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Surgical excision of a thrombosed persistent median artery in a professional hockey player. Sheridan, J., G. Waslewski and D. Sheridan (2022) Level of Evidence : 5 Follow recommendation : 👍 (1/4 thumbs up) Type of study : Diagnostic/Therapeutic This is the answer to last week's Sherlock Handy. The patient was a 29 years old, right-handed, male professional hockey player presenting with two months insidious onset of pain at the carpal tunnel, which also presented with intermittent median nerve distribution paraesthesia. On objective examination there was no obvious deformity, range of movement was full, and Allen’s test was normal. However, Tinel’s, Phalen’s, and Durkan’s tests were positive. There was also a slight reduction in two-point discrimination at the median compared to the ulnar nerve distribution of the hand. The MRI imaging is shown below. The report identified the presence of a median artery (present in 10% of the population), which was associated with thrombosis. Surgery debrided the thrombosis and removed the median nerve artery after the surgeon had confirmed the evidence of a sufficient vascular supply from the radial and ulnar artery. After surgery, the patient wore a wrist splint for 4 weeks after which a strengthening regime was initiated. They resumed playing hockey at 6 weeks. Several months after surgery, they still presented with minor pain in the wrist, but no paraesthesias in the median nerve distribution. 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, carpal tunnel syndrome is a clinical presentation with several potential causes. An ultrasound investigation may be useful to exclude the presence of space invading lesions or other anatomical variations such as the one described in this article. Imaging to exclude the presence of space invading lesions is often utilised to assess people with cubital tunnel syndrome and may be useful for the assessment of carpal tunnel syndrome too. Furthermore, ultrasound imaging is often required prior to the delivery of a cortisone injection, which has been shown to be quite effective for people with carpal tunnel syndrome . I f you are interested in tests for carpal tunnel syndrome, have a look at this synopsis . URL : https://doi.org/10.1016/j.jhsa.2021.01.002 Abstract A persistent median artery is a rare anatomical variant found in approximately 10% of the population. Carpal tunnel syndrome due to a thrombosed persistent median artery is exceptionally rare. A 29-year-old professional hockey player presented with a 2 months history of hand pain and intermittent paresthesias without vascular symptoms. Magnetic resonance imaging and angiography demonstrated a 2-cm thrombosis in a persistent median artery at the level of the carpal tunnel, with otherwise normal vascular anatomy. He was treated with surgical excision of the thrombus and carpal tunnel decompression. The patient's symptoms resolved rapidly and he was able to return to sport without restrictions. Incidental imaging performed several months after surgery demonstrated a normal vascular pattern in the treated hand. 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

Arm sling after carpal tunnel surgery: Myth or evidence based? Kroeze, M., Rakhorst, H., & Houpt, P. (2020) Level of Evidence : 2c Follow recommendation : 👍 👍 (2/4 thumbs up) Type of study : Therapeutic Topic : Carpal tunnel release post-surgical care - sling vs no sling This is a quasi-experimental study (no randomisation) assessing the effect of an arm sling for elevation vs no sling use following carpal tunnel (CT) release surgery on swelling, full fist range of movement, pain, and function. All patients underwent an open CT release and the sling group was advised to wear it for 3-4 days while the no sling group kept their hands in their preferred position. The results showed no difference between groups on swelling, full fist range of movement, or pain 3-4 days post-surgery. At six weeks there was no difference in function when measured through the Boston Carpal Tunnel Questionnaire. 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, there is no need to wear an arm sling following carpal tunnel release. Arm slings do not appear to provide benefits in terms of swelling, range of movement, pain, or function in this group of patients. If you would like to have a look at the full collection of synopses on carpal tunnel syndrome, you can find it here . URL : https://doi.org/10.1177%2F1753193419880312 Abstract Arm sling elevation is widely used after hand surgery to prevent swelling and pain. This prospective cohort study investigated whether arm sling elevation has any value after carpal tunnel release surgery. Patients were assigned to one of two groups after carpal tunnel release: with or without arm sling elevation. The primary outcome was postoperative swelling. Secondary outcomes were pain and symptom relief and functional outcome. Volumetric analysis showed no significant difference between the sling and non-sling group. Pain scores and improvement of symptom severity and functional status scores were similar for both groups. Thirty-eight per cent found the sling uncomfortable. These results do not support routine use of arm sling elevation after carpal tunnel release. 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

