175 results found
- Upper extremity malignant tumors, how can you identify them?
Diagnosis and management of primary malignant tumors in the upper extremity. MacKay, B. J., et al. (2020). Level of Evidence: 5 Follow recommendation: 👍 Type of study: Diagnostic/Therapeutic Incidence: Rare Topic: Malignant tumors - Diagnosis This is a narrative review on diagnosis and treatment of malignant tumors in the upper limb. The incidence of malignant tutor is rare although they are more likely in older people. X-ray and ultrasound imaging are reported as useful tools for diagnostic purposes. X-rays showing clearly demarcated lesions usually suggest a benign tumor while poorly defined lesions usually suggest a malignant tumor (can you find the osteosarcoma in the picture below? - look at previous synopsis for the full clinical case). Treatment of malignant tumor involves resection of the lesion, which at times requires amputation. When possible, limb salvage procedures are performed. In this cases the likelihood of local recurrence is greater (15-20%), however, survival rate is not affected. Chemotherapy is often utilised to increase survival rate. Osteosarcomas are the most common bone malignancy, which is more frequent in younger clients (20 to 30 years old), although it can occur in older subjects. These type of lesions can often result into fractures due to weakening of the affected bone. Chemotherapy is often included in the treatment of these conditions. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message: Malignant tumors of the upper limb are rare conditions that we may encounter in practice. These pathologies may be incidentally identified when performing imaging for other hand conditions. It is however possible that they are directly responsible for the clinical presentation such as in fractures due to bone weakness caused by an osteosarcoma. In other cases, clients may present to the clinic complaining of a painful palpable mass like in the case of this trapezium osteosarcoma. Either way, they will require surgery to remove the lesion and they likely undergo chemiotherapy. If our clients develop chemiotherapy induced neuropathy, they may benefit from low to moderate aerobic exercise and/or medications (e.g. gabapentin) to reduce pain. Open Access URL: https://doi.org/10.4081/or.2020.8345 Abstract Bone and soft tissue sarcomas of the upper extremity are relatively uncommon. In many cases, they are discovered incidentally during evaluation of traumatic injuries or common ailments such as rotator cuff tendonitis or tennis elbow. Thus, it is important for all orthopedic surgeons to understand the differential diagnosis, workup, and treatment for upper extremity lesions. An appreciation of the clinical and radiographic features of primary malignant lesions aids in identifying patients that need referral to an orthopedic oncologist and a multidisciplinary team.
- Answer - What is the differential diagnosis for this condition? - Wrist ganglion
Synovial hemangioma of the wrist with cystic invasion of trapezoid and capitate bones Zhao, X., Qi, C., Chen, J., Li, H., Zhang, Y., & Yu, T. Level of Evidence: 5 Follow recommendation: 👍 Type of study: Diagnostic/Therapeutic Incidence: Rare Topic: Synovial Haemangioma - Diagnosis and treatment This is the answer for the case study from last week. The patient was an 18 year old male who had been experiencing pain and swelling in the back of the wrist in the last 2 years. Objectively, there was a 3x3 cm non-pulsatile mass in the back of the wrist. Extension range of movement had a deficit of 20 degrees. X-ray was impeccable, however, computer tomography and MRI scans revealed an ill-defined soft tissue mass between scaphoid, trapezoid, and capitate. Following surgery, it was possible to make a diagnosis of wrist synovial haemangioma. Synovial haemangiomas are rare benign tumours which usually affect children or young adults. Only 300 cases have been reported in the literature, most of which occurred in the knee. Symptoms vary and intermittent pain may be present or absent. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message: Hand therapists should refer young children or teenagers for x-rays and ultrasound when there is evidence of an irregularly shaped, soft mass which appears to or is reported to have grown over time. The likelihood of identifying a synovial haemangioma is extremely rare, however, this work up would help differentiating among different conditions including ganglion cyst, rheumatoid arthritis, haematomas associated with haemophilia, infections or other rare forms of cancer. URL: https://www.jhandsurg.org/article/S0363-5023(18)30316-2/fulltext Available through The Journal of Hand Surgery (American Volume) for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Synovial hemangiomas (SHs) are rare lesions of the joints or tendon sheaths that are difficult to diagnose. We present the case of an 18-year-old man with an SH in the wrist joint. Physical examination revealed a slightly tender, ill-defined, nonpulsatile soft mass, 3 cm × 3 cm in size on the dorsal aspect of the left wrist. Computed tomography showed an irregular, ill-defined, soft tissue mass in the expanded joint space, which was formed by the scaphoid, trapezoid, and capitate bones. Magnetic resonance imaging showed the typical features of SH and also revealed cavitary erosion of the scaphoid, trapezoid, and capitate bones. An open arthrotomy was performed via a dorsal approach, and the mass was excised. The histological examination findings were consistent with the diagnosis of SH.
