.
Get your chronic LE clients to feel some pain with exercise! They will thank you after six weeks
Investigating the effects of neuromobilization in lateral epicondylitis. Yilmaz, K., K. Yigiter Bayramlar, C. Ayhan and O. Tufekci (2020) Level of Evidence: 1b Follow recommendation: 👍 👍 👍 Type of study: Therapeutic Topic: Lateral epicondylalgia - Radial nerve gliding This is a randomised controlled trial assessing the effectiveness of radial nerve tensioners plus eccentric exercises vs eccentric exercises only for lateral epicondylalgia (LE). A total of 34 participants were included in the study. To be included, participants had to present with LE (no details on the diagnostic process were provided), and have experienced symptoms for more than three months. Participants were excluded if they presented with neck or arm symptoms, if they presented with neurological symptoms, if they reported bilateral LE or wide spread pain, or if they had received treatment for their LE in the last 6 months. Participant were randomised to radial nerve tensioners plus eccentric exercises (eperimental group, n = 18), or eccentric exercises only (control group, n = 16). Both groups performed three sets of ten repetitions of graded eccentric exercises for the wrist extensor every day. Participants started with no resistance and progressed to eccentric exercises with weight when there was no pain during the exercise. Each week, the participants in the eccentric exercise only, attended a physiotherapy session during which the eccentric exercises were progressed (total of 6 sessions). The nerve tensioner group performed the same exercises described above plus 10 repetitions (3 seconds holds) of radial nerve tensioners (see picture below). The nerve tensioner group also attended 3 physiotherapy sessions per week for 3 weeks after which they continued with their tensioners exercises at home (total of 9 sessions). Efficacy of intervention was assessed through pain severity (VAS) at baseline, 3 weeks, and 6 weeks. Compliance with the home exercise program was self-reported. The results showed that both groups improved over the course of the six weeks to a statistically and clinically significant level. The radial tensioner group consistently reported clinical significant improvements in pain at rest, night, and during activity. The eccentric only group improved to a clinically significant level in the pain during activity only. The self reported compliance was 88% and 80% in the experimental and control group respectively. There results of this study need to be considered in light of a few limitations. First, the pain level in the control group was overall lower at baseline compared to the radial tensioner group, which has the potential for greater improvements in the tensioner group. Second, there was an imbalance in the number of physiotherapy sessions provided between groups. In particular, 6 session were provided to the eccentric only group and 9 sessions to the radial tensioner group. Finally, symptoms reduction through radial tensioners may be due to a Condition Pain Modulation response (artificially inducing pain with treatment can provide pain relief after treatment - pain inhibits pain). Unfortunately, the eccentric exercises were performed pain-free and we cannot exclude the effect of this confounding variable on the treatment effect. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message: Based on what we know today, the adjunct of a radial nerve tensioners to eccentric exercises may provide additional pain relief compared to eccentric exercises alone in clients with chronic lateral epicondylalgia (symptoms for more than 3 moths). It is also possible that performing resistance exercises that cause some pain during their execution may provide similar effects through what we call Condition Pain Modulation. This approach would probably be most appropriate during the disrepair/degenerative phase of tendinopathy. Radial tensioners or resistance exercises may be inappropriate during the reactive phase (acute phase) of LE. URL: Available through The Journal of Hand Therapy for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract STUDY DESIGN: Randomized controlled study. INTRODUCTION: Lateral epicondylitis (LE) causes pain and loss of function in the affected limb. Different exercises have been used for the treatment of LE. In recent years, the technique of neuromobilization has been frequently used to treat tendinopathy. However, there is no study that demonstrates the effects of neuromobilization techniques on patients with LE. PURPOSE OF THE STUDY: The aim of the present study was to determine the effects of neuromobilization techniques on pain, grip strength, and functional status in LE patients and to compare them with conservative rehabilitation treatment. METHODS: A total of 40 patients (26 females and 14 males; age: 42.80 ± 8.91 years) with a history of LE participated in the study. The patients were randomly assigned to two groups: the neuromobilization group and the control group. The neuromobilization group completed a 6-week conservative rehabilitation and radial nerve mobilization program, whereas the control group received conservative rehabilitation therapy only. Both groups underwent a 7-day weekly conservative home rehabilitation program. Pain severity, grip strength, pinch strength, joint motions, and upper extremity functional level were assessed before treatment, at the third week after treatment, and at the sixth week after treatment. RESULTS: There was a significant decrease in all pain scores in favor of the neuromobilization group at week 6 after treatment (at rest: P = .001, effect size (ES) = 0.84; at night: P = .001, ES = 0.91 and during activity: P = .004, ES = 1.06). No significant differences were found for grip strength, pinch strength, joint motions, and functional level in the neuromobilization group, although trends toward better improvement were observed. CONCLUSIONS: Radial nerve mobilization techniques are more effective on pain than conservative rehabilitation therapy in LE patients, and this effect continues after treatment.
Do stress reduction interventions speed up your clients' wound healing?
The effect of Mindfulness-Based Stress Reduction on wound healing: A preliminary study. Meesters, A., et al. (2018) Level of Evidence: 2b Follow recommendation: 👍 👍 👍 Type of study: Therapeutic Topic: Wound healing - Stress reduction programs This is a randomised controlled trial assessing the effectiveness of Mindfulness-Based Stress Reduction (MBSR) program on wound healing in the short term. Healthy participants (N = 49) were included in the study. Importantly, participants were excluded if they had experienced a stressful event in the last 3 months. Wound healing was assessed through evaluation of high resolution images taken at 3, 4, 5, 6, 7, and 10 from the artificial wound creation. Eight artificial wounds of 8mm were created in the forearm of all participants one month after the completion of the MBSR program or inclusion in the study for the control group. Assessors were blinded to treatment allocation. Participants were randomised to either a MBSR (n = 23) or wait and see (n = 26) group. The MBSR group underwent an 8 weeks mindfulness program once a week, guided by an experienced practitioner. Each weekly session lasted 2 hrs and participants were invited to meditate at home every day (30-60 minutes). The wait and see group underwent no specific intervention for 8 weeks. The results showed that there was no difference in surface wound healing between the two groups analysed (see picture below). A limitation of this study is that they excluded participants who had undergone a stressful event in the last 3 months. It is therefore possible that they excluded participants who would have benefited the most from this intervention. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message: Based on what we know today, 8 weeks of Mindfulness-Based Stress Reduction (MBSR) programme does not improve short term healing in clients who are not going through stressful times. Considering the association between levels of mental stress and wound healing, it is possible that in subgroups of people with high levels of stress, MBSR may be useful, however, this has not been substantiated by research. In addition, MBSR may require longer periods of time to show effectiveness compared to a control group. Something that appears to improve healing rate (in sedentary clients) is aerobic exercise performed for 3hrs/week for 3 months. Considering that physical activity has also been suggested to improve mental health, you might kill two birds with one stone. Open Access URL: Abstract Psychological factors have been shown to influence the process of wound healing. This study examined the effect of Mindfulness-Based Stress Reduction (MBSR) on the speed of wound healing. The local production of pro-inflammatory cytokines and growth factors was studied as potential underlying mechanism. Forty-nine adults were randomly allocated to a waiting-list control group (n = 26) or an 8-week MBSR group (n = 23). Pre- and post-intervention/waiting period assessment for both groups consisted of questionnaires. Standardized skin wounds were induced on the forearm using a suction blister method. Primary outcomes were skin permeability and reduction in wound size monitored once a day at day 3, 4, 5, 6, 7, and 10 after injury. Secondary outcomes were cytokines and growth factors and were measured in wound exudates obtained at 3, 6, and 22 h after wounding. Although there was no overall condition effect on skin permeability or wound size, post hoc analyses indicated that larger increases in mindfulness were related to greater reductions in skin permeability 3 and 4 days after wound induction. In addition, MBSR was associated with lower levels of interleukin (IL)-8 and placental growth factor in the wound fluid 22 h after wound induction. These outcomes suggest that increasing mindfulness by MBSR might have beneficial effects on early stages of wound healing.
Wounds: Are your stressed clients going to take longer to heal?
Psychological stress and wound healing in humans: A systematic review and meta-analysis. Walburn, J., K. Vedhara, M. Hankins, L. Rixon and J. Weinman (2009) Level of Evidence: 1a- Follow recommendation: 👍 👍 👍 👍 Type of study: Prognostic, Therapeutic Topic: Stress - Wound healing This is systematic review and meta-analysis on the correlation between stress and wound healing. Twenty-two studies, which included both observational and experimental studies, were included for a total of 1,226 participants. Of these, 11 studies were included in the meta-analysis and they were assessed through a study quality criteria. No overall strength of the evidence was assessed. Studies were included if the wounds were due to surgical interventions or artificially produced under experimental conditions. Studies comparing participants undergoing mentally stressful situations that were either experimentally manipulated (e.g. tests, exams, laboratory challenges) or naturally occurring (e.g. marital difficulties) were compared to participants who did not report these events in their lives. Wound healing was measured differently across studies and included wound size, inflammatory cytokines, and infections. The results showed that there was a moderate correlation between mental stress and wound healing. A limitation of this study is the inclusion of observational studies, which limits the extrapolation of causality between stress and wound healing. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message: Based on what we know today, mental stress is correlated with slower wound healing. This correlation does not prove causation and there may be other factors (e.g. low levels of physical activity) contributing to the impaired healing. Interventions aiming at reducing mental stress (e.g. mindfulness) have not been shown to be effective in improving wound healing in the very short term, although the specific study was not performed in clients with high levels of stress. To speed up wound healing, you may want to prescribe aerobic exercise in your sedentary clients as it has been shown to have a clinically important effect. In addition, physical activity has been shown to improve mental health and it may help relieving stress in our clients. URL: Available through EBSCO Health Databases for PNZ members. Abstract Objective: The current review aims to synthesize existing knowledge about the relationship between psychological stress and wound healing. Methods: A systematic search strategy was conducted using electronic databases to search for published articles up to the end of October 2007. The reference lists of retrieved articles were inspected for further studies and citation searches were conducted. In addition, a meta-analysis of a subset of studies was conducted to provide a quantitative estimation of the influence of stress on wound healing. Results: Twenty-two papers met the inclusion criteria of the systematic review and a subsample of 11 was included in a meta-analysis. The studies assessed the impact of stress on the healing of a variety of wound types in different contexts, including acute and chronic clinical wounds, experimentally created punch biopsy and blister wounds, and minor damage to the skin caused by tape stripping. Seventeen studies in the systematic review reported that stress was associated with impaired healing or dysregulation of a biomarker related to wound healing. The relationship between stress and wound healing estimated by the meta-analysis was r=−0.42 (95% CI=−0.51 to −0.32) (P<.01). Conclusion: Attention now needs to be directed towards investigating potential moderators of the relationship, mediating mechanisms underpinning the association, as well as the demonstration of a causal link by the development of experimental interventions in healthy populations.
Have you ever used aerobic exercise to speed up your clients' wound healing?
Exercise accelerates wound healing among healthy older adults: A preliminary investigation. Emery, C. F., J. K. Kiecolt-Glaser, R. Glaser, W. B. Malarkey and D. J. Frid (2005) Level of Evidence: 2b Follow recommendation: 👍 👍 👍 Type of study: Therapeutic Topic: Wound healing - aerobic exercise This is a randomised controlled trial assessing the effectiveness of aerobic exercise on wound healing. Healthy sedentary participants (N = 28) were included in the study. Importantly, participants were excluded if they were diabetic, presented with peripheral artery disease, or autoimmune conditions. Wound healing was assessed through evaluation of high resolution images taken at regular intervals. An artificial wound of 3.5mm was created in the back of the arm of all participants one month after group randomisation. Assessors were blinded to treatment allocation. Participants were randomised to either an aerobic exercise (n = 10) or nonexercise (n = 12) group. The exercise group trained 3 times per week at 70% of their maximal heart rate for 3 months. They started each exercise session with a 10 minutes warm up followed by 30 minutes on an exercycle. They finished the training session with 15 minutes of brisk walking and 15 of upper limb strengthening (arm ergometer). The nonexercise group were asked not to change their physical activity regime for 3 months. The results showed that participants in the exercise group had a consistent faster wound healing rate compared to the control group (see picture below). More than 50% of the exercising group had a fully healed wound by 4 weeks compared to 0% in the nonexercise group (See picture below). The limitation of the present study is that the nonexercising group did not receive as much attention as the exercising group, which may have influenced the results of the present study. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message: Based on what we know today, 1 hr of aerobic exercise three times per week significantly improves wound healing in sedentary clients. This is an achievable amount of exercise and it is in line with the recent World Health Organisation guidelines for physical activity. To help with wound healing post surgery we should also advise our smoking client to quit (see this previous synopsis on smoking cessation advice) as smoking has been shown to delay healing and be associated with several complications post surgery. Open Access URL: Abstract Background: Older adults are likely to experience delayed rates of wound healing, impaired neuroendocrine responsiveness, and increased daily stress. Exercise activity has been shown to have a positive effect on physiological functioning and psychological functioning among older adults. This study evaluated the effect of a 3-month exercise program on wound healing, neuroendocrine function, and perceived stress among healthy older adults. Methods: Twenty-eight healthy older adults (mean age 61.0 ± 5.5 years) were assigned randomly to an exercise activity group (n = 13) or to a nonexercise control group (n = 15). One month following baseline randomization, after exercise participants had acclimated to the exercise routine, all participants underwent an experimental wound procedure. Wounds were measured 3 times per week until healed to calculate rate of wound healing. All participants completed assessments of exercise endurance, salivary cortisol, and self-reported stress prior to randomization and at the conclusion of the intervention. Results: Exercise participants achieved significant improvements in cardiorespiratory fitness, as reflected by increased oxygen consumption (VO2max) and exercise duration. Wound healing occurred at a significantly faster rate in the exercise group [mean = 29.2 (9.0) days] than in the nonexercise group [38.9 (7.4) days; p =.012]. Exercise participants also experienced increased cortisol secretion during stress testing following the intervention. Group differences in wound healing and neuroendocrine responsiveness were found despite low levels of self-reported stress. Conclusions: A relatively short-term exercise intervention is associated with enhanced rates of wound healing among healthy older adults. Thus, exercise activity may be an important component of health care to promote wound healing.
Is good sleep going to reduce the risk of sports injuries in your clients?
The association between poor sleep and the incidence of sport and physical training-related injuries in adult athletic populations: A systematic review. Dobrosielski, D. A., L. Sweeney and P. J. Lisman (2021) Level of Evidence: 2a Follow recommendation: 👍 👍 👍 👍 Type of study: Prognostic Topic: Sleep - Injury risk This is a systematic review assessing the correlation between quality/quantity of sleep and the likelihood of musculoskeletal injuries in adults. Twelve prospective studies were included in the systematic review, for a total of 1,139 participants. The studies included were assessed through the Newcastle-Ottawa Scale (NOS) for cohort studies. The overall quality of evidence was classified as "strong", "moderate", "limited", "conflicting", or "insufficient" (this overall quality of evidence is similar to our follow recommendation criteria). The results showed that there is insufficient/limited evidence suggesting an association between quantity/quality of sleep and the likelihood of musculoskeletal injuries. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message: Based on what we know today, lack of sleep quality and duration do not appear to increase the risk of musculoskeletal injuries in adults. In contrast to adults, chronic lack of sleep in teenagers has been shown to be a risk factor for musculoskeletal injuries. URL: Available through EBSCO Health Databases for PNZ members. Abstract Background: The importance of achieving an adequate amount of sleep to optimize health and athletic performance is well recognized. Yet, a systematic evidence compilation of the risk for sport-related injury in adult athletic populations due to poor sleep does not exist. Objective: To examine the association between poor sleep and sport and physical training-related injuries in adult athletic populations. Data Sources: Electronic databases were searched using keywords relevant to sleep quantity and quality, and musculoskeletal injury and sport-related concussion (SRC). Eligibility Criteria for Selecting Studies: Studies were included in this systematic review if they were comprised of adult athletic populations, reported measures of sleep quantity or quality, followed participants prospectively for injury, and reported an association between sleep and incidence of sport or physical training-related injury. Study Appraisal: The methodological quality of each study was assessed using the Newcastle–Ottawa Scale for Cohort Studies. Results: From our review of 12 prospective cohort studies, we found limited evidence supporting an association between poor sleep and injury in adult athletic populations. Specifically, there is (a) insufficient evidence supporting the associations between poor sleep and increased risk of injury in specific groups of athletic adults, including professional or elite athletes, collegiate athletes, elite or collegiate dancers, and endurance sport athletes; and (b) limited evidence of an association between poor sleep and increased risk of SRC in collegiate athletes. Conclusions: The current evidence does not support poor sleep as an independent risk factor for increased risk of sport or physical training-related injuries in adult athletic populations. Given the methodological heterogeneity and limitations across previous studies, more prospective studies are required to determine the association between sleep and injury in this population.
I like to move it move it...physically fit, physically, physically, physically fit
World Health Organization 2020 guidelines on physical activity and sedentary behaviour. Bull, F. C., Al-Ansari, S. S., Biddle, S., Borodulin, K., Buman, M. P., Cardon, G., . . . Willumsen, J. F. (2020) Level of Evidence: 1a Follow recommendation: 👍 👍 👍 👍 Type of study: Preventative, Therapeutic Topic: Pregnancy and older adults - Physical activity guidelines I am publishing again this synopsis because I think it did not get enough attention when I first published it at the beginning of the year. More information on why I think it's important in the clinical take home message below. These are the updated guidelines for physical activity from the World Health Organisation (WHO). Importantly, they included updated information for pregnant women and older adults. The results showed that regular physical activity provides several benefits (e.g. reducing the likelihood of gestational diabetes in pregnant women). For older adults, at least three sessions per week including balance and strength training, have been advised. The table below presents a nice summary. Some extra information is provided below, specifically for pregnant women. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message: Based on what we know today, physical activity appears to be necessary across all life stages. Although this statement makes sense and is well known, it is rarely reiterated in clinical practice. Several of our older clients such as those with distal forearm/wrist fractures may particularly benefit by being reminded about the need to perform structured resistance and aerobic training (if they cannot attend the gym, Nymbl - a mobile app - has been sponsored by ACC for older adults in NZ and it can be used to keep them active and reduce their risk of falls). Thus, lack of physical exercise seems to be associated with greater frailty. In addition, older clients with a distal radius fracture are 5 times more likely to have another fracture in the following year compared to their healthy peers. You may be thinking that physical activity advice is appropriate for your older clients only. I would argue that we see several mothers postpartum for De Quervain syndrome, who are at risk of gestational diabetes, post partum depression, and future osteoporosis. The current physical activity guidelines suggest that physical activity during pregnancy and post partum are safe and may reduce the risk of all these conditions. Also, resistance training has been previously suggested to improve bone mass density if performed for a long enough period. Overall, I think I am not asking enough questions about physical activity to my clients, I will try to ask more in the future. What about you? Open Access URL: Abstract Objectives: To describe new WHO 2020 guidelines on physical activity and sedentary behaviour. Methods: The guidelines were developed in accordance with WHO protocols. An expert Guideline Development Group reviewed evidence to assess associations between physical activity and sedentary behaviour for an agreed set of health outcomes and population groups. The assessment used and systematically updated recent relevant systematic reviews; new primary reviews addressed additional health outcomes or subpopulations. Results: The new guidelines address children, adolescents, adults, older adults and include new specific recommendations for pregnant and postpartum women and people living with chronic conditions or disability. All adults should undertake 150–300 min of moderate-intensity, or 75–150 min of vigorous-intensity physical activity, or some equivalent combination of moderate-intensity and vigorous-intensity aerobic physical activity, per week. Among children and adolescents, an average of 60 min/day of moderate-to-vigorous intensity aerobic physical activity across the week provides health benefits. The guidelines recommend regular muscle-strengthening activity for all age groups. Additionally, reducing sedentary behaviours is recommended across all age groups and abilities, although evidence was insufficient to quantify a sedentary behaviour threshold. Conclusion: These 2020 WHO guidelines update previous WHO recommendations released in 2010. They reaffirm messages that some physical activity is better than none, that more physical activity is better for optimal health outcomes and provide a new recommendation on reducing sedentary behaviours. These guidelines highlight the importance of regularly undertaking both aerobic and muscle strengthening activities and for the first time, there are specific recommendations for specific populations including for pregnant and postpartum women and people living with chronic conditions or disability. These guidelines should be used to inform national health policies aligned with the WHO Global Action Plan on Physical Activity 2018–2030 and to strengthen surveillance systems that track progress towards national and global targets.
Should we start using virtual reality for hand therapy?
Effectiveness of virtual reality in the treatment of hand function in children with cerebral palsy: A systematic review Rathinam, C., Mohan, V., Peirson, J., Skinner, J., Nethaji, K., & Kuhn, I. (2019) Level of Evidence: 2a Follow recommendation: 👍 👍 👍 Type of study: Therapeutic Topic: Hand rehabilitation in Cerebral Palsy (CP) - Effectiveness of non-immersive virtual reality (VR) in children with CP This systematic review compared the effectiveness of non-immersive VR (e.g. games and PC interface) vs traditional physiotherapy on hand function in children/teenagers with cerbral palsy (CP). A total of six studies were included in the review. Of these, three were randomised controlled trials, one was an abstract, and the remaining were non-experimental studies. The results were inconsistent across studies and only two studies reported added benefits of VR. Of these, one compared VR plus physiotherapy to physiotherapy only and showed greater functional improvements when VR was included. The other study showed greater effectiveness with VR treatment, however, the study had the lowest methodological quality. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message: Based on what we know today, we may not include VR in the rehabilitation of children/teenagers with CP. Considering the added cost of non-immersive VR, its use does not appear to be justified considering the lack of improvements in hand function. URL: Available through The Journal of Hand Therapy for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Introduction: Children with cerebral palsy (CP) may have limited use of their hands for functional activities and for fine motor skills. Virtual reality (VR) is a relatively new and innovative approach to facilitate hand function in children with CP. Purpose of the study: The primary purpose of this study was to determine the effectiveness of VR as an intervention to improve hand function in children with CP compared to either conventional physiotherapy or other therapeutic interventions. The secondary purpose was to classify the outcomes evaluated according to the International Classification of Functioning, Disability and Health (ICF) dimensions. Methods: A International prospective register of systematic reviews (PROSPERO)-registered literature search was carried out in August 2015 in MEDLINE, CINAHL, ERIC, HealthSTAR, AMED, BNI, Embase, PsycINFO, PEDro, Cochrane Central Register, DARE, OTSeeker, REHABDATA, HaPI, CIRRIE, and Scopus. PRISMA guidelines were followed. Only randomized controlled trials (RCTs) were included, and their methodological qualities were examined using the Cochrane collaboration's risk of bias (RoB) tool. A narrative synthesis was performed. Results: The 6 RCTs published on this topic provide conflicting results. Four studies reported improved hand function (2 low RoB, 1 high RoB, and 1 unclear RoB), whereas 2 studies reported no improvement. All of the RCTs reported the activity element of ICF, but no study explicitly described the effect of VR intervention based on the ICF model. Conclusion: The role of VR to improve hand function in children with CP is unclear due to limited evidence; use as an adjunct has some support.
Upper extremity malignant tumors, how can you identify them?
Diagnosis and management of primary malignant tumors in the upper extremity. MacKay, B. J., et al. (2020). Level of Evidence: 5 Follow recommendation: 👍 Type of study: Diagnostic/Therapeutic Incidence: Rare Topic: Malignant tumors - Diagnosis This is a narrative review on diagnosis and treatment of malignant tumors in the upper limb. The incidence of malignant tutor is rare although they are more likely in older people. X-ray and ultrasound imaging are reported as useful tools for diagnostic purposes. X-rays showing clearly demarcated lesions usually suggest a benign tumor while poorly defined lesions usually suggest a malignant tumor (can you find the osteosarcoma in the picture below? - look at previous synopsis for the full clinical case). Treatment of malignant tumor involves resection of the lesion, which at times requires amputation. When possible, limb salvage procedures are performed. In this cases the likelihood of local recurrence is greater (15-20%), however, survival rate is not affected. Chemotherapy is often utilised to increase survival rate. Osteosarcomas are the most common bone malignancy, which is more frequent in younger clients (20 to 30 years old), although it can occur in older subjects. These type of lesions can often result into fractures due to weakening of the affected bone. Chemotherapy is often included in the treatment of these conditions. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message: Malignant tumors of the upper limb are rare conditions that we may encounter in practice. These pathologies may be incidentally identified when performing imaging for other hand conditions. It is however possible that they are directly responsible for the clinical presentation such as in fractures due to bone weakness caused by an osteosarcoma. In other cases, clients may present to the clinic complaining of a painful palpable mass like in the case of this trapezium osteosarcoma. Either way, they will require surgery to remove the lesion and they likely undergo chemiotherapy. If our clients develop chemiotherapy induced neuropathy, they may benefit from low to moderate aerobic exercise and/or medications (e.g. gabapentin) to reduce pain. Open Access URL: Abstract Bone and soft tissue sarcomas of the upper extremity are relatively uncommon. In many cases, they are discovered incidentally during evaluation of traumatic injuries or common ailments such as rotator cuff tendonitis or tennis elbow. Thus, it is important for all orthopedic surgeons to understand the differential diagnosis, workup, and treatment for upper extremity lesions. An appreciation of the clinical and radiographic features of primary malignant lesions aids in identifying patients that need referral to an orthopedic oncologist and a multidisciplinary team.
Answer - What is the differential diagnosis for this condition? - Wrist ganglion
Synovial hemangioma of the wrist with cystic invasion of trapezoid and capitate bones Zhao, X., Qi, C., Chen, J., Li, H., Zhang, Y., & Yu, T. Level of Evidence: 5 Follow recommendation: 👍 Type of study: Diagnostic/Therapeutic Incidence: Rare Topic: Synovial Haemangioma - Diagnosis and treatment This is the answer for the case study from last week. The patient was an 18 year old male who had been experiencing pain and swelling in the back of the wrist in the last 2 years. Objectively, there was a 3x3 cm non-pulsatile mass in the back of the wrist. Extension range of movement had a deficit of 20 degrees. X-ray was impeccable, however, computer tomography and MRI scans revealed an ill-defined soft tissue mass between scaphoid, trapezoid, and capitate. Following surgery, it was possible to make a diagnosis of wrist synovial haemangioma. Synovial haemangiomas are rare benign tumours which usually affect children or young adults. Only 300 cases have been reported in the literature, most of which occurred in the knee. Symptoms vary and intermittent pain may be present or absent. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message: Hand therapists should refer young children or teenagers for x-rays and ultrasound when there is evidence of an irregularly shaped, soft mass which appears to or is reported to have grown over time. The likelihood of identifying a synovial haemangioma is extremely rare, however, this work up would help differentiating among different conditions including ganglion cyst, rheumatoid arthritis, haematomas associated with haemophilia, infections or other rare forms of cancer. URL: Available through The Journal of Hand Surgery (American Volume) for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Synovial hemangiomas (SHs) are rare lesions of the joints or tendon sheaths that are difficult to diagnose. We present the case of an 18-year-old man with an SH in the wrist joint. Physical examination revealed a slightly tender, ill-defined, nonpulsatile soft mass, 3 cm × 3 cm in size on the dorsal aspect of the left wrist. Computed tomography showed an irregular, ill-defined, soft tissue mass in the expanded joint space, which was formed by the scaphoid, trapezoid, and capitate bones. Magnetic resonance imaging showed the typical features of SH and also revealed cavitary erosion of the scaphoid, trapezoid, and capitate bones. An open arthrotomy was performed via a dorsal approach, and the mass was excised. The histological examination findings were consistent with the diagnosis of SH.
Dissociative segmental instability (DISI and VISI) of the wrist: How do you diagnose it?
Defining DISI and VISI. S. Braun, N., R. A. Berger and S. W. Wolfe (2021). Level of Evidence: 5 Follow recommendation: 👍 Type of study: Diagnostic/Therapeutic Topic: Dissociative segmental instability DISI and VISI - Diagnosis This is an expert opinion on radiographic diagnosis of dissociative carpal instability (dorsal intercalated segmental instability - DISI; volar intercalated segmental instability - VISI). These conditions are commonly referred to as scapholunate instability (DISI) or lunotriquetral instability (VISI). In contrast to non dissociative instability (rare condition), which is a lesion of of extrinsic ligaments of the wrist, DISI and VISI are due to lesions of intrinsic ligaments (scapholunate and lunotriquetral respectively). In DISI and VISI the "intercalated segment" simply refers to the lunate and triquetrum unit, which forms a "layer" (intercalated segment) within the wrist. In this article, the authors suggest to make a diagnosis of DISI or VISI only based on the position of the lunate in relation to the radius. More specifically, a dorsal orientation of the lunate in relation to the radius greater than 15° suggests a DISI. In contrast a palmar orientation of the lunate in relation to the radius greater than 20° suggests a VISI. One important assumption is that the x-ray projection needs to be a pure lateral (3rd metacarpal in line with radius) without ulnar or radial deviation. These suggestions are based on the authors' review of the original article describing DISI and VISI in which the lunate positioning was the most indicative of the presence of these conditions. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message: Based on what we know today, it may be possible to diagnose a DISI or VISI by looking at the position of the lunate in relation to the radius. Be aware that this method requires a pure lateral x-ray view without radial and ulnar deviation. If we suspect a DISI due to scapholunate instability, the "clenched pencil" view may provide useful information. If you are interested in additional information on wrist instability, have a look at this previous synopsis on non dissociative wrist instability (extrinsic ligaments diagnosis and treatment). URL: Available through EBSCO Health Databases for PNZ members. Abstract not available
Identify your frail clients! You may be able to extend their health span!
Frailty and physical fitness in elderly people: A systematic review and meta-analysis. Navarrete-Villanueva, D., et al. (2021). Level of Evidence: 1a- Follow recommendation: 👍 👍 👍 👍 Type of study: Prognostic, Preventative, Therapeutic Topic: Frailty – How to identify it This is a systematic review of cross-sectional and randomised controlled studies assessing the relationship between physical fitness and frailty (function and biological aging). Twenty studies were included in the meta-analysis for a total of 13,527 participants (average age range: 71-83 years old). The overall quality of evidence was assessed through the COSMOS-E approach ("low", "moderate", "high"), which is a tool to assess risk of bias in observational studies. There was moderate to low quality evidence showing that walking speed (6 minutes walking test - 6MWT), lower limb strength, and grip strength were able to differentiate between frail and robust participants. All robust participants had more than 20kg of grip strength, while 60% of the frail participants had less than 20kg of grip strength. Clinical Take Home Message: Based on what we know today, several measures of physical fitness can discriminate between frail vs robust clients. The most useful measure appears to be walking speed that can be measured through the 6MWT (you can find the age and sex normative values in this paper - see picture below - this was my favourite paper when I was assessing clients through the 6MWT at the DHB). If you do not have the resources or you do not feel comfortable performing a 6MWT, hand grip strength is still a useful tool to screen your clients and we perform this test routinely. It appears that grip strength below 20kg may indicate that the client is fragile. The reason why I am interested in identifying fragile clients is that they are more likely to have an upper limb or lower limb fracture in the future. We may may be able to reduce the likelihood of these injuries by inviting them to take at least 8,000 steps/day. Thus, a greater number of daily steps has been shown to reduce mortality in previous studies. In addition, general resistance training may increase grip strength and overall strength, which is another predictor of mortality. URL: Available through EBSCO Health Databases for PNZ members. Abstract Background: Frailty is an age-related condition that implies a vulnerability status affecting quality of life and independence of the elderly. Physical fitness is closely related to frailty, as some of its components are used for the detection of this condition. Objectives: This systematic review and meta-analysis was conducted to investigate the magnitude of the associations between frailty and different physical fitness components and to analyse if several health-related factors can act as mediators in the relationship between physical fitness and frailty. Methods: A systematic search was conducted of PubMed, SPORTDiscus, and Web of Science, covering the period from the respective start date of each database to March 2020, published in English, Spanish or Portuguese. Two investigators evaluated 1649 studies against the inclusion criteria (cohort and cross-sectional studies in humans aged ≥ 60 years that measured physical fitness with validated tests and frailty according to the Fried Frailty Phenotype or the Rockwood Frailty Index). The quality assessment tool for observational cross-sectional studies was used to assess the quality of the studies. Results: Twenty studies including 13,527 participants met the inclusion criteria. A significant relationship was found between frailty and each physical fitness component. Usual walking speed was the physical fitness variable most strongly associated with frailty status, followed by aerobic capacity, maximum walking speed, lower body strength and grip strength. Potential mediators such as age, sex, body mass index or institutionalization status did not account for the heterogeneity between studies following a meta-regression. Conclusions: Taken together, these findings suggest a clear association between physical fitness components and frailty syndrome in elderly people, with usual walking speed being the most strongly associated fitness test. These results may help to design useful strategies, to attenuate or prevent frailty in elders.
Neuropathic pain post hand burns, who is going to develop it?
Chronic neuropathic pain following hand burns: Etiology, treatment, and long-term outcomes. Klifto, K. M., P. S. Yesantharao, A. L. Dellon, C. S. Hultman and S. D. Lifchez (2021). Level of Evidence: 4 Follow recommendation: 👍 👍 Type of study: Prognostic Topic: Neuropathic pain in burns - Variables influencing its development This is a retrospective study assessing risk factors for the development of neuropathic pain and lack of response to pharmacological treatment following hand and upper limb burns. A total of 914 participants were included in the study. A series of risk factors including demographic characteristics and burn type were included in the statistical analysis. Burning pain was defined as long lasting pain for at least six months following the injury (no standardised tool such as the "Douleur Neuropathique en 4 Questions" - DN4 was utilised to make the diagnosis of neuropathic pain). Lack of response to medical treatment was defined as no change in pain after 3 consecutive months of pharmacological treatment (e.g. gabapentin/pregabalin/opioids). The results showed that 6% of the sample developed neuropathic pain by six months. In addition, 50% of this group of people with neuropathic pain did not respond to pharmaclogical treatment. The burn's severity appeared to be a risk factor for both the development of neuropathic pain and lack of response to medications, with greater areas of total body surface burns being associated with worse outcomes. In addition, a history of substance/alcohol abuse or smoking, increased the odds of developing neuropathic pain. Burning pain was also found to be a pain descriptor that reduced the likelihood of pharmacological response at the six months point. It is important to remember that this was a retrospective study with a small proportion of patients presenting with neuropathic pain (n = 55). It is therefore possible that other variables, not accounted for in the analysis are responsible for the findings reported. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message: Based on what we know today, the development of persistent "neuropathic" pain following burns injuries may be related to their severity. In addition, a history of smoking and substance abuse, appear to increase the likelihood of its development (for advice on how to help your clients quit smoking, see this synopsis). Clients with post burn neuropathic pain may benefit from gabapentin treatment (see this synopsis on gabapentin effectiveness), however, if they describe burning pain, their likelihood of benefiting from pharmacological treatment may be reduced. URL: Available through the Journal of Hand Surgery (American volume) for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract PURPOSE: Chronic neuropathic pain (CNP) after burn injury to the hand/upper extremity is relatively common, but not well described in the literature. This study characterizes patients with CNP after hand/upper extremity burns to help guide risk stratification and treatment strategies. We hypothesize that multiple risk factors contribute to the development of CNP and refractory responses to treatment. METHODS: Patients older than 15 years admitted to the burn center after hand/upper extremity burns, from January 1, 2014, through January 1, 2019, were included. Chronic neuropathic pain was defined as self-described pain for longer than 6 months after burn injury, not including pain due to preexisting illness/medications. Two analyses were undertaken: (1) determining risk factors for developing CNP among patients with hand/upper extremity burns, and (2) determining risk factors for developing refractory pain (ie, nonresponsive to treatment) among hand/upper extremity burn patients with CNP. RESULTS: Of the 914 patients who met the inclusion criteria, 55 (6%) developed CNP after hand/upper extremity burns. Twenty-nine of these patients (53%) had refractory CNP. Significant risk factors for developing CNP after hand/upper extremity burns included history of substance abuse and tobacco use. Among CNP patients, significant risk factors for developing refractory pain included symptoms of burning sensations. In all CNP patients, gabapentin and ascorbic acid were associated with significant decreases in pain scores on follow-up. CONCLUSIONS: Substance abuse and tobacco use may contribute to the development of CNP after hand/upper extremity burns. Those who developed refractory CNP were more likely to use the pain descriptor, burning sensations. Pharmacological pain management with gabapentin or pregabalin and ascorbic acid may provide the most relief of CNP symptoms.
Are neurodynamic exercises effective for clients with hand osteoarthritis?
Effects of neurodynamic mobilizations on pain hypersensitivity in patients with hand osteoarthritis compared to robotic assisted mobilization: A randomized controlled trial. Pedersini, P., et al. (2021). Level of Evidence: 1b Follow recommendation: 👍 👍 👍 👍 Type of study: Therapeutic Topic: Hand OA - neurodynamic Vs passive movement treatments This is a randomised placebo controlled trial assessing the effectiveness of neurodynamic treatment vs passive mobilisation on pain in people with hand osteoarthritis (OA). A total of 72 participants were included in the study. To be included, participants had to present with symptoms of hand OA in the dominant hand and a kellgren-lawrence score of 3-4 on x-ray of the dominant hand (no other specific criteria were utilised for the diagnosis). Participants were excluded if they presented with depression or anxiety, other hand conditions of the hand (e.g. carpal tunnel syndrome), if they presented with neurological symptom or conditions. Participant were randomised to neurodynamic treatment (n = 36) or robotic fingers mobilisation (placebo) (n = 36). Neurodynamic treatment included gliders of the median, radial, and ulnar nerves for three sets of 3 minutes each with one minute rest in between each set. The robotic group underwent passive fingers flexion/extension through a robotic device. Both groups received 12 sessions of thirty minutes (3 per week) over the course of 4 weeks. Both groups were given hand exercises. Efficacy of intervention was assessed through pain intensity (VAS) at one baseline, at the end of treatment (4 weeks), and at three months. The results showed that both groups improved on average by 1 point out of 10 in each group. Some of the pain measurements (e.g. pain in the last 24 hrs) we're statistically significant different between groups (favoring neurodynamic treatment), however, the difference was not clinically relevant (less than 1 point out of 10). As for all experimental studies, it is possible that improvements in pain were simply due to participants being aware of being part of an intervention study rather than treatment itself (Hawthorne effect). It is also possible that the limited effectiveness of this intervention is due the low levels of pain the participants to reported, causing a floor effect. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message: Based on what we know today, neurodynamic interventions are no more effective than passive finger mobilisation in reducing pain in people with symptomatic hand OA. We may therefore encourage joint motion for lotion, promote joint movement for amusement, and suggest meditation for elation. If this is not enough and clients want something passive (no exercises) that has been shown to have some effect (compared to placebo), although small, look at supplements for osteoarthritis. In addition, preliminary evidence also showed that clients with hand OA present with sensorimotor changes and illusory resizing of the hand may help reducing symptoms. Clients with hand OA are also at greater risk of cardiovascular disease. They would therefore benefit from advice on aerobic and strength training exercise. Also remember: keep smiling, your clients' pain will decrease! If you are interested in knowing what does not appear to be more effective than placebo in clients with hand OA, here is the list: acupuncture, cortisone injections for thumb OA, joint protection programs, resistance training interventions, and splinting for thumb OA. URL: Available through EBSCO Health Databases for PNZ members. Abstract OBJECTIVE: To evaluate the effectiveness of the neurodynamic mobilization techniques compared with passive robotic physiologic movement in patients with hand osteoarthritis (OA). METHODS: We conducted a randomized controlled trial. A total of 72 patients (mean ± SD age 71 ± 11 years) with dominant symptomatic hand OA were randomized in 2 groups, and both received 12 treatment sessions over 4 weeks. The experimental group received neurodynamic mobilization of the median, radial, and ulnar nerves, and the control group received robotic-assisted passive movement treatment. Both groups also participated in a program of hand stability exercises. Outcome measures included pain intensity, pressure pain thresholds (PPTs), and strength measurements. Group-by-time effects were compared using mixed-model analyses of variance. RESULTS: After the intervention, the experimental group had statistically significant, higher PPTs than the control group at the thumb carpometacarpal joint by 0.7 kg/cm(2) (95% confidence interval [95% CI] 0.6, 0.8), the median nerve by 0.7 kg/cm(2) (95% CI 0.6, 0.7), and the radial nerve by 0.5 kg/cm(2) (95% CI 0.3, 0.6); however, the difference was not statistically significant at 3 months postintervention. Although mean values in the experimental group were higher than in the control group at all PPT sites at both assessments, these differences were not statistically significant. The experimental group experienced a statistically significant reduction in pain immediately postintervention, but this was not present at the 3-month follow-up. There were no statistically significant differences in pinch or grip strength between groups. CONCLUSION: We found that neurodynamic mobilizations decreased hypersensitivity in patients with hand OA immediately after the intervention; however, differences were no longer present at 3 months. The results suggest that these techniques may have some limited value in the short term but do not have lasting effects.
What is the differential diagnosis for this condition? - Wrist ganglion
Level of Evidence: 5 Follow recommendation: 👍 Type of study: Diagnostic/Therapeutic Incidence: Rare Have a think about this case study. Leave a diagnostic comment if you like. I will publish the diagnosis and treatment reported by the paper next week. The patient was an 18 years old male who had been experiencing pain and swelling in the back of the wrist in the last 2 years. Objectively, there was a 3x3 cm non-pulsatile mass in the back of the wrist. Extension range of movement had a deficit of 20 degrees. X-ray was impeccable, however, computer tomography and MRI scans revealed an ill-defined soft tissue mass between scaphoid, trapezoid, and capitate (see picture below). What is it?
How can you stage and treat tennis elbow?
