175 results found
- Cupping for clients with persistent pain?
Cupping for patients with chronic pain: A systematic review and meta-analysis. Cramer, H., et al. (2020) Level of Evidence: 1a- Follow recommendation: 👍 👍 👍 👍 Type of study: Therapeutic Topic: Cupping effectiveness - Chronic pain This is a systematic review and meta-analysis assessing the effectiveness of cupping for persistent pain. Eighteen RCTs were included in the systematic review, for a total of 1,172 participants. All the studies were included in the meta-analysis and they were assessed through the Risk of Bias criteria recommended by the Cochrane Review Group. The overall strength of evidence was not assessed in the paper but I decided to assess it through the GRADE approach ("low", "very low", "moderate", "high"), which has also been suggested by the Cochrane group for systematic reviews. The effectiveness of cupping was applied to several different musculoskeletal conditions (e.g. lower back pain, osteoarthritis). Efficacy of intervention was assessed through improvements in function or pain intensity (i.e. NRS, VAS). Cupping was compared to no intervention, sham cupping, or an active treatment. In this synopsis I just focused on the results of sham cupping (very low negative pressure or no negative pressure), which provide a reasonable placebo comparison. The treatment duration varied between 3 to 4 weeks, with biweekly treatment frequency. There is low quality evidence suggesting that sham cupping is as effective as cupping (both groups improved), without any statistically significant difference between the two interventions for both pain intensity and disability. Clinical Take Home Message: Based on what we know today, cupping is no more effective than placebo in clients with persistent pain. If you have applied it in clinical practice with significant success, it may be due to the contextual effect of your treatment session rather than any specific mechanism associated with cupping. Similar results have been shown when comparing cortisone injections or acupuncture for thumb OA, PRP or MWMs for tennis elbow to placebo interventions. They all work in clinical practice but the results is probably due to the placebo effect. URL: http://www.sciencedirect.com/science/article/pii/S1526590020300031 Available through EBSCO Health Databases for PNZ members. Abstract There is a growing interest in nonpharmacological pain treatment options such as cupping. This meta-analysis aimed to assess the effectiveness and safety of cupping in chronic pain. PubMed, Cochrane Library, and Scopus were searched through November 2018 for randomized controlled trials on effects of cupping on pain intensity and disability in patients with chronic pain. Risk of bias was assessed using the Cochrane risk of bias tool. Of the 18 included trials (n =1,172), most were limited by clinical heterogeneity and risk of bias. Meta-analyses found large short-term effects of cupping on pain intensity compared to no treatment (standardized mean difference [SMD] = −1.03; 95% confidence interval [CI] = −1.41, −.65), but no significant effects compared to sham cupping (SDM = −.27; 95% CI = −.58, .05) or other active treatment (SMD = −.24; 95% CI = −.57, .09). For disability, there were medium-sized short-term effects of cupping compared to no treatment (SMD = −.66; 95% CI = −.99, −.34), and compared to other active treatments (SMD = −.52; 95% CI = −1.03, −.0028), but not compared to sham cupping (SMD = −.26; 95% CI = −.57,.05). Adverse events were more frequent among patients treated with cupping compared to no treatment; differences compared to sham cupping or other active treatment were not statistically significant. Cupping might be a treatment option for chronic pain, but the evidence is still limited by the clinical heterogeneity and risk of bias. Perspective: This article presents the results of a meta-analysis aimed to assess the effectiveness and safety of cupping with chronic pain. The results suggest that cupping might be a treatment option; however, the evidence is still limited due to methodical limitations of the included trials. High-quality trials seem warranted.
- A2 pulley injury, what to do?
A potential classification schema and management approach for individuals with A2 flexor pulley strain. Cooper, C. and P. LaStayo (2020). Level of Evidence: 5 Follow recommendation: 👍 Type of study: Therapeutic Topic: A2 pulley injury - Assessment and treatment This is an expert opinion article on assessment and treatment of A2 pulley injury. These injuries are very common in rock climbers and they do occur most often while crimping (see picture below). The classification suggested in this article (i.e. severe, moderate, and mild - see table below) is based on assessment of pain, active range of movement, resisted tests, and palpation. According to this classification system, severe pulley injury should be immobilised except for gentle active range of movement exercises and climbing training should be significantly modified. A mild injury should be managed with progressive resistance training and hang board training (avoiding crimping). With a moderate injury, the routine would be similar to a mild injury, however, the intensity would be lower. Additionally, H tape and pulley orthoses may be utilised to control symptoms in adjunct to climbing volume modification. Clinical Take Home Message: Based on what we know today, we may decide to classify A2 pulley injuries according to the assessment procedures described in this article. The only issue with a symptomatic driven assessment is that several factors can increase or decrease pain intensity independently of tissue damage (see the overuse injury and fracture TOP synopses). Triangulation of clinical presentation with investigations such as ultrasound and x-ray may help in the differential diagnosis (e.g. stress fractures) and may provide a more objective assessment of tissue damage (if any). If you are interested in other climbing injuries, see this previous synopsis. URL: https://doi.org/10.1016/j.jht.2019.01.002 Available through the Journal of Hand Therapy for HTNZ members. Available through EBSCO Health Databases for PNZ members. No abstract available
- Answer for - What is the differential diagnosis for this case? - Little finger pain
Extensive Tumoral Calcinosis of the Hand. Gonzalez, M., M. Rettig and O. Ayalon (2020) Level of Evidence: 5 Follow recommendation: 👍 Type of study: Diagnostic Topic: What is the differential diagnosis? – Case study This is the answer for the case study from last week. The patient was a 34 years old female with a six months history of atraumatic painless mass on the volar aspect of the right little finger (especially at the middle phalanx). The mass had grown significantly in the last few weeks and it was now associated with pain and blanching of the skin. Objectively, they were unable to bend the right little finger. The patient reported a history of hypothiroidisn and Sjogren's syndrome. The x-ray image is shown below. The results suggested the presence of a tumoral calcinosis on the volar aspect of the right little finger. Surgery was performed to remove the mass which had a chalk like consistency. Six weeks post surgery, the pain had resolved and the range of movement had significantly improved. URL: https://doi.org/10.1016/j.jhsa.2020.10.030 Available through The Journal of Hand Surgery (American Volume) for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Tumoral calcinosis is a rare and benign subtype of calcinosis cutis, a group of disorders involving soft tissue calcium deposition. Only 250 cases have been described since 1898; hand involvement is exceedingly rare. We report a case of extensive calcinosis within the flexor sheath of the little finger. Presentation included a painful mass over the volar aspect of the little finger, restricted digit motion, and skin compromise at the site of the mass. Surgical debulking was performed resulting in restoration of finger function.
- Lots of our patients present with osteopenia and sarcopenia - what can we you do?
Non-pharmacological interventions in osteosarcopenia: A systematic review. Atlihan, R., B. Kirk and G. Duque (2020). Level of Evidence: 1a- Follow recommendation: 👍 👍 👍 👍 Type of study: Prognostic, Preventative, Therapeutic Topic: Musculoskeletal and bone health – Resistance training This is a systematic review of randomised controlled studies assessing the effect of resistance training on muscle and bone health in older participants with sarcopenia (loss of muscle mass) and osteopenia/osteoporosis (loss of bone density). Two studies were included for a total of 106 participants (average age range: 64-79 years old). The overall strength of evidence was assessed through the GRADE approach ("low", "very low", "moderate", "high"), which has also been suggested by the Cochrane group for systematic reviews. Participants took part in upper and lower limb resistance training 2-3/week for 3 to 18 months. There was moderate quality evidence that resistance training improved muscle strength and muscle mass. Low quality evidence suggests that by the 6 months mark, bony density improved. Clinical Take Home Message: Based on what we know today, resistance training improves our clients' muscle strength and mass in the short and long term. Furthermore, if performed for at least 6 months, resistance training has the potential to maintain if not improve bone density in our older clients. As hand therapist we are privileged to see several older patients after a distal radius fracture. These clients are often fragile and would definitely benefit from resistance training. We may also invite our clients to take at least 8,000 steps/day as a greater number of daily steps has been shown to reduce mortality in previous studies. In addition, general resistance training may increase grip strength, which is another predictor of mortality. URL: https://link.springer.com/article/10.1007/s12603-020-1537-7 Available through EBSCO Health Databases for PNZ members. Abstract BACKGROUND: Osteosarcopenia is a geriatric syndrome defined by the concomitant presence of osteopenia/osteoporosis (loss of bone mineral density (BMD)) and sarcopenia (loss of muscle mass and/or function), which increases the risk of falls, fractures, and premature mortality. OBJECTIVE: To examine the efficacy of non-pharmacological (exercise and/or nutritional) interventions on musculoskeletal measures and outcomes in osteosarcopenic adults by reviewing findings from randomized controlled trials (RCTs). METHODS: This review was registered at PROSPERO (registration number: CRD42020179292) and conducted in accordance with the PRISMA guidelines. Electronic databases were searched for RCTs assessing the effect of at least one non-pharmacological intervention (any form of exercise and/or supplementation with protein, vitamin D, calcium or creatine) on any musculoskeletal measure/outcome of interest (BMD, bone strength/turnover, muscle mass and strength, physical performance, falls/fractures) in adults with osteosarcopenia as defined by any proposed criteria. RESULTS: Two RCTs (of n=106 older osteosarcopenic adults (≥65 years)) assessing the effects of progressive resistance training (RT) (via resistance bands or machines; 2-3 times/week; ~60 minutes in duration) were eligible for inclusion. The two RCTs demonstrated moderate quality evidence that RT increases muscle mass, strength, and quality, with changes in strength and quality occurring before muscle mass (12 vs 28 weeks). There was low quality evidence that RT increases lumbar spine BMD and maintains total hip BMD when performed for 12 and 18 months, respectively, and moderate quality evidence that RT has no effect on markers of bone turnover or physical performance. No major adverse effects were recorded in either of the RCTs. There were no eligible RCTs examining the impact of nutritional interventions. CONCLUSION: Chronic RT is safe and effective at potentiating gains in muscle mass, strength, and quality, and increasing or maintaining BMD in older osteosarcopenic adults. No RCT has examined the effects of protein, vitamin D, calcium, or creatine against a control/placebo in this high-risk population.
- What is the differential diagnosis for this case? - Little finger pain
Level of Evidence: 5 Follow recommendation: 👍 Type of study: Diagnostic Topic: What is the differential diagnosis? – Case study Have a think about this case study. Leave a diagnostic comment if you like. I will publish the diagnosis and treatment reported by the paper next week. The patient was a 34 years old female with a six months history of atraumatic painless mass on the volar aspect of the right little finger (especially at the middle phalanx). The mass had grown significantly in the last few weeks and it was now associated with pain and blanching of the skin. Objectively, they were unable to bend the right little finger. The patient reported a history of hypothyroidism and Sjogren's syndrome. The x-ray image is shown below. What is it?
- Active vs passive interventions for lateral epicondylalgia - What's best?
Exercise interventions in lateral elbow tendinopathy have better outcomes than passive interventions, but the effects are small: A systematic review and meta-analysis of 2123 subjects in 30 trials. Karanasios, S., et al. (2020). Level of Evidence: 1a- Follow recommendation: 👍 👍 👍 👍 Type of study: Therapeutic Topic: Lateral epicondylalgia - Eccentric resistance training This is a systematic review and meta-analysis of randomised controlled trials assessing the effectiveness of active vs passive interventions for lateral epicondylalgia. Thirty randomised controlled trials were included for a total of 2,123 participants (21 studies were included in the meta-analysis). The results from this systematic review and meta-analysis were assessed through the GRADE approach (suggested by the Cochrane Group), which scores the evidence as "very low", "low", "moderate", or "high" quality. Efficacy of intervention was assessed through changes in pain, pain-free grip strength (PFG), and elbow disability. Pain was assessed through the visual analogue scale (VAS) or the numerical rating scale (NRS), pain-free grip strength (PFG), and elbow disability through the Patient-Rated Tennis Elbow Evaluation (PRTEE) and the Disability of the Arm, Shoulder, and Hand (DASH) questionnaire. Follow-up times ranged between very short term (less than 2 months), short term (2-3 months), mid-term (3-12 months), and long term (more than 12 months). The results showed that there was low to very low quality evidence suggesting that exercise provided clinically and statistically significant greater improvements in PFG compared to cortisone injections at all time points. No difference was noted between exercise or wait and see. Eccentric exercises were not superior to concentric exercises. Clinical Take Home Message: Based on what we know today, exercises are more effective than cortisone injections in both the short and long term for clients with lateral epicondylalgia. This is not surprising considering the results from previous trials showing that people undergoing cortisone injection for lateral epicondylalgia are twice as likely to present with a recurrence at one year compared to somebody receiving a saline (placebo) injection. Any form of resistance exercise appears to be useful and eccentric exercises do not appear to be superior to concentric exercises, although they may provide with greater analgesia once the acute reactive tendinopathy has subsided. If clients are happy to wait and see, they may improve without the need of any intervention. URL: http://bjsm.bmj.com/content/early/2020/11/04/bjsports-2020-102525.abstract Available through EBSCO Health Databases for PNZ members. Abstract Objective: To evaluate the effectiveness of exercise compared with other conservative interventions in the management of lateral elbow tendinopathy (LET) on pain and function.Design Systematic review and meta-analysis. Methods: We used the Cochrane risk-of-bias tool 2 for randomised controlled trials (RCTs) to assess risk of bias and the Grading of Recommendations Assessment, Development and Evaluation methodology to grade the certainty of evidence. Self-perceived improvement, pain intensity, pain-free grip strength (PFGS) and elbow disability were used as primary outcome measures.Eligibility criteria RCTs assessing the effectiveness of exercise alone or as an additive intervention compared with passive interventions, wait-and-see or injections in patients with LET. Results: 30 RCTs (2123 participants, 5 comparator interventions) were identified. Exercise outperformed (low certainty) corticosteroid injections in all outcomes at all time points except short-term pain reduction. Clinically significant differences were found in PFGS at short-term (mean difference (MD): 12.15, (95% CI) 1.69 to 22.6), mid-term (MD: 22.45, 95% CI 3.63 to 41.3) and long-term follow-up (MD: 18, 95% CI 11.17 to 24.84). Statistically significant differences (very low certainty) for exercise compared with wait-and-see were found only in self-perceived improvement at short-term, pain reduction and elbow disability at short-term and long-term follow-up. Substantial heterogeneity in descriptions of equipment, load, duration and frequency of exercise programmes were evident. Conclusions: Low and very low certainty evidence suggests exercise is effective compared with passive interventions with or without invasive treatment in LET, but the effect is small. PROSPERO registration number CRD42018082703.
- Entrapment neuropathies? Could the thoracic outlet contribute to symptoms?
Nerve compression syndromes of the shoulder. Patetta, M. J., E. Naami, B. M. Sullivan and M. H. Gonzalez (2020) Level of Evidence: 5 Follow recommendation: 👍 Type of study: Diagnostic, Therapeutic Topic: Thoracic outlet - Symptoms and treatment This is a narrative review on entrapment neuropathies of the shoulder. I selected to cover the neurogenic thoracic outlet syndrome as this is the one that may present with symptoms in forearm and hand. In addition, neurogenic thoracic outlet syndrome constitute 90% of all the thoracic outlet syndromes. In term of diagnostic tests, there is not one single test that present with high specificity (ability to confirm the diagnosis) or sensitivity (ability to exclude the diagnosis). Nerve conduction studies rarely show any objective impairments, making the diagnosis even more challenging. Conservative treatment is always advocated before any surgical approach. The positive news is that if surgery is required, 56% to 89% of clients report improvements in their symptoms following the surgical procedure. Clinical Take Home Message: Based on what we know today, thoracic outlet syndrome may be in part responsible for vague upper limb symptoms reported by clients. Unfortunately, there is not one single test that is useful to confirm or exclude the diagnosis. It may be useful to utilised tests such as the arm squeeze test, Spurling's, Cx distraction, and neurodynamic tests to confirm or exclude the presence of a cervical radiculopathy. Dermatomal patterns are not always consistent in presence of a cervical radiculopathy and the presence of vague symptoms alone does not increase the likelihood of a thoracic outlet syndrome. In clients with a potential thoracic outlet syndrome it is worth remembering that psychological factors (e.g. anxiety, depression, pain catastrophising) have been shown to mediate pain/recovery. Light aerobic exercise (e.g. walking, cycling) may be a helpful intervention to reduce symptoms in clients with neurogenic thoracic outlet syndrome. URL: https://doi.org/10.1016/j.jhsa.2020.09.022 Available through EBSCO Health Databases for PNZ members. Abstract Nerve compression syndromes of the shoulder contribute to pain, paresthesia, and weakness of the upper extremity. This review examines the recent literature regarding thoracic outlet syndrome, suprascapular neuropathy, long thoracic nerve palsy, and quadrilateral space syndrome. Overlapping features are common among shoulder pathologies, and thus, key anatomical features, pathophysiology, clinical manifestations, diagnostic techniques, and treatments are highlighted for all aforementioned conditions.
- Neural mobilisation for nerve-related arm and neck pain?
Effect of neural mobilization on nerve-related neck and arm pain: A randomized controlled trial. Basson, C. A., A. Stewart, W. Mudzi and E. Musenge (2020). Level of Evidence: 1b Follow recommendation: 👍 👍 👍 👍 Type of study: Therapeutic Topic: Nerve pain - Usual care vs usual care plus neural mobilisation This is a randomised, single-blind, controlled trial assessing the effectiveness of nerve gliding on pain, function, and quality of life in participants with nerve-related neck and arm pain. Participants (N = 78) were included if they presented with clinical signs of neck pain associated with nerve-related symptoms (participants had to had positive neurodynamic tests and allodynia on peripheral nerve palpation). Pain was assessed through the Numerical Rating Scale (NRS), function through the Patient Specific Functional Scale (PSFS), and quality of life through the EuroQol-5. Participants were randomised (2:1) to either usual care (n = 25), or usual care plus neural mobilisation (n = 53). The usual care included cervical and thoracic mobilisation, exercises and the advice to keep active. The experimental group received the usual care plus mobilisation of the tissues surrounding the peripheral nerve involved (e.g. pronator teres for median nerve). On average, participants were treated over 4 sessions. Outcomes were measured at baseline, 3, 6 weeks, 6 months, and one year. The results showed that participants in all groups improved by one year. There were no differences between groups in function and quality of life. Pain was significantly better at 6 months for the usual care plus neural mobilisation, however, this difference was not clinically relevant (see picture below). Clinical Take Home Message: Based on what we know today, the addition of neural mobilisation to an evidence based program for people with nerve-related cervical and arm pain does not provide better results. In contrast, neural mobilisation may be helpful for clients presenting with isolated carpal tunnel syndrome. If you are interested, you can also reduce the likelihood of clients undergoing carpal tunnel surgery by adding a night splint and education to your intervention. Finally, have a look at what is the most effective and safe nerve gliding approach for carpal tunnel syndrome. URL: https://www.utpjournals.press/doi/abs/10.3138/ptc-2018-0056 Available through EBSCO Health Databases for PNZ members. Abstract Purpose: Neural mobilization (NM) is often used to treat nerve-related conditions, and its use is reasonable with nerve-related neck and arm pain (NNAP). The aims of this study were to establish the effect of NM on the pain, function, and quality of life (QOL) of patients with NNAP and to establish whether high catastrophizing and neuropathic pain influence treatment outcomes. Method: A randomized controlled trial compared a usual-care (UC; n = 26) group, who received cervical and thoracic mobilization, exercises, and advice, with an intervention (UCNM; n = 60) group, who received the same treatment but with the addition of NM. Soft tissue mobilization along the tract of the nerve was used as the NM technique. The primary outcomes were pain intensity (rated on the Numerical Pain Rating Scale), function (Patient-Specific Functional Scale), and QOL (EuroQol-5D) at 3 weeks, 6 weeks, 6 months, and 12 months. The secondary outcomes were the presence of neuropathic pain (using the Neuropathic Diagnostic Questionnaire) and catastrophizing (Pain Catastrophising Scale). Results: Both groups improved in terms of pain, function, and QOL over the 12-month period (p < 0.05). No between-groups differences were found at 12 months, but the UCNM group had significantly less pain at 6 months (p = 0.03). Patients who still presented with neuropathic pain (p < 0.001) and high pain catastrophizing (p = 0.02) at 6- and 12-mo follow-ups had more pain. Conclusions: Both groups had similar improvements in function and QOL at 12-month follow-up. The UCNM group had significantly less pain at 6-month follow-up and a lower mean pain rating at 12-month follow-up, although the difference between groups was not significant. Neuropathic pain is common among this population and, where it persisted, patients had more pain and functional limitations at 12-mo follow-up.
- Lumbrical tear, what to do?
Lumbrical muscle tear: Clinical presentation, imaging findings and outcome. Lutter, C., A. Schweizer, V. Schöffl, F. Römer and T. Bayer (2018). Level of Evidence: 4 Follow recommendation: 👍 👍 Type of study: Diagnostic, Therapeutic Topic: Lumbricals' tear - Imaging and treatment This is case series on lumbrical muscle tear's diagnosis and treatment. A total of 60 clients with a positive lumbrical stress test (see figure below) were included in the study. This type of injury occurs when a finger (middle/ring finger) is forcefully extended while the other fingers are actively flexed. Rock climbers are at greatest risk for lumbricals muscles tears. The diagnostic recommendation is to request an US investigation to determine the lesion grade: Grade I (microtear - non visible on US), a Grade II or III (both visible on US). In case of a grade I tear, gentle intrinsic minus pain-free stretching is performed for 4-6 weeks followed by graded lumbricals loading. For grade II, buddy taping is recommended for a max of 8 weeks, followed by a similar treatment as per grade I. For a grade III, immobilisation with an ulnar gutter including MF, RF, and LF to the proximal phalanx is recommended for 2 weeks. This is followed by the same treatment as per grade II lesion. Clinical Take Home Message: Based on what we know today, the lumbrical stress test is a quick way to assess the involvement of the 3rd or 4th lumbricals. An US has been indicated as the most appropriate way to confirm a clinical diagnosis, especially if there is a grade II or III, which is visible through this investigation. Considering the potential role of lumbrical in finger proprioception (see previous synopsis), the inclusion of dexterity exercises may be appropriate in this subgroup of clients. URL: https://doi.org/10.1177/1753193418765716 Available through EBSCO Health Databases for PNZ members. Abstract The incidence of lumbrical muscle tear is increasing due to the popularity of climbing sport. We reviewed data from 60 consecutive patients with a positive lumbrical stress test, including clinical examination, ultrasound and clinical outcomes in all patients, and magnetic resonance imaging in 12 patients. Fifty-seven patients were climbers. Lumbrical muscle tears were graded according to the severity of clinical and imaging findings as Grade I-III injuries. Eighteen patients had Grade I injuries (microtrauma), 32 had Grade II injuries (muscle fibre disruption) and 10 had Grade III injuries (musculotendinous disruption). The treatment consisted of adapted functional therapy. All patients completely recovered and were able to return to climbing. The healing period in Grade III injuries was significantly longer than in the patients with Grade I or II injuries (p < 0.001). We recommend evaluation of specific clinical and imaging findings to grade the injuries and to determine suitable therapy.
- Answer for - What is the differential diagnosis for this case? - Wrist pain
Osteosarcoma of the Trapezium. Ferrando, E., Navarro, J., Rojas, R., Mata, D., & Silvestre, A. (2020) Level of Evidence: 5 Follow recommendation: 👍 Type of study: Diagnostic Topic: What is the differential diagnosis? – Case study This is the answer for the last week case study. The patient was a 51 years old female with a three years history of painless palpable firm mass on the dorsal and radial aspect of the wrist. Subjectively, they reported swelling and pain in the last two months. The patient reported a history of hypertension. The x-ray that you see below revealed a calcification on the radial aspect of the wrist. An MRI was completed, which revealed a soft tissue mass. Surgery was performed to remove the mass and histological studies revealed that it was a low grade osteosarcoma. URL: https://www.jhandsurg.org/action/showPdf?pii=S0363-5023%2820%2930607-9 Available through EBSCO Health Databases for PNZ members. Abstract Osteogenic sarcoma is a malignant tumor that rarely affects the hand. When it does, it most often involves the phalanges or metacarpal heads. We present the case of a 51-year-old woman with a low-grade osteosarcoma affecting the trapezium bone of her left hand. A total trapeziectomy with partial removal of the first metatarsal, scaphoid, trapezoid, and capitate bones was performed, and no adjuvant therapy was administered. Six years after the intervention, the patient is disease-free, with excellent functionality and yearly imaging tests showing no signs of recurrence.