- Dissociative segmental instability (DISI and VISI) of the wrist: How do you diagnose it?
Defining DISI and VISI. S. Braun, N., R. A. Berger and S. W. Wolfe (2021). Level of Evidence: 5 Follow recommendation: 👍 Type of study: Diagnostic/Therapeutic Topic: Dissociative segmental instability DISI and VISI - Diagnosis This is an expert opinion on radiographic diagnosis of dissociative carpal instability (dorsal intercalated segmental instability - DISI; volar intercalated segmental instability - VISI). These conditions are commonly referred to as scapholunate instability (DISI) or lunotriquetral instability (VISI). In contrast to non dissociative instability (rare condition), which is a lesion of of extrinsic ligaments of the wrist, DISI and VISI are due to lesions of intrinsic ligaments (scapholunate and lunotriquetral respectively). In DISI and VISI the "intercalated segment" simply refers to the lunate and triquetrum unit, which forms a "layer" (intercalated segment) within the wrist. In this article, the authors suggest to make a diagnosis of DISI or VISI only based on the position of the lunate in relation to the radius. More specifically, a dorsal orientation of the lunate in relation to the radius greater than 15° suggests a DISI. In contrast a palmar orientation of the lunate in relation to the radius greater than 20° suggests a VISI. One important assumption is that the x-ray projection needs to be a pure lateral (3rd metacarpal in line with radius) without ulnar or radial deviation. These suggestions are based on the authors' review of the original article describing DISI and VISI in which the lunate positioning was the most indicative of the presence of these conditions. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message: Based on what we know today, it may be possible to diagnose a DISI or VISI by looking at the position of the lunate in relation to the radius. Be aware that this method requires a pure lateral x-ray view without radial and ulnar deviation. Considering that pure lateral views are rarely seen in clinical practice, this method may not always be reliable (even if the 3rd metacarpal is in line with the radius, it would be hard to determine whether there was any radial/ulnar deviation when the x-ray was taken). If we suspect a DISI due to scapholunate instability, the "clenched pencil" view may provide useful information. If you are interested in additional information on wrist instability, have a look at this previous synopsis on non dissociative wrist instability (extrinsic ligaments diagnosis and treatment). URL: https://doi.org/10.1177/1753193421989933 Available through EBSCO Health Databases for PNZ members. Abstract not available
- Identify your frail clients! You may be able to extend their health span!
Frailty and physical fitness in elderly people: A systematic review and meta-analysis. Navarrete-Villanueva, D., et al. (2021). Level of Evidence: 1a- Follow recommendation: 👍 👍 👍 👍 Type of study: Prognostic, Preventative, Therapeutic Topic: Frailty – How to identify it This is a systematic review of cross-sectional and randomised controlled studies assessing the relationship between physical fitness and frailty (function and biological aging). Twenty studies were included in the meta-analysis for a total of 13,527 participants (average age range: 71-83 years old). The overall quality of evidence was assessed through the COSMOS-E approach ("low", "moderate", "high"), which is a tool to assess risk of bias in observational studies. There was moderate to low quality evidence showing that walking speed (6 minutes walking test - 6MWT), lower limb strength, and grip strength were able to differentiate between frail and robust participants. All robust participants had more than 20kg of grip strength, while 60% of the frail participants had less than 20kg of grip strength. Clinical Take Home Message: Based on what we know today, several measures of physical fitness can discriminate between frail vs robust clients. The most useful measure appears to be walking speed that can be measured through the 6MWT (you can find the age and sex normative values in this paper - see picture below - this was my favourite paper when I was assessing clients through the 6MWT at the DHB). If you do not have the resources or you do not feel comfortable performing a 6MWT, hand grip strength is still a useful tool to screen your clients and we perform this test routinely. It appears that grip strength below 20kg may indicate that the client is fragile. The reason why I am interested in identifying fragile clients is that they are more likely to have an upper limb or lower limb fracture in the future. We may may be able to reduce the likelihood of these injuries by inviting them to take at least 8,000 steps/day. Thus, a greater number of daily steps has been shown to reduce mortality in previous studies. In addition, general