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.
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 to hard 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.
How to proceed when evidence-based practice is required but very little evidence available? Leboeuf-Yde, C., Lanlo, O., & Walker, B. F. (2013) Level of Evidence: 5 Follow recommendation: 👍 Type of study: Therapeutic Topic: Limited evidence - How to proceed? This article presents a discussion on how to manage lack of evidence in clinical practice. You can find an exhaustive figure below the synopsis. The following recommendations were made: - If there is no evidence on a specific topic, use plausibility and experience. - If a treatment/test's plausibility is questioned (i.e. preclinical or basic science studies do not support the mechanism), experience is not enough to justify treatment/test. - If a treatment/test's plausibility is questioned (i.e. preclinical or basic science studies do not support the mechanism) but its use is supported by several high quality clinical studies, use the treatment/test. Clinical Take Home Message: Based on this approach, our clinical decisions should rely on consistent high quality evidence (if available). If not enough evidence (research in clinical populations) is available we should question whether a specific test/treatment is logical and whether its logical assumptions are supported by preclinical/basic science. If not, the specific test/treatment should not be used. On the other hand, if there is limited evidence (research in clinical populations), but the test/treatment is logical and its logical assumptions are supported by preclinical/basic science we should use. In this last case we need to keep an open mind and be ready to change our practice when new evidence arises. Open Access URL: Abstract Background All clinicians of today know that scientific evidence is the base on which clinical practice should rest. However, this is not always easy, in particular in those disciplines, where the evidence is scarce. Although the last decades have brought an impressive production of research that is of interest to chiropractors, there are still many areas such as diagnosis, prognosis, choice of treatment, and management that have not been subjected to extensive scrutiny. Discussion In this paper we argue that a simple system consisting of three questions will help clinicians deal with some of the complexities of clinical practice, in particular what to do when clear clinical evidence is lacking. Question 1 asks: are there objectively tested facts to support the concept? Question 2: are the concepts that form the basis for this clinical act or decision based on scientifically acceptable concepts? And question three; is the concept based on long-term and widely accepted experience? This method that we call the “Traffic Light System” can be applied to most clinical processes. Summary We explain how the Traffic Light System can be used as a simple framework to help chiropractors make clinical decisions in a simple and lucid manner. We do this by explaining the roles of biological plausibility and clinical experience and how they should be weighted in relation to scientific evidence in the clinical decision making process, and in particular how to proceed, when evidence is missing.
Upper extremity fragility fractures. Shoji, M. M., Ingall, E. M., & Rozental, T. D. (2020) Level of Evidence: 5 Follow recommendation: 👍 👍 Type of study: Preventative Topic: Fragility fractures - Prevention of secondary osteoporotic fractures This is a narrative review on screening and prevention of fragility fractures in patients presenting with a distal radius fracture (DRF). Fragility fractures are defined as fractures associated with low energy trauma. Interestingly, older clients presenting with a DRF, are 5 times more likely to have a fragility fracture within one year compared to their peers. The presence of a DRF in people older than 50 can suggest the presence of bone weakness (osteopenia or osteoporosis) and a Bone Mass Density (BMD) assessment is therefore indicated in these clients. A BMD assessment can be combined with the Fracture Risk Assessment Tool (FRAX) to provide a 10 years risk of hip fracture or other osteoporotic type fractures. If the results of the FRAX suggest that there is ≥ 3% risk of hip fracture or ≥ 20% risk of osteoporotic fractures in patients older than 50, bisphosphonate therapy should be initiated. In addition, a balance and strength training exercise program should be started. Clinical Take Home Message: Hand therapists have a great opportunity to reduce the risk of fragility fractures among their clients by screening them through tools such as the FRAX. Hand therapists may also refer their clients with a distal radius fracture, who are older than 50, to their GP suggesting a bone mass density assessment. 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, an 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 The population of elderly patients is rapidly increasing in the United States and worldwide, leading to an increased prevalence of osteoporosis and a concurrent rise in fragility fractures. Fragility fractures are defined as fractures involving a low-energy mechanism, such as a fall from a standing height or less, and have been associated with a significant increase in the risk of a future fragility fracture. Distal radius fractures in the elderly often present earlier than hip and vertebral fractures and frequently involve underlying abnormalities in bone mass and microarchitecture. This affords a unique opportunity for upper extremity surgeons to aid in the diagnosis and treatment of osteoporosis and the prevention of secondary fractures. This review aims to outline current recommendations for orthopedic surgeons in the evaluation and treatment of upper extremity fragility fractures.
Management of radial tunnel syndrome: A therapist's clinical perspective. Cleary, C. K. (2006) Level of Evidence: 5 Follow recommendation: 👍 Type of study: Therapeutic Topic: Posterior interosseous nerve entrapment - Conservative treatment This is a expert opinion article on conservative interventions for radial tunnel syndrome (RTS). Unfortunately, I was unable to find a more recent paper on conservative interventions for RTS. I have excluded from this synopses modalities such as ultrasound treatment (US) described in the paper. The author's recommendation is based on animal studies showing improvements in nerve conduction (NC) following US. I am not however convinced about the clinical relevance of these findings, as changes in clients' symptoms are not always correlated with improvements in NC (see this synopsis). If you are really interested in US modalities and the author's opinion on the topic, you can always read the paragraph yourself (page 186-187), it is a 5-10 minutes read. The other treatment approach, which has recently been shown to be effective in other entrapment neuropathies, includes radial/median nerve glides. In addition, a wrist splint may limit the amount of wrist flexion, which may otherwise contribute to nociception in mechanosensitive radial nerves. It was also suggested to do sensorimotor training (e.g. graphesthesia, mirror therapy) to address potential cortical remapping, which can be present in clients with entrapment neuropathies. Clinical Take Home Message: Currently there is very limited evidence supporting the use of any conservative intervention for radial tunnel syndrome (RTS), which is a mild entrapment neuropathy of the posterior interosseous nerve. This may be due to the extremely low incidence of this condition which affects 1 in 10,000 people. The current best approach is therefore based on indirect evidence from other entrapment neuropathies (e.g. carpal tunnel syndrome) and preclinical science. In particular, it appears that nerve glides may be helpful in reducing symptoms in RTS. In addition, the treatment of other potential compression points along the radial nerve, may be useful (see this synopsis on carpal tunnel syndrome). Finally, there appears to be preclinical evidence of a neuroprotective and neuroregenerative effect of mild to moderate aerobic exercise (e.g. walking, swimming, jogging) for peripheral entrapment neuropathies (Jesson et al. 2020 - I will make a synopsis on this). Due to the very low incidence of RTS, other more common conditions such as cervical radiculopathy and lateral epicondylalgia should be excluded first. Open Access URL: Abstract Current best evidence for the conservative management of radial tunnel syndrome (RTS) consists primarily of expert opinion and inferences taken from studies on other nerve compressions and related syndromes. There are limited data reported in the literature of this particular disorder. This article reviews literature on modalities, therapeutic exercise, ergonomic interventions, and cortical reorganization, and how they may be considered for intervention with RTS. The author's preferred method of treatment, as based on theoretical constructs, for RTS is presented. Definitive evidence in the literature to support the conservative interventions suggested is lacking. Suggestions for clinical management and study are included in this therapist's clinical perspective.
Why are median nerve anatomical variations important in carpal tunnel syndrome?
Median and ulnar nerve anastomoses in the upper limb: A meta-analysis. Roy, J., Henry, B. M., PĘkala, P. A., Vikse, J., Saganiak, K., Walocha, J. A., & Tomaszewski, K. A. (2016) Level of Evidence: 1a Follow recommendation: 👍 👍 👍 👍 Type of study: Anatomical Topic: Median nerve variations - Relevance in carpal tunnel syndrome This is a systematic review and meta-analysis assessing the prevalence of median nerve variations in the forearm and hand. There were a total of 58 studies assessing 10,562 upper limbs (from cadavers and nerve conduction studies in living participants). All the studies were pooled in a prevalence meta-analysis. The three most common median nerve anatomical variations in the forearm were described and their prevalence reported (I excluded the Marinacci anastomosis as it is rare 0.7% of the population). These included Martin‐Gruber anastomosis (MGA), Riche‐Cannieu anastomosis (RCA), and Berrettini anastomosis (BA). The Martin‐Gruber anastomosis (MGA) is described as a communicating branch from the median nerve to ulnar nerve in the forearm. Through this anastomosis, the median nerve innervates the thenar eminence bypassing the carpal tunnel. The pooled prevalence of this anastomosis (which is mainly motor) has been shown to be 20% (95%CI: 16% to 23%). The Riche‐Cannieu anastomosis (RCA) is defined as a communicating branch from the ulnar nerve to the median nerve in the palm of the hand. Through this anastomosis the ulnar nerve innervates the thenar eminence muscles. The pooled prevalence of this anastomosis (which is motor) has been shown to be 60% (95%CI: 30% to 80%). Last but not least, Berrettini anastomosis (BA) is a sensory connection between median and ulnar nerve in the palm that innervate the middle and ring finger (digital nerves). Through this anastomosis, both the ulnar and median nerve provide sensory innervation to the ulnar aspect of the middle finger and radial aspect of the ring finger. The pooled prevalence of this anastomosis (which is sensory) has been shown to be 60% (95%CI: 40% to 80%). Clinical Take Home Message: Based on what we know today, at least three median nerve variations in the forearm and hand are common or normal in our clients. These variations may explain why a limited number of people presenting with severe carpal tunnel compression (significant numbness with or without pain) do not present with motor impairments in the thenar muscles (MGA and RCA anastomosis). In addition, sensory changes involving the middle and ring finger in clients with carpal tunnel syndrome may depend on the presence of communicating branches between median and ulnar nerve (BA anastomosis). This last anastomosis may explain why there is significant variance in the textbooks description of sensory changes associated with carpal tunnel syndrome (involvement or not of ring finger). URL: You can ask the authors for the full text through Research Gate. Available through EBSCO Health Databases for PNZ members. Abstract Introduction: The most frequently described anomalous neural connections between the median and ulnar nerves in the upper limb are: Martin‐Gruber anastomosis (MGA), Marinacci anastomosis (MA), Riche‐Cannieu anastomosis (RCA), and Berrettini anastomosis (BA). The reported prevalence rates and characteristics of these anastomoses vary significantly between studies. Methods: A search of electronic databases was performed to identify all eligible articles. Anatomical data regarding the anastomoses were pooled into a meta‐analysis using MetaXL 2.0. Results: A total of 58 (n = 10,562 upper limbs) articles were included in the meta‐analysis. The pooled prevalences were: MGA, 19.5% (95% confidence interval [CI], 16.2%–23.1%); MA, 0.7% (95% CI, 0.1%–1.7%); RCA, 55.5% (95% CI, 30.6%–79.1%); and BA, 60.9% (95% CI, 36.9%–82.6%). The results also showed that MGA was more commonly found unilaterally (66.8%), on the right side (15.7%), following an oblique course (84.8%), and originating from the anterior interosseous nerve with a prevalence of 57.6%. Conclusions: As anastomoses between the median and ulnar nerves occur commonly, detailed anatomical knowledge is essential for accurate interpretation of electrophysiological findings and reducing the risk of iatrogenic injuries during surgical procedures.
What logical fallacies should we be aware of when relying on experience and published opinions?
Why are assumptions passed off as established knowledge? Weisman, A., Quintner, J., Galbraith, M., & Masharawi, Y. (2020) Level of Evidence: 5 Follow recommendation: 👍 Type of study: Therapeutic Topic: Logical fallacies This article presents a discussion on logical fallacies in medicine. These fallacies apply to both expert opinions and published articles introducing new hypotheses rather than established theories. The following recommendations were made: - Avoid assuming that the achieved outcomes are the result of what preceded it (fallacy - post hoc ergo propter hoc). For example, you have given your clients "stabilisation" exercises for symptomatic 1st cmcj OA and their pain improved. You therefore assume that the issue is 1st cmcj instability when in fact pain may have improved with general thumb exercises. - Avoid assuming that incidental findings associated with a certain pathology are the cause of that pathology (e.g. repetitive strain injury, central sensitisation). For example, one of your clients is an athlete doing high exercise volume and you assume that the symptoms that they developed are due to repetitive strain injury. High loads and repetitive activities may not be the only cause of their pain and other factors such as poor sleep, fatigue, and mental health may be large contributing factors to their pain (see this synopsis). Clinical Take Home Message: This paper suggests keeping an open mind and challenging the concepts guiding our treatment approach, as well as the opinion of experts in the field. By assuming that we are wrong and logically test the potential alternatives (e.g. diagnostic, therapeutic) we can increase the likelihood of doing what is best for our patients. Challenging one's own practice is difficult and it has always been throughout history. URL: Possibly available through EBSCO Health Databases for PNZ members. Abstract “What can be asserted without evidence can also be dismissed without evidence.” (Christopher Hitchens, 2007).
A randomized clinical trial comparing early active motion programs: Earlier hand function, TAM, and orthotic satisfaction with a relative motion extension program for zones V and VI extensor tendon repairs. Collocott, S. J. F., Kelly, E., Foster, M., Myhr, H., Wang, A., & Ellis, R. F. (2020) Level of Evidence: 1b Follow recommendation: 👍 👍 👍 👍 Type of study: Therapeutic Topic: RME - Zone V and VI extensor repair This is a randomised controlled trial assessing the effectiveness of controlled active motion (CAM) and relative motion extension (RME) splinting program following zone V and VI extensor tendon repair. Participants (N = 42) were included if they presented with a primary repair of maximum two digits in zone V and VI. Participants were excluded if they presented with additional injuries (e.g. fractures). Effectiveness of each intervention was assessed through the Sollerman Hand Function Test (SHFT - primary outcome), QuickDASH, total active motion (TAM), days to return to full work duties, grip strength, compliance with splinting regime, and participants' satisfaction (all secondary outcomes). The outcomes were measured at 4 and 8 weeks after surgery, except for grip strength, which was measured at 8 weeks only. Treatment allocation was randomised. The assessor was blinded to treatment allocation. Participants were provided with either a RME splint of the affected finger/s (n = 21) or CAM protocol (n = 21). The RME splint group was advised to wear the RME splint all day and a volar block at night. Advice was given to avoid composite flexion during the day. At 10 days, participants could return to work lifting a maximum of 5 kg. The splint was gradually weaned from week 4 post surgery (RME off for light tasks), and at week 6 participants used the RME for heavy tasks only without the need to wear a volar block at night. From week 8, any splint was to be discontinued. The RME group did not have to do any exercises unless they presented with range of movement limitations at week 4. The CAM splint group had to wear a volar block (except for pipj and dipj) during the day, which was reinforced at night (including pipj and dipj). In addition, they had to perform several exercises during the day. Return to work was similar to the RME splint group, although the CAM group was advised not to resume heavy duties at work until week 8 (two weeks later than CAM splint). The results showed that participants in the RME group recovered more quickly in terms of function (SHFT, QuickDASH) and TAM compared to the CAM group at 4 weeks. These results were both statistically and clinically significant. Overall, participants were more satisfied with the RME compared to the CAM approach. At 8 weeks TAM was still statistically and clinically significant greater in the RME splint group, however, function was no longer different between groups. No differences were noted in return to work, adherence, or complications between the two groups. Overall there was a 10% probability that these group differences were due to chance (10 group comparisons were performed, 5 of these were significant). Clinical Take Home Message: Based on what we know today, hand therapists may choose to use an RME over the CAM splinting program for extensor tendon repair in zone V and VI. The RME protocol provides greater improvement in function and finger range of movement at four weeks without the need to do a home exercise program. In addition, the number of complications (e.g. tendon rupture) was as low as in the CAM group, making the RME a safe protocol. URL: Available through the Journal of Hand Therapy for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Study Design: Randomized clinical trial with parallel groups. Introduction: Early active mobilization programs are used after zones V and VI extensor tendon repairs; two programs used are relative motion extension (RME) orthosis and controlled active motion (CAM). Although no comparative studies exist, use of the RME orthosis has been reported to support earlier hand function. Purpose of the Study: This randomized clinical trial investigated whether patients managed with an RME program would recover hand function earlier postoperatively than those managed with a CAM program. Methods: Forty-two participants with zones V-VI extensor tendon repairs were randomized into either a CAM or RME program. The Sollerman Hand Function Test (SHFT) was the primary outcome measure of hand function. Days to return to work, QuickDASH (Disabilities of Arm, Shoulder and Hand) questionnaire, total active motion (TAM), grip strength, and patient satisfaction were the secondary measures of outcome. Results: The RME group demonstrated better results at four weeks for the SHFT score (P = .0073; 95% CI: −10.9, −1.8), QuickDASH score (P = .05; 95% CI: −0.05, 19.5), and TAM (P = .008; 95% CI: −65.4, −10.6). Days to return to work were similar between groups (P = .77; 95% CI: −28.1, 36.1). RME participants were more satisfied with the orthosis (P < .0001; 95% CI: 3.5, 8.4). No tendon ruptures occurred. Discussion: Participants managed using an RME program, and RME finger orthosis demonstrated significantly better early hand function, TAM, and orthosis satisfaction than those managed by the CAM program using a static wrist-hand-finger orthosis. This is likely due to the less restrictive design of the RME orthosis. Conclusions: The RME program supports safe earlier recovery of hand function and motion when compared to a CAM program following repair of zones V and VI extensor tendons.
Use of a relative motion flexion orthosis for postoperative management of zone I/II flexor digitorum profundus repair: A retrospective consecutive case series. Henry, S. L., & Howell, J. W. (2020) Level of Evidence: 4 Follow recommendation: 👍 👍 Type of study: Therapeutic Topic: RMF - Flexor tendon zone I and II This is a retrospective case series assessing the effectiveness of a relative motion flexion (RMF) splinting program following zone I and II flexor tendon repair. Participants (N = 10) were included if they presented with a single digit lesion in zone I and II. Surgical interventions included a four strand repair of flexor digitorum profundus (FDP) with pulley venting. Flexor digitorum superficialis (FDS) was not repaired if injured. The RMF splint placed the affected finger in 30°-40° of relative flexion compared to the other fingers. A wrist orthosis was utilised in combination with the RMF splint 24/7 for the first 3 weeks. After 3 weeks, the RMF was worn full time while the wrist splint was used at night and during at risk tasks (e.g. jogging) only. Lifting light objects with both hands was allowed at the three weeks mark. At six weeks, the RMF splint was still worn 24/7 and patients could lift a maximum of 3.5 kg. Use of the wrist splint was discontinued at this point. All restrictions, which included the use of the RMF splint, were lifted between week 8 and 10. Effectiveness of the intervention was assessed through ipj range of movement (total active range of movement - %TAM), grip strength, and rupture rate. The results showed that 4 participants had an excellent, 1 had a good, and 3 had a fair range of movement at the end of the rehabilitation (% of contralateral TAM outcome). Grip strength ranged from 63% to 100% of the contralateral. No ruptures were reported. Clinical Take Home Message: In the future, a RMF splint in combination with a wrist splint may be an alternative to more traditional flexor tendon repair in zone I and II when only one digit is involved. There is however not enough high quality research (at this point in time) to allow the implementation of this approach according to an evidence based approach. The risk of tendon ruptures has not been formally assessed through randomised controlled trials and there is a possibility of it being higher than the currently adopted protocols. URL: Available through the Journal of Hand Therapy for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Study Design: A retrospective, single-center, consecutive case series. Introduction: In concept, a relative motion flexion (RMF) orthosis will induce a “quadriga effect” on a given flexor digitorum profundus (FDP) tendon, limiting its excursion and force of flexion while still permitting a wide range of finger motion. This effect can be exploited in the rehabilitation of zone I and II FDP repairs. Purpose of the Study: To describe the use of RMF orthoses to manage zone I and II FDP 4-strand repairs. Methods: Medical record review of 10 consecutive zone I and II FDP tendon repairs managed with RMF orthosis for 8 to 10 weeks in combination with a static dorsal blocking or wrist orthosis for the initial 3 weeks. Results: Indications included sharp lacerations (n = 6), ragged lacerations (n = 2), staged flexor tendon reconstruction (n = 1), and type IV avulsion (n = 1). In 8 of the 10 cases that completed follow-up, the mean arc of proximal interphalangeal/distal interphalangeal active motion were as follows: sharp, 0° to 106°/0° to 75°; ragged, 0° to 90°/0° to 25°; reconstruction, 0° to 90°/10° to 45°; and avulsion, 0° to 95°/0° to 20°. Grip performance available for 6 of 10 cases was 62% to 108% of the dominant hand. There were no tendon ruptures, secondary surgeries, or proximal interphalangeal joint contractures. Conclusion: Based on this small series, the RMF approach appears to be safe and effective. It can lead to similar mobility and functional recovery as other early active motion protocols, with certain practical advantages and without major complications. Further investigation with larger, multicenter, prospective, longitudinal cohorts and/or randomized clinical trials is necessary.