Revisiting the continuum model of tendon pathology: What is its merit in clinical practice and research? Cook, J. L., E. Rio, C. R. Purdam and S. I. Docking (2016). Level of Evidence: 5 Follow recommendation: 👍 Type of study: Aetiology, Therapeutic Topic: Lateral epicondylalgia - Staging and treatment This is a narrative review on tendinopathy staging and their respective treatments. Although this narrative review is 5 years old, I decided to include it in HandyEvidence as it provides useful information for tendinopathy treatment. Staging of tendinopathies has been suggested as a useful way to treat these conditions and these include: reactive, disrepair, and degenerative stages (see picture below). In terms of treatment, during the reactive stage (acute phase), unloading of the tendon is advised. During disrepair and degenerative stages, graded tendon loading has been suggested as an effective approach. The difference between the disrepair and degenerative stage is simply related to the structural reversibility (disrepair) vs non-reversibility (degenerative) of the tendon structure. From a clinical point of view, the distinction between disrepair and degenerative stage may be less relevant as both stages can be treated with good outcomes. One last comment was made in relation to treatments aiming at improving tendon cell proliferation through injections (e.g. PRP injections). In particular, the rationale for the use of these interventions was questioned due to an already excessive proliferation of cells across all the three tendinopathy stages (reactive, disrepair, and degenerative). Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message: Based on what we know today, tendinopathies can be classified and treated according to their pathological stage. Treatments can vary from unloading (during the reactive stage) to graded loading (during the disrepair or degenerative stage). These concepts can be applied to several conditions such as lateral epicondylalgia (i.e. tennis elbow) or De Quervain tenosynovitis. If we consider for example lateral epicondylalgia, for an acute reactive tendinopathy, we may provide our clients with a counterforce brace, which appears to reduce loading at the common extender tendon during daily activities and improve pain-free grip strength. Once the acute reactive stage has settled and the irritability has improved (reduction in pain intensity and duration of symptoms after mechanical loading), graded loading may be appropriate. During this stage, graded resistance training has been suggested as an effective approach without one form of loading (e.g. eccentric, concentric, isometric) deemed superior to another. It is however possible that for lateral epicondylalgia, eccentric resistance training may provide better analgesia. Open access URL: Abstract The pathogenesis of tendinopathy and the primary biological change in the tendon that precipitates pathology have generated several pathoaetiological models in the literature. The continuum model of tendon pathology, proposed in 2009, synthesised clinical and laboratory-based research to guide treatment choices for the clinical presentations of tendinopathy. While the continuum has been cited extensively in the literature, its clinical utility has yet to be fully elucidated. The continuum model proposed a model for staging tendinopathy based on the changes and distribution of disorganisation within the tendon. However, classifying tendinopathy based on structure in what is primarily a pain condition has been challenged. The interplay between structure, pain and function is not yet fully understood, which has partly contributed to the complex clinical picture of tendinopathy. Here we revisit and assess the merit of the continuum model in the context of new evidence. We (1) summarise new evidence in tendinopathy research in the context of the continuum, (2) discuss tendon pain and the relevance of a model based on structure and (3) describe relevant clinical elements (pain, function and structure) to begin to build a better understanding of the condition. Our goal is that the continuum model may help guide targeted treatments and improved patient outcomes.
Are corticosteroid injections 💉 a good idea for tennis elbow?
Revisiting the continuum model of tendon pathology: What is its merit in clinical practice and research? Cook, J. L., E. Rio, C. R. Purdam and S. I. Docking (2016). Level of Evidence: 1b Follow recommendation: 👍 👍 👍 👍 Type of study: Therapeutic Topic: Lateral epicondylalgia - cortisone injections This is a randomised placebo controlled trial assessing the effectiveness of cortisone injections for lateral epicondylalgia (LE). A total of 165 participants were included in the study. To be included, participants had to been experiencing symptoms for at least six weeks. Pain had to be unilateral, intensity of at least 3/10, had to be located at the lateral epicondyle of the elbow and participants had to present with at least two of the following: pain on gripping, resisted middle finger or wrist extension, palpation at the lateral epicondyle, or stretching of the wrist extensors. Participants were excluded if they presented with neck or arm symptoms, if they presented with neurological symptoms, had receive cortisone injections or physiotherapy in the previous six and three months respectively for LE. Participant were randomised to cortisone injection alone (n = 43), saline injection alone (placebo) (n = 41), physiotherapy with cortisone injection (n = 40), or physiotherapy with saline injection (n = 41). Physiotherapy included 8 sessions of thirty minutes each over the course of 8 weeks. These included manual therapy (mobilisation with movement - see this previous synopsis on their effectiveness) or graded progression of concentric and eccentric exercises for the wrist extensors. Efficacy of intervention was assessed by self reported complete recovery and recurrence at one year. The results showed that 93% of participants had recovered in the placebo group compared to 83% in the corticosteroid injection group. In addition, participants undergoing corticosteroid injections had a significant improvement at 4-8 weeks followed by a greater recurrence of symptoms at one year (55% recurrence) compared to the placebo injection group (20%). Both these results were statistically significant. There was no difference between the physiotherapy vs no physiotherapy groups at one year follow up. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message: Based on what we know today, corticosteroid injections for lateral epicondylalgia hinder our clients' recovery and increase the recurrence rate in the long term (one year). It may be better to provide our clients with a course of physiotherapy, which does not hinder recovery and may facilitate return to function in clients with severe pain. Graded resistance training may be appropriate in the disrepair/degenerative phase of LE (sub acute/chronic - see previous synopsis on tendinopathy grading and treatment). During the acute phase, tendon unloading may be more appropriate through rest or the use of a counterforce splint (see previous synopses on splint effectiveness and biomechanics). Open access URL: Abstract Importance: Corticosteroid injection and physiotherapy, common treatments for lateral epicondylalgia, are frequently combined in clinical practice. However, evidence on their combined efficacy is lacking. Objective: To investigate the effectiveness of corticosteroid injection, multimodal physiotherapy, or both in patients with unilateral lateral epicondylalgia. Design, setting, and patients: A 2 × 2 factorial, randomized, injection-blinded, placebo-controlled trial was conducted at a single university research center and 16 primary care settings in Brisbane, Australia. A total of 165 patients aged 18 years or older with unilateral lateral epicondylalgia of longer than 6 weeks' duration were enrolled between July 2008 and May 2010; 1-year follow-up was completed in May 2011. Interventions: Corticosteroid injection (n = 43), placebo injection (n = 41), corticosteroid injection plus physiotherapy (n = 40), or placebo injection plus physiotherapy (n = 41). Main outcome measures: The 2 primary outcomes were 1-year global rating of change scores for complete recovery or much improvement and 1-year recurrence (defined as complete recovery or much improvement at 4 or 8 weeks, but not later) analyzed on an intention-to-treat basis (P < .01). Secondary outcomes included complete recovery or much improvement at 4 and 26 weeks. Results: Corticosteroid injection resulted in lower complete recovery or much improvement at 1 year vs placebo injection (83% vs 96%, respectively; relative risk [RR], 0.86 [99% CI, 0.75-0.99]; P = .01) and greater 1-year recurrence (54% vs 12%; RR, 0.23 [99% CI, 0.10-0.51]; P < .001). The physiotherapy and no physiotherapy groups did not differ on 1-year ratings of complete recovery or much improvement (91% vs 88%, respectively; RR, 1.04 [99% CI, 0.90-1.19]; P = .56) or recurrence (29% vs 38%; RR, 1.31 [99% CI, 0.73-2.35]; P = .25). Similar patterns were found at 26 weeks, with lower complete recovery or much improvement after corticosteroid injection vs placebo injection (55% vs 85%, respectively; RR, 0.79 [99% CI, 0.62-0.99]; P < .001) and no difference between the physiotherapy and no physiotherapy groups (71% vs 69%, respectively; RR, 1.22 [99% CI, 0.97-1.53]; P = .84). At 4 weeks, there was a significant interaction between corticosteroid injection and physiotherapy (P = .01), whereby patients receiving the placebo injection plus physiotherapy had greater complete recovery or much improvement vs no physiotherapy (39% vs 10%, respectively; RR, 4.00 [99% CI, 1.07-15.00]; P = .004). However, there was no difference between patients receiving the corticosteroid injection plus physiotherapy vs corticosteroid alone (68% vs 71%, respectively; RR, 0.95 [99% CI, 0.65-1.38]; P = .57). Conclusion and relevance: Among patients with chronic unilateral lateral epicondylalgia, the use of corticosteroid injection vs placebo injection resulted in worse clinical outcomes after 1 year, and physiotherapy did not result in any significant differences.
Why research does not work in clinical practice and clinical practice does not work in research?
Are you translating research into clinical practice? What to think about when it does not seem to be working. Murphy, M. C., W. Gibson, G. L. Moseley and E. K. Rio (2021). Level of Evidence: 5 Follow recommendation: 👍 Type of study: Therapeutic Topic: Research implementation This article presents a potential few reasons of why evidence based practice does not always work in clinical practice: 1) Participants included in a study may be different from the ones that you are seeing. Furthermore, the diagnostic criteria for participants inclusion may be different from the ones that you use. 2) Are your clients presenting with comorbidities that were utilised as exclusion criteria in research? If this is the case, the effectiveness of treatment in clinical practice may not be as significant. 3) Is there any placebo effect that has not been controlled for in research or in clinical practice? Consider potential confounding variables that could contribute to the findings - Take home message - "believe nothing, question everything, trust nobody" 4) Case series are not answering questions. They provide a story about clients' presentation, treatment, and outcomes. Causality cannot be ascertained. Same goes for clinical experience. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message: Evidence guided practice is not easy to implement and at times can cause frustration. I still think that we should try to implement research while keeping an eye on the characteristics of the research sample (participants may be different from the clients we see in clinical practice). It is good practice to keep questioning what we read and hear, not out of disrespect, but to get closer to what actually works. I reviewed another article that you may find useful to take decisions when there is a lack of research available. URL: Available through EBSCO Health Databases for PNZ members. Abstract The value of clinical research can be lost in translation and implementation. One often overlooked issue is whether clinicians can determine if their patient is similar to research participants and, ipso facto, whether the clinician treating that patient will have the same effects as what was reported in a research study. We present five questions and clinical tips for clinicians.
Distal forearm fracture - is bone density screening required?
Rate of bone mineral density testing and subsequent fracture-free interval after distal forearm fracture in the medicare population. Parikh, K., D. Reinhardt, K. Templeton, B. Toby and J. Brubacher (2021). Level of Evidence: 2b Follow recommendation: 👍 👍 👍 Type of study: Prognostic Topic: Bone mass density post forearm fractures - Prognosis for fragility fractures This is a retrospective study assessing the rate of Bone Mass Density (BMD) scans performed after distal forearm fractures (e.g. radius fracture) and whether this testing was effective in reducing the risk of further fractures. A total of 37,473 participants who had not been previously screened for BMD were included. Of these, 80% were female and 85% of the total sample were older than 65 years old. The results show that out of the total, 26% of the people over 65 were screened for bone fragility through BMD. Also, the results showed that those females who had undergone BMD testing after a distal forearm fracture had a lower risk of any other fracture. More precisely, females who underwent a BMD scan had 1.5 extra years of life without a fracture (see picture below). Due to the retrospective nature of the study, it is not possible to determine causality between BMD testing and reduction of fragility fractures. Several factors such as medication prescription for osteoporosis, referral to physiotherapy to reduce risk of fall, or a combination of these and other variables may be responsible for a reduction in risk following BMD testing. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message: Based on what we know today, getting a BMD assessment following a distal forearm fracture may reduce the risk of fragility fractures in our older female clients. It may therefore be worth to ask our clients (especially older females) if they have had a bone density scan in recent years. In addition, we could screen our clients through tools such as the FRAX. Hand therapist can also assess lower limb strength and balance in people with distal radius fracture through simple tests such as the Chair Stand Test and the Timed up and Go test. Recently, a mobile app called Nymbl has been sponsored by ACC and can be used by our older clients to keep active and reduce their risk of falls. If clients are provided with medications such as bisphosphonate, hand therapists should encourage them to take them as prescribed and provide educational resources on osteoporosis (e.g. NIH, NOF, IOF). For further information on our key role in fragility fracture screening, see this synopsis. URL: Available through the Journal of Hand Surgery (American volume) for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Purpose: Distal forearm fractures are prevalent among the Medicare population. Many patients who sustain these fractures have poor bone health and are at increased risk for subsequent fractures. We sought to determine the rate of bone mineral density (BMD) testing and subsequent fragility fracture-free interval after distal forearm fractures in the Medicare population. Methods: We examined the 5% Medicare Standard Analytic File dataset using the PearlDiver Application from 2005 to 2014 to identify patients with distal forearm fractures based on International Classification of Diseases–Ninth Revision and Current Procedural Terminology codes. We queried these records to determine the incidence and timing of BMD testing after fracture and the number of patients who went on to hip or vertebral fractures. Survival curves were generated using Kaplan-Meier analysis with hip or vertebral fracture as the end point. Results: A total of 37,473 patients with distal forearm fractures were identified who did not have BMD testing within the 2 years before fracture. Only 9,605 of this unscreened cohort underwent testing after the fracture (26%) and only 2,684 underwent testing within 6 months (7%). The patients least likely to be tested were males (9%), those aged over 85 years (12%), and those less than 65 years (22%). Twenty percent of these patients sustained a subsequent hip or vertebral fracture (n = 7,326). Patients who underwent testing after fracture had a longer fracture-free interval compared with patients without BMD testing (819 vs 579 days). When separated by sex and controlling for comorbidities, males with BMD testing had a worsened fracture-free interval whereas females had an improved fracture-free interval. Conclusions: Bone mineral density testing is underused nationwide in patients sustaining distal forearm fractures despite current guidelines. Orthopedic surgeons should ensure proper testing of patients because this may be an important time point for intervention.
Resistance training or stretching to improve range of movement?
Strength training is as effective as stretching for improving range of motion: A systematic review and meta-analysis. Afonso, J., et al. (2021). Level of Evidence: 1a- Follow recommendation: 👍 👍 👍 👍 Type of study: Therapeutic Topic: Resistance training and stretching - Range of movement improvements This is a systematic review and meta-analysis assessing the effectiveness of resistance training and stretching exercises on joint range of movement. Eleven RCTs were included in the systematic review, for a total of 452 participants. Participants included had a wide age range, health status (healthy and persistent pain). All the studies were included in the meta-analysis and they were assessed through the Risk of Bias criteria recommended by the Cochrane Review Group. The overall strength of evidence was assessed through the GRADE approach ("low", "very low", "moderate", "high"), which has also been suggested by the Cochrane group for systematic reviews. Resistance training exercises were compared to stretching exercises. Efficacy of intervention was assessed through active and passive range of movement of lower and upper limb joints. Interventions duration ranged betwee 5 and 16 weeks, with a maximum training frequency of 5 and a minimum of 2. The assessment time points varied significantly, and they ranged from 6 to 24 weeks. Moderate quality evidence showed that stretching or resistance training provided similar range of movement improvements by the end of the training regime. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message: Based on what we know today, resistance training or stretching interventions appear to be equally effective in improving range of movement. Either intervention can be used if the goal of treatment is to improve range of movement in our clients. However, if resistance training is well tolerated, it may be the best option. Thus, the international guidelines for physical activity advise on the implementation of resistance training across all ages. Stretching is only mentioned as an adjunct to aerobic and resistance training for pregnant women. Open access URL: Abstract Background: Range of motion (ROM) is an important feature of sports performance and health. Stretching is usually prescribed to improve promote ROM gains, but evidence has suggested that strength training (ST) also improves ROM. However, it is unclear if its efficacy is comparable to stretching. Objective: To perform a systematic review and meta-analysis of randomized controlled trials (RCTs) assessing the effects of ST and stretching on ROM. Protocol: INPLASY: 10.37766/inplasy2020.9.0098. Data sources: Cochrane Library, EBSCO, PubMed, Scielo, Scopus, and Web of Science were consulted in early October 2020, followed by search within reference lists and consultation of four experts. No constraints on language or year. Eligibility criteria (PICOS): (P) humans of any sex, age, health or training status; (I) ST interventions; (C) stretching interventions (O) ROM; (S) supervised RCTs. Data extraction and synthesis: Independently conducted by multiple authors. Quality of evidence assessed using GRADE; risk-of-bias assessed with RoB 2. Results: Eleven articles (n = 452 participants) were included. Pooled data showed no differences between ST and stretching on ROM (ES = -0.22; 95% CI = -0.55 to 0.12; p = 0.206). Sub-group analyses based on RoB, active vs. passive ROM, and specific movement-per-joint analyses for hip flexion and knee extension showed no between-protocol differences in ROM gains. Conclusion: ST and stretching were not different in improving ROM, regardless of the diversity of protocols and populations. Barring specific contra-indications, people who do not respond well or do not adhere to stretching protocols can change to ST programs, and vice-versa.
Answer for - What is the differential diagnosis for this case? - Forearm pain
Acute bilateral compartment syndrome of the forearms. Wrafter, P., O. Kelly and M. O’Shaughnessy (2020). Level of Evidence: 5 Follow recommendation: 👍 Type of study: Diagnostic Incidence: Rare Topic: What is the differential diagnosis? – Case study This is the answer for the case study from last week. The patient was a 43 year old female who had been experiencing 4 hours of forearm pain and paraesthesia in both hands. She was on angiotensin II medications (for hypertension treatment) and she had probably been dehydrated after sunbathing for the whole day. Objectively, there was no evidence of sunburn. Forearms were swollen. Fingers' position was in flexion and excruciating pain was reproduced when an attempting to passively extend the fingers. Pulses were palpable, capillary refill time was 2 seconds. A diagnosis of bilateral forearm compartment syndrome was made, possibly secondary to rhabdomyolysis. Rhabdomyolysis is a pathology leading to muscle break down. This condition is often caused by unaccustomed overexertion, dehydration and myotoxic medications (medications toxic to muscle), which include statins and angiotensin inhibitors. The patient was treated with bilateral forearm fasciotomy, which relieved pressure and lead to a good overall recovery. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message: Compartment syndrome may be considered as a differential diagnosis in clients who report: taking statins or angiotensin inhibitors, recently having overexerted themselves, being dehydrated, or consuming alcohol. Objectively they would present with swollen painful muscles, which cause extreme pain when stretched. If acute compartment syndrome is suspected, clients should immediately be referred to ED. URL: Available through The Journal of Hand Surgery (American Volume) for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract A 43-year-old woman presented to our emergency department with severe bilateral forearm pain. On examination, both forearms were tense and swollen and the patient had excruciating pain, made much worse on passive extension of the fingers. The pain did not resolve with analgesia. The symptoms and clinical examination were highly suspicious for compartment syndrome. However, there was no history of trauma, strenuous physical activity, or any other obvious factor that might have precipitated the onset of a compartment syndrome. The serum creatinine kinase at presentation was greater than 37,000. The patient, however, did have a history of hypertension and was taking losartan, an angiotensinogen II antagonist that has been associated with rhabdomyolysis. The patient was brought to surgery for emergency fasciotomies and made an excellent recovery after surgery. The etiology of this patient’s bilateral compartment syndrome is uncertain but may be a manifestation of drug-induced rhabdomyolysis.
Can botulinum 💉 help with Raynaud's phenomenon?
Botulinum toxin for the treatment of intractable raynaud phenomenon. Gallegos, J. E., D. C. Inglesby, Z. T. Young and F. A. Herrera (2020). Level of Evidence: 4 Follow recommendation: 👍 Type of study: Therapeutic Topic: Raynaud's phenomenon - Botox This is narrative review on the use of botulinum injection therapy in people with Raynaud's Phenomenon (RP). This condition is characterised by painful vasocontriction of vessels within the hand, which may lead to ulceration and digit loss in severe cases (see picture below). Several vasodilation medications have been trialled with varies degrees of success. These medications appear to counteract the excessive sympathetic activity leading to vasocontriction. Botulinum toxins injections have been trialled in small studies and appear to be effective in clients who do not respond to more traditional pharmacological approaches. It has been suggested that Botulinum toxin injections are effective in RP by preventing the recruitment of vessels' smoot muscles. Following a Botulinum injection, follow ups should be completed at 1, 3, 6 months. Common transient complications include pain at the site of injection and intrinsic muscle weakness. Rare complications may include generalised muscle weakness, dyaphagia, troubles breathing, and fatigue. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message: Based on what we know today, Raynaud's phenomenon unresponsive to mainstream medical management may benefit from Botulinum toxin injections. Hand therapist may monitor potential complications such as intrinsic muscle weakness through grip strength after the injections (50% of grip strength comes from the intrinsic muscles of the hand) and reassure clients about this transient impairment. Hand therapist may also monitor for other symptoms (e.g. difficulty breathing), which although rare requires medical attention. URL: Available through The Journal of Hand Surgery (American Volume) for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Raynaud phenomenon (RP) is a condition causing vasospasm in the fingers and toes of patients that can have a significant negative impact on quality of life. This can lead to pain, ulceration, and possible loss of digits. Several pharmacological options are available for treatment. However, RP can often be refractory to traditional modalities, leaving surgery or injections as the next available options. This article provides a review and update on the use of botulinum toxin as an effective therapy for the treatment of RP refractory to medical management.
RA? - To glove or not to glove, that is the question
Clinical and cost effectiveness of arthritis gloves in rheumatoid arthritis (A-GLOVES): randomised controlled trial with economic analysis. Hammond, A., et al. (2021). Level of Evidence: 1b Follow recommendation: 👍 👍 👍 👍 Type of study: Therapeutic Topic: Rheumatoid Arthritis - Gloves This is a randomised, multicentre, double-blind, placebo controlled trial assessing the effectiveness of compression gloves on pain in participants with rheumatoid arthritis (RA) affecting the hand. Participants (N = 206) were included if they were diagnosed with rheumatoid arthritis by a Rheumatology consultant and if they had difficulty sleeping due to hand pain or using their hands during the day. Importantly, participants were excluded if they had previously tried arthritis gloves. Pain was assessed through the numerical rating scale (NRS) at baseline and 12 weeks. Participants and assessors were blinded to treatment allocation. Participants were randomised to either wear arthritis gloves providing between 23 to 32 mmHg of compression (real gloves), or loose fitting gloves providing 15 to 25 mmHg of compression (placebo gloves). Participants were advised to wear the gloves for most of the day but less than 24 hours per day. Participants in both groups were also provided with joint protection advice and hand exercises. The results showed that participants in all groups used the gloves for an average of 5 hours during the day and 6 hours at night. Both groups had minor improvements in pain (1 point out of 10) at 12 weeks, which was not statistically or clinically different between groups. The arthritis gloves increased the cost of care by £129 without providing any significant benefit. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message: Based on what we know today, arthritis gloves do not provide any additional benefit than loose fitting gloves. Providing gloves is more pricey and the expense does not appear to be justified. Instead of providing gloves, it may be more useful to use those resources (money) for an additional session of hand therapy where we can provide them with exercise interventions which have been shown to be effective through the SARAH trial (See previous synopsis with links to free online course). Open access URL: Abstract Arthritis (or compression) gloves are widely prescribed to people with rheumatoid arthritis and other forms of hand arthritis. They are prescribed for daytime wear to reduce hand pain and improve hand function, and/or night-time wear to reduce pain, improve sleep and reduce morning stiffness. However, evidence for their effectiveness is limited. The aims of this study were to investigate the clinical and cost effectiveness of arthritis gloves compared to placebo gloves on hand pain, stiffness and function in people with rheumatoid arthritis and persistent hand pain.
Is joint position sense impaired in people with symptomatic thumb OA?
Joint position sense impairments in older adults with carpometacarpal osteoarthritis: A descriptive comparative study. Ouegnin, A. and K. Valdes (2020). Level of Evidence: 3b Follow recommendation: 👍 👍 Type of study: Aetiologic Topic: Symptomatic thumb osteoarthritis - Proprioception This is a multicentre case-control study assessing differences on proprioception (joint position test) in participants with thumb OA (cases) and healthy participants (controls). A total of 29 participants were included in the study. Thumb OA was diagnosed through clinical examination (e.g. positive grind test) and confirmed through x-ray in some participants but not all. Proprioception (joint position sense) was assessed through a hand held goniometer by asking participants to reproduce a specific thumb position (30 degrees of abduction) after moving the thumb through the full range of abduction. The difference between the target angle and the angle reproduced (error) was recorded. The results showed that participants with thumb OA presented with an average error of 10 degrees while the healthy participants presented with 1 degree error in joint repositioning. This finding was statistically and potentially clinically significant. There are however, a couple of limitations in this study. First, not all participants with thumb OA were matched to a healthy participant. In some cases, when thumb OA was unilateral, the controlateral thumb of the same participant was assessed. This leads to the second limitation, which is a statistical one. For the data analysis, an independent t-test was used, although this test can only be utilised when the two groups (thumb OA and controls) do not include the same participants. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article.
Clinical Take Home Message: Based on what we know today, clients with thumb OA may present with proprioception deficit. It is possible that these impairments may contribute to functional deficits. Currently, there is no evidence supporting the use of specific proprioceptive training and other multidisciplinary approaches, supported by higher quality evidence, may be implemented first. URL: Available through The Journal of Hand Therapy for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Study Design This study has a descriptive-comparative, cross-sectional design. Introduction Sensorimotor (SM) impairments have been observed after common wrist and hand injuries such as distal radius fractures. However, there is a lack of research regarding SM impairments in patients with carpometacarpal (CMC) osteoarthritis (OA). Purpose of the Study This study sought to quantify proprioception deficits in older adults with CMC OA as compared with healthy adults using the joint position sense (JPS) test. Methods The active JPS test was used to measure proprioception function in 29 thumbs with CMC OA and their 29 matched-control healthy counterparts. For comparison, participants with unilateral CMC OA were matched against themselves, whereas those with lateral CMC OA were age matched with a healthy participant. Data analysis was performed to compute the mean error of JPS; an unpaired t test was used to compare the mean error of the non–CMC OA group with the healthy control group. Results The mean positional error measured from subjects with CMC OA was 9.53° compared with 1.32° for the age-matched healthy subjects. The effect size for the difference in means was D = 1.96. Conclusions Thumb SM impairments were found to be greater in subjects with CMC OA than in their healthy counterparts when using the JPS test to assess proprioception.
What is the differential diagnosis for this case? - Forearm pain
Level of Evidence: 5 Follow recommendation: 👍 Type of study: Diagnostic Incidence: Rare Topic: What is the differential diagnosis? – Case study Have a think about this case study. Leave a diagnostic comment if you like. I will publish the diagnosis and treatment reported by the paper next week. The patient was a 43 year old female who had been experiencing 4 hours of forearm pain and paraesthesia in both hands. She was on angiotensin II medications (for hypertension treatment) and she had probably been dehydrated after sunbathing for the whole day. Objectively, there was no evidence of sunburn. Forearms were swollen. Fingers' position was in flexion and excruciating pain was reproduced when an attempting to passively extend the fingers. Pulses were palpable, capillary refill time was 2 seconds. What is it? Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article.
Physical activity: Is it going to help our clients with depression?
Customary physical activity and odds of depression: A systematic review and meta-analysis of 111 prospective cohort studies. Dishman, R. K., C. P. McDowell and M. P. Herring (2021). Level of Evidence: 1a- Follow recommendation: 👍 👍 👍 👍 Type of study: Therapeutic Topic: Mental health - Physical activity This is a systematic review and meta-analysis assessing the effectiveness of physical activity in reducing symptoms of depression. Hundred and eleven observational studies were included in the systematic review, for a total of 1,404 participants. All the studies were included in the meta-analysis and they were assessed through the Risk of Bias criteria recommended by the Cochrane Review Group. The overall strength of evidence was based on some aspects of the GRADE approach, although the evidence was classified as "good", "acceptable", or "poor". Studies were included if physical activity was quantified and comparable to a guideline threshold. The results showed that there is moderate quality evidence showing that physical activity, when performed according to international guidelines, reduces the odds of presenting with depression by 20%. Importantly, there is a dose-response between physical activity and symptoms of depression. A limitation of this study is the inclusion of observational studies, which limits the extrapolation of causality between physical activity and depression. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message: Based on what we know today, physical activity has the potential to reduce depression symptoms. Interesting, effectiveness appears to be dependent on exercise dosage, which needs to follow international guidelines. The type of activity does not appear to matter as long as we meet a sufficient intensity and volume of exercise. Among the many forms of exercise available, a previous meta-analysis has shown that yoga, can reduce depression (see contraindications of yoga classes with a significant amount of meditation). Considering the relationship between depressive symptoms and upper limb recovery as well as mental health and post surgical satisfaction, it may be worthwhile encouraging our clients to follow the international guidelines for physical activity. URL: Available through EBSCO Health Databases for PNZ members. Abstract Objective: To explore whether physical activity is inversely associated with the onset of depression, we quantified the cumulative association of customary physical activity with incident depression and with an increase in subclinical depressive symptoms over time as reported from prospective observational studies. Design: Systematic review and meta-analysis. Data sources MEDLINE, PsycINFO, PsycARTICLES and CINAHL Complete databases, supplemented by Google Scholar.Eligibility criteria Prospective cohort studies in adults, published prior to January 2020, reporting associations between physical activity and depression.Study appraisal and synthesis Multilevel random-effects meta-analysis was performed adjusting for study and cohort or region. Mixed-model meta-regression of putative modifiers. Results: Searches yielded 111 reports including over 3 million adults sampled from 11 nations in five continents. Odds of incident cases of depression or an increase in subclinical depressive symptoms were reduced after exposure to physical activity (OR, 95% CI) in crude (0.69, 0.63 to 0.75; I2=93.7) and adjusted (0.79, 0.75 to 0.82; I2=87.6) analyses. Results: were materially the same for incident depression and subclinical symptoms. Odds were lower after moderate or vigorous physical activity that met public health guidelines than after light physical activity. These odds were also lower when exposure to physical activity increased over time during a study period compared with the odds when physical activity was captured as a single baseline measure of exposure. Conclusion: Customary and increasing levels of moderate-to-vigorous physical activity in observational studies are inversely associated with incident depression and the onset of subclinical depressive symptoms among adults regardless of global region, gender, age or follow-up period.
Diagnostic tests for occult scaphoid fractures?
Reliability of clinical tests for prediction of occult scaphoid fractures and cost benefit analysis of a dedicated scaphoid pathway. Kodumuri, P., A. McDonough, V. Lyle, Z. Naqui and L. Muir (2020). Level of Evidence: 3b Follow recommendation: 👍 👍 Type of study: Diagnostic Topic: Scaphoid fractures - Physical tests This is a retrospective study on the specificity and sensitivity of physical tests for occult schapoid fractures. If a test is very sensitive and its result is negative, you can be more certain that the patient does not have the condition. If the test is specific and its result is positive, you can be more certain that the patient has the condition. Only participants (n = 920) presenting with a negative x-ray for scaphoid fracture (occult fracture) were included in the present study. The diagnostic tests utilised were: tenderness on palpation at the snuff box or scaphoid tubercle, pain on axial compression of the thumb, pinch test, and ulnar deviation. The pinch test simply consisted in a tip to tip pinch between the thumb and index. The test was deemed positive when it caused pain in the client (see table 1 below). MRI was used as the gold standard against which the physical tests were assessed. The results showed that the absence of tenderness on palpation of the snuff box, moderately reduced the probability of an occult scaphoid fracture (see table 2 below - I calculated likelihood ratios for you, which are useful in assessing the diagnostic ability of a test). Tenderness on palpation of the snuff box increased the probability of an occult scaphoid fracture by a small degree (see table 2 below). The combination of multiple tests did not improve diagnostic accuracy. There was however a flaw within the study. When all the physical tests were negative, participants were not referred for an MRI, which is the gold standard against which all the tests were supposed to be assessed against (Thanks Dr. Steve White for pointing out this limitation and having a look at my likelihood ratio calculations). Table 2. Test specificity, sensitivity, and likelihood ratios (I calculated the LR+ and LR-, they were not provided in the article) Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message: Based on what we know today, assessment of snuff box tenderness may be the most useful test for excluding an occult scaphoid fracture. However, given the limitations of the study analysed, it may be still worth repeating a hand x-ray at two weeks to exclude the presence of an occult scaphoid fracture. If you would like more information, look at the previous synopsis on scaphoid fractures requiring surgery. URL: Available through EBSCO Health Databases for PNZ members. Abstract We reviewed the outcomes of our dedicated clinic for suspected scaphoid fractures. The primary outcome measure was to test the reliability of accurately diagnosing an occult scaphoid fracture with a combination of anatomical snuff box, scaphoid tubercle, longitudinal compression tenderness, ulnar deviation and the pinch test. Cost savings of the new patient pathway was our secondary outcome measure. Between December 2016 and March 2020, 922 patients were recruited at a mean of 12 days post-injury. Sixty-five per cent (n=602) with a low clinical suspicion were discharged and 35% (n=320) with a high clinical suspicion had same day MRI scan. Fifty-eight scaphoid fractures were diagnosed and treated with no nonunions reported. Anatomical snuff box tenderness was the most sensitive test (90%). A combination of five tests better excluded an occult fracture (80% accuracy). The dedicated scaphoid clinic pathway resulted in 350 fewer follow-up visits and an overall saving of £59,666.
What are the repercussions of smoking in clients with a distal radius fracture?
A matched comparison of postoperative complications between smokers and nonsmokers following open reduction internal fixation of distal radius fractures. Galivanche, A. R., et al. (2021). Level of Evidence: 2b Follow recommendation: 👍 👍 👍 Type of study: Prognostic Topic: Distal radius fracture – Smoking and prognosis This is a retrospective study assessing the effect of smoking on post surgical complications in participants undergoing open reduction and internal fixation (ORIF) for distal radius fracture. A total of 16,158 participants was included in the study. Of these, 3,062 (19%) we're smokers. Participants' average age ranged between 50 to 58. Complications were measured 30 days after surgery and included infections, re-operation, readmission, cardiovascular events, and mortality. The statistical analyses took into account demographic and comorbidity information to reduce the contribution of confounding factors to the overall results. The results showed that although mortality was not different between smokers and non smokers, all the other complications were more likely in smokers. In particular, the prevalence of any adverse event was 4% in smokers and 3% in non smokers. Clinical Take Home Message: Based on what we know today, smoking not only increases the risk of post surgical infections but also increases the chance of other complications (e.g. re-operation) following distal radius fracture. Hand therapist may therefore ask their clients about their smoking status and whether they are interested in quitting. If they are, a previous synopsis provides information on some of the evidence-based advice to help clients quit smoking. URL: Available through The Journal of Hand Surgery (American Volume) for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Purpose: The purpose of the present study was to identify differences in 30-day adverse events, reoperations, readmissions, and mortality for smokers and nonsmokers who undergo operative treatment for a distal radius fracture. Methods: The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was queried for patients who had operatively treated distal radius fractures between 2005 and 2017. Patient characteristics and surgical variables were assessed. Thirty-day outcome data were collected on serious (SAEs) and minor adverse events (MAEs), as well as on infection, return to the operating room, readmission, and mortality. Multivariable logistic analyses with and without propensity-score matching was used to compare outcome measures between the smoker and the nonsmoker cohorts. Results: In total, 16,158 cases were identified, of whom 3,062 were smokers. After 1:1 propensity-score matching, the smoking and nonsmoking cohorts had similar demographic characteristics. Based on the multivariable propensity-matched logistic regression, cases in the smoking group had a significantly higher rate of any adverse event (AAE) (odds ratio [OR], 1.75; 95% confidence interval [95% CI], 1.28–2.38), serious adverse event (SAE) (OR, 1.75; 95% CI, 1.22–2.50), and minor adverse event (MAE) (OR, 1.84; 95% CI, 1.04–3.23). Smokers also had higher rates of infection (OR, 1.73; 95% CI, 1.26–2.39), reoperation (OR, 2.07; 95% CI, 1.13–3.78), and readmission (OR, 1.83; 95% CI, 1.20–2.79). There was no difference in 30-day mortality rate. Conclusions: Smokers who undergo open reduction internal fixation of distal radius fractures had an increased risk of 30-day perioperative adverse events, even with matching and controlling for demographic characteristics and comorbidity status. This information can be used for patient counseling and may be helpful for treatment/management planning.
Cupping for clients with persistent pain?
Cupping for patients with chronic pain: A systematic review and meta-analysis. Cramer, H., et al. (2020) Level of Evidence: 1a- Follow recommendation: 👍 👍 👍 👍 Type of study: Therapeutic Topic: Cupping effectiveness - Chronic pain This is a systematic review and meta-analysis assessing the effectiveness of cupping for persistent pain. Eighteen RCTs were included in the systematic review, for a total of 1,172 participants. All the studies were included in the meta-analysis and they were assessed through the Risk of Bias criteria recommended by the Cochrane Review Group. The overall strength of evidence was not assessed in the paper but I decided to assess it through the GRADE approach ("low", "very low", "moderate", "high"), which has also been suggested by the Cochrane group for systematic reviews. The effectiveness of cupping was applied to several different musculoskeletal conditions (e.g. lower back pain, osteoarthritis). Efficacy of intervention was assessed through improvements in function or pain intensity (i.e. NRS, VAS). Cupping was compared to no intervention, sham cupping, or an active treatment. In this synopsis I just focused on the results of sham cupping (very low negative pressure or no negative pressure), which provide a reasonable placebo comparison. The treatment duration varied between 3 to 4 weeks, with biweekly treatment frequency. There is low quality evidence suggesting that sham cupping is as effective as cupping (both groups improved), without any statistically significant difference between the two interventions for both pain intensity and disability. Clinical Take Home Message: Based on what we know today, cupping is no more effective than placebo in clients with persistent pain. If you have applied it in clinical practice with significant success, it may be due to the contextual effect of your treatment session rather than any specific mechanism associated with cupping. Similar results have been shown when comparing cortisone injections or acupuncture for thumb OA, PRP or MWMs for tennis elbow to placebo interventions. They all work in clinical practice but the results is probably due to the placebo effect. URL: Available through EBSCO Health Databases for PNZ members. Abstract There is a growing interest in nonpharmacological pain treatment options such as cupping. This meta-analysis aimed to assess the effectiveness and safety of cupping in chronic pain. PubMed, Cochrane Library, and Scopus were searched through November 2018 for randomized controlled trials on effects of cupping on pain intensity and disability in patients with chronic pain. Risk of bias was assessed using the Cochrane risk of bias tool. Of the 18 included trials (n =1,172), most were limited by clinical heterogeneity and risk of bias. Meta-analyses found large short-term effects of cupping on pain intensity compared to no treatment (standardized mean difference [SMD] = −1.03; 95% confidence interval [CI] = −1.41, −.65), but no significant effects compared to sham cupping (SDM = −.27; 95% CI = −.58, .05) or other active treatment (SMD = −.24; 95% CI = −.57, .09). For disability, there were medium-sized short-term effects of cupping compared to no treatment (SMD = −.66; 95% CI = −.99, −.34), and compared to other active treatments (SMD = −.52; 95% CI = −1.03, −.0028), but not compared to sham cupping (SMD = −.26; 95% CI = −.57,.05). Adverse events were more frequent among patients treated with cupping compared to no treatment; differences compared to sham cupping or other active treatment were not statistically significant. Cupping might be a treatment option for chronic pain, but the evidence is still limited by the clinical heterogeneity and risk of bias. Perspective: This article presents the results of a meta-analysis aimed to assess the effectiveness and safety of cupping with chronic pain. The results suggest that cupping might be a treatment option; however, the evidence is still limited due to methodical limitations of the included trials. High-quality trials seem warranted.
A2 pulley injury, what to do?
A potential classification schema and management approach for individuals with A2 flexor pulley strain. Cooper, C. and P. LaStayo (2020). Level of Evidence: 5 Follow recommendation: 👍 Type of study: Therapeutic Topic: A2 pulley injury - Assessment and treatment This is an expert opinion article on assessment and treatment of A2 pulley injury. These injuries are very common in rock climbers and they do occur most often while crimping (see picture below). The classification suggested in this article (i.e. severe, moderate, and mild - see table below) is based on assessment of pain, active range of movement, resisted tests, and palpation. According to this classification system, severe pulley injury should be immobilised except for gentle active range of movement exercises and climbing training should be significantly modified. A mild injury should be managed with progressive resistance training and hang board training (avoiding crimping). With a moderate injury, the routine would be similar to a mild injury, however, the intensity would be lower. Additionally, H tape and pulley orthoses may be utilised to control symptoms in adjunct to climbing volume modification. Clinical Take Home Message: Based on what we know today, we may decide to classify A2 pulley injuries according to the assessment procedures described in this article. The only issue with a symptomatic driven assessment is that several factors can increase or decrease pain intensity independently of tissue damage (see the overuse injury and fracture TOP synopses). Triangulation of clinical presentation with investigations such as ultrasound and x-ray may help in the differential diagnosis (e.g. stress fractures) and may provide a more objective assessment of tissue damage (if any). If you are interested in other climbing injuries, see this previous synopsis. URL: Available through the Journal of Hand Therapy for HTNZ members. Available through EBSCO Health Databases for PNZ members. No abstract available
Lots of our patients present with osteopenia and sarcopenia - what can we you do?