resistance training may increase grip strength and overall strength, which is another predictor of mortality. URL: https://doi.org/10.1007/s40279-020-01361-1 Available through EBSCO Health Databases for PNZ members. Abstract Background: Frailty is an age-related condition that implies a vulnerability status affecting quality of life and independence of the elderly. Physical fitness is closely related to frailty, as some of its components are used for the detection of this condition. Objectives: This systematic review and meta-analysis was conducted to investigate the magnitude of the associations between frailty and different physical fitness components and to analyse if several health-related factors can act as mediators in the relationship between physical fitness and frailty. Methods: A systematic search was conducted of PubMed, SPORTDiscus, and Web of Science, covering the period from the respective start date of each database to March 2020, published in English, Spanish or Portuguese. Two investigators evaluated 1649 studies against the inclusion criteria (cohort and cross-sectional studies in humans aged ≥ 60 years that measured physical fitness with validated tests and frailty according to the Fried Frailty Phenotype or the Rockwood Frailty Index). The quality assessment tool for observational cross-sectional studies was used to assess the quality of the studies. Results: Twenty studies including 13,527 participants met the inclusion criteria. A significant relationship was found between frailty and each physical fitness component. Usual walking speed was the physical fitness variable most strongly associated with frailty status, followed by aerobic capacity, maximum walking speed, lower body strength and grip strength. Potential mediators such as age, sex, body mass index or institutionalization status did not account for the heterogeneity between studies following a meta-regression. Conclusions: Taken together, these findings suggest a clear association between physical fitness components and frailty syndrome in elderly people, with usual walking speed being the most strongly associated fitness test. These results may help to design useful strategies, to attenuate or prevent frailty in elders.
- Are neurodynamic exercises effective for clients with hand osteoarthritis?
Effects of neurodynamic mobilizations on pain hypersensitivity in patients with hand osteoarthritis compared to robotic assisted mobilization: A randomized controlled trial. Pedersini, P., et al. (2021). Level of Evidence: 1b Follow recommendation: 👍 👍 👍 👍 Type of study: Therapeutic Topic: Hand OA - neurodynamic Vs passive movement treatments This is a randomised placebo controlled trial assessing the effectiveness of neurodynamic treatment vs passive mobilisation on pain in people with hand osteoarthritis (OA). A total of 72 participants were included in the study. To be included, participants had to present with symptoms of hand OA in the dominant hand and a kellgren-lawrence score of 3-4 on x-ray of the dominant hand (no other specific criteria were utilised for the diagnosis). Participants were excluded if they presented with depression or anxiety, other hand conditions of the hand (e.g. carpal tunnel syndrome), if they presented with neurological symptom or conditions. Participant were randomised to neurodynamic treatment (n = 36) or robotic fingers mobilisation (placebo) (n = 36). Neurodynamic treatment included gliders of the median, radial, and ulnar nerves for three sets of 3 minutes each with one minute rest in between each set. The robotic group underwent passive fingers flexion/extension through a robotic device. Both groups received 12 sessions of thirty minutes (3 per week) over the course of 4 weeks. Both groups were given hand exercises. Efficacy of intervention was assessed through pain intensity (VAS) at one baseline, at the end of treatment (4 weeks), and at three months. The results showed that both groups improved on average by 1 point out of 10 in each group. Some of the pain measurements (e.g. pain in the last 24 hrs) we're statistically significant different between groups (favoring neurodynamic treatment), however, the difference was not clinically relevant (less than 1 point out of 10). As for all experimental studies, it is possible that improvements in pain were simply due to participants being aware of being part of an intervention study rather than treatment itself (Hawthorne effect). It is also possible that the limited effectiveness of this intervention is due the low levels of pain the participants to reported, causing a floor effect. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message: Based on what we know today, neurodynamic interventions are no more effective than passive finger mobilisation in reducing pain in people with symptomatic hand OA. We may therefore encourage joint motion for lotion, promote joint movement for amusement, and suggest meditation for elation. If this is not enough and clients want something passive (no exercises) that has been shown to have some effect (compared to placebo), although small, look at supplements for osteoarthritis. In addition, preliminary evidence also showed that clients with hand OA present with sensorimotor changes and illusory resizing of the hand may help reducing symptoms. Clients with hand OA are also at greater risk of cardiovascular disease. They would therefore benefit from advice on aerobic and strength training exercise. Also remember: keep smiling, your clients' pain will decrease! If you are interested in knowing what does not appear to be more effective than placebo in clients with hand OA, here is the list: acupuncture, cortisone injections for thumb OA, joint protection programs, resistance training interventions, and splinting for thumb OA. URL: https://onlinelibrary.wiley.com/doi/10.1002/acr.24103 Available through EBSCO Health Databases for PNZ members. Abstract OBJECTIVE: To evaluate the effectiveness of the neurodynamic mobilization techniques compared with passive robotic physiologic movement in patients with hand osteoarthritis (OA). METHODS: We conducted a randomized controlled trial. A total of 72 patients (mean ± SD age 71 ± 11 years) with dominant symptomatic hand OA were randomized in 2 groups, and both received 12 treatment sessions over 4 weeks. The experimental group received neurodynamic mobilization of the median, radial, and ulnar nerves, and the control group received robotic-assisted passive movement treatment. Both groups also participated in a program of hand stability exercises. Outcome measures included pain intensity, pressure pain thresholds (PPTs), and strength measurements. Group-by-time effects were compared using mixed-model analyses of variance. RESULTS: After the intervention, the experimental group had statistically significant, higher PPTs than the control group at the thumb carpometacarpal joint by 0.7 kg/cm(2) (95% confidence interval [95% CI] 0.6, 0.8), the median nerve by 0.7 kg/cm(2) (95% CI 0.6, 0.7), and the radial nerve by 0.5 kg/cm(2) (95% CI 0.3, 0.6); however, the difference was not statistically significant at 3 months postintervention. Although mean values in the experimental group were higher than in the control group at all PPT sites at both assessments, these differences were not statistically significant. The experimental group experienced a statistically significant reduction in pain immediately postintervention, but this was not present at the 3-month follow-up. There were no statistically significant differences in pinch or grip strength between groups. CONCLUSION: We found that neurodynamic mobilizations decreased hypersensitivity in patients with hand OA immediately after the intervention; however, differences were no longer present at 3 months. The results suggest that these techniques may have some limited value in the short term but do not have lasting effects.
- Neuropathic pain post hand burns, who is going to develop it?
Chronic neuropathic pain following hand burns: Etiology, treatment, and long-term outcomes. Klifto, K. M., P. S. Yesantharao, A. L. Dellon, C. S. Hultman and S. D. Lifchez (2021). Level of Evidence: 4 Follow recommendation: 👍 👍 Type of study: Prognostic Topic: Neuropathic pain in burns - Variables influencing its development This is a retrospective study assessing risk factors for the development of neuropathic pain and lack of response to pharmacological treatment following hand and upper limb burns. A total of 914 participants were included in the study. A series of risk factors including demographic characteristics and burn type were included in the statistical analysis. Burning pain was defined as long lasting pain for at least six months following the injury (no standardised tool such as the "Douleur Neuropathique en 4 Questions" - DN4 was utilised to make the diagnosis of neuropathic pain). Lack of response to medical treatment was defined as no change in pain after 3 consecutive months of pharmacological treatment (e.g. gabapentin/pregabalin/opioids). The results showed that 6% of the sample developed neuropathic pain by six months. In addition, 50% of this group of people with neuropathic pain did not respond to pharmaclogical treatment. The burn's severity appeared to be a risk factor for both the development of neuropathic pain and lack of response to medications, with greater areas of total body surface burns being associated with worse outcomes. In addition, a history of substance/alcohol abuse or smoking, increased the odds of developing neuropathic pain. Burning pain was also found to be a pain descriptor that reduced the likelihood of pharmacological response at the six months point. It is important to remember that this was a retrospective study with a small proportion of patients presenting with neuropathic pain (n = 55). It is therefore possible that other variables, not accounted for in the analysis are responsible for the findings reported. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message: Based on what we know today, the development of persistent "neuropathic" pain following burns injuries may be related to their severity. In addition, a history of smoking and substance abuse, appear to increase the likelihood of its development (for advice on how to help your clients quit smoking, see this synopsis). Clients with post burn neuropathic pain may benefit from gabapentin treatment (see this synopsis on gabapentin effectiveness), however, if they describe burning pain, their likelihood of benefiting from pharmacological treatment may be reduced. URL: https://www.jhandsurg.org/article/S0363-5023(20)30396-8/fulltext Available through the Journal of Hand Surgery (American volume) for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract PURPOSE: Chronic neuropathic pain (CNP) after burn injury to the hand/upper extremity is relatively common, but not well described in the literature. This study characterizes patients with CNP after hand/upper extremity burns to help guide risk stratification and treatment strategies. We hypothesize that multiple risk factors contribute to the development of CNP and refractory responses to treatment. METHODS: Patients older than 15 years admitted to the burn center after hand/upper extremity burns, from January 1, 2014, through January 1, 2019, were included. Chronic neuropathic pain was defined as self-described pain for longer than 6 months after burn injury, not including pain due to preexisting illness/medications. Two analyses were undertaken: (1) determining risk factors for developing CNP among patients with hand/upper extremity burns, and (2) determining risk factors for developing refractory pain (ie, nonresponsive to treatment) among hand/upper extremity burn patients with CNP. RESULTS: Of the 914 patients who met the inclusion criteria, 55 (6%) developed CNP after hand/upper extremity burns. Twenty-nine of these patients (53%) had refractory CNP. Significant risk factors for developing CNP after hand/upper extremity burns included history of substance abuse and tobacco use. Among CNP patients, significant risk factors for developing refractory pain included symptoms of burning sensations. In all CNP patients, gabapentin and ascorbic acid were associated with significant decreases in pain scores on follow-up. CONCLUSIONS: Substance abuse and tobacco use may contribute to the development of CNP after hand/upper extremity burns. Those who developed refractory CNP were more likely to use the pain descriptor, burning sensations. Pharmacological pain management with gabapentin or pregabalin and ascorbic acid may provide the most relief of CNP symptoms.
- What is the differential diagnosis for this condition? - Wrist ganglion
Level of Evidence: 5 Follow recommendation: 👍 Type of study: Diagnostic/Therapeutic Incidence: Rare Have a think about this case study. Leave a diagnostic comment if you like. I will publish the diagnosis and treatment reported by the paper next week. The patient was an 18 years old male who had been experiencing pain and swelling in the back of the wrist in the last 2 years. Objectively, there was a 3x3 cm non-pulsatile mass in the back of the wrist. Extension range of movement had a deficit of 20 degrees. X-ray was impeccable, however, computer tomography and MRI scans revealed an ill-defined soft tissue mass between scaphoid, trapezoid, and capitate (see picture below). What is it?
- Are corticosteroid injections 💉 a good idea for tennis elbow?
Revisiting the continuum model of tendon pathology: What is its merit in clinical practice and research? Cook, J. L., E. Rio, C. R. Purdam and S. I. Docking (2016). Level of Evidence: 1b Follow recommendation: 👍 👍 👍 👍 Type of study: Therapeutic Topic: Lateral epicondylalgia - cortisone injections This is a randomised placebo controlled trial assessing the effectiveness of cortisone injections for lateral epicondylalgia (LE). A total of 165 participants were included in the study. To be included, participants had to been experiencing symptoms for at least six weeks. Pain had to be unilateral, intensity of at least 3/10, had to be located at the lateral epicondyle of the elbow and participants had to present with at least two of the following: pain on gripping, resisted middle finger or wrist extension, palpation at the lateral epicondyle, or stretching of the wrist extensors. Participants were excluded if they presented with neck or arm symptoms, if they presented with neurological symptoms, had receive cortisone injections or physiotherapy in the previous six and three months respectively for LE. Participant were randomised to cortisone injection alone (n = 43), saline injection alone (placebo) (n = 41), physiotherapy with cortisone injection (n = 40), or physiotherapy with saline injection (n = 41). Physiotherapy included 8 sessions of thirty minutes each over the course of 8 weeks. These included manual therapy (mobilisation with movement - see this previous synopsis on their effectiveness) or graded progression of concentric and eccentric exercises for the wrist extensors. Efficacy of intervention was assessed by self reported complete recovery and recurrence at one year. The results showed that 93% of participants had recovered in the placebo group compared to 83% in the corticosteroid injection group. In addition, participants undergoing corticosteroid injections had a significant improvement at 4-8 weeks followed by a greater recurrence of symptoms at one year (55% recurrence) compared to the placebo injection group (20%). Both these results were statistically significant. There was no difference between the physiotherapy vs no physiotherapy groups at one year follow up. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message: Based on what we know today, corticosteroid injections for lateral epicondylalgia hinder our clients' recovery and increase the recurrence rate in the long term (one year). It may be better to provide our clients with a course of physiotherapy, which does not hinder recovery and may facilitate return to function in clients with severe pain. Graded resistance training may be appropriate in the disrepair/degenerative phase of LE (sub acute/chronic - see previous synopsis on tendinopathy grading and treatment). During the acute phase, tendon unloading may be more appropriate through rest or the use of a counterforce splint (see previous synopses on splint effectiveness and biomechanics). Open access URL: https://jamanetwork.com/journals/jama/fullarticle/1568252 Abstract Importance: Corticosteroid injection and physiotherapy, common treatments for lateral epicondylalgia, are frequently combined in clinical practice. However, evidence on their combined efficacy is lacking. Objective: To investigate the effectiveness of corticosteroid injection, multimodal physiotherapy, or both in patients with unilateral lateral epicondylalgia. Design, setting, and patients: A 2 × 2 factorial, randomized, injection-blinded, placebo-controlled trial was conducted at a single university research center and 16 primary care settings in Brisbane, Australia. A total of 165 patients aged 18 years or older with unilateral lateral epicondylalgia of longer than 6 weeks' duration were enrolled between July 2008 and May 2010; 1-year follow-up was completed in May 2011. Interventions: Corticosteroid injection (n = 43), placebo injection (n = 41), corticosteroid injection plus physiotherapy (n = 40), or placebo injection plus physiotherapy (n = 41). Main outcome measures: The 2 primary outcomes were 1-year global rating of change scores for complete recovery or much improvement and 1-year recurrence (defined as complete recovery or much improvement at 4 or 8 weeks, but not later) analyzed on an intention-to-treat basis (P < .01). Secondary outcomes included complete recovery or much improvement at 4 and 26 weeks. Results: Corticosteroid injection resulted in lower complete recovery or much improvement at 1 year vs placebo injection (83% vs 96%, respectively; relative risk [RR], 0.86 [99% CI, 0.75-0.99]; P = .01) and greater 1-year recurrence (54% vs 12%; RR, 0.23 [99% CI, 0.10-0.51]; P < .001). The physiotherapy and no physiotherapy groups did not differ on 1-year ratings of complete recovery or much improvement (91% vs 88%, respectively; RR, 1.04 [99% CI, 0.90-1.19]; P = .56) or recurrence (29% vs 38%; RR, 1.31 [99% CI, 0.73-2.35]; P = .25). Similar patterns were found at 26 weeks, with lower complete recovery or much improvement after corticosteroid injection vs placebo injection (55% vs 85%, respectively; RR, 0.79 [99% CI, 0.62-0.99]; P < .001) and no difference between the physiotherapy and no physiotherapy groups (71% vs 69%, respectively; RR, 1.22 [99% CI, 0.97-1.53]; P = .84). At 4 weeks, there was a significant interaction between corticosteroid injection and physiotherapy (P = .01), whereby patients receiving the placebo injection plus physiotherapy had greater complete recovery or much improvement vs no physiotherapy (39% vs 10%, respectively; RR, 4.00 [99% CI, 1.07-15.00]; P = .004). However, there was no difference between patients receiving the corticosteroid injection plus physiotherapy vs corticosteroid alone (68% vs 71%, respectively; RR, 0.95 [99% CI, 0.65-1.38]; P = .57). Conclusion and relevance: Among patients with chronic unilateral lateral epicondylalgia, the use of corticosteroid injection vs placebo injection resulted in worse clinical outcomes after 1 year, and physiotherapy did not result in any significant differences.
- How can you stage and treat tennis elbow?
Revisiting the continuum model of tendon pathology: What is its merit in clinical practice and research? Cook, J. L., E. Rio, C. R. Purdam and S. I. Docking (2016). Level of Evidence: 5 Follow recommendation: 👍 Type of study: Aetiology, Therapeutic Topic: Lateral epicondylalgia - Staging and treatment This is a narrative review on tendinopathy staging and their respective treatments. Although this narrative review is 5 years old, I decided to include it in HandyEvidence as it provides useful information for tendinopathy treatment. Staging of tendinopathies has been suggested as a useful way to treat these conditions and these include: reactive, disrepair, and degenerative stages (see picture below). In terms of treatment, during the reactive stage (acute phase), unloading of the tendon is advised. During disrepair and degenerative stages, graded tendon loading has been suggested as an effective approach. The difference between the disrepair and degenerative stage is simply related to the structural reversibility (disrepair) vs non-reversibility (degenerative) of the tendon structure. From a clinical point of view, the distinction between disrepair and degenerative stage may be less relevant as both stages can be treated with good outcomes. One last comment was made in relation to treatments aiming at improving tendon cell proliferation through injections (e.g. PRP injections). In particular, the rationale for the use of these interventions was questioned due to an already excessive proliferation of cells across all the three tendinopathy stages (reactive, disrepair, and degenerative). Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message: Based on what we know today, tendinopathies can be classified and treated according to their pathological stage. Treatments can vary from unloading (during the reactive stage) to graded loading (during the disrepair or degenerative stage). These concepts can be applied to several conditions such as lateral epicondylalgia (i.e. tennis elbow) or De Quervain tenosynovitis. If we consider for example lateral epicondylalgia, for an acute reactive tendinopathy, we may provide our clients with a counterforce brace, which appears to reduce loading at the common extender tendon during daily activities and improve pain-free grip strength. Once the acute reactive stage has settled and the irritability has improved (reduction in pain intensity and duration of symptoms after mechanical loading), graded loading may be appropriate. During this stage, graded resistance training has been suggested as an effective approach without one form of loading (e.g. eccentric, concentric, isometric) deemed superior to another. It is however possible that for lateral epicondylalgia, eccentric resistance training may provide better analgesia. Open access URL: https://bjsm.bmj.com/content/50/19/1187 Abstract The pathogenesis of tendinopathy and the primary biological change in the tendon that precipitates pathology have generated several pathoaetiological models in the literature. The continuum model of tendon pathology, proposed in 2009, synthesised clinical and laboratory-based research to guide treatment choices for the clinical presentations of tendinopathy. While the continuum has been cited extensively in the literature, its clinical utility has yet to be fully elucidated. The continuum model proposed a model for staging tendinopathy based on the changes and distribution of disorganisation within the tendon. However, classifying tendinopathy based on structure in what is primarily a pain condition has been challenged. The interplay between structure, pain and function is not yet fully understood, which has partly contributed to the complex clinical picture of tendinopathy. Here we revisit and assess the merit of the continuum model in the context of new evidence. We (1) summarise new evidence in tendinopathy research in the context of the continuum, (2) discuss tendon pain and the relevance of a model based on structure and (3) describe relevant clinical elements (pain, function and structure) to begin to build a better understanding of the condition. Our goal is that the continuum model may help guide targeted treatments and improved patient outcomes.
- Why research does not work in clinical practice and clinical practice does not work in research?
Are you translating research into clinical practice? What to think about when it does not seem to be working. Murphy, M. C., W. Gibson, G. L. Moseley and E. K. Rio (2021). Level of Evidence: 5 Follow recommendation: 👍 Type of study: Therapeutic Topic: Research implementation This article presents a potential few reasons of why evidence based practice does not always work in clinical practice: 1) Participants included in a study may be different from the ones that you are seeing. Furthermore, the diagnostic criteria for participants inclusion may be different from the ones that you use. 2) Are your clients presenting with comorbidities that were utilised as exclusion criteria in research? If this is the case, the effectiveness of treatment in clinical practice may not be as significant. 3) Is there any placebo effect that has not been controlled for in research or in clinical practice? Consider potential confounding variables that could contribute to the findings - Take home message - "believe nothing, question everything, trust nobody" 4) Case series are not answering questions. They provide a story about clients' presentation, treatment, and outcomes. Causality cannot be ascertained. Same goes for clinical experience. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message: Evidence guided practice is not easy to implement and at times can cause frustration. I still think that we should try to implement research while keeping an eye on the characteristics of the research sample (participants may be different from the clients we see in clinical practice). It is good practice to keep questioning what we read and hear, not out of disrespect, but to get closer to what actually works. I reviewed another article that you may find useful to take decisions when there is a lack of research available. URL: http://bjsm.bmj.com/content/early/2021/01/11/bjsports-2020-102369.abstract Available through EBSCO Health Databases for PNZ members. Abstract The value of clinical research can be lost in translation and implementation. One often overlooked issue is whether clinicians can determine if their patient is similar to research participants and, ipso facto, whether the clinician treating that patient will have the same effects as what was reported in a research study. We present five questions and clinical tips for clinicians.