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Effects of heavy slow resistance training combined with corticosteroid injections or tendon needling in patients with lateral elbow tendinopathy: A 3-arm randomized double-blinded placebo-controlled study. Couppé, C., et al. (2022) Level of Evidence : 1b Follow recommendation : 👍 👍 👍 👍 (4/4 thumbs up) Type of study : Therapeutic Topic : Lateral epicondylalgia - cortisone injections This is a randomised placebo-controlled trial assessing the benefit of adding cortisone injections or placebo tendon needling to a resistance training program for tennis elbow. A total of 58 participants took part in the study. To be included, participants had to be experiencing symptoms for at least three months. Pain had to be unilateral, located at the lateral epicondyle of the elbow, and participants had to present with at least two of the following: pain on resisted supination, resisted middle finger extension, and resisted wrist extension. Participants were excluded if they presented with elbow osteoarthritis, or had received a cortisone injection in the previous three months. Participant were randomised to cortisone injection (n = 21), tendon needling (n = 17), or placebo tendon needling (n = 20). All groups performed resisted exercises for wrist extension, flexion, and forearm supination three times per week for 12 weeks (see figure below). Each concentric and eccentric phase lasted 3-4 seconds. Several outcomes were assessed and they included function (DASH, QuickDASH) and pain (numerical rating scale). The outcomes were assessed at baseline, 3 months, 6 months, and 12 months. The results showed that participants in all groups improved to a clinically relevant level after three months of treatment. No clinically relevant differences between groups in function/pain were noted at any time point. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message : Based on what we know today, slow resistance training exercises are beneficial for people with tennis elbow. The addition of a corticosteroid injection does not appear to be more effective than placebo needling. In light of previous evidence suggesting that cortisone injections may be associated with a higher likelihood of tennis elbow recurrence at 12 months , we may avoid suggesting this intervention for our clients. In people with tennis elbow, it may also be important to assess the relative strength of wrist extensors and flexors, as this seems to predict the risk of future recurrence . URL : https://doi.org/10.1177/03635465221110214 Abstract BACKGROUND: Lateral elbow tendinopathy is a disabling tendon overuse injury. It remains unknown if a corticosteroid injection (CSI) or tendon needling (TN) combined with heavy slow resistance (HSR) training is superior to HSR alone in treating lateral elbow tendinopathy. PURPOSE/HYPOTHESIS: The purpose was to investigate the effects of HSR combined with either (1) a CSI, (2) TN, or (3) placebo needling (PN) as treatment for lateral elbow tendinopathy. We hypothesized that 12 weeks of HSR in combination with a CSI or TN would have superior effects compared with PN at 12, 26, and 52 (primary endpoint) weeks' follow-up on primary (Disabilities of the Arm, Shoulder and Hand [DASH] score) and secondary outcomes in patients with chronic unilateral lateral elbow tendinopathy. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: A total of 60 patients with chronic unilateral lateral elbow tendinopathy were randomized to perform 12 weeks of home-based HSR with elastic band exercises combined with either (1) a CSI, (2) TN, or (3) PN, and at 12, 26, and 52 weeks, we assessed the primary outcome, the DASH score, and secondary outcomes: shortened version of the DASH (QuickDASH) score, pain (numerical rating scale [NRS] score), pain-free grip strength, and hypervascularization (power Doppler area). RESULTS: A CSI, TN, and PN improved patient outcomes equally based on the DASH (Δ20 points), QuickDASH (Δ21 points), and NRS (Δ2.5 points) scores after 12 weeks. Further, after 12 weeks, a CSI also resulted in decreased hypervascularization (power Doppler area) compared with PN (Δ-2251 pixels, P = .0418). Except for the QuickDASH score (CSI increased score by Δ15 points compared with PN; P = .0427), there were no differences between the groups after 52 weeks. CONCLUSION: These results suggest that 12 weeks of HSR improved symptoms in both the short and the long term and that a CSI or TN did not amplify this effect. In addition, a CSI seemed to impair patient-reported outcomes compared with HSR alone at long-term follow-up. publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings

Abbreviated psychologic questionnaires are valid in patients with hand conditions. Bot, A. G. J., Becker, S. J. E., van Dijk, C. N., Ring, D. and Vranceanu, A.-M. (2013) Level of Evidence : 3b Follow recommendation : 👍 👍 (2/4 thumbs up) Type of study : Diagnostic Topic : Catastrophising and depression - Short forms This was a prospective study assessing the validity of shortened forms assessing pain catastrophising, anxiety, and depression. A total of 164 participants with hand and upper limb conditions were included. These participants completed several questionnaires including the Pain Catastrophising Scale (PCS), the Short Health Anxiety Index (SHAI), and the Patient Health Questionnaire (PHQ). A subset of questions was extracted from the longer version of each questionnaire and their (construct) validity was assessed. The results showed that the PCS-4 (including 4 questions), the SHAI-5 (including five questions), and the PHQ-2 (including two questions) were valid when compared to the full-length questionnaires (see figures below for the short form of these questionnaires). The PHQ-2 shown above was obtained from this link . Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message : Based on what we know today, the short version of the Pain Catastrophising Scale (PCS-4), the Short Anxiety Health Index (SAHI-5), and the Patient Health Questionnaire (PHQ-2; which assesses depression) are valid when compared to their longer questionnaires counterparts. Considering that psychological factors do appear to be associated with pain and disability in people with hand and upper limb conditions, these short forms may be useful in screening our clients. Open Access URL : https://doi.org/10.1007/s11999-013-3213-2 Abstract Background: The Pain Catastrophizing Scale (PCS) and Short Health Anxiety Inventory (SHAI) can help hand surgeons identify opportunities for psychologic support, but they are time consuming. If easier-to-use tools were available and valid, they might be widely adopted. Questions/purposes: We tested the validity of shorter versions of the PCS and SHAI, the PCS-4 and the SHAI-5, by assessing: (1) the difference in mean scaled scores of the short and long questionnaires; (2) floor and ceiling effects between the short and long questionnaires; (3) correlation between the short questionnaires and the outcome measures (an indication of construct validity); and (4) variability in disability and pain, between the short and long questionnaires. Methods: One hundred sixty-four new or followup adult patients in one hand surgery clinic completed the SHAI-18, SHAI-5, PCS-13, PCS-4, Patient Health Questionnaire (PHQ)-9, PHQ-2, DASH, and QuickDASH questionnaires, and an ordinal pain scale, as part of a prospective cross-sectional study. Mean scores for the short and long questionnaires were compared with paired t-tests. Floor and ceiling effects were calculated. Pearson’s correlation was used to assess the correlation between the short and long questionnaires and with outcome measures. Regression analyses were performed to find predictors of pain and disability. Results: There were small, but significant differences between the mean scores for the DASH and QuickDASH (QuickDASH higher), SHAI-18 and SHAI-5 (SHAI-18 higher), and PCS-13 and PCS-4 (PCS-4 higher), but not the PHQ-9 and PHQ-2. Floor effects ranged between 0% and 65% and ceiling effects between 0% and 3%. There were greater floor effects for the PHQ-2 than for the PHQ-9, but floor and ceiling effects were otherwise comparable for the other short and long questionnaires. All questionnaires showed convergent and divergent validity and criterion validity was shown in multivariable analyses. Conclusions: Content validity, construct convergent validity, and criterion validity were established for the short versions of the PCS and SHAI. Using shorter forms creates small differences in mean values that we believe are unlikely to affect study results and are more efficient and advantageous because of the decreased responder burden. publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings

Upper limb position affects pain-free grip strength in individuals with lateral elbow tendinopathy. Cooke, N., Obst, S., Vicenzino, B., Hodges, P. W. and Heales, L. J. (2021) Level of Evidence : 3b Follow recommendation : 👍 👍 (2/4 thumbs up) Type of study : Diagnostic Topic : Tennis elbow - Pain-free grip strength This is a cohort study assessing the effect of elbow and forearm position on pain-free grip (PFG) strength in people with lateral epicondylalgia. Twenty-one participants with tennis elbow were included in the study. Four testing positions, which included elbow flexion/extension in forearm neutral/pronation, were randomly assessed. The results showed that the elbow flexion, forearm neutral position led to the greatest PFG measurement. The other positions showed on average a lower PFG (3 kg lower). These findings were normalised to the contralateral healthy limb and are therefore unlikely to be due to a position effect. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message : Based on what we know today, pain-free grip (PFG) strength position affects the strength clients can develop. The elbow flexion and forearm neutral position appear to be the most appropriate one. It may also be useful to normalise the PFG to the contralateral grip strength to get an understanding of the relative deficit. If you would like more information on staging and treatment of tendinopathies, have a look at this synopsis . URL : https://doi.org/10.1002/pri.1906 Abstract Background and Purpose: Pain-free grip (PFG) force is commonly used to monitor treatment outcomes in lateral elbow tendinopathy (LET); however, it is unclear whether changes in forearm and elbow position affect PFG force values. This study aims to examine the effect of elbow/shoulder and forearm position on non-normalised and normalised PFG force in individuals with unilateral LET. Methods: A cohort study including 21 subjects with clinically diagnosed unilateral LET (13 females, mean [SD] age 50 [8] years) performed PFG force (symptomatic arm) and maximal grip (asymptomatic arm) tasks using four upper limb positions: (1) shoulder neutral, elbow flexed (90°), forearm pronated; (2) shoulder neutral, elbow flexed (90°), forearm neutral; (3) shoulder flexed (90°), elbow extended, forearm pronated; and (4) shoulder flexed (90°), elbow extended, forearm neutral. PFG force was normalised to the maximal grip of the asymptomatic side. Repeated-measures analyses of variance were used to compare non-normalised and PFG force normalised to maximal grip between positions. Results: Both non-normalised and normalised PFG forces were greater in position 2 than position 1, position 3 and position 4 (elbow-by-forearm interaction non-normalised p = 0.002, normalised p = 0.004). There were no differences between positions 1, 3 and 4 for either non-normalised or normalised PFG strength. Discussion: This study shows that PFG force was higher when performed with forearm neutral supination/pronation, elbow flexion and shoulder neutral than other tested positions, and irrespective of whether PFG force was normalised to the maximal grip force of the contralateral limb. This indicates that arm position should be standardised for comparison. publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings

A structured exercise programme combined with proprioceptive neuromuscular facilitation stretching or static stretching in posttraumatic stiffness of the elbow: A randomized controlled trial. Birinci, T., A. Razak Ozdincler, S. Altun and C. Kural (2019) Level of Evidence : 1b Follow recommendation : 👍 👍 👍 👍 (4/4 thumbs up) Type of study : Therapeutic Topic : Post-fracture elbow rehab - Static stretching vs PNF This is a randomised single-blind trial assessing the effectiveness of proprioceptive neuromsucular facilitation (PNF) and static stretching in participants with post-traumatic elbow stiffness following a fracture. Participants (N = 40) were included if they were between 18 and 55, had confirmed fracture healing as per surgeon and imaging review, and had a flexion or extension limitation. Participants were excluded if they had an infection, heterotopic ossification, malunion, or nerve lesions. The effectiveness of each intervention was assessed through the Disability of Arm, Shoulder, and Hand (DASH) questionnaire, elbow range of movement, and several other outcomes, which were not included in this synopsis. The outcomes were measured at baseline, after 6, and 10 weeks. All participants attended two sessions with a physiotherapist each week for 6 weeks. Treatment allocation was randomised. The assessor was blinded to treatment allocation. Participants were provided with either PNF (n = 20) or static stretching (n = 20). The PNF was performed by getting participants to actively resist the stretch for 15 seconds, followed by passive stretching of the joint; this was repeated 10 times with 10 seconds of rest. The static stretching followed a similar routine with a passive stretching held for 20 seconds; this was repeated 10 times with 10 seconds rest. Participants in both groups completed additional exercises, which are available at the following link . Of interest, the PNF and stretching regimes were performed with pain starting from 4/10 and progressed to 7/10. The results showed that both groups improved to a clinically relevant level at 6 weeks on both DASH and elbow range of movement. The between-group difference for the DASH score was not clinically relevant and the improvement in range of movement was similar for both interventions. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message : Based on what we know today, static stretching or PNF appear to equally improve function and range of movement in those who present with elbow stiffness due to a fracture. It appears important to push these interventions into pain and not shy away from it (starting at 4/10 and gradually building up to a max of 7/10), once the fracture has healed. An alternative to these interventions is graded motor imagery , if elbow pain is very high. It is useful to remember that once the client is able to introduce resistance exercises, eccentric training is useful to improve range of movement . URL : https://doi.org/10.1177/0269215518802886 Abstract OBJECTIVES: To compare the different stretching techniques, proprioceptive neuromuscular facilitation (PNF) stretching and static stretching, in patients with elbow stiffness after a treated elbow fracture. DESIGN: Randomized-controlled, single-blind study. SETTING: Department of physiotherapy and rehabilitation. SUBJECTS: Forty patients with posttraumatic elbow stiffness (24 women; mean age, 41.34 ± 7.57 years). INTERVENTION: PNF stretching group ( n = 20), hold-relax PNF stretching combined with a structured exercise programme (two days per week for six weeks); static stretching group ( n = 20), static stretching combined with a structured exercise programme (two days per week for six weeks). MAIN MEASURES: The primary outcome is the Disabilities of the Arm, Shoulder and Hand (DASH). The secondary outcomes are active range of motion (AROM), visual analogue scale (VAS), Tampa Scale for Kinesiophobia, Short Form-12 and Global Rating of Change. Participants were assessed at baseline, after a six-week intervention period and one-month later (follow-up). RESULTS: After treatment, improvement in the mean DASH score was slightly better in the PNF stretching group (8.66 ± 6.15) compared with the static stretching group (19.25 ± 10.30) ( p = 0.03). The overall group-by-time interaction for the 2 × 3 mixed-model analysis of covariance (ANCOVA) was also significant for elbow flexion AROM (mean change for PNF stretching group; static stretching group; 41.10, 34.42, p = 0.04), VAS-rest (-1.31, -1.08, p = 0.03) and VAS-activity (-3.78, -3.47, p = 0.01) in favour of PNF stretching group. The other outcomes did not differ significantly between the two groups. CONCLUSION: The study demonstrated that the structured exercise programme combined with PNF stretching might be effective in patients with posttraumatic elbow stiffness with regard to improving function, elbow flexion AROM, pain at rest and during activity. publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings

Effect of perioperative vitamin C on the incidence of Complex Regional Pain Syndrome: A systematic review and meta-analysis. Seth, I., et al. (2021) Level of Evidence : 1a Follow recommendation : 👍 👍 👍 👍 (4/4 thumbs up) Type of study : Therapeutic/Preventative Topic : Radius fracture - vitamin C to reduce CRPS incidence This is a systematic review and meta-analysis assessing the effectiveness of vitamin C vs placebo in preventing complex regional pain syndrome type I (CRPS-I; absence of nerve lesions) post distal radius fracture and ankle/foot surgery. A total of 7 RCTs and 1 quasi-experimental (no randomisation) study were included in the review. Of these studies, six were completed in people with a distal radius fracture. The total number of participants was 1,427 evenly distributed between vitamin C and placebo treatment. The overall strength of evidence was assessed through the GRADE approach ("low", "very low", "moderate", "high"), which has been suggested by the Cochrane group for systematic reviews. Vitamin C in 500mg or 1g dose was provided daily for 40-50 days post-injury/surgical intervention to the experimental group. The presence of CRPS was assessed from 3 to 12 months. The results showed that there is moderate to high-quality evidence suggesting that 500mg/1g of daily vitamin C significantly reduced (odds ratio: 0.37) the risk of developing CRPS-I compared to placebo. Both dosages (500mg and 1g) were effective in reducing the risk. The risk of complications was equal between placebo and vitamin C. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message : Based on what we know today, 500mg or 1g of vitamin C taken daily for 40-50 days post distal radius fracture can significantly reduce the risk of developing CRPS-I. It may be feasible to reach these dosages through diet, however, considering for example that one medium-size orange contains around 70mg of vitamin C , you would need to eat quite a few of them to reach therapeutic levels. It may be best to refer our clients to a pharmacist to make sure that these dosages of vitamin C are safe for them, and advise on the best vitamin C supplement. URL : https://doi.org/10.1053/j.jfas.2021.11.008 Abstract Complex regional pain syndrome type 1 (CRPS-I) is a complex complication that occurs after limb extremity surgeries. Controversy exists regarding the effectiveness of vitamin C in reducing that condition. Therefore, we conducted this systematic review and meta-analysis to assess the role of vitamin C on CRPS-I and functional outcomes after distal radius, wrist, foot, and ankle surgeries. We searched Medline (via PubMed), Embase, the Cochrane Library, Clinicaltrial.gov, and Google Scholar for relevant studies comparing perioperative vitamin C versus placebo after distal radius, wrist, foot, and ankle surgeries from infinity to May 2021. Continuous data such as functional outcomes and pain scores were pooled as mean differences, while dichotomous variables such as the incidence of complex regional pain syndrome and complications were pooled as odds ratios, with 95% confidence interval, using R software (meta package, version 4.9-0) for Windows. Eight studies were included. The timeframe for vitamin C administration in each study ranged from 42 to 50 days postinjury and/or surgical fixation. The effect size showed that vitamin C was associated with a decreased rate of CRPS-1 than placebo (odds ratio 0.33, 95% confidence interval [0.17, 0.63]). No significant difference was found between vitamin C and placebo in terms of complications (odds ratio 1.90, 95% confidence interval [0.99, 3.65]), functional outcomes (mean difference 6.37, 95% confidence interval [-1.40, 14.15]), and pain scores (mean difference -0.14, 95% confidence interval [-1.07, 0.79]). Overall, vitamin C was associated with a decreased rate of CRPS-I than placebo, while no significant difference was found regarding complications, functional outcomes, and pain scores. These results hold true when stratifying fracture type (distal radius, ankle, and foot surgeries) and vitamin C dose (500 mg or 1 g). publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings

Revisiting the continuum model of tendon pathology: What is its merit in clinical practice and research? Cook, J. L., E. Rio, C. R. Purdam and S. I. Docking (2016). Level of Evidence : 5 Follow recommendation : 👍 Type of study : Aetiology, Therapeutic Topic : Lateral epicondylalgia - Staging and treatment This is a narrative review on tendinopathy staging and their respective treatments. Although this narrative review is 5 years old, I decided to include it in HandyEvidence as it provides useful information for tendinopathy treatment. Staging of tendinopathies has been suggested as a useful way to treat these conditions and these include: reactive, disrepair, and degenerative stages (see picture below). In terms of treatment, during the reactive stage (acute phase), unloading of the tendon is advised. During disrepair and degenerative stages, graded tendon loading has been suggested as an effective approach. The difference between the disrepair and degenerative stage is simply related to the structural reversibility (disrepair) vs non-reversibility (degenerative) of the tendon structure. From a clinical point of view, the distinction between disrepair and degenerative stage may be less relevant as both stages can be treated with good outcomes. One last comment was made in relation to treatments aiming at improving tendon cell proliferation through injections (e.g. PRP injections). In particular, the rationale for the use of these interventions was questioned due to an already excessive proliferation of cells across all the three tendinopathy stages (reactive, disrepair, and degenerative). Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message : Based on what we know today, tendinopathies can be classified and treated according to their pathological stage. Treatments can vary from unloading (during the reactive stage) to graded loading (during the disrepair or degenerative stage). These concepts can be applied to several conditions such as lateral epicondylalgia (i.e. tennis elbow) or De Quervain tenosynovitis. If we consider for example lateral epicondylalgia, for an acute reactive tendinopathy, we may provide our clients with a counterforce brace, which appears to reduce loading at the common extender tendon during daily activities and improve pain-free grip strength . Once the acute reactive stage has settled and the irritability has improved (reduction in pain intensity and duration of symptoms after mechanical loading), graded loading may be appropriate. During this stage, graded resistance training has been suggested as an effective approach without one form of loading (e.g. eccentric, concentric, isometric) deemed superior to another . It is however possible that for lateral epicondylalgia, eccentric resistance training may provide better analgesia . Open access URL : https://bjsm.bmj.com/content/50/19/1187 Abstract The pathogenesis of tendinopathy and the primary biological change in the tendon that precipitates pathology have generated several pathoaetiological models in the literature. The continuum model of tendon pathology, proposed in 2009, synthesised clinical and laboratory-based research to guide treatment choices for the clinical presentations of tendinopathy. While the continuum has been cited extensively in the literature, its clinical utility has yet to be fully elucidated. The continuum model proposed a model for staging tendinopathy based on the changes and distribution of disorganisation within the tendon. However, classifying tendinopathy based on structure in what is primarily a pain condition has been challenged. The interplay between structure, pain and function is not yet fully understood, which has partly contributed to the complex clinical picture of tendinopathy. Here we revisit and assess the merit of the continuum model in the context of new evidence. We (1) summarise new evidence in tendinopathy research in the context of the continuum, (2) discuss tendon pain and the relevance of a model based on structure and (3) describe relevant clinical elements (pain, function and structure) to begin to build a better understanding of the condition. Our goal is that the continuum model may help guide targeted treatments and improved patient outcomes. publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings

The influence of kinesiophobia on perceived disability in patients with an upper-extremity injury: A critically appraised topic. Bartlett, O. and J. L. Farnsworth (2021) Level of Evidence : 2a Follow recommendation : 👍 👍 👍 Type of study : Symptoms prevalence study Topic : Psychology in upper limb conditions - Kinesiophobia and disability This was a systematic review of studies assessing the association between kinesiophobia and self-perceived disability in participants with an upper limb injury. Three studies in total were included, two of which were cross-sectional studies and one a prospective study. A total of 1,140 general population participants (no athletes) were included across all studies. Kinesiophobia was assessed through the Tampa Scale for Kinesiophobias (TKS) and upper limb disability was assessed through the Disability of the Arm, Shoulder and Hand (DASH) or the Shoulder Pain and Disability Index (SPADI). The results showed that kinesiophobia was a significant predictor of upper limb disability. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message : Based on what we know today, fear of movement contributes to disability in upper limb injuries in the general population. It may be useful to keep this in mind when treating our clients and immobilise a joint/limb only if required. Following tissue healing, reassuring patients that pain is probably associated with tissue sensitivity rather than actual tissue damage may be a useful approach to reduce pain and self-reported disability. Open Access URL : https://doi.org/10.1123/jsr.2020-0179 Abstract Clinical Scenario: Kinesiophobia is a common psychological phenomenon that occurs following injury involving fear of movement. These psychological factors contribute to the variability among patients' perceived disability scores following injury. In addition, the psychophysiological, behavioral, and cognitive factors of kinesiophobia have been shown to be predictive of a patient's self-reported disability and pain. Previous kinesiophobia research has mostly focused on lower-extremity injuries. There are fewer studies that investigate upper-extremity injuries despite the influence that upper-extremity injuries can have on an individual's activities of daily living and, therefore, disability scores. The lack of research calls for a critical evaluation and appraisal of available evidence regarding kinesiophobia and its contribution to perceived disability for the upper-extremity. Focused Clinical Question: How does kinesiophobia in patients with upper-extremity injuries influence perceptions of disability and quality of life measurements? Summary of Key Findings: Two cross-sectional studies and one cohort study were included. The first study found a positive relationship between kinesiophobia and a high degree of perceived disability. Another study found that kinesiophobia and catastrophic thinking scores were the most important predictors of perceived upper-extremity disability. The third study found that kinesiophobia contributes to self-reported disability in the shoulder. Clinical Bottom Line: There is moderate evidence that supports the relationship between kinesiophobia and perceived disability, and the relationship between elevated perceptions of disability and increased kinesiophobia scores in patients with an upper-extremity injury. Clinicians should evaluate and monitor kinesiophobia in patients following injury, a condition that can enhance perceptions of disability. An elevated perception of disability can create a cycle of fear that leads to hypervigilance and fear-avoidance behavior. Strength of Recommendation: Consistent findings from reviewed studies suggest there is grade B evidence to support that kinesiophobia is related to an increased perceived disability following upper-extremity injuries. publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings

The efficacy of graded motor imagery in post-traumatic stiffness of elbow: A randomized controlled trial. Birinci, T., E. K. Mutlu and S. Altun (2022) Level of Evidence : 1b Follow recommendation : 👍 👍 👍 👍 (4/4 thumbs up) Type of study : Therapeutic Topic : Post-fracture elbow rehab - graded motor imagery This is a randomised single-blind controlled trial assessing the effectiveness of Graded Motor Imagery (GMI) and traditional rehabilitation in participants following surgical treatment of an elbow fracture. Participants (N = 50) were included if they were between 20 and 55, if they were 4 to 8 weeks postoperatively, and if they had elbow stiffness. Participants were excluded if they had an infection, heterotopic ossification, malunion, or nerve lesions. The effectiveness of each intervention was assessed through the Disability of Arm, Shoulder, and Hand (DASH) questionnaire, elbow range of movement, and several other outcomes, which were not included in this synopsis. The outcomes were measured at baseline and after 6 weeks of treatment. All participants attended two sessions with a physiotherapist each week for 6 weeks. Treatment allocation was randomised. The assessor was blinded to treatment allocation. Participants were provided with either GMI (n = 25) or traditional rehabilitation (n = 25). Participants in the GMI completled left/right-hand discrimination during the first stage. This was followed by explicit motor imagery in which participants had to look at a hand/shoulder picture and imagine moving their upper limb. The last phase of the GMI involved mirror therapy. The traditional rehabilitation group included a gradual range of movement, stretching, and strengthening program. The results showed that both groups improved to a clinically relevant level at 6 weeks. Function improved to a larger extent in the GMI compared to the traditional rehabilitation group (10 points out of 100 between-group difference), although it is uncertain whether this difference was clinically relevant. Similarly, range of movement was slightly larger for the GMI group, but it is unclear whether this would be clinically relevant. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message : Based on what we know today, traditional rehabilitation or graded motor imagery appear to equally improve function and range of movement in people treated surgically for an elbow fracture. These findings are similar to previous research showing similar effectiveness of GMI and standard rehabilitation following a distal radius fracture . Graded motor imagery may be particularly appropriate in the initial stages of the rehabilitation when immobilisation is required and pain may limit clients' willingness to perform exercises. URL : https://doi.org/10.1016/j.jse.2022.05.031 Abstract Background: Physiotherapy improves the movement range after the onset of post-traumatic elbow stiffness and reduces the pain, which is a factor limiting elbow range of motion. However, no results have been reported for motor-cognitive intervention programs in post-traumatic elbow stiffness management. The objective was to investigate the efficacy of Graded Motor Imagery (GMI) in post-traumatic elbow stiffness. Methods: Fifty patients with post-traumatic elbow stiffness (18 female; mean age, 41.9±10.9 years) were divided into two groups. The GMI group (n=25) received a program consisting of left/right discrimination, motor imagery, and mirror therapy (twice a week for six weeks); the structured exercise (SE) group (n=25) received a program consisting of the range of motion, stretching, and strengthening exercises (twice a week for six weeks). Both groups received a 6-week home exercise program. The primary outcome was the Disabilities of the Arm, Shoulder and Hand (DASH). The secondary outcomes were the active range of motion (AROM), Visual Analogue Scale (VAS), Tampa Scale for Kinesiophobia (TSK), muscle strength of elbow flexors and extensors, grip strength, left/right discrimination, and Global Rating of Change. Patients were assessed at baseline, at the end of treatment (12 sessions), and a 6-week follow-up. Results: The results indicated that both GMl and SE interventions significantly improved outcomes (p<0.05). After a 6-week intervention, the DASH score was significantly improved with a medium effect size in the GMI group compared to the SE group and improvement continued at the 6-week follow-up (F1,45=3.10, p=0.01). The results with a medium to large effect size were also significant for elbow flexion AROM (p=0.02), elbow extension AROM (p=0.03), VAS-activity (p=0.001), TSK (p=0.01), muscle strength of elbow flexors and elbow extensors (p=0.03) in favor of GMI group. Conclusion: The GMI is an effective motor-cognitive intervention program that might be applied to the rehabilitation of post-traumatic elbow stiffness to improve function, elbow AROM, pain, fear of movement-related pain, and muscle strength. publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings

Determining the level of cervical radiculopathy: Agreement between visual inspection of pain drawings and magnetic resonance imaging. Barbero, M., et al. (2022) Level of Evidence : 2b Follow recommendation : 👍 👍 👍 (3/4 thumbs up) Type of study : Symptoms prevalence study Topic : Cervical radiculopathy – Dermatomal patterns This is a retrospective study assessing whether clinicians were able to determine the level of cervical radiculopathy given pain drawings. A total of 98 participants with single-level cervical radiculopathy were recruited. Participants were included if they presented with persistent pain for at least two months, were between 18 and 70, and showed evidence of radiculopathy on MRI. Potential participants were excluded if they had any fractures, previous surgery to the cervical spine, and multilevel cervical radiculopathy. Two musculoskeletal physiotherapists and spine surgeons with a minimum of 17 and 22 years of experience respectively, determined the level of radiculopathy based on the pain drawings. The results showed that both the physiotherapists and surgeons presented a low level of agreement with the MRI findings regarding the level of cervical radiculopathy (see table below for further details). Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message : Based on what we know today, even experienced clinicians are unable to identify correctly the level of cervical radiculopathy based on pain distribution. This is not surprising as pain/numbness of single-level radiculopathies does not always follow the dermatomal distribution . It is possible that the combination of subjective and objective assessment, including cervical myotomes , will help clinicians determine the radiculopathy level. If you would like to read more about cervical radiculopathies, look at the whole database . URL : https://doi.org/10.1111/papr.13147 Abstract Background and Aims: Pain drawings are commonly used in the clinical assessment of people with cervical radiculopathy. This study aimed to assess: 1) the agreement of clinical interpretation of pain drawings and MRI findings in identifying the affected level of cervical radiculopathy 2) the agreement of these predictions based on the pain drawing among four clinicians from two different professions (i.e. physiotherapy and surgery) 3) the topographical pain distribution of people presenting with cervical radiculopathy (C4 to C7). Methods: Ninety-eight pain drawings were obtained from a baseline assessment of participants in a randomised clinical trial, in which single-level cervical radiculopathy was determined using MRI. Four experienced clinicians independently rated each pain drawing, attributing the pain distribution to a single nerve root (C4-C7). A post-hoc analysis was performed to assess agreement. Outcome measures: Percentage agreement and kappa values were used to assess the level of agreement. Topographic pain frequency maps were created for each cervical radiculopathy level as determined by MRI. Results: The radiculopathy level determined from the pain drawings showed poor overall agreement with MRI (mean=35.7%, K=-0.007-0.139). The inter-clinician agreement ranged from fair to moderate (K=0.212-0.446). Topographic frequency maps revealed that pain distributions were widespread and overlapped markedly between patients presenting with different levels cervical radiculopathy. Conclusion: This study revealed a lack of agreement between the segmental level affected determined from the patient's pain drawing and the affected level as identified on MRI. The large overlap of pain and non-dermatomal distribution of pain reported by patients likely contributed to this result. publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings

Reliable change and minimum important difference (MID) proportions facilitated group responsiveness comparisons using individual threshold criteria. Schmitt, J. S. and R. P. Di Fabio (2004) Level of Evidence : 1b Follow recommendation : 👍 👍 👍 (3/4 thumbs up) Type of study : Diagnostic Topic : Minimal clinically important difference - DASH This was a prospective study assessing the minimally clinically important difference in the Disability of the Arm, Shoulder, and Hand questionnaire in people undergoing hand therapy. By minimal clinically important difference, we refer to the smallest change in a measure (e.g. DASH) which can be considered as a real improvement in the clinical presentation of our clients. In this study, the anchor-based method calculated the minimal clinical important difference by determining the score of those participants who report benefiting from the intervention/treatment. In this paper, a total of 155 participants with shoulder, elbow, wrist, and hand problems were included. These participants underwent three months of hand therapy regime, after which their DASH score was recorded. The results showed that, for those patients with elbow, wrist, and hand conditions, the minimal clinically important difference was 17 points out of 100. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message : Based on what we know today, the minimal clinically important difference for the DASH is 17 points out of 100. This is similar to the minimal clinically important difference for the QuickDASH, which was 18 out of 100 points . This means that if one of our clients scored 50/100 on the QuickDASH at the first assessment and 33/100 on discharge, we would have achieved a clinically meaningful improvement. Considering that both the QuickDASH and DASH present the same minimal clinically important difference, we can confidently choose the QuickDASH, which takes less time to complete. URL : https://doi.org/10.1016/j.jclinepi.2004.02.007 Abstract Objective: This study contrasted the use of responsiveness indices at the group level vs. individual patient level. Study Design and Setting: We followed a cohort of 211 patients (50% male; mean age 47.5 years; SD 14) with musculoskeletal upper extremity problems for a total of 3 months. Outcome measures: included the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, Shoulder Pain and Disability Index (SPADI), Patient-Rated Wrist Evaluation (PRWE), and the Medical Outcomes Study 12-Item Short-Form Health Survey (SF-12). We calculated confidence intervals on various group-level responsiveness statistics based on effect size and correlation with global change. The proportion of patients exceeding the minimum detectable change (or reliable change proportion) and minimum important difference (MID proportion) were included as indices applicable to the individual patient. Results: For the DASH, effect size ranged from 1.06 to 1.67 for various patient subgroups, and the reliable change and MID proportions indicated that 50%–70% of individuals exhibited change based on individual change scores. Only the SRM and reliable change proportion indicated differences among the outcome measures used in this study. Conclusion: The reliable change and MID proportions have an intuitive interpretation and facilitate quantitative responsiveness comparisons among outcome measures based on individual patient criteria. publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings

Does reading a book in bed make a difference to sleep in comparison to not reading a book in bed? The People’s Trial—an online, pragmatic, randomised trial. Finucane, E., et al. (2021) Level of Evidence : 1b- Follow recommendation : 👍 👍 👍 👍 (4/4 thumbs up) Type of study : Therapeutic Topic : Reading in bed - Sleep quality This is randomised pragmatical trial assessing whether sleeping before bed improves sleep within one week in healthy participants. A total of 774 participants took part in the study. Participants were randomised to either read a book for 15-30 minutes prior to sleeping or the control group, who did not read a book. Both groups could use devices such as phone/tablet prior to sleeping if they liked. Sleep quality was assessed at baseline and after one week through the single item sleep quality scale. The results showed that sleep improve by 8% to 22% in the reading group compared to the control. In a small portion of the reading (10%) and control group (16%), sleep worsened after one week. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message : Based on what we know today, reading in bed at night for 15-30 minutes improves sleep quality. This may be useful advice for our clients as it appears that worse sleep increases the risk of them developing persistent pain . Considering that this is a simple, low-cost option to improve sleep, it may be worth trialling. Open Access URL : https://doi.org/10.1186/s13063-021-05831-3 Abstract Background: The best way of comparing healthcare treatments is through a randomised trial. In a randomised trial, we compare something (a treatment or intervention) to something else, often another treatment. Who gets what is decided at random, meaning everyone has an equal chance of getting any of the treatments. This means any differences found can be put down to the treatment received rather than other things, such as where people live, or health conditions they might have. The People’s Trial aimed to help the public better understand randomised trials by inviting them to design and carry out a trial. The question chosen by the public for The People’s Trial was: ‘Does reading a book in bed make a difference to sleep, in comparison to not reading a book in bed?’ This paper describes that trial, called ‘The Reading Trial’. Methods: The Reading Trial was an online, randomised trial. Members of the public were invited to take part through social media campaigns. People were asked to either read a book in bed before going to sleep (intervention group) or not read a book in bed before going to sleep (control group). We asked everyone to do this for 7 days, after which they measured their sleep quality. Results: During December 2019, a total of 991 people took part in The Reading Trial, half (496 (50%)) in the intervention group and half (495 (50%)) in the control group. Not everyone finished the trial: 127 (25.6%) people in the intervention group and 90 (18.18%) people in the control group. Of those providing data, 156/369 (42%) people in the intervention group felt their sleep improved, compared to 112/405 (28%) of those in the control group, a difference of 14%. When we consider how certain we are of this finding, we estimate that, in The Reading Trial, sleep improved for between 8 and 22% more people in the intervention group compared to the control group. Conclusions: Reading a book in bed before going to sleep improved sleep quality, compared to not reading a book in bed. publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings

Hand laterality recognition in distal radius and/or ulna fracture. Geete, D. B., P. U. Mehta, N. Dewan and A. A. Mehta (2022) Level of Evidence : 3b Follow recommendation : 👍 👍 (2/4 thumbs up) Type of study : Aetiologic Topic : Motor imagery - Immobilisation This is a case-control study assessing differences in motor imagery following immobilisation in people who had a distal radius/ulna fracture. A total of 60 participants were included in the study. Of these, 30 had undergone 4-6 weeks of wrist immobilisation and 30 were age-matched controls. Motor imagery was assessed through a hand left-right discrimination task (reaction time and response accuracy). The results showed that participants who had undergone immobilisation were significantly slower (0.4 seconds slower) and less accurate (20% less accurate) in discriminating between left-right hands during the motor imagery task. It is unknown whether these impairments resolved with rehabilitation as there wasn't a longer-term follow-up. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message : Based on what we know today, clients who undergo a period of immobilisation, are likely to present with impairments in hand motor imagery. This is similar to what happens with persistent pain (e.g. Hand OA) and may be due to limb disuse. We should probably aim at keeping immobilisation to a minimum as we know that early mobilisation, if possible, not only improves function but also the psychological well-being of our clients . URL : https://doi.org/10.1016/j.jht.2022.01.003 Abstract Introduction: Hand laterality, an important ability to determine the orientation of a limb is common to get affected after short term immobilization. Distal radius and/or ulna fracture is a commonly encountered fracture resulting from upper-limb trauma. Conservative treatment using closed reduction and plaster cast application to immobilize the joint remains choice of treatment over surgery in the treatment of these fractures. There is a paucity of literature reporting impairment in hand laterality after long term immobilization as commonly performed in patients with distal radius and/or ulna fractures. Understanding effect of immobilization on hand laterality in distal-end radius/ulna fractures warranted present investigation. Purpose: To evaluate hand laterality based on the accuracy and response time for hand determination after plaster cast removal in distal radius and/or ulna fracture. Study design Prospective cross-sectional study. Methodology: Subjects (n = 60, age range = 40-59 years, females (n) = 28 and males (n) = 32) were shown 24 real-hand images with various degrees of angular rotation and instructed to identify the hand as left and/or right. Accuracy (% correctly identified) and Response time (milliseconds to identify left or right hand in the image) of motor imagery during hand laterality task were recorded. Pain intensity before and after the hand laterality task were noted using Visual Analogue Scale. Repeated measures of ANOVA and t-tests were used to analyze the accuracy and response times among two groups. Results: The experimental group showed significantly (P < .05) lower accuracy and longer response time as compared to the control group. No significant difference in the accuracy and response time were noted in the immobilization of the dominant and the non-dominant hand within the experimental group (P > .05). Also, there was no change in pain pre- to post-hand laterality task. Conclusion: Findings of this study could aid in enhancing the understanding of post-immobilization effect on hand laterality and open new arenas for assessment and rehabilitation of distal-end radius and/or ulna fractures where immobilization is the principal treatment. publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings