Search Results

149 results found

  • What about pronator teres syndrome?

    Proximal median nerve compression: Pronator syndrome. Adler, J. A., & Wolf, J. M. (2020) Level of Evidence: 5 Follow recommendation: 👍 Type of study: Diagnostic, Therapeutic Topic: Median nerve compression - Pronator teres syndrome This is a narrative review on pronator teres syndrome. Pronator teres syndrome presents clinically with paresthesias in the median nerve distribution distally to the pronator teres and pain in the volar aspect of the forearm. The differential diagnosis includes cervical radiculopathy, brachial neuritis, thoracic outlet syndrome, anterior interosseous nerve (AIN) syndrome, and carpal tunnel syndrome (CTS). Physical tests may be helpful in discriminating between pronator teres syndrome, AIN syndrome, and CTS when they are present in isolation. In particular, the AIN syndrome is associated with motor but no sensory changes in comparison to pronator teres and CTS syndrome. Pronator teres syndrome may be associated with thenar eminence numbness (palmar cutaneous branch of the median nerve branches before the carpal tunnel) while in CTS there should be no numbness in the thenar eminence. With AIN syndrome, weakness (if present) is usually localisted to FPL and FDP of the index and middle finger. In terms of special tests, Phalen's and Tinel's test should be negative if there is an isolated pronator teres syndrome. These two condition may however present in combination. Unfortunately, nerve conduction studies are not useful to assess pronator teres syndrome. Conservative treatment should always be trialled for 3 to 6 month before surgery. This may include rest NSAIDs, activity modification, and physical therapy. Clinical Take Home Message: Hand therapists may consider pronator teres syndrome diagnosis when clients present with pain in the forearm and numbness in the peripheral median nerve distribution. Differential diagnoses for this condition may include cervical radiculopathy, brachial neuritis, thoracic outlet syndrome, anterior interosseous nerve (AIN) syndrome, and carpal tunnel syndrome (CTS). A few tests are available to make a diagnosis of cervical radiculopathy, however, dermatomal patterns are not reliable. Brachial neuritis and thoracic outlet syndrome present with limited special tests available as a gold standard for their diagnosis does not exist (similar to pronator teres syndrome). AIN syndrome has no sensory impairments and may present with FPL, index and middle finger FDP weakness. Carpal tunnel syndrome easier to diagnose, with nerve conduction studies helpful in the identification of moderate to severe CTS. For more information on nerve conduction study impairments in CTS have a look at this synopsis. URL: https://www.sciencedirect.com/science/article/pii/S0363502320304019 Available through the Journal of Hand Surgery (American volume) for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Pronator syndrome (PS) is a compressive neuropathy of the median nerve in the proximal forearm, with symptoms that often overlap with carpal tunnel syndrome (CTS). Because electrodiagnostic studies are often negative in PS, making the correct diagnosis can be challenging. All patients should be initially managed with nonsurgical treatment, but surgical intervention has been shown to result in satisfactory outcomes. Several surgical techniques have been described, with most outcomes data based on retrospective case series. It is essential for clinicians to have a thorough understanding of median nerve anatomy, possible sites of compression, and characteristic clinical findings of PS to provide a reliable diagnosis and treat their patients.

  • Should we use motor imagery post trapeziectomy?

    Thumbs up: Imagined hand movements counteract the adverse effects of post-surgical hand immobilization. Gandola, M., Zapparoli, L., Saetta, G., De Santis, A., Zerbi, A., Banfi, G., . . . Paulesu, E. (2019) Level of Evidence: 3b Follow recommendation: 👍 👍 Type of study: Therapeutic Topic: Trapeziectomy - Motor imagery This is a prospective study assessing the outcomes of participants undergoing explicit motor imagery post trapeziectomy for first carpometacarpal joint (cmcj) OA. Explicit motor imagery simply means imagining to perform a movement without physically performing it. A total of 22 participants underwent motor imagery (n=12) or limited motor imagery training (n=10) during the immobilisation period (2 weeks) post trapeziectomy. The differentiation between the motor imagery vs limited motor imagery groups was the compliance with the program (no randomisation). In particular, the motor imagery group had an 84% compliance while the limited motor imagery group had a 20% compliance with the program. Outcomes included were pain during thumb movement (VAS -thumb opposition, flexion, and circumduction) and disability (DASH). These outcomes were measured after 2 weeks immobilisation. The motor imagery task involved two daily sessions (AM and PM) during which participants had to imagine performing thumb opposition, flexion, and circumduction. The results showed that there was no statistically significant difference between groups in function (DASH). Pain improved to a statistically and clinically significant level in the motor imagery group (2.3 points improvement out of 10) during thumb circumduction movement, with a large between groups difference (4 points out of 10). There were no differences between groups for pain with thumb flexion and opposition. Overall, there is a low risk that these differences are due to chance as corrections for multiple statistical tests were completed. Clinical Take Home Message: Based on what we know today, motor imagery imagery may be useful for clients undergoing a period of immobilisation following trapeziectomy. This intervention does not appear to improve function, although it reduces significantly the pain on movement that clients experience when coming out of the cast. If interested, clinicians can download the Orientate app (It's free) and ask clients to imagine replicating the hand position shown on the app. Open access URL: https://www.sciencedirect.com/science/article/pii/S2213158219301883 Abstract Motor imagery (M.I.) training has been widely used to enhance motor behavior. To characterize the neural foundations of its rehabilitative effects in a pathological population we studied twenty-two patients with rhizarthrosis, a chronic degenerative articular disease in which thumb-to-fingers opposition becomes difficult due to increasing pain while the brain is typically intact. Before and after surgery, patients underwent behavioral tests to measure pain and motor performance and fMRI measurements of brain motor activity. After surgery, the affected hand was immobilized, and patients were enrolled in a M.I. training. The sample was split in those who had a high compliance with the program of scheduled exercises (T+, average compliance: 84%) and those with low compliance (T−, average compliance: 20%; cut-off point: 55%). We found that more intense M.I. training counteracts the adverse effects of immobilization reducing pain and expediting motor recovery. fMRI data from the post-surgery session showed that T+ patients had decreased brain activation in the premotor cortex and the supplementary motor area (SMA); meanwhile, for the same movements, the T− patients exhibited a reversed pattern. Furthermore, in the post-surgery fMRI session, pain intensity was correlated with activity in the ipsilateral precentral gyrus and, notably, in the insular cortex, a node of the pain matrix. These findings indicate that the motor simulations of M.I. have a facilitative effect on recovery by cortical plasticity mechanisms and optimization of motor control, thereby establishing the rationale for incorporating the systematic use of M.I. into standard rehabilitation for the management of post-immobilization syndromes characteristic of hand surgery.

  • Resistance training for hand OA?

    The effects of resistance training on muscle strength, joint pain, and hand function in individuals with hand osteoarthritis: a systematic review and meta-analysis. Magni, N. E., McNair, P. J., & Rice, D. A. (2017) Level of Evidence: 1a- Follow recommendation: 👍 👍 👍 👍 Type of study: Therapeutic Topic: Resistance training - application in hand OA This is a systematic review and meta-analysis assessing the effectiveness of resistance training exercises for hand OA. Five RCTs were included in the systematic review, for a total of 350 participants. All the studies were included in the meta-analysis and they were assessed through the Risk of Bias criteria recommended by the Cochrane Review Group. The overall strength of evidence was assessed through the GRADE approach ("low", "very low", "moderate", "high"), which has also been suggested by the Cochrane group for systematic reviews. Resistance training exercises were compared to control groups undergoing no exercise. Efficacy of intervention was assessed through improvements in grip strength, function (e.g. FIHOA, AUSCAN), and pain (e.g. NRS, AUSCAN pain). The assessment time points varied significantly, and they ranged from 6 to 24 weeks. Moderate quality evidence showed that resistance training did not improve grip strength to a statistically or clinically significant level (8% difference between groups in favor of resistance training). Low quality evidence showed no effect of resistance training on function, and a small, non clinically significant, effect on pain relief (0.5 out of 10 points improvement in favor of resistance training). Overall, due to multitude of statistical tests performed (3 tests) and the number of significant findings (1 test) there is a 15% probability that the results are just due to chance. Clinical Take Home Message: Based on what we know today, resistance training interventions do not appear to have a clinically relevant effect in clients with hand OA. They do not appear to improve grip strength, function, nor joint pain. Considering these results, a multimodal approach to the treatment of hand OA may be more effective (see previous synopsis on the topic). Open access URL: https://arthritis-research.biomedcentral.com/articles/10.1186/s13075-017-1348-3 Abstract Background: Hand osteoarthritis is a common condition characterised by joint pain and muscle weakness. These factors are thought to contribute to ongoing disability. Some evidence exists that resistance training decreases pain, improves muscle strength, and enhances function in people with knee and hip osteoarthritis. However, there is currently a lack of consensus regarding its effectiveness in people with hand osteoarthritis. Therefore, the aim of this systematic review and meta-analysis was to establish whether resistance training in people with hand osteoarthritis increases grip strength, decreases joint pain, and improves hand function. Methods: Seven databases were searched from 1975 until July 1, 2016. Randomised controlled trials were included. The Cochrane Risk of Bias Tool was used to assess studies' methodological quality. The Grade of Recommendations Assessment, Development, and Evaluation system was adopted to rate overall quality of evidence. Suitable studies were pooled using a random-effects meta-analysis. Results: Five studies were included with a total of 350 participants. The majority of the training programs did not meet recommended intensity, frequency, or progression criteria for muscle strengthening. There was moderate-quality evidence that resistance training does not improve grip strength (mean difference = 1.35; 95% confidence interval (CI) = -0.84, 3.54; I 2 = 50%; p = 0.23 ). Low-quality evidence showed significant improvements in joint pain (standardised mean difference (SMD) = -0.23; 95% CI = -0.42, -0.04; I 2 = 0%; p = 0.02) which were not clinically relevant. Low-quality evidence demonstrated no improvements in hand function following resistance training (SMD = -0.1; 95% CI = -0.33, 0.13; I 2 = 28%; p = 0.39). Conclusion: There is no evidence that resistance training has a significant effect on grip strength or hand function in people with hand osteoarthritis. Low-quality evidence suggests it has a small, clinically unimportant pain-relieving effect. Future studies should investigate resistance training regimes with adequate intensity, frequency, and progressions to achieve gains in muscle strength.

  • What about radial tunnel syndrome?

    Radial tunnel syndrome: definition, distinction and treatments. Bo Tang, J. (2020) Level of Evidence: 5 Follow recommendation: 👍 Type of study: Diagnostic, Therapeutic Topic: Posterior interosseous nerve entrapment - Radial tunnel syndrome vs PIN syndrome This is a narrative review on radial tunnel syndrome (RTS) and posterior interosseous nerve syndrome (PINS). These two presentations are both entrapment neuropathies of the posterior interosseous nerve, however, RTS is a mild entrapment neuropathy while PIN is a severe entrapment neuropathy (similar to mild vs severe carpal tunnel syndrome). The clinical presentations of RTS and PINS are different. RTS presents with pain in the lateral aspect of forearm 4-5 cm distal from the lateral epicondyle. PINS presents with no pain but with palsy of the wrist, finger, and thumb extensors, except for extensor carpi radialis longus. Clients with PINS will therefore present with painless weak wrist extension associated with radial deviation. Investigations for people with RTS or PINS may include x-rays and US, which will be able to exclude the presence of radiocapitellar joint osteoarthritis or space invading lesions which may be responsible for the entrapment. The differential diagnosis includes lateral epicondylalgia, cervical radiculopathy, high radial nerve palsy (e.g. Saturday night palsy), and extensive tendon ruptures of the extensors compartment. If a diagnosis of RTS is made, conservative treatment should be trialed for at least 6 months before surgery is considered. Overall, entrapment of the posterior interosseous nerve, especially severe entrapment, appears to be rare compared to median and ulnar nerve entrapment neuropathies (e.g. carpal tunnel syndrome, cubital tunnel syndrome). Clinical Take Home Message: A mild (RTS) or severe (PINS) entrapment neuropathy of the posterior interosseous nerve is rare. A mild entrapment neuropathy (RTS) usually presents with pain 4-5 cm distal to the lateral epicondyle. A severe entrapment neuropathy (PINS) presents with no forearm pain but significant motor weakness of the extensors compartment of the forearm. The key characteristic discriminating PINS from a higher nerve palsy (e.g. Saturday night palsy) or cervical radiculopathy with motor impairments, is that PINS will present with weak wrist extension associated with radial deviation (ECRL is intact). In addition, cervical radiculopathies present with neck pain in 80% of cases and often present with pain above the elbow. When differentiating between RTS and lateral epicondylalgia, the location of pain is the most useful indicator, with lateral epicondylalgia presenting with more proximal symptoms. URL: https://journals.sagepub.com/doi/10.1177/1753193420953990 Available through EBSCO Health Databases for PNZ members. Abstract Radial tunnel syndrome (RTS) is a disease causing lateral elbow and proximal dorsolateral forearm pain that may radiate to the wrist and dorsum of the fingers without obvious extensor muscle weakness. An epidemiological study shows an incidence of nine new cases of radial neuropathy per 100,000 population for men and six per 100,000 for women in a 10-year period (Hulkkonen et al., 2020). These incidences are far less than entrapments of the median and ulnar nerves. There are ambiguous descriptions of RTS in relation to posterior interosseous nerve (PIN) compression. This article intends to discuss the anatomy of the radial tunnel and the clinical distinctions between two entities.

  • Should you warn your diabetic clients about carpal tunnel surgery outcomes?

    Does diabetes mellitus change the carpal tunnel release outcomes? Evidence from a systematic review and meta-analysis. Moradi, A., Sadr, A., Ebrahimzadeh, M. H., Hassankhani, G. G., & Mehrad-Majd, H. (2020) Level of Evidence: 1a Follow recommendation: 👍 👍 👍 👍 Type of study: Therapeutic Topic: Surgical decompression of the carpal tunnel - Outcomes in diabetic vs healthy clients This is a systematic review and meta-analysis assessing outcomes in participants with and without diabetes following surgical decompression of the carpal tunnel. Ten studies were included for a total of 2,869 participants. Of these participants, 2423 were healthy and 446 presented with diabetes. Seventy percent of these participants were females. On average, participants were 56 years old. Outcomes included function, sensory, and motor nerve conduction studies. The results showed that there were no functional differences between clients with or without diabetes. Sensory nerve conduction improved to a greater extent in the healthy compared to diabetic participants. However, considering the multiple statistical tests undertaken, 23% of the results are due to chance. This reduces our confidence in these findings, especially considering that these differences did not have clinical repercussions in terms of function. Clinical Take Home Message: Hand therapists may reassure clients that diabetes does not appear to affect the results of surgery for carpal tunnel syndrome. However, hand therapists should remember that depression and mental health do affect post surgical satisfaction and the amount of health care resources required following carpal tunnel decompression. URL: https://www.sciencedirect.com/science/article/pii/S0894113020300235 Available through the Journal of Hand Therapy for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Study Design: A systematic review and meta-analysis. Introduction: Carpal tunnel syndrome (CTS) is one of the most common upper extremity conditions which mostly affect women. Management of patients suffering from both CTS and diabetes mellitus (DM) is challenging, and it was suggested that DM might affect the diagnosis as well as the outcome of surgical treatment. Purpose of the Study: This meta-analysis was aimed to compare the response with CTS surgical treatment in diabetic and nondiabetic patients. Methods: Electronic databases were searched to identify eligible studies comparing the symptomatic, functional, and neurophysiological outcomes between diabetic and nondiabetic patients with CTS. Pooled MDs with 95% CIs were applied to assess the level of outcome improvements. Results: Ten articles with 2869 subjects were included. The sensory conduction velocities in the wrist-palm and wrist–middle finger segments showed a significantly better improvement in nondiabetic compared with diabetic patients (MD = −4.31, 95% CI = −5.89 to −2.74, P < .001 and MD = −2.74, 95% CI = −5.32 to −0.16, P = .037, respectively). However, no significant differences were found for the improvement of symptoms severity and functional status based on the Boston Carpal Tunnel Questionnaire and Quick Disabilities of the Arm, Shoulder, and Hand questionnaire as well as motor conduction velocities and distal motor latencies. Conclusion: Metaresults revealed no significant difference in improvements of all various outcomes except sensory conduction velocities after CTS surgery between diabetic and nondiabetic patients. A better diabetic neuropathy care is recommended to achieve better sensory recovery after CTS surgery in diabetic patients.