Non-pharmacological interventions in osteosarcopenia: A systematic review. Atlihan, R., B. Kirk and G. Duque (2020). Level of Evidence: 1a- Follow recommendation: 👍 👍 👍 👍 Type of study: Prognostic, Preventative, Therapeutic Topic: Musculoskeletal and bone health – Resistance training This is a systematic review of randomised controlled studies assessing the effect of resistance training on muscle and bone health in older participants with sarcopenia (loss of muscle mass) and osteopenia/osteoporosis (loss of bone density). Two studies were included for a total of 106 participants (average age range: 64-79 years old). The overall strength of evidence was assessed through the GRADE approach ("low", "very low", "moderate", "high"), which has also been suggested by the Cochrane group for systematic reviews. Participants took part in upper and lower limb resistance training 2-3/week for 3 to 18 months. There was moderate quality evidence that resistance training improved muscle strength and muscle mass. Low quality evidence suggests that by the 6 months mark, bony density improved. Clinical Take Home Message: Based on what we know today, resistance training improves our clients' muscle strength and mass in the short and long term. Furthermore, if performed for at least 6 months, resistance training has the potential to maintain if not improve bone density in our older clients. As hand therapist we are privileged to see several older patients after a distal radius fracture. These clients are often fragile and would definitely benefit from resistance training. We may also invite our clients to take at least 8,000 steps/day as a greater number of daily steps has been shown to reduce mortality in previous studies. In addition, general resistance training may increase grip strength, which is another predictor of mortality. URL: Available through EBSCO Health Databases for PNZ members. Abstract BACKGROUND: Osteosarcopenia is a geriatric syndrome defined by the concomitant presence of osteopenia/osteoporosis (loss of bone mineral density (BMD)) and sarcopenia (loss of muscle mass and/or function), which increases the risk of falls, fractures, and premature mortality. OBJECTIVE: To examine the efficacy of non-pharmacological (exercise and/or nutritional) interventions on musculoskeletal measures and outcomes in osteosarcopenic adults by reviewing findings from randomized controlled trials (RCTs). METHODS: This review was registered at PROSPERO (registration number: CRD42020179292) and conducted in accordance with the PRISMA guidelines. Electronic databases were searched for RCTs assessing the effect of at least one non-pharmacological intervention (any form of exercise and/or supplementation with protein, vitamin D, calcium or creatine) on any musculoskeletal measure/outcome of interest (BMD, bone strength/turnover, muscle mass and strength, physical performance, falls/fractures) in adults with osteosarcopenia as defined by any proposed criteria. RESULTS: Two RCTs (of n=106 older osteosarcopenic adults (≥65 years)) assessing the effects of progressive resistance training (RT) (via resistance bands or machines; 2-3 times/week; ~60 minutes in duration) were eligible for inclusion. The two RCTs demonstrated moderate quality evidence that RT increases muscle mass, strength, and quality, with changes in strength and quality occurring before muscle mass (12 vs 28 weeks). There was low quality evidence that RT increases lumbar spine BMD and maintains total hip BMD when performed for 12 and 18 months, respectively, and moderate quality evidence that RT has no effect on markers of bone turnover or physical performance. No major adverse effects were recorded in either of the RCTs. There were no eligible RCTs examining the impact of nutritional interventions. CONCLUSION: Chronic RT is safe and effective at potentiating gains in muscle mass, strength, and quality, and increasing or maintaining BMD in older osteosarcopenic adults. No RCT has examined the effects of protein, vitamin D, calcium, or creatine against a control/placebo in this high-risk population.
Answer for - What is the differential diagnosis for this case? - Little finger pain
Extensive Tumoral Calcinosis of the Hand. Gonzalez, M., M. Rettig and O. Ayalon (2020) Level of Evidence: 5 Follow recommendation: 👍 Type of study: Diagnostic Topic: What is the differential diagnosis? – Case study This is the answer for the case study from last week. The patient was a 34 years old female with a six months history of atraumatic painless mass on the volar aspect of the right little finger (especially at the middle phalanx). The mass had grown significantly in the last few weeks and it was now associated with pain and blanching of the skin. Objectively, they were unable to bend the right little finger. The patient reported a history of hypothiroidisn and Sjogren's syndrome. The x-ray image is shown below. The results suggested the presence of a tumoral calcinosis on the volar aspect of the right little finger. Surgery was performed to remove the mass which had a chalk like consistency. Six weeks post surgery, the pain had resolved and the range of movement had significantly improved. URL: Available through The Journal of Hand Surgery (American Volume) for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Tumoral calcinosis is a rare and benign subtype of calcinosis cutis, a group of disorders involving soft tissue calcium deposition. Only 250 cases have been described since 1898; hand involvement is exceedingly rare. We report a case of extensive calcinosis within the flexor sheath of the little finger. Presentation included a painful mass over the volar aspect of the little finger, restricted digit motion, and skin compromise at the site of the mass. Surgical debulking was performed resulting in restoration of finger function.
What is the differential diagnosis for this case? - Little finger pain
Level of Evidence: 5 Follow recommendation: 👍 Type of study: Diagnostic Topic: What is the differential diagnosis? – Case study Have a think about this case study. Leave a diagnostic comment if you like. I will publish the diagnosis and treatment reported by the paper next week. The patient was a 34 years old female with a six months history of atraumatic painless mass on the volar aspect of the right little finger (especially at the middle phalanx). The mass had grown significantly in the last few weeks and it was now associated with pain and blanching of the skin. Objectively, they were unable to bend the right little finger. The patient reported a history of hypothyroidism and Sjogren's syndrome. The x-ray image is shown below. What is it?
Active vs passive interventions for lateral epicondylalgia - What's best?
Exercise interventions in lateral elbow tendinopathy have better outcomes than passive interventions, but the effects are small: A systematic review and meta-analysis of 2123 subjects in 30 trials. Karanasios, S., et al. (2020). Level of Evidence: 1a- Follow recommendation: 👍 👍 👍 👍 Type of study: Therapeutic Topic: Lateral epicondylalgia - Eccentric resistance training This is a systematic review and meta-analysis of randomised controlled trials assessing the effectiveness of active vs passive interventions for lateral epicondylalgia. Thirty randomised controlled trials were included for a total of 2,123 participants (21 studies were included in the meta-analysis). The results from this systematic review and meta-analysis were assessed through the GRADE approach (suggested by the Cochrane Group), which scores the evidence as "very low", "low", "moderate", or "high" quality. Efficacy of intervention was assessed through changes in pain, pain-free grip strength (PFG), and elbow disability. Pain was assessed through the visual analogue scale (VAS) or the numerical rating scale (NRS), pain-free grip strength (PFG), and elbow disability through the Patient-Rated Tennis Elbow Evaluation (PRTEE) and the Disability of the Arm, Shoulder, and Hand (DASH) questionnaire. Follow-up times ranged between very short term (less than 2 months), short term (2-3 months), mid-term (3-12 months), and long term (more than 12 months). The results showed that there was low to very low quality evidence suggesting that exercise provided clinically and statistically significant greater improvements in PFG compared to cortisone injections at all time points. No difference was noted between exercise or wait and see. Eccentric exercises were not superior to concentric exercises. Clinical Take Home Message: Based on what we know today, exercises are more effective than cortisone injections in both the short and long term for clients with lateral epicondylalgia. This is not surprising considering the results from previous trials showing that people undergoing cortisone injection for lateral epicondylalgia are twice as likely to present with a recurrence at one year compared to somebody receiving a saline (placebo) injection. Any form of resistance exercise appears to be useful and eccentric exercises do not appear to be superior to concentric exercises, although they may provide with greater analgesia once the acute reactive tendinopathy has subsided. If clients are happy to wait and see, they may improve without the need of any intervention. URL: Available through EBSCO Health Databases for PNZ members. Abstract Objective: To evaluate the effectiveness of exercise compared with other conservative interventions in the management of lateral elbow tendinopathy (LET) on pain and function.Design Systematic review and meta-analysis. Methods: We used the Cochrane risk-of-bias tool 2 for randomised controlled trials (RCTs) to assess risk of bias and the Grading of Recommendations Assessment, Development and Evaluation methodology to grade the certainty of evidence. Self-perceived improvement, pain intensity, pain-free grip strength (PFGS) and elbow disability were used as primary outcome measures.Eligibility criteria RCTs assessing the effectiveness of exercise alone or as an additive intervention compared with passive interventions, wait-and-see or injections in patients with LET. Results: 30 RCTs (2123 participants, 5 comparator interventions) were identified. Exercise outperformed (low certainty) corticosteroid injections in all outcomes at all time points except short-term pain reduction. Clinically significant differences were found in PFGS at short-term (mean difference (MD): 12.15, (95% CI) 1.69 to 22.6), mid-term (MD: 22.45, 95% CI 3.63 to 41.3) and long-term follow-up (MD: 18, 95% CI 11.17 to 24.84). Statistically significant differences (very low certainty) for exercise compared with wait-and-see were found only in self-perceived improvement at short-term, pain reduction and elbow disability at short-term and long-term follow-up. Substantial heterogeneity in descriptions of equipment, load, duration and frequency of exercise programmes were evident. Conclusions: Low and very low certainty evidence suggests exercise is effective compared with passive interventions with or without invasive treatment in LET, but the effect is small. PROSPERO registration number CRD42018082703.
Entrapment neuropathies? Could the thoracic outlet contribute to symptoms?
Nerve compression syndromes of the shoulder. Patetta, M. J., E. Naami, B. M. Sullivan and M. H. Gonzalez (2020) Level of Evidence: 5 Follow recommendation: 👍 Type of study: Diagnostic, Therapeutic Topic: Thoracic outlet - Symptoms and treatment This is a narrative review on entrapment neuropathies of the shoulder. I selected to cover the neurogenic thoracic outlet syndrome as this is the one that may present with symptoms in forearm and hand. In addition, neurogenic thoracic outlet syndrome constitute 90% of all the thoracic outlet syndromes. In term of diagnostic tests, there is not one single test that present with high specificity (ability to confirm the diagnosis) or sensitivity (ability to exclude the diagnosis). Nerve conduction studies rarely show any objective impairments, making the diagnosis even more challenging. Conservative treatment is always advocated before any surgical approach. The positive news is that if surgery is required, 56% to 89% of clients report improvements in their symptoms following the surgical procedure. Clinical Take Home Message: Based on what we know today, thoracic outlet syndrome may be in part responsible for vague upper limb symptoms reported by clients. Unfortunately, there is not one single test that is useful to confirm or exclude the diagnosis. It may be useful to utilised tests such as the arm squeeze test, Spurling's, Cx distraction, and neurodynamic tests to confirm or exclude the presence of a cervical radiculopathy. Dermatomal patterns are not always consistent in presence of a cervical radiculopathy and the presence of vague symptoms alone does not increase the likelihood of a thoracic outlet syndrome. In clients with a potential thoracic outlet syndrome it is worth remembering that psychological factors (e.g. anxiety, depression, pain catastrophising) have been shown to mediate pain/recovery. Light aerobic exercise (e.g. walking, cycling) may be a helpful intervention to reduce symptoms in clients with neurogenic thoracic outlet syndrome. URL: Available through EBSCO Health Databases for PNZ members. Abstract Nerve compression syndromes of the shoulder contribute to pain, paresthesia, and weakness of the upper extremity. This review examines the recent literature regarding thoracic outlet syndrome, suprascapular neuropathy, long thoracic nerve palsy, and quadrilateral space syndrome. Overlapping features are common among shoulder pathologies, and thus, key anatomical features, pathophysiology, clinical manifestations, diagnostic techniques, and treatments are highlighted for all aforementioned conditions.
Neural mobilisation for nerve-related arm and neck pain?
Effect of neural mobilization on nerve-related neck and arm pain: A randomized controlled trial. Basson, C. A., A. Stewart, W. Mudzi and E. Musenge (2020). Level of Evidence: 1b Follow recommendation: 👍 👍 👍 👍 Type of study: Therapeutic Topic: Nerve pain - Usual care vs usual care plus neural mobilisation This is a randomised, single-blind, controlled trial assessing the effectiveness of nerve gliding on pain, function, and quality of life in participants with nerve-related neck and arm pain. Participants (N = 78) were included if they presented with clinical signs of neck pain associated with nerve-related symptoms (participants had to had positive neurodynamic tests and allodynia on peripheral nerve palpation). Pain was assessed through the Numerical Rating Scale (NRS), function through the Patient Specific Functional Scale (PSFS), and quality of life through the EuroQol-5. Participants were randomised (2:1) to either usual care (n = 25), or usual care plus neural mobilisation (n = 53). The usual care included cervical and thoracic mobilisation, exercises and the advice to keep active. The experimental group received the usual care plus mobilisation of the tissues surrounding the peripheral nerve involved (e.g. pronator teres for median nerve). On average, participants were treated over 4 sessions. Outcomes were measured at baseline, 3, 6 weeks, 6 months, and one year. The results showed that participants in all groups improved by one year. There were no differences between groups in function and quality of life. Pain was significantly better at 6 months for the usual care plus neural mobilisation, however, this difference was not clinically relevant (see picture below). Clinical Take Home Message: Based on what we know today, the addition of neural mobilisation to an evidence based program for people with nerve-related cervical and arm pain does not provide better results. In contrast, neural mobilisation may be helpful for clients presenting with isolated carpal tunnel syndrome. If you are interested, you can also reduce the likelihood of clients undergoing carpal tunnel surgery by adding a night splint and education to your intervention. Finally, have a look at what is the most effective and safe nerve gliding approach for carpal tunnel syndrome. URL: Available through EBSCO Health Databases for PNZ members. Abstract Purpose: Neural mobilization (NM) is often used to treat nerve-related conditions, and its use is reasonable with nerve-related neck and arm pain (NNAP). The aims of this study were to establish the effect of NM on the pain, function, and quality of life (QOL) of patients with NNAP and to establish whether high catastrophizing and neuropathic pain influence treatment outcomes. Method: A randomized controlled trial compared a usual-care (UC; n = 26) group, who received cervical and thoracic mobilization, exercises, and advice, with an intervention (UCNM; n = 60) group, who received the same treatment but with the addition of NM. Soft tissue mobilization along the tract of the nerve was used as the NM technique. The primary outcomes were pain intensity (rated on the Numerical Pain Rating Scale), function (Patient-Specific Functional Scale), and QOL (EuroQol-5D) at 3 weeks, 6 weeks, 6 months, and 12 months. The secondary outcomes were the presence of neuropathic pain (using the Neuropathic Diagnostic Questionnaire) and catastrophizing (Pain Catastrophising Scale). Results: Both groups improved in terms of pain, function, and QOL over the 12-month period (p < 0.05). No between-groups differences were found at 12 months, but the UCNM group had significantly less pain at 6 months (p = 0.03). Patients who still presented with neuropathic pain (p < 0.001) and high pain catastrophizing (p = 0.02) at 6- and 12-mo follow-ups had more pain. Conclusions: Both groups had similar improvements in function and QOL at 12-month follow-up. The UCNM group had significantly less pain at 6-month follow-up and a lower mean pain rating at 12-month follow-up, although the difference between groups was not significant. Neuropathic pain is common among this population and, where it persisted, patients had more pain and functional limitations at 12-mo follow-up.
Lumbrical tear, what to do?
Lumbrical muscle tear: Clinical presentation, imaging findings and outcome. Lutter, C., A. Schweizer, V. Schöffl, F. Römer and T. Bayer (2018). Level of Evidence: 4 Follow recommendation: 👍 👍 Type of study: Diagnostic, Therapeutic Topic: Lumbricals' tear - Imaging and treatment This is case series on lumbrical muscle tear's diagnosis and treatment. A total of 60 clients with a positive lumbrical stress test (see figure below) were included in the study. This type of injury occurs when a finger (middle/ring finger) is forcefully extended while the other fingers are actively flexed. Rock climbers are at greatest risk for lumbricals muscles tears. The diagnostic recommendation is to request an US investigation to determine the lesion grade: Grade I (microtear - non visible on US), a Grade II or III (both visible on US). In case of a grade I tear, gentle intrinsic minus pain-free stretching is performed for 4-6 weeks followed by graded lumbricals loading. For grade II, buddy taping is recommended for a max of 8 weeks, followed by a similar treatment as per grade I. For a grade III, immobilisation with an ulnar gutter including MF, RF, and LF to the proximal phalanx is recommended for 2 weeks. This is followed by the same treatment as per grade II lesion. Clinical Take Home Message: Based on what we know today, the lumbrical stress test is a quick way to assess the involvement of the 3rd or 4th lumbricals. An US has been indicated as the most appropriate way to confirm a clinical diagnosis, especially if there is a grade II or III, which is visible through this investigation. Considering the potential role of lumbrical in finger proprioception (see previous synopsis), the inclusion of dexterity exercises may be appropriate in this subgroup of clients. URL: Available through EBSCO Health Databases for PNZ members. Abstract The incidence of lumbrical muscle tear is increasing due to the popularity of climbing sport. We reviewed data from 60 consecutive patients with a positive lumbrical stress test, including clinical examination, ultrasound and clinical outcomes in all patients, and magnetic resonance imaging in 12 patients. Fifty-seven patients were climbers. Lumbrical muscle tears were graded according to the severity of clinical and imaging findings as Grade I-III injuries. Eighteen patients had Grade I injuries (microtrauma), 32 had Grade II injuries (muscle fibre disruption) and 10 had Grade III injuries (musculotendinous disruption). The treatment consisted of adapted functional therapy. All patients completely recovered and were able to return to climbing. The healing period in Grade III injuries was significantly longer than in the patients with Grade I or II injuries (p < 0.001). We recommend evaluation of specific clinical and imaging findings to grade the injuries and to determine suitable therapy.
Answer for - What is the differential diagnosis for this case? - Wrist pain
Osteosarcoma of the Trapezium. Ferrando, E., Navarro, J., Rojas, R., Mata, D., & Silvestre, A. (2020) Level of Evidence: 5 Follow recommendation: 👍 Type of study: Diagnostic Topic: What is the differential diagnosis? – Case study This is the answer for the last week case study. The patient was a 51 years old female with a three years history of painless palpable firm mass on the dorsal and radial aspect of the wrist. Subjectively, they reported swelling and pain in the last two months. The patient reported a history of hypertension. The x-ray that you see below revealed a calcification on the radial aspect of the wrist. An MRI was completed, which revealed a soft tissue mass. Surgery was performed to remove the mass and histological studies revealed that it was a low grade osteosarcoma. URL: Available through EBSCO Health Databases for PNZ members. Abstract Osteogenic sarcoma is a malignant tumor that rarely affects the hand. When it does, it most often involves the phalanges or metacarpal heads. We present the case of a 51-year-old woman with a low-grade osteosarcoma affecting the trapezium bone of her left hand. A total trapeziectomy with partial removal of the first metatarsal, scaphoid, trapezoid, and capitate bones was performed, and no adjuvant therapy was administered. Six years after the intervention, the patient is disease-free, with excellent functionality and yearly imaging tests showing no signs of recurrence.
How does diabetes affect recovery after trigger finger surgery?
Functional outcomes of trigger finger release in non-diabetic and diabetic patients. Stirling, P. H. C., P. J. Jenkins, A. D. Duckworth, N. D. Clement and J. E. McEachan (2020) Level of Evidence: 2b Follow recommendation: 👍 👍 Type of study: Prognostic Topic: Trigger finger surgery - diabetes and functional recovery This retrospective study assessed the effect of diabetes on functional recovery following surgery for trigger finger (A1 pulley release). Functional recovery was measured through the QuickDASH questionnaire, and the presence of diabetes was self-reported by participants. A total of 192 participants were recruited at baseline and they were assessed pre-surgery and one year post-surgery. The results showed that 25% (n = 49) of the participants reported diabetes (no information was provided on number of participants with Type 1 or Type 2 diabetes). Participants' function at baseline was significantly worst in diabetic subjects (16 points worse). However, improvements in functional outcome following surgery were similar in both the diabetic (13 points improvement) and non-diabetic participants (9 points improvement). Clinical Take Home Message: Based on what we know today, clients affected by trigger finger and diabetes may have greater disability than clients without diabetes. It may be worth checking with the client if they are compliant with their diabetes medications (e.g. metformin) and if they have had a check up with their GP recently. The functional outcomes of A1 pulley release are similar between clients with and without diabetes. This synopsis is a nice addition to the one written on the effect of diabetes on functional recovery following distal radius fracture. URL: Available through EBSCO Health Databases for PNZ members. Abstract We compared the functional outcomes, health-related quality of life, and satisfaction in diabetic and non-diabetic patients undergoing A1 pulley release for trigger finger in 192 patients. Preoperative and postoperative Quick Disabilities of the Arm, Shoulder and Hand questionnaire (Quick DASH), EuroQol-5 dimensions, and satisfaction scores were collected prospectively over a 6-year period. These patients had a mean follow-up of 14 months (range 11?40) after surgery. There were 143 patients (143 trigger fingers) without diabetes and 49 patients (49 trigger fingers) with diabetes. We found overall QuickDASH improvement was the same in both groups (-4.5 points). Patient satisfaction rates were comparable in both groups (90% versus 96%), and no significant difference in postoperative health-related quality of life was observed. No complications were reported in either group. We conclude from this study that A1 pulley release leads to similar functional improvement and high patient satisfaction at one year postoperatively in diabetic and non-diabetic patients.
What is the differential diagnosis for this case? - Wrist pain
Level of Evidence: 5 Follow recommendation: 👍 Type of study: Diagnostic Topic: What is the differential diagnosis? – Case study Have a think about this case study. Leave a diagnostic comment if you like. I will publish the diagnosis and treatment reported by the paper next week. The patient was a 51 years old female with a three years history of painless palpable firm mass on the dorsal and radial aspect of the wrist. Subjectively, they reported swelling and pain in the last two months. The patient reported a history of hypertension. X-ray images are shown below. What is it?
Do you know which hand muscles were originally called earthworms?
The lumbricals are not the workhorse of digital extension and do not relax their own antagonist. Crowley, J. S., M. Meunier, R. L. Lieber and R. A. Abrams (2020) Level of Evidence: 5 Follow recommendation: 👍 Type of study: Anatomical Topic: Lumbricals' action - Action and interaction This is biomechanical study on the role of lumbricals in the hand. The major points of this article are reported below: - Lumbricals are not able to produce enough force to counteract flexor digitorum profondus (FDP) or superficialis (FDS) at the pipj or dipj. This is due to their small cross sectional area when compared to FDP or FDS. - Lumbricals are weak mcpj flexors compared to the interossei muscles as their cross sectional area is 1/15 of the interossei - Lumbricals present the greatest number of muscle spindles (used for proprioception) among all the muscles of the upper limb Considering these facts, it is hypothesised that lumbricals have a proprioceptive role important for finger dexterity. Clinical Take Home Message: Based on what we know today, the lumbricals are more likely to have a sensory function rather than a force or movement generating capability in healthy clients. A possible exception is the presence of paradoxical flexion following laceration or avulsion of FDP. Knowing that lumbricals are also involved in proprioception may direct us to include a dexterity treatment component in those clients presenting with a grade III or IV lumbrical strain or tear. This injury may occur in climbers following a forced middle or ring finger extension while having the other fingers curled in your hand (Fall while on a mono or small ledge holds). URL: Available through The Journal of Hand Surgery (American Volume) for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract That the lumbrical muscles are the workhorse of digital extension and that they can relax their own antagonist have been time-honored principles. However, we believe this dogma is incorrect and an oversimplification. We base our assertion on anatomy, innervation, and the notion that muscle architecture is the most important determinant of muscle function. Wang and colleagues proposed the lumbrical to be a sophisticated tension monitoring device. We elaborate on their well-supported thesis, further proposing that the lumbricals also function as a constant tension spring within the closed loop composed of the digital flexors and the extensor mechanism.
Are your clients with symptomatic hand OA at greater risk of cardiovascular disease?
Hand osteoarthritis in relation to mortality and incidence of cardiovascular disease: Data from the Framingham heart study. Haugen, I. K., Ramachandran, V. S., Misra, D., Neogi, T., Niu, J., Yang, T., . . . Felson, D. T. (2015) Level of Evidence: 2b Follow recommendation: 👍 👍 👍 Type of study: Prognostic Topic: Symptomatic hand OA - Mortality prediction This is a prospective cohort study assessing the risk of cardiovascular disease and associated mortality in people with symptomatic hand OA. A total of 1,348 participants were included at baseline (1948-1953) and followed up for 60 years (2008-2011). Participants' offspring were included as well in this study. Participants were 50 to 75 years old at baseline. Participants were divided into two groups: participants with symptomatic and radiographic evidence of hand OA, and participants with radiographic hand OA only. The results showed that participants with symptomatic hand OA were at least twice as likely to present with a significant cardiovascular condition (e.g. coronary heart disease) during the course of their life compared to the rest of the sample. People with radiographic but not symptomatic hand OA were at no greater risk that the rest of the population. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message: Based on what we know today, people with symptomatic hand OA are at least 2 times more likely to develop cardiovascular disease. We should therefore encourage our clients with this condition to keep as active as possible. Remember that previous research showed a relation between grip strength and mortality and walking and mortality. Have a look at the recent WHO 2020 guidelines on physical activity, which will give you an idea of the level and type of exercise that we should recommend to our clients. Clients who do not present with symptomatic hand OA but x-ray evidence of OA do not seem to be at greater risk then other people to develop cardiovascular disease. Open Access URL: Abstract Objectives: To study whether hand osteoarthritis (OA) is associated with increased mortality and cardiovascular events in a large community based cohort (Framingham Heart Study) in which OA, mortality and cardiovascular events have been carefully assessed. Methods: We examined whether symptomatic (≥1 joint(s) with radiographic OA and pain in the same joint) and radiographic hand OA (≥1 joint(s) with radiographic OA without pain) were associated with mortality and incident cardiovascular events (coronary heart disease, congestive heart failure and/or atherothrombotic brain infarction) using Cox proportional hazards models. In the adjusted models, we included possible confounding factors from baseline (eg, metabolic factors, medication use, smoking/alcohol). We also adjusted for the number of painful joints in the lower limb and physical inactivity. Results: We evaluated 1348 participants (53.8% women) with mean (SD) age of 62.2 (8.2) years, of whom 540 (40.1%) and 186 (13.8%) had radiographic and symptomatic hand OA, respectively. There was no association between hand OA and mortality. Although there was no significant relation to incident cardiovascular events overall or a relation of radiographic hand OA with events, we found a significant association between symptomatic hand OA and incident coronary heart disease (myocardial infarction/coronary insufficiency syndrome) (HR 2.26, 95% CI 1.22 to 4.18). The association remained after additional adjustment for pain in the lower limb or physical inactivity. Conclusions: Symptomatic hand OA, but not radiographic hand OA, was associated with an increased risk of coronary heart disease events. The results suggest an effect of pain, which may be a possible marker of inflammation.
A surgeon's opinion on thumb OA 💉
Trapeziometacarpal joint arthritis: A personal approach to its treatment. Davis, T. R. C. (2020) Level of Evidence: 5 Follow recommendation: 👍 Type of study: Therapeutic Topic: Thumb OA - Surgeon's point of view This is a surgeon's opinion on treatment of thumb osteoarthritis (OA). I particularly enjoyed the open minded approach that this surgeon has about thumb OA. They recognise the limitations of their own approach and they are ready to change their practice in light of new evidence, which will inevitably arise in the future. The approach suggested is to delay surgery (e.g. trapeziotomy) as much as possible. This is based on evidence suggesting that a limited proportion of the pain is correlated with radiographic findings and that a flare in pain may resolve within 6 months to a year. Furthermore, conservative treatments may help in the resolution or reduction of pain. More importantly, they recognise the significant impact of psychological factors in the exacerbation of pain (which is the driver for surgery) and the potential effect of other conservative interventions in the management of thumb OA. Cortisone injections are suggested as an additional treatment option. They report being happy to provide more than 3 injections if the benefits last for more than 6 months. A final point was made on the lack of evidence suggesting greater effectiveness of trapeziotomy alone vs trapeziotomy plus suspension arthroplasty. No differences have been identified between these approaches at short and long term in randomised controlled trials. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message: Based on what we know today, thumb OA should be initially treated conservatively. Conservative treatments should last between 6 to 12 months and consider other factors contributing to pain other than radiographic evidence of thumb OA. Psychological factors (e.g. anxiety, depression, pain catastrophising) have been shown to mediate pain/recovery and should be taken into account more than the degree of "degeneration" of the joint (up to 75% of people with radiographic evidence of thumb OA do not have pain). Have a look at conservative treatments for hand OA (e.g. manual therapy/exercise, illusory resizing, mental health component), we can make a difference! URL: Available through EBSCO Health Databases for PNZ members. Abstract Many hand surgeons have fixed beliefs on how trapeziometcarpal (TMC) osteoarthritis should be treated. However, not all hand surgeons share the same fixed beliefs, so different factions of hand surgeons can hold contradictory beliefs. Many retain their fixed beliefs, rather than reconsidering them, when the best available evidence challenges them. The problem causing this heterogeneity of fixed beliefs is the lack of high-quality evidence that can withstand critical appraisal and cannot be ignored or simply dismissed by those with rigid contradictory beliefs. This article examines some of the dogmas surrounding the treatment of TMC osteoarthritis.
Diabetic clients are at much higher risk of amputation following a washout procedure
Factors affecting suboptimal outcomes in hand infections. Botma, N., McGuire, D., Koller, I., & Solomons, M. (2020) Level of Evidence: 4 Follow recommendation: 👍 👍 Type of study: Prognostic Topic: Revision surgery following infection – Diabetes This is a non-peer reviewed prospective study assessing the risk factors for the development of complications following a hand washout procedure. A total of 674 participants diagnosed with a hand infection were included in the study. The results showed that being diabetic increased the risk of a second infection by at least twofold. In people with diabetes, delayed presentation to ED (i.e. more than 1 week) increased the odds of amputation due to sepsis by 6 times. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message: Based on what we know today, diabetes is a risk factor for the development of a secondary infection following a washout procedure. A prompt referral to ED is warranted given the substantial risk of sepsis and potential amputation in clients with diabetes. This synopsis is a nice addition to a previous synopsis on risk factors for hand infection. URL: Available through EBSCO Health Databases if you have access (PNZ) No abstract available.
Can type 2 diabetes contribute to the development of lateral epicondylalgia?
The impact of type 2 diabetes on the development of tendinopathy. Cannata, F., Vadalà, G., Ambrosio, L., Napoli, N., Papalia, R., Denaro, V., & Pozzilli, P. (2020) Level of Evidence: 5 Follow recommendation: 👍 Type of study: Prognostic Topic: Lateral epicondylalgia – Risk factors This is a narrative review assessing the connection between type 2 diabetes and tendinopathy, and exploring the potential treatment pathways. Type 2 diabetes is associated with chronic hyperglycemia (high levels and significant fluctuations of glucose in the bloodstream - especially if not treated) and poses several risks for tendons. In particular, it reduces the loading threshold at which tendons enter a degenerative phase, and it reduces the ability of tendon to heal due to tenocytes oxidative stress and impairment of stem cells activity. This is not to mention the effect that hyperglycemia has on connective and vascular tissue. Thus, glycation of connective tissue makes it more stiff and less resilient to loading. Vascular impairments lead to a reduction of neoangiogenesis (formation of new vessels), which is fundamental for tendon healing. Management of people presenting with type 2 diabetes and tendinopathy includes both local treatment (reduction in loading during the acute phase and gradual resistance training) and other interventions aiming at weight-loss (i.e. exercise, diet, and pharmacological, +/- surgical). Interventions aiming at weight loss have shown to reduce symptoms in both weight-bearing and non-weight-bearing tissues. Finally, resistance training and aerobic exercises are fundamental interventions in the management of type 2 diabetes and should be undertaken under the supervision of a health professional. Clinical Take Home Message: Based on what we know today, clients with type 2 diabetes may be predisposed to develop lateral epicondylalgia. When assessing clients with Type 2 diabetes, hand therapists should investigate whether they are compliant with medications (e.g. metformin) and encourage clients to take part in supervised resistance and/or aerobic training exercises (as per international guidelines). This article is a nice addition to what we already know on the risk factors for lateral epicondylalgia. URL: Available through EBSCO Health Databases for PNZ members. Abstract Tendinopathy is a chronic and often painful condition affecting both professional athletes and sedentary subjects. It is a multi‐etiological disorder caused by the interplay among overload, ageing, smoking, obesity (OB) and type 2 diabetes (T2D). Several studies have identified a strong association between tendinopathy and T2D, with increased risk of tendon pain, rupture and worse outcomes after tendon repair in patients with T2D. Moreover, consequent immobilization due to tendon disorder has a strong impact on diabetes management by reducing physical activity and worsening the quality of life. Multiple investigations have been performed to analyse the causal role of the individual metabolic factors occurring in T2D on the development of tendinopathy. Chronic hyperglycaemia, advanced glycation end‐products, OB and insulin resistance have been shown to contribute to the development of diabetic tendinopathy. This review aims to explore the relationship between tendinopathy and T2D, in order to define the contribution of metabolic factors involved in the degenerative process and to discuss possible strategies for the clinical management of diabetic tendinopathy.
Are cortisone or hyaluronic acid injections a good idea if trapeziectomy is coming up?
Corticosteroid or hyaluronic acid injections to the carpometacarpal joint of the thumb joint are associated with early complications after subsequent surgery. Giladi, A. M., Rahgozar, P., Zhong, L., & Chung, K. C. (2018) Level of Evidence: 4 Follow recommendation: 👍 👍 Type of study: Prognostic Topic: 1st cmcj OA injections - Are they safe? This is a retrospective study assessing post-surgical complications in clients who underwent injection therapy vs those who did not, prior to surgery for symptomatic 1st cmcj OA. The surgical procedure was trapeziotomy with or without suspension arthroplasty or fusion. A total of 16,268 participants, took part in this study. Of these, 4,462 (27%) and 252 (1.5%) received at least one cortisone or hyaluronic acid injection respectively prior to surgery. The average time between injection and surgery was 12 months. The results showed that one cortisone injection increased the odds of post surgical infection by 20% while three cortisone injections increased the odds of post surgical infection by 70%. Hyaluronic acid injections increased the risk of post surgical infection by 110%. Unfortunately, the absolute number of participants presenting with post-surgical infections was not provided ( I also contacted the authors but they were unable provide me with the numbers). It is therefore possible that the effect reported is overestimated and potentially not clinically relevant. Clinical Take Home Message: Based on what we know today, cortisone or hyaluronic injections for 1st cmcj OA may not be the best therapeutic options if clients are scheduled for a trapeziotomy in the near future. The risk of post-surgical complications may be higher and other therapeutic interventions may be as effective and less harmful. Considering that the effectiveness of cortisone injections for 1st cmcj OA is not superior to placebo, their use is questionable. The results from this study are not surprising considering that cortisone injections have shown to increase the risk of post surgical infections in other joint (e.g. hip). URL: Available through EBSCO Health Databases for PNZ members. Abstract Truven MarketScan® Databases were used to identify patients with thumb carpometacarpal arthritis who underwent surgical treatment. Pre-operative corticosteroid or hyaluronic acid injections were identified, as were post-operative complications. Multivariable regressions assessed the relationship between injections and complications. Of 16,268 patients, 4462 had steroid injections and 252 received hyaluronic acid injections. Twenty-one per cent (3381 patients) had post-operative complications. Diabetes and smoking increased the odds of complications in all models. Odds of any complication, most notably infectious complications, were increased 20% by corticosteroids (OR 1.2; 95% CI: 1.1 to 1.3). More than three injections increased the odds of a complication by 70% (OR 1.7; 95% CI: 1.3 to 2.1). Hyaluronic acid increased the odds of wound-healing complications by 110% (OR 2.1; 95% CI: 1.3 to 3.4). Corticosteroid and hyaluronic acid injections for thumb carpometacarpal arthritis increase the odds of post-operative complications.
Upper limb laceration in fresh water? Keep an eye on it
Rapidly progressive soft tissue infection of the upper extremity with aeromonas veronii biovar sobria. Lujan-Hernandez, J., Schultz, K. S., & Rothkopf, D. M. (2020) Level of Evidence: 5 Follow recommendation: 👍 Type of study: Diagnostic/Therapeutic Topic: Fresh water laceration – Infection This is a case report on Aeromonas infection following a laceration in fresh water. The patient was a 20 years old male who had been experiencing pain in the forearm following a laceration injury experienced while swimming in a fresh water reservoir. They were not immunocompromised and their injury had been attended in ED a few hours (2 hrs) prior to the worsening of symptoms. Objectively, they presented with pain in the forearm, erythema around the wound site, pain with passive wrist extension, and purulent discharge from the wounds attended two hours prior. They had no fever. X-ray investigations revealed a small air sack within the volar forearm. Blood tests revealed the presence of a high white blood cells count. The patient was immediately treated with a wide spectrum series of antibiotics and went through two washout with the wound left open for primary healing. The symptoms resolved after a few weeks of discharge and the there were no hand or upper limb impairments at 6 or 12 months. Clinical Take Home Message: Lacerations or wounds in fresh or salt water environments should be followed closely in all clients. Particular attention should be paid to those clients working/spending time in high risk environments (e.g. fisherman, aquarist). The risk of severe repercussions if an infection is not treated is high. The risk of having an additional infection after a washout is 15% higher if clients are smokers or diabetic, and 20% higher if they are both. It is therefore worth investigating whether they are smokers and helping them to quit if they are interested. X-rays and US are the primary investigations to be utilised if suspecting an infection. URL: Available through The Journal of Hand Surgery (American Volume) for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Aeromonas veronii, a bacterium found in freshwater, is an unusual pathogen in healthy patients. We present a case report of a rare, aggressive subtype in a young, immunocompetent individual. History of injury in an aquatic environment and culture data are key for identification of the causal agent and should dictate acute clinical management and antibiotic therapy. Coverage should include cephalosporins, quinolones, or sulfas if Aeromonas is suspected, and adjusted depending on culture and sensitivity. Early surgical exploration, incision and drainage, and appropriate antimicrobial therapy are the cornerstones for successful treatment of these aggressive, sometimes life-threatening infections.
Should we and our clients walk/cycle to work?
Protective effect on mortality of active commuting to work: A systematic review and meta-analysis. Dutheil, F., Pélangeon, S., Duclos, M., Vorilhon, P., Mermillod, M., Baker, J. S., . . . Navel, V. (2020). Level of Evidence: 1a- Follow recommendation: 👍 👍 👍 👍 Type of study: Prognostic, Preventative, Therapeutic Topic: Mortality – Active commuting This is a systematic review and meta-analysis of prospective cohort studies assessing the effect of active commuting (e.g. walking, cycling) on mortality at 5-25 years follow up. Seventeen studies were included for a total of 829,098 participants. The results from this systematic review and meta-analysis were assessed through the Newcastle-Ottawa Quality Assessment Scale, which score from 0 (low quality) to 100 (High quality). The quality of evidence was moderate to high (average of 75 out of 100). Active commuting was defined as cycling or walking. The results showed that moderate to high intensity walking reduced mortality by 15% (95%CI: 2% to 28%) and 19% (95%CI: 8% to 30%) respectively. Cycling reduced mortality independently of intensity from 14% to 28%. It is necessary to keep in mind that the studies included were not randomised (as it would be unethical to randomise participants to 5-25 of sedentary behavior) and other systemic factors may contributed to the findings (e.g. less stressful lifestyle). Clinical Take Home Message: Based on what we know today, walking briskly or at a fast pace, or cycling to work, will reduce our clients' mortality risk in the next 5 to 25 years. As hand therapist we are privileged to be able to positively affect our clients' life and a simple advice on active commuting may provide them with longer healthspan and lifespan. We may also encourage our clients to be active outside of work as a greater number of daily steps, ability to do more than 10 push-ups (in middle aged males), and a greater grip strength have all been shown to predict mortality in previous studies. URL: Available through EBSCO Health Databases for PNZ members. Abstract Background: Sedentary behaviour is a major risk of mortality. However, data are contradictory regarding the effects of active commuting on mortality. Objectives: To perform a systematic review and meta-analysis on the effects of active commuting on mortality. Methods: The PubMed, Cochrane Library, Embase, and Science Direct databases were searched for studies reporting mortality data and active commuting (walking or cycling) to or from work. We computed meta-analysis stratified on type of mortality, type of commuting, and level of commuting, each with two models (based on fully adjusted estimates of risks, and on crude or less adjusted estimates). Results: 17 studies representing 829,098 workers were included. Using the fully adjusted estimates of risks, active commuting decreased all-cause mortality by 9% (95% confidence intervals 3–15%), and cardiovascular mortality by 15% (3–27%) (p < 0.001). For stratification by type of commuting, walking decreased significantly all-cause mortality by 13% (1–25%), and cycling decreased significantly both all-cause mortality by 21% (11–31%) and cardiovascular mortality by 33% (10–55%) (p < 0.001). For stratification by level of active commuting, only high level decreased all-cause mortality by 11% (3–19%) and both intermediate and high level decreased cardiovascular mortality. Low level did not decrease any type of mortality. Cancer mortality did not decrease with walking or cycling, and the level of active commuting had no effect. Low level walking did not decrease any type of mortality, intermediate level of walking decreased only all-cause mortality by 15% (2–28%), and high level of walking decreased both all-cause and cardiovascular mortality by 19% (8–30%) and by 31% (9–52%), respectively. Both low, intermediate and high intensities of cycling decreased all-cause mortality. Meta-analysis based on crude or less fully adjusted estimates retrieved similar results, with also significant reductions of cancer mortality with cycling (23%, 5–42%), high level of active commuting (14%, 4–24%), and high level of active commuting by walking (16%, 0–32%). Conclusion: Active commuting decreases mainly all-cause and cardiovascular mortality, with a dose–response relationship, especially for walking. Preventive strategies should focus on the benefits of active commuting.
Another quick and reliable way to assess upper limb strength in older clients!
The reliability and validity of novel clinical strength measures of the upper body in older adults.