Stress, non-restorative sleep, and physical inactivity as risk factors for chronic pain in young adults: A cohort study. Lindell, M. and A. Grimby-Ekman (2022) Level of Evidence : 2b Follow recommendation : 👍 👍 (2/4 thumbs up) Type of study : Prognostic Topic : Persistent pain risk factors - Young adults This is a longitudinal study assessing the association between risk factors and the development of persistent pain in young adults. A total of 1,759 participants without pain at baseline were included. Participants’ age ranged from 19 to 25. Participants filled out a series of questionnaires which included self-reports of stress, sleep quality, and weekly physical activity. People were defined as stressed if they reported this feeling for more than seven consecutive days in a row. Disturbed sleep was defined as consistently waking up not feeling rested for more than two times a week. Participants who did not take part in any physical activity in the week prior to baseline assessment were defined as inactive. At one and four years follow up, researchers asked participants whether they presented with persistent pain (more than 90 days per year). The results showed that people who were stressed, had non-restorative sleep, and were inactive were more likely to have persistent pain at one year. In particular, stress in the past year increased the odds of presenting with persistent pain by 60%, bad sleep twice weekly/everyday increased the odds by 50%, and those people who participated in no physical activity had 80% increased odds. At four years follow up, only stress was associated with persistent pain (90% increase in odds). 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, young adults who are stressed, don’t get good sleep, and are physically inactive, have a greater chance of presenting with persistent pain at one year (including upper limb persistent pain). This study adds to the growing amount of evidence suggesting that factors other than biomechanics contribute to the development of persistent pain. This does not mean that biomechanics are not important, but that they play a smaller role in the development of persistent pain compared to what clinicians and researchers used to believe. Open Access URL : https://doi.org/10.1371/journal.pone.0262601 Abstract Background: Chronic pain is a common condition which causes patients much suffering and is very costly to society. Factors known to be associated with chronic pain include female gender, acute pain, depression, and anxiety. This study investigated whether stress, sleep disturbance, and physical inactivity were risk factors for developing chronic pain among young adults, and whether there were any interactions between these. Methods: This retrospective longitudinal study was based on an existing database from a cohort study on IT use and health, called Health 24 Years. A questionnaire was sent to students aged 19–24 in Sweden for five consecutive years, containing questions on pain, stress, sleep, physical activity, technology use, health, and more. In logistic regressions, stress, sleep, and physical activity at baseline were potential predictors of chronic pain one and four years later. In addition, a new variable including all possible interactions between potential predictors was created to test for effect modification between risk factors. Results: At the one-year follow-up, stress, non-restorative sleep, and physical inactivity showed odds ratios of 1.6 (95% CI: 1.0–2.4), 1.5 (95% CI: 1.0–2.3), and 1.8 (95% CI: 1.1–3.0) respectively after adjusting for confounders, the reference being non-stressed, having restorative sleep and being active. At the four-year follow-up, stress showed an adjusted odds ratio of 1.9 (95% CI: 1.3–2.9), while non-restorative sleep and physical inactivity were statistically insignificant. At the one-year follow-up, the interaction between risk factors were significant. The most clear example of this effect modification was to be inactive and not have -restorative sleep, compared to individuals who were active and had restorative sleep, showing an adjusted odds ratio of 6.9 (95% CI: 2.5–19.2) for developing chronic pain one year after baseline. This in comparison of odds ratios for only inactive respectively only non-restorative sleep being 1.7 (95% CI: 0.6–5.3) respectively 1.6 (95% CI: 0.7–3.5). Conclusions: Stress, non-restorative sleep, and physical inactivity were risk factors for developing chronic pain one year after baseline, and stress were also a risk factor four years after baseline. These findings suggest that non-restorative sleep and inactivity are risk factors in the short term while stress is a risk factor in both the short and the long term. In addition to the independent effects of non-restorative sleep and inactivity, their combination seems to further increase the odds of chronic pain. 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