Sensorimotor performance and function in people with osteoarthritis of the hand: A case-control comparison. Magni, N., McNair, P., & Rice, D. (2017) Level of Evidence: 3b Follow recommendation: 👍 👍 Type of study: Aetiologic Topic: Symptomatic hand osteoarthritis - Brain changes This is a case-control study assessing differences on motor imagery, tactile acuity, and neglect-like symptoms in participants with hand OA (cases) and healthy participants (controls). A total of 39 participants were included in the study. Hand OA (n = 20) was diagnosed through the American College of Rheumatology (ACR) criteria and confirmed through x-ray. Healthy participants (n = 19) were age and gender matched to the hand OA participants. Motor imagery was assessed through a hand left-right discrimination task (reaction time and response accuracy), tactile acuity was measured through two-point discrimination, and neglect-like symptoms were measured through the neurobehavioral questionnaire. The results showed that participants with hand OA were significantly slower (0.5 seconds slower) and less accurate (10% less accurate) in discriminating between left-right hands during the motor imagery task. It is unclear whether these differences are clinically relevant as no study as assessed the minimal clinically important difference for this test. There was no difference between groups on two-point discrimination. There was a statistically significant difference between groups on neglect-like symptoms, with 50% of the hand OA sample reporting them (0% of the healthy people reported them). Overall, due to multitude of statistical tests performed (23 tests) and the number of significant findings (11 test) there is a 10% probability that the results are just due to chance (the correlation analysis was not reported in this synopsis). Due to the cross-sectional nature of this study it is not possible to comment on the causality between these findings (motor imagery and neglect-like symptoms) and their contribution to pain. It is possible that on-going pain associated with hand OA may contribute to these findings or vice-versa. Clinical Take Home Message: Based on what we know today, clients with hand OA may present with brain changes that are the result of, or contribute to, their pain experience. This may explain why illusory resizing temporarily reduces pain in hand OA (see this synopsis). Currently, this type of treatment is supported by low quality of evidence and other multidisciplinary approaches, supported by higher quality evidence, may be implemented first. Open access URL: Abstract Objectives: To determine whether hand left/right judgements, tactile acuity, and body perception are impaired in people with hand OA. To examine the relationships between left right judgements, tactile acuity and hand pain. To explore the relationships between sensorimotor measures (left/right judgements and tactile acuity) and measures of hand function in people with hand OA. Methods: Twenty patients with symptomatic hand OA and 19 healthy pain-free controls undertook a hand left/right judgment task, a control left/right judgement task, two-point discrimination (TPD) threshold testing (assessing tactile acuity), a neglect-like symptoms questionnaire (assessing body perception) and several established measures of hand function. Results: Neglect-like symptoms were experienced more frequently in the hand OA group (P < 0.05). People with hand OA were slower (P < 0.05) and less accurate (P < 0.05) in the hand left/right judgement task when compared to healthy controls, with no significant difference in the control task. Significant associations were found between hand left/right judgement reaction time and pain intensity (P < 0.05) and accuracy and pain intensity (P < 0.05). TPD was not different between groups, and no correlation was found between TPD and left/right judgement performance. No association was found between left/right judgement performance and measures of hand function (all P > 0.05). However, TPD (tactile acuity) was related to several measures of hand function (all P < 0.05). Conclusion: People with hand OA had more frequent neglect-like symptoms and were slower and less accurate compared to healthy controls at hand left/right judgments, which was indicative of disrupted working body schema. Future studies may wish to examine whether interventions targeting sensorimotor dysfunction are effective at reducing pain and improving hand function and dexterity in people with hand OA.
Proximal median nerve compression: Pronator syndrome. Adler, J. A., & Wolf, J. M. (2020) Level of Evidence: 5 Follow recommendation: 👍 Type of study: Diagnostic, Therapeutic Topic: Median nerve compression - Pronator teres syndrome This is a narrative review on pronator teres syndrome. Pronator teres syndrome presents clinically with paresthesias in the median nerve distribution distally to the pronator teres and pain in the volar aspect of the forearm. The differential diagnosis includes cervical radiculopathy, brachial neuritis, thoracic outlet syndrome, anterior interosseous nerve (AIN) syndrome, and carpal tunnel syndrome (CTS). Physical tests may be helpful in discriminating between pronator teres syndrome, AIN syndrome, and CTS when they are present in isolation. In particular, the AIN syndrome is associated with motor but no sensory changes in comparison to pronator teres and CTS syndrome. Pronator teres syndrome may be associated with thenar eminence numbness (palmar cutaneous branch of the median nerve branches before the carpal tunnel) while in CTS there should be no numbness in the thenar eminence. With AIN syndrome, weakness (if present) is usually localisted to FPL and FDP of the index and middle finger. In terms of special tests, Phalen's and Tinel's test should be negative if there is an isolated pronator teres syndrome. These two condition may however present in combination. Unfortunately, nerve conduction studies are not useful to assess pronator teres syndrome. Conservative treatment should always be trialled for 3 to 6 month before surgery. This may include rest NSAIDs, activity modification, and physical therapy. Clinical Take Home Message: Hand therapists may consider pronator teres syndrome diagnosis when clients present with pain in the forearm and numbness in the peripheral median nerve distribution. Differential diagnoses for this condition may include cervical radiculopathy, brachial neuritis, thoracic outlet syndrome, anterior interosseous nerve (AIN) syndrome, and carpal tunnel syndrome (CTS). A few tests are available to make a diagnosis of cervical radiculopathy, however, dermatomal patterns are not reliable. Brachial neuritis and thoracic outlet syndrome present with limited special tests available as a gold standard for their diagnosis does not exist (similar to pronator teres syndrome). AIN syndrome has no sensory impairments and may present with FPL, index and middle finger FDP weakness. Carpal tunnel syndrome easier to diagnose, with nerve conduction studies helpful in the identification of moderate to severe CTS. For more information on nerve conduction study impairments in CTS have a look at this synopsis. URL: Available through the Journal of Hand Surgery (American volume) for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Pronator syndrome (PS) is a compressive neuropathy of the median nerve in the proximal forearm, with symptoms that often overlap with carpal tunnel syndrome (CTS). Because electrodiagnostic studies are often negative in PS, making the correct diagnosis can be challenging. All patients should be initially managed with nonsurgical treatment, but surgical intervention has been shown to result in satisfactory outcomes. Several surgical techniques have been described, with most outcomes data based on retrospective case series. It is essential for clinicians to have a thorough understanding of median nerve anatomy, possible sites of compression, and characteristic clinical findings of PS to provide a reliable diagnosis and treat their patients.
Thumbs up: Imagined hand movements counteract the adverse effects of post-surgical hand immobilization. Gandola, M., Zapparoli, L., Saetta, G., De Santis, A., Zerbi, A., Banfi, G., . . . Paulesu, E. (2019) Level of Evidence: 3b Follow recommendation: 👍 👍 Type of study: Therapeutic Topic: Trapeziectomy - Motor imagery This is a prospective study assessing the outcomes of participants undergoing explicit motor imagery post trapeziectomy for first carpometacarpal joint (cmcj) OA. Explicit motor imagery simply means imagining to perform a movement without physically performing it. A total of 22 participants underwent motor imagery (n=12) or limited motor imagery training (n=10) during the immobilisation period (2 weeks) post trapeziectomy. The differentiation between the motor imagery vs limited motor imagery groups was the compliance with the program (no randomisation). In particular, the motor imagery group had an 84% compliance while the limited motor imagery group had a 20% compliance with the program. Outcomes included were pain during thumb movement (VAS -thumb opposition, flexion, and circumduction) and disability (DASH). These outcomes were measured after 2 weeks immobilisation. The motor imagery task involved two daily sessions (AM and PM) during which participants had to imagine performing thumb opposition, flexion, and circumduction. The results showed that there was no statistically significant difference between groups in function (DASH). Pain improved to a statistically and clinically significant level in the motor imagery group (2.3 points improvement out of 10) during thumb circumduction movement, with a large between groups difference (4 points out of 10). There were no differences between groups for pain with thumb flexion and opposition. Overall, there is a low risk that these differences are due to chance as corrections for multiple statistical tests were completed. Clinical Take Home Message: Based on what we know today, motor imagery imagery may be useful for clients undergoing a period of immobilisation following trapeziectomy. This intervention does not appear to improve function, although it reduces significantly the pain on movement that clients experience when coming out of the cast. If interested, clinicians can download the Orientate app (It's free) and ask clients to imagine replicating the hand position shown on the app. Open access URL: Abstract Motor imagery (M.I.) training has been widely used to enhance motor behavior. To characterize the neural foundations of its rehabilitative effects in a pathological population we studied twenty-two patients with rhizarthrosis, a chronic degenerative articular disease in which thumb-to-fingers opposition becomes difficult due to increasing pain while the brain is typically intact. Before and after surgery, patients underwent behavioral tests to measure pain and motor performance and fMRI measurements of brain motor activity. After surgery, the affected hand was immobilized, and patients were enrolled in a M.I. training. The sample was split in those who had a high compliance with the program of scheduled exercises (T+, average compliance: 84%) and those with low compliance (T−, average compliance: 20%; cut-off point: 55%). We found that more intense M.I. training counteracts the adverse effects of immobilization reducing pain and expediting motor recovery. fMRI data from the post-surgery session showed that T+ patients had decreased brain activation in the premotor cortex and the supplementary motor area (SMA); meanwhile, for the same movements, the T− patients exhibited a reversed pattern. Furthermore, in the post-surgery fMRI session, pain intensity was correlated with activity in the ipsilateral precentral gyrus and, notably, in the insular cortex, a node of the pain matrix. These findings indicate that the motor simulations of M.I. have a facilitative effect on recovery by cortical plasticity mechanisms and optimization of motor control, thereby establishing the rationale for incorporating the systematic use of M.I. into standard rehabilitation for the management of post-immobilization syndromes characteristic of hand surgery.
The effects of resistance training on muscle strength, joint pain, and hand function in individuals with hand osteoarthritis: a systematic review and meta-analysis. Magni, N. E., McNair, P. J., & Rice, D. A. (2017) Level of Evidence: 1a- Follow recommendation: 👍 👍 👍 👍 Type of study: Therapeutic Topic: Resistance training - application in hand OA This is a systematic review and meta-analysis assessing the effectiveness of resistance training exercises for hand OA. Five RCTs were included in the systematic review, for a total of 350 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 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 control groups undergoing no exercise. Efficacy of intervention was assessed through improvements in grip strength, function (e.g. FIHOA, AUSCAN), and pain (e.g. NRS, AUSCAN pain). The assessment time points varied significantly, and they ranged from 6 to 24 weeks. Moderate quality evidence showed that resistance training did not improve grip strength to a statistically or clinically significant level (8% difference between groups in favor of resistance training). Low quality evidence showed no effect of resistance training on function, and a small, non clinically significant, effect on pain relief (0.5 out of 10 points improvement in favor of resistance training). Overall, due to multitude of statistical tests performed (3 tests) and the number of significant findings (1 test) there is a 15% probability that the results are just due to chance. Clinical Take Home Message: Based on what we know today, resistance training interventions do not appear to have a clinically relevant effect in clients with hand OA. They do not appear to improve grip strength, function, nor joint pain. Considering these results, a multimodal approach to the treatment of hand OA may be more effective (see previous synopsis on the topic). Open access URL: Abstract Background: Hand osteoarthritis is a common condition characterised by joint pain and muscle weakness. These factors are thought to contribute to ongoing disability. Some evidence exists that resistance training decreases pain, improves muscle strength, and enhances function in people with knee and hip osteoarthritis. However, there is currently a lack of consensus regarding its effectiveness in people with hand osteoarthritis. Therefore, the aim of this systematic review and meta-analysis was to establish whether resistance training in people with hand osteoarthritis increases grip strength, decreases joint pain, and improves hand function. Methods: Seven databases were searched from 1975 until July 1, 2016. Randomised controlled trials were included. The Cochrane Risk of Bias Tool was used to assess studies' methodological quality. The Grade of Recommendations Assessment, Development, and Evaluation system was adopted to rate overall quality of evidence. Suitable studies were pooled using a random-effects meta-analysis. Results: Five studies were included with a total of 350 participants. The majority of the training programs did not meet recommended intensity, frequency, or progression criteria for muscle strengthening. There was moderate-quality evidence that resistance training does not improve grip strength (mean difference = 1.35; 95% confidence interval (CI) = -0.84, 3.54; I 2 = 50%; p = 0.23 ). Low-quality evidence showed significant improvements in joint pain (standardised mean difference (SMD) = -0.23; 95% CI = -0.42, -0.04; I 2 = 0%; p = 0.02) which were not clinically relevant. Low-quality evidence demonstrated no improvements in hand function following resistance training (SMD = -0.1; 95% CI = -0.33, 0.13; I 2 = 28%; p = 0.39). Conclusion: There is no evidence that resistance training has a significant effect on grip strength or hand function in people with hand osteoarthritis. Low-quality evidence suggests it has a small, clinically unimportant pain-relieving effect. Future studies should investigate resistance training regimes with adequate intensity, frequency, and progressions to achieve gains in muscle strength.
Radial tunnel syndrome: definition, distinction and treatments. Bo Tang, J. (2020) Level of Evidence: 5 Follow recommendation: 👍 Type of study: Diagnostic, Therapeutic Topic: Posterior interosseous nerve entrapment - Radial tunnel syndrome vs PIN syndrome This is a narrative review on radial tunnel syndrome (RTS) and posterior interosseous nerve syndrome (PINS). These two presentations are both entrapment neuropathies of the posterior interosseous nerve, however, RTS is a mild entrapment neuropathy while PIN is a severe entrapment neuropathy (similar to mild vs severe carpal tunnel syndrome). The clinical presentations of RTS and PINS are different. RTS presents with pain in the lateral aspect of forearm 4-5 cm distal from the lateral epicondyle. PINS presents with no pain but with palsy of the wrist, finger, and thumb extensors, except for extensor carpi radialis longus. Clients with PINS will therefore present with painless weak wrist extension associated with radial deviation. Investigations for people with RTS or PINS may include x-rays and US, which will be able to exclude the presence of radiocapitellar joint osteoarthritis or space invading lesions which may be responsible for the entrapment. The differential diagnosis includes lateral epicondylalgia, cervical radiculopathy, high radial nerve palsy (e.g. Saturday night palsy), and extensive tendon ruptures of the extensors compartment. If a diagnosis of RTS is made, conservative treatment should be trialed for at least 6 months before surgery is considered. Overall, entrapment of the posterior interosseous nerve, especially severe entrapment, appears to be rare compared to median and ulnar nerve entrapment neuropathies (e.g. carpal tunnel syndrome, cubital tunnel syndrome). Clinical Take Home Message: A mild (RTS) or severe (PINS) entrapment neuropathy of the posterior interosseous nerve is rare. A mild entrapment neuropathy (RTS) usually presents with pain 4-5 cm distal to the lateral epicondyle. A severe entrapment neuropathy (PINS) presents with no forearm pain but significant motor weakness of the extensors compartment of the forearm. The key characteristic discriminating PINS from a higher nerve palsy (e.g. Saturday night palsy) or cervical radiculopathy with motor impairments, is that PINS will present with weak wrist extension associated with radial deviation (ECRL is intact). In addition, cervical radiculopathies present with neck pain in 80% of cases and often present with pain above the elbow. When differentiating between RTS and lateral epicondylalgia, the location of pain is the most useful indicator, with lateral epicondylalgia presenting with more proximal symptoms. URL: Available through EBSCO Health Databases for PNZ members. Abstract Radial tunnel syndrome (RTS) is a disease causing lateral elbow and proximal dorsolateral forearm pain that may radiate to the wrist and dorsum of the fingers without obvious extensor muscle weakness. An epidemiological study shows an incidence of nine new cases of radial neuropathy per 100,000 population for men and six per 100,000 for women in a 10-year period (Hulkkonen et al., 2020). These incidences are far less than entrapments of the median and ulnar nerves. There are ambiguous descriptions of RTS in relation to posterior interosseous nerve (PIN) compression. This article intends to discuss the anatomy of the radial tunnel and the clinical distinctions between two entities.
Should you warn your diabetic clients about carpal tunnel surgery outcomes?
Does diabetes mellitus change the carpal tunnel release outcomes? Evidence from a systematic review and meta-analysis. Moradi, A., Sadr, A., Ebrahimzadeh, M. H., Hassankhani, G. G., & Mehrad-Majd, H. (2020) Level of Evidence: 1a Follow recommendation: 👍 👍 👍 👍 Type of study: Therapeutic Topic: Surgical decompression of the carpal tunnel - Outcomes in diabetic vs healthy clients This is a systematic review and meta-analysis assessing outcomes in participants with and without diabetes following surgical decompression of the carpal tunnel. Ten studies were included for a total of 2,869 participants. Of these participants, 2423 were healthy and 446 presented with diabetes. Seventy percent of these participants were females. On average, participants were 56 years old. Outcomes included function, sensory, and motor nerve conduction studies. The results showed that there were no functional differences between clients with or without diabetes. Sensory nerve conduction improved to a greater extent in the healthy compared to diabetic participants. However, considering the multiple statistical tests undertaken, 23% of the results are due to chance. This reduces our confidence in these findings, especially considering that these differences did not have clinical repercussions in terms of function. Clinical Take Home Message: Hand therapists may reassure clients that diabetes does not appear to affect the results of surgery for carpal tunnel syndrome. However, hand therapists should remember that depression and mental health do affect post surgical satisfaction and the amount of health care resources required following carpal tunnel decompression. URL: Available through the Journal of Hand Therapy for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Study Design: A systematic review and meta-analysis. Introduction: Carpal tunnel syndrome (CTS) is one of the most common upper extremity conditions which mostly affect women. Management of patients suffering from both CTS and diabetes mellitus (DM) is challenging, and it was suggested that DM might affect the diagnosis as well as the outcome of surgical treatment. Purpose of the Study: This meta-analysis was aimed to compare the response with CTS surgical treatment in diabetic and nondiabetic patients. Methods: Electronic databases were searched to identify eligible studies comparing the symptomatic, functional, and neurophysiological outcomes between diabetic and nondiabetic patients with CTS. Pooled MDs with 95% CIs were applied to assess the level of outcome improvements. Results: Ten articles with 2869 subjects were included. The sensory conduction velocities in the wrist-palm and wrist–middle finger segments showed a significantly better improvement in nondiabetic compared with diabetic patients (MD = −4.31, 95% CI = −5.89 to −2.74, P < .001 and MD = −2.74, 95% CI = −5.32 to −0.16, P = .037, respectively). However, no significant differences were found for the improvement of symptoms severity and functional status based on the Boston Carpal Tunnel Questionnaire and Quick Disabilities of the Arm, Shoulder, and Hand questionnaire as well as motor conduction velocities and distal motor latencies. Conclusion: Metaresults revealed no significant difference in improvements of all various outcomes except sensory conduction velocities after CTS surgery between diabetic and nondiabetic patients. A better diabetic neuropathy care is recommended to achieve better sensory recovery after CTS surgery in diabetic patients.
