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127 results found

  • 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 to hard exercise performed three times per week. This is great as there is otherwise not much that we can otherwise offer to these clients. In addition, you may suggest you next client with a focal peripheral entrapment neuropathy (e.g. cervical radiculopathy, carpal tunnel syndrome) to go for a walk every day in addition to your mainstream treatment. This form of exercise would be defined as low to moderate intensity and it may help reducing symptoms. In addition, you may extend their healthspan by a few years! Why don't you give it a try? Open Access URL: Abstract Pharmacological treatment for peripheral neuropathic pain has only modest effects and is often limited by serious adverse responses. Alternative treatment approaches including physiotherapy management have thus gained interest in the management of people with peripheral neuropathies. This narrative review summarises the current literature on the efficacy and safety of physiotherapy to reduce pain and disability in people with radicular pain and chemotherapy-induced peripheral neuropathy, 2 common peripheral neuropathies. For chemotherapy-induced peripheral neuropathy, the current evidence based on 8 randomised controlled trials suggests that exercise may reduce symptoms in patients with established neuropathy, but there is a lack of evidence for its preventative effect in patients who do not yet have symptoms. For radicular pain, most of the 21 trials investigated interventions targeted at improving motor control or reducing neural mechanosensitivity. The results were equivocal, with some indication that neural tissue management may show some benefits in reducing pain. Adverse events to physiotherapy seemed rare; however, these were not consistently reported across all studies. Although it is encouraging to see that the evidence base for physiotherapy in the treatment of peripheral neuropathic pain is growing steadily, the mixed quality of available studies currently prevents firm treatment recommendations. Based on promising preliminary data, suggestions are made on potential directions to move the field forward.

  • Central 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: Available through EBSCO Health Databases for PNZ members. Abstract Central sensitization is a physiological mechanism associated with enhanced sensitivity and pain responses. At present, central sensitization cannot be determined directly in humans, but certain signs and symptoms may be suggestive of it. Although central sensitization has received increasing attention in the clinical literature, there is a risk that certain distinctions are being lost. This paper summarizes current knowledge of the physiology of central sensitization and its possible manifestations in patients, in order to inform a debate about the relevance of central sensitization for physical therapists. It poses 6 challenges associated with the application of central sensitization concepts in clinical practice and makes suggestions for assessment, treatment, and use of terminology. Physical therapists are asked to be mindful of central sensitization and consider potential top-down as well as bottom-up drivers, in the context of a person-centered biopsychosocial approach.

  • Early mobilisation for distal radius fracture ORIF? - Great work Julie!

    A systematic review of how daily activities and exercises are recommended following volar plating of distal radius fractures and the efficacy and safety of early versus late mobilisation. Collis, J., Signal, N., Mayland, E., & Clair, V. W.-S. (2020) Level of Evidence: 1a- Follow recommendation: 👍 👍 👍 👍 Type of study: Therapeutic Topic: Radius fracture – Early mobilisation This is a systematic review assessing the effectiveness and safety of early mobilisation following a distal radius fracture treated surgically with a volar plate. Eight studies, for a total of 519 participants (72% females) were included in the review. Of these, 5 were RCTs and 3 were retrospective studies. All the studies were assessed through the Downs and Black Quality Index, which is appropriate for both experimental and non-experimental studies. Each paper was scored as "excellent", "good", "fair", or "poor". Efficacy of intervention was assessed through improvements in pain (e.g. NRS, VAS), function (e.g. DASH, PRWE), and wrist and forearm range of movement (extension/flexion/supination/pronation) in the short-term (6-8/52), midterm (10-12/52), and long-term (24-26/52). Safety was assessed by counting the number of adverse events. Early mobilisation (1-8 days from surgery) was compared to a delayed mobilisation (2-6 weeks post surgery). On average, the studies included were of "good" quality. The results showed that early mobilisation provided a small possibly non clinically relevant differences (see Supplementary file 2) in pain compared to delayed mobilisation. However, function improved to a small/large extent in the early mobilisation group and these differences were clinically relevant. Early mobilisation also led to small/moderate improvement in range of movement, possibly not clinically relevant (I only looked at supination as we know that for this measurement we require at least an 8deg change for it to be clinically meaningful - Reid et al. 2020) when compared to delayed mobilisation. There were no differences in the number of adverse events between the early vs delayed mobilisation. Clinical Take Home Message: Based on what we know today, early mobilisation (within 2 weeks from surgery) of distal radius fractures ORIF may provide better functional outcomes compared to delayed mobilisation (more than 2 weeks post surgery). A recent randomised controlled study showed that there was no difference in terms of pain, function, and AROM if mobilisation was started on the day after surgery vs at 2 weeks (see this synopsis). It is therefore possible that delaying mobilisation by a max of two weeks is acceptable. However, immobilisation beyond the two weeks mark may lead to sub-optimal functional recovery off our clients. URL: Available through the Hand Therapy for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Introduction: Following surgical repair of distal radius fractures, mobilisation timeframes and interventions vary. Early mobilisation (<2 weeks postoperatively) usually includes range of motion exercises and may include recommendations to perform daily activities. The review investigated (i) how early mobilisation was recommended, particularly with respect to wrist use during daily activities and (ii) the efficacy and safety of early versus delayed mobilisation (< or ≥2 weeks). Methods: The study protocol was registered on PROSPERO (CRD42019136490). Five databases were searched for studies that compared early and delayed mobilisation in adults with volar plating of distal radius fractures. The Downs and Black Quality Index and the Template for Intervention Description and Replication checklist were used for quality evaluation. Effect sizes were calculated for range of movement, function and pain at 6–8, 10–12 and 26 weeks. A descriptive analysis of outcomes and mobilisation regimes was conducted. Results: Eight studies with a mean Quality Index score of 20 out of 28 (SD=5.6) were included. Performing daily activities was commonly recommended as part of early mobilisation. Commencing mobilisation prior to two weeks resulted in greater range of movement, function and less pain at up to eight weeks postoperatively than delaying mobilisation until two weeks or later. Discussion: Performance of daily activities was used alongside exercise to promote recovery but without clearly specifying the type, duration or intensity of activities. In combination with exercise, early daily activity was safe and beneficial. Performing daily activities may have discrete advantages. Hand therapists are challenged to incorporate activity-approaches into early mobilisation regimes.

  • Is mirror therapy or mental practice useful post distal radius fracture?

    Does Mental Practice or Mirror Therapy help prevent functional loss after distal radius fracture? A randomized controlled trial. Korbus, H., & Schott, N. (2020) Level of Evidence: 2b Follow recommendation: 👍 👍 👍 Type of study: Therapeutic Topic: Radius fracture - motor imagery or mirror therapy vs relaxation This is a randomised single-blind controlled trial assessing the effectiveness of mental practice (Motor Imagery - MI) and mirror therapy (MT) in participants with distal radius fracture. Participants (N = 36) were included if they had undergone a closed fracture reduction or an open reduction internal fixation surgery. Participants were excluded if they had bilateral fracture or had any neurological condition. Effectiveness of each intervention was assessed through several functional measures (I choose to consider the QuickDASH as it is commonly used in clinical practice). Outcomes were measured at baseline and 12 weeks from injury. All participants trained with one therapist 5 times per week for 45 minutes during the first three weeks, and 3 times per week in the last three weeks of training (total of 6 weeks). Treatment allocation was randomised. The assessor was blinded to treatment allocation. Participants were provided with either MI (n = 8), MT (n = 12), or relaxation techniques (control group, n = 9). Participants in the MI mentally rehearsed several wrist movements of the affected wrist, which included wrist flexion, extension, radial and ulnar deviation, pronation, supination, and gripping. The MT group watched the reflection of the healthy hand performing the movements indicated above. The relaxation group was provided with the same duration intervention and relaxation interventions were provided. The results showed that the two intervention groups improved to a larger extent (MI = 43 points improvement; MT = 42 points improvement) compared to the control group (CG = 39 points improvement) in the QuickDASH, however, these differences were not clinically significant (the difference between groups was less than 15 points). Clinical Take Home Message: Based on what we know today, motor imagery or mirror therapy alone do not appear to improve QuickDASH outcomes at 3 months compared to a control group receiving relaxation interventions. A more appropriate approach is to follow a graded motor imagery approach, which has previously been shown to reduce pain and improve function at 8 weeks post distal radius fracture (see synopsis here). This paper followed a precise series of steps (based on neurophysiological concepts) which included a left/right hand discrimination task (3 weeks), explicit motor imagery (3 weeks), and mirror therapy (2 weeks). This approach may be particularly appropriate in patients presenting with high levels of pain within the first week of injury (these patients are also more likely to develop CRPS). Open Access URL: Available through the Journal of Hand Therapy for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Background Therapy results after distal radius fractures (DRF) especially with older patients are often suboptimal. One possible approach for counteracting the problems are motor-cognitive training interventions such as Mental Practice (MP) or Mirror Therapy (MT), which may be applied in early rehabilitation without stressing the injured wrist. Purpose The aim of the study is to investigate the effects of MP and MT on wrist function after DRF. The pilot study should furthermore provide information about the feasibility and efficacy of these methods. Study Design The study was designed as a randomized, single-blinded controlled trial. Methods Thirty-one women were assigned either to one of the two experimental groups (MP, MT) or to a control group (relaxation intervention). The participants completed a training for six weeks, administered at their homes. Measurements were taken at four times (weeks 0, 3, 6 and 12) to document the progression in subjective function (PRWE, QuickDASH) and objective constraints of the wrist (ROM, grip strength) as well as in health-related quality of life (EQ-5D). Results The results indicated that both experimental groups showed higher improvements across the intervention period compared to the control group; e.g. PRWE: MT 74.0%, MP 66.2%, CG 56.9%. While improvements in grip strength were higher for the MP group, the MT group performed better in all other measures. However, time by group interactions approached significance at best; e.g. ROM: p = .076; ηp2 = .141. Conclusion The superiority of MP as well as MT supports the simulation theory. Motor-cognitive intervention programmes are feasible and promising therapy supplements, which may be applied in early rehabilitation to counteract the consequences of immobilization without stressing the injured wrist.

  • 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: 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 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: 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.

  • Why are median nerve anatomical variations important in carpal tunnel syndrome?

    Median and ulnar nerve anastomoses in the upper limb: A meta-analysis. Roy, J., Henry, B. M., PĘkala, P. A., Vikse, J., Saganiak, K., Walocha, J. A., & Tomaszewski, K. A. (2016) Level of Evidence: 1a Follow recommendation: 👍 👍 👍 👍 Type of study: Anatomical Topic: Median nerve variations - Relevance in carpal tunnel syndrome This is a systematic review and meta-analysis assessing the prevalence of median nerve variations in the forearm and hand. There were a total of 58 studies assessing 10,562 upper limbs (from cadavers and nerve conduction studies in living participants). All the studies were pooled in a prevalence meta-analysis. The three most common median nerve anatomical variations in the forearm were described and their prevalence reported (I excluded the Marinacci anastomosis as it is rare 0.7% of the population). These included Martin‐Gruber anastomosis (MGA), Riche‐Cannieu anastomosis (RCA), and Berrettini anastomosis (BA). The Martin‐Gruber anastomosis (MGA) is described as a communicating branch from the median nerve to ulnar nerve in the forearm. Through this anastomosis, the median nerve innervates the thenar eminence bypassing the carpal tunnel. The pooled prevalence of this anastomosis (which is mainly motor) has been shown to be 20% (95%CI: 16% to 23%). The Riche‐Cannieu anastomosis (RCA) is defined as a communicating branch from the ulnar nerve to the median nerve in the palm of the hand. Through this anastomosis the ulnar nerve innervates the thenar eminence muscles. The pooled prevalence of this anastomosis (which is motor) has been shown to be 60% (95%CI: 30% to 80%). Last but not least, Berrettini anastomosis (BA) is a sensory connection between median and ulnar nerve in the palm that innervate the middle and ring finger (digital nerves). Through this anastomosis, both the ulnar and median nerve provide sensory innervation to the ulnar aspect of the middle finger and radial aspect of the ring finger. The pooled prevalence of this anastomosis (which is sensory) has been shown to be 60% (95%CI: 40% to 80%). Clinical Take Home Message: Based on what we know today, at least three median nerve variations in the forearm and hand are common or normal in our clients. These variations may explain why a limited number of people presenting with severe carpal tunnel compression (significant numbness with or without pain) do not present with motor impairments in the thenar muscles (MGA and RCA anastomosis). In addition, sensory changes involving the middle and ring finger in clients with carpal tunnel syndrome may depend on the presence of communicating branches between median and ulnar nerve (BA anastomosis). This last anastomosis may explain why there is significant variance in the textbooks description of sensory changes associated with carpal tunnel syndrome (involvement or not of ring finger). URL: You can ask the authors for the full text through Research Gate. Available through EBSCO Health Databases for PNZ members. Abstract Introduction: The most frequently described anomalous neural connections between the median and ulnar nerves in the upper limb are: Martin‐Gruber anastomosis (MGA), Marinacci anastomosis (MA), Riche‐Cannieu anastomosis (RCA), and Berrettini anastomosis (BA). The reported prevalence rates and characteristics of these anastomoses vary significantly between studies. Methods: A search of electronic databases was performed to identify all eligible articles. Anatomical data regarding the anastomoses were pooled into a meta‐analysis using MetaXL 2.0. Results: A total of 58 (n = 10,562 upper limbs) articles were included in the meta‐analysis. The pooled prevalences were: MGA, 19.5% (95% confidence interval [CI], 16.2%–23.1%); MA, 0.7% (95% CI, 0.1%–1.7%); RCA, 55.5% (95% CI, 30.6%–79.1%); and BA, 60.9% (95% CI, 36.9%–82.6%). The results also showed that MGA was more commonly found unilaterally (66.8%), on the right side (15.7%), following an oblique course (84.8%), and originating from the anterior interosseous nerve with a prevalence of 57.6%. Conclusions: As anastomoses between the median and ulnar nerves occur commonly, detailed anatomical knowledge is essential for accurate interpretation of electrophysiological findings and reducing the risk of iatrogenic injuries during surgical procedures.

  • What 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: 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.

  • What logical fallacies should we be aware of when relying on experience and published opinions?

    Why are assumptions passed off as established knowledge? Weisman, A., Quintner, J., Galbraith, M., & Masharawi, Y. (2020) Level of Evidence: 5 Follow recommendation: 👍 Type of study: Therapeutic Topic: Logical fallacies This article presents a discussion on logical fallacies in medicine. These fallacies apply to both expert opinions and published articles introducing new hypotheses rather than established theories. The following recommendations were made: - Avoid assuming that the achieved outcomes are the result of what preceded it (fallacy - post hoc ergo propter hoc). For example, you have given your clients "stabilisation" exercises for symptomatic 1st cmcj OA and their pain improved. You therefore assume that the issue is 1st cmcj instability when in fact pain may have improved with general thumb exercises. - Avoid assuming that incidental findings associated with a certain pathology are the cause of that pathology (e.g. repetitive strain injury, central sensitisation). For example, one of your clients is an athlete doing high exercise volume and you assume that the symptoms that they developed are due to repetitive strain injury. High loads and repetitive activities may not be the only cause of their pain and other factors such as poor sleep, fatigue, and mental health may be large contributing factors to their pain (see this synopsis). Clinical Take Home Message: This paper suggests keeping an open mind and challenging the concepts guiding our treatment approach, as well as the opinion of experts in the field. By assuming that we are wrong and logically test the potential alternatives (e.g. diagnostic, therapeutic) we can increase the likelihood of doing what is best for our patients. Challenging one's own practice is difficult and it has always been throughout history. URL: Possibly available through EBSCO Health Databases for PNZ members. Abstract “What can be asserted without evidence can also be dismissed without evidence.” (Christopher Hitchens, 2007).

  • 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: 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.


by Dr Nico Magni

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