  • Fracture's tenderness on palpation: don't let it fool you

    Pain during physical examination of a healing upper extremity fracture. Gonzalez, A. I., Kortlever, J. T. P., Crijns, T. J., Ring, D., Reichel, L. M., & Vagner, G. A. (2020) Level of Evidence: 2c Follow recommendation: 👍 👍 👍 Type of study: Prognostic Topic: Fracture tenderness - Healing This is a prospective study assessing the correlation between clients ability to cope with pain in daily life and tenderness on palpation of a hand or wrist fracture. A total of 117 participants were included. Of these participants 33% had a distal radius fracture, 21% had a metacarpal fracture, (18%) and phalanx fracture (the remaining 34% had other upper limb fractures). All of the participants included, presented with fractures which were unlikely to present complications or prolonged healing times (e.g. displaced). Clients ability to cope with pain in daily life was assessed through the Pain Self-Efficacy Questionnaire - Two-Item Short Form (PSEQ-2) (scroll to the bottom of the link to find this handy questionnaire), and the PROMIS CATs for physical function, depression, and pain interference (score it yourself or use it for your clients - Try the PROMIS CAT Demo>>). Tenderness on palpation at the fracture site was scored on a 0 to 10 numerical rating scale. Participants were assessed 3 to 6 weeks post injury. On average, participants were over 48 years old. The results showed that participants presenting with greater pain interference and lower self efficacy, presented with greater tenderness on palpation at the fracture site. This study did not objectively assess fracture's union because there is currently no gold standard that can measure this outcome. It is possible that delayed union affected participants' pain and as a results this affected their ability to cope with pain (this is a limitation of the study). This last option is however unlikely due to the type of fractures assessed, which usually heal fast without complications. Clinical Take Home Message: Based on what we know today, hand therapists may not decide on extending or reducing a fracture's immobilisation period based on tenderness on palpation of the fracture site. It appears that clients presenting with limited coping strategies report greater pain with fracture palpation. Traditional fracture healing times may be a better guide, compared to pain, in deciding how long a fracture should be immobilised. URL: https://journals.sagepub.com/doi/abs/10.1177/1753193420952010 You can ask the authors for the full text through Research Gate Available through EBSCO Health Databases for PNZ members. Abstract The evidence that symptom intensity and magnitude of limitations correlate with thoughts and emotions means that subjective signs, such as pain with physical examination, reflect both physical and mental health. During a 1-month evaluation of a rapidly healing upper extremity fracture with no risk of nonunion, 117 people completed measures of adaptiveness to pain and pain during the physical examination. Greater pain during examination correlated with less adaptive responses to pain and older age. This finding raises questions about using tenderness to assess fracture union.

  • Does digital nerve sensory loss cause pinch and grip weakness?

    The effect of digital sensory loss on hand dexterity. Luukinen, P., Leppänen, O. V., & Jokihaara, J. (2020) Level of Evidence: 4 Follow recommendation: 👍 👍 Type of study: Diagnostic Topic: DIgital nerve anaesthesia - Grip and pinch strength This is a study assessing dexterity, grip, and pinch strength before and after digital nerve blocks at the thumb, index, and middle finger (within-subject design). Twelve healthy participants were recruited for this study. Hand dexterity was measured through the Moberg pick-up test. Grip and pinch strength were assessed through a Jamar hand dynamometer (power grip) and pinch dynamometer (tripod and key pinch). The measurement were taken before and after the injection. The results showed that thumb anaesthesia led to the greatest loss of dexterity while it did not affect grip or pinch strength. Index or middle finger anaesthesia, led to a significant loss of grip (25% reduction) and tripod pinch strength (30% reduction). Clinical Take Home Message: Hand therapists should be aware that a digital nerve lesion can contribute to grip and tripod pinch weakness as well as lack of dexterity. In addition, these findings may also suggest that grip or pinch strength deficits in entrapment neuropathies (e.g. carpal tunnel syndrome) may be due to a combination of motor and sensory rather than just motor impairments. This synopsis is a nice addition to the previous one on the effect of anaesthesia to the ulnar nerve at the Guyon's canal. URL: https://journals.sagepub.com/doi/10.1177/1753193420936598 You can ask the authors for the full text through ResearchGate. Available through EBSCO Health Databases for PNZ members. Abstract The purpose of this study is to determine how loss of sensation affect hand dexterity. In this study, digital nerve block anaesthesia was performed in different stages of timing for thumb, index and middle fingers of 12 volunteers. The Moberg pick-up test was conducted in the assessment of hand dexterity. Grip and pinch forces were also measured. Loss of thumb sensation had the greatest effect on dexterity, increasing average timing by at least 10.5 seconds (range 3.4 to 32.4). Loss of sensation to the index and middle fingers has a lesser impact, but decreased hand grip and chuck pinch forces (grip –25% or –33%, chuck pinch –31% or –32% depending on the timing of injections). We concluded that loss of thumb sensation has the greatest impact on hand dexterity. Index and middle finger sensory loss had less of an impact on hand dexterity but decreased grip and chuck pinch forces.

  • Is the term "overuse injury" overused and overdue for an update?

    There is more to pain than tissue damage: Eight principles to guide care of acute non-traumatic pain in sport. Caneiro, J. P., Alaiti, R. K., Fukusawa, L., Hespanhol, L., Brukner, P., & Sullivan, P. P. B. (2020) Level of Evidence: 5 Follow recommendation: 👍 👍 👍 Type of study: Therapeutic Topic: Acute non-traumatic pain – Biopsychosocial approach This is an editorial from the British Journal of Sports Medicine. Eight points on how to better manage acute non-traumatic pain presentations were made. The first one suggested to move away from the assumption that pain is due to tissue trauma. Specifically, it was suggested to avoid wording that implies trauma for non-traumatic cases (e.g. overuse syndrome, microtrauma). Instead we could call it pain associated with a specific activity (e.g. sport-related pain, work related pain). Imaging was also advised against, especially if there are no red flags or if it does not guide treatment. The third advice was to consider biopsychosocial factors such as fatigue, poor sleep, mental health, and pain believes as contributing factors to pain. The importance of providing positive messages was also indicated. Messages suggesting that the body is strong and discussions around tissue sensitivity rather than microtrauma/overuse were encouraged. The fifth point suggested a gradual increase in tissue loading. The sixth point advised against utilising passive modalities as a first line approach. Empowering the client by involving them in our decision making was the seventh point. The eight and last point advised to deliver a consistent message (across different health professionals) regarding the lack of trauma (e.g. overuse, microtrauma) in non-traumatic pain presentations. Clinical Take Home Message: We should probably stop talking to our clients about overuse syndromes, repetitive strain injuries, and microtrauma, when no evident trauma is present. We should instead frame it as pain associated with the activity that is exacerbating their symptoms and explain that a recent change in activity levels, stress, lack of sleep, and fatigue may be contributing to an increased sensitivity of their tissue. These explanations are evidence-informed and may help our clients making sense of their non-traumatic pain. URL: https://bjsm.bmj.com/content/early/2020/09/08/bjsports-2019-101705 You can ask the authors for the full text through ResearchGate. May be available through EBSCO Health Databases for PNZ members - you may need to wait a few weeks to get access to this article. Abstract Are you careful with how you label an athlete’s pain? Musculoskeletal pain in athletes is common, but not always associated with injury (ie, tissue damage). Damage occurs when load exceeds tissue tolerance, such as ligament tear or a fracture. However, pain in athletes that occurs in the absence of trauma and tissue damage is still often labelled an ‘injury’ by clinicians, coaches and athletes themselves. This highlights a gap between knowledge (tissue damage is not necessary for pain) and practice (assuming that all pain arises from tissue damage) in our clinical community. This applies particularly in the area of acute non-traumatic pain (such as back and joint pain). To help bridge this gap, we outline eight principles to guide clinicians who manage musculoskeletal pain in sport (see infographic in figure 1).

  • Should we move away from joint protection programs for RA and OA of the hand?

    The effectiveness of joint-protection programs on pain, hand function, and grip strength levels in patients with hand arthritis: A systematic review and meta-analysis. Bobos, P., Nazari, G., Szekeres, M., Lalone, E. A., Ferreira, L., & MacDermid, J. C. (2019) Level of Evidence: 1a- Follow recommendation: 👍 👍 👍 Type of study: Therapeutic Topic: Hand RA and OA – Joint protection vs no intervention This is a systematic review and meta-analysis assessing the effectiveness of joint protection vs control interventions for RA and OA of the hand. Seventeen RCTs were included in the systematic review, for a total of 1,847 participants (80% were diagnosed with RA). Only nine of these studies were included in the meta-analysis. All the RCTs were assessed through the Risk of Bias criteria recommended by the Cochrane Review Group. The overall strength of evidence was assessed through the GRADE approach ("low", "very low", "moderate", "high"), which has also been suggested by the Cochrane group for systematic reviews. Joint protection with an exercise component was compared to a control group undergoing either standard care, advice, no treatment, or patient education. Efficacy of intervention was assessed through improvements in pain (e.g. NRS, VAS), and function (e.g. Michigan Hand Questionnaire, AUSCAN), at short-term (3-4/12), midterm (6-8/12), and long-term (1 year). The results showed that publication bias was present (low sample size studies were more likely to over-inflate the effectiveness of joint protection interventions). There was very low to low quality of evidence showing that joint protection may have a small, unlikely to be clinically relevant, positive effectiveness in people with RA. In OA, joint protection had no effect compared to the control groups. Overall, due to multitude of statistical tests performed (16 tests) and the number of significant findings (4 test - all in RA) there is a 20% probability that the results are just due to chance. Clinical Take Home Message: Hand therapists should be aware that joint protection interventions appear to have a small, not clinically relevant effect in hand RA. Considering these results, other interventions such as stretching and strengthening may be more appropriate as they have been shown to have relevant effectiveness in a large RCT and a recent implementation study. No effect was shown for joint protection interventions in hand OA. Therefore, other approaches (see previous synopsis on the topic) for hand OA may be more effective. URL: https://www.jhandtherapy.org/article/S0894-1130(18)30164-9/fulltext Available through the Journal of Hand Therapy for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Study Design: Systematic review with meta-analysis. Introduction Joint protection (JP) has been developed as a self-management intervention to assist people with hand arthritis to improve occupational performance and minimize joint deterioration over time. Purpose of the Study: We examined the effectiveness between JP and usual care/control on pain, hand function, and grip strength levels for people with hand osteoarthritis and rheumatoid arthritis. Methods: A search was performed in 5 databases from January 1990 to February 2017. Two independent assessors applied Cochrane's risk of bias tool, and a Grading of Recommendations Assessement, Development and Evaluation (GRADE) approach was adopted. Results: For pain levels at short term, we found similar effects between JP and control standardized mean difference (SMD; −0.00, 95% confidence interval [CI]: −0.42 to 0.42, I2 = 49%), and at midterm and long-term follow-up, JP was favored over usual care SMD (−0.32, 95% CI: −0.53 to −0.11, I2 = 0) and SMD (−0.27, 95% CI: −0.41 to −0.12, I2 = 9%), respectively. For function levels at midterm and long-term follow-up, JP was favored over usual care SMD (−0.49, 95% CI: −0.75 to −0.22, I2 = 34%) and SMD (−0.31, 95% CI: −0.50 to −0.11, I2 = 56%), respectively. For grip strength levels, at long term, JP was inferior over usual care mean difference (0.93, 95% CI: −0.74 to 2.61, I2 = 0%). Conclusions: Evidence of very low to low quality indicates that the effects of JP programs compared with usual care/control on pain and hand function are too small to be clinically important at short-, intermediate-, and long-term follow-ups for people with hand arthritis.

  • What can smiles do?

    A qualitative systematic review of effects of provider characteristics and nonverbal behavior on pain, and placebo and nocebo effects. Daniali, H., & Flaten, M. A. (2019) Level of Evidence: 1a- Follow recommendation: 👍👍👍👍 Type of study: Therapeutic Topic: Smiling - Placebo and nocebo This is a systematic review on the effect on non-verbal interactions on placebo and nocebo. Placebo, a positive effect (e.g. pain reduction), and nocebo, a negative effect (e.g. increase in pain), are the result of treatment expectations. Fourteen experimental studies were included for a total of 1,778 participants. Non-verbal interactions were divided in positive and negative. Positive non-verbal interactions included smiling, nodding, making eye contact, and a warm and friendly voice. Negative non-verbal interactions included a flat and cold tone of voice, frowning, and looking away. The findings showed that negative non-verbal interactions led to a reduced placebo effect, or a nocebo effect, resulting in lower pain tolerance, and higher pain. In contrast, positive non verbal interactions (e.g. smiling) led to a boost in the placebo effect leading to a better emotional and physical state of the patients, lower pain, and a reduction in opioid medications use. Clinical Take Home Message: A positive non-verbal attitude of a hand therapist can enhance the effect of the treatment provided. Smiling, making eye contact, and nodding may improve our clinician-client relationship and lead to reduction in pain, enhanced emotional well-being, and a reduction in pain medications consumption. This synopsis is a nice adjunct to the one written about the effect of an empathetic attitude of clinicians and its effect on endogenous analgesia. Open Access URL: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6476260/pdf/fpsyt-10-00242.pdf Abstract Background: Previous research has indicated that the sex, status, and nonverbal behaviors of experimenters or clinicians can contribute to reported pain, and placebo and nocebo effects in patients or research participants. However, no systematic review has been published. Objective: The aim of this study was to investigate the effects of experimenter/clinician characteristics and nonverbal behavior on pain, placebo, and nocebo effects. Methods: Using EmBase, Web of Knowledge, and PubMed databases, several literature searches were conducted to find studies that investigated the effects of the experimenter’s/ clinician’s sex, status, and nonverbal behaviors on pain, placebo, and nocebo effects. Results: Thirty-four studies were included, 20 on the effects of characteristics of the experimenter/clinician, 11 on the role of nonverbal behaviors, and 3 on the effects of both nonverbal behaviors and characteristics of experimenters/clinicians on pain and placebo/nocebo effects. There was a tendency for experimenters/clinicians to induce lower pain report in participants of the opposite sex. Furthermore, higher confidence, competence, and professionalism of experimenters/clinicians resulted in lower pain report and higher placebo effects, whereas lower status of experimenters/clinicians such as lower confidence, competence, and professionalism generated higher reported pain and lower placebo effects. Positive nonverbal behaviors (e.g., smiling, strong tone of voice, more eye contact, more leaning toward the patient/participant, and more body gestures) contributed to lower reported pain and higher placebo effects, whereas negative nonverbal behaviors (i.e., no smile, monotonous tone of voice, no eye contact, leaning backward from the participant/patient, and no body gestures) contributed to higher reported pain and nocebo effects. Conclusion: Characteristics and nonverbal behaviors of experimenters/clinicians contribute to the elicitation and modulation of pain, placebo, and nocebo effects.

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