Fracture's tenderness on palpation: don't let it fool you
Pain during physical examination of a healing upper extremity fracture. Gonzalez, A. I., Kortlever, J. T. P., Crijns, T. J., Ring, D., Reichel, L. M., & Vagner, G. A. (2020) Level of Evidence: 2c Follow recommendation: 👍 👍 👍 Type of study: Prognostic Topic: Fracture tenderness - Healing This is a prospective study assessing the correlation between clients ability to cope with pain in daily life and tenderness on palpation of a hand or wrist fracture. A total of 117 participants were included. Of these participants 33% had a distal radius fracture, 21% had a metacarpal fracture, (18%) and phalanx fracture (the remaining 34% had other upper limb fractures). All of the participants included, presented with fractures which were unlikely to present complications or prolonged healing times (e.g. displaced). Clients ability to cope with pain in daily life was assessed through the Pain Self-Efficacy Questionnaire - Two-Item Short Form (PSEQ-2) (scroll to the bottom of the link to find this handy questionnaire), and the PROMIS CATs for physical function, depression, and pain interference (score it yourself or use it for your clients - Try the PROMIS CAT Demo>>). Tenderness on palpation at the fracture site was scored on a 0 to 10 numerical rating scale. Participants were assessed 3 to 6 weeks post injury. On average, participants were over 48 years old. The results showed that participants presenting with greater pain interference and lower self efficacy, presented with greater tenderness on palpation at the fracture site. This study did not objectively assess fracture's union because there is currently no gold standard that can measure this outcome. It is possible that delayed union affected participants' pain and as a results this affected their ability to cope with pain (this is a limitation of the study). This last option is however unlikely due to the type of fractures assessed, which usually heal fast without complications. Clinical Take Home Message: Based on what we know today, hand therapists may not decide on extending or reducing a fracture's immobilisation period based on tenderness on palpation of the fracture site. It appears that clients presenting with limited coping strategies report greater pain with fracture palpation. Traditional fracture healing times may be a better guide, compared to pain, in deciding how long a fracture should be immobilised. URL: You can ask the authors for the full text through Research Gate Available through EBSCO Health Databases for PNZ members. Abstract The evidence that symptom intensity and magnitude of limitations correlate with thoughts and emotions means that subjective signs, such as pain with physical examination, reflect both physical and mental health. During a 1-month evaluation of a rapidly healing upper extremity fracture with no risk of nonunion, 117 people completed measures of adaptiveness to pain and pain during the physical examination. Greater pain during examination correlated with less adaptive responses to pain and older age. This finding raises questions about using tenderness to assess fracture union.
Does digital nerve sensory loss cause pinch and grip weakness?
The effect of digital sensory loss on hand dexterity. Luukinen, P., Leppänen, O. V., & Jokihaara, J. (2020) Level of Evidence: 4 Follow recommendation: 👍 👍 Type of study: Diagnostic Topic: DIgital nerve anaesthesia - Grip and pinch strength This is a study assessing dexterity, grip, and pinch strength before and after digital nerve blocks at the thumb, index, and middle finger (within-subject design). Twelve healthy participants were recruited for this study. Hand dexterity was measured through the Moberg pick-up test. Grip and pinch strength were assessed through a Jamar hand dynamometer (power grip) and pinch dynamometer (tripod and key pinch). The measurement were taken before and after the injection. The results showed that thumb anaesthesia led to the greatest loss of dexterity while it did not affect grip or pinch strength. Index or middle finger anaesthesia, led to a significant loss of grip (25% reduction) and tripod pinch strength (30% reduction). Clinical Take Home Message: Hand therapists should be aware that a digital nerve lesion can contribute to grip and tripod pinch weakness as well as lack of dexterity. In addition, these findings may also suggest that grip or pinch strength deficits in entrapment neuropathies (e.g. carpal tunnel syndrome) may be due to a combination of motor and sensory rather than just motor impairments. This synopsis is a nice addition to the previous one on the effect of anaesthesia to the ulnar nerve at the Guyon's canal. URL: You can ask the authors for the full text through ResearchGate. Available through EBSCO Health Databases for PNZ members. Abstract The purpose of this study is to determine how loss of sensation affect hand dexterity. In this study, digital nerve block anaesthesia was performed in different stages of timing for thumb, index and middle fingers of 12 volunteers. The Moberg pick-up test was conducted in the assessment of hand dexterity. Grip and pinch forces were also measured. Loss of thumb sensation had the greatest effect on dexterity, increasing average timing by at least 10.5 seconds (range 3.4 to 32.4). Loss of sensation to the index and middle fingers has a lesser impact, but decreased hand grip and chuck pinch forces (grip –25% or –33%, chuck pinch –31% or –32% depending on the timing of injections). We concluded that loss of thumb sensation has the greatest impact on hand dexterity. Index and middle finger sensory loss had less of an impact on hand dexterity but decreased grip and chuck pinch forces.
Should we move away from joint protection programs for RA and OA of the hand?
The effectiveness of joint-protection programs on pain, hand function, and grip strength levels in patients with hand arthritis: A systematic review and meta-analysis. Bobos, P., Nazari, G., Szekeres, M., Lalone, E. A., Ferreira, L., & MacDermid, J. C. (2019) Level of Evidence: 1a- Follow recommendation: 👍 👍 👍 Type of study: Therapeutic Topic: Hand RA and OA – Joint protection vs no intervention This is a systematic review and meta-analysis assessing the effectiveness of joint protection vs control interventions for RA and OA of the hand. Seventeen RCTs were included in the systematic review, for a total of 1,847 participants (80% were diagnosed with RA). Only nine of these studies were included in the meta-analysis. All the RCTs 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. Joint protection with an exercise component was compared to a control group undergoing either standard care, advice, no treatment, or patient education. Efficacy of intervention was assessed through improvements in pain (e.g. NRS, VAS), and function (e.g. Michigan Hand Questionnaire, AUSCAN), at short-term (3-4/12), midterm (6-8/12), and long-term (1 year). The results showed that publication bias was present (low sample size studies were more likely to over-inflate the effectiveness of joint protection interventions). There was very low to low quality of evidence showing that joint protection may have a small, unlikely to be clinically relevant, positive effectiveness in people with RA. In OA, joint protection had no effect compared to the control groups. Overall, due to multitude of statistical tests performed (16 tests) and the number of significant findings (4 test - all in RA) there is a 20% probability that the results are just due to chance. Clinical Take Home Message: Hand therapists should be aware that joint protection interventions appear to have a small, not clinically relevant effect in hand RA. Considering these results, other interventions such as stretching and strengthening may be more appropriate as they have been shown to have relevant effectiveness in a large RCT and a recent implementation study. No effect was shown for joint protection interventions in hand OA. Therefore, other approaches (see previous synopsis on the topic) for hand OA may be more effective. URL: Available through the Journal of Hand Therapy for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Study Design: Systematic review with meta-analysis. Introduction Joint protection (JP) has been developed as a self-management intervention to assist people with hand arthritis to improve occupational performance and minimize joint deterioration over time. Purpose of the Study: We examined the effectiveness between JP and usual care/control on pain, hand function, and grip strength levels for people with hand osteoarthritis and rheumatoid arthritis. Methods: A search was performed in 5 databases from January 1990 to February 2017. Two independent assessors applied Cochrane's risk of bias tool, and a Grading of Recommendations Assessement, Development and Evaluation (GRADE) approach was adopted. Results: For pain levels at short term, we found similar effects between JP and control standardized mean difference (SMD; −0.00, 95% confidence interval [CI]: −0.42 to 0.42, I2 = 49%), and at midterm and long-term follow-up, JP was favored over usual care SMD (−0.32, 95% CI: −0.53 to −0.11, I2 = 0) and SMD (−0.27, 95% CI: −0.41 to −0.12, I2 = 9%), respectively. For function levels at midterm and long-term follow-up, JP was favored over usual care SMD (−0.49, 95% CI: −0.75 to −0.22, I2 = 34%) and SMD (−0.31, 95% CI: −0.50 to −0.11, I2 = 56%), respectively. For grip strength levels, at long term, JP was inferior over usual care mean difference (0.93, 95% CI: −0.74 to 2.61, I2 = 0%). Conclusions: Evidence of very low to low quality indicates that the effects of JP programs compared with usual care/control on pain and hand function are too small to be clinically important at short-, intermediate-, and long-term follow-ups for people with hand arthritis.
Is the term "overuse injury" overused and overdue for an update?
There is more to pain than tissue damage: Eight principles to guide care of acute non-traumatic pain in sport. Caneiro, J. P., Alaiti, R. K., Fukusawa, L., Hespanhol, L., Brukner, P., & Sullivan, P. P. B. (2020) Level of Evidence: 5 Follow recommendation: 👍 👍 👍 Type of study: Therapeutic Topic: Acute non-traumatic pain – Biopsychosocial approach This is an editorial from the British Journal of Sports Medicine. Eight points on how to better manage acute non-traumatic pain presentations were made. The first one suggested to move away from the assumption that pain is due to tissue trauma. Specifically, it was suggested to avoid wording that implies trauma for non-traumatic cases (e.g. overuse syndrome, microtrauma). Instead we could call it pain associated with a specific activity (e.g. sport-related pain, work related pain). Imaging was also advised against, especially if there are no red flags or if it does not guide treatment. The third advice was to consider biopsychosocial factors such as fatigue, poor sleep, mental health, and pain believes as contributing factors to pain. The importance of providing positive messages was also indicated. Messages suggesting that the body is strong and discussions around tissue sensitivity rather than microtrauma/overuse were encouraged. The fifth point suggested a gradual increase in tissue loading. The sixth point advised against utilising passive modalities as a first line approach. Empowering the client by involving them in our decision making was the seventh point. The eight and last point advised to deliver a consistent message (across different health professionals) regarding the lack of trauma (e.g. overuse, microtrauma) in non-traumatic pain presentations. Clinical Take Home Message: We should probably stop talking to our clients about overuse syndromes, repetitive strain injuries, and microtrauma, when no evident trauma is present. We should instead frame it as pain associated with the activity that is exacerbating their symptoms and explain that a recent change in activity levels, stress, lack of sleep, and fatigue may be contributing to an increased sensitivity of their tissue. These explanations are evidence-informed and may help our clients making sense of their non-traumatic pain. URL: You can ask the authors for the full text through ResearchGate. May be available through EBSCO Health Databases for PNZ members - you may need to wait a few weeks to get access to this article. Abstract Are you careful with how you label an athlete’s pain? Musculoskeletal pain in athletes is common, but not always associated with injury (ie, tissue damage). Damage occurs when load exceeds tissue tolerance, such as ligament tear or a fracture. However, pain in athletes that occurs in the absence of trauma and tissue damage is still often labelled an ‘injury’ by clinicians, coaches and athletes themselves. This highlights a gap between knowledge (tissue damage is not necessary for pain) and practice (assuming that all pain arises from tissue damage) in our clinical community. This applies particularly in the area of acute non-traumatic pain (such as back and joint pain). To help bridge this gap, we outline eight principles to guide clinicians who manage musculoskeletal pain in sport (see infographic in figure 1).
A qualitative systematic review of effects of provider characteristics and nonverbal behavior on pain, and placebo and nocebo effects. Daniali, H., & Flaten, M. A. (2019) Level of Evidence: 1a- Follow recommendation: 👍👍👍👍 Type of study: Therapeutic Topic: Smiling - Placebo and nocebo This is a systematic review on the effect on non-verbal interactions on placebo and nocebo. Placebo, a positive effect (e.g. pain reduction), and nocebo, a negative effect (e.g. increase in pain), are the result of treatment expectations. Fourteen experimental studies were included for a total of 1,778 participants. Non-verbal interactions were divided in positive and negative. Positive non-verbal interactions included smiling, nodding, making eye contact, and a warm and friendly voice. Negative non-verbal interactions included a flat and cold tone of voice, frowning, and looking away. The findings showed that negative non-verbal interactions led to a reduced placebo effect, or a nocebo effect, resulting in lower pain tolerance, and higher pain. In contrast, positive non verbal interactions (e.g. smiling) led to a boost in the placebo effect leading to a better emotional and physical state of the patients, lower pain, and a reduction in opioid medications use. Clinical Take Home Message: A positive non-verbal attitude of a hand therapist can enhance the effect of the treatment provided. Smiling, making eye contact, and nodding may improve our clinician-client relationship and lead to reduction in pain, enhanced emotional well-being, and a reduction in pain medications consumption. This synopsis is a nice adjunct to the one written about the effect of an empathetic attitude of clinicians and its effect on endogenous analgesia. Open Access URL: Abstract Background: Previous research has indicated that the sex, status, and nonverbal behaviors of experimenters or clinicians can contribute to reported pain, and placebo and nocebo effects in patients or research participants. However, no systematic review has been published. Objective: The aim of this study was to investigate the effects of experimenter/clinician characteristics and nonverbal behavior on pain, placebo, and nocebo effects. Methods: Using EmBase, Web of Knowledge, and PubMed databases, several literature searches were conducted to find studies that investigated the effects of the experimenter’s/ clinician’s sex, status, and nonverbal behaviors on pain, placebo, and nocebo effects. Results: Thirty-four studies were included, 20 on the effects of characteristics of the experimenter/clinician, 11 on the role of nonverbal behaviors, and 3 on the effects of both nonverbal behaviors and characteristics of experimenters/clinicians on pain and placebo/nocebo effects. There was a tendency for experimenters/clinicians to induce lower pain report in participants of the opposite sex. Furthermore, higher confidence, competence, and professionalism of experimenters/clinicians resulted in lower pain report and higher placebo effects, whereas lower status of experimenters/clinicians such as lower confidence, competence, and professionalism generated higher reported pain and lower placebo effects. Positive nonverbal behaviors (e.g., smiling, strong tone of voice, more eye contact, more leaning toward the patient/participant, and more body gestures) contributed to lower reported pain and higher placebo effects, whereas negative nonverbal behaviors (i.e., no smile, monotonous tone of voice, no eye contact, leaning backward from the participant/patient, and no body gestures) contributed to higher reported pain and nocebo effects. Conclusion: Characteristics and nonverbal behaviors of experimenters/clinicians contribute to the elicitation and modulation of pain, placebo, and nocebo effects.
Would your RA clients benefit from a hand strengthening and stretching program?
Translating the strengthening and stretching for rheumatoid arthritis of the hand programme from clinical trial to clinical practice: An effectiveness–implementation study. Williamson, E., Srikesavan, C., Thompson, J., Tonga, E., Eldridge, L., Adams, J., & Lamb, S. E. (2020) Level of Evidence: 2c Follow recommendation: 👍 👍 👍 Type of study: Therapeutic Topic: Rheumatoid arthritis - Stretching and strengthening This is a pragmatic trial, assessing the effectiveness of a hand exercise program for people with rheumatoid arthritis (RA) affecting their hands. A total of 448 hand therapists were trained through an online course. The hand exercise program taught in the online course, has previously been shown to be effective for RA in a randomised controlled trial published in the Lancet. Hand therapists were then asked to collect data from their patients with RA during the first visit and at discharge. In addition, a four months follow up was completed. Function was assessed through the Michigan Hand Questionnaire, pain was assessed through a 5-points likert scale, and grip strength was measured through a hand dynamometer. Data were collected from 118 clients with RA. All of these clients were guided in the implementation of the hand exercise program, although compliance with the original exercises program varied significantly. The results showed that hand function improved to a statistically significant level at discharge and at four months follow up. It is however unclear whether the results were clinically relevant (a minimal clinical important change threshold for the total score of the Michigan Hand Questionnaire has not been published yet). Pain was unchanged, however, grip strength improved to a clinically and statistically significant level (25-30%) from baseline (14kg). Clinical Take Home Message: Hand therapists treating clients with hand RA may benefit from completing the training course created for this study. The course is accessible online (iSARAH) and it is entirely free. Both this study and the original RCT were completed in participants with an average grip strength close to 14kg. It is possible that clients presenting with higher grip strength (i.e. 25kg) may benefit less from this hand exercise program. Thus, a grip strength of 25kg appears to be sufficient to complete most of the daily tasks. URL: Available through Hand Therapy for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Introduction: The Strengthening and Stretching for Rheumatoid Arthritis of the Hand programme is a hand exercise programme for people with rheumatoid arthritis. It was clinically effective when delivered during a clinical trial but there was a need to evaluate translation into routine care. Methods:We conducted an effectiveness–implementation study. We adapted the trial training into an online format for National Health Service hand therapists. Educational outcomes included confidence and capability to deliver the programme. Implementation outcomes included training reach and adoption. Therapists were invited to collect clinical outcomes. Patients receiving the programme provided data on function (Michigan Hand Questionnaire function scale), pain and grip strength at baseline, treatment discharge and four-month follow-up. Results: A total of 790 therapists (188 National Health Service organizations) enrolled in the training; 584/790 (74%) therapists (162 National Health Service organizations) completed the training; 448/790 therapists (145 National Health Service organizations) (57%) evaluated the training and were confident (447/448, 99.8%) and capable (443/448, 99%) to deliver the programme with 85% intending to adopt it (379/448). Follow-up data were provided by 116/448 (26%) therapists. Two-thirds (77/116; 51 National Health Service organizations) reported adopting the programme. One hundred and eighteen patients (15 National Health Service trusts) participated. Patients reported improved function (mean change Michigan Hand Questionnaire scores: 10 (95% CI 6.5–13.6) treatment discharge; 7 (95% CI 3.8–10.2) 4-month follow-up). Grip strength increased 24.5% (left) and 31% (right). Pain was stable. Discussion: Online training was an effective way to train therapists with good reach. Clinical outcomes were similar to the clinical trial providing preliminary evidence of successful translation into routine care.
Should you refer clients with 1st cmcj OA for cortisone injections?
