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149 results found

  • Would your RA clients benefit from a hand strengthening and stretching program?

    Translating the strengthening and stretching for rheumatoid arthritis of the hand programme from clinical trial to clinical practice: An effectiveness–implementation study. Williamson, E., Srikesavan, C., Thompson, J., Tonga, E., Eldridge, L., Adams, J., & Lamb, S. E. (2020) Level of Evidence: 2c Follow recommendation: 👍 👍 👍 Type of study: Therapeutic Topic: Rheumatoid arthritis - Stretching and strengthening This is a pragmatic trial, assessing the effectiveness of a hand exercise program for people with rheumatoid arthritis (RA) affecting their hands. A total of 448 hand therapists were trained through an online course. The hand exercise program taught in the online course, has previously been shown to be effective for RA in a randomised controlled trial published in the Lancet. Hand therapists were then asked to collect data from their patients with RA during the first visit and at discharge. In addition, a four months follow up was completed. Function was assessed through the Michigan Hand Questionnaire, pain was assessed through a 5-points likert scale, and grip strength was measured through a hand dynamometer. Data were collected from 118 clients with RA. All of these clients were guided in the implementation of the hand exercise program, although compliance with the original exercises program varied significantly. The results showed that hand function improved to a statistically significant level at discharge and at four months follow up. It is however unclear whether the results were clinically relevant (a minimal clinical important change threshold for the total score of the Michigan Hand Questionnaire has not been published yet). Pain was unchanged, however, grip strength improved to a clinically and statistically significant level (25-30%) from baseline (14kg). Clinical Take Home Message: Hand therapists treating clients with hand RA may benefit from completing the training course created for this study. The course is accessible online (iSARAH) and it is entirely free. Both this study and the original RCT were completed in participants with an average grip strength close to 14kg. It is possible that clients presenting with higher grip strength (i.e. 25kg) may benefit less from this hand exercise program. Thus, a grip strength of 25kg appears to be sufficient to complete most of the daily tasks. URL: Available through Hand Therapy for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Introduction: The Strengthening and Stretching for Rheumatoid Arthritis of the Hand programme is a hand exercise programme for people with rheumatoid arthritis. It was clinically effective when delivered during a clinical trial but there was a need to evaluate translation into routine care. Methods:We conducted an effectiveness–implementation study. We adapted the trial training into an online format for National Health Service hand therapists. Educational outcomes included confidence and capability to deliver the programme. Implementation outcomes included training reach and adoption. Therapists were invited to collect clinical outcomes. Patients receiving the programme provided data on function (Michigan Hand Questionnaire function scale), pain and grip strength at baseline, treatment discharge and four-month follow-up. Results: A total of 790 therapists (188 National Health Service organizations) enrolled in the training; 584/790 (74%) therapists (162 National Health Service organizations) completed the training; 448/790 therapists (145 National Health Service organizations) (57%) evaluated the training and were confident (447/448, 99.8%) and capable (443/448, 99%) to deliver the programme with 85% intending to adopt it (379/448). Follow-up data were provided by 116/448 (26%) therapists. Two-thirds (77/116; 51 National Health Service organizations) reported adopting the programme. One hundred and eighteen patients (15 National Health Service trusts) participated. Patients reported improved function (mean change Michigan Hand Questionnaire scores: 10 (95% CI 6.5–13.6) treatment discharge; 7 (95% CI 3.8–10.2) 4-month follow-up). Grip strength increased 24.5% (left) and 31% (right). Pain was stable. Discussion: Online training was an effective way to train therapists with good reach. Clinical outcomes were similar to the clinical trial providing preliminary evidence of successful translation into routine care.

  • Should you refer clients with 1st cmcj OA for cortisone injections?

    Injection therapy for base of thumb osteoarthritis: a systematic review and meta-analysis. Riley, N., Vella-Baldacchino, M., Thurley, N., Hopewell, S., Carr, A. J., & Dean, B. J. F. (2019) Level of Evidence: 1a- Follow recommendation: 👍 👍 👍 Type of study: Therapeutic Topic: 1st cmcj OA – cortisone vs other types of injections This is a systematic review and meta-analysis assessing the effectiveness of cortisone injections vs other types of injections for 1st cmcj OA. Nine RCTs were included in the present review, for a total of 504 participants. Only three of these (cortisone vs hyaluronic acid) were included in the meta-analysis. All the RCTs were assessed through the Risk of Bias criteria recommended by the Cochrane Review Group. Efficacy of intervention was assessed through improvements in pain (VAS), pinch and grip strength. The results showed that most of the studies presented with a high risk of bias, large heterogeneity, and small sample sizes. There was very low quality of evidence showing that cortisone injections were not more effective in improving pain, pinch or grip strength when compared to hyaluronic acid injections. Interestingly, when cortisone or hyaluronic acid injections where compared to placebo injections (narrative review of 3 RCTs), there were no differences in pain, pinch or grip strength. Similar findings were reported when hyaluronic acid was compared to placebo injections. The authors reported that corticosteroid injections provided statistically significant improvements in the medium term compared to hyaluronic acid injections. However, due to multitude of statistical tests performed (11 tests) and the number of significant findings (1 test) there is a 55% probability that this result is just due to chance. Clinical Take Home Message: Corticosteroid injections do not appear to provide any additional benefit on pain, pinch, or grip strength when compared to hyaluronic acid injections for 1st cmcj OA. From the results of two RCTs it appears that neither cortisone nor hyluronic acid injections are superior to placebo (saline) injections. As shown by another study, most of the clinical effect shown by cortisone or hyaluronic acid injections may be due to contextual factors associated with the therapeutic intervention. Hand therapists may refer clients for cortisone or hyluronic acid injections if other conservative interventions have failed, and if surgery is not viable due to comorbidities. If clients may be eligible for 1st cmcj OA surgery, cortisone or hyaluronic acid injections may actually increase the odds of post surgical complications. Open Access URL: Abstract Objective: To evaluate the effectiveness of injection-based therapy in base of thumb osteoarthritis. Design: Systematic review and meta-analysis. Data sources: MEDLINE and EMBASE via OVID, CINAHL and SPORTDiscus via EBSCO were searched from inception to 22 May 2018. Study selection: Randomised controlled trials (RCTs) and non-RCTs of adults with base of thumb osteoarthritis investigating an injection-based intervention with any comparator/s. Data extraction and analysis: Data were extracted and checked for accuracy and completeness by pairs of reviewers. Primary outcomes were pain and function. Comparative treatment effects were analysed by random-effects model for short-term and medium-term follow-up. Results: In total, 9 RCTs involving 504 patients were identified for inclusion. All compared different injection-based therapies with each other, no studies compared an injection-based therapy with a non-injection-based intervention. Twenty injection-based intervention groups were present within these nine trials, consisting of hyaluronic acid (n=9), corticosteroid (n=7), saline placebo (n=3) and dextrose (n=1). Limited meta-analysis was possible due to the heterogeneity in the injections and outcomes used, as well as incomplete outcome data. Meta-analysis of two RCTs (92 patients) demonstrated reduced Visual Analogue Scale pain on activity with corticosteroid versus hyaluronic acid (mean difference (MD) −1.32, 95% CI −2.23 to −0.41) in the medium term, but no differences in other measures of pain or function in the short term and medium term. Overall, the available evidence does not suggest that any of the commonly used injection therapies are superior to placebo, one another or a non-injection-based comparator. Conclusion: Current evidence is equivocal regarding the use of injection therapy in base of thumb osteoarthritis, both in terms of which injection-based therapy is the most effective and in terms of whether any injection-based therapy is more effective than other non-injection-based interventions. Given limited understanding of both the short-term and long-term effects, there is a need for a large, methodologically robust RCT investigating the commonly used injection therapies and comparing them with other therapeutic options and placebo. PROSPERO registration number CRD42018095384.

  • Answer for: What is the differential diagnosis for this case? - Circumferential rash

    Rumple-Leede phenomenon after tourniquet application in acute hand surgery: A case report. Imran, R., & Jose, R. M. (2020) Level of Evidence: 5 Follow recommendation: 👍 Type of study: Diagnostic Incidence: Rare Topic: Skin rash – proximal compression This is a case report of unilateral Rumple-Leede phenomenon. The patient was a 65 year old male who had undergone terminalisation of a finger and wound closure following a traumatic injury. A tourniquet was applied to the proximal arm for 75 minutes during surgery. Upon tourniquet release, a circumferential rash, which was non-blanching, developed in the whole arm below the tourniquet level. The patient was neurovascularly intact at the level of the hand. The patient was discharged following two hours of observation with a diagnosis of Rumple-Leede phenomenon. This condition is due to an acute rupture of skin capillaries following the application of a limb compression (pressure cuff or tourniquet). This is a benign condition which resolves withing 2-3 weeks and it is unrelated to the time of tourniquet application. It is however important to exclude the presence of other conditions such as diabetes, trombocytopenia (low number of platelets), hypertension, and connective tissue disorders, which may increase the likelihood of this condition to occur or mimicker such as vasculitis (vessels inflammation). In this case, no predisposing factors were identified. The patient was reassured and the condition resolved within two weeks. Clinical Take Home Message: Clients may present with Rumple-Leede phenomenon following surgery, blood pressure measurements, application of any type of limb compression (e.g. counterforce brace at the forearm), or blood flow restriction training. Hand therapist should reassure clients and refer them to their GP for follow up testing, which aims at excluding other mimickers or contributing factors to the phenomenon (e.g. emathological or connective tissue conditions). Although this condition has been described in the literature several times, it is quite rare and it is unlikely to occur. URL: You can ask the authors for the full through ResearchGate Available through EBSCO Health Databases for PNZ members. No Abstract available.

  • Can your clients' brain help with pain reduction?

    Ronald Melzack Award Lecture: Putting the brain to work in cognitive behavioral therapy for chronic pain. Thorn, B. E. (2020) Level of Evidence: 5 Follow recommendation: 👍 👍 Type of study: Therapeutic Topic: Chronic pain – Biopsychosocial approach This is a invited lecture for the Ronald Melzack Award (IASP). The Ronald Melzack Award was established by the International Association for the Study of Pain in honour of Ronald Melzack who contributed exceptionally to the study of pain. In this invited lecture, Dr. Beverly Thorn highlights how pain can be modulated by getting our clients' brain to work. It was made clear from the beginning that psychosocial interventions for chronic pain are not targeted for people affected by mental health. This is often one of the main barriers that hinder patients' or clinicians' adoption of this model. By embracing the ability of the brain to modulate the response of thoughts and emotions, pain can be more amenable. A key word appeared multiple times: simplicity. Simplicity in terms of the explanations that we provide to clients on the link between psychosocial factors, and pain. Simplicity in terms of treatments provided. Other key concepts included the lack of association between pain and tissue damage in chronic pain conditions, and the fact that thoughts and emotions can worsen the suffering associated with pain. In addition, it was clarified that psychosocial interventions and pain education do not aim to distract or be an academic exercise. They aim to get people better by understanding how pain works. Clinical Take Home Message: Psychosocial and pain education interventions are useful for chronic pain clients. They have a very real biological effects and we should clarify that to our clients. We have plenty of evidence showing that a positive attitude of a clinician can boost the effect of the treatment provided, pain conditioning can influence future pain experiences, and that our words can increase or decrease clients' pain perception. The brain is responsible for the pain experience, and it can be used to reduce it. Open Access URL: No abstract available.

  • Are neurodynamic exercises superior to general exercises for carpal tunnel syndrome?

    The long term effect of neurodynamics vs exercise therapy on pain and function in people with carpal tunnel syndrome: A randomized parallel-group clinical trial. Hamzeh, H., Madi, M., Alghwiri, A. A., & Hawamdeh, Z. (2020) Level of Evidence: 1b- Follow recommendation: 👍 👍 👍 Type of study: Therapeutic Topic: Carpal tunnel conservative intervention - Neurodynamic vs general exercise This is a randomised controlled trial assessing the effectiveness of neurodynamic exercise vs general exercises on function, pain, range of movement (ROM), and grip strength in people with carpal tunnel syndrome (CTS). All the participants included (n = 41) were diagnosed with CTS through subjective reports of paraesthesia in the median nerve distribution at the hand, a positive Phalen's test, and impairments on nerve conduction studies. Potential participants were excluded if they presented with a history of neck pain radiating to the upper limb and/or previous hand trauma. Participants were randomised to a neurodynamic exercise group (n = 26), or to a general exercise group (n = 25). Both groups received four individual supervised sessions of one hour each. The neurodynamic group underwent neurodynamic exercises and they were progressed to the next level of exercise when the symptoms were no longer elicited by previous week neurodynamic testing. They also completed neurodynamic exercises at home. The general exercise group received tendon gliding exercises, active range of movement, stretching, and strengthening exercises. Both groups were asked to perform the exercises twice daily. Treatment effectiveness was assessed through the Boston Carpal Tunnel Syndrome Questionnaire (Primary outcome), QuickDASH, numerical pain rating scale (NRS), wrist ROM, and grip strength (All secondary outcomes). Participants were assessed at baseline, one month, and six months. Both groups improved to a statistically and clinically significant level for most outcomes. Considering the multiple statistical tests undertaken, 25% of the results are due to chance. Nevertheless, neurodynamic testing appeared to provide statistically and clinically relevant greater improvements in pain and function (QuickDASH) at 1 month compared to the general exercise group. Thus, the difference between the two groups was close to 2 (95%CI: -3.45 to -0.41) points out of 10, and 13 (95%CI: -24.5 to -0.7) points out of 100 for the NRS and QuickDASH respectively. No adverse events were reported. The confidence intervals for both outcomes were quite wide, suggesting that the effect of the intervention was not consistent. Clinical Take Home Message: Hand therapists may use either neurodynamic or general exercises to improve the clinical presentation of people with CTS. Neurodynamic exercises may be more effective in improving pain and function compared to general exercises in the short term. Hand therapists should be aware that the improvements reported with neurodynamic exercises are substantially variable and range from large, beyond clinically relevant improvements, to the same improvement as with general exercises. URL: Available through the Journal of Hand Therapy for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Introduction: Carpal tunnel syndrome (CTS) is a common disorder that limits function and quality of life. Little evidence is available on the long-term effect of neurodynamics and exercise therapy. Purpose of the Study: This study aimed to examine the long-term effect of neurodynamic techniques vs exercise therapy in managing patients with CTS. Study Design: Parallel group randomized clinical trial. Methods: Of 57 patients screened, 51 were randomly assigned to either receiving four sessions of neurodynamics and exercise or home exercise therapy alone as a control. Blinded assessment was performed before treatment allocation, at treatment completion, and 6 months posttreatment. Outcome measures included Symptom Severity Scale (SSS), Functional Status Scale (FSS), Shortened version of the Disabilities of the Arm, Shoulder, and Hand (DASH), Numerical Pain Rating Scale, grip strength and range of motion. Results: Data from 41 individuals (52 hands) were analyzed. The neurodynamics group demonstrated significant improvement in all outcome measures at 1 and 6 months (P < .05). Mean difference in SSS was 1.4 (95% CI= 0.9-1.4) at 1 month and 1.6 (95% CI = 0.9-2.2) at 6 months. Mean difference in FSS was 0.9 (95% CI = 0.4-1.4) at 1 month and 1.4 (95% CI = 0.7-2.0) at 6 months. Significant between-group differences were found in pain score at 1 month (−1.93) and in FSS (−0.5) and Shortened version of DASH (−12.6) at 6 months (P < .05). No patient needed surgery 1 year after treatment. Conclusions: Although both treatments led to positive outcomes, neurodynamics therapy was superior in improving function and strength and in decreasing pain.

  • What is the differential diagnosis for this case? - Circumferantial rash

    The title will be provided next week. Imran, R., & Jose, R. M. (2020) Level of Evidence: 5 Follow recommendation: 👍 Type of study: Diagnostic Topic: Skin rash – proximal compression Have a think about it this case study. If you like, you can leave a comment indicating what the diagnosis may be. I will publish the diagnosis and treatment reported by the paper next week. The patient was a 65 year old male who had undergone terminalisation of a finger and wound closure following a traumatic injury. A tourniquet was applied to the arm proximally for 75 minutes during surgery. Upon tourniquet release, a circumferential rash, which was non-blanching, developed in the whole arm below the tourniquet level. The patient was neurovascularly intact at the level of the hand. What is it? URL: Next week

  • Rehab and return to work post distal triceps repair: How long does it take?

    Return to work following distal triceps repair. Agarwalla, A., Gowd, A. K., Jan, K., Liu, J. N., Garcia, G. H., Naami, E., . . . Verma, N. N. (2020) Level of Evidence: 4 Follow recommendation: 👍 Type of study: Prognostic Topic: Distal triceps repair - Return to work This is a retrospective study assessing return to work following a distal triceps repair surgery. Distal triceps ruptures have an incident of 1% in the general population. A repair is usually undertaken when the tear is greater than 50% of the tendon. A total of 81 participants with distal triceps repair were included. Patients' average age was 46 (SD: 11 years ) years old. Return to work outcomes timeframes (in months) were recorded according to work intensity. Work intensity was defined based on the maximum lifting involved. Work intensity was classified as sedentary (max 5kg), light (max 10kg), moderate (max 25kg), and heavy (max 50kg). Pain was assessed through the visual analogue scale (VAS), and function through the quickDASH. All patients followed the same post surgical instructions. These included a limitation to 20deg of elbow flexion (hinge brace) for the fist two weeks followed by a progression to 90deg by weeks six. At six weeks there were no restrictions in active range of movement. At eight weeks patients could start performing isometric triceps resisted exercises. The results showed that all the patients in sedentary and light jobs returned to work within one month and three months respectively. Most (80%) of the patients in moderate and heavy jobs returned to work within six months and nine months respectively. The average return to work time reported across all work intensities is 2 months. Clinical Take Home Message: Hand therapists may provide patients with an estimate return to work timeframe of 1 to 9 months following distal triceps repair. The timeframe will depend on the work intensity required. The average return to work for people undergoing distal triceps repair (2 months) appears to be shorter than the time required for distal biceps repair (3-4 months). This may be due to the fact that biceps is heavily involved in lifting activities compared to triceps. Unlike distal biceps repair, no major surgical complication were reported URL: You can ask the authors for the full through ResearchGate. Available through EBSCO Health Databases if you have access (PNZ) Abstract Purpose: Evaluate the rate and duration of return to work in patients undergoing distal triceps repair (DTR). Methods: Consecutive patients undergoing DTR from 2009-2017 at our institution were retrospectively reviewed at a minimum of one year postoperatively. Patients completed a standardized and validated work questionnaire, a visual analog scale for pain (VAS-Pain), Mayo Elbow Performance Score (MEPS), Quick Disabilities of the Arm, Shoulder, and Hand Score (quick-DASH) and a satisfaction survey. Results: Out of 113 eligible patients who had a DTR, eighty-one patients (71.7%) were contacted. Of which, 74 patients (91.4%) were employed within three years prior to surgery (mean age: 46.0 ± 10.7 years; mean follow-up: 5.9 ± 3.9 years). Sixty-nine patients (93.2%) returned to work by 2.2 ± 3.2 months postoperatively. 66 patients (89.2%) patients were able to return to the same level of occupational intensity. Patients who held sedentary, light, medium, or high intensity occupations were able to return to work at a rate of 100.0%, 100.0%, 80.0%, and 76.9% by 0.3 ± 0.5 months, 1.8 ± 1.9 months, 2.5 ± 3.6 months, and 4.8 ± 3.9 months postoperatively. Fifteen (75%) workers compensation (WC) patients returned to work by 6.5 ± 4.3 months postoperatively, while 100% of non-WC patients returned to work by 1.1 ± 1.6 months (p<0.001). Seventy-one patients (95.9%) were at least somewhat satisfied with 50 patients (67.6%) reporting excellent satisfaction. Seventy-two patients (97.3%) would still have the operation again if presented the opportunity. A single patient (1.4%) required revision distal triceps repair. Conclusions: Approximately 93% of patients that undergo DTR returned to work by 2.2 ± 3.2 months postoperatively. Patients with higher intensity occupations had an equivalent rate of RTW, but took longer to return to their preoperative level of occupational intensity. Information regarding return to work is imperative in preoperative patient consultation to manage expectations.

  • What should you tell clients when advising them to take mediation classes?

    Adverse events in meditation practices and meditation-based therapies: a systematic review. Farias, M., Maraldi, E., Wallenkampf, K. C., & Lucchetti, G. (2020) Level of Evidence: 1a Follow recommendation: 👍 👍 👍 👍 Type of study: Therapeutic Topic: Meditation - Adverse events This is a systematic review and meta-analysis assessing adverse events associated with meditation practice. Fifty-four experimental studies, 14 cross sectional studies, and 15 case studies were included for a total of 6,464 participants. Studies were included if mindfulness or trascendental mediation were utilised. No formal critique of the included studies was reported (limitation). The prevalence and type of adverse events were reported. The overall prevalence of adverse events was 8.3% (95%CI: 5% to 12%). When only experimental studies were included, the prevalence reduced to 4% (95%CI: 2% to 5%). The most common adverse events included a worsening of anxiety (33%) and depression (26%). Clinical Take Home Message: Due to the close relationship between psychological factors and upper limb recovery or post surgical satisfaction following CTS surgery, we may refer our clients for meditation classes. If we decide to do so, we should warn them that there may be side effects such as worsening of their anxiety or depression. This occurs on average in 1 person out of 25. An alternative that does not appear to present with as many adverse event is yoga. Yoga sessions including at least 50% of physical exercise (e.g. asanas) appear to provide benefits with little or no side effects. Open Access URL: Abstract Objective: Meditation techniques are widely used as therapy and wellbeing practices, but there are growing concerns about its potential for harm. The aim of the present study is to systematically revie w meditation adverse events (MAEs), investigating its major clinical categories and its prevalence. Method: We searched PubMed, PsycINFO, Scopus, Embase and AMED up to October 2019. Eligible studies included origin al reports of meditation practices (excluding related physical practices such as Yoga postures) with adult samples across experimental, observational and case studies. We identified a total of 6742 citations, 83 of which met the inclusion criteria for MAEs with a total of 6703 participants who undertook meditation practice. Results: Of the 83 studies analysed, 55 (65%) included reports of at least one type of MAE. The total prevalence of adverse events was 8.3% (95% CI 0.05–0.12), though this varied considerably across types of studies – 3.7% (95% CI 0.02–0.05) for experimental and 33.2% (95% CI 0.25–0.41) for observational studies. The most common AEs were anxiety (33%, 18), depression (27%, 15) and cognitive anomalies (25%, 14); gastrointestinal problems and suicidal behaviours (both 11%, 6) were the least frequent. Conclusion: We found that the occurrence of AEs during or after meditation practices is not uncommon, and may occu r in individuals with no previous history of mental health problems. These results are relevant both for practitioners and clinicians, and con tribute to a balanced perspective of meditation as a practice that may lead to both positive and negative outcomes

  • Answer for: What is the differential diagnosis for this case? - Radial wrist pain

    Enigmatic and unusual cases of upper extremity pain: Mislabeling as malingerers. Bradburn, K. N., Beleckas, C. M., Peck, K. M., Kaplan, F. T., & Merrell, G. A. (2020) Level of Evidence: 5 Follow recommendation: 👍 Type of study: Diagnostic Topic: What is the differential diagnosis? – Case study The patient was a 38 years old female who had undergone conservative management of radial styloid fracture two years previously. Subjectively, they reported persistent pain on the radial-volar aspect of the wrist. Aggravating factors included writing and flexing the interphalangeal joint of the thumb while keeping a straight index finger. Previous treatment included 1st dorsal compartment cortisone injection (one year after the original injury), which temporarily relieved pain. During that period, they were also treated with intermittent thumb splinting. Objectively, there was no tenderness on palpation of the first dorsal compartment. Wrist range of movement was 85°, 85°, 50°, and 80° of pronation, supination, extension, and flexion respectively. The interphalangeal joint of the thumb could not flex without the distal interphalangeal joint of the index finger flexing. X-rays, MRI, and CT scans revealed no soft tissue or bony abnormalities. Surgical exploration for diagnostic and potential treatment purposes was undertaken. The procedure revealed the presence of a Linburg-Comstock syndrome. This is a tendinous connection between flexor pollicius longus (FPL) and flexor digitorum profondus (FDP) (of the index finger in this case) which is present in 30% of people. A tenosynovectomy was completed to allow for independent tendon gliding of the FPL and FDP. At three months follow up symptoms had markedly improved and at one year follow up, symptoms had completely resolved. Clinical take home message: Hand therapists may consider Lindburg-Comstock syndrome when the ipj of the thumb is unable to flex without dipj flexion of the index finger. This syndrome may be painful and surgical release can provide symptoms resolution. If you enjoyed this type of synopsis, put a like on it! URL: Available through the Journal of Hand Surgery (American Volume) for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract With the intricate anatomy of the hand and upper extremity, there are many possible etiologies of pain. In addition, one must be alert to conditions typically affecting other areas of the body presenting in the hand and upper extremity. To add to the complexity of diagnosis, one must also be aware of potential secondary gains. With this in mind, a thorough history, physical examination, and broad differential can help avoid mislabeling patients with uncommon ailments. In this article, we present 4 cases of unusual causes of hand and upper extremity pain.

  • Update on entrapment neuropathies! What should you know?

    Entrapment neuropathies: A contemporary approach to pathophysiology, clinical assessment, and management. Schmid, A. B., Fundaun, J., & Tampin, B. (2020) Level of Evidence: 5 Follow recommendation: 👍 Type of study: Symptoms prevalence, Aetiologic, Diagnostic, Therapeutic Topic: Entrapment neuropaties - Presentation and diagnostics This is an updated narrative review on clinical presentation, aetiology, and diagnostic tests for peripheral neuropathies (e.g. carpal tunnel syndrome - CTS). In terms of aetiology, genetic predisposition appears to be one of the strongest risk factors for entrapment neuropathies. It is unknown whether these genetic changes cause entrapment neuropathies due to anatomical alterations of the tunnels or connective tissue impairments within the nerve. The pathophysiology of compression neuropathy includes oedema, ischemia, and fibrosis of tissues within the nerve and outside of the nerve, which are believed to limit neural gliding. Moderate to severe entrapment neuropathies also present with axonal degeneration and/or demyelination, which causes nerve conduction blocks or slowing down of information transmission. These changes may lead to random electric shock symptoms or symptoms provoked by Tinel's testing. These axonal impairments often involve small fibre (detecting hot/cold and pinprick) during the initial stages of the entrapment neuropathy and large fibre (affecting light touch and muscle contraction) when the neuropathy becomes more severe. Interestingly, neuroinflamation has been suggested to increase the sensitivity of the affected nerve, often causing symptoms beyond the peripheral innervation territory of the compressed nerve. Changes within the central nervous system have also been identified in people with entrapment neuropathies. However, it is still unclear whether changes within the central nervous system can lead to on-going symptoms in absence of peripheral nerve entrapment. From an objective assessment point of view, in addition to motor and monofilament testing (Aβ - large fibre), pin prick testing (Aδ and C - small fibre) should be completed. A loss of function (painless weakness, larger monofilament required, or inability to feel pain on pin prick testing) could be used to confirm a neuropathy. Nerve conduction studies and US imaging may be useful in excluding differential diagnoses. Clinical Take Home Message: Hand therapists should be aware that entrapment neuropathies often present with unconventional peripheral nerve patterns. The distribution of symptoms outside of peripheral nerve patterns or dermatomal patterns does not excluded the presence of an entrapment neuropathy. Pin prick testing should be included in the objective assessment, and US imaging may be useful in assessing nerve edema and exclude other conditions. The same authors have published another article, which has been covered in a previous synopsis. Open Access URL: Abstract Entrapment neuropathies such as carpal tunnel syndrome, radiculopathies, or radicular pain are the most common peripheral neuropathies and also the most common cause for neuropathic pain. Despite their high prevalence, they often remain challenging to diagnose and manage in a clinical setting. Summarising the evidence from both preclinical and clinical studies, this review provides an update on the aetiology and pathophysiology of entrapment neuropathies. Potential mechanisms are put in perspective with clinical findings. The contemporary assessment is discussed and diagnostic pitfalls highlighted. The evidence for the noninvasive and surgical management of common entrapment neuropathies is summarised and future areas of research are identified.


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