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Is joint position sense impaired in people with symptomatic thumb OA?

Joint position sense impairments in older adults with carpometacarpal osteoarthritis: A descriptive comparative study. Ouegnin, A. and K. Valdes (2020). Level of Evidence: 3b Follow recommendation: 👍 👍 Type of study: Aetiologic Topic: Symptomatic thumb osteoarthritis - Proprioception This is a multicentre case-control study assessing differences on proprioception (joint position test) in participants with thumb OA (cases) and healthy participants (controls). A total of 29 participants were included in the study. Thumb OA was diagnosed through clinical examination (e.g. positive grind test) and confirmed through x-ray in some participants but not all. Proprioception (joint position sense) was assessed through a hand held goniometer by asking participants to reproduce a specific thumb position (30 degrees of abduction) after moving the thumb through the full range of abduction. The difference between the target angle and the angle reproduced (error) was recorded. The results showed that participants with thumb OA presented with an average error of 10 degrees while the healthy participants presented with 1 degree error in joint repositioning. This finding was statistically and potentially clinically significant. There are however, a couple of limitations in this study. First, not all participants with thumb OA were matched to a healthy participant. In some cases, when thumb OA was unilateral, the controlateral thumb of the same participant was assessed. This leads to the second limitation, which is a statistical one. For the data analysis, an independent t-test was used, although this test can only be utilised when the two groups (thumb OA and controls) do not include the same participants. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article.

Clinical Take Home Message: Based on what we know today, clients with thumb OA may present with proprioception deficit. It is possible that these impairments may contribute to functional deficits. Currently, there is no evidence supporting the use of specific proprioceptive training and other multidisciplinary approaches, supported by higher quality evidence, may be implemented first. URL: http://www.sciencedirect.com/science/article/pii/S0894113018302904 Available through The Journal of Hand Therapy for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Study Design This study has a descriptive-comparative, cross-sectional design. Introduction Sensorimotor (SM) impairments have been observed after common wrist and hand injuries such as distal radius fractures. However, there is a lack of research regarding SM impairments in patients with carpometacarpal (CMC) osteoarthritis (OA). Purpose of the Study This study sought to quantify proprioception deficits in older adults with CMC OA as compared with healthy adults using the joint position sense (JPS) test. Methods The active JPS test was used to measure proprioception function in 29 thumbs with CMC OA and their 29 matched-control healthy counterparts. For comparison, participants with unilateral CMC OA were matched against themselves, whereas those with lateral CMC OA were age matched with a healthy participant. Data analysis was performed to compute the mean error of JPS; an unpaired t test was used to compare the mean error of the non–CMC OA group with the healthy control group. Results The mean positional error measured from subjects with CMC OA was 9.53° compared with 1.32° for the age-matched healthy subjects. The effect size for the difference in means was D = 1.96. Conclusions Thumb SM impairments were found to be greater in subjects with CMC OA than in their healthy counterparts when using the JPS test to assess proprioception.

What is the differential diagnosis for this case? - Forearm pain

Level of Evidence: 5 Follow recommendation: 👍 Type of study: Diagnostic Incidence: Rare Topic: What is the differential diagnosis? – Case study Have a think about this case study. Leave a diagnostic comment if you like. I will publish the diagnosis and treatment reported by the paper next week. The patient was a 43 year old female who had been experiencing 4 hours of forearm pain and paraesthesia in both hands. She was on angiotensin II medications (for hypertension treatment) and she had probably been dehydrated after sunbathing for the whole day. Objectively, there was no evidence of sunburn. Forearms were swollen. Fingers' position was in flexion and excruciating pain was reproduced when an attempting to passively extend the fingers. Pulses were palpable, capillary refill time was 2 seconds. What is it? Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article.

Physical activity: Is it going to help our clients with depression?

Customary physical activity and odds of depression: A systematic review and meta-analysis of 111 prospective cohort studies. Dishman, R. K., C. P. McDowell and M. P. Herring (2021). Level of Evidence: 1a- Follow recommendation: 👍 👍 👍 👍 Type of study: Therapeutic Topic: Mental health - Physical activity This is a systematic review and meta-analysis assessing the effectiveness of physical activity in reducing symptoms of depression. Hundred and eleven observational studies were included in the systematic review, for a total of 1,404 participants. All the studies were included in the meta-analysis and they were assessed through the Risk of Bias criteria recommended by the Cochrane Review Group. The overall strength of evidence was based on some aspects of the GRADE approach, although the evidence was classified as "good", "acceptable", or "poor". Studies were included if physical activity was quantified and comparable to a guideline threshold. The results showed that there is moderate quality evidence showing that physical activity, when performed according to international guidelines, reduces the odds of presenting with depression by 20%. Importantly, there is a dose-response between physical activity and symptoms of depression. A limitation of this study is the inclusion of observational studies, which limits the extrapolation of causality between physical activity and depression. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message: Based on what we know today, physical activity has the potential to reduce depression symptoms. Interesting, effectiveness appears to be dependent on exercise dosage, which needs to follow international guidelines. The type of activity does not appear to matter as long as we meet a sufficient intensity and volume of exercise. Among the many forms of exercise available, a previous meta-analysis has shown that yoga, can reduce depression (see contraindications of yoga classes with a significant amount of meditation). Considering the relationship between depressive symptoms and upper limb recovery as well as mental health and post surgical satisfaction, it may be worthwhile encouraging our clients to follow the international guidelines for physical activity. URL: http://bjsm.bmj.com/content/early/2021/01/04/bjsports-2020-103140.abstract Available through EBSCO Health Databases for PNZ members. Abstract Objective: To explore whether physical activity is inversely associated with the onset of depression, we quantified the cumulative association of customary physical activity with incident depression and with an increase in subclinical depressive symptoms over time as reported from prospective observational studies. Design: Systematic review and meta-analysis. Data sources MEDLINE, PsycINFO, PsycARTICLES and CINAHL Complete databases, supplemented by Google Scholar.Eligibility criteria Prospective cohort studies in adults, published prior to January 2020, reporting associations between physical activity and depression.Study appraisal and synthesis Multilevel random-effects meta-analysis was performed adjusting for study and cohort or region. Mixed-model meta-regression of putative modifiers. Results: Searches yielded 111 reports including over 3 million adults sampled from 11 nations in five continents. Odds of incident cases of depression or an increase in subclinical depressive symptoms were reduced after exposure to physical activity (OR, 95% CI) in crude (0.69, 0.63 to 0.75; I2=93.7) and adjusted (0.79, 0.75 to 0.82; I2=87.6) analyses. Results: were materially the same for incident depression and subclinical symptoms. Odds were lower after moderate or vigorous physical activity that met public health guidelines than after light physical activity. These odds were also lower when exposure to physical activity increased over time during a study period compared with the odds when physical activity was captured as a single baseline measure of exposure. Conclusion: Customary and increasing levels of moderate-to-vigorous physical activity in observational studies are inversely associated with incident depression and the onset of subclinical depressive symptoms among adults regardless of global region, gender, age or follow-up period.

Diagnostic tests for occult scaphoid fractures?

Reliability of clinical tests for prediction of occult scaphoid fractures and cost benefit analysis of a dedicated scaphoid pathway. Kodumuri, P., A. McDonough, V. Lyle, Z. Naqui and L. Muir (2020). Level of Evidence: 3b Follow recommendation: 👍 👍 Type of study: Diagnostic Topic: Scaphoid fractures - Physical tests This is a retrospective study on the specificity and sensitivity of physical tests for occult schapoid fractures. If a test is very sensitive and its result is negative, you can be more certain that the patient does not have the condition. If the test is specific and its result is positive, you can be more certain that the patient has the condition. Only participants (n = 920) presenting with a negative x-ray for scaphoid fracture (occult fracture) were included in the present study. The diagnostic tests utilised were: tenderness on palpation at the snuff box or scaphoid tubercle, pain on axial compression of the thumb, pinch test, and ulnar deviation. The pinch test simply consisted in a tip to tip pinch between the thumb and index. The test was deemed positive when it caused pain in the client (see table 1 below). MRI was used as the gold standard against which the physical tests were assessed. The results showed that the absence of tenderness on palpation of the snuff box, moderately reduced the probability of an occult scaphoid fracture (see table 2 below - I calculated likelihood ratios for you, which are useful in assessing the diagnostic ability of a test). Tenderness on palpation of the snuff box increased the probability of an occult scaphoid fracture by a small degree (see table 2 below). The combination of multiple tests did not improve diagnostic accuracy. There was however a flaw within the study. When all the physical tests were negative, participants were not referred for an MRI, which is the gold standard against which all the tests were supposed to be assessed against (Thanks Dr. Steve White for pointing out this limitation and having a look at my likelihood ratio calculations). Table 2. Test specificity, sensitivity, and likelihood ratios (I calculated the LR+ and LR-, they were not provided in the article) Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message: Based on what we know today, assessment of snuff box tenderness may be the most useful test for excluding an occult scaphoid fracture. However, given the limitations of the study analysed, it may be still worth repeating a hand x-ray at two weeks to exclude the presence of an occult scaphoid fracture. If you would like more information, look at the previous synopsis on scaphoid fractures requiring surgery. URL: https://doi.org/10.1177/1753193420979465 Available through EBSCO Health Databases for PNZ members. Abstract We reviewed the outcomes of our dedicated clinic for suspected scaphoid fractures. The primary outcome measure was to test the reliability of accurately diagnosing an occult scaphoid fracture with a combination of anatomical snuff box, scaphoid tubercle, longitudinal compression tenderness, ulnar deviation and the pinch test. Cost savings of the new patient pathway was our secondary outcome measure. Between December 2016 and March 2020, 922 patients were recruited at a mean of 12 days post-injury. Sixty-five per cent (n=602) with a low clinical suspicion were discharged and 35% (n=320) with a high clinical suspicion had same day MRI scan. Fifty-eight scaphoid fractures were diagnosed and treated with no nonunions reported. Anatomical snuff box tenderness was the most sensitive test (90%). A combination of five tests better excluded an occult fracture (80% accuracy). The dedicated scaphoid clinic pathway resulted in 350 fewer follow-up visits and an overall saving of £59,666.

What are the repercussions of smoking in clients with a distal radius fracture?

A matched comparison of postoperative complications between smokers and nonsmokers following open reduction internal fixation of distal radius fractures. Galivanche, A. R., et al. (2021). Level of Evidence: 2b Follow recommendation: 👍 👍 👍 Type of study: Prognostic Topic: Distal radius fracture – Smoking and prognosis This is a retrospective study assessing the effect of smoking on post surgical complications in participants undergoing open reduction and internal fixation (ORIF) for distal radius fracture. A total of 16,158 participants was included in the study. Of these, 3,062 (19%) we're smokers. Participants' average age ranged between 50 to 58. Complications were measured 30 days after surgery and included infections, re-operation, readmission, cardiovascular events, and mortality. The statistical analyses took into account demographic and comorbidity information to reduce the contribution of confounding factors to the overall results. The results showed that although mortality was not different between smokers and non smokers, all the other complications were more likely in smokers. In particular, the prevalence of any adverse event was 4% in smokers and 3% in non smokers. Clinical Take Home Message: Based on what we know today, smoking not only increases the risk of post surgical infections but also increases the chance of other complications (e.g. re-operation) following distal radius fracture. Hand therapist may therefore ask their clients about their smoking status and whether they are interested in quitting. If they are, a previous synopsis provides information on some of the evidence-based advice to help clients quit smoking. URL: http://www.sciencedirect.com/science/article/pii/S0363502320305712 Available through The Journal of Hand Surgery (American Volume) for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Purpose: The purpose of the present study was to identify differences in 30-day adverse events, reoperations, readmissions, and mortality for smokers and nonsmokers who undergo operative treatment for a distal radius fracture. Methods: The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was queried for patients who had operatively treated distal radius fractures between 2005 and 2017. Patient characteristics and surgical variables were assessed. Thirty-day outcome data were collected on serious (SAEs) and minor adverse events (MAEs), as well as on infection, return to the operating room, readmission, and mortality. Multivariable logistic analyses with and without propensity-score matching was used to compare outcome measures between the smoker and the nonsmoker cohorts. Results: In total, 16,158 cases were identified, of whom 3,062 were smokers. After 1:1 propensity-score matching, the smoking and nonsmoking cohorts had similar demographic characteristics. Based on the multivariable propensity-matched logistic regression, cases in the smoking group had a significantly higher rate of any adverse event (AAE) (odds ratio [OR], 1.75; 95% confidence interval [95% CI], 1.28–2.38), serious adverse event (SAE) (OR, 1.75; 95% CI, 1.22–2.50), and minor adverse event (MAE) (OR, 1.84; 95% CI, 1.04–3.23). Smokers also had higher rates of infection (OR, 1.73; 95% CI, 1.26–2.39), reoperation (OR, 2.07; 95% CI, 1.13–3.78), and readmission (OR, 1.83; 95% CI, 1.20–2.79). There was no difference in 30-day mortality rate. Conclusions: Smokers who undergo open reduction internal fixation of distal radius fractures had an increased risk of 30-day perioperative adverse events, even with matching and controlling for demographic characteristics and comorbidity status. This information can be used for patient counseling and may be helpful for treatment/management planning.

Cupping for clients with persistent pain?

Cupping for patients with chronic pain: A systematic review and meta-analysis. Cramer, H., et al. (2020) Level of Evidence: 1a- Follow recommendation: 👍 👍 👍 👍 Type of study: Therapeutic Topic: Cupping effectiveness - Chronic pain This is a systematic review and meta-analysis assessing the effectiveness of cupping for persistent pain. Eighteen RCTs were included in the systematic review, for a total of 1,172 participants. All the studies were included in the meta-analysis and they were assessed through the Risk of Bias criteria recommended by the Cochrane Review Group. The overall strength of evidence was not assessed in the paper but I decided to assess it through the GRADE approach ("low", "very low", "moderate", "high"), which has also been suggested by the Cochrane group for systematic reviews. The effectiveness of cupping was applied to several different musculoskeletal conditions (e.g. lower back pain, osteoarthritis). Efficacy of intervention was assessed through improvements in function or pain intensity (i.e. NRS, VAS). Cupping was compared to no intervention, sham cupping, or an active treatment. In this synopsis I just focused on the results of sham cupping (very low negative pressure or no negative pressure), which provide a reasonable placebo comparison. The treatment duration varied between 3 to 4 weeks, with biweekly treatment frequency. There is low quality evidence suggesting that sham cupping is as effective as cupping (both groups improved), without any statistically significant difference between the two interventions for both pain intensity and disability. Clinical Take Home Message: Based on what we know today, cupping is no more effective than placebo in clients with persistent pain. If you have applied it in clinical practice with significant success, it may be due to the contextual effect of your treatment session rather than any specific mechanism associated with cupping. Similar results have been shown when comparing cortisone injections or acupuncture for thumb OA, PRP or MWMs for tennis elbow to placebo interventions. They all work in clinical practice but the results is probably due to the placebo effect. URL: http://www.sciencedirect.com/science/article/pii/S1526590020300031 Available through EBSCO Health Databases for PNZ members. Abstract There is a growing interest in nonpharmacological pain treatment options such as cupping. This meta-analysis aimed to assess the effectiveness and safety of cupping in chronic pain. PubMed, Cochrane Library, and Scopus were searched through November 2018 for randomized controlled trials on effects of cupping on pain intensity and disability in patients with chronic pain. Risk of bias was assessed using the Cochrane risk of bias tool. Of the 18 included trials (n =1,172), most were limited by clinical heterogeneity and risk of bias. Meta-analyses found large short-term effects of cupping on pain intensity compared to no treatment (standardized mean difference [SMD] = −1.03; 95% confidence interval [CI] = −1.41, −.65), but no significant effects compared to sham cupping (SDM = −.27; 95% CI = −.58, .05) or other active treatment (SMD = −.24; 95% CI = −.57, .09). For disability, there were medium-sized short-term effects of cupping compared to no treatment (SMD = −.66; 95% CI = −.99, −.34), and compared to other active treatments (SMD = −.52; 95% CI = −1.03, −.0028), but not compared to sham cupping (SMD = −.26; 95% CI = −.57,.05). Adverse events were more frequent among patients treated with cupping compared to no treatment; differences compared to sham cupping or other active treatment were not statistically significant. Cupping might be a treatment option for chronic pain, but the evidence is still limited by the clinical heterogeneity and risk of bias. Perspective: This article presents the results of a meta-analysis aimed to assess the effectiveness and safety of cupping with chronic pain. The results suggest that cupping might be a treatment option; however, the evidence is still limited due to methodical limitations of the included trials. High-quality trials seem warranted.

A2 pulley injury, what to do?

A potential classification schema and management approach for individuals with A2 flexor pulley strain. Cooper, C. and P. LaStayo (2020). Level of Evidence: 5 Follow recommendation: 👍 Type of study: Therapeutic Topic: A2 pulley injury - Assessment and treatment This is an expert opinion article on assessment and treatment of A2 pulley injury. These injuries are very common in rock climbers and they do occur most often while crimping (see picture below). The classification suggested in this article (i.e. severe, moderate, and mild - see table below) is based on assessment of pain, active range of movement, resisted tests, and palpation. According to this classification system, severe pulley injury should be immobilised except for gentle active range of movement exercises and climbing training should be significantly modified. A mild injury should be managed with progressive resistance training and hang board training (avoiding crimping). With a moderate injury, the routine would be similar to a mild injury, however, the intensity would be lower. Additionally, H tape and pulley orthoses may be utilised to control symptoms in adjunct to climbing volume modification. Clinical Take Home Message: Based on what we know today, we may decide to classify A2 pulley injuries according to the assessment procedures described in this article. The only issue with a symptomatic driven assessment is that several factors can increase or decrease pain intensity independently of tissue damage (see the overuse injury and fracture TOP synopses). Triangulation of clinical presentation with investigations such as ultrasound and x-ray may help in the differential diagnosis (e.g. stress fractures) and may provide a more objective assessment of tissue damage (if any). If you are interested in other climbing injuries, see this previous synopsis. URL: https://doi.org/10.1016/j.jht.2019.01.002 Available through the Journal of Hand Therapy for HTNZ members. Available through EBSCO Health Databases for PNZ members. No abstract available

Lots of our patients present with osteopenia and sarcopenia - what can we you do?

Non-pharmacological interventions in osteosarcopenia: A systematic review. Atlihan, R., B. Kirk and G. Duque (2020). Level of Evidence: 1a- Follow recommendation: 👍 👍 👍 👍 Type of study: Prognostic, Preventative, Therapeutic Topic: Musculoskeletal and bone health – Resistance training This is a systematic review of randomised controlled studies assessing the effect of resistance training on muscle and bone health in older participants with sarcopenia (loss of muscle mass) and osteopenia/osteoporosis (loss of bone density). Two studies were included for a total of 106 participants (average age range: 64-79 years old). The overall strength of evidence was assessed through the GRADE approach ("low", "very low", "moderate", "high"), which has also been suggested by the Cochrane group for systematic reviews. Participants took part in upper and lower limb resistance training 2-3/week for 3 to 18 months. There was moderate quality evidence that resistance training improved muscle strength and muscle mass. Low quality evidence suggests that by the 6 months mark, bony density improved. Clinical Take Home Message: Based on what we know today, resistance training improves our clients' muscle strength and mass in the short and long term. Furthermore, if performed for at least 6 months, resistance training has the potential to maintain if not improve bone density in our older clients. As hand therapist we are privileged to see several older patients after a distal radius fracture. These clients are often fragile and would definitely benefit from resistance training. We may also invite our clients to take at least 8,000 steps/day as a greater number of daily steps has been shown to reduce mortality in previous studies. In addition, general resistance training may increase grip strength, which is another predictor of mortality. URL: https://link.springer.com/article/10.1007/s12603-020-1537-7 Available through EBSCO Health Databases for PNZ members. Abstract BACKGROUND: Osteosarcopenia is a geriatric syndrome defined by the concomitant presence of osteopenia/osteoporosis (loss of bone mineral density (BMD)) and sarcopenia (loss of muscle mass and/or function), which increases the risk of falls, fractures, and premature mortality. OBJECTIVE: To examine the efficacy of non-pharmacological (exercise and/or nutritional) interventions on musculoskeletal measures and outcomes in osteosarcopenic adults by reviewing findings from randomized controlled trials (RCTs). METHODS: This review was registered at PROSPERO (registration number: CRD42020179292) and conducted in accordance with the PRISMA guidelines. Electronic databases were searched for RCTs assessing the effect of at least one non-pharmacological intervention (any form of exercise and/or supplementation with protein, vitamin D, calcium or creatine) on any musculoskeletal measure/outcome of interest (BMD, bone strength/turnover, muscle mass and strength, physical performance, falls/fractures) in adults with osteosarcopenia as defined by any proposed criteria. RESULTS: Two RCTs (of n=106 older osteosarcopenic adults (≥65 years)) assessing the effects of progressive resistance training (RT) (via resistance bands or machines; 2-3 times/week; ~60 minutes in duration) were eligible for inclusion. The two RCTs demonstrated moderate quality evidence that RT increases muscle mass, strength, and quality, with changes in strength and quality occurring before muscle mass (12 vs 28 weeks). There was low quality evidence that RT increases lumbar spine BMD and maintains total hip BMD when performed for 12 and 18 months, respectively, and moderate quality evidence that RT has no effect on markers of bone turnover or physical performance. No major adverse effects were recorded in either of the RCTs. There were no eligible RCTs examining the impact of nutritional interventions. CONCLUSION: Chronic RT is safe and effective at potentiating gains in muscle mass, strength, and quality, and increasing or maintaining BMD in older osteosarcopenic adults. No RCT has examined the effects of protein, vitamin D, calcium, or creatine against a control/placebo in this high-risk population.

Answer for - What is the differential diagnosis for this case? - Little finger pain

Extensive Tumoral Calcinosis of the Hand. Gonzalez, M., M. Rettig and O. Ayalon (2020) Level of Evidence: 5 Follow recommendation: 👍 Type of study: Diagnostic Topic: What is the differential diagnosis? – Case study This is the answer for the case study from last week. The patient was a 34 years old female with a six months history of atraumatic painless mass on the volar aspect of the right little finger (especially at the middle phalanx). The mass had grown significantly in the last few weeks and it was now associated with pain and blanching of the skin. Objectively, they were unable to bend the right little finger. The patient reported a history of hypothiroidisn and Sjogren's syndrome. The x-ray image is shown below. The results suggested the presence of a tumoral calcinosis on the volar aspect of the right little finger. Surgery was performed to remove the mass which had a chalk like consistency. Six weeks post surgery, the pain had resolved and the range of movement had significantly improved. URL: https://doi.org/10.1016/j.jhsa.2020.10.030 Available through The Journal of Hand Surgery (American Volume) for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Tumoral calcinosis is a rare and benign subtype of calcinosis cutis, a group of disorders involving soft tissue calcium deposition. Only 250 cases have been described since 1898; hand involvement is exceedingly rare. We report a case of extensive calcinosis within the flexor sheath of the little finger. Presentation included a painful mass over the volar aspect of the little finger, restricted digit motion, and skin compromise at the site of the mass. Surgical debulking was performed resulting in restoration of finger function.

What is the differential diagnosis for this case? - Little finger pain

Level of Evidence: 5 Follow recommendation: 👍 Type of study: Diagnostic Topic: What is the differential diagnosis? – Case study Have a think about this case study. Leave a diagnostic comment if you like. I will publish the diagnosis and treatment reported by the paper next week. The patient was a 34 years old female with a six months history of atraumatic painless mass on the volar aspect of the right little finger (especially at the middle phalanx). The mass had grown significantly in the last few weeks and it was now associated with pain and blanching of the skin. Objectively, they were unable to bend the right little finger. The patient reported a history of hypothyroidism and Sjogren's syndrome. The x-ray image is shown below. What is it?

Active vs passive interventions for lateral epicondylalgia - What's best?

Exercise interventions in lateral elbow tendinopathy have better outcomes than passive interventions, but the effects are small: A systematic review and meta-analysis of 2123 subjects in 30 trials. Karanasios, S., et al. (2020). Level of Evidence: 1a- Follow recommendation: 👍 👍 👍 👍 Type of study: Therapeutic Topic: Lateral epicondylalgia - Eccentric resistance training This is a systematic review and meta-analysis of randomised controlled trials assessing the effectiveness of active vs passive interventions for lateral epicondylalgia. Thirty randomised controlled trials were included for a total of 2,123 participants (21 studies were included in the meta-analysis). The results from this systematic review and meta-analysis were assessed through the GRADE approach (suggested by the Cochrane Group), which scores the evidence as "very low", "low", "moderate", or "high" quality. Efficacy of intervention was assessed through changes in pain, pain-free grip strength (PFG), and elbow disability. Pain was assessed through the visual analogue scale (VAS) or the numerical rating scale (NRS), pain-free grip strength (PFG), and elbow disability through the Patient-Rated Tennis Elbow Evaluation (PRTEE) and the Disability of the Arm, Shoulder, and Hand (DASH) questionnaire. Follow-up times ranged between very short term (less than 2 months), short term (2-3 months), mid-term (3-12 months), and long term (more than 12 months). The results showed that there was low to very low quality evidence suggesting that exercise provided clinically and statistically significant greater improvements in PFG compared to cortisone injections at all time points. No difference was noted between exercise or wait and see. Eccentric exercises were not superior to concentric exercises. Clinical Take Home Message: Based on what we know today, exercises are more effective than cortisone injections in both the short and long term for clients with lateral epicondylalgia. This is not surprising considering the results from previous trials showing that people undergoing cortisone injection for lateral epicondylalgia are twice as likely to present with a recurrence at one year compared to somebody receiving a saline (placebo) injection. Any form of resistance exercise appears to be useful and eccentric exercises do not appear to be superior to concentric exercises, although they may provide with greater analgesia once the acute reactive tendinopathy has subsided. If clients are happy to wait and see, they may improve without the need of any intervention. URL: http://bjsm.bmj.com/content/early/2020/11/04/bjsports-2020-102525.abstract Available through EBSCO Health Databases for PNZ members. Abstract Objective: To evaluate the effectiveness of exercise compared with other conservative interventions in the management of lateral elbow tendinopathy (LET) on pain and function.Design Systematic review and meta-analysis. Methods: We used the Cochrane risk-of-bias tool 2 for randomised controlled trials (RCTs) to assess risk of bias and the Grading of Recommendations Assessment, Development and Evaluation methodology to grade the certainty of evidence. Self-perceived improvement, pain intensity, pain-free grip strength (PFGS) and elbow disability were used as primary outcome measures.Eligibility criteria RCTs assessing the effectiveness of exercise alone or as an additive intervention compared with passive interventions, wait-and-see or injections in patients with LET. Results: 30 RCTs (2123 participants, 5 comparator interventions) were identified. Exercise outperformed (low certainty) corticosteroid injections in all outcomes at all time points except short-term pain reduction. Clinically significant differences were found in PFGS at short-term (mean difference (MD): 12.15, (95% CI) 1.69 to 22.6), mid-term (MD: 22.45, 95% CI 3.63 to 41.3) and long-term follow-up (MD: 18, 95% CI 11.17 to 24.84). Statistically significant differences (very low certainty) for exercise compared with wait-and-see were found only in self-perceived improvement at short-term, pain reduction and elbow disability at short-term and long-term follow-up. Substantial heterogeneity in descriptions of equipment, load, duration and frequency of exercise programmes were evident. Conclusions: Low and very low certainty evidence suggests exercise is effective compared with passive interventions with or without invasive treatment in LET, but the effect is small. PROSPERO registration number CRD42018082703.

Entrapment neuropathies? Could the thoracic outlet contribute to symptoms?

Nerve compression syndromes of the shoulder. Patetta, M. J., E. Naami, B. M. Sullivan and M. H. Gonzalez (2020) Level of Evidence: 5 Follow recommendation: 👍 Type of study: Diagnostic, Therapeutic Topic: Thoracic outlet - Symptoms and treatment This is a narrative review on entrapment neuropathies of the shoulder. I selected to cover the neurogenic thoracic outlet syndrome as this is the one that may present with symptoms in forearm and hand. In addition, neurogenic thoracic outlet syndrome constitute 90% of all the thoracic outlet syndromes. In term of diagnostic tests, there is not one single test that present with high specificity (ability to confirm the diagnosis) or sensitivity (ability to exclude the diagnosis). Nerve conduction studies rarely show any objective impairments, making the diagnosis even more challenging. Conservative treatment is always advocated before any surgical approach. The positive news is that if surgery is required, 56% to 89% of clients report improvements in their symptoms following the surgical procedure. Clinical Take Home Message: Based on what we know today, thoracic outlet syndrome may be in part responsible for vague upper limb symptoms reported by clients. Unfortunately, there is not one single test that is useful to confirm or exclude the diagnosis. It may be useful to utilised tests such as the arm squeeze test, Spurling's, Cx distraction, and neurodynamic tests to confirm or exclude the presence of a cervical radiculopathy. Dermatomal patterns are not always consistent in presence of a cervical radiculopathy and the presence of vague symptoms alone does not increase the likelihood of a thoracic outlet syndrome. In clients with a potential thoracic outlet syndrome it is worth remembering that psychological factors (e.g. anxiety, depression, pain catastrophising) have been shown to mediate pain/recovery. Light aerobic exercise (e.g. walking, cycling) may be a helpful intervention to reduce symptoms in clients with neurogenic thoracic outlet syndrome. URL: https://doi.org/10.1016/j.jhsa.2020.09.022 Available through EBSCO Health Databases for PNZ members. Abstract Nerve compression syndromes of the shoulder contribute to pain, paresthesia, and weakness of the upper extremity. This review examines the recent literature regarding thoracic outlet syndrome, suprascapular neuropathy, long thoracic nerve palsy, and quadrilateral space syndrome. Overlapping features are common among shoulder pathologies, and thus, key anatomical features, pathophysiology, clinical manifestations, diagnostic techniques, and treatments are highlighted for all aforementioned conditions.

Neural mobilisation for nerve-related arm and neck pain?

Effect of neural mobilization on nerve-related neck and arm pain: A randomized controlled trial. Basson, C. A., A. Stewart, W. Mudzi and E. Musenge (2020). Level of Evidence: 1b Follow recommendation: 👍 👍 👍 👍 Type of study: Therapeutic Topic: Nerve pain - Usual care vs usual care plus neural mobilisation This is a randomised, single-blind, controlled trial assessing the effectiveness of nerve gliding on pain, function, and quality of life in participants with nerve-related neck and arm pain. Participants (N = 78) were included if they presented with clinical signs of neck pain associated with nerve-related symptoms (participants had to had positive neurodynamic tests and allodynia on peripheral nerve palpation). Pain was assessed through the Numerical Rating Scale (NRS), function through the Patient Specific Functional Scale (PSFS), and quality of life through the EuroQol-5. Participants were randomised (2:1) to either usual care (n = 25), or usual care plus neural mobilisation (n = 53). The usual care included cervical and thoracic mobilisation, exercises and the advice to keep active. The experimental group received the usual care plus mobilisation of the tissues surrounding the peripheral nerve involved (e.g. pronator teres for median nerve). On average, participants were treated over 4 sessions. Outcomes were measured at baseline, 3, 6 weeks, 6 months, and one year. The results showed that participants in all groups improved by one year. There were no differences between groups in function and quality of life. Pain was significantly better at 6 months for the usual care plus neural mobilisation, however, this difference was not clinically relevant (see picture below). Clinical Take Home Message: Based on what we know today, the addition of neural mobilisation to an evidence based program for people with nerve-related cervical and arm pain does not provide better results. In contrast, neural mobilisation may be helpful for clients presenting with isolated carpal tunnel syndrome. If you are interested, you can also reduce the likelihood of clients undergoing carpal tunnel surgery by adding a night splint and education to your intervention. Finally, have a look at what is the most effective and safe nerve gliding approach for carpal tunnel syndrome. URL: https://www.utpjournals.press/doi/abs/10.3138/ptc-2018-0056 Available through EBSCO Health Databases for PNZ members. Abstract Purpose: Neural mobilization (NM) is often used to treat nerve-related conditions, and its use is reasonable with nerve-related neck and arm pain (NNAP). The aims of this study were to establish the effect of NM on the pain, function, and quality of life (QOL) of patients with NNAP and to establish whether high catastrophizing and neuropathic pain influence treatment outcomes. Method: A randomized controlled trial compared a usual-care (UC; n = 26) group, who received cervical and thoracic mobilization, exercises, and advice, with an intervention (UCNM; n = 60) group, who received the same treatment but with the addition of NM. Soft tissue mobilization along the tract of the nerve was used as the NM technique. The primary outcomes were pain intensity (rated on the Numerical Pain Rating Scale), function (Patient-Specific Functional Scale), and QOL (EuroQol-5D) at 3 weeks, 6 weeks, 6 months, and 12 months. The secondary outcomes were the presence of neuropathic pain (using the Neuropathic Diagnostic Questionnaire) and catastrophizing (Pain Catastrophising Scale). Results: Both groups improved in terms of pain, function, and QOL over the 12-month period (p < 0.05). No between-groups differences were found at 12 months, but the UCNM group had significantly less pain at 6 months (p = 0.03). Patients who still presented with neuropathic pain (p < 0.001) and high pain catastrophizing (p = 0.02) at 6- and 12-mo follow-ups had more pain. Conclusions: Both groups had similar improvements in function and QOL at 12-month follow-up. The UCNM group had significantly less pain at 6-month follow-up and a lower mean pain rating at 12-month follow-up, although the difference between groups was not significant. Neuropathic pain is common among this population and, where it persisted, patients had more pain and functional limitations at 12-mo follow-up.

Lumbrical tear, what to do?

Lumbrical muscle tear: Clinical presentation, imaging findings and outcome. Lutter, C., A. Schweizer, V. Schöffl, F. Römer and T. Bayer (2018). Level of Evidence: 4 Follow recommendation: 👍 👍 Type of study: Diagnostic, Therapeutic Topic: Lumbricals' tear - Imaging and treatment This is case series on lumbrical muscle tear's diagnosis and treatment. A total of 60 clients with a positive lumbrical stress test (see figure below) were included in the study. This type of injury occurs when a finger (middle/ring finger) is forcefully extended while the other fingers are actively flexed. Rock climbers are at greatest risk for lumbricals muscles tears. The diagnostic recommendation is to request an US investigation to determine the lesion grade: Grade I (microtear - non visible on US), a Grade II or III (both visible on US). In case of a grade I tear, gentle intrinsic minus pain-free stretching is performed for 4-6 weeks followed by graded lumbricals loading. For grade II, buddy taping is recommended for a max of 8 weeks, followed by a similar treatment as per grade I. For a grade III, immobilisation with an ulnar gutter including MF, RF, and LF to the proximal phalanx is recommended for 2 weeks. This is followed by the same treatment as per grade II lesion. Clinical Take Home Message: Based on what we know today, the lumbrical stress test is a quick way to assess the involvement of the 3rd or 4th lumbricals. An US has been indicated as the most appropriate way to confirm a clinical diagnosis, especially if there is a grade II or III, which is visible through this investigation. Considering the potential role of lumbrical in finger proprioception (see previous synopsis), the inclusion of dexterity exercises may be appropriate in this subgroup of clients. URL: https://doi.org/10.1177/1753193418765716 Available through EBSCO Health Databases for PNZ members. Abstract The incidence of lumbrical muscle tear is increasing due to the popularity of climbing sport. We reviewed data from 60 consecutive patients with a positive lumbrical stress test, including clinical examination, ultrasound and clinical outcomes in all patients, and magnetic resonance imaging in 12 patients. Fifty-seven patients were climbers. Lumbrical muscle tears were graded according to the severity of clinical and imaging findings as Grade I-III injuries. Eighteen patients had Grade I injuries (microtrauma), 32 had Grade II injuries (muscle fibre disruption) and 10 had Grade III injuries (musculotendinous disruption). The treatment consisted of adapted functional therapy. All patients completely recovered and were able to return to climbing. The healing period in Grade III injuries was significantly longer than in the patients with Grade I or II injuries (p < 0.001). We recommend evaluation of specific clinical and imaging findings to grade the injuries and to determine suitable therapy.

Answer for - What is the differential diagnosis for this case? - Wrist pain

Osteosarcoma of the Trapezium. Ferrando, E., Navarro, J., Rojas, R., Mata, D., & Silvestre, A. (2020) Level of Evidence: 5 Follow recommendation: 👍 Type of study: Diagnostic Topic: What is the differential diagnosis? – Case study This is the answer for the last week case study. The patient was a 51 years old female with a three years history of painless palpable firm mass on the dorsal and radial aspect of the wrist. Subjectively, they reported swelling and pain in the last two months. The patient reported a history of hypertension. The x-ray that you see below revealed a calcification on the radial aspect of the wrist. An MRI was completed, which revealed a soft tissue mass. Surgery was performed to remove the mass and histological studies revealed that it was a low grade osteosarcoma. URL: https://www.jhandsurg.org/action/showPdf?pii=S0363-5023%2820%2930607-9 Available through EBSCO Health Databases for PNZ members. Abstract Osteogenic sarcoma is a malignant tumor that rarely affects the hand. When it does, it most often involves the phalanges or metacarpal heads. We present the case of a 51-year-old woman with a low-grade osteosarcoma affecting the trapezium bone of her left hand. A total trapeziectomy with partial removal of the first metatarsal, scaphoid, trapezoid, and capitate bones was performed, and no adjuvant therapy was administered. Six years after the intervention, the patient is disease-free, with excellent functionality and yearly imaging tests showing no signs of recurrence.

How does diabetes affect recovery after trigger finger surgery?

Functional outcomes of trigger finger release in non-diabetic and diabetic patients. Stirling, P. H. C., P. J. Jenkins, A. D. Duckworth, N. D. Clement and J. E. McEachan (2020) Level of Evidence: 2b Follow recommendation: 👍 👍 Type of study: Prognostic Topic: Trigger finger surgery - diabetes and functional recovery This retrospective study assessed the effect of diabetes on functional recovery following surgery for trigger finger (A1 pulley release). Functional recovery was measured through the QuickDASH questionnaire, and the presence of diabetes was self-reported by participants. A total of 192 participants were recruited at baseline and they were assessed pre-surgery and one year post-surgery. The results showed that 25% (n = 49) of the participants reported diabetes (no information was provided on number of participants with Type 1 or Type 2 diabetes). Participants' function at baseline was significantly worst in diabetic subjects (16 points worse). However, improvements in functional outcome following surgery were similar in both the diabetic (13 points improvement) and non-diabetic participants (9 points improvement). Clinical Take Home Message: Based on what we know today, clients affected by trigger finger and diabetes may have greater disability than clients without diabetes. It may be worth checking with the client if they are compliant with their diabetes medications (e.g. metformin) and if they have had a check up with their GP recently. The functional outcomes of A1 pulley release are similar between clients with and without diabetes. This synopsis is a nice addition to the one written on the effect of diabetes on functional recovery following distal radius fracture. URL: https://doi.org/10.1177/1753193420925027 Available through EBSCO Health Databases for PNZ members. Abstract We compared the functional outcomes, health-related quality of life, and satisfaction in diabetic and non-diabetic patients undergoing A1 pulley release for trigger finger in 192 patients. Preoperative and postoperative Quick Disabilities of the Arm, Shoulder and Hand questionnaire (Quick DASH), EuroQol-5 dimensions, and satisfaction scores were collected prospectively over a 6-year period. These patients had a mean follow-up of 14 months (range 11?40) after surgery. There were 143 patients (143 trigger fingers) without diabetes and 49 patients (49 trigger fingers) with diabetes. We found overall QuickDASH improvement was the same in both groups (-4.5 points). Patient satisfaction rates were comparable in both groups (90% versus 96%), and no significant difference in postoperative health-related quality of life was observed. No complications were reported in either group. We conclude from this study that A1 pulley release leads to similar functional improvement and high patient satisfaction at one year postoperatively in diabetic and non-diabetic patients.

What is the differential diagnosis for this case? - Wrist pain

Level of Evidence: 5 Follow recommendation: 👍 Type of study: Diagnostic Topic: What is the differential diagnosis? – Case study Have a think about this case study. Leave a diagnostic comment if you like. I will publish the diagnosis and treatment reported by the paper next week. The patient was a 51 years old female with a three years history of painless palpable firm mass on the dorsal and radial aspect of the wrist. Subjectively, they reported swelling and pain in the last two months. The patient reported a history of hypertension. X-ray images are shown below. What is it?

Do you know which hand muscles were originally called earthworms?

The lumbricals are not the workhorse of digital extension and do not relax their own antagonist. Crowley, J. S., M. Meunier, R. L. Lieber and R. A. Abrams (2020) Level of Evidence: 5 Follow recommendation: 👍 Type of study: Anatomical Topic: Lumbricals' action - Action and interaction This is biomechanical study on the role of lumbricals in the hand. The major points of this article are reported below: - Lumbricals are not able to produce enough force to counteract flexor digitorum profondus (FDP) or superficialis (FDS) at the pipj or dipj. This is due to their small cross sectional area when compared to FDP or FDS. - Lumbricals are weak mcpj flexors compared to the interossei muscles as their cross sectional area is 1/15 of the interossei - Lumbricals present the greatest number of muscle spindles (used for proprioception) among all the muscles of the upper limb Considering these facts, it is hypothesised that lumbricals have a proprioceptive role important for finger dexterity. Clinical Take Home Message: Based on what we know today, the lumbricals are more likely to have a sensory function rather than a force or movement generating capability in healthy clients. A possible exception is the presence of paradoxical flexion following laceration or avulsion of FDP. Knowing that lumbricals are also involved in proprioception may direct us to include a dexterity treatment component in those clients presenting with a grade III or IV lumbrical strain or tear. This injury may occur in climbers following a forced middle or ring finger extension while having the other fingers curled in your hand (Fall while on a mono or small ledge holds). URL: https://doi.org/10.1016/j.jhsa.2020.10.022 Available through The Journal of Hand Surgery (American Volume) for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract That the lumbrical muscles are the workhorse of digital extension and that they can relax their own antagonist have been time-honored principles. However, we believe this dogma is incorrect and an oversimplification. We base our assertion on anatomy, innervation, and the notion that muscle architecture is the most important determinant of muscle function. Wang and colleagues proposed the lumbrical to be a sophisticated tension monitoring device. We elaborate on their well-supported thesis, further proposing that the lumbricals also function as a constant tension spring within the closed loop composed of the digital flexors and the extensor mechanism.

Are your clients with symptomatic hand OA at greater risk of cardiovascular disease?

Hand osteoarthritis in relation to mortality and incidence of cardiovascular disease: Data from the Framingham heart study. Haugen, I. K., Ramachandran, V. S., Misra, D., Neogi, T., Niu, J., Yang, T., . . . Felson, D. T. (2015) Level of Evidence: 2b Follow recommendation: 👍 👍 👍 Type of study: Prognostic Topic: Symptomatic hand OA - Mortality prediction This is a prospective cohort study assessing the risk of cardiovascular disease and associated mortality in people with symptomatic hand OA. A total of 1,348 participants were included at baseline (1948-1953) and followed up for 60 years (2008-2011). Participants' offspring were included as well in this study. Participants were 50 to 75 years old at baseline. Participants were divided into two groups: participants with symptomatic and radiographic evidence of hand OA, and participants with radiographic hand OA only. The results showed that participants with symptomatic hand OA were at least twice as likely to present with a significant cardiovascular condition (e.g. coronary heart disease) during the course of their life compared to the rest of the sample. People with radiographic but not symptomatic hand OA were at no greater risk that the rest of the population. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message: Based on what we know today, people with symptomatic hand OA are at least 2 times more likely to develop cardiovascular disease. We should therefore encourage our clients with this condition to keep as active as possible. Remember that previous research showed a relation between grip strength and mortality and walking and mortality. Have a look at the recent WHO 2020 guidelines on physical activity, which will give you an idea of the level and type of exercise that we should recommend to our clients. Clients who do not present with symptomatic hand OA but x-ray evidence of OA do not seem to be at greater risk then other people to develop cardiovascular disease. Open Access URL: https://ard.bmj.com/content/annrheumdis/74/1/74.full.pdf Abstract Objectives: To study whether hand osteoarthritis (OA) is associated with increased mortality and cardiovascular events in a large community based cohort (Framingham Heart Study) in which OA, mortality and cardiovascular events have been carefully assessed. Methods: We examined whether symptomatic (≥1 joint(s) with radiographic OA and pain in the same joint) and radiographic hand OA (≥1 joint(s) with radiographic OA without pain) were associated with mortality and incident cardiovascular events (coronary heart disease, congestive heart failure and/or atherothrombotic brain infarction) using Cox proportional hazards models. In the adjusted models, we included possible confounding factors from baseline (eg, metabolic factors, medication use, smoking/alcohol). We also adjusted for the number of painful joints in the lower limb and physical inactivity. Results: We evaluated 1348 participants (53.8% women) with mean (SD) age of 62.2 (8.2) years, of whom 540 (40.1%) and 186 (13.8%) had radiographic and symptomatic hand OA, respectively. There was no association between hand OA and mortality. Although there was no significant relation to incident cardiovascular events overall or a relation of radiographic hand OA with events, we found a significant association between symptomatic hand OA and incident coronary heart disease (myocardial infarction/coronary insufficiency syndrome) (HR 2.26, 95% CI 1.22 to 4.18). The association remained after additional adjustment for pain in the lower limb or physical inactivity. Conclusions: Symptomatic hand OA, but not radiographic hand OA, was associated with an increased risk of coronary heart disease events. The results suggest an effect of pain, which may be a possible marker of inflammation.

A surgeon's opinion on thumb OA 💉

Trapeziometacarpal joint arthritis: A personal approach to its treatment. Davis, T. R. C. (2020) Level of Evidence: 5 Follow recommendation: 👍 Type of study: Therapeutic Topic: Thumb OA - Surgeon's point of view This is a surgeon's opinion on treatment of thumb osteoarthritis (OA). I particularly enjoyed the open minded approach that this surgeon has about thumb OA. They recognise the limitations of their own approach and they are ready to change their practice in light of new evidence, which will inevitably arise in the future. The approach suggested is to delay surgery (e.g. trapeziotomy) as much as possible. This is based on evidence suggesting that a limited proportion of the pain is correlated with radiographic findings and that a flare in pain may resolve within 6 months to a year. Furthermore, conservative treatments may help in the resolution or reduction of pain. More importantly, they recognise the significant impact of psychological factors in the exacerbation of pain (which is the driver for surgery) and the potential effect of other conservative interventions in the management of thumb OA. Cortisone injections are suggested as an additional treatment option. They report being happy to provide more than 3 injections if the benefits last for more than 6 months. A final point was made on the lack of evidence suggesting greater effectiveness of trapeziotomy alone vs trapeziotomy plus suspension arthroplasty. No differences have been identified between these approaches at short and long term in randomised controlled trials. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message: Based on what we know today, thumb OA should be initially treated conservatively. Conservative treatments should last between 6 to 12 months and consider other factors contributing to pain other than radiographic evidence of thumb OA. Psychological factors (e.g. anxiety, depression, pain catastrophising) have been shown to mediate pain/recovery and should be taken into account more than the degree of "degeneration" of the joint (up to 75% of people with radiographic evidence of thumb OA do not have pain). Have a look at conservative treatments for hand OA (e.g. manual therapy/exercise, illusory resizing, mental health component), we can make a difference! URL: https://journals.sagepub.com/doi/abs/10.1177/1753193420970343?journalCode=jhsc Available through EBSCO Health Databases for PNZ members. Abstract Many hand surgeons have fixed beliefs on how trapeziometcarpal (TMC) osteoarthritis should be treated. However, not all hand surgeons share the same fixed beliefs, so different factions of hand surgeons can hold contradictory beliefs. Many retain their fixed beliefs, rather than reconsidering them, when the best available evidence challenges them. The problem causing this heterogeneity of fixed beliefs is the lack of high-quality evidence that can withstand critical appraisal and cannot be ignored or simply dismissed by those with rigid contradictory beliefs. This article examines some of the dogmas surrounding the treatment of TMC osteoarthritis.

Diabetic clients are at much higher risk of amputation following a washout procedure

Factors affecting suboptimal outcomes in hand infections. Botma, N., McGuire, D., Koller, I., & Solomons, M. (2020) Level of Evidence: 4 Follow recommendation: 👍 👍 Type of study: Prognostic Topic: Revision surgery following infection – Diabetes This is a non-peer reviewed prospective study assessing the risk factors for the development of complications following a hand washout procedure. A total of 674 participants diagnosed with a hand infection were included in the study. The results showed that being diabetic increased the risk of a second infection by at least twofold. In people with diabetes, delayed presentation to ED (i.e. more than 1 week) increased the odds of amputation due to sepsis by 6 times. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message: Based on what we know today, diabetes is a risk factor for the development of a secondary infection following a washout procedure. A prompt referral to ED is warranted given the substantial risk of sepsis and potential amputation in clients with diabetes. This synopsis is a nice addition to a previous synopsis on risk factors for hand infection. URL: https://journals.sagepub.com/doi/full/10.1177/1753193420977791 Available through EBSCO Health Databases if you have access (PNZ) No abstract available.

Can type 2 diabetes contribute to the development of lateral epicondylalgia?

The impact of type 2 diabetes on the development of tendinopathy. Cannata, F., Vadalà, G., Ambrosio, L., Napoli, N., Papalia, R., Denaro, V., & Pozzilli, P. (2020) Level of Evidence: 5 Follow recommendation: 👍 Type of study: Prognostic Topic: Lateral epicondylalgia – Risk factors This is a narrative review assessing the connection between type 2 diabetes and tendinopathy, and exploring the potential treatment pathways. Type 2 diabetes is associated with chronic hyperglycemia (high levels and significant fluctuations of glucose in the bloodstream - especially if not treated) and poses several risks for tendons. In particular, it reduces the loading threshold at which tendons enter a degenerative phase, and it reduces the ability of tendon to heal due to tenocytes oxidative stress and impairment of stem cells activity. This is not to mention the effect that hyperglycemia has on connective and vascular tissue. Thus, glycation of connective tissue makes it more stiff and less resilient to loading. Vascular impairments lead to a reduction of neoangiogenesis (formation of new vessels), which is fundamental for tendon healing. Management of people presenting with type 2 diabetes and tendinopathy includes both local treatment (reduction in loading during the acute phase and gradual resistance training) and other interventions aiming at weight-loss (i.e. exercise, diet, and pharmacological, +/- surgical). Interventions aiming at weight loss have shown to reduce symptoms in both weight-bearing and non-weight-bearing tissues. Finally, resistance training and aerobic exercises are fundamental interventions in the management of type 2 diabetes and should be undertaken under the supervision of a health professional. Clinical Take Home Message: Based on what we know today, clients with type 2 diabetes may be predisposed to develop lateral epicondylalgia. When assessing clients with Type 2 diabetes, hand therapists should investigate whether they are compliant with medications (e.g. metformin) and encourage clients to take part in supervised resistance and/or aerobic training exercises (as per international guidelines). This article is a nice addition to what we already know on the risk factors for lateral epicondylalgia. URL: https://doi.org/10.1002/dmrr.3417 Available through EBSCO Health Databases for PNZ members. Abstract Tendinopathy is a chronic and often painful condition affecting both professional athletes and sedentary subjects. It is a multi‐etiological disorder caused by the interplay among overload, ageing, smoking, obesity (OB) and type 2 diabetes (T2D). Several studies have identified a strong association between tendinopathy and T2D, with increased risk of tendon pain, rupture and worse outcomes after tendon repair in patients with T2D. Moreover, consequent immobilization due to tendon disorder has a strong impact on diabetes management by reducing physical activity and worsening the quality of life. Multiple investigations have been performed to analyse the causal role of the individual metabolic factors occurring in T2D on the development of tendinopathy. Chronic hyperglycaemia, advanced glycation end‐products, OB and insulin resistance have been shown to contribute to the development of diabetic tendinopathy. This review aims to explore the relationship between tendinopathy and T2D, in order to define the contribution of metabolic factors involved in the degenerative process and to discuss possible strategies for the clinical management of diabetic tendinopathy.

Are cortisone or hyaluronic acid injections a good idea if trapeziectomy is coming up?

Corticosteroid or hyaluronic acid injections to the carpometacarpal joint of the thumb joint are associated with early complications after subsequent surgery. Giladi, A. M., Rahgozar, P., Zhong, L., & Chung, K. C. (2018) Level of Evidence: 4 Follow recommendation: 👍 👍 Type of study: Prognostic Topic: 1st cmcj OA injections - Are they safe? This is a retrospective study assessing post-surgical complications in clients who underwent injection therapy vs those who did not, prior to surgery for symptomatic 1st cmcj OA. The surgical procedure was trapeziotomy with or without suspension arthroplasty or fusion. A total of 16,268 participants, took part in this study. Of these, 4,462 (27%) and 252 (1.5%) received at least one cortisone or hyaluronic acid injection respectively prior to surgery. The average time between injection and surgery was 12 months. The results showed that one cortisone injection increased the odds of post surgical infection by 20% while three cortisone injections increased the odds of post surgical infection by 70%. Hyaluronic acid injections increased the risk of post surgical infection by 110%. Unfortunately, the absolute number of participants presenting with post-surgical infections was not provided ( I also contacted the authors but they were unable provide me with the numbers). It is therefore possible that the effect reported is overestimated and potentially not clinically relevant. Clinical Take Home Message: Based on what we know today, cortisone or hyaluronic injections for 1st cmcj OA may not be the best therapeutic options if clients are scheduled for a trapeziotomy in the near future. The risk of post-surgical complications may be higher and other therapeutic interventions may be as effective and less harmful. Considering that the effectiveness of cortisone injections for 1st cmcj OA is not superior to placebo, their use is questionable. The results from this study are not surprising considering that cortisone injections have shown to increase the risk of post surgical infections in other joint (e.g. hip). URL: https://journals.sagepub.com/doi/10.1177/1753193418805391 Available through EBSCO Health Databases for PNZ members. Abstract Truven MarketScan® Databases were used to identify patients with thumb carpometacarpal arthritis who underwent surgical treatment. Pre-operative corticosteroid or hyaluronic acid injections were identified, as were post-operative complications. Multivariable regressions assessed the relationship between injections and complications. Of 16,268 patients, 4462 had steroid injections and 252 received hyaluronic acid injections. Twenty-one per cent (3381 patients) had post-operative complications. Diabetes and smoking increased the odds of complications in all models. Odds of any complication, most notably infectious complications, were increased 20% by corticosteroids (OR 1.2; 95% CI: 1.1 to 1.3). More than three injections increased the odds of a complication by 70% (OR 1.7; 95% CI: 1.3 to 2.1). Hyaluronic acid increased the odds of wound-healing complications by 110% (OR 2.1; 95% CI: 1.3 to 3.4). Corticosteroid and hyaluronic acid injections for thumb carpometacarpal arthritis increase the odds of post-operative complications.

Upper limb laceration in fresh water? Keep an eye on it

Rapidly progressive soft tissue infection of the upper extremity with aeromonas veronii biovar sobria. Lujan-Hernandez, J., Schultz, K. S., & Rothkopf, D. M. (2020) Level of Evidence: 5 Follow recommendation: 👍 Type of study: Diagnostic/Therapeutic Topic: Fresh water laceration – Infection This is a case report on Aeromonas infection following a laceration in fresh water. The patient was a 20 years old male who had been experiencing pain in the forearm following a laceration injury experienced while swimming in a fresh water reservoir. They were not immunocompromised and their injury had been attended in ED a few hours (2 hrs) prior to the worsening of symptoms. Objectively, they presented with pain in the forearm, erythema around the wound site, pain with passive wrist extension, and purulent discharge from the wounds attended two hours prior. They had no fever. X-ray investigations revealed a small air sack within the volar forearm. Blood tests revealed the presence of a high white blood cells count. The patient was immediately treated with a wide spectrum series of antibiotics and went through two washout with the wound left open for primary healing. The symptoms resolved after a few weeks of discharge and the there were no hand or upper limb impairments at 6 or 12 months. Clinical Take Home Message: Lacerations or wounds in fresh or salt water environments should be followed closely in all clients. Particular attention should be paid to those clients working/spending time in high risk environments (e.g. fisherman, aquarist). The risk of severe repercussions if an infection is not treated is high. The risk of having an additional infection after a washout is 15% higher if clients are smokers or diabetic, and 20% higher if they are both. It is therefore worth investigating whether they are smokers and helping them to quit if they are interested. X-rays and US are the primary investigations to be utilised if suspecting an infection. URL: https://www.jhandsurg.org/article/S0363-5023(20)30080-0/fulltext?s=03 Available through The Journal of Hand Surgery (American Volume) for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Aeromonas veronii, a bacterium found in freshwater, is an unusual pathogen in healthy patients. We present a case report of a rare, aggressive subtype in a young, immunocompetent individual. History of injury in an aquatic environment and culture data are key for identification of the causal agent and should dictate acute clinical management and antibiotic therapy. Coverage should include cephalosporins, quinolones, or sulfas if Aeromonas is suspected, and adjusted depending on culture and sensitivity. Early surgical exploration, incision and drainage, and appropriate antimicrobial therapy are the cornerstones for successful treatment of these aggressive, sometimes life-threatening infections.

Should we and our clients walk/cycle to work?

Protective effect on mortality of active commuting to work: A systematic review and meta-analysis. Dutheil, F., Pélangeon, S., Duclos, M., Vorilhon, P., Mermillod, M., Baker, J. S., . . . Navel, V. (2020). Level of Evidence: 1a- Follow recommendation: 👍 👍 👍 👍 Type of study: Prognostic, Preventative, Therapeutic Topic: Mortality – Active commuting This is a systematic review and meta-analysis of prospective cohort studies assessing the effect of active commuting (e.g. walking, cycling) on mortality at 5-25 years follow up. Seventeen studies were included for a total of 829,098 participants. The results from this systematic review and meta-analysis were assessed through the Newcastle-Ottawa Quality Assessment Scale, which score from 0 (low quality) to 100 (High quality). The quality of evidence was moderate to high (average of 75 out of 100). Active commuting was defined as cycling or walking. The results showed that moderate to high intensity walking reduced mortality by 15% (95%CI: 2% to 28%) and 19% (95%CI: 8% to 30%) respectively. Cycling reduced mortality independently of intensity from 14% to 28%. It is necessary to keep in mind that the studies included were not randomised (as it would be unethical to randomise participants to 5-25 of sedentary behavior) and other systemic factors may contributed to the findings (e.g. less stressful lifestyle). Clinical Take Home Message: Based on what we know today, walking briskly or at a fast pace, or cycling to work, will reduce our clients' mortality risk in the next 5 to 25 years. As hand therapist we are privileged to be able to positively affect our clients' life and a simple advice on active commuting may provide them with longer healthspan and lifespan. We may also encourage our clients to be active outside of work as a greater number of daily steps, ability to do more than 10 push-ups (in middle aged males), and a greater grip strength have all been shown to predict mortality in previous studies. URL: https://link.springer.com/article/10.1007/s40279-020-01354-0 Available through EBSCO Health Databases for PNZ members. Abstract Background: Sedentary behaviour is a major risk of mortality. However, data are contradictory regarding the effects of active commuting on mortality. Objectives: To perform a systematic review and meta-analysis on the effects of active commuting on mortality. Methods: The PubMed, Cochrane Library, Embase, and Science Direct databases were searched for studies reporting mortality data and active commuting (walking or cycling) to or from work. We computed meta-analysis stratified on type of mortality, type of commuting, and level of commuting, each with two models (based on fully adjusted estimates of risks, and on crude or less adjusted estimates). Results: 17 studies representing 829,098 workers were included. Using the fully adjusted estimates of risks, active commuting decreased all-cause mortality by 9% (95% confidence intervals 3–15%), and cardiovascular mortality by 15% (3–27%) (p < 0.001). For stratification by type of commuting, walking decreased significantly all-cause mortality by 13% (1–25%), and cycling decreased significantly both all-cause mortality by 21% (11–31%) and cardiovascular mortality by 33% (10–55%) (p < 0.001). For stratification by level of active commuting, only high level decreased all-cause mortality by 11% (3–19%) and both intermediate and high level decreased cardiovascular mortality. Low level did not decrease any type of mortality. Cancer mortality did not decrease with walking or cycling, and the level of active commuting had no effect. Low level walking did not decrease any type of mortality, intermediate level of walking decreased only all-cause mortality by 15% (2–28%), and high level of walking decreased both all-cause and cardiovascular mortality by 19% (8–30%) and by 31% (9–52%), respectively. Both low, intermediate and high intensities of cycling decreased all-cause mortality. Meta-analysis based on crude or less fully adjusted estimates retrieved similar results, with also significant reductions of cancer mortality with cycling (23%, 5–42%), high level of active commuting (14%, 4–24%), and high level of active commuting by walking (16%, 0–32%). Conclusion: Active commuting decreases mainly all-cause and cardiovascular mortality, with a dose–response relationship, especially for walking. Preventive strategies should focus on the benefits of active commuting.

Another quick and reliable way to assess upper limb strength in older clients!

The reliability and validity of novel clinical strength measures of the upper body in older adults.
Legg, H. S., Spindor, J., Dziendzielowski, R., Sharkey, S., Lanovaz, J. L., Farthing, J. P., & Arnold, C. M. (2020) Level of Evidence: 2b Follow recommendation: 👍 👍 Type of study: Diagnostic test Topic: Push off test – Validity and reliability as a strength measure This is a longitudinal study (two repeated measures over 48 hrs) assessing the validity and reliability of the push off test in comparison to hand held dynamometer strength testing of the upper limb. Seventeen healthy participants (11 females, 6 males), who were on average 71 years old, took part in the study. The push off test was completed by inverting the handle of a hand held dynamometer and positioning it on a table. Participants were then asked to put as much weight as possible through it with the elbow and shoulder in 10°-40° of flexion and extension respectively (See picture below from the article). The results from this test were repeated two times (to assess reliability after 48 hrs) and compared to strength measurements of shoulder extension, shoulder abduction, and elbow extension (assessed through a hand held dynamometer) to assess validity. The results showed that the push off test was reliable (meaning that the measurements taken at two different times were very similar) with intraclass correlation coefficient between 0.92 and 0.94 (the closer to 1 the better). The push off test was also valid (it was indeed measuring upper limb strength) with strong correlation with the other measures of upper limb strength ranging from 0.8 to 0.9 (the closer to 1 the better). On average, the push off test was 27kg, and the average weight of the participants was 77kg. This suggests that for healthy patients around the age of 70, they should be able to push off during the test 35% of their weight (27kg/77kg=0.35). Clinical Take Home Message: Based on what we know today, the push off test can be utilised to assess upper limb strength in older people. This test has been previously used to assess late stage TFCC recovery. Getting our clients to achieve 35% of their body weight during this test may be an appropriate goal for our treatment. If our clients are younger, a better test may be the maximum number of push up that they can do in a row without stopping (Reaching 11 push-up may be an appropriate goal). Open Access URL: https://journals.sagepub.com/doi/10.1177/1758998320957373 Abstract Introduction: Research investigating psychometric properties of multi-joint upper body strength assessment tools for older adults is limited. This study aimed to assess the test–retest reliability and concurrent validity of novel clinical strength measures assessing functional concentric and eccentric pushing activities compared to other more traditional upper limb strength measures. Methods: Seventeen participants (6 males and 11 females; 71 ± 10 years) were tested two days apart, performing three maximal repetitions of the novel measurements: vertical push-off test and dynamometer-controlled concentric and eccentric single-arm press. Three maximal repetitions of hand-grip dynamometry and isometric hand-held dynamometry for shoulder flexion, shoulder abduction and elbow extension were also collected. Results: For all measures, strong test–retest reliability was shown (all ICC > 0.90, p < 0.001), root-mean-squared coefficient of variation percentage: 5–13.6%; standard error of mean: 0.17–1.15 Kg; and minimal detectable change (90%): 2.1–9.9. There were good to high significant correlations between the novel and traditional strength measures (all r > 0.8, p < 0.001). Discussion: The push-off test and dynamometer-controlled concentric and eccentric single-arm press are reliable and valid strength measures feasible for testing multi-joint functional upper limb strength assessment in older adults. Higher precision error compared to traditional uni-planar measures warrants caution when completing comparative clinical assessments over time.

Thumb OA? - To splint or not to splint, that is the question

The clinical and cost effectiveness of splints for thumb base osteoarthritis: A randomized controlled clinical trial. Adams, J., Barratt, P., Rombach, I., Arden, N., Barbosa Bouças, S., Bradley, S., . . . Dziedzic, K. (2020) Level of Evidence: 1b Follow recommendation: 👍 👍 👍 👍 Type of study: Therapeutic Topic: Thumb osteoarthritis - Real vs Sham thumb splint This is a randomised, multicentre, double-blind, placebo controlled trial assessing the effectiveness of thumb splinting on pain and function in participants with thumb osteoarthritis (OA). Participants (N = 292) were included if they presented with clinical signs of 1st cmcj OA (inclusion criteria available through their supplemental data) and if they had moderate hand pain and disability. Importantly, participants were excluded if they had previously tried thumb splinting. Pain and function were assessed through the AUSCAN at baseline, 8 weeks, and 12 weeks. Participants and assessors were blinded to treatment allocation. Participants were randomised to either an 8 weeks self-management program which provided participants with a handout from Arthritis Research UK and a series of exercises to perform three times per week (n = 97), or the self-management program (advice + exercise) plus a true splint limiting 1st cmcj movement (n = 97), or the self-management treatment (advice + exercise) plus a placebo splint, which did not provide any support to the 1st cmcj (n = 102). Participants in all groups attended one hour session at baseline for the introduction to the program. They also had a follow-up at 4 weeks for 30 minutes where key concepts were reiterated. At the eight weeks mark, a final session reminded participants to continue doing their exercises three times per week and wear the splint for at least 6hrs/day (in the splinting groups). The results showed that participants in all groups improved at the 8 and 12 weeks follow up without differences between groups. The placebo and true splint increased the cost of care by at least £100 without providing any significant benefit. Clinical Take Home Message: Based on what we know today, splinting for thumb OA does not provide any additional benefit than education and simple exercises. Providing a splint is more pricey and the expense does not appear to be justified. Instead of providing a splint, it may be more useful to use those resources (money and time) for an additional session of hand therapy where we can encourage joint motion for lotion, promote joint movement for amusement, and suggest meditation for elation. If this is not enough and clients want something passive (no exercises) that has been shown to have some effect (compared to placebo), although small, look at supplements for osteoarthritis. Also remember: keep smiling, your clients' pain will decrease! Open access URL: https://doi.org/10.1093/rheumatology/keaa726 Abstract Objectives: To investigate the clinical effectiveness, efficacy and cost effectiveness of splints (orthoses) in people with symptomatic basal thumb joint OA (BTOA). Methods: A pragmatic, multicentre parallel group randomized controlled trial at 17 National Health Service (NHS) hospital departments recruited adults with symptomatic BTOA and at least moderate hand pain and dysfunction. We randomized participants (1:1:1) using a computer-based minimization system to one of three treatment groups: a therapist supported self-management programme (SSM), a therapist supported self-management programme plus a verum thumb splint (SSM+S), or a therapist supported self-management programme plus a placebo thumb splint (SSM+PS). Participants were blinded to group allocation, received 90 min therapy over 8 weeks and were followed up for 12 weeks from baseline. Australian/Canadian (AUSCAN) hand pain at 8 weeks was the primary outcome, using intention to treat analysis. We calculated costs of treatment. Results: We randomized 349 participants to SSM (n = 116), SSM+S (n = 116) or SSM+PS (n = 117) and 292 (84%) provided AUSCAN Osteoarthritis Hand Index hand pain scores at the primary end point (8 weeks). All groups improved, with no mean treatment difference between groups: SSM+S vs SSM −0.5 (95% CI: −1.4, 0.4), P = 0.255; SSM+PS vs SSM −0.1 (95% CI: −1.0, 0.8), P = 0.829; and SSM+S vs SSM+PS −0.4 (95% CI: −1.4, 0.5), P = 0.378. The average 12-week costs were: SSM £586; SSM+S £738; and SSM+PS £685. Conclusion: There was no additional benefit of adding a thumb splint to a high-quality evidence-based, supported self-management programme for thumb OA delivered by therapists.

Are we getting weaker?

Temporal trends in the handgrip strength of 2,592,714 adults from 14 countries between 1960 and 2017: A systematic analysis.
Dufner, T. J., Fitzgerald, J. S., Lang, J. J., & Tomkinson, G. R. (2020) Level of Evidence: 2a Follow recommendation: 👍 👍 Type of study: Symptoms prevalence Topic: Grip strength – Changes in the last 57 years This is a systematic review assessing the change in grip strength in the last 57 years. Ten prospective studies were included for a total of 2,592,714 participants. The age of participants ranged between 20 and 90. Data were collected from high to moderate income countries. Hand grip strength was assessed through hand held dynamometers. The results showed that no significant change in grip strength was identified before 2000. However, between 2000 and 2017, there was a trend towards a decrease in grip strength. Clinical Take Home Message: Based on what we know today, grip strength has been declining in the last 20 years. This is unfortunate because grip strength is predictor of mortality at 10 years. It may be worth reminding our clients about the importance of general body strengthening and aerobic exercise to increase lifespan and more importantly health span. URL: https://link.springer.com/article/10.1007/s40279-020-01339-z Available through EBSCO Health Databases for PNZ members. Abstract Background: Handgrip strength (HGS) is an excellent marker of functional capability and health in adults, although little is known about temporal trends in adult HGS. Objectives: The aim of this study was to systematically analyze national (country-level) temporal trends in adult HGS, and to examine the relationships between national trends in adult HGS and national trends in health-related and socioeconomic/demographic indicators. Methods: Data were obtained from a systematic search of studies reporting temporal trends in HGS for adults (aged ≥ 20 years) and by examining national fitness datasets. Trends in mean HGS were estimated at the country–sex–age group level by best-fitting sample-weighted linear/polynomial regression models, with national and sub-regional (pooled data across geographically similar countries) trends estimated by a post-stratified population-weighting procedure. Pearson’s correlations quantified relationships between national trends in adult HGS and national trends in health-related and socioeconomic/demographic indicators. Results: Data from ten studies/datasets were extracted to estimate trends in mean HGS for 2,592,714 adults from 12 high- and 2 upper-middle-income countries (from Asia, Europe and North America) between 1960 and 2017. National trends were few, mixed and generally negligible pre-2000, whereas most countries (75% or 9/12) experienced negligible-to-small declines ranging from an effect size of 0.05 to 0.27, or 0.6 to 6.3%, per decade post-2000. Sex- and age-related temporal differences were negligible. National trends in adult HGS were not significantly related to national trends in health and socioeconomic/demographic indicators. Conclusions: While trends in adult HGS are currently limited to 14 high- and upper-middle-income countries from three continents, adult HGS appears to have declined since 2000 (at least among most of the countries in this analysis), which is suggestive of corresponding declines in functional capability and health.

Do you want to help your clients quit smoking?

The role of physiotherapists in smoking cessation. Luxton, N., & Redfern, J. (2020) Level of Evidence: 5 Follow recommendation: 👍 Type of study: Preventative, Therapeutic Topic: Smoking - Help them quit This is a guideline for health professionals on how to help clients quit smoking. A simple 3 steps process is suggested: 1) Ask if they are smoking and when they stopped smoking. If they stopped smoking in the last 6 months, they may benefit from extra support to avoid a relapse. 2) Advise to stop smoking if they are smoking. The advice should be personalised and refer to the impact of smoking in relation to their personal circumstances. These could include delays in wound healing and increased risk of infections, delays in fracture healing, as well as reduce effectiveness of painkillers. 3) Help by connecting your client with a specialist telephone service like Quitline (0800 778 778), internet interventions, or the QuitNow app. A relapse within the first few weeks from quitting is very common and health professionals should kindly check in on their client's progress. Clinical Take Home Message: The figure below speaks for itself. I feel I should screen my clients more than what I do at the moment, I often stop at the "Asking". If you have time, have a look at the Ministry of Health page on "Stop smoking", it has some great resources! Open Access URL: https://www.researchgate.net/profile/Nia_Luxton2/publication/344637357_The_role_of_physiotherapists_in_smoking_cessation/links/5f861c7e92851c14bcc69473/The-role-of-physiotherapists-in-smoking-cessation.pdf No Abstract available

Can your clients do enough push-up?

Association between push-up exercise capacity and future cardiovascular events among active adult men.
Yang, J., Christophi, C. A., Farioli, A., Baur, D. M., Moffatt, S., Zollinger, T. W., & Kales, S. N. (2019) Level of Evidence: 2b Follow recommendation: 👍 👍 👍 Type of study: Prognostic Topic: Push-up - Mortality prediction This is a retrospective longitudinal cohort study assessing the ability to predict cardiovascular events (CV - e.g. heart failure, coronary hearth disease) in the next 10 years based on the number of push up that somebody can do. A total of 1,562 male firefighters participants were included at baseline. Participants were followed up for 10 years. Participants were on average 40 years old at baseline. The number of push-up was assessed at baseline. Participants had to do as many push ups as possible following the rhythm of a metronome set at 80 beats per minute. The test was interrupted if participants were unable to keep up with the beat for 3 or more consecutive repetitions. The results showed that participants completing less than 10 push-up were at much greater risk of having a CV event in the next 10 years. Participant able to do at least 11 push-up had a 64% reduction in risk at 10 years and those able to complete 40 push-up had a 96% risk reduction. Clinical Take Home Message: Based on what we know today, this push-up test is a quick reference that allows us to assess our clients CV risk at 10 years. This test is however currently applicable to males only. The results do not suggest that just training push-up will reduce your risk as this is just an adaptation to specific training. What this test does however suggest is that by getting people overall stronger, their risk of CV will reduce. This synopsis is a nice addition to the one that was previously completed on grip strength and mortality and walking and mortality. Getting our clients fitter may provide them with a longer lifespan (length of life) and healthspan (years of quality life - free from disease). Open Access URL: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2724778 Abstract Importance: Cardiovascular disease (CVD) remains the leading cause of mortality worldwide. Robust evidence indicates an association of increased physical fitness with a lower risk of CVD events and improved longevity; however, few have studied simple, low-cost measures of functional status. Objective: To evaluate the association between push-up capacity and subsequent CVD event incidence in a cohort of active adult men. Design, Setting, and Participants: Retrospective longitudinal cohort study conducted between January 1, 2000, and December 31, 2010, in 1 outpatient clinics in Indiana of male firefighters aged 18 years or older. Baseline and periodic physical examinations, including tests of push-up capacity and exercise tolerance, were performed between February 2, 2000, and November 12, 2007. Participants were stratified into 5 groups based on number of push-ups completed and were followed up for 10 years. Final statistical analyses were completed on August 11, 2018. Main Outcomes and Measures: Cardiovascular disease–related outcomes through 2010 included incident diagnoses of coronary artery disease and other major CVD events. Incidence rate ratios (IRRs) were computed, and logistic regression models were used to model the time to each outcome from baseline, adjusting for age and body mass index (BMI) (calculated as weight in kilograms divided by height in meters squared). Kaplan-Meier estimates for cumulative risk were computed for the push-up categories. Results: A total of 1562 participants underwent baseline examination, and 1104 with available push-up data were included in the final analyses. Mean (SD) age of the cohort at baseline was 39.6 (9.2) years, and mean (SD) BMI was 28.7 (4.3). During the 10-year follow up, 37 CVD-related outcomes (8601 person-years) were reported in participants with available push-up data. Significant negative associations were found between increasing push-up capacity and CVD events. Participants able to complete more than 40 push-ups were associated with a significantly lower risk of incident CVD event risk compared with those completing fewer than 10 push-ups (IRR, 0.04; 95% CI, 0.01-0.36). Conclusions and Relevance: The findings suggest that higher baseline push-up capacity is associated with a lower incidence of CVD events. Although larger studies in more diverse cohorts are needed, push-up capacity may be a simple, no-cost measure to estimate functional status.

Shall we upgrade our sensory testing for carpal tunnel syndrome?

Concurrent validity of a low-cost and time-efficient clinical sensory test battery to evaluate somatosensory dysfunction. Zhu, G. C., Böttger, K., Slater, H., Cook, C., Farrell, S. F., Hailey, L., . . . Schmid, A. B. (2019) Level of Evidence: 1b Follow recommendation: 👍 👍 👍 Type of study: Diagnostic Topic: Sensory testing - Bed side tests This is a validation study of bedside tests for clients presenting with musculoskeletal conditions including carpal tunnel syndrome (CTS). The results of a series of bedside tests, which included temperature detection (heat, cold), mechanical detection (e.g. monofilament testing), pressure pain thresholds, and others were compared to quantitative sensory testing, which is the current gold standard to assess the function of the sensory system. The most valid tests for loss of sensation were the warm/cold detection and the cotton wool touch detection. The most valid tests for sensory gain (hyperalgesia) were pressure pain thresholds on the thenar eminence with a pencil eraser or the clinicians' thumb. All the tests were compared to the contralateral limb or a non affected are of the hand to determine whether there was a loss of sensation or hyperalgesia. Clinical Take Home Message: Based on what we know today, a few bedside tests can be implemented in addition to our monofilament and manual muscle tests for carpal tunnel syndrome. These tests include cold/warm sensation assessment, which can be done through cold/warm coins, and pain pressure threshold based on compression of the thenar eminence through a clinician's thumb. These tests need to be compared to the healthy contralateral limb (if asymptomatic) to identify whether we have a loss or gain in sensation. In addition, we can perform pinprick testing, which is on indicator of small nerve fibre integrity. By monitoring our patients through these tests, we may be able to identify improvements following our intervention, which may go unnoticed if assessed through monofilament or manual muscle testing only. Open Access URL: https://onlinelibrary.wiley.com/doi/full/10.1002/ejp.1456 Abstract Background This study describes a low‐cost and time‐efficient clinical sensory test (CST) battery and evaluates its concurrent validity as a screening tool to detect somatosensory dysfunction as determined using quantitative sensory testing (QST). Method Three patient cohorts with carpal tunnel syndrome (CTS, n = 76), non‐specific neck and arm pain (NSNAP, n = 40) and lumbar radicular pain/radiculopathy (LR, n = 26) were included. The CST consisted of 13 tests, each corresponding to a QST parameter and evaluating a broad spectrum of sensory functions using thermal (coins, ice cube, hot test tube) and mechanical (cotton wool, von Frey hairs, tuning fork, toothpicks, thumb and eraser pressure) detection and pain thresholds testing both loss and gain of function. Agreement rate, statistical significance and strength of correlation (phi coefficient) between CST and QST parameters were calculated. Results Several CST parameters (cold, warm and mechanical detection thresholds as well as cold and pressure pain thresholds) were significantly correlated with QST, with a majority demonstrating >60% agreement rates and moderate to relatively strong correlations. However, agreement varied among cohorts. Gain of function parameters showed stronger agreement in the CTS and LR cohorts, whereas loss of function parameters had better agreement in the NSNAP cohort. Other CST parameters (16 mN von Frey tests, vibration detection, heat and mechanical pain thresholds, wind‐up ratio) did not significantly correlate with QST. Conclusion Some of the tests in the CST could help detect somatosensory dysfunction as determined with QST. Parts of the CST could therefore be used as a low‐cost screening tool in a clinical setting. Significance Quantitative sensory testing, albeit considered the gold standard to evaluate somatosensory dysfunction, requires expensive equipment, specialized examiner training and substantial time commitment which challenges its use in a clinical setting. Our study describes a CST as a low‐cost and time‐efficient alternative. Some of the CST tools (cold, warm, mechanical detection thresholds; pressure pain thresholds) significantly correlated with the respective QST parameters, suggesting that they may be useful in a clinical setting to detect sensory dysfunction.

5ht metacarpal neck fracture - I like to move it move it

Challenging the dogma: Severely angulated neck fractures of the fifth metacarpal must be treated surgically.
Boeckstyns, M. E. H. (2020) Level of Evidence: 3a Follow recommendation: 👍 👍 Type of study: Therapeutic Topic: 5th metacarpal neck fracture - conservative vs surgical This is a systematic review comparing the effectiveness of different conservative treatment or conservative treatments vs surgical treatment for 5th metacarpal neck fractures. Eighteen studies were included in the systematic review. The studies included were quite heterogeneous and only one author completed the review (usually we have two authors assessing research independently). Efficacy of intervention was assessed by functional outcomes (e.g. DASH), maintenance of fracture reduction, return to work, and complications.The results showed that different types of conservative treatment did not affect any of the outcomes to a significant level. Some of the studies elected to mobilise participants immediately and others utilised a clam shell around the 5th metacarpal without including the mcpj. Return to work was quicker in those participants who were allowed to mobilise early. No clear difference was identified in clients treated surgically or conservatively. Complications appeared to be higher in the surgically treated group. Clinical Take Home Message: Based on what we know today, hand therapists may choose to mobilise early clients with a 5th metacarpal neck fracture. If a form of splinting is chosen, there appears to be no difference between a clam shall including or not the mcpj, or buddy splinting. Surgical treatment seem to lead to worse outcomes. For another great study on this topic, see previous synopsis. URL: https://journals.sagepub.com/doi/abs/10.1177/1753193420968040 Available through EBSCO Health Databases for PNZ members. Abstract Cadaveric studies suggest that the acceptable deformity in fifth metacarpal neck fractures is maximally 30° palmar angulation. This systematic review verifies the validity of these threshold values. Eighteen prospective comparative studies on operative and/or conservative treatment options in adults were included. None of the studies demonstrated any correlation between the residual or initial angulation and the clinical results despite accepting more severe angular deformities. Closed reduction and immobilization without internal fixation improved the palmar angle by 5° to 9° in three studies and 29° in a fourth. Operative treatments compared with non-reducing conservative treatments showed no benefit of the surgery other than aesthetic issues. The synthesis of this review indicates that 90% of fractures of the metacarpal neck with apex angulation up to 70° can be treated successfully with a functional metacarpal brace without reduction. Disability of the Arm, Shoulder and Hand questionnaire scores <10 are uniformly reported. I modified my own practice accordingly a decade ago to treating these fractures conservatively regardless of the palmar angulation, except in patients with exceptional demands or other fracture deformities.

What can you do for elbow instability?

Rehabilitation of elbow instability. Pipicelli, J. G., & King, G. J. W. (2020) Level of Evidence: 5 Follow recommendation: 👍 Type of study: Aetiologic, Therapeutic Topic: Elbow instability - Aetiology and treatment This is a narrative review on aetiology and treatment of elbow stiffness. The aetiology of elbow instability is usually due to a trauma associated with elbow extension. The goal of treatment is to allow time for the ligaments, capsule, and potentially tendinous lesions to heal. Conservative treatment depends on the severity and type of injury. The presence of a "drop sign" on x-ray (more than 4mm distance between the humerus and ulna in 90deg of elbow flexion) suggest significant elbow laxity. If the lateral collateral ligaments (LCL) of the elbow are involved, the forearm should be maintained in pronation to increase the support provided by the common extensor tendons. If the medical collateral ligaments (MCL) have been injured, the forearm should be positioned in supination to increase support from the common flexor tendon. If both LCL and MCL are involved, the forearm should be placed in neutral. Acutely after injury, the elbow is placed in a splint which limits elbow extension to 60deg. Extension is subsequently increased by 10deg per week. Active range of movement exercises can be initiated soon after the injury and they involve flexion/extension of the elbow (within the brace limits) and pronation/supination of the forearm (in 90 deg of elbow flexion) in a supine position with 90deg of shoulder flexion. This position has been suggested to improve joint congruence and reduce instability during the exercises. Elbow x-rays should be repeated at 3 weeks post injury and if a "drop sign" is still present, surgery is indicated. Isometric biceps and triceps exercises should be included within the first 3 weeks if the "drop sign" is present and this may help in reducing instability. At six weeks post injury, isotonic (e.g. dynamic exercises holding a dumbbell) strengthening can generally be initiated. Clinical Take Home Message: Based on what we know today, elbow instability should be treated with ROM brace than can limit AROM to 60deg of extension. The additional positioning of a resting pronation/supination may be used to protect the LCL and MCL respectively. X-rays should be obtained at baseline and at 3 weeks. If a "drop sign" is present, this suggest significant instability and isometric biceps and triceps resistance exercises should be utilised in combination with AROM in supine to reduce instability and maintain range of movement. The development of stiffness following an elbow injury is common and you can take a look at a previous synopsis on the topic. URL: https://www.sciencedirect.com/science/article/abs/pii/S0749071220300871?via%3Dihub 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: https://www.jhandsurg.org/article/S0363-5023(19)31388-7/fulltext 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: https://bjsm.bmj.com/content/bjsports/52/3/167.full.pdf Abstract Objective: To investigate the efficacy and safety of dietary supplements for patients with osteoarthritis. Design: An intervention systematic review with random effects meta-analysis and meta-regression. Data sources: MEDLINE, EMBASE, Cochrane Register of Controlled Trials, Allied and Complementary Medicine and Cumulative Index to Nursing and Allied Health Literature were searched from inception to April 2017. Study eligibility criteria: Randomised controlled trials comparing oral supplements with placebo for hand, hip or knee osteoarthritis. Results: Of 20 supplements investigated in 69 eligible studies, 7 (collagen hydrolysate, passion fruit peel extract, Curcuma longa extract, Boswellia serrata extract, curcumin, pycnogenol and L-carnitine) demonstrated large (effect size >0.80) and clinically important effects for pain reduction at short term. Another six (undenatured type II collagen, avocado soybean unsaponifiables, methylsulfonylmethane, diacerein, glucosamine and chondroitin) revealed statistically significant improvements on pain, but were of unclear clinical importance. Only green-lipped mussel extract and undenatured type II collagen had clinically important effects on pain at medium term. No supplements were identified with clinically important effects on pain reduction at long term. Similar results were found for physical function. Chondroitin demonstrated statistically significant, but not clinically important structural improvement (effect size −0.30, –0.42 to −0.17). There were no differences between supplements and placebo for safety outcomes, except for diacerein. The Grading of Recommendations Assessment, Development and Evaluation suggested a wide range of quality evidence from very low to high. Conclusions: The overall analysis including all trials showed that supplements provided moderate and clinically meaningful treatment effects on pain and function in patients with hand, hip or knee osteoarthritis at short term, although the quality of evidence was very low. Some supplements with a limited number of studies and participants suggested large treatment effects, while widely used supplements such as glucosamine and chondroitin were either ineffective or showed small and arguably clinically unimportant treatment effects. Supplements had no clinically important effects on pain and function at medium-term and long-term follow-ups.

Neuropathic pain - lets throw a few crazy ideas?

Physiotherapy for people with painful peripheral neuropathies: A narrative review of its efficacy and safety. Jesson, T., Runge, N., & Schmid, A. (2020) Level of Evidence: 5 Follow recommendation: 👍 Type of study: Therapeutic Topic: Neuropathic pain - Chemotherapy induced and focal neuropathies This is a narrative review on physiotherapy interventions for chemotherapy-induced neuropathic pain and focal entrapment neuropathies (e.g. carpal tunnel, cervical radiculopathy). The results suggest that for established chemotherapy-induced neuropathic pain, an 8 weeks exercise program (participants trained at a perceived rate of exertion of "somewhat hard" to "hard" three times per week) can reduce symptoms. However, these findings were based on one study only with a small sample size. The following few sentences are only based on the preclinical science section of the paper, which I really liked. These findings suggested that aerobic training of low to moderate intensity may have "neuroprotective" and "neuroregenerative" effects independently of the form of exercise (e.g. walking, swimming, cycling). In addition, aerobic training may be more beneficial than resistance training in neuropathic pain. The perpetrated mechanism of pain relief is suggested to be due to modulation of inflammatory markers and the release of a soup of chemical that reduces nociceptive stimuli reaching the brain as well as reducing the firing thresholds of peripheral nociceptors. Clinical Take Home Message: Based on what we know today, clients presenting with chemotherapy-induced neuropathic pain, may benefit from an eight weeks program of moderate aerobic exercise performed three times per week. This is great as there is otherwise not much that we can otherwise offer to these clients. In addition, you may suggest you next client with a focal peripheral entrapment neuropathy (e.g. cervical radiculopathy, carpal tunnel syndrome) to go for a walk every day in addition to your mainstream treatment. This form of exercise would be defined as low to moderate intensity and it may help reducing symptoms. In addition, you may extend their healthspan by a few years! Why don't you give it a try? Open Access URL: https://journals.lww.com/painrpts/Fulltext/2020/10000/Physiotherapy_for_people_with_painful_peripheral.14.aspx 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 sensitisation?

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: https://www.jospt.org/doi/abs/10.2519/jospt.2020.0610 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: https://journals.sagepub.com/doi/abs/10.1177/1758998320967032 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: https://www.sciencedirect.com/science/article/pii/S0894113020302076 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.

What can you do when there is limited evidence?

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: https://chiromt.biomedcentral.com/articles/10.1186/2045-709X-21-24 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.

Fragility fractures and opportunities

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: https://www.jhandsurg.org/article/S0363-5023(20)30407-X/fulltext 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.

What can you do for radial tunnel syndrome?

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: https://www.jhandtherapy.org/article/S0894-1130(06)00060-3/fulltext 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: https://onlinelibrary.wiley.com/doi/epdf/10.1002/mus.24993 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: https://www.sciencedirect.com/science/article/abs/pii/S0306987720302437 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).

RME for extensors zone V and VI?

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: https://www.jhandtherapy.org/article/S0894-1130(18)30082-6/abstract 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.

RMF for flexor tendon repair zone I and II?

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: https://www.jhandtherapy.org/article/S0894-1130(18)30389-2/fulltext 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.

Is the brain involved in symptomatic hand OA?

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: https://www.sciencedirect.com/science/article/pii/S0049017217302809 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.

What about pronator teres syndrome?

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: https://www.sciencedirect.com/science/article/pii/S0363502320304019 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.

Should we use motor imagery post trapeziectomy?

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: https://www.sciencedirect.com/science/article/pii/S2213158219301883 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.

Resistance training for hand OA?

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: https://arthritis-research.biomedcentral.com/articles/10.1186/s13075-017-1348-3 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.

What about radial tunnel syndrome?

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: https://journals.sagepub.com/doi/10.1177/1753193420953990 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: https://www.sciencedirect.com/science/article/pii/S0894113020300235 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: https://journals.sagepub.com/doi/abs/10.1177/1753193420952010 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: https://journals.sagepub.com/doi/10.1177/1753193420936598 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: https://www.jhandtherapy.org/article/S0894-1130(18)30164-9/fulltext 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: https://bjsm.bmj.com/content/early/2020/09/08/bjsports-2019-101705 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).

What can smiles do?

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: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6476260/pdf/fpsyt-10-00242.pdf 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: https://journals.sagepub.com/doi/abs/10.1177/1758998320948538 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: https://bmjopen.bmj.com/content/bmjopen/9/9/e027507.full.pdf 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: https://journals.sagepub.com/doi/abs/10.1177/1753193420930595 You can ask the authors for the full through ResearchGate Available through EBSCO Health Databases for PNZ members. No Abstract available.

Can your clients' brain help with pain reduction?

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: https://journals.lww.com/pain/Fulltext/2020/09001/Ronald_Melzack_Award_Lecture__Putting_the_brain_to.4.aspx 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: https://www.sciencedirect.com/science/article/abs/pii/S0894113020301447 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: https://onlinelibrary.wiley.com/doi/epdf/10.1111/acps.13225 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: https://www.jshoulderelbow.org/article/S1058-2746(19)30836-5/pdf 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: https://www.jhandsurg.org/article/S0363-5023(20)30280-X/fulltext 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: https://www.jhandsurg.org/article/S0363-5023(20)30189-1/fulltext 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: https://journals.lww.com/painrpts/Fulltext/2020/08000/Entrapment_neuropathies__a_contemporary_approach.4.aspx 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.

Are exercises useful for cervical radiculopathy?

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: https://journals.lww.com/md-journal/Fulltext/2019/11080/The_effect_of_exercise_on_cervical_radiculopathy_.18.aspx