Injection therapy for base of thumb osteoarthritis: a systematic review and meta-analysis. Riley, N., Vella-Baldacchino, M., Thurley, N., Hopewell, S., Carr, A. J., & Dean, B. J. F. (2019) Level of Evidence: 1a- Follow recommendation: 👍 👍 👍 Type of study: Therapeutic Topic: 1st cmcj OA – cortisone vs other types of injections This is a systematic review and meta-analysis assessing the effectiveness of cortisone injections vs other types of injections for 1st cmcj OA. Nine RCTs were included in the present review, for a total of 504 participants. Only three of these (cortisone vs hyaluronic acid) were included in the meta-analysis. All the RCTs were assessed through the Risk of Bias criteria recommended by the Cochrane Review Group. Efficacy of intervention was assessed through improvements in pain (VAS), pinch and grip strength. The results showed that most of the studies presented with a high risk of bias, large heterogeneity, and small sample sizes. There was very low quality of evidence showing that cortisone injections were not more effective in improving pain, pinch or grip strength when compared to hyaluronic acid injections. Interestingly, when cortisone or hyaluronic acid injections where compared to placebo injections (narrative review of 3 RCTs), there were no differences in pain, pinch or grip strength. Similar findings were reported when hyaluronic acid was compared to placebo injections. The authors reported that corticosteroid injections provided statistically significant improvements in the medium term compared to hyaluronic acid injections. However, due to multitude of statistical tests performed (11 tests) and the number of significant findings (1 test) there is a 55% probability that this result is just due to chance. Clinical Take Home Message: Corticosteroid injections do not appear to provide any additional benefit on pain, pinch, or grip strength when compared to hyaluronic acid injections for 1st cmcj OA. From the results of two RCTs it appears that neither cortisone nor hyluronic acid injections are superior to placebo (saline) injections. As shown by another study, most of the clinical effect shown by cortisone or hyaluronic acid injections may be due to contextual factors associated with the therapeutic intervention. Hand therapists may refer clients for cortisone or hyluronic acid injections if other conservative interventions have failed, and if surgery is not viable due to comorbidities. If clients may be eligible for 1st cmcj OA surgery, cortisone or hyaluronic acid injections may actually increase the odds of post surgical complications. Open Access URL: Abstract Objective: To evaluate the effectiveness of injection-based therapy in base of thumb osteoarthritis. Design: Systematic review and meta-analysis. Data sources: MEDLINE and EMBASE via OVID, CINAHL and SPORTDiscus via EBSCO were searched from inception to 22 May 2018. Study selection: Randomised controlled trials (RCTs) and non-RCTs of adults with base of thumb osteoarthritis investigating an injection-based intervention with any comparator/s. Data extraction and analysis: Data were extracted and checked for accuracy and completeness by pairs of reviewers. Primary outcomes were pain and function. Comparative treatment effects were analysed by random-effects model for short-term and medium-term follow-up. Results: In total, 9 RCTs involving 504 patients were identified for inclusion. All compared different injection-based therapies with each other, no studies compared an injection-based therapy with a non-injection-based intervention. Twenty injection-based intervention groups were present within these nine trials, consisting of hyaluronic acid (n=9), corticosteroid (n=7), saline placebo (n=3) and dextrose (n=1). Limited meta-analysis was possible due to the heterogeneity in the injections and outcomes used, as well as incomplete outcome data. Meta-analysis of two RCTs (92 patients) demonstrated reduced Visual Analogue Scale pain on activity with corticosteroid versus hyaluronic acid (mean difference (MD) −1.32, 95% CI −2.23 to −0.41) in the medium term, but no differences in other measures of pain or function in the short term and medium term. Overall, the available evidence does not suggest that any of the commonly used injection therapies are superior to placebo, one another or a non-injection-based comparator. Conclusion: Current evidence is equivocal regarding the use of injection therapy in base of thumb osteoarthritis, both in terms of which injection-based therapy is the most effective and in terms of whether any injection-based therapy is more effective than other non-injection-based interventions. Given limited understanding of both the short-term and long-term effects, there is a need for a large, methodologically robust RCT investigating the commonly used injection therapies and comparing them with other therapeutic options and placebo. PROSPERO registration number CRD42018095384.
Answer for: What is the differential diagnosis for this case? - Circumferential rash
Rumple-Leede phenomenon after tourniquet application in acute hand surgery: A case report. Imran, R., & Jose, R. M. (2020) Level of Evidence: 5 Follow recommendation: 👍 Type of study: Diagnostic Incidence: Rare Topic: Skin rash – proximal compression This is a case report of unilateral Rumple-Leede phenomenon. The patient was a 65 year old male who had undergone terminalisation of a finger and wound closure following a traumatic injury. A tourniquet was applied to the proximal arm for 75 minutes during surgery. Upon tourniquet release, a circumferential rash, which was non-blanching, developed in the whole arm below the tourniquet level. The patient was neurovascularly intact at the level of the hand. The patient was discharged following two hours of observation with a diagnosis of Rumple-Leede phenomenon. This condition is due to an acute rupture of skin capillaries following the application of a limb compression (pressure cuff or tourniquet). This is a benign condition which resolves withing 2-3 weeks and it is unrelated to the time of tourniquet application. It is however important to exclude the presence of other conditions such as diabetes, trombocytopenia (low number of platelets), hypertension, and connective tissue disorders, which may increase the likelihood of this condition to occur or mimicker such as vasculitis (vessels inflammation). In this case, no predisposing factors were identified. The patient was reassured and the condition resolved within two weeks. Clinical Take Home Message: Clients may present with Rumple-Leede phenomenon following surgery, blood pressure measurements, application of any type of limb compression (e.g. counterforce brace at the forearm), or blood flow restriction training. Hand therapist should reassure clients and refer them to their GP for follow up testing, which aims at excluding other mimickers or contributing factors to the phenomenon (e.g. emathological or connective tissue conditions). Although this condition has been described in the literature several times, it is quite rare and it is unlikely to occur. URL: You can ask the authors for the full through ResearchGate Available through EBSCO Health Databases for PNZ members. No Abstract available.
Ronald Melzack Award Lecture: Putting the brain to work in cognitive behavioral therapy for chronic pain. Thorn, B. E. (2020) Level of Evidence: 5 Follow recommendation: 👍 👍 Type of study: Therapeutic Topic: Chronic pain – Biopsychosocial approach This is a invited lecture for the Ronald Melzack Award (IASP). The Ronald Melzack Award was established by the International Association for the Study of Pain in honour of Ronald Melzack who contributed exceptionally to the study of pain. In this invited lecture, Dr. Beverly Thorn highlights how pain can be modulated by getting our clients' brain to work. It was made clear from the beginning that psychosocial interventions for chronic pain are not targeted for people affected by mental health. This is often one of the main barriers that hinder patients' or clinicians' adoption of this model. By embracing the ability of the brain to modulate the response of thoughts and emotions, pain can be more amenable. A key word appeared multiple times: simplicity. Simplicity in terms of the explanations that we provide to clients on the link between psychosocial factors, and pain. Simplicity in terms of treatments provided. Other key concepts included the lack of association between pain and tissue damage in chronic pain conditions, and the fact that thoughts and emotions can worsen the suffering associated with pain. In addition, it was clarified that psychosocial interventions and pain education do not aim to distract or be an academic exercise. They aim to get people better by understanding how pain works. Clinical Take Home Message: Psychosocial and pain education interventions are useful for chronic pain clients. They have a very real biological effects and we should clarify that to our clients. We have plenty of evidence showing that a positive attitude of a clinician can boost the effect of the treatment provided, pain conditioning can influence future pain experiences, and that our words can increase or decrease clients' pain perception. The brain is responsible for the pain experience, and it can be used to reduce it. Open Access URL: No abstract available.
Are neurodynamic exercises superior to general exercises for carpal tunnel syndrome?
The long term effect of neurodynamics vs exercise therapy on pain and function in people with carpal tunnel syndrome: A randomized parallel-group clinical trial. Hamzeh, H., Madi, M., Alghwiri, A. A., & Hawamdeh, Z. (2020) Level of Evidence: 1b- Follow recommendation: 👍 👍 👍 Type of study: Therapeutic Topic: Carpal tunnel conservative intervention - Neurodynamic vs general exercise This is a randomised controlled trial assessing the effectiveness of neurodynamic exercise vs general exercises on function, pain, range of movement (ROM), and grip strength in people with carpal tunnel syndrome (CTS). All the participants included (n = 41) were diagnosed with CTS through subjective reports of paraesthesia in the median nerve distribution at the hand, a positive Phalen's test, and impairments on nerve conduction studies. Potential participants were excluded if they presented with a history of neck pain radiating to the upper limb and/or previous hand trauma. Participants were randomised to a neurodynamic exercise group (n = 26), or to a general exercise group (n = 25). Both groups received four individual supervised sessions of one hour each. The neurodynamic group underwent neurodynamic exercises and they were progressed to the next level of exercise when the symptoms were no longer elicited by previous week neurodynamic testing. They also completed neurodynamic exercises at home. The general exercise group received tendon gliding exercises, active range of movement, stretching, and strengthening exercises. Both groups were asked to perform the exercises twice daily. Treatment effectiveness was assessed through the Boston Carpal Tunnel Syndrome Questionnaire (Primary outcome), QuickDASH, numerical pain rating scale (NRS), wrist ROM, and grip strength (All secondary outcomes). Participants were assessed at baseline, one month, and six months. Both groups improved to a statistically and clinically significant level for most outcomes. Considering the multiple statistical tests undertaken, 25% of the results are due to chance. Nevertheless, neurodynamic testing appeared to provide statistically and clinically relevant greater improvements in pain and function (QuickDASH) at 1 month compared to the general exercise group. Thus, the difference between the two groups was close to 2 (95%CI: -3.45 to -0.41) points out of 10, and 13 (95%CI: -24.5 to -0.7) points out of 100 for the NRS and QuickDASH respectively. No adverse events were reported. The confidence intervals for both outcomes were quite wide, suggesting that the effect of the intervention was not consistent. Clinical Take Home Message: Hand therapists may use either neurodynamic or general exercises to improve the clinical presentation of people with CTS. Neurodynamic exercises may be more effective in improving pain and function compared to general exercises in the short term. Hand therapists should be aware that the improvements reported with neurodynamic exercises are substantially variable and range from large, beyond clinically relevant improvements, to the same improvement as with general exercises. URL: Available through the Journal of Hand Therapy for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Introduction: Carpal tunnel syndrome (CTS) is a common disorder that limits function and quality of life. Little evidence is available on the long-term effect of neurodynamics and exercise therapy. Purpose of the Study: This study aimed to examine the long-term effect of neurodynamic techniques vs exercise therapy in managing patients with CTS. Study Design: Parallel group randomized clinical trial. Methods: Of 57 patients screened, 51 were randomly assigned to either receiving four sessions of neurodynamics and exercise or home exercise therapy alone as a control. Blinded assessment was performed before treatment allocation, at treatment completion, and 6 months posttreatment. Outcome measures included Symptom Severity Scale (SSS), Functional Status Scale (FSS), Shortened version of the Disabilities of the Arm, Shoulder, and Hand (DASH), Numerical Pain Rating Scale, grip strength and range of motion. Results: Data from 41 individuals (52 hands) were analyzed. The neurodynamics group demonstrated significant improvement in all outcome measures at 1 and 6 months (P < .05). Mean difference in SSS was 1.4 (95% CI= 0.9-1.4) at 1 month and 1.6 (95% CI = 0.9-2.2) at 6 months. Mean difference in FSS was 0.9 (95% CI = 0.4-1.4) at 1 month and 1.4 (95% CI = 0.7-2.0) at 6 months. Significant between-group differences were found in pain score at 1 month (−1.93) and in FSS (−0.5) and Shortened version of DASH (−12.6) at 6 months (P < .05). No patient needed surgery 1 year after treatment. Conclusions: Although both treatments led to positive outcomes, neurodynamics therapy was superior in improving function and strength and in decreasing pain.
What is the differential diagnosis for this case? - Circumferantial rash
The title will be provided next week. Imran, R., & Jose, R. M. (2020) Level of Evidence: 5 Follow recommendation: 👍 Type of study: Diagnostic Topic: Skin rash – proximal compression Have a think about it this case study. If you like, you can leave a comment indicating what the diagnosis may be. I will publish the diagnosis and treatment reported by the paper next week. The patient was a 65 year old male who had undergone terminalisation of a finger and wound closure following a traumatic injury. A tourniquet was applied to the arm proximally for 75 minutes during surgery. Upon tourniquet release, a circumferential rash, which was non-blanching, developed in the whole arm below the tourniquet level. The patient was neurovascularly intact at the level of the hand. What is it? URL: Next week
What should you tell clients when advising them to take mediation classes?
Adverse events in meditation practices and meditation-based therapies: a systematic review. Farias, M., Maraldi, E., Wallenkampf, K. C., & Lucchetti, G. (2020) Level of Evidence: 1a Follow recommendation: 👍 👍 👍 👍 Type of study: Therapeutic Topic: Meditation - Adverse events This is a systematic review and meta-analysis assessing adverse events associated with meditation practice. Fifty-four experimental studies, 14 cross sectional studies, and 15 case studies were included for a total of 6,464 participants. Studies were included if mindfulness or trascendental mediation were utilised. No formal critique of the included studies was reported (limitation). The prevalence and type of adverse events were reported. The overall prevalence of adverse events was 8.3% (95%CI: 5% to 12%). When only experimental studies were included, the prevalence reduced to 4% (95%CI: 2% to 5%). The most common adverse events included a worsening of anxiety (33%) and depression (26%). Clinical Take Home Message: Due to the close relationship between psychological factors and upper limb recovery or post surgical satisfaction following CTS surgery, we may refer our clients for meditation classes. If we decide to do so, we should warn them that there may be side effects such as worsening of their anxiety or depression. This occurs on average in 1 person out of 25. An alternative that does not appear to present with as many adverse event is yoga. Yoga sessions including at least 50% of physical exercise (e.g. asanas) appear to provide benefits with little or no side effects. Open Access URL: Abstract Objective: Meditation techniques are widely used as therapy and wellbeing practices, but there are growing concerns about its potential for harm. The aim of the present study is to systematically revie w meditation adverse events (MAEs), investigating its major clinical categories and its prevalence. Method: We searched PubMed, PsycINFO, Scopus, Embase and AMED up to October 2019. Eligible studies included origin al reports of meditation practices (excluding related physical practices such as Yoga postures) with adult samples across experimental, observational and case studies. We identiﬁed a total of 6742 citations, 83 of which met the inclusion criteria for MAEs with a total of 6703 participants who undertook meditation practice. Results: Of the 83 studies analysed, 55 (65%) included reports of at least one type of MAE. The total prevalence of adverse events was 8.3% (95% CI 0.05–0.12), though this varied considerably across types of studies – 3.7% (95% CI 0.02–0.05) for experimental and 33.2% (95% CI 0.25–0.41) for observational studies. The most common AEs were anxiety (33%, 18), depression (27%, 15) and cognitive anomalies (25%, 14); gastrointestinal problems and suicidal behaviours (both 11%, 6) were the least frequent. Conclusion: We found that the occurrence of AEs during or after meditation practices is not uncommon, and may occu r in individuals with no previous history of mental health problems. These results are relevant both for practitioners and clinicians, and con tribute to a balanced perspective of meditation as a practice that may lead to both positive and negative outcomes
Rehab and return to work post distal triceps repair: How long does it take?
Return to work following distal triceps repair. Agarwalla, A., Gowd, A. K., Jan, K., Liu, J. N., Garcia, G. H., Naami, E., . . . Verma, N. N. (2020) Level of Evidence: 4 Follow recommendation: 👍 Type of study: Prognostic Topic: Distal triceps repair - Return to work This is a retrospective study assessing return to work following a distal triceps repair surgery. Distal triceps ruptures have an incident of 1% in the general population. A repair is usually undertaken when the tear is greater than 50% of the tendon. A total of 81 participants with distal triceps repair were included. Patients' average age was 46 (SD: 11 years ) years old. Return to work outcomes timeframes (in months) were recorded according to work intensity. Work intensity was defined based on the maximum lifting involved. Work intensity was classified as sedentary (max 5kg), light (max 10kg), moderate (max 25kg), and heavy (max 50kg). Pain was assessed through the visual analogue scale (VAS), and function through the quickDASH. All patients followed the same post surgical instructions. These included a limitation to 20deg of elbow flexion (hinge brace) for the fist two weeks followed by a progression to 90deg by weeks six. At six weeks there were no restrictions in active range of movement. At eight weeks patients could start performing isometric triceps resisted exercises. The results showed that all the patients in sedentary and light jobs returned to work within one month and three months respectively. Most (80%) of the patients in moderate and heavy jobs returned to work within six months and nine months respectively. The average return to work time reported across all work intensities is 2 months. Clinical Take Home Message: Hand therapists may provide patients with an estimate return to work timeframe of 1 to 9 months following distal triceps repair. The timeframe will depend on the work intensity required. The average return to work for people undergoing distal triceps repair (2 months) appears to be shorter than the time required for distal biceps repair (3-4 months). This may be due to the fact that biceps is heavily involved in lifting activities compared to triceps. Unlike distal biceps repair, no major surgical complication were reported URL: You can ask the authors for the full through ResearchGate. Available through EBSCO Health Databases if you have access (PNZ) Abstract Purpose: Evaluate the rate and duration of return to work in patients undergoing distal triceps repair (DTR). Methods: Consecutive patients undergoing DTR from 2009-2017 at our institution were retrospectively reviewed at a minimum of one year postoperatively. Patients completed a standardized and validated work questionnaire, a visual analog scale for pain (VAS-Pain), Mayo Elbow Performance Score (MEPS), Quick Disabilities of the Arm, Shoulder, and Hand Score (quick-DASH) and a satisfaction survey. Results: Out of 113 eligible patients who had a DTR, eighty-one patients (71.7%) were contacted. Of which, 74 patients (91.4%) were employed within three years prior to surgery (mean age: 46.0 ± 10.7 years; mean follow-up: 5.9 ± 3.9 years). Sixty-nine patients (93.2%) returned to work by 2.2 ± 3.2 months postoperatively. 66 patients (89.2%) patients were able to return to the same level of occupational intensity. Patients who held sedentary, light, medium, or high intensity occupations were able to return to work at a rate of 100.0%, 100.0%, 80.0%, and 76.9% by 0.3 ± 0.5 months, 1.8 ± 1.9 months, 2.5 ± 3.6 months, and 4.8 ± 3.9 months postoperatively. Fifteen (75%) workers compensation (WC) patients returned to work by 6.5 ± 4.3 months postoperatively, while 100% of non-WC patients returned to work by 1.1 ± 1.6 months (p<0.001). Seventy-one patients (95.9%) were at least somewhat satisfied with 50 patients (67.6%) reporting excellent satisfaction. Seventy-two patients (97.3%) would still have the operation again if presented the opportunity. A single patient (1.4%) required revision distal triceps repair. Conclusions: Approximately 93% of patients that undergo DTR returned to work by 2.2 ± 3.2 months postoperatively. Patients with higher intensity occupations had an equivalent rate of RTW, but took longer to return to their preoperative level of occupational intensity. Information regarding return to work is imperative in preoperative patient consultation to manage expectations.
Should you treat a 5th metacarpal neck fracture with cast or buddy taping?
A prospective randomized trial comparing the functional results of buddy taping versus closed reduction and cast immobilization in patients with fifth metacarpal neck fractures. Martínez-Catalán, N., Pajares, S., Llanos, L., Mahillo, I., & Calvo, E. (2020) Level of Evidence: 1b Follow recommendation: 👍 👍 👍 👍 Type of study: Therapeutic Topic: 5th metacarpal neck fracture - buddy splinting This is a randomised controlled trial assessing the effectiveness of buddy taping vs close reduction and immobilisation in participants with 5th metacarpal neck fracture with less than 70° of volar angulation. Participants (N = 72) were included if they presented with a 5th metacarpal fracture within 72 hours to the emergency department. Participants were excluded if they presented with more than 70° of volar angulation, a comminuted fracture, previous 5th metacarpal fracture, rotational deformity, additional fractures, tendon injuries, or open fractures. Effectiveness of each intervention was assessed through the DASH (primary outcome) and pain (VAS), radiographs for fracture alignment, range of movement (degrees of mcpj movement), time for return to work, and grip strength (all secondary outcomes). The outcomes were measured at baseline, 3 and 9 weeks, and 12 months. Treatment allocation was randomised. The assessor was not blinded to treatment allocation. Participants were provided with either buddy taping of the ring finger and little finger (n = 36) or closed reduction and cast immobilisation (n = 38). The buddy taping group did not undergo a closed reduction and could mobilise wrist and fingers immediately. Buddy strapping was removed at three weeks and from nine weeks they could do heavier exercises. The immobilisation group underwent closed reduction followed by casting from the pipj to the forearm. The cast was removed at three weeks and followed a similar treatment progression to the buddy splinting group (You will not find the treatment details in the full text as they did not include them. I emailed the first author Natalia and they kindly provided with further information). The results showed that participants in the buddy splinting group had much greater function (twice the minimal clinical important difference), lower pain, similar volar angulation, and grip strength at 3 weeks compared to the close reduction and immobilisation group. In addition, the buddy splinting group returned to work 29 days earlier compared to the closed reduction and immobilisation group. Unfortunately, no information was provided in terms of what work they return to (sedentary vs manual). When asked, the first author confirmed that also manual laborers took part in the study without complications (Thanks Aaron for suggesting to get more information in this regard). Clinical Take Home Message: Hand therapists may choose to use buddy splinting for 5th metacarpal neck fracture presenting with no rotational deformity and less than 70° of volar angulation. However, hand therapists may utilise a hand based ulnar gutter splint to limit clients who are really eager to return to heavy manual tasks and reduce pain associated with potential knocking of the fracture site (Thanks Aaron White for the awesome discussion about this article!). URL: Available through the Journal of Hand Surgery (American Volume) for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Purpose: Although fifth metacarpal neck fractures are typically treated nonsurgically, most often with closed reduction and orthosis immobilization, cast immobilization may not improve outcomes compared with buddy taping without reduction. The aim of this study was to compare functional outcomes of buddy taping versus reduction and cast immobilization in patients with fifth metacarpal neck fractures. Methods: Adult patients with acute fifth metacarpal neck fractures with less than 70º volar angulation and without rotational deformity were randomly assigned to be treated either with buddy taping or a cast after closed reduction. The primary outcome was the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire score at 9 weeks. Secondary outcomes included the DASH score at 3 weeks and 1 year, range of motion of the metacarpophalangeal joint, pain, grip strength, return to work, radiographic angulation, and complication rate. Results: We recruited 72 patients between August 2016 and January 2018. After 3 weeks, the DASH score was significantly lower for patients treated with buddy taping (19.7 ± 19.7) compared with cast immobilization (44.6 ± 15.0). At 9 weeks, clinical outcomes in the buddy taping group were better in terms of range of motion and DASH score, with a mean difference of 6.3 points, which did not exceed the minimally clinically important difference. There were more complications in the cast immobilization group. Fracture angulation after reduction was followed by a loss of reduction at 3 weeks’ follow-up and equivalent residual radiographic volar angulation was observed at 3 and 9 weeks after injury in both groups. Duration of time off from work was 28 days shorter with buddy taping compared with cast treatment. Conclusion: There is no benefit to reduction and orthosis immobilization of fifth metacarpal neck fractures with an initial angulation less than 70°. Use of buddy taping and early mobilization had good clinical results as well as significant improvement in time lost from work.
Answer for: What is the differential diagnosis for this case? - Radial wrist pain
Enigmatic and unusual cases of upper extremity pain: Mislabeling as malingerers. Bradburn, K. N., Beleckas, C. M., Peck, K. M., Kaplan, F. T., & Merrell, G. A. (2020) Level of Evidence: 5 Follow recommendation: 👍 Type of study: Diagnostic Topic: What is the differential diagnosis? – Case study The patient was a 38 years old female who had undergone conservative management of radial styloid fracture two years previously. Subjectively, they reported persistent pain on the radial-volar aspect of the wrist. Aggravating factors included writing and flexing the interphalangeal joint of the thumb while keeping a straight index finger. Previous treatment included 1st dorsal compartment cortisone injection (one year after the original injury), which temporarily relieved pain. During that period, they were also treated with intermittent thumb splinting. Objectively, there was no tenderness on palpation of the first dorsal compartment. Wrist range of movement was 85°, 85°, 50°, and 80° of pronation, supination, extension, and flexion respectively. The interphalangeal joint of the thumb could not flex without the distal interphalangeal joint of the index finger flexing. X-rays, MRI, and CT scans revealed no soft tissue or bony abnormalities. Surgical exploration for diagnostic and potential treatment purposes was undertaken. The procedure revealed the presence of a Linburg-Comstock syndrome. This is a tendinous connection between flexor pollicius longus (FPL) and flexor digitorum profondus (FDP) (of the index finger in this case) which is present in 30% of people. A tenosynovectomy was completed to allow for independent tendon gliding of the FPL and FDP. At three months follow up symptoms had markedly improved and at one year follow up, symptoms had completely resolved. Clinical take home message: Hand therapists may consider Lindburg-Comstock syndrome when the ipj of the thumb is unable to flex without dipj flexion of the index finger. This syndrome may be painful and surgical release can provide symptoms resolution. If you enjoyed this type of synopsis, put a like on it! URL: Available through the Journal of Hand Surgery (American Volume) for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract With the intricate anatomy of the hand and upper extremity, there are many possible etiologies of pain. In addition, one must be alert to conditions typically affecting other areas of the body presenting in the hand and upper extremity. To add to the complexity of diagnosis, one must also be aware of potential secondary gains. With this in mind, a thorough history, physical examination, and broad differential can help avoid mislabeling patients with uncommon ailments. In this article, we present 4 cases of unusual causes of hand and upper extremity pain.
Update on entrapment neuropathies! What should you know?
Entrapment neuropathies: A contemporary approach to pathophysiology, clinical assessment, and management. Schmid, A. B., Fundaun, J., & Tampin, B. (2020) Level of Evidence: 5 Follow recommendation: 👍 Type of study: Symptoms prevalence, Aetiologic, Diagnostic, Therapeutic Topic: Entrapment neuropaties - Presentation and diagnostics This is an updated narrative review on clinical presentation, aetiology, and diagnostic tests for peripheral neuropathies (e.g. carpal tunnel syndrome - CTS). In terms of aetiology, genetic predisposition appears to be one of the strongest risk factors for entrapment neuropathies. It is unknown whether these genetic changes cause entrapment neuropathies due to anatomical alterations of the tunnels or connective tissue impairments within the nerve. The pathophysiology of compression neuropathy includes oedema, ischemia, and fibrosis of tissues within the nerve and outside of the nerve, which are believed to limit neural gliding. Moderate to severe entrapment neuropathies also present with axonal degeneration and/or demyelination, which causes nerve conduction blocks or slowing down of information transmission. These changes may lead to random electric shock symptoms or symptoms provoked by Tinel's testing. These axonal impairments often involve small fibre (detecting hot/cold and pinprick) during the initial stages of the entrapment neuropathy and large fibre (affecting light touch and muscle contraction) when the neuropathy becomes more severe. Interestingly, neuroinflamation has been suggested to increase the sensitivity of the affected nerve, often causing symptoms beyond the peripheral innervation territory of the compressed nerve. Changes within the central nervous system have also been identified in people with entrapment neuropathies. However, it is still unclear whether changes within the central nervous system can lead to on-going symptoms in absence of peripheral nerve entrapment. From an objective assessment point of view, in addition to motor and monofilament testing (Aβ - large fibre), pin prick testing (Aδ and C - small fibre) should be completed. A loss of function (painless weakness, larger monofilament required, or inability to feel pain on pin prick testing) could be used to confirm a neuropathy. Nerve conduction studies and US imaging may be useful in excluding differential diagnoses. Clinical Take Home Message: Hand therapists should be aware that entrapment neuropathies often present with unconventional peripheral nerve patterns. The distribution of symptoms outside of peripheral nerve patterns or dermatomal patterns does not excluded the presence of an entrapment neuropathy. Pin prick testing should be included in the objective assessment, and US imaging may be useful in assessing nerve edema and exclude other conditions. The same authors have published another article, which has been covered in a previous synopsis. Open Access URL: Abstract Entrapment neuropathies such as carpal tunnel syndrome, radiculopathies, or radicular pain are the most common peripheral neuropathies and also the most common cause for neuropathic pain. Despite their high prevalence, they often remain challenging to diagnose and manage in a clinical setting. Summarising the evidence from both preclinical and clinical studies, this review provides an update on the aetiology and pathophysiology of entrapment neuropathies. Potential mechanisms are put in perspective with clinical findings. The contemporary assessment is discussed and diagnostic pitfalls highlighted. The evidence for the noninvasive and surgical management of common entrapment neuropathies is summarised and future areas of research are identified.
The effect of exercise on cervical radiculopathy: A systematic review and meta-analysis. Irby, A., Gutierrez, J., Chamberlin, C., Thomas, S. J., & Rosen, A. B. (2020) Level of Evidence: 1a- Follow recommendation: 👍 👍 👍 👍 Type of study: Therapeutic Topic: Cervical radiculopathy – Conservative treatment This is a systematic review and meta-analysis of randomised controlled trials assessing the effectiveness of exercise for cervical radiculopathy. Ten randomised controlled trials were included for a total of 751 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 and function. Pain was assessed through the visual analogue scale (VAS) (9 studies) and function was assessed through the Neck Disability Index (NDI) (5 studies). The quality of evidence was "low", suggesting that there is limited confidence in the estimated effect of exercise on pain and function for cervical radiculopathies. Exercises included range of movement and graded resistance exercises for the superficial and deep neck muscles. There was however a lack of detailed description in the interventions. The control groups either provided no exercises or conservative interventions other than exercise. The results showed that exercises provided a statistically and clinically significant change in pain of 2.8 (95%CI: 1.4 to 4.2) points out of 10 (this change was calculated from the study by Kuijper et al. (2009) based on the standardised mean difference provided). There was also a statistically significant but not clinically relevant change in function, showing a 3.6 point (95%CI: 6.3 to 1) point change in the NDI. The minimal clinically important change for the NDI is 10 points, which was not achieved through exercise. Clinical Take Home Message: Clients often present to hand therapists with symptoms that suggest a double crush syndrome (e.g. carpal tunnel syndrome and cervical radiculopathy). In these cases, it may be beneficial to include cervical exercises if there are symptoms and signs suggesting a cervical radiculopathy. Exercises may be useful to improve pain but not function. Open Access URL:
Should you have a conversation with your clients' GP if they are prescribing gabapentin for CTS?
Inappropriate preoperative gabapentinoid use among patients with carpal tunnel syndrome. Billig, J. I., Sears, E. D., Gunaseelan, V., Santosa, K. B., Iwashyna, T. J., Englesbe, M. J., . . . Waljee, J. F. (2020) Level of Evidence: 2b Follow recommendation: 👍 👍 👍 Type of study: Prognostic Topic: Gabapentin - Carpal tunnel syndrome This is a prospective study assessing the risks associated with the use of gabapentinoids (i.e. gabapentin and pregabalin) before a carpal tunnel syndrome (CTS) decompression surgery. A total of 56,593 participants were included. Participants were followed up at 3 and 6 months after surgery. More than 50% of participants were over 50 years old. The risk was assessed by quantifying the number of patients who continued utilising gabapentinoids or started utilising opioids after CTS surgery. The results showed that participants who utilised gabapentinoids prior to CTS surgery were 19 times (relative risk) more likely to continue utilising gabapentinoids after surgery. In addition, patients taking gabapentinoids pre-surgery were 2.3 times more likelly (relative risk) to start using opiods after CTS surgery. The findings did not change when people with persistent pain conditions (e.g. arthritis) in addition to CTS were excluded from the analyses. Clinical Take Home Message: Hand therapists should advise against the use of gabapentinoids for the treatment of CTS. Gabapentinoids have not shown to be more effective than placebo for CTS (Hui et al., 2010) and they may double the probability of clients starting to use opioids after CTS surgery. Hand therapists should encourage the implementation of evidence-based non surgical interventions (e.g. education and splinting, manual therapy) instead of gabapentinoids use. If non surgical interventions fail, referral to a hand specialist for potential surgery is indicated. URL: Available through the Journal of Hand Surgery (American Volume) for HTNZ members. Available through EBSCO Health Databases for PNZ members.
What is the differential diagnosis for this case? - Radial wrist pain
Enigmatic and unusual cases of upper extremity pain: Mislabeling as malingerers. Bradburn, K. N., Beleckas, C. M., Peck, K. M., Kaplan, F. T., & Merrell, G. A. (2020) Level of Evidence: 5 Follow recommendation: 👍 Type of study: Diagnostic Topic: What is the differential diagnosis? – Case study This paper presents with four case studies. I covered one case in a previous synopsis and the following is another interesting case. Have a think about it. If you like, you can leave a comment indicating what the diagnosis may be and how you would treat it. I will publish the diagnosis and treatment reported by the paper next week. The patient was a 38 years old female who had undergone conservative management of radial styloid fracture two years previously. Subjectively, they reported persistent pain on the radial-volar aspect of the wrist. Aggravating factors included writing and flexing the interphalangeal joint of the thumb while keeping a straight index finger. Previous treatment included 1st dorsal compartment cortisone injection (one year after the original injury), which temporarily relieved pain. During that period, they were also treated with intermittent thumb splinting. Objectively, there was no tenderness on palpation of the first dorsal compartment. Wrist range of movement was 85°, 85°, 50°, and 80° of pronation, supination, extension, and flexion respectively. The interphalangeal joint of the thumb could not flex without the distal interphalangeal joint of the index finger flexing. X-rays, MRI, and CT scans revealed no soft tissue or bony abnormalities. What is it and how would you treat it? URL: Available through the Journal of Hand Surgery (American Volume) for HTNZ members. Available through EBSCO Health Databases for PNZ members.
What scaphoid fractures should you refer for surgery?
Acute scaphoid fractures: guidelines for diagnosis and treatment. Clementson, M., Björkman, A., & Thomsen, N. O. B. (2020) Level of Evidence: 5 Follow recommendation: 👍 Type of study: Diagnostic, Therapeutic Topic: Scaphoid fractures - when to refer This is a narrative review on diagnosis and treatment of schapoid fractures. Scaphoid fractures represent 60% of the carpal fractures and 10% of all hand fractures. Most often, the scaphoid fracture is located at the waist (70%) with a smaller percentage affecting the distal pole (25%), or the proximal proximal pole (5%). A few clinical diagnostic tests are available and they include tenderness on palpation at the snuff box or scaphoid tubercle, and pain on axial compression of the thumb. Each of these three tests is very sensitive (100%), meaning that if no pain is elicited, it is very unlikely that the client presents with a scaphoid fracture. However, only the combination of three positive tests has a reasonable specificity (74%), meaning that if all three tests reproduce pain there is a higher probability of scaphoid fracture. X-rays are useful but are not very sensitive (70% sensitivity - not always useful in excluding a fracture). If an x-ray is negative and there is clinical suspicious of a scaphoid fracture, the wrist should be immobilised and x-ray repeated at 2 weeks. If a scaphoid fracture is identified on x-ray, the treatment depends on the fracture location and stability of the fracture. Distal pole fractures (25% of scaphoid fractures) are the most likely to heal with conservative treatment and require between 4 (tubercle fracture) and 6 weeks (distal pole, not tubercle) of immobilisation. Surgical treatment of scaphoid distal pole fracture should be considered if the fracture is displaced. Scaphoid waist fractures can be treated conservativaly with immobilisation for 6 to 10 weeks if they are not displaced. Longer immobilisation periods are suggested if the fracture is comminuted, the client is a smoker, or if there is limited compliance. Displaced fractures of the waist of the scaphoid require surgical treatment. Proximal pole scaphoid fractures require surgical treatment more often than conservative treatment. This is irrespective of fracture displacement. A short arm cast should be utilised for conservative treatment as there is no benefit in utilising a cast which includes the whole thumb. Clinical Take Home Message: Hand therapists may treat scaphoid distal pole or waist fractures conservatively if there is no displacement. This can be done with a short arm cast, which allows thumb movement. If fracture displacement is suspected, referral to a hand surgeon is warranted in all cases except for a scaphoid tubercle fracture. Scaphoid proximal pole fractures require surgical treatment without exception. Open Access URL:
Association of daily step count and step intensity with mortality among us adults. Saint-Maurice, P. F., Troiano, R. P., Bassett, D. R., Jr., Graubard, B. I., Carlson, S. A., Shiroma, E. J., . . . Matthews, C. E. (2020) Level of Evidence: 1a Follow recommendation: 👍 👍 👍 👍 Type of study: Prognostic Topic: Daily steps - Mortality prediction This is a prospective cohort study assessing the effectiveness of step count and intensity on mortality. A total of 6,355 participants were included at baseline. Participants were followed up for 3 years. Participants were on average 57 years old. The step count and intensity was measured for one week only at baseline. The step count and intensity (walking speed) was measured through a device placed at the ankle. The results showed that participants completing 8,000 steps a day (7.5% of them died) were 50% less likely to die at any timepoint during the three year study compared to participants completing 4,000 steps per day (15% of them died). Greater step counts (12,000 steps/day - 5% of them died) reduced the likelihood of dying (at any point during the study) by 75% compared to the participants completing 4,000 steps per day. Stepping intensity (walking speed) did not predict mortality. The correlation reported in this study does not suggest causation and there may be other factors that explain this association. Clinical Take Home Message: Mortality appears to be higher in adults with lower number of daily step count. This synopsis is a nice addition to the one that was previously completed on grip strength and mortality. Due to the nature of the study considered, it is not possible to determine causality between the number of daily steps and mortality. However, hand therapists may prescribe clients with a walking regime with the aim of achieving the well known 10,000 seps per day. This may provide them with a longer lifespan (length of life) and healthspan (years of quality life - free from disease). URL: Available through EBSCO Health Databases for PNZ members.
Answer for: What is the differential diagnosis for this case? - Finger pain
Enigmatic and unusual cases of upper extremity pain: Mislabeling as malingerers. Bradburn, K. N., Beleckas, C. M., Peck, K. M., Kaplan, F. T., & Merrell, G. A. (2020) Level of Evidence: 5 Follow recommendation: 👍 Type of study: Diagnostic Topic: What is the differential diagnosis? – Case study This synopsis provides you with the answer! The patient was a 33 year old female with an insidious onset of pain at the base of the index finger for the last 3 months. Aggravating factors included playing tennis and increasing tennis frequency. In the last three months, they had been playing tennis more frequently. Objectively, there were no massess or skin changes. There was tenderness on palpation at the second metacarpal. There was no extensor digitorum subluxation at mcpj. Laboratory testing was negative for inflammatory conditions. X-rays revealed no bony abnormalities. MRI showed cortical thickening and bone edema of the second metacarpal shaft. The subjective history, the objective testing, and the MRI result suggested that the client presented with a stress fracture of the second metacarpal. The client was treated with rest for three months. No splinting was provided. A repeat MRI at three months showed stress fracture healing. Clinical take home message: Hand therapists may consider stress fractures of the upper limb as a differential diagnosis in athletes. Females appear to be at greater risk compared to males. The presence of eating disorders, menstrual cycle alterations, and osteopenia (female athlete triad) may increase the likelihood of this condition. URL: Available through the Journal of Hand Surgery (American Volume) for HTNZ members. Available through EBSCO Health Databases for PNZ members.
How can you make a the difference for your clients with carpal tunnel syndrome? No surgery required
Manual therapy versus surgery for carpal tunnel syndrome: 4-year follow-up from a randomized controlled trial. Fernández-de-las-Peñas, C., Arias-Buría, J. L., Cleland, J. A., Pareja, J. A., Plaza-Manzano, G., & Ortega-Santiago, R. (2020) Level of Evidence: 1b- Follow recommendation: 👍 👍 👍 👍 Type of study: Therapeutic Topic: Carpal tunnel conservative intervention - Manual therapy and exercise This is a randomised controlled trial assessing the effectiveness of a manual therapy approach vs surgery on pain in people with carpal tunnel syndrome (CTS). All the participants included (n = 120) were females on a waiting list for CTS surgery. Diagnosis of CTS was made through clinical findings (e.g. pain/paraesthesia in median nerve distribution and positive findings on Phalen's/Tinel's signs) and confirmed by nerve conduction studies. Participants were excluded if they had diabetes or thyroid conditions (which are known to worsen treatment prognosis), depression, if they were pregnant, or if they had other musculoskeletal conditions. Participants were randomised to a manual therapy and exercise program group (n = 60), or carpal tunnel decompression surgery (n = 60). The manual therapy and exercise program was delivered over the course of three sessions (one per week), each lasting 30 minutes. These sessions involved soft tissue mobilisation of potential entrapment sites af the median nerve. These included the pronator teres, biceps brachii, pectoralis minor, and scalene muscles. Lateral glides of the cervical spine and tendon/nerve gliding exercises were also completed. If interested, participants were also provided with an information sheet on how to perform tendon and nerve gliding. Treatment effectiveness was assessed through pain intensity (current and worst pain in the last week) on a numerical rating scale. Participants were assessed at baseline, one year, and 4 years. The results showed no difference between manual therapy and surgery at one year, and at 4 years. During the 4 years follow up, 9 participants (15%) in the manual therapy group, and 8 participants (13%) in the surgical group underwent surgery or a second surgery respectively (no differences between groups). Clinical Take Home Message: A manual therapy approach (mobilisation and tendon/nerve glides) directed at the upper limb appears to be as effective as surgery in the treatment of clients with carpal tunnel syndrome at one and four years follow up. Considering the low cost of three sessions of manual therapy compared to surgery, hand therapists should offer this treatment to clients. The combination of manual therapy, nerve gliding exercises, night splinting, and education may provide even better results, and a this conservative management approach should be trialed before undergoing surgery. URL: Available through EBSCO Health Databases if you have access (PNZ)
How much hand weakness is caused by an ulnar nerve motor impairment at the Guyon's canal?