Boxer's elbow: Internal impingement of the coronoid and olecranon process. A report of seven cases. Robinson, P. M., Loosemore, & M., Watts, A. C. (2017) Level of Evidence : 5 Follow recommendation : 👍 (1/4 thumb up) Type of study : Diagnostic/Therapeutic Topic : Boxer's elbow - Locking This is a case series describing Boxer's elbow syndrome, which is characterised by anterior or posterior elbow pain. The onset of this syndrome is characterised by hyperextension or hyperflexion injuries that occur when missing a punch or pushing off the opponent following a clinch. Mechanical impingement is produced by olecranon vs posterior fossa or coronoid process vs anterior fossa. Objectively, patients present with pain on palpation of the postero-lateral joint line, swelling, pain with full elbow flexion or extension, but with symptomless pronation-supination. X-ray imaging to exclude loose bodies may be required if patients report locking. This investigation will detect, if present, osteophytes, which can be responsible for objective limitations in extension or flexion. Conservative treatment may be appropriate, however, if symptoms do not resolve and locking is present, referral to an orthopaedic surgeon is required. 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, Boxer's elbow is characterised by anterior or posterior elbow pain following a hyperflexion or hyperextension injury respectively. Despite its name, gymnasts and weightlifters can present with the same syndrome. Imaging may be required to exclude the presence of osteophytes and/or loose bodies. Referring to an orthopaedic surgeon is appropriate if there are no improvements with conservative treatment or if the elbow is locking, which is suggestive of loose bodies. If we encounter a similar presentation in kids, we should exclude other conditions such as osteochondritis dissecans . URL : https://doi.org/10.1016/j.jse.2016.09.035 Abstract Background: Boxer's elbow has been described in the literature as an extension and hyperextension injury. However, in our experience, there is a coexisting impingement lesion in the anterior compartment of the elbow that has not previously been described. We report a series of professional boxers with elbow disease treated arthroscopically. The aim of the paper was to accurately describe the pathoanatomy of the condition, the key points in its diagnosis, and the outcomes of surgical treatment. Methods: Seven professional boxers were treated for symptomatic elbow disease. Clinical evaluation included range of motion and Disabilities of the Arm, Shoulder, and Hand score. The arthroscopic findings and procedures were documented. Results: Symptoms were mainly those of anterior and posterior impingement; 6 elbows had an anterior impingement lesion and 6 had a posterior impingement lesion. Postoperatively, the mean Disabilities of the Arm, Shoulder, and Hand score was 2.7 (range, 0-13.3) at a median of 15 (range, 6-36) months postoperatively. All boxers returned to their previous level of competition and 5 won their next bout. All of the boxers used an orthodox stance, and in all but 1 case the left elbow was the pathologic elbow. Conclusion: Boxers are prone to development of anterior and posterior elbow impingement. The side of the pathologic process is related to the boxer's stance, with the lead arm being more vulnerable. Arthroscopic débridement is an effective treatment, enabling return to a high competitive level. Surgeons, sports medicine physicians, and physiotherapists should be aware of the condition. 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

Level of Evidence : 5 Follow recommendation : 👍 (1/4 thumbs up) Type of study : Diagnostic/Therapeutic Have a think about this case study. Leave a diagnostic comment if you like. The patient was a 29 years old, right-handed, male professional hockey player presenting with two months insidious onset of pain at the carpal tunnel, which also presented with intermittent median nerve distribution paraesthesia. On objective examination there was no obvious deformity, range of movement was full, and Allen’s test was normal. However, Tinel’s, Phalen’s, and Durkan’s tests were positive. There was also a slight reduction in two-point discrimination at the median compared to the ulnar nerve distribution of the hand. The MRI imaging is reported below. What is it?

Effectiveness of the graded motor imagery to improve hand function in patients with distal radius fracture: A randomized controlled trial. Dilek, B., Ayhan, C., Yagci, G., & Yakut, Y. (2018) Level of Evidence : 2b Follow recommendation : 👍 👍 👍 (3/4 thumbs up) Type of study : Therapeutic Topic : Radius fracture - graded motor imagery This is a randomised single-blind controlled trial assessing the effectiveness of Graded Motor Imagery (GMI) and traditional rehabilitation in participants with distal radius fracture. Participants (N = 36) were included if they had undergone a closed fracture reduction or an open reduction internal fixation surgery. Participants were excluded if they had bilateral fracture or had any neurological/rheumatological condition. Effectiveness of each intervention was assessed through pain at rest (VAS), range of movement (degrees of wrist movement), and function (DASH). The outcomes were measured at baseline and after 8 weeks of treatment. All participants attended two session (1 hour each) with a physiotherapist each week for 8 weeks. Participants in every group received a home exercise program. Treatment allocation was randomised. The assessor was blind to treatment allocation. Participants were provided with either GMI (n = 17) or traditional rehabilitation (n = 19). Participants in the GMI completled 3 weeks of left/right hand discrimination (10 minutes each waking hour). This was followed by 3 weeks of explicit motor imagery in which participants had to look at a hand picture and imagining moving their own hand (10 minutes each waking hour). The last phase of the GMI (2 weeks) involved mirror therapy (10 minutes each waking hour). The traditional rehabilitation group included a gradual AROM home exercise program which was then progressed into resistance exercises towards the end of the intervention program. There were no differences between groups in the number of participant that undervent a conservative or surgical intervention for their fracture. All the participants reported high adherence to the physiotherapy intervention (100%) and home exercise program (90-100%), although the latter was self-reported. The results showed that GMI improved pain at rest (GMI - Mean difference: 2.2, SD: 2.1; Control - Mean difference: 1,1, SD: 1.2) and function (GMI - Mean difference: 38, SD: 14.3; Control - Mean difference: 27, SD: 17) to a statistically and clinically significant level compared to the traditional rehabilitation group. From a practical poin of view, these results suggest that there is an average improvement in pain at rest of 2 points out of 10 with GMI (clinically significant change) and 1 point out of 10 with traditional physiotherapy (non clinically significant change). For function, there is an improvement of 38 points on the DASH with GMI and 27 points with traditional physiotherapy (both clinically significant changes). Contrasting results were reported in text and in the tables for range of movement. It is therefore not possible to comment on these findings with certainty. 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 : Hand therapists may choose GMI training if the main goal of rehabilitation is to reduce pain and improve function. This may be particularly appropriate in patients presenting with high levels of pain within the first week of injury (these patients are also more likely to develop CRPS ). It is unclear whether GMI can lead to improvements in range of movement. Open Access URL : https://doi.org/10.1016/j.jht.2017.09.004 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

Osteoarthritis as an inflammatory disease (osteoarthritis is not osteoarthrosis!). Berenbaum, F. (2013) Level of Evidence : 5 Follow recommendation : 👍 👍 (2/4 thumbs up) Type of study : Aetiology Topic : Osteoarthritis - Beyond instability and biomechanics This is a narrative review on the role of factors other than instability and biomechanics in the development of pain associated with osteoarthritis (OA). The authors report evidence from several studies suggesting that synovitis and inflammation are key features of osteoarthritis. In particular, high levels of systemic inflammation (C reactive protein) have been shown to correlate with symptoms and evidence of synovitis in osteoarthritic joints. In addition, a low-grade autoimmune response appears to potentially contribute to the development or maintenance of OA. Interestingly, obese people appear to present with a greater risk of developing hand OA, suggesting that factors other than biomechanics potentially contribute to the development of osteoarthritis. Of interest is also the association between distal interphalangeal OA and the presence of carotid artery atherosclerosis. Once again suggesting that low-grade inflammation may be contributing to the development of both OA and cardiovascular comorbidities. 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, OA has a wide range of contributing factors and is not only due to biomechanical or instability factors. This is probably why a recently published study showed that factors such as BMI, sleep quality, physical activity, and overall perceived health are able to predict (at least partially) who is more likely to develop hand OA . In addition, evidence from another research group has shown that alteration of sleep patterns in shift workers is associated with higher levels of inflammation (C reactive protein) and that the greater the level of inflammation the greater pain intensity . Open Access URL : https://doi.org/10.1016/j.joca.2012.11.012 Abstract Summary Osteoarthritis (OA) has long been considered a “wear and tear” disease leading to loss of cartilage. OA used to be considered the sole consequence of any process leading to increased pressure on one particular joint or fragility of cartilage matrix. Progress in molecular biology in the 1990s has profoundly modified this paradigm. The discovery that many soluble mediators such as cytokines or prostaglandins can increase the production of matrix metalloproteinases by chondrocytes led to the first steps of an “inflammatory” theory. However, it took a decade before synovitis was accepted as a critical feature of OA, and some studies are now opening the way to consider the condition a driver of the OA process. Recent experimental data have shown that subchondral bone may have a substantial role in the OA process, as a mechanical damper, as well as a source of inflammatory mediators implicated in the OA pain process and in the degradation of the deep layer of cartilage. Thus, initially considered cartilage driven, OA is a much more complex disease with inflammatory mediators released by cartilage, bone and synovium. Low-grade inflammation induced by the metabolic syndrome, innate immunity and inflammaging are some of the more recent arguments in favor of the inflammatory theory of OA and highlighted in this review. 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

Association between physical activity and risk of depression: A systematic review and meta-analysis. Pearce, M., et al. (2022) Level of Evidence : 1a Follow recommendation : 👍 👍 👍 👍 (4/4 thumbs up) Type of study : Therapeutic Topic : Depression - Does exercise reduce risk This is a systematic review and meta-analysis assessing the effectiveness of exercise on the incidence of depressive symptoms. Fifteen prospective studies were included for a total of 19,113 participants. Studies were included if they reported the type of physical activity and its weekly amount. Depressive symptoms were assessed through a variety of methods including psychiatric evaluations as well as validated questionnaires. Incidence of depression was determined by either a psychiatrist's diagnosis or previously defined thresholds on validated questionnaires. The results showed that reaching 4.4 metabolic equivalents (MET) per week (e.g. 1 hr 15 minutes brisk walking/week) reduced depression by 18%. By reaching 8.8 MET per week (2 hr 30 minutes brisk walking/week) the risk of depression reduced by 25%. Reaching higher levels of MET did not reduce the risk of depression to a large extent (see figure). 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, engaging in any form of moderate exercise for at least 1 hr and 15 minutes per week can reduce the risk of developing depression in our clients. Considering that several of our clients with upper limb conditions are predisposed to develop depressive symptoms , encouraging them to follow the WHO guidelines for physical activity would be beneficial. In addition, physical activity has been shown to reduce depressive symptoms in people with this condition . Considering the link between depressive symptoms and upper limb recovery , and mental health and post-surgical satisfaction in (e.g. CTS) , we should encourage our clients to become active. Open Access URL : https://doi.org/10.1001/jamapsychiatry.2022.0609 Abstract Depression is the leading cause of mental health–related disease burden and may be reduced by physical activity, but the dose-response relationship between activity and depression is uncertain.To systematically review and meta-analyze the dose-response association between physical activity and incident depression from published prospective studies of adults.PubMed, SCOPUS, Web of Science, PsycINFO, and the reference lists of systematic reviews retrieved by a systematic search up to December 11, 2020, with no language limits. The date of the search was November 12, 2020.We included prospective cohort studies reporting physical activity at 3 or more exposure levels and risk estimates for depression with 3000 or more adults and 3 years or longer of follow-up.Data extraction was completed independently by 2 extractors and cross-checked for errors. A 2-stage random-effects dose-response meta-analysis was used to synthesize data. Study-specific associations were estimated using generalized least-squares regression and the pooled association was estimated by combining the study-specific coefficients using restricted maximum likelihood.The outcome of interest was depression, including (1) presence of major depressive disorder indicated by self-report of physician diagnosis, registry data, or diagnostic interviews and (2) elevated depressive symptoms established using validated cutoffs for a depressive screening instrument.Fifteen studies comprising 191 130 participants and 2 110 588 person-years were included. An inverse curvilinear dose-response association between physical activity and depression was observed, with steeper association gradients at lower activity volumes; heterogeneity was large and significant (I2 = 74%; P < .001). Relative to adults not reporting any activity, those accumulating half the recommended volume of physical activity (4.4 marginal metabolic equivalent task hours per week [mMET-h/wk]) had 18% (95% CI, 13%-23%) lower risk of depression. Adults accumulating the recommended volume of 8.8 mMET hours per week had 25% (95% CI, 18%-32%) lower risk with diminishing potential benefits and higher uncertainty observed beyond that exposure level. There were diminishing additional potential benefits and greater uncertainty at higher volumes of physical activity. Based on an estimate of exposure prevalences among included cohorts, if less active adults had achieved the current physical activity recommendations, 11.5% (95% CI, 7.7%-15.4%) of depression cases could have been prevented.This systematic review and meta-analysis of associations between physical activity and depression suggests significant mental health benefits from being physically active, even at levels below the public health recommendations. Health practitioners should therefore encourage any increase in physical activity to improve mental health. 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

Evaluation of a grip-strengthening algorithm for the initial treatment of chronic, nonspecific wrist pain in adolescents. Dorich, J. M. and R. Cornwall (2022) Level of Evidence : 4 Follow recommendation : 👍 (1/4 thumbs up) Type of study : Therapeutic Topic : Nonspecific wrist pain - Treatment This is a retrospective study on the effectiveness of six weeks of gripping exercises in adolescents with persistent nonspecific wrist pain. A total of 32 participants with an average age of 14 were included. To be included, participants had to present with a lack of pathology identified on x-ray and no evidence of specific pathology on objective examination. Outcome measures included grip strength and subjective reports of upper limb function. Grip strength was assessed through a dynamometer and function through the Pediatric Outcomes Data Collection Instrument’s (PODCI’s) Upper Extremity Function domain. Gripping resistance training was performed twice daily for five minutes each time for 6 weeks. Following this period, the same outcomes were recorded again. The results showed that grip strength improved by on average 7 kg in the affected side (this would be defined as a clinically significant improvement based on a previous synopsis ), and function improved by 13 points on the PDCI Upper Extremety Function domain (this would be defined as a clinically significant improvement based on a previous paper ). It is important to keep in mind that this study did not present a control group and that the results could be due to other confounding variables including natural history. 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, grip strengthening exercises for adolescents with persistent nonspecific wrist pain may be useful in reducing symptoms and improving function. If you are interested in another upper limb condition that may affect adolescents, have a look at this synopsis . Open Access URL : https://doi.org/10.1016/j.jhsg.2021.09.001 Abstract Purpose: Chronic, nonspecific wrist pain in adolescents can be challenging to assess and treat. We hypothesized that an algorithmic approach beginning with grip strengthening can alleviate pain, improve function, and identify patients in need of further intervention. Methods: We retrospectively reviewed the results of a grip-strengthening protocol for adolescents with chronic, nonspecific wrist pain. Before and after treatment, grip strength was measured using handheld dynamometry, and patient-reported pain and function were measured using the adolescent self-reported Pediatric Outcomes Data Collection Instrument’s (PODCI’s) Pain/Comfort and Upper Extremity Function domains (PODCI/pain and PODCI/UE, respectively). Results: Thirty-two patients (28 female, 4 male) were included, with a mean age of 14 years (range, 10–18 years) and the dominant hand affected in 19, nondominant hand in 9, and bilateral impacts in 4. The mean symptom duration prior to presentation was 9 months (range, 1–63 months); 17 patients had undergone prior immobilization and 5 prior occupational/physical therapy. Grip-strengthening treatment, lasting a mean of 40 days (range, 21–82 days) with a median of 4 therapy visits (range, 2–6), was associated with significantly improved grip strength (mean, 32–48 lbs), PODCI/pain scores (mean, 49.0–78.2 points), and PODCI/UE scores (mean, 78.2–91.2 points). Improvements in grip strength correlated with improvements in PODCI/pain and PODCI/UE scores (r = 0.64 and 0.70, respectively). Eight patients (25%) had either no or incomplete pain relief: 5 underwent successful further intervention (2 ganglion cyst excisions, 1 triangular fibrocartilage complex repair, 1 arthroscopic debridement, 1 steroid injection), 2 received ongoing pain management for generalized pain syndromes, and 1 was lost to further follow-up. No pretreatment variables were identified that predicted failure. Conclusions: Grip strengthening relieves pain and improves function in the majority of adolescents with chronic, nonspecific wrist pain. Systematic use of this protocol helps to identify patients who require further intervention. 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

Sensorimotor performance and function in people with osteoarthritis of the hand: A case-control comparison. Magni, N., McNair, P., & Rice, D. (2017) Level of Evidence : 3b Follow recommendation : 👍 👍 Type of study : Aetiologic Topic : Symptomatic hand osteoarthritis - Brain changes This is a case-control study assessing differences on motor imagery, tactile acuity, and neglect-like symptoms in participants with hand OA (cases) and healthy participants (controls). A total of 39 participants were included in the study. Hand OA (n = 20) was diagnosed through the American College of Rheumatology (ACR) criteria and confirmed through x-ray. Healthy participants (n = 19) were age and gender matched to the hand OA participants. Motor imagery was assessed through a hand left-right discrimination task (reaction time and response accuracy), tactile acuity was measured through two-point discrimination, and neglect-like symptoms were measured through the neurobehavioral questionnaire . The results showed that participants with hand OA were significantly slower (0.5 seconds slower) and less accurate (10% less accurate) in discriminating between left-right hands during the motor imagery task. It is unclear whether these differences are clinically relevant as no study as assessed the minimal clinically important difference for this test. There was no difference between groups on two-point discrimination. There was a statistically significant difference between groups on neglect-like symptoms, with 50% of the hand OA sample reporting them (0% of the healthy people reported them). Overall, due to multitude of statistical tests performed (23 tests) and the number of significant findings (11 test) there is a 10% probability that the results are just due to chance (the correlation analysis was not reported in this synopsis). Due to the cross-sectional nature of this study it is not possible to comment on the causality between these findings (motor imagery and neglect-like symptoms) and their contribution to pain. It is possible that on-going pain associated with hand OA may contribute to these findings or vice-versa. Clinical Take Home Message : Based on what we know today, clients with hand OA may present with brain changes that are the result of, or contribute to, their pain experience. This may explain why illusory resizing temporarily reduces pain in hand OA (see this synopsis ). Currently, this type of treatment is supported by low quality of evidence and other multidisciplinary approaches , supported by higher quality evidence, may be implemented first. Open access URL : https://www.sciencedirect.com/science/article/pii/S0049017217302809 Abstract Objectives: To determine whether hand left/right judgements, tactile acuity, and body perception are impaired in people with hand OA. To examine the relationships between left right judgements, tactile acuity and hand pain. To explore the relationships between sensorimotor measures (left/right judgements and tactile acuity) and measures of hand function in people with hand OA. Methods: Twenty patients with symptomatic hand OA and 19 healthy pain-free controls undertook a hand left/right judgment task, a control left/right judgement task, two-point discrimination (TPD) threshold testing (assessing tactile acuity), a neglect-like symptoms questionnaire (assessing body perception) and several established measures of hand function. Results: Neglect-like symptoms were experienced more frequently in the hand OA group (P < 0.05). People with hand OA were slower (P < 0.05) and less accurate (P < 0.05) in the hand left/right judgement task when compared to healthy controls, with no significant difference in the control task. Significant associations were found between hand left/right judgement reaction time and pain intensity (P < 0.05) and accuracy and pain intensity (P < 0.05). TPD was not different between groups, and no correlation was found between TPD and left/right judgement performance. No association was found between left/right judgement performance and measures of hand function (all P > 0.05). However, TPD (tactile acuity) was related to several measures of hand function (all P < 0.05). Conclusion: People with hand OA had more frequent neglect-like symptoms and were slower and less accurate compared to healthy controls at hand left/right judgments, which was indicative of disrupted working body schema. Future studies may wish to examine whether interventions targeting sensorimotor dysfunction are effective at reducing pain and improving hand function and dexterity in people with hand OA.

Shift work, inflammation and musculoskeletal pain-The HUNT Study. Matre, D., et al. (2021) Level of Evidence : 2c Follow recommendation : 👍 👍 Type of study : Aetiologic Topic : Night shifts - Low grade systemic inflammation and persistent pain This is a cross-sectional study assessing the association between shift work, inflammation, and persistent musculoskeletal pain. A total of 23,223 participants were included in the study. Of these, 5,091 were shift workers whilst 18,132 were not. Blood tests to assess C-reactive protein (CRP), which is a marker of inflammation, were completed on all participants. In addition, participants were asked whether they had any persistent musculoskeletal pain (pain for more than 3 months in the last year), and how many persistent pain sites they had. The results showed that shift work and inflammation were independently associated with the presence of persistent musculoskeletal pain and the number of persistent musculoskeletal pain sites. Shift work was still association with persistent pain and the number of painful sites even when different levels of systemic inflammation were controlled for. All these analyses were adjusted for age, sex, and education. 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, it appears that shift workers are more likely to present with chronic musculoskeletal pain compared to people working regular hours. This may also be also a contributing factor to the slow recovery rate of some of your clients such as nurses, chefs, and security guards. It appears that low-grade inflammation may be contributing to the symptoms. These findings suggest that loading and repetitive tasks may not be the only factors contributing to our clients musculoskeletal pain and that a more holistic approach of our clients may be justified. Next week I will give you some extra information on what may benefit your shift workers! URL : https://doi.org/10.1093/occmed/kqab133 Available through EBSCO Health Databases for PNZ members. Abstract BACKGROUND Studies have indicated that shift work, in particular night work, is associated with chronic musculoskeletal pain but the mechanisms are unclear. It has been suggested that sleep disturbance, a common complaint among shift and night workers, may induce low-grade inflammation as well as heightened pain sensitivity. AIMS Firstly, this study was aimed to examine the cross-sectional associations between shift work, C-reactive protein (CRP) level and chronic musculoskeletal pain, and secondly, to analyse CRP as a mediator between shift work and chronic musculoskeletal pain. METHODS The study included 23 223 vocationally active women and men who participated in the HUNT4 Survey of the Trøndelag Health Study (HUNT). Information was collected by questionnaires, interviews, biological samples and clinical examination. RESULTS Regression analyses adjusted for sex, age and education revealed significant associations between shift work and odds of any chronic musculoskeletal pain (odd ratio [OR] 1.11, 95% confidence interval [CI] 1.04-1.19), between shift work and CRP level (OR 1.09, 95% CI 1.03-1.16) and between CRP level 3.00-10 mg/L and any chronic musculoskeletal pain (OR 1.38, 95% CI 1.27-1.51). Shift work and CRP were also associated with number of chronic pain sites. Mediation analysis indicated that shift work was indirectly associated with any chronic musculoskeletal pain through CRP (OR 1.03, 95% CI 1.01-1.06). CONCLUSIONS The results support the hypothesis that shift work is associated with chronic musculoskeletal pain, and that systemic inflammation may be a biological mechanism linking shift work to chronic pain. 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

Minimal clinically important difference for grip strength: A systematic review. Bohannon, R. W. (2019) Level of Evidence : 2a Follow recommendation : 👍 👍 👍 Type of study : Diagnostic Topic : Minimal clinically important difference - Grip strength Through HandyEvidence surveys, I have discovered that Hand Therapists are interested in tips on how to critique research articles. This synopsis is the third of a series providing tips on how to interpret the research that you read. In particular, this synopsis revolves around the minimally clinically important difference concept. By minimal clinically important difference, people refer to the smallest change in a measure (e.g. Grip strength) which can be considered as a real improvement in the clinical presentation of our clients. There are at least a couple of methods that can be used to estimate this value, and they are called "anchor-based" and "distribution-based" methods. The anchor-based method calculates the minimal clinically important difference by determining the score of those participants who report benefiting from an intervention/treatment. The distribution-based methods instead does not take into account participants' opinion of improvement and simply calculate the minimal clinically important difference based on the error of the measure utilised. In the paper that I read this week, an anchor based method was utilised to calculate the minimal clinically important difference for grip strength in a group of participants with several different upper limb conditions. The results showed that the minimal clinically important difference calculated through an anchor-based method (utilising clients' feedback) ranged between 3 to 6 kg. 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 grip strength ranges between 3 to 6 kg. Personally, I prefer to lean towards larger changes, hence I would suggest that a change of 5-6 kg could be clinically meaningful. This means that if one of our client's grip strength at baseline (at first appointment) was 18 kg and 23 kg on discharge, we would have achieved a clinically meaningful improvement. Once again, it is possible that this change could be either due to our treatment, other people's treatment (e.g. GP medications) , regression to the mean , variables that we have not considered (e.g. reduction in kinesiophobia ), or natural history of the condition. If you liked this synopsis you may also like other topics such as the minimal clinically important difference for the QuickDASH relevance of statistical significance or p<0.05 , implementation of research to clinical practice , and how to make evidence guided decisions when limited evidence is available . Open access URL : https://doi.org/10.1589/jpts.31.75 Abstract Purpose The minimal clinically important difference (MCID) in grip strength is critical to interpreting changes in hand strength over time. This review was undertaken to summarize extant descriptions of the MCID for grip strength. Methods A search of 3 bibliographic databases as well as a hand search were completed to identify articles reporting the MCID for grip forces obtained by dynamometry. Results Of 38 unique articles identified as potentially relevant, 4 met the inclusion and exclusion criteria of this review. The MCIDs ranged from 0.04 kg to 6.5 kg. However, only a single study used receiver operating characteristic curve analysis and had an associated area under the curve exceeding 0.70. That study reported an MCID of 6.5 kg, which was similar to the MCIDs of another included study and minimal detectable changes reported elsewhere. Conclusion Additional, more rigorous, studies are needed to identify MCIDs for grip strength. In the meantime changes of 5.0 to 6.5 kg may be reasonable estimates of meaningful changes in grip 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