Search Results

149 results found

  • Do you want to help your clients quit smoking?

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

  • Are we getting weaker?

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

  • Can your clients do enough push-up?

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

  • Shall we upgrade our sensory testing for carpal tunnel syndrome?

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

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

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

  • What can you do for elbow instability?

    Rehabilitation of elbow instability. Pipicelli, J. G., & King, G. J. W. (2020) Level of Evidence: 5 Follow recommendation: 👍 Type of study: Aetiologic, Therapeutic Topic: Elbow instability - Aetiology and treatment This is a narrative review on aetiology and treatment of elbow stiffness. The aetiology of elbow instability is usually due to a trauma associated with elbow extension. The goal of treatment is to allow time for the ligaments, capsule, and potentially tendinous lesions to heal. Conservative treatment depends on the severity and type of injury. The presence of a "drop sign" on x-ray (more than 4mm distance between the humerus and ulna in 90deg of elbow flexion) suggest significant elbow laxity. If the lateral collateral ligaments (LCL) of the elbow are involved, the forearm should be maintained in pronation to increase the support provided by the common extensor tendons. If the medical collateral ligaments (MCL) have been injured, the forearm should be positioned in supination to increase support from the common flexor tendon. If both LCL and MCL are involved, the forearm should be placed in neutral. Acutely after injury, the elbow is placed in a splint which limits elbow extension to 60deg. Extension is subsequently increased by 10deg per week. Active range of movement exercises can be initiated soon after the injury and they involve flexion/extension of the elbow (within the brace limits) and pronation/supination of the forearm (in 90 deg of elbow flexion) in a supine position with 90deg of shoulder flexion. This position has been suggested to improve joint congruence and reduce instability during the exercises. Elbow x-rays should be repeated at 3 weeks post injury and if a "drop sign" is still present, surgery is indicated. Isometric biceps and triceps exercises should be included within the first 3 weeks if the "drop sign" is present and this may help in reducing instability. At six weeks post injury, isotonic (e.g. dynamic exercises holding a dumbbell) strengthening can generally be initiated. Clinical Take Home Message: Based on what we know today, elbow instability should be treated with ROM brace than can limit AROM to 60deg of extension. The additional positioning of a resting pronation/supination may be used to protect the LCL and MCL respectively. X-rays should be obtained at baseline and at 3 weeks. If a "drop sign" is present, this suggest significant instability and isometric biceps and triceps resistance exercises should be utilised in combination with AROM in supine to reduce instability and maintain range of movement. The development of stiffness following an elbow injury is common and you can take a look at a previous synopsis on the topic. URL: Available through Hand Clinics for HTNZ members. Available through EBSCO Health Databases for PNZ members. No Abstract available

  • Should we keep Telerehabilitation as an alternative to in person appointments?

    Telemedicine in hand and upper-extremity surgery Grandizio, L. C., Foster, B. K., & Klena, J. C. (2020) Level of Evidence: 5 Follow recommendation: 👍 Type of study: Therapeutic Topic: Telemedicine – Implementation and feasibility This narrative review provides advice on the implementation of telemedicine, and its strength/limitations, for upper limb conditions. Written consent should be gathered before any telemedicine session. This can be obtained online before the appointment. When starting a telemedicine consultation, patients should be made aware of any other people present in the room. Radiology referrals and reports are usually available online making it easier for clinicians to make decisions. Range of movement assessments of wrists and fingers appear to be feasible through video calls. One of the limitations is the assessment of sensation (monofilament testing). No evidence has assessed the feasibility of special tests and reliability of special tests through telemedicine. It appears that wound assessment is feasible with telemedicine and that complications are easily assessed. The cost of telemedicine appears to be lower compared to a traditional outpatient visit, and it seems to be as safe as in person assessments. Clinical Take Home Message: Based on what we know today, telemedicine is possible and may be utilised as an alternative to in person appointments. Limited evidence has assessed the validity and reliability of objective assessments performed remotely. For skin sensation, the Ten Test can be performed by the patient independently and may be suitable for telemedicine use. Toothpicks may be used as an alternative to assess pinprick sensation (assessing nerves' small fibre). In addition, most splints can be posted to patients without them leaving the comfort (or safety) of their own house. Companies such as @Therapy can organise the delivery, without too much effort from the clinician's point of view. URL: Available through The Journal of Hand Surgery for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Smartphones, computers, and Internet access continue to become more available to both patients and physicians. As these technologies develop with respect to health care, opportunities for telemedicine visits continue to emerge. The purpose of this review article was to analyze the current use and potential applications of telemedicine in hand and upper-extremity surgery. Although the literature pertaining to the use of telemedicine in hand surgery is limited, videoconferencing visits may provide benefits to patients. Particularly in rural and underserved regions, patients can decrease considerable travel burdens. Potential applications for this technology include remote inpatient and emergency room consultations, outpatient clinic visits, and postoperative care. There are unique considerations with respect to confidentiality and security. As with any new technology, it is important to analyze safety concerns. Future randomized, prospective investigations are necessary to define the economic implications of telemedicine programs more clearly within hand and upper-extremity surgery.

  • Are dietary supplements useful for hand osteoarthritis?