Quantification of hand function by power grip and pinch strength force measurements in ulnar nerve lesion simulated by ulnar nerve block. Wachter, N. J., Mentzel, M., Krischak, G. D., & Gülke, J. (2018) Level of Evidence: 4 Follow recommendation: 👍 👍 👍 Type of study: Diagnostic Topic: Ulnar nerve impairment - Grip strength This is a study assessing hand strength before and after an ulnar nerve block at the Guyon's canal in the same participants (within-subject design). Twenty-five healthy participants were recruited for this study. Hand strength was assessed through a Jamar hand dynamometer (power grip) and pinch dynamometer (tip to tip, tripod, and key pinch). The measurement were taken before and after the injection, without randomisation of condition (this is a limitation). The results showed that the greatest impairments were identified in the pinching tests (58-60% reduction) compared to grip testing (27% reduction in strength). Clinical Take Home Message: Hand therapists may utilise pinch strength as a measure of impairment/recovery for clients with entrapment neuropathies or lacerations of the ulnar nerve. The significant impairments in pinch strength following an ulnar nerve block are not surprising considering the innervation of the flexor pollicis brevis (deep portion), adductor pollicis and first dorsal interosseous by the ulnar nerve. In addition, the presence of a Riche-Cannieu anastomosis (ulnar to median nerve within the hand), which is present in 60% of subjects, may further explain the significant impairment caused by an ulnar nerve block at the Guyon's canal. URL: Available through the Journal of Hand Therapy for HTNZ members. Available through EBSCO Health Databases for PNZ members.
What is the differential diagnosis for this case? - Finger pain
Enigmatic and unusual cases of upper extremity pain: Mislabeling as malingerers. Bradburn, K. N., Beleckas, C. M., Peck, K. M., Kaplan, F. T., & Merrell, G. A. (2020) Level of Evidence: 5 Follow recommendation: 👍 Type of study: Diagnostic Topic: What is the differential diagnosis? – Case study This paper presents with four case studies. I found one particularly interesting. Have a think about it. If you like, you can leave a comment indicating what the diagnosis may be and how you would treat it. I will publish the diagnosis and treatment reported by the paper next week. The patient was a 33 year old female with an insidious onset of pain at the base of the index finger for the last 3 months. Aggravating factors included playing tennis and increasing tennis frequency. In the last three months, they had been playing tennis more frequently. Objectively, there were no massess or skin changes. There was tenderness on palpation at the second metacarpal. There was no extensor digitorum subluxation at mcpj. Laboratory testing was negative for inflammatory conditions. X-rays revealed no bony abnormalities. MRI showed cortical thickening and bone edema of the second metacarpal shaft. What is it and how would you treat it? URL: Available through the Journal of Hand Surgery (American Volume) for HTNZ members. Available through EBSCO Health Databases for PNZ members.
Evaluation of written and video education tools after mallet finger injury. Novak, C., Mak, L., & Chang, M. (2019) Level of Evidence: 4 Follow recommendation: 👍 👍 Type of study: Therapeutic Topic: Mallet splint resources - Video This is a prospective cohort study assessing the usefulness of written and video resources for clients with an acute mallet finger. Participants (N = 61) were diagnosed within four weeks from the injury and never presented with the condition before. They were all able to read and speak English. Participants were provided with a written pamphlet (not provided in the article) and video links to watch in their own time. The effectiveness of the written and video (stack or through splint) resources was assessed through a 0 (not helpful) to 10 (extremely helpful) numerical rating scale. Outcomes were assessed after 2 weeks from treatment initiation. The results showed that most participants (n = 57) utilised written instruction compared to video instructions (n = 30). However, participants watching the video and reading the material found the video particularly helpful and more easy to understand compared to the written information. Clinical Take Home Message: Hand therapists may provide video resources on finger hygiene to clients presenting with a mallet finger injury. This may be particularly useful when clients cannot physically visit the clinic. In addition, alternatives to a custom made splint exist and may be available at the pharmacy. For instance, a finger cot splint can be easily bought at most pharmacies. URL: Available through the Journal of Hand Therapy if you have direct access (HTNZ) Available through EBSCO Health Databases if you have access (PNZ)
When do you need to refer clients with trigger finger?
Predictive factors associated with proximal interphalangeal joint contracture in trigger finger. Sato, J., Ishii, Y., & Noguchi, H. (2020) Level of Evidence: 4 Follow recommendation: 👍 👍 Type of study: Prognostic Topic: Flexion deformity in trigger finger – How to predict it This is a non-peer reviewed prospective study assessing pipj flexion deformity predicting factors in trigger finger. A total of 126 participants affected by trigger finger were included in the study. Potential participants were excluded if the thumb was involved. The variables of interest were the digit involved, gender, age, body mass index (BMI), hand dominance, history of previous trigger finger in other digits, multiple digits involved, previous history of carpal tunnel syndrome (CTS) or De Quervain's syndrome, heavy manual labour, diabetes mellitus, trigger finger grade (I - intermittent, II - actively correctable, III - passively correctable), and duration of triggering. Participants were followed prospectively for a maximum of six years, however, there was no information on the follow up time range. The results showed that on average 30% of trigger digit presented with pipj contracture. In addition participants with a previous history of CTS or De Quervain's (n = 8/29; 28%) had 4.6 times greater odds of presenting with pipj deformity compared to participants without it (5/84; 6%). In addition, trigger finger grade was also found to be a predictor. Participants with a grade III trigger finger (14/22; 64%) had 5 to 8 times greater odds of presenting with pipj flexion deformity compared to participants with grade I (11/48; 19%) and II (12/33; 27%). Lenght of time with trigger finger was not identified as a predictive factor. Clinical Take Home Message: The risk of developing a pipj flexion deformity with grade I trigger finger is relatively low (1 in 5 people). If clients present with grade II or III they have a greater chance of developing pipj flexion deformity (grade II: 1 in 3 people; grade III: 2 in 3 people). Clients with grade III should therefore be referred for surgical management immediately. Clients with grade II may be monitored monitored over time and referred if the clinical presentation worsen. URL: Available through EBSCO Health Databases if you have access (PNZ)
Counterforce bracing of lateral epicondylitis: A prospective, randomized, double-blinded, placebo-controlled clinical trial. Kroslak, M., Pirapakaran, K., & Murrell, G. A. (2019) Level of Evidence: 2b Follow recommendation: 👍 👍 👍 Type of study: Therapeutic Topic: Counterforce brace - Real vs Placebo brace on pain and function This is a randomised double-blind placebo controlled trial assessing the effectiveness of counterforce brace on pain frequency and intensity in participants with lateral epicondylalgia (LE). Participants (N = 31) were diagnosed with LE if they presented point tenderness at the lateral epicondyle of the elbow and if they reported localised elbow pain with maximal grip strength testing. In addition, they had to present with a history of LE between 4 weeks and 6 months. Participants were excluded if they had sensory or motor changes distally to the elbow, if they had previous elbow surgery, or if they had a cortisone injection in the elbow within the past three months. Pain frequency and intensity during manual activities, during sleep, and at rest was assessed through a 5-points likert scale. Outcomes were assessed at 2, 6,12, and 26 weeks. Treatment allocation was randomised. No information on allocation concealment was provided. Participants and assessors were blinded to treatment allocation. The trial protocol was not registered a-priori. Participants were provided with a counterforce brace which was tightened around the proximal forearm (n = 17) or a strap withouth padding which was applied with a very low tension to the proximal forearm (sham) (n = 14). Both groups were provided with a resistance training program for the affected upper limb. The results showed that both groups reported lower pain frequency and intensity at 6 weeks and subsequent follow ups. Between groups differences were limited and a high number of statistical tests were performed. This increased the likelihood of a type II error (identification of statistically significant findings due to the high number of tests performed). It is not possible to comment on the clinical relevance of these findings because pain intensity was measured on a 5-points likert scale, which is rarely used in clllinical practice. Overall, the counterforce brace appeared to consistently provide greater improvements compared to the sham. Clinical Take Home Message: Hand therapists may provide a counterforce brace to clients affected by LE. This brace appears to reduce the frequency and intensity of pain to a greater extent compared to a placebo brace. URL: Available through EBSCO Health Databases if you have access (PNZ)
Are sex and smoking history risk factors for lateral epicondylalgia?
Risk factors of lateral epicondylitis: A meta-analysis. Sayampanathan, A. A., Basha, M., & Mitra, A. K. (2020) Level of Evidence: 2a- Follow recommendation: 👍 👍 👍 Type of study: Prognostic Topic: Lateral epicondylalgia – Risk factors This is a systematic review and meta-analysis assessing risk factors for the development of lateral epicondylalgia (LE). Fourteen studies, most of which were retrospective, were included in the meta-analysis, for a total of 24,526 participants. A diagnosis of LE was confirmed in all studies by pain localised at the lateral epicondyle and pain reproduction on palpation of the lateral epicondyle and resisted wrist extension. The results showed that females had 1.3 greater odds of presenting with LE compared to males (95%CI: 1.12 to 1.5). In addition, a current or past history of smoking increased the odds of having LE by 1.5 times (95%CI: 1.2 to 1.9). The results showed that smoke cessation did not reduce the likelihood of presenting with LE, suggesting that a past history of smoking has an ongoing effect on tendons' health. A high body mass index (BMI) did not increase the odds of presenting with LE (OR: 1.12; 95%CI: 0.7 to 1.3). Other factors that increased the odds of presenting with LE were metabolic conditions including diabetes mellitus and elevated blood pressure. However, a limited number of studies investigated these risk factors. The results of this study need to be considered in the context of a few limitations. Due to the retrospective nature of the studies included, causation between these risk factors and LE cannot be proven. A third variable not measured in the studies may be the causative factor for the development of LE. Clinical Take Home Message: Hand therapists may find that LE is more common among female clients or clients with an present or past smoking history. A high BMI does not appear to increase the likelihood of presenting with LE, although metabolic diseases may increase the odds of presenting with the condition. It is possible that an improvement in the metabolic profile of our patients, may reduce the likelihood of presenting with LE. Smoking cessation does not appear to reduce the risk of developing LE, however, this should clearly be encouraged due to other health benefits. URL:
An unusual presentation of Boxer’s knuckle in the little finger: A case report. Leon Lam, W., Bruyere, A., & Leclercq, C. (2020) Level of Evidence: 5 Follow recommendation: 👍 Type of study: Diagnostic/Therapeutic Topic: Mcpj injury – Surgical treatment This is a case report of an uncommon clinical presentation of boxer's knuckle. The patient was a 34 year old male who had been experiencing worsening pain in the little finger mcpj for 2 months following a professional boxing competition. They presented with swelling and pain on the dorsal aspect of the mcpj of the little finger. In addition, they reported a snapping sensation on the dorsal aspect of the little finger mcpj when going from extension to flexion. Conservative treatment for 2 months had provided no relief. Ulstrasound investigations confirmed the presence of a dorsal expansion lesion between extensor digiti minimi (EDM) and extensor digitorum communis (EDC). Upon surgical examination, a pseudo-mass had developed between EDM and EDC. This was removed in association with part of the joint capsule as the two could not be separated. An extensive repair had to be performed to re-establish the integrity of the dorsal aponeurosis of the mcpj. Surgery was followed by six weeks immobilisation in a position of safe immobilisation. This allowed them to return to their competitive boxing without further symptoms. Clinical Take Home Message: Hand therapists may refer clients presenting with a boxer's knuckle for x-ray and ultrasound. Delaying care may result in on-going symptoms with development of soft tissue massess, which may be difficult to repair if surgery is required. URL:
Should we use early mobilisation for distal radius fractures using ORIF?
Early mobilization after volar locking plate osteosynthesis of distal radial fractures in older patients: A randomized controlled trial. Sørensen, T. J., Ohrt-Nissen, S. M. D., Ardensø, K. V., Laier, G. H. M. S., & Mallet, S. K. M. D. (2020). Level of Evidence: 1b Follow recommendation: 👍 👍 👍 Type of study: Therapeutic Topic: Distal radius fracture - Early vs delayed mobilisation This is a randomised single-blind placebo controlled trial assessing the effectiveness of early mobilisation vs late mobilisation on grip strength, range of movement, and function. Participants (N = 85) were treated with volar open reduction and internal fixation (ORIF) of a distal radius fracture. Participants were excluded if they were younger than 50 years old, if they presented with an open fracture, neurological defficits, or if surgery was dealayed more than 14 days. Grip strength was assessed through a hand-held dynamometer, range of movement in pronation-supination, flexion-extension, and radial-ulnar deviation of the wrist was measured through a goniometer. Function was measured through the Disability of the Arm, Shoulder, and Hand (DASH) questionnaire. Outcomes were assessed at 4 weeks, 3, 6, and 12 months post surgery. Treatment allocation was randomised. No information on allocation concealment was provided. Assessors were blinded to treatment allocation. Participants were provided with either early mobilisation (n = 42) or late mobilisation (n = 43). The early mobilisation group initiated wrist and finger exercises the day after surgery and received a removable wrist splint. The late mobilisation group was put in a dorsal cast for two weeks, which was followed by wrist and finger exercises with intermittent immobilisation through a removable wrist splint. Exercise adherence was not measured. The results showed that both groups improved to a statistically and clinically significant level on grip strength, range of movement, and function at six months. However, there were no differences between groups. Clinical Take Home Message: Hand therapists may elect to immobilise clients for two weeks following distal radius fracture or initiate them on early mobilisation. No differences have been shown between the two modalities. However, it is possible that early mobilisation may increase the risk of plate loosening in older people. This may be due osteoporosis and additional screening should be performed in this group of clients. URL:
Should you use graded motor imagery to improve pain and function post distal radius fracture?
Effectiveness of the graded motor imagery to improve hand function in patients with distal radius fracture: A randomized controlled trial. Dilek, B., Ayhan, C., Yagci, G., & Yakut, Y. (2018) Level of Evidence: 2b Follow recommendation: 👍 👍 👍 Type of study: Therapeutic Topic: Radius fracture - graded motor imagery This is a randomised single-blind controlled trial assessing the effectiveness of Graded Motor Imagery (GMI) and traditional rehabilitation 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/rheumatological condition. Effectiveness of each intervention was assessed through pain at rest (VAS), range of movement (degrees of wrist movement), and function (DASH). The outcomes were measured at baseline and after 8 weeks of treatment. All participants attended two session (1 hour each) with a physiotherapist each week for 8 weeks. Participants in every group received a home exercise program. Treatment allocation was randomised. The assessor was blind to treatment allocation. Participants were provided with either GMI (n = 17) or traditional rehabilitation (n = 19). Participants in the GMI completled 3 weeks of left/right hand discrimination (10 minutes each waking hour). This was followed by 3 weeks of explicit motor imagery in which participants had to look at a hand picture and imagining moving their own hand (10 minutes each waking hour). The last phase of the GMI (2 weeks) involved mirror therapy (10 minutes each waking hour). The traditional rehabilitation group included a gradual AROM home exercise program which was then progressed into resistance exercises towards the end of the intervention program. There were no differences between groups in the number of participant that undervent a conservative or surgical intervention for their fracture. All the participants reported high adherence to the physiotherapy intervention (100%) and home exercise program (90-100%), although the latter was self-reported. The results showed that GMI improved pain at rest (GMI - Mean difference: 2.2, SD: 2.1; Control - Mean difference: 1,1, SD: 1.2) and function (GMI - Mean difference: 38, SD: 14.3; Control - Mean difference: 27, SD: 17) to a statistically and clinically significant level compared to the traditional rehabilitation group. From a practical poin of view, these results suggest that there is an average improvement in pain at rest of 2 points out of 10 with GMI (clinically significant change) and 1 point out of 10 with traditional physiotherapy (non clinically significant change). For function, there is an improvement of 38 points on the DASH with GMI and 27 points with traditional physiotherapy (both clinically significant changes). Contrasting results were reported in text and in the tables for range of movement. It is therefore not possible to comment on these findings with certainty. Clinical Take Home Message: Hand therapists may choose GMI training if the main goal of rehabilitation is to reduce pain and improve function. This 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). It is unclear whether GMI can lead to improvements in range of movement. Open Access URL:
Elbow MWM for lateral epicondylalgia? Chuck it or keep it?
Do joint mobilizations assist in the recovery of lateral elbow tendinopathy? A systematic review and meta-analysis. Lucado, A. M., Dale, R. B., Vincent, J., & Day, J. M. (2019) Level of Evidence: 1a Follow recommendation: 👍 👍 👍 👍 Type of study: Therapeutic Topic: Lateral epicondylalgia – Manual therapy This is a systematic review and meta-analysis assessing the effectiveness of elbow Mobilisation With Movements (MWMs) on pain and pain-free grip strength in people with lateral epicondylalgia. Four randomised-controlled studies and one controlled study were included in the meta-analysis, for a total of 407 participants. All the studies were assessed through the PEDro scale (score 0 to 11 with greater scores indicating greater study quality). Efficacy of intervention was assessed through improvements in pain (VAS) and pain-free grip strength. The control groups included either no interventions or other interventions (e.g. ultrasound, exercise) without MWMs. Follow-up periods ranged from one months to one year. The study quality ranged between 5 to 10 and the average quality score was 7. There was a statistically significant but not clinical significant difference in favour of the MWMs group compared to the control group on pain (Mean difference: 0.43; 95%CI: 0.2 to 0.7) and pain-free grip strength (Mean difference: 0.31; 95%CI: 0.11 to 0.51). These differences equated to 0.43/10 point change on VAS and 0.31kg improvements in pain-free grip strength. Clinical Take Home Message: MWMs do not appear to be useful in improving pain or pain-free grip strength in lateral epicondylalgia in the short to long term (4 weeks to one year). These interventions may provide an immediate pain relief which is however quickly lost. Hand therapists may obtain better long term results by reducing extensor tendon loading in the acute phase and provide a graded resistance training program when pain irritability reduces. URL:
Zone 2 flexor tendon repair: Is repair of FDS mandatory?