Legg, H. S., Spindor, J., Dziendzielowski, R., Sharkey, S., Lanovaz, J. L., Farthing, J. P., & Arnold, C. M. (2020) Level of Evidence: 2b Follow recommendation: 👍 👍 Type of study: Diagnostic test Topic: Push off test – Validity and reliability as a strength measure This is a longitudinal study (two repeated measures over 48 hrs) assessing the validity and reliability of the push off test in comparison to hand held dynamometer strength testing of the upper limb. Seventeen healthy participants (11 females, 6 males), who were on average 71 years old, took part in the study. The push off test was completed by inverting the handle of a hand held dynamometer and positioning it on a table. Participants were then asked to put as much weight as possible through it with the elbow and shoulder in 10°-40° of flexion and extension respectively (See picture below from the article). The results from this test were repeated two times (to assess reliability after 48 hrs) and compared to strength measurements of shoulder extension, shoulder abduction, and elbow extension (assessed through a hand held dynamometer) to assess validity. The results showed that the push off test was reliable (meaning that the measurements taken at two different times were very similar) with intraclass correlation coefficient between 0.92 and 0.94 (the closer to 1 the better). The push off test was also valid (it was indeed measuring upper limb strength) with strong correlation with the other measures of upper limb strength ranging from 0.8 to 0.9 (the closer to 1 the better). On average, the push off test was 27kg, and the average weight of the participants was 77kg. This suggests that for healthy patients around the age of 70, they should be able to push off during the test 35% of their weight (27kg/77kg=0.35). Clinical Take Home Message: Based on what we know today, the push off test can be utilised to assess upper limb strength in older people. This test has been previously used to assess late stage TFCC recovery. Getting our clients to achieve 35% of their body weight during this test may be an appropriate goal for our treatment. If our clients are younger, a better test may be the maximum number of push up that they can do in a row without stopping (Reaching 11 push-up may be an appropriate goal). Open Access URL: Abstract Introduction: Research investigating psychometric properties of multi-joint upper body strength assessment tools for older adults is limited. This study aimed to assess the test–retest reliability and concurrent validity of novel clinical strength measures assessing functional concentric and eccentric pushing activities compared to other more traditional upper limb strength measures. Methods: Seventeen participants (6 males and 11 females; 71 ± 10 years) were tested two days apart, performing three maximal repetitions of the novel measurements: vertical push-off test and dynamometer-controlled concentric and eccentric single-arm press. Three maximal repetitions of hand-grip dynamometry and isometric hand-held dynamometry for shoulder flexion, shoulder abduction and elbow extension were also collected. Results: For all measures, strong test–retest reliability was shown (all ICC > 0.90, p < 0.001), root-mean-squared coefficient of variation percentage: 5–13.6%; standard error of mean: 0.17–1.15 Kg; and minimal detectable change (90%): 2.1–9.9. There were good to high significant correlations between the novel and traditional strength measures (all r > 0.8, p < 0.001). Discussion: The push-off test and dynamometer-controlled concentric and eccentric single-arm press are reliable and valid strength measures feasible for testing multi-joint functional upper limb strength assessment in older adults. Higher precision error compared to traditional uni-planar measures warrants caution when completing comparative clinical assessments over time.
Thumb OA? - To splint or not to splint, that is the question
The clinical and cost effectiveness of splints for thumb base osteoarthritis: A randomized controlled clinical trial. Adams, J., Barratt, P., Rombach, I., Arden, N., Barbosa Bouças, S., Bradley, S., . . . Dziedzic, K. (2020) Level of Evidence: 1b Follow recommendation: 👍 👍 👍 👍 Type of study: Therapeutic Topic: Thumb osteoarthritis - Real vs Sham thumb splint This is a randomised, multicentre, double-blind, placebo controlled trial assessing the effectiveness of thumb splinting on pain and function in participants with thumb osteoarthritis (OA). Participants (N = 292) were included if they presented with clinical signs of 1st cmcj OA (inclusion criteria available through their supplemental data) and if they had moderate hand pain and disability. Importantly, participants were excluded if they had previously tried thumb splinting. Pain and function were assessed through the AUSCAN at baseline, 8 weeks, and 12 weeks. Participants and assessors were blinded to treatment allocation. Participants were randomised to either an 8 weeks self-management program which provided participants with a handout from Arthritis Research UK and a series of exercises to perform three times per week (n = 97), or the self-management program (advice + exercise) plus a true splint limiting 1st cmcj movement (n = 97), or the self-management treatment (advice + exercise) plus a placebo splint, which did not provide any support to the 1st cmcj (n = 102). Participants in all groups attended one hour session at baseline for the introduction to the program. They also had a follow-up at 4 weeks for 30 minutes where key concepts were reiterated. At the eight weeks mark, a final session reminded participants to continue doing their exercises three times per week and wear the splint for at least 6hrs/day (in the splinting groups). The results showed that participants in all groups improved at the 8 and 12 weeks follow up without differences between groups. The placebo and true splint increased the cost of care by at least £100 without providing any significant benefit. Clinical Take Home Message: Based on what we know today, splinting for thumb OA does not provide any additional benefit than education and simple exercises. Providing a splint is more pricey and the expense does not appear to be justified. Instead of providing a splint, it may be more useful to use those resources (money and time) for an additional session of hand therapy where we can encourage joint motion for lotion, promote joint movement for amusement, and suggest meditation for elation. If this is not enough and clients want something passive (no exercises) that has been shown to have some effect (compared to placebo), although small, look at supplements for osteoarthritis. Also remember: keep smiling, your clients' pain will decrease! Open access URL: Abstract Objectives: To investigate the clinical effectiveness, efficacy and cost effectiveness of splints (orthoses) in people with symptomatic basal thumb joint OA (BTOA). Methods: A pragmatic, multicentre parallel group randomized controlled trial at 17 National Health Service (NHS) hospital departments recruited adults with symptomatic BTOA and at least moderate hand pain and dysfunction. We randomized participants (1:1:1) using a computer-based minimization system to one of three treatment groups: a therapist supported self-management programme (SSM), a therapist supported self-management programme plus a verum thumb splint (SSM+S), or a therapist supported self-management programme plus a placebo thumb splint (SSM+PS). Participants were blinded to group allocation, received 90 min therapy over 8 weeks and were followed up for 12 weeks from baseline. Australian/Canadian (AUSCAN) hand pain at 8 weeks was the primary outcome, using intention to treat analysis. We calculated costs of treatment. Results: We randomized 349 participants to SSM (n = 116), SSM+S (n = 116) or SSM+PS (n = 117) and 292 (84%) provided AUSCAN Osteoarthritis Hand Index hand pain scores at the primary end point (8 weeks). All groups improved, with no mean treatment difference between groups: SSM+S vs SSM −0.5 (95% CI: −1.4, 0.4), P = 0.255; SSM+PS vs SSM −0.1 (95% CI: −1.0, 0.8), P = 0.829; and SSM+S vs SSM+PS −0.4 (95% CI: −1.4, 0.5), P = 0.378. The average 12-week costs were: SSM £586; SSM+S £738; and SSM+PS £685. Conclusion: There was no additional benefit of adding a thumb splint to a high-quality evidence-based, supported self-management programme for thumb OA delivered by therapists.
Are we getting weaker?
Temporal trends in the handgrip strength of 2,592,714 adults from 14 countries between 1960 and 2017: A systematic analysis.
Dufner, T. J., Fitzgerald, J. S., Lang, J. J., & Tomkinson, G. R. (2020) Level of Evidence: 2a Follow recommendation: 👍 👍 Type of study: Symptoms prevalence Topic: Grip strength – Changes in the last 57 years This is a systematic review assessing the change in grip strength in the last 57 years. Ten prospective studies were included for a total of 2,592,714 participants. The age of participants ranged between 20 and 90. Data were collected from high to moderate income countries. Hand grip strength was assessed through hand held dynamometers. The results showed that no significant change in grip strength was identified before 2000. However, between 2000 and 2017, there was a trend towards a decrease in grip strength. Clinical Take Home Message: Based on what we know today, grip strength has been declining in the last 20 years. This is unfortunate because grip strength is predictor of mortality at 10 years. It may be worth reminding our clients about the importance of general body strengthening and aerobic exercise to increase lifespan and more importantly health span. URL: Available through EBSCO Health Databases for PNZ members. Abstract Background: Handgrip strength (HGS) is an excellent marker of functional capability and health in adults, although little is known about temporal trends in adult HGS. Objectives: The aim of this study was to systematically analyze national (country-level) temporal trends in adult HGS, and to examine the relationships between national trends in adult HGS and national trends in health-related and socioeconomic/demographic indicators. Methods: Data were obtained from a systematic search of studies reporting temporal trends in HGS for adults (aged ≥ 20 years) and by examining national fitness datasets. Trends in mean HGS were estimated at the country–sex–age group level by best-fitting sample-weighted linear/polynomial regression models, with national and sub-regional (pooled data across geographically similar countries) trends estimated by a post-stratified population-weighting procedure. Pearson’s correlations quantified relationships between national trends in adult HGS and national trends in health-related and socioeconomic/demographic indicators. Results: Data from ten studies/datasets were extracted to estimate trends in mean HGS for 2,592,714 adults from 12 high- and 2 upper-middle-income countries (from Asia, Europe and North America) between 1960 and 2017. National trends were few, mixed and generally negligible pre-2000, whereas most countries (75% or 9/12) experienced negligible-to-small declines ranging from an effect size of 0.05 to 0.27, or 0.6 to 6.3%, per decade post-2000. Sex- and age-related temporal differences were negligible. National trends in adult HGS were not significantly related to national trends in health and socioeconomic/demographic indicators. Conclusions: While trends in adult HGS are currently limited to 14 high- and upper-middle-income countries from three continents, adult HGS appears to have declined since 2000 (at least among most of the countries in this analysis), which is suggestive of corresponding declines in functional capability and health.
Do you want to help your clients quit smoking?
The role of physiotherapists in smoking cessation. Luxton, N., & Redfern, J. (2020) Level of Evidence: 5 Follow recommendation: 👍 Type of study: Preventative, Therapeutic Topic: Smoking - Help them quit This is a guideline for health professionals on how to help clients quit smoking. A simple 3 steps process is suggested: 1) Ask if they are smoking and when they stopped smoking. If they stopped smoking in the last 6 months, they may benefit from extra support to avoid a relapse. 2) Advise to stop smoking if they are smoking. The advice should be personalised and refer to the impact of smoking in relation to their personal circumstances. These could include delays in wound healing and increased risk of infections, delays in fracture healing, as well as reduce effectiveness of painkillers. 3) Help by connecting your client with a specialist telephone service like Quitline (0800 778 778), internet interventions, or the QuitNow app. A relapse within the first few weeks from quitting is very common and health professionals should kindly check in on their client's progress. Clinical Take Home Message: The figure below speaks for itself. I feel I should screen my clients more than what I do at the moment, I often stop at the "Asking". If you have time, have a look at the Ministry of Health page on "Stop smoking", it has some great resources! Open Access URL: No Abstract available
Can your clients do enough push-up?
Association between push-up exercise capacity and future cardiovascular events among active adult men.
Yang, J., Christophi, C. A., Farioli, A., Baur, D. M., Moffatt, S., Zollinger, T. W., & Kales, S. N. (2019) Level of Evidence: 2b Follow recommendation: 👍 👍 👍 Type of study: Prognostic Topic: Push-up - Mortality prediction This is a retrospective longitudinal cohort study assessing the ability to predict cardiovascular events (CV - e.g. heart failure, coronary hearth disease) in the next 10 years based on the number of push up that somebody can do. A total of 1,562 male firefighters participants were included at baseline. Participants were followed up for 10 years. Participants were on average 40 years old at baseline. The number of push-up was assessed at baseline. Participants had to do as many push ups as possible following the rhythm of a metronome set at 80 beats per minute. The test was interrupted if participants were unable to keep up with the beat for 3 or more consecutive repetitions. The results showed that participants completing less than 10 push-up were at much greater risk of having a CV event in the next 10 years. Participant able to do at least 11 push-up had a 64% reduction in risk at 10 years and those able to complete 40 push-up had a 96% risk reduction. Clinical Take Home Message: Based on what we know today, this push-up test is a quick reference that allows us to assess our clients CV risk at 10 years. This test is however currently applicable to males only. The results do not suggest that just training push-up will reduce your risk as this is just an adaptation to specific training. What this test does however suggest is that by getting people overall stronger, their risk of CV will reduce. This synopsis is a nice addition to the one that was previously completed on grip strength and mortality and walking and mortality. Getting our clients fitter may provide them with a longer lifespan (length of life) and healthspan (years of quality life - free from disease). Open Access URL: Abstract Importance: Cardiovascular disease (CVD) remains the leading cause of mortality worldwide. Robust evidence indicates an association of increased physical fitness with a lower risk of CVD events and improved longevity; however, few have studied simple, low-cost measures of functional status. Objective: To evaluate the association between push-up capacity and subsequent CVD event incidence in a cohort of active adult men. Design, Setting, and Participants: Retrospective longitudinal cohort study conducted between January 1, 2000, and December 31, 2010, in 1 outpatient clinics in Indiana of male firefighters aged 18 years or older. Baseline and periodic physical examinations, including tests of push-up capacity and exercise tolerance, were performed between February 2, 2000, and November 12, 2007. Participants were stratified into 5 groups based on number of push-ups completed and were followed up for 10 years. Final statistical analyses were completed on August 11, 2018. Main Outcomes and Measures: Cardiovascular disease–related outcomes through 2010 included incident diagnoses of coronary artery disease and other major CVD events. Incidence rate ratios (IRRs) were computed, and logistic regression models were used to model the time to each outcome from baseline, adjusting for age and body mass index (BMI) (calculated as weight in kilograms divided by height in meters squared). Kaplan-Meier estimates for cumulative risk were computed for the push-up categories. Results: A total of 1562 participants underwent baseline examination, and 1104 with available push-up data were included in the final analyses. Mean (SD) age of the cohort at baseline was 39.6 (9.2) years, and mean (SD) BMI was 28.7 (4.3). During the 10-year follow up, 37 CVD-related outcomes (8601 person-years) were reported in participants with available push-up data. Significant negative associations were found between increasing push-up capacity and CVD events. Participants able to complete more than 40 push-ups were associated with a significantly lower risk of incident CVD event risk compared with those completing fewer than 10 push-ups (IRR, 0.04; 95% CI, 0.01-0.36). Conclusions and Relevance: The findings suggest that higher baseline push-up capacity is associated with a lower incidence of CVD events. Although larger studies in more diverse cohorts are needed, push-up capacity may be a simple, no-cost measure to estimate functional status.
Shall we upgrade our sensory testing for carpal tunnel syndrome?
Concurrent validity of a low-cost and time-efficient clinical sensory test battery to evaluate somatosensory dysfunction. Zhu, G. C., Böttger, K., Slater, H., Cook, C., Farrell, S. F., Hailey, L., . . . Schmid, A. B. (2019) Level of Evidence: 1b Follow recommendation: 👍 👍 👍 Type of study: Diagnostic Topic: Sensory testing - Bed side tests This is a validation study of bedside tests for clients presenting with musculoskeletal conditions including carpal tunnel syndrome (CTS). The results of a series of bedside tests, which included temperature detection (heat, cold), mechanical detection (e.g. monofilament testing), pressure pain thresholds, and others were compared to quantitative sensory testing, which is the current gold standard to assess the function of the sensory system. The most valid tests for loss of sensation were the warm/cold detection and the cotton wool touch detection. The most valid tests for sensory gain (hyperalgesia) were pressure pain thresholds on the thenar eminence with a pencil eraser or the clinicians' thumb. All the tests were compared to the contralateral limb or a non affected are of the hand to determine whether there was a loss of sensation or hyperalgesia. Clinical Take Home Message: Based on what we know today, a few bedside tests can be implemented in addition to our monofilament and manual muscle tests for carpal tunnel syndrome. These tests include cold/warm sensation assessment, which can be done through cold/warm coins, and pain pressure threshold based on compression of the thenar eminence through a clinician's thumb. These tests need to be compared to the healthy contralateral limb (if asymptomatic) to identify whether we have a loss or gain in sensation. In addition, we can perform pinprick testing, which is on indicator of small nerve fibre integrity. By monitoring our patients through these tests, we may be able to identify improvements following our intervention, which may go unnoticed if assessed through monofilament or manual muscle testing only. Open Access URL: Abstract Background This study describes a low‐cost and time‐efficient clinical sensory test (CST) battery and evaluates its concurrent validity as a screening tool to detect somatosensory dysfunction as determined using quantitative sensory testing (QST). Method Three patient cohorts with carpal tunnel syndrome (CTS, n = 76), non‐specific neck and arm pain (NSNAP, n = 40) and lumbar radicular pain/radiculopathy (LR, n = 26) were included. The CST consisted of 13 tests, each corresponding to a QST parameter and evaluating a broad spectrum of sensory functions using thermal (coins, ice cube, hot test tube) and mechanical (cotton wool, von Frey hairs, tuning fork, toothpicks, thumb and eraser pressure) detection and pain thresholds testing both loss and gain of function. Agreement rate, statistical significance and strength of correlation (phi coefficient) between CST and QST parameters were calculated. Results Several CST parameters (cold, warm and mechanical detection thresholds as well as cold and pressure pain thresholds) were significantly correlated with QST, with a majority demonstrating >60% agreement rates and moderate to relatively strong correlations. However, agreement varied among cohorts. Gain of function parameters showed stronger agreement in the CTS and LR cohorts, whereas loss of function parameters had better agreement in the NSNAP cohort. Other CST parameters (16 mN von Frey tests, vibration detection, heat and mechanical pain thresholds, wind‐up ratio) did not significantly correlate with QST. Conclusion Some of the tests in the CST could help detect somatosensory dysfunction as determined with QST. Parts of the CST could therefore be used as a low‐cost screening tool in a clinical setting. Significance Quantitative sensory testing, albeit considered the gold standard to evaluate somatosensory dysfunction, requires expensive equipment, specialized examiner training and substantial time commitment which challenges its use in a clinical setting. Our study describes a CST as a low‐cost and time‐efficient alternative. Some of the CST tools (cold, warm, mechanical detection thresholds; pressure pain thresholds) significantly correlated with the respective QST parameters, suggesting that they may be useful in a clinical setting to detect sensory dysfunction.
5ht metacarpal neck fracture - I like to move it move it
Challenging the dogma: Severely angulated neck fractures of the fifth metacarpal must be treated surgically.
Boeckstyns, M. E. H. (2020) Level of Evidence: 3a Follow recommendation: 👍 👍 Type of study: Therapeutic Topic: 5th metacarpal neck fracture - conservative vs surgical This is a systematic review comparing the effectiveness of different conservative treatment or conservative treatments vs surgical treatment for 5th metacarpal neck fractures. Eighteen studies were included in the systematic review. The studies included were quite heterogeneous and only one author completed the review (usually we have two authors assessing research independently). Efficacy of intervention was assessed by functional outcomes (e.g. DASH), maintenance of fracture reduction, return to work, and complications.The results showed that different types of conservative treatment did not affect any of the outcomes to a significant level. Some of the studies elected to mobilise participants immediately and others utilised a clam shell around the 5th metacarpal without including the mcpj. Return to work was quicker in those participants who were allowed to mobilise early. No clear difference was identified in clients treated surgically or conservatively. Complications appeared to be higher in the surgically treated group. Clinical Take Home Message: Based on what we know today, hand therapists may choose to mobilise early clients with a 5th metacarpal neck fracture. If a form of splinting is chosen, there appears to be no difference between a clam shall including or not the mcpj, or buddy splinting. Surgical treatment seem to lead to worse outcomes. For another great study on this topic, see previous synopsis. URL: Available through EBSCO Health Databases for PNZ members. Abstract Cadaveric studies suggest that the acceptable deformity in fifth metacarpal neck fractures is maximally 30° palmar angulation. This systematic review verifies the validity of these threshold values. Eighteen prospective comparative studies on operative and/or conservative treatment options in adults were included. None of the studies demonstrated any correlation between the residual or initial angulation and the clinical results despite accepting more severe angular deformities. Closed reduction and immobilization without internal fixation improved the palmar angle by 5° to 9° in three studies and 29° in a fourth. Operative treatments compared with non-reducing conservative treatments showed no benefit of the surgery other than aesthetic issues. The synthesis of this review indicates that 90% of fractures of the metacarpal neck with apex angulation up to 70° can be treated successfully with a functional metacarpal brace without reduction. Disability of the Arm, Shoulder and Hand questionnaire scores <10 are uniformly reported. I modified my own practice accordingly a decade ago to treating these fractures conservatively regardless of the palmar angulation, except in patients with exceptional demands or other fracture deformities.
What can you do for elbow instability?
Rehabilitation of elbow instability. Pipicelli, J. G., & King, G. J. W. (2020) Level of Evidence: 5 Follow recommendation: 👍 Type of study: Aetiologic, Therapeutic Topic: Elbow instability - Aetiology and treatment This is a narrative review on aetiology and treatment of elbow stiffness. The aetiology of elbow instability is usually due to a trauma associated with elbow extension. The goal of treatment is to allow time for the ligaments, capsule, and potentially tendinous lesions to heal. Conservative treatment depends on the severity and type of injury. The presence of a "drop sign" on x-ray (more than 4mm distance between the humerus and ulna in 90deg of elbow flexion) suggest significant elbow laxity. If the lateral collateral ligaments (LCL) of the elbow are involved, the forearm should be maintained in pronation to increase the support provided by the common extensor tendons. If the medical collateral ligaments (MCL) have been injured, the forearm should be positioned in supination to increase support from the common flexor tendon. If both LCL and MCL are involved, the forearm should be placed in neutral. Acutely after injury, the elbow is placed in a splint which limits elbow extension to 60deg. Extension is subsequently increased by 10deg per week. Active range of movement exercises can be initiated soon after the injury and they involve flexion/extension of the elbow (within the brace limits) and pronation/supination of the forearm (in 90 deg of elbow flexion) in a supine position with 90deg of shoulder flexion. This position has been suggested to improve joint congruence and reduce instability during the exercises. Elbow x-rays should be repeated at 3 weeks post injury and if a "drop sign" is still present, surgery is indicated. Isometric biceps and triceps exercises should be included within the first 3 weeks if the "drop sign" is present and this may help in reducing instability. At six weeks post injury, isotonic (e.g. dynamic exercises holding a dumbbell) strengthening can generally be initiated. Clinical Take Home Message: Based on what we know today, elbow instability should be treated with ROM brace than can limit AROM to 60deg of extension. The additional positioning of a resting pronation/supination may be used to protect the LCL and MCL respectively. X-rays should be obtained at baseline and at 3 weeks. If a "drop sign" is present, this suggest significant instability and isometric biceps and triceps resistance exercises should be utilised in combination with AROM in supine to reduce instability and maintain range of movement. The development of stiffness following an elbow injury is common and you can take a look at a previous synopsis on the topic. URL: Available through Hand Clinics for HTNZ members. Available through EBSCO Health Databases for PNZ members. No Abstract available
Should we keep Telerehabilitation as an alternative to in person appointments?
Telemedicine in hand and upper-extremity surgery Grandizio, L. C., Foster, B. K., & Klena, J. C. (2020) Level of Evidence: 5 Follow recommendation: 👍 Type of study: Therapeutic Topic: Telemedicine – Implementation and feasibility This narrative review provides advice on the implementation of telemedicine, and its strength/limitations, for upper limb conditions. Written consent should be gathered before any telemedicine session. This can be obtained online before the appointment. When starting a telemedicine consultation, patients should be made aware of any other people present in the room. Radiology referrals and reports are usually available online making it easier for clinicians to make decisions. Range of movement assessments of wrists and fingers appear to be feasible through video calls. One of the limitations is the assessment of sensation (monofilament testing). No evidence has assessed the feasibility of special tests and reliability of special tests through telemedicine. It appears that wound assessment is feasible with telemedicine and that complications are easily assessed. The cost of telemedicine appears to be lower compared to a traditional outpatient visit, and it seems to be as safe as in person assessments. Clinical Take Home Message: Based on what we know today, telemedicine is possible and may be utilised as an alternative to in person appointments. Limited evidence has assessed the validity and reliability of objective assessments performed remotely. For skin sensation, the Ten Test can be performed by the patient independently and may be suitable for telemedicine use. Toothpicks may be used as an alternative to assess pinprick sensation (assessing nerves' small fibre). In addition, most splints can be posted to patients without them leaving the comfort (or safety) of their own house. Companies such as @Therapy can organise the delivery, without too much effort from the clinician's point of view. URL: Available through The Journal of Hand Surgery for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Smartphones, computers, and Internet access continue to become more available to both patients and physicians. As these technologies develop with respect to health care, opportunities for telemedicine visits continue to emerge. The purpose of this review article was to analyze the current use and potential applications of telemedicine in hand and upper-extremity surgery. Although the literature pertaining to the use of telemedicine in hand surgery is limited, videoconferencing visits may provide benefits to patients. Particularly in rural and underserved regions, patients can decrease considerable travel burdens. Potential applications for this technology include remote inpatient and emergency room consultations, outpatient clinic visits, and postoperative care. There are unique considerations with respect to confidentiality and security. As with any new technology, it is important to analyze safety concerns. Future randomized, prospective investigations are necessary to define the economic implications of telemedicine programs more clearly within hand and upper-extremity surgery.
Are dietary supplements useful for hand osteoarthritis?
Dietary supplements for treating osteoarthritis: a systematic review and meta-analysis.
Liu, X., Machado, G. C., Eyles, J. P., Ravi, V., & Hunter, D. J. (2018) Level of Evidence: 1a Follow recommendation: 👍 👍 👍 👍 Type of study: Therapeutic Topic: Dietary supplements – Osteoarthritis This is a systematic review and meta-analysis of randomised placebo-controlled trials assessing the effectiveness of dietary supplements for osteoarthritis (hand, knee, and hip). Sixty-nine randomised placebo-controlled trials were included for a total of 11,586 participants. The results from this systematic review and meta-analysis were assessed through the GRADE approach (suggested by the Cochrane Group), which scores the evidence as "very low", "low", "moderate", or "high" quality. Efficacy of intervention was assessed through changes in pain (other outcomes were included but I decided to keep it simple). Pain was assessed through the visual analogue scale (e.g. VAS). Several supplements were utilised, however, I selected chondroitin (it had the greatest number of studies for a total of 1,822 participants). The results showed that there was "moderate" to "high" quality of evidence suggesting that chondroitin is effective in the short term (less than 3 months) in reducing pain. The authors report these findings as been non clinically meaningful because their overall effect (standardised mean difference - SMD of 0.34) was smaller than the selected threshold of SMD = 0.37. Interestingly, they reported other supplements (e.g. Boswellia serrata extract, Curcuma longa extract) showing large and clinically important findings although the number of participants was relatively small (33 to 427) and the 95% CI of the therapeutic effect was larger compared to chondroitin. Clinical Take Home Message: Based on what we know today, chondroitin and other supplements (see figure below) may relieve pain in osteoarthritis (hand included) in the short term. These supplements may be utilised as an adjunct to other treatments for hand osteoarthritis, which have previously been shown to be effective (see this synopsis). Although the reported effect sizes (SMD) are small for chondroitin, their effect size is very similar to the one reported by placebo controlled RCTs assessing the effectiveness of Nonsteroidal anti-inflammatory drugs (NSAIDs). The cost of ongoing supplementation should be considered and if clients are on a restricted budget this intervention should not be advocated. Clients should also be advised to review the appropriateness of these supplements with their GP to avoid negative interactions with prescribed drugs or allergic reactions. Open Access URL: Abstract Objective: To investigate the efficacy and safety of dietary supplements for patients with osteoarthritis. Design: An intervention systematic review with random effects meta-analysis and meta-regression. Data sources: MEDLINE, EMBASE, Cochrane Register of Controlled Trials, Allied and Complementary Medicine and Cumulative Index to Nursing and Allied Health Literature were searched from inception to April 2017. Study eligibility criteria: Randomised controlled trials comparing oral supplements with placebo for hand, hip or knee osteoarthritis. Results: Of 20 supplements investigated in 69 eligible studies, 7 (collagen hydrolysate, passion fruit peel extract, Curcuma longa extract, Boswellia serrata extract, curcumin, pycnogenol and L-carnitine) demonstrated large (effect size >0.80) and clinically important effects for pain reduction at short term. Another six (undenatured type II collagen, avocado soybean unsaponifiables, methylsulfonylmethane, diacerein, glucosamine and chondroitin) revealed statistically significant improvements on pain, but were of unclear clinical importance. Only green-lipped mussel extract and undenatured type II collagen had clinically important effects on pain at medium term. No supplements were identified with clinically important effects on pain reduction at long term. Similar results were found for physical function. Chondroitin demonstrated statistically significant, but not clinically important structural improvement (effect size −0.30, –0.42 to −0.17). There were no differences between supplements and placebo for safety outcomes, except for diacerein. The Grading of Recommendations Assessment, Development and Evaluation suggested a wide range of quality evidence from very low to high. Conclusions: The overall analysis including all trials showed that supplements provided moderate and clinically meaningful treatment effects on pain and function in patients with hand, hip or knee osteoarthritis at short term, although the quality of evidence was very low. Some supplements with a limited number of studies and participants suggested large treatment effects, while widely used supplements such as glucosamine and chondroitin were either ineffective or showed small and arguably clinically unimportant treatment effects. Supplements had no clinically important effects on pain and function at medium-term and long-term follow-ups.
Neuropathic pain - lets throw a few crazy ideas?
Physiotherapy for people with painful peripheral neuropathies: A narrative review of its efficacy and safety. Jesson, T., Runge, N., & Schmid, A. (2020) Level of Evidence: 5 Follow recommendation: 👍 Type of study: Therapeutic Topic: Neuropathic pain - Chemotherapy induced and focal neuropathies This is a narrative review on physiotherapy interventions for chemotherapy-induced neuropathic pain and focal entrapment neuropathies (e.g. carpal tunnel, cervical radiculopathy). The results suggest that for established chemotherapy-induced neuropathic pain, an 8 weeks exercise program (participants trained at a perceived rate of exertion of "somewhat hard" to "hard" three times per week) can reduce symptoms. However, these findings were based on one study only with a small sample size. The following few sentences are only based on the preclinical science section of the paper, which I really liked. These findings suggested that aerobic training of low to moderate intensity may have "neuroprotective" and "neuroregenerative" effects independently of the form of exercise (e.g. walking, swimming, cycling). In addition, aerobic training may be more beneficial than resistance training in neuropathic pain. The perpetrated mechanism of pain relief is suggested to be due to modulation of inflammatory markers and the release of a soup of chemical that reduces nociceptive stimuli reaching the brain as well as reducing the firing thresholds of peripheral nociceptors. Clinical Take Home Message: Based on what we know today, clients presenting with chemotherapy-induced neuropathic pain, may benefit from an eight weeks program of moderate aerobic exercise performed three times per week. This is great as there is otherwise not much that we can otherwise offer to these clients. In addition, you may suggest you next client with a focal peripheral entrapment neuropathy (e.g. cervical radiculopathy, carpal tunnel syndrome) to go for a walk every day in addition to your mainstream treatment. This form of exercise would be defined as low to moderate intensity and it may help reducing symptoms. In addition, you may extend their healthspan by a few years! Why don't you give it a try? Open Access URL: Abstract Pharmacological treatment for peripheral neuropathic pain has only modest effects and is often limited by serious adverse responses. Alternative treatment approaches including physiotherapy management have thus gained interest in the management of people with peripheral neuropathies. This narrative review summarises the current literature on the efficacy and safety of physiotherapy to reduce pain and disability in people with radicular pain and chemotherapy-induced peripheral neuropathy, 2 common peripheral neuropathies. For chemotherapy-induced peripheral neuropathy, the current evidence based on 8 randomised controlled trials suggests that exercise may reduce symptoms in patients with established neuropathy, but there is a lack of evidence for its preventative effect in patients who do not yet have symptoms. For radicular pain, most of the 21 trials investigated interventions targeted at improving motor control or reducing neural mechanosensitivity. The results were equivocal, with some indication that neural tissue management may show some benefits in reducing pain. Adverse events to physiotherapy seemed rare; however, these were not consistently reported across all studies. Although it is encouraging to see that the evidence base for physiotherapy in the treatment of peripheral neuropathic pain is growing steadily, the mixed quality of available studies currently prevents firm treatment recommendations. Based on promising preliminary data, suggestions are made on potential directions to move the field forward.
Central sensitization in musculoskeletal pain: Lost in translation? van Griensven, H., Schmid, A., Trendafilova, T., & Low, M. (2020) Level of Evidence: 5 Follow recommendation: 👍 Type of study: Aetiologic, Diagnostic, Therapeutic Topic: Central sensitisation - Presentation and diagnostics This is a view point on the definition of central sensitisation, clinical presentation of central sensitisation, and the challenges associated with the application of this concept in clinical practice. Central sensitisation original definition, referred to neurophysiological changes within the dorsal horn of the spinal cord. These changes could amplify nociceptive stimuli coming from the periphery or allow the translation of mechanical (not nociceptive stimuli) into nociceptive stimuli (leading to allodynia - perception of pain with a non painful stimuli). Currently, clients presenting with widespread, ongoing, severe, and prolonged pain (caused by an "innocuous stimulus"), may present with central sensitisation. The problem with the implementation of this concept in clinical practice is that we do not have biomarkers/tests able to confirm the presence or absence of central sensitisation. In addition, the quantitative sensory testing (QST) utilised in research is far from perfect and records painful responses to stimuli rather than spontaneous pain. The validity of questionnaires for central sensitisation (e.g. Central Sensitisation Inventory) has also recently been questioned, leaving us with limited options. We should also not exclude peripheral drivers (e.g. ongoing nociceptive inputa) to central sensitisation, which may be responsible for allodynia (perception of pain with a non painful stimuli), and hyperalgesia (exaggerated pain response to a usually painful stimuli). Finally, a couple of key concepts which caught my attention were: the need to differentiate between psychological factors and central sensitisation, and the need for knowledge humility. We know that psychological factors (e.g. depression, anxiety) can heighten pain response by reducing pain inhibition (top-down), however, they are not the same thing as central sensitisation (changes within the dorsal horn of the spinal cord). In addition, the concept of epistemic humility (I interpreted it as "knowledge humility") is introduced and suggests that we need to keep an open mind in terms of "truth" provided by scientific research. This means that what is "true" today will most likely be challenged tomorrow and another shade of grey will be introduced. Clinical Take Home Message: Based on what we know today, central sensitisation may amplify nociceptive inputs coming from peripheral joints or soft tissues. Central sensitisation is for most part reversible, and the reduction of nociceptive inputs from the periphery should reverse the neurophysiological processes back to normal. Clients presenting with an extreme pain response, to what is normally not deemed as a particular painful activity, may present with central sensitisation. A diagnosis of central sensitisation is hard, if not impossible, to make with the tools available today. This may question its use in clinical practice, especially with patients. On a final note, central sensitisation is different from psychological factors such as depression, which are known to heighten pain response through top-down pathways. The two concepts (i.e. central sensitisation and psychological factors) should be therefore kept separate. URL: Available through EBSCO Health Databases for PNZ members. Abstract Central sensitization is a physiological mechanism associated with enhanced sensitivity and pain responses. At present, central sensitization cannot be determined directly in humans, but certain signs and symptoms may be suggestive of it. Although central sensitization has received increasing attention in the clinical literature, there is a risk that certain distinctions are being lost. This paper summarizes current knowledge of the physiology of central sensitization and its possible manifestations in patients, in order to inform a debate about the relevance of central sensitization for physical therapists. It poses 6 challenges associated with the application of central sensitization concepts in clinical practice and makes suggestions for assessment, treatment, and use of terminology. Physical therapists are asked to be mindful of central sensitization and consider potential top-down as well as bottom-up drivers, in the context of a person-centered biopsychosocial approach.
Early mobilisation for distal radius fracture ORIF? - Great work Julie!
A systematic review of how daily activities and exercises are recommended following volar plating of distal radius fractures and the efficacy and safety of early versus late mobilisation.
Collis, J., Signal, N., Mayland, E., & Clair, V. W.-S. (2020) Level of Evidence: 1a- Follow recommendation: 👍 👍 👍 👍 Type of study: Therapeutic Topic: Radius fracture – Early mobilisation This is a systematic review assessing the effectiveness and safety of early mobilisation following a distal radius fracture treated surgically with a volar plate. Eight studies, for a total of 519 participants (72% females) were included in the review. Of these, 5 were RCTs and 3 were retrospective studies. All the studies were assessed through the Downs and Black Quality Index, which is appropriate for both experimental and non-experimental studies. Each paper was scored as "excellent", "good", "fair", or "poor". Efficacy of intervention was assessed through improvements in pain (e.g. NRS, VAS), function (e.g. DASH, PRWE), and wrist and forearm range of movement (extension/flexion/supination/pronation) in the short-term (6-8/52), midterm (10-12/52), and long-term (24-26/52). Safety was assessed by counting the number of adverse events. Early mobilisation (1-8 days from surgery) was compared to a delayed mobilisation (2-6 weeks post surgery). On average, the studies included were of "good" quality. The results showed that early mobilisation provided a small possibly non clinically relevant differences (see Supplementary file 2) in pain compared to delayed mobilisation. However, function improved to a small/large extent in the early mobilisation group and these differences were clinically relevant. Early mobilisation also led to small/moderate improvement in range of movement, possibly not clinically relevant (I only looked at supination as we know that for this measurement we require at least an 8deg change for it to be clinically meaningful - Reid et al. 2020) when compared to delayed mobilisation. There were no differences in the number of adverse events between the early vs delayed mobilisation. Clinical Take Home Message: Based on what we know today, early mobilisation (within 2 weeks from surgery) of distal radius fractures ORIF may provide better functional outcomes compared to delayed mobilisation (more than 2 weeks post surgery). A recent randomised controlled study showed that there was no difference in terms of pain, function, and AROM if mobilisation was started on the day after surgery vs at 2 weeks (see this synopsis). It is therefore possible that delaying mobilisation by a max of two weeks is acceptable. However, immobilisation beyond the two weeks mark may lead to sub-optimal functional recovery off our clients. URL: Available through the Hand Therapy for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Introduction: Following surgical repair of distal radius fractures, mobilisation timeframes and interventions vary. Early mobilisation (<2 weeks postoperatively) usually includes range of motion exercises and may include recommendations to perform daily activities. The review investigated (i) how early mobilisation was recommended, particularly with respect to wrist use during daily activities and (ii) the efficacy and safety of early versus delayed mobilisation (< or ≥2 weeks). Methods: The study protocol was registered on PROSPERO (CRD42019136490). Five databases were searched for studies that compared early and delayed mobilisation in adults with volar plating of distal radius fractures. The Downs and Black Quality Index and the Template for Intervention Description and Replication checklist were used for quality evaluation. Effect sizes were calculated for range of movement, function and pain at 6–8, 10–12 and 26 weeks. A descriptive analysis of outcomes and mobilisation regimes was conducted. Results: Eight studies with a mean Quality Index score of 20 out of 28 (SD=5.6) were included. Performing daily activities was commonly recommended as part of early mobilisation. Commencing mobilisation prior to two weeks resulted in greater range of movement, function and less pain at up to eight weeks postoperatively than delaying mobilisation until two weeks or later. Discussion: Performance of daily activities was used alongside exercise to promote recovery but without clearly specifying the type, duration or intensity of activities. In combination with exercise, early daily activity was safe and beneficial. Performing daily activities may have discrete advantages. Hand therapists are challenged to incorporate activity-approaches into early mobilisation regimes.
Is mirror therapy or mental practice useful post distal radius fracture?
Does Mental Practice or Mirror Therapy help prevent functional loss after distal radius fracture? A randomized controlled trial.
Korbus, H., & Schott, N. (2020) Level of Evidence: 2b Follow recommendation: 👍 👍 👍 Type of study: Therapeutic Topic: Radius fracture - motor imagery or mirror therapy vs relaxation This is a randomised single-blind controlled trial assessing the effectiveness of mental practice (Motor Imagery - MI) and mirror therapy (MT) in participants with distal radius fracture. Participants (N = 36) were included if they had undergone a closed fracture reduction or an open reduction internal fixation surgery. Participants were excluded if they had bilateral fracture or had any neurological condition. Effectiveness of each intervention was assessed through several functional measures (I choose to consider the QuickDASH as it is commonly used in clinical practice). Outcomes were measured at baseline and 12 weeks from injury. All participants trained with one therapist 5 times per week for 45 minutes during the first three weeks, and 3 times per week in the last three weeks of training (total of 6 weeks). Treatment allocation was randomised. The assessor was blinded to treatment allocation. Participants were provided with either MI (n = 8), MT (n = 12), or relaxation techniques (control group, n = 9). Participants in the MI mentally rehearsed several wrist movements of the affected wrist, which included wrist flexion, extension, radial and ulnar deviation, pronation, supination, and gripping. The MT group watched the reflection of the healthy hand performing the movements indicated above. The relaxation group was provided with the same duration intervention and relaxation interventions were provided. The results showed that the two intervention groups improved to a larger extent (MI = 43 points improvement; MT = 42 points improvement) compared to the control group (CG = 39 points improvement) in the QuickDASH, however, these differences were not clinically significant (the difference between groups was less than 15 points). Clinical Take Home Message: Based on what we know today, motor imagery or mirror therapy alone do not appear to improve QuickDASH outcomes at 3 months compared to a control group receiving relaxation interventions. A more appropriate approach is to follow a graded motor imagery approach, which has previously been shown to reduce pain and improve function at 8 weeks post distal radius fracture (see synopsis here). This paper followed a precise series of steps (based on neurophysiological concepts) which included a left/right hand discrimination task (3 weeks), explicit motor imagery (3 weeks), and mirror therapy (2 weeks). This approach may be particularly appropriate in patients presenting with high levels of pain within the first week of injury (these patients are also more likely to develop CRPS). Open Access URL: Available through the Journal of Hand Therapy for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Background Therapy results after distal radius fractures (DRF) especially with older patients are often suboptimal. One possible approach for counteracting the problems are motor-cognitive training interventions such as Mental Practice (MP) or Mirror Therapy (MT), which may be applied in early rehabilitation without stressing the injured wrist. Purpose The aim of the study is to investigate the effects of MP and MT on wrist function after DRF. The pilot study should furthermore provide information about the feasibility and efficacy of these methods. Study Design The study was designed as a randomized, single-blinded controlled trial. Methods Thirty-one women were assigned either to one of the two experimental groups (MP, MT) or to a control group (relaxation intervention). The participants completed a training for six weeks, administered at their homes. Measurements were taken at four times (weeks 0, 3, 6 and 12) to document the progression in subjective function (PRWE, QuickDASH) and objective constraints of the wrist (ROM, grip strength) as well as in health-related quality of life (EQ-5D). Results The results indicated that both experimental groups showed higher improvements across the intervention period compared to the control group; e.g. PRWE: MT 74.0%, MP 66.2%, CG 56.9%. While improvements in grip strength were higher for the MP group, the MT group performed better in all other measures. However, time by group interactions approached significance at best; e.g. ROM: p = .076; ηp2 = .141. Conclusion The superiority of MP as well as MT supports the simulation theory. Motor-cognitive intervention programmes are feasible and promising therapy supplements, which may be applied in early rehabilitation to counteract the consequences of immobilization without stressing the injured wrist.