    Dietary supplements for treating osteoarthritis: a systematic review and meta-analysis. Liu, X., Machado, G. C., Eyles, J. P., Ravi, V., & Hunter, D. J. (2018) Level of Evidence: 1a Follow recommendation: 👍 👍 👍 👍 Type of study: Therapeutic Topic: Dietary supplements – Osteoarthritis This is a systematic review and meta-analysis of randomised placebo-controlled trials assessing the effectiveness of dietary supplements for osteoarthritis (hand, knee, and hip). Sixty-nine randomised placebo-controlled trials were included for a total of 11,586 participants. The results from this systematic review and meta-analysis were assessed through the GRADE approach (suggested by the Cochrane Group), which scores the evidence as "very low", "low", "moderate", or "high" quality. Efficacy of intervention was assessed through changes in pain (other outcomes were included but I decided to keep it simple). Pain was assessed through the visual analogue scale (e.g. VAS). Several supplements were utilised, however, I selected chondroitin (it had the greatest number of studies for a total of 1,822 participants). The results showed that there was "moderate" to "high" quality of evidence suggesting that chondroitin is effective in the short term (less than 3 months) in reducing pain. The authors report these findings as been non clinically meaningful because their overall effect (standardised mean difference - SMD of 0.34) was smaller than the selected threshold of SMD = 0.37. Interestingly, they reported other supplements (e.g. Boswellia serrata extract, Curcuma longa extract) showing large and clinically important findings although the number of participants was relatively small (33 to 427) and the 95% CI of the therapeutic effect was larger compared to chondroitin. Clinical Take Home Message: Based on what we know today, chondroitin and other supplements (see figure below) may relieve pain in osteoarthritis (hand included) in the short term. These supplements may be utilised as an adjunct to other treatments for hand osteoarthritis, which have previously been shown to be effective (see this synopsis). Although the reported effect sizes (SMD) are small for chondroitin, their effect size is very similar to the one reported by placebo controlled RCTs assessing the effectiveness of Nonsteroidal anti-inflammatory drugs (NSAIDs). The cost of ongoing supplementation should be considered and if clients are on a restricted budget this intervention should not be advocated. Clients should also be advised to review the appropriateness of these supplements with their GP to avoid negative interactions with prescribed drugs or allergic reactions. Open Access URL: Abstract Objective: To investigate the efficacy and safety of dietary supplements for patients with osteoarthritis. Design: An intervention systematic review with random effects meta-analysis and meta-regression. Data sources: MEDLINE, EMBASE, Cochrane Register of Controlled Trials, Allied and Complementary Medicine and Cumulative Index to Nursing and Allied Health Literature were searched from inception to April 2017. Study eligibility criteria: Randomised controlled trials comparing oral supplements with placebo for hand, hip or knee osteoarthritis. Results: Of 20 supplements investigated in 69 eligible studies, 7 (collagen hydrolysate, passion fruit peel extract, Curcuma longa extract, Boswellia serrata extract, curcumin, pycnogenol and L-carnitine) demonstrated large (effect size >0.80) and clinically important effects for pain reduction at short term. Another six (undenatured type II collagen, avocado soybean unsaponifiables, methylsulfonylmethane, diacerein, glucosamine and chondroitin) revealed statistically significant improvements on pain, but were of unclear clinical importance. Only green-lipped mussel extract and undenatured type II collagen had clinically important effects on pain at medium term. No supplements were identified with clinically important effects on pain reduction at long term. Similar results were found for physical function. Chondroitin demonstrated statistically significant, but not clinically important structural improvement (effect size −0.30, –0.42 to −0.17). There were no differences between supplements and placebo for safety outcomes, except for diacerein. The Grading of Recommendations Assessment, Development and Evaluation suggested a wide range of quality evidence from very low to high. Conclusions: The overall analysis including all trials showed that supplements provided moderate and clinically meaningful treatment effects on pain and function in patients with hand, hip or knee osteoarthritis at short term, although the quality of evidence was very low. Some supplements with a limited number of studies and participants suggested large treatment effects, while widely used supplements such as glucosamine and chondroitin were either ineffective or showed small and arguably clinically unimportant treatment effects. Supplements had no clinically important effects on pain and function at medium-term and long-term follow-ups.

  • Neuropathic pain - lets throw a few crazy ideas?

    Physiotherapy for people with painful peripheral neuropathies: A narrative review of its efficacy and safety. Jesson, T., Runge, N., & Schmid, A. (2020) Level of Evidence: 5 Follow recommendation: 👍 Type of study: Therapeutic Topic: Neuropathic pain - Chemotherapy induced and focal neuropathies This is a narrative review on physiotherapy interventions for chemotherapy-induced neuropathic pain and focal entrapment neuropathies (e.g. carpal tunnel, cervical radiculopathy). The results suggest that for established chemotherapy-induced neuropathic pain, an 8 weeks exercise program (participants trained at a perceived rate of exertion of "somewhat hard" to "hard" three times per week) can reduce symptoms. However, these findings were based on one study only with a small sample size. The following few sentences are only based on the preclinical science section of the paper, which I really liked. These findings suggested that aerobic training of low to moderate intensity may have "neuroprotective" and "neuroregenerative" effects independently of the form of exercise (e.g. walking, swimming, cycling). In addition, aerobic training may be more beneficial than resistance training in neuropathic pain. The perpetrated mechanism of pain relief is suggested to be due to modulation of inflammatory markers and the release of a soup of chemical that reduces nociceptive stimuli reaching the brain as well as reducing the firing thresholds of peripheral nociceptors. Clinical Take Home Message: Based on what we know today, clients presenting with chemotherapy-induced neuropathic pain, may benefit from an eight weeks program of moderate 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.


by Dr Nico Magni

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