Flexor digitorum profundus with or without flexor digitorum superficialis tendon repair in acute Zone 2B injuries. Sadek, A. F. (2020)
Level of Evidence: 3b
Follow recommendation: 👍 👍
Type of study: Therapeutic
Topic: Zone 2 flexor tendon repair - FDP and FDS vs FDP only repair
This is a retrospective study assessing the outcomes of zone 2 flexor tendon repairs with or without FDS repair. A total of 53 patients underwent repair of FDP only (n=23), or FDP plus FDS (n=30). The surgical outcome was assessed through total active/passive range of movement in the operated digit/s and grip strength. Both outcomes were reported and analysed as a percentage of the controlateral healhy limb. Wide awake surgery with no tourniquet was used for 30 patients. The decision to repair or not FDS was based on FDP ease of gliding after the 6 strands repair. A2 pulley was resected or vented in all cases. Independently of repair completed, the postoperative care included a dorsal blocking wrist splint (50° mcpj flexion and ipj/dipj extension) and rubber band attached to the nail to provide passive finger flexion. During the first week, patients performed active finger flexion and extension exercises (as tolerated by pain) once a day for 5 minutes. Between week 2 and 4, patients performed passive finger extension/flexion exercises followed by pain free active extension and flexion twice a day for five minutes. In week 2 to 4 patients were also encouraged to perform dipj and pipj passive and active movements, flat fist and hook fist exercises. During this phase, patients were also asked to practice grasping, without lifting, objects of large diameter (e.g. water bottle) followed by a progression to small diameter objects. This was gradually progressed until in week 6 they were able to obtain a full fist. Between week 4 and 5 the wrist splint was discarded and the only protection left was an elastic band to provide passive flexion of the operated finger. Between week 5 and 6 full active range of movement exercises were promoted and participants were asked to exercise three times per day for 15 minutes. At the end of week 6, the elastic band was removed. At 12 weeks, participants initiated resisted exercises. Total active movement and grip strength were assessed with a goniometer and a hand held dynamometer respectively. The assessment time ranged between 12 and 84 months post surgery. The results showed that there was no statistically significant difference between groups in total active/passive range of movement. However, the average pipj flexion deformity was 20° in the FDP only repair group and 5° in the FDP plus FDS repair. Grip strength was statistically and clinically significant different between the two groups. The FDP and FDS repair group presented with 15% greater grip strength (Mean difference: 5kg) compared to the FDP repair only. There was one rerupture (FDP repair: 4%; FDP plus FDS repair: 3%) in each group. Involvement of multiple digits was associated with worse outcomes. Clinical Take Home Message: Hand therapists may expect similar outcomes after a zone 2 flexor tendon repair involving FPD and FDS, or FDP alone. However, it appears that repair of FPD alone leads to lower grip strength levels and greater pipj flexion deformities.
Imaging and laboratory workup for hand infections. (2020) Level of Evidence: 5 Follow recommendation: 👍 Type of study: Diagnostic, Therapeutic Topic: Fingertip infections - Diagnostic tests This is a narrative review on epidemiology and treatment of fingertip infections. Finger tip infections included acute and chronic paronychia, felon, and infection mimickers. Acute paronychia often affect the middle 3 digits and should be differentiated from herpetic whitlow. If the condition does not resolve within a few days, oral antibiotics or antibiotic creams should be prescribed. Chronic paronychia is defined as an inflammation of the nail fold that lastes longer than 6 weeks. This condition is not as severe as an acute paronychia and it often develops due to on-going mechanical or chemical insults (e.g. swimmers, homemakers) following an acute paronchia. Felon is an infection of the finger pulp and it represent 15-20% of all the hand infections. These infections are often reported after fingerprick testing for diabetes or splinters' punctures. Felons can be treated conservatively through antibiotics or surgically with incfection evacuation. If not treated appropriately, they may result in osteomylietis, flexor tenosynovitis, and potentially tendon rupture. Mimickers of paronychia or felons include calcific tendinitis, gout, herpetic whitlow, cancer, rheumatologic conditions, and zoonoses. Calcific tendinitis can be easily identified through x-rays and responds well to anti-inflammatories and corticosteroids. Gout may be identified through bony erosions evident on x-ray and it can affect the dipj. Herpetic whitlow is a herpes simplex infection which is extremely contagious during the first two week. The use of gloves by the clinician significantly reduce the risk of them contracting the condition. Oral acyclovir should be prescribed. Cancer can mimick paronychia and treatment depends on the type of malignancy. Rheumatologic conditions such as psoriasis and reactive arthritis may cause nail changes and are usually associated with systemic issues (e.g. conjunctivitis, urethritis). Zoonoses are other fingertip infections which are transferred from vertebrate animals to humans (remember the word "zoo"). Zoonoses require close follow up as they may require hospital admission. Clinical Take Home Message: Hand therapists should monitor patients with a suspected fingertip infection closely. If the condition is not responsive to antibiotics or surgical evacuation an infection mimicker should be considered as a differential diagnosis. The most common mimickers appear to be gout and herpetic whitlow. A thorough subjective examination, including client's occupation, may aid in the diagnosis. URL:
Are platelet-rich plasma injections useful in the treatment of lateral epicondylalgia?
Clinical efficacy of platelet-rich plasma in the treatment of lateral epicondylitis: A systematic review and meta-analysis of randomized placebo-controlled clinical trials. Simental-Mendía, M., Vilchez-Cavazos, F., Álvarez-Villalobos, N., Blázquez-Saldaña, J., Peña-Martínez, V., Villarreal-Villarreal, G., & Acosta-Olivo, C. (2020) Level of Evidence: 1a- Follow recommendation: 👍 👍 👍 👍 Type of study: Therapeutic Topic: Lateral epicondylalgia – platelet-rich plasma injections This is a systematic review and meta-analysis assessing the effectiveness of platelet-rich plasma (PRP) vs placebo injections for lateral epicondylalgia. Five randomised placebo-controlled trials (RCT) were included for a total of 276 participants (PRP = 153; Placebo injection = 123). All the RCTs were assessed through the Risk of Bias criteria recommended by the Cochrane Review Group. Efficacy of intervention was assessed through improvements in pain (VAS) and function (patient-rated tennis elbow evaluation - PRTEE). To be included in the review, RCTs had to compare PRP injections to placebo injections (saline). Follow-up periods ranged between 2 to 6 months. The results showed that all the RCTs presented a low risk of bias. There was no difference between PRP or placebo injections on pain (Mean difference: -0.51; 95%CI: -1.32 to 0.3) or function (Standardised mean difference: -0.07; 95%CI: -0.46 to 0.33). Pain improved to a clinically significant level in both placebo and PRP injections groups (median reduction in pain of 5 points out of 10 in both groups). Neither the placebo nor the PRP injection group improved to a clinically significant level in the functional outcomes (1 point change on DASH). Clinical Take Home Message: PRP injections do not appear to show any additional benefit on pain or function when compared to placebo (saline) injections. Both interventions appeared to provide a clinically meaningful improvement in pain, which is most likely due to the contextual effect of the injection treatment. URL:
Placebo and nocebo effects. Colloca, L., & Barsky, A. J. (2020) Level of Evidence: 5 Follow recommendation: 👍 Type of study: Therapeutic Topic: Placebo and nocebo – What are they? This is a narrative review on placebo and nocebo for clinical practice. Placebo, a positive effect (e.g. pain reduction), and nocebo, a negative effect (e.g. increase in pain), are the result of treatment expectations. Words can induce a placebo or a nocebo effect. Verbal hyperalgesia (hyperalgesia = a nociceptive stimulus usually perceived as a little pain is perceived as a high intensity pain) is an example of nocebo effect. Verbal hyperalgesia is induced in patients when we suggest that something that we are going to do (e.g. ligament testing) or that they are already doing (e.g. activity or movement) will be painful. This nocebo effect has been suggested to be due to an increase in anxiety and inhibition of endogenous analgesic pathways. Classical conditioning (Pavlovian conditioning) is another mechanism that can induce a placebo or nocebo response. For example, repeatedly associating a movement with a highly nociceptive stimulus has been shown to increase the likelihood of perceiving pain in the presence of a mild nociceptive stimulus after the conditioning. In clinical practice, breaking down the association with movement and pain, as well as providing a realistic and positive explanation of the treatment, have both been shown to reduce the pain experience. In addition, an empathetic attitude and smiling have been shown to reduce the experience of pain by improving the endogenous analgesic response of our patients. Clinical Take Home Message: The positive attitude of a hand therapist can boost the effect of the treatment provided. It may be useful to avoid suggesting that a specific activity or movement will cause pain. This may set up patients to feel more pain than what they would otherwise experience. Hand therapists should also be aware that patients may associate a specific activity or movement with pain. This may cause ongoing symptoms even after the tissues have healed. URL:
A novel staged wrist sensorimotor rehabilitation program for a patient with triangular fibrocartilage complex injury: A case report. Chen, Z. B. (2019) Level of Evidence: 5 Follow recommendation: 👍 Type of study: Therapeutic Topic: Triangular Fibrocartilage Complex (TFCC) rehabilitation - Four stages treatment over three months This case study reported the rehabilitation phases of a young patient (20s) presenting with two months’ history of wrist ulnar sided pain in the dominant hand. The pain developed while carrying a heavy object and it impaired their ability to work in a sedentary job (computer typing and answering phone calls). No information was provided on hobbies or sport activities. The patient presented with a pain of 4/10 on wrist movements at baseline. The diagnosis of TFCC was based on a positive fovea sign. The assessment also included self-reported measures of function (QuickDASH and Patient-Related Wrist Evaluation), active range of movement, grip strength, wrist joint position sense, and weight bearing ability through the Push Off test. Treatment was provided in four stages, each lasting one month. In the first stage, active range of movement exercises, splinting, and laser therapy were provided. If pain at rest and during exercises was less than 2/10, the next phases was initiated. This included isometric strengthening of pronator quadratus and extensor carpi ulnaris, light weightbearing wrist extension and flexion, and gradual splint weaning. Progression to the third phase initiated when wrist extension with overpressure was not painful and when pain was less than 2/10 with the exercises. This phase included progression of strength training intensity and introduction of wrist and upper limb perturbations. The fourth and last phase included graded return to functional activities with more complex tasks. Clinical Take Home Message: Progression of exercises for patients with TFCC injury may be based on symptoms. It appears that 2/10 pain may be the maximum advisable pain for patients to experience during or after exercises. A wrist splint may be worn for the first six weeks, after which a weaning process could commence according to pain irritability. The Push Off test might be a good assessment tool to assess patients at 8 weeks. URL:
Imaging and laboratory workup for hand infections. Whitaker, C. M., Low, S., Gorbachova, T., Raphael, J. S., & Williamson, C. (2020) Level of Evidence: 5 Follow recommendation: 👍 Type of study: Diagnostic Topic: Hand infections - Diagnostic tests This is a narrative review on diagnostics for of hand infections. The hand infections included abscesses, cellulitis, septic arthritis, pyogenic tenosynovitis, osteomyelitis, and necrotising fasciitis. X-rays are useful in identifying focal bone erosion, cortical changes, and associated fractures in infections. In addition, they can be useful in excluding differential diagnoses for infections such as gout or calcific tendinitis. US imaging is also useful in identifying non radiopaque foreign bodies. Abscesses often present as soft tissues mass on x-rays associated with an hypoechoic (dark appearance) collection of fluid and increased vascularity on US (US is 97% sensitive for this condition, meaning that a negative finding can exclude this diagnosis). Cellulitis often presents with an increase in subcutaneus edema on x-rays and US, which is common to other conditions and requires clinical confirmation. Septic arthritis consists in an infection limited to the articular joint. X-rays and US are not particularly useful in the initial stages even though they may identify capsular distension. Pyogenic tenosynovitis is an infection of the flexor tendon sheet. Unfortunately, x-rays and US are not often useful in confirming the diagnosis, although they can exclude the presence of a foreign body. Osteomyelitis is an infection of the bone marrow and bone. X-rays are usually negative for 1-3 weeks since onset and US are not useful in identifying this condition. Necrotising fascitis is a potentially fatal infection of the soft tissue which is not easily diagnosed through x-rays or US in the initial stages of the condition. Emergency care is required for this condition. Clinical Take Home Message: Hand therapists should refer patients for x-rays and US when they suspect an infection. These investigations are useful in identifying the presence of foreign bodies and exclude other conditions (e.g. gout, calcific tendinitis), which may mimic infection presentations. Signs of osteomyelitis are not evident on x-ray until 1-3 weeks since onset and x-rays may be repeated to exclude this condition. A prompt referral to ED or hand surgeon may be required. URL:
Hand Infections: Epidemiology and Public Health Burden. Gundlach, B. K., Sasor, S. E., & Chung, K. C. (2020) Level of Evidence: 5 Follow recommendation: 👍 Type of study: Aetiologic, Diagnostic, Therapeutic Topic: Hand infections - Epidemiology This is a narrative review on epidemiology, risk factors, diagnosis, and treatment of hand infections. The frequency of hand infections is two times greater in men compared to women, with more than 30% of infections caused by trauma. Animal bites account for a large proportion of hand infections. Hand surgery rarely leads to hand infections (0.17%). Close to 50% of hand infections are caused by staphylococcus aureus. Risk factors for hand infections include diabetes, HIV infection, immunosuppression, and intravenous drug use. In addition, being an horticulturist, fisherman, aquarist, veterinarian, or dentists increases the chances of presenting with a hand infection. The mechanism of injury, symptoms duration as well as hobbies and occupation may help with the diagnosis. Tetanus vaccination may be required following any bite injury or open skin trauma. Patients with hand infections often do not present with fevers or chills and laboratory testing is often normal in the initial stage of infections. Rapid changes in the clinical presentation and pain beyond what is reasonable expected, should hint towards the presence of an infection. The use of radiographs may help exclude the presence of a foreign body or a fracture. Mobilisation of the hand should start as soon as possible and the use of slings avoided. Clinical Take Home Message: Hand therapists should be aware that diabetes and animal bites are risk factors for hand infection. This information is supported by previous evidence as well as one of our synopsis. In addition, occupations where there is close contact with animals or plants (e.g. vets, gardeners/horticulturists) appear to expose people to greater risk of hand infections. URL:
How good are US and MRI in identifying thumb UCL ruptures?
The value of magnetic resonance imaging and ultrasound in diagnosing displaced rupture of the thumb ulnar collateral ligament. Hamborg-Petersen, E., Torfing, T., & Viberg, B. (2020) Level of Evidence: 4 Follow recommendation: 👍 👍 Type of study: Diagnostic Topic: Thumb UCL – Ultrasound and MRI diagnostic This is a non-peer reviewed prospective study assessing the usefulness of MRI and Ultrasound (US) in identifying thumb UCL (mcpj) ruptures. A total of 49 participants were included in the study. Only participants with a ruptured UCL identified clinically and with fluoroscopic diagnsosis were included. UCL rupture was confirmed if there was a greater than 35° of mcpj medial gapping on stress test (in 0° to 30° of mcpj flexion) or if there was more than 10° difference between sides. Potential participants were excluded if trauma had occured longer than 6 weeks before assessment. The variables of interest were the sensitivity of MRI and US. If a test is very sensitive and its result is negative, you can be more certain that the patient does not have the condition (good for screening purposes). Diagnostic accuracy of MRI and US was based on the intraoperative findings (gold standard). The results showed that median time from injury to MRI and US was 6 and 9 days respectively (range 1-20). Median time from injury to surgery was 9 days (range 1-33). The sensitivity of MRI was 65% and 73% for UCL rupture and Stener lesion respectively. The sensitivity of US was 65% and 36% for UCL rupture and Stener lesion respectively. Clinical Take Home Message: Hand therapists may not refer patients for US scans to screen for an UCL rupture or a Stener lesion. The sensitivity of this test is too low and does not appear to be useful in excluding these pathologies when the scans are negative. URL:
Longitudinal excursion and strain in the median nerve during novel nerve gliding exercises for carpal tunnel syndrome. Coppieters, M. W., & Alshami, A. M. (2007) Level of Evidence: 1b Follow recommendation: 👍 👍 👍 Type of study: Therapeutic Topic: Nerve gliding - Median nerve This is an experimental study assessing median nerve excursion and strain with different exercises in cadavers. Six cadavers' arms were prepared for this study. To measure strain, two displacement tansducers were applied to the median nerve just proximally to the wrist at 12cm proximal to the medial condile of the humerus. To measure excursion, a high precision caliper assessed displacement of the median nerve at the wrist and at the humerus. The median nerve strain and excursion was measured under six different conditions. These included a median glider (wrist flexion-elbow extension and vice versa), median tensioner (wrist and elbow extension and vice versa), wrist motion (extension-neutral) in elbow extension or flexion, elbow motion (flexion-extension) with wrist in extension or neutral. The study needs to be considered in the context of a few limitations. The experiment was performed in cadavers and in vivo studies may show different results. The cadavers did not have a history of carpal tunnel syndrome, which may change the ability of the median nerve to glide within the carpal tunnel. The results showed that there was a statistically significant greater excursion (nerves usually like excursion or gliding but not straining) of the median nerve during the median glider exercise (wrist flexion-elbow extension and vice versa) compared to all the other exercises. The absolute excursion for the glider exercise ranged betweeen 3 to 9 mm which may be clinically relevant. The median nerve strain was statistically significant higher (the median nerve was under greater tension) in the exercises combining wrist and elbow extension in any order compared to the other exercises. The strain increased by 2% with these exercises. Interestingly, the overall strain never exceded 4% of the initial length (6% of strain may be deleterius if held for a prolonged period of time - see Wall et al. 1992). Clinical Take Home Message: Median nerve gliders appear to be safe for use in carpal tunnel syndrome. Hand therapists may avoid combining wrist and elbow extension exercises, which have been shown to to reduce nerve excursion and increase nerve strain. Median nerve gliding exercises do not appear to reduce symptoms in people with carpal tunnel syndrome when added to a splinting regime. However, they may be used in patient prone to develop stiffness. Open Access:
Overuse syndrome of the hand and wrist in musicians: a systematic review. Betzl, J., Kraneburg, U., & Megerle, K. (2020) Level of Evidence: 5 Follow recommendation: 👍 Type of study: Aetiology, Preventative, Therapeutic Topic: Musicians – Overuse syndromes This is a systematic review on epidemiology, pathophysiology, symptoms, and treatment of overuse syndromes in the upper limb of musicians. Forty-two studies were included for a total of more than 1300 musicians. The methodology of the studies varied significantly with a combination of case studies, retrospective studies, and prospective studies. Overuse syndrome was defined as a specific or non-specific painful condition which was aggravated by playing an instrument. The results indicated that the point prevalence for overused syndrome (prevalence measured at one time point) in musicians ranges between 40% to 50%. The lifetime prevalence for overuse syndrome (percentage of musicians who will experience an overuse syndrome at some point in their lifespan) in musicians ranges between 70% to 90%. Very limited research assessed the pathophysiology of overuse syndromes in musicians, with results showing muscle fibre changes as well as local muscle edema in participants with pain compared to controls. Symptoms may be present during practice and at rest. Forced rest appears to be useful in a small subgroup of patients only. An individualised rehabilitation plan with a biopsychosocial approach appears to be more effective in a greater number of musicians. This biopsychosocial approach includes mind-body interventions (e.g. yoga, mindfulness) as well as physical treatments aiming at increasing the general level of fitness of musicians. Clinical Take Home Message: Hand therapists may take a biopsychosocial approach in the treatment of muscians with overuse syndrome. Forced rest does not appear to be a very effective approach. Increasing the overall fitness of musicians and reducing stress may be helpful in reducing pain associated with overuse syndromes of the hand. URL:
What is best treatment for bony mallet greater than 1/3 of joint surface? Splinting or pinning?
Splinting versus extension-block pinning of bony mallet finger: A randomized clinical trial. Thillemann, J. K., Thillemann, T. M., Kristensen, P. K., Foldager-Jensen, A. D., & Munk, B. (2020) Level of Evidence: 2b Follow recommendation: 👍 👍 👍 Type of study: Therapeutic Topic: Bony mallet - Conservative vs surgical treatment This is a randomised single-blind controlled trial assessing the effectiveness of surgery vs splinting in participants bony mallet greater than 1/3 of the articular surface. Participants (N=28) were diagnosed with bony mallet through lateral radiographs. Participants were excluded if the bony mallet fragment was less than 1/3 of the dipj articular surface or if the dipj presented with volar subluxation. Participants with bony mallet of the thumb were excluded. Effectiveness of treatment was assessed by extension lag of the dipj and subluxation of the distal phalanx. Extension lag was assessed at baseline and at 6 months. Subluxation of the distal phalanx was assessed before treatment, immediately after surgery or immobilisation, at 6 weeks, and 6 months. After inclusion in the study, participants were randomised to surgical treatment through extension block pinning (n=14) or splinting (n=14). The extension block pinning group was treated with two k-wire to avoid extensor tendon traction on the bony fragment and distal phalanx subluxation. K-wire were removed after 6 weeks. The splinting group was immobilised in dipj extension with an aluminium splint fixed in place with tape. This had to be worn 24/7 for 6 weeks with regular changes of padding and tape. Care was taken to avoid loss of dipj extension during tape changes, although the process was not supervised. In both groups, the pipj of the affected finger was free to move. Correct position of the distal phalanx was assessed for both groups after immobilisation with a lateral x-ray and revealed good alignment in all participants. Rehabilitation was initiated for both groups after 6 weeks and it included active dipj extension/flexion and a static night splint. This was progressed to loaded dipj extension/flexion and night splint at 8 weeks. At 12 weeks, patients resumed their normal activities without limitations. The results showed that there was no difference in dipj lag at 6 months between the two groups (splint: 12°, range: 8-16; surgery: 10, range: 4-16). Three participants in the splinting group vs no participants in the surgical group presented with distal phalanx subluxation at six months. This difference was not statistically signifcant (I performed a Fisher t-test), although it is possible that the study was underpowered to detect differences. Clinical Take Home Message: Hand therapists may expect similar treatment outcomes when bony mallet greater than 1/3 of the articular surface (without subluxation) are treated conservatively or surgically. However, follow up x-rays during conservative treatment may be required to exclude distal phalanx subluxation. URL:
Do mind-body interventions reduce pain, anxiety, and stress just before a hand therapy session?
Mindful body scans and sonographic biofeedback as preparatory activities to address patient psychological states in hand therapy: A pilot study. Roll, S. C., Hardison, M. E., Vigen, C., & Black, D. S. (2020) Level of Evidence: 2b Follow recommendation: 👍 👍 👍 Type of study: Therapeutic Topic: Mindfulness - Pain and anxiety This is a randomised crossed-over single-blind control trial assessing the effectiveness of mindfulness body scan, sonographic biofeedback, and standard care on pain and anxiety in paticipants attending hand therapy sessions. Participants (N=19) were included if they were referred for hand therapy and if they presented with unilateral hand pathology. Participants were excluded if they were in a cast, if they presented with openn wounds, or if they attended hand therapy less than twice a week. Pain was assessed through the visual analogue scale (VAS), and anxiety was measured through the state-trait anxiety inventory (STAI). All the measurements were taken immediately before and after the hand therapy sessions. After inclusion in the study, participants were allocated to standard care for the first visit and subsequently randomised to either mindfulness body scan (n=10) or Biofeedback (n=10). They were then crossed over to the other group in the following two sessions. Standard care, which was provided at the first appointment, included an assessment and treatment selected by the treating hand therapist. The mindfulness body scan was delivered for 20 minutes through an audio-guided meditation. The sonographic biofeedback provided participants with an understanding of tendon movements within the affected and unaffected hand before therapy. Participants in the biofeedback group were also asked to think about their tendons gliding during the hand therapy treatment. The results showed that all the interventions reduced pain and anxiety, although the changes were not clinically relevant. There were no statistically or clinically significant differences in pain or anxiety between the experimental groups (Mindfulness and biofeedback) and the standard care group. It is possible that this study was underpowered to identify any difference between groups. The washout period for the cross-over was short (2-3 days) and it is possible that the carryover effect of standard care or mind-body intervention was still present when the assessment was taking place. Clinical Take Home Message: Hand therapists should not expect a change in pain or anxiety in patients undergoing a brief mindfulness practice or biofeedback intervention. A 10 weeks mindfulnes-based stress reduction program may be required to induce clinically and statistically significant changes in pain and anxiety in selected patients presenting with significant anxiety. URL:
What is the evidence for hand fractures treatment?
Current methods, outcomes and challenges for the treatment of hand fractures. Boeckstyns, M. E. H. (2020) Level of Evidence: 5 Follow recommendation: 👍 Type of study: Therapeutic Topic: Hand fractures - Surgical vs conservative treatment This is a narrative review on treatment of metacarpal, carpometacarpal, and phalangeal fractures. Most metcarpal fractures can be treated conservatively with good outcomes. Surgey is required if dorsal angulation is greater than 20-40° is present or if there is an open or unstable fracture. Carpometacarpal fractures can be managed conservatively when no dislocation is present. Phalangeal shaft fractures can be treated conservatively with splinting if there is no rotational deformity (scissoring). If rotation deformity is identified, this requires surgical correction. Phalangeal base fractures can be managed conservatively with close monitoring of rotational malunion (scissoring). Salter-Harris type 2, commonly seen in kids, can be managed conservatively. Intrarticular pipj fractures are the most challenging fractures to treat and there is an ongoing debate on what is the most appropriate line of treatment. Intrarticular pipj fractures often involve either the volar or dorsal aspect of the distal phalanx. For volar fractures, surgical treatment is required if a "V" sign is identified on the dorsal apsect of the pipj on a lateral view. Dorsal fractures usually requires surgical intervention. Bony Mallet is often treated conservatively and a recent study has suggested that even with bony fragments greater than 1/3 of the articular surface, conservative treatment is feasible. During conservative treatment, it is advisable to perform radiographic controls the to assess the development of distal phalanx subluxation. Thumb bony avulsion of ucl of mcpj associated with Stener lesion (interposition of adductor pollicis) usually requires surgical intervention. This condition can be identified on x-ray if a bony fragment is present. Bennett's fracture is a fracture of the proximal metacarpal of the thumb, which extends into the cmcj of the thumb. No research has shown better outcomes with either conservative or surgical management in Bennett's fracture. Clinical Take Home Message: Hand therapists should be able to treat most hand fractures conservatively. A few exceptions include open and/or unstable fractures, metacarpal fractures with severe angulation, metacarpal or phalangeal fractures associated with scissoring of fingers, pipj intrarticular fractures, bony mallet with subluxation, and Stener's lesions of the thumb. When in doubt a second opinion from a hand surgeon is always indicated. URL:
Clinical management of tendinopathy: A systematic review of systematic reviews evaluating the effectiveness of tendinopathy treatments. Irby, A., Gutierrez, J., Chamberlin, C., Thomas, S. J., & Rosen, A. B. (2020) Level of Evidence: 1a Follow recommendation: 👍 👍 👍 👍 Type of study: Therapeutic Topic: Tendinopathies – Conservative and surgical interventions This is a systematic review of systematic reviews assessing the effectiveness of conservative and surgical treatments for symptomatic tendinopathies irrespective of location. Twenty-five systematic reviews (Total of 228 RCTs) were included for a total of 15,000 participants. All the systematic reviews included randomised controlled trials (RCT) only. No systematic reviews on pharmacological intervention (e.g. NSAIDs) were included. All the systematic reviews included were assessed through the Assessment of Multiple Systematic Reviews (AMSTAR), which is scored on a scale from 0 to 11 (higher scores reflect higher study quality). Efficacy of intervention was assessed through changes in pain. The visual analogue scale (VAS) was the most common pain outcome recorded (n=22). The average quality score of the reviews was 9 (SD:1), suggesting that more than 50% of the studies were of high quality. Most of the reviews focused on Achilles and patella tendinopathy (n=23) followed by lateral elbow tendinopathy (n=11) and rotator cuff tendinopathy (n=10) (some of the studies included more than one tendinopathy type). Exercise was the only intervention that was shown to consistently reduce pain in tendinopathy. Heavy eccentric exercises appeared to be particularly effective in reducing pain. Low level laser therapy and extracorporeal shock wave therapy showed some effectiveness in the treatment of symptomatic tendinopathies. Injections, needling, and surgery provided mix results for the treatment of tendinopathies. Clinical Take Home Message: Exercise should be the first line treatment for tendinopathy. Findings across different body sites consistently suggest that heavy eccentric exercises are helpful in reducing pain. Hand therapists may use eccentric training in the treatment of hand and elbow tendinopathies. Open Access URL:
Modifiable risk factors, cardiovascular disease, and mortality in 155 722 individuals from 21 high-income, middle-income, and low-income countries (PURE): A prospective cohort study. Yusuf, S., Joseph, P., Rangarajan, S., Islam, S., Mente, A., Hystad, P., . . . Dagenais, G. (2020) Level of Evidence: 1b Follow recommendation: 👍 👍 👍 👍 Type of study: Prognostic Topic: Grip strength - Mortality prediction This is a prospective cohort study assessing the effectiveness of a series of risk factors for mortality in countries with high, middle, and low income. In this synopsis we only considered grip strength as a risk factor. A total of 155,722 participants were included at baseline. Participants were followed up for 12 years. Participants were on average 50.2 (SD: 10) years old. High income countries included Saudi Arabia, United Arab Emirates, Canada, and Sweden. Middle income countries included South Africa, Argentina, Chile, Brazil, Colmbia, Iran, Palestine, Poland, Turkey, Malaysia, and Philippines. Low income countries included Zimbawe, Tanzania, India, Pakistan, and Bangladesh. Grip strength was measured through a Jamar hand dynamometer. The results showed that participants with a grip strength below 15-20 kg (1st quintile - calculated based on mean and SD reported) were 1.6 (95%CI: 1.4 to 1.8) times more likely to die compared to participants with greater grip strength within the study time (12 years). This correlation does not suggest causation and there may be other factors that explain this association. Clinical Take Home Message: Mortality appears to be higher in adults with lower grip strength (below 15-20kg). Hand therapists may refer or prescribe whole body exercise (e.g. aerobic, strength training) for patients who present with low grip strength reduce frailty in their patients. URL:
Do you need a splint following cortisone injection for De Quervain tenosynovitis?
Nonsurgical treatment of De Quervain tenosynovitis: a prospective randomized trial. Ippolito, J. A., Hauser, S., Patel, J., Vosbikian, M., & Ahmed, I. (2018) Level of Evidence: 2b Follow recommendation: 👍 👍 Type of study: Therapeutic Topic: De Quervain tenosynovitis - Conservative management This is a randomised controlled trial assessing the effectiveness of immobilisation following cortisone injection in participants with De Quervain tenosynovitis. Participants (N = 20) were diagnosed with De Quervain if they had pain on the radial side of the wrist, pain greater than 4/10 (VAS), positive Finkelstein test, tenderness on palpation at the first dorsal compartment of the wrist. Participants were excluded if they had a previous cortisone injection within the last 6 months, carpal tunnel syndrome, radiculopathy, or previous infection at the treatment site. Effectiveness of treatment was assessed through the VAS for pain anf the DASH score for function. These outcomes were assessed before treatment, at 3 weeks post treatment, and at 6 months post treatment. Participants and assessors were not blinded to treatment allocation. Participants were randomised to a cortisone injection only (n = 9) or a cortisone injection and splinting for 3 weeks (n = 11). Participants in both groups were advised to rest and limit exercise as much as possible for three weeks. The results showed no difference between the two groups on pain or function at 3 and 6 months. Clinical Take Home Message: Hand therapists should advise their patients to rest their hand as much as possible for 3 weeks following a cortison injection for De Quervain tenosynovitis. Immobilisation does not appear to add any benefit in terms of pain and function at short and long term follow-up. URL:
A systematic review of musculoskeletal disorders related to mobile phone usage. Zirek, E., Mustafaoglu, R., Yasaci, Z., & Griffiths, M. D. (2020) Level of Evidence: 3a Follow recommendation: 👍 Type of study: Symptoms prevalence study Topic: Mobile phone use - Association with MSK pain This is a systematic review assessing the effect of mobile phones on musculoskeletal (MSK) pain conditions. Eighteen studies were included for a total of 36,243 participants. Of these, 15 were cross-sectional studies, 2 were case-control studies, and 1 was a prospective cohort study. The Scottish Intercollegiate Guidelines Network (SIGN) checklist was utilised to assess study quality. The overall strength of evidence was assessed through the GRADE approach ("low", "very low", "moderate", "high"), which is suggested by the Cochrane group for systematic reviews. The results show that there was overall a low and very low quality of evidence supporting the findings of this review. The prevalence of MSK pain was 19% to 53% in the thumb, 15% in the elbow, and 13% to 32% in the wrist and hand. One of the limitations of this review was that the prevalence of MSK pain in people not using mobile technology was not reported. In addition, most of the studies reported correlations between mobile technology use and MSK pain. Correlation does not equate to causation and there may be other factors (e.g. amount of physical activity, mental helath) that contribute to these pain presentations. Clinical Take Home Message: Hand therapists should not advise their patients against the use of mobile technology to avoid MSK pain conditions. Instead, hand therapists may invite patients to be physically active and vary their movements and physical activity during the day. URL:
What is the incidence of CRPS I after a wrist fracture?
What is the incidence of complex regional pain syndrome (CRPS) Type I within four months of a wrist fracture in the adult population? A systematic review. Rolls, C., McCabe, C., Llewellyn, A., & Jones, G. T. (2020) Level of Evidence: 1a Follow recommendation: 👍 👍 👍 👍 Type of study: Prognostic Topic: CRPS I - Incidence after wrist fracture This is a systematic review assessing the incidence of complex regional pain syndrom (CRPS) following a wrist fracture. Nine prospective cohort trials were included for a total of 2465 participants. Studies were only included if CRPS type I (no nerve damage) was assessed. All papers included were scored on the Newcastle-Ottowa Scale for cohort study (0 lowest score, 6 highest score). The diagnosis of CRPS was made through the Budapest Criteria in most studies (n=6). Incidence of CRPS was assessed at 4 months post wrist fracture. Data were extracted from the highest quality studies only (n=3). Wrist fractures included distal radius fractures, ulnar fractures, and carpal fractures (e.g. scaphoid). The pooled results showed that 7% (95%CI: 2% to 13%) of participants with a distal radius fracture developed CRPS type I at 4 months (An incidence meta-analysis was completed for this synopsis as the authors of the study only provided a range). Of interest, one of the studies with the greatest sample size (n=1506), identified pain greater than 5/10 within the first week after trauma as a prognostic factor for the development of CRPS. Clinical Take Home Message: Hand therapists should be aware of the possibility of CRPS type I following wrist fracture. The condition appears to develop in 1 person out of 20 at four months after injury. Moderate to high levels of pain in the first week after trauma may predispose to the development of CRPS type I. URL:
What are some treatment options for base of thumb OA?
The effectiveness of physical therapies for patients with base of thumb osteoarthritis: Systematic review and meta-analysis. Ahern, M., Skyllas, J., Wajon, A., & Hush, J. (2018) Level of Evidence: 1a Follow recommendation: 👍 👍 👍 👍 Type of study: Therapeutic Topic: Thumb OA – Unimodal and multimodal treatments This is a systematic review and meta-analysis assessing the effectiveness of unimodal and multimodal treatments for symptomatic thumb osteoarthritis (OA) on pain and function. Five randomised controlled trials were included for a total of 198 participants. All the studies included were assessed through the risk of bias tool suggested by the Cochrane review group (higher scores reflect higher study quality). The active treatments for the studies included varied from mobilisation of the 1st cmcj and surrounding tissues (exercises, neurodynamic exercises, manual therapy) to splinting for the 1st cmcj. Pain was assessed at rest or after pinching through a visual analogue scale (0 to 10). Function was measured through the QuickDASH and the AUSCAN questionnaires. The results showed that four studies scored 5/6 on the study quality score (high quality studies), while one study scored 4/6 (moderate quality study). Pain improved to a clinically and statistically significant level in both multimodal (mean difference 2.9: 95%CI: 2.8 to 3) and unimodal interventions (mean difference 3.1: 95%CI: 2.5 to 3.8) when compared to either a control group or sham treatment. Function improved to a statistically but not to a clinically significant level in the unimodal intervention (mean difference 6.8: 95%CI: 1.7 to 11.9) compared to the control group or sham intervention (no function was reported for multimodal interventions). Clinical Take Home Message: Hand therapists may use manual therapy, exercise, neurodynamic exercise, or splinting to reduce pain for 1st cmcj OA. These interventions do not appear to improve function to a clinically relevant level. URL:
What is the evidence for post-traumatic elbow stiffness treatment?
Post-traumatic elbow stiffness: Pathogenesis and current treatments. Zhang, D., Nazarian, A., & Rodriguez, E. (2018) Level of Evidence: 5 Follow recommendation: 👍 Type of study: Aetiologic, Therapeutic Topic: Post traumatic elbow stiffness - Aetiology and treatment This is a narrative review on aetiology and treatment of post-traumatic elbow stiffness. The aetiology of elbow stiffness is usually classified as intrinsic (e.g. osteophytes), extrinsic (e.g. heterotopic ossification), or mixed (intrinsic + extrinsic). The goal of treatment for elbow stifness is the re-establishment of 100° to 30° of elbow flexion/extension and 100° of pronation (50°) and supination (50°). Conservative treatment should aim at starting active mobilisation as soon as possible after the injury and introducing passive range of motion exercises at 6-12 weeks after injury/surgery. Delayed movemement interventions result in worse outcomes. Very little evidence supports the use of manual therapy in the recovery range of movement in post-traumatic elbow stiffness. Level 2b evidence (systematic review of cohort studies) supports the use of static progressive or dynamic bracing for post-traumatic elbow stiffness. It has been suggested that after 4 to 6 weeks of bracing, range of movement should improve by 30-40°. During the bracing period, care should be taken to avoid pressure sores and ulnar neuropathies (when splinting to regain elbow flexion). Surgical treatment is utilised when nonoperative treatments fails. Improvements following surgery range between 18° to 66° of elbow flexion/extension. Traumatic elbow osteoarthritis is a negative predicting factor for surgical success (surgery is less likely to be effective). The presence of heterotopic ossification is a positive predicting factor for surgical success (surgery is more likely to be effective). Clinical Take Home Message: Hand therapists may use a conservative trial of static progressive or dynamic bracing to treat post traumatic elbow stiffness. This should be trialled for 4-6 weeks to assess its effectiveness. Surgical intervention may be required if no improvements are noted with conservative treatment. URL:
What can you do for your patients with depression? Have you thought of Yoga?
Effects of yoga on depressive symptoms in people with mental disorders: a systematic review and meta-analysis. Brinsley, J., Schuch, F., Lederman, O., Girard, D., Smout, M., Immink, M. A., Stubbs, B., Firth, J., Davison, K., & Rosenbaum, S. (2020) Level of Evidence: 1a Follow recommendation: 👍 👍 👍 👍 Type of study: Therapeutic Topic: Depression - Yoga vs treatment as usual This is a systematic review and meta-analysis assessing the effectiveness of yoga on depressive symptoms. Thirteen randomised controlled trials were included for a total of 1080 participants. Studies were included if at least 50% of each yoga session included a movement component - the rest of the yoga session could include breathing control exercises, or mindfulness. The control group underwent either standard care, or were put on a waitlist. The effectiveness of the interventions was assessed by measuring changes in depressive symptoms. Out of the studies included, nine studies included participants with depressive disorders, five included participants with schizophrenia and depression, three included participants with post-traumatic stress disorder and depression, one included participants with substance dependence and depression, and another one included participants with a mix of mental health conditions and depression. The frequency of yoga sessions varied from 1-3 sessions per week with a variable duration between 20-90 minutes. Out of all the studies included, 53% were of high quality and 47% were of fair quality (PEDro scale). The results showed that yoga had a moderate effect (Standardised mean difference=−0.41; 95%CI −0.65 to -0.17) in reducing depressive symptoms compared to all the control groups. The effectiveness of yoga was correlated with the number of sessions attended each weak, with higher number of sessions attended resulting in greater reduction of depressive symptoms. The remission rates (number of participants who were no longer diagnosed as depressed after the intervention) ranged between 39% to 60% in the yoga group compared 10% to 24% in the control group. This difference was statistically significant. No adverse events were reported. Clinical Take Home Message: Hand therapists may suggest the attendance of yoga classes to patients presenting with depressive symptoms. Considering the relationship between depressive symptoms and upper limb recovery as well as mental health and post surgical satisfaction in CTS, it may be worthwile to help patients improving their depressive symptoms. URL: