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Soft-tissue injuries simply need PEACE and LOVE. Dubois, B. and J.-F. Esculier (2020) Level of Evidence : 5 Follow recommendation : 👍 (1/4 thumbs) Type of study : Therapeutic Topic : Acute non-traumatic pain – Biopsychosocial approach This is an editorial from the British Journal of Sports Medicine. A new PEACE and LOVE era has started for soft tissue injuries. This era comes after the RICE era and aims at updating it. The PEACE and LOVE acronyms stands for several steps that we can follow to rehabilitate soft tissue injuries. P rotection is the first pillars which aims at allow tissue healing following an injury. This is followed by E levation which allows for reduction of swelling. A voidance of anti-inflammatories is also suggested as they inhibit the remodelling of injured tissue, which is a necessary step in the healing process. C ompression goes alongside elevation and it aims at reducing swelling. E ducation clearly follows these steps as it is important to provide clients with a timeframe and get them to buy into the rehabilitation process. Gradual L oading favours tissue healing and can modulate pain. O ptimism is also fundamental as a positive attitude can make a significant difference. Getting clients to take part in aerobic exercise has also been shown to improve V ascularisation and healing. Regaining strength, local tissue capacity, and proprioception is then achieved through active E xercises. Overall this article summarises nicely a large body of literature, which encompasses not only biological but also psychosocial aspects of rehabilitation. 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, we should provide PEACE and LOVE to our clients with soft tissue injuries. A large amount of evidence supports this approach. Thus it has been shown that education in combination with exercise can reduce pain , and that gradual loading can build up local tissue capacity . In addition, there is a growing amount of evidence showing that aerobic exercise may favour soft tissue healing, including wounds healing . Finally, several research studies have shown a correlation between upper limb disability and mental health (e.g. kinesiophobia , pain catastrophising , depression ). URL : http://dx.doi.org/10.1136/bjsports-2019-101253 Abstract Rehabilitation of soft-tissue injuries can be complex. Over the years, acronyms guiding their management have evolved from ICE to RICE , then on to PRICE and POLICE .1 Although widely known, these previous acronyms focus on acute management, unfortunately ignoring subacute and chronic stages of tissue healing. Our contemporary acronyms encompass the rehabilitation continuum from immediate care ( PEACE ) to subsequent management ( LOVE ). PEACE and LOVE (figure 1) outline the importance of educating patients and addressing psychosocial factors to enhance recovery. While anti-inflammatories show benefits on pain and function, our acronyms flag their potential harmful effects on optimal tissue repair. We suggest that they may not be included in the standard management of soft-tissue 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

Heterotopic ossification after revision carpal tunnel release causing mixed ulnar and median compression neuropathy. Maheshwari, A. V., et al. (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 46 years old right-handed woman. They reported previous surgery for carpal tunnel syndrome 6 years prior. This was followed by a second surgery for ongoing symptoms where additional fibrotic tissue was removed from the volar aspect of the wrist. After the second surgery, a mass on the volar aspect of the wrist slowly developed. Subjectively, the patient presented with numbness in all fingers. Objectively, there was a hard, non-mobile mass in the volar aspect of the distal forearm. They also presented with limited wrist range of movement, a positive Allen's test, and reduced 2-points discrimination ability in all fingers. An x-ray was taken and is shown below. Surgery was performed to remove the mass and diagnose the lesion. The median and ulnar neurovascular bundles were found to be stretched by the mass. Following surgery, the patient underwent hand therapy and within four months they had regained full strength and sensation in the hand. The pathology report indicated that this was a heterotopic ossification with no evidence of malignancy. 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, heterotopic ossification is a rare space invading lesion following carpal tunnel surgery. In contrast, the elbow is a more common site for heterotopic ossification and it can be a significant contributing factor to post-traumatic elbow stiffness . URL : https://doi.org/10.1016/j.jhsa.2020.12.009 Abstract We report a case of heterotopic ossification formation 6 years after a revision carpal tunnel release in a 46-year-old woman, causing new-onset mixed ulnar and median nerve compression symptoms. The patient underwent excision of the heterotopic ossification mass along with decompression of the median and ulnar nerves, and postoperative radiation. Four years after treatment, the patient was completely asymptomatic with full range of motion in her hand and wrist. 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

Fluoroquinolone-associated tendinopathy of the hand and wrist: A systematic review and case report. Berger, I., I. Goodwin and G. M. Buncke (2017) Level of Evidence : 1a- Follow recommendation : 👍 👍 (2/4 thumbs up) Type of study : Therapeutic/Preventative Topic : Medications - hand and wrist tendinopathy This is a systematic review investigating antibiotics-induced tendinopathies in the hand and wrist. The review identified 7 case studies on fluoroquinolone (antibiotic) induced hand and wrist tendinopathy. Several types of fluoroquinolones were suggested to cause hand/wrist tendinopathy (see table). Tendinopathies occured one to four weeks since the start of antibiotic therapy. Antibiotic care was initiated to treat a suspected or confirmed hand infection. Most cases of tendinopathy or rupture (finger flexors/extensors) presented with unilateral symptoms. Due to nature of the studies involved in the review (case studies) it is hard to identify causality between the antibiotics use and tendinopathy/tendon rupture. There are, however, basic science studies showing that fluoroquinolone antibiotics lead to connective tissue matrix degradation and the formation of weaker collagen fibres. 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, fluoroquinolone used to treat hand infections may contribute to the development of tendinopathies or tendon rupture. It is therefore important to ask our clients what medications they take and be particularly alert when they are taking these antibiotics (see table). In particular, if they start reporting pain which is not in line with the expected recovery trajectory, fluoroquinolones should be interrupted. URL : https://doi.org/10.1177/1558944717701237 Abstract Background: Fluoroquinolone use has been known to be associated with tendinopathy and tendon rupture for over 30 years. Hand and wrist involvement has been reported rarely, yet without early recognition and withdrawal of the fluoroquinolone, there is potential for significant morbidity. Methods: We searched Medline using a comprehensive search strategy for fluoroquinolones and tendinopathy of the hand and wrist, and provide a case report of a possible levofloxacin-related tendon rupture in a patient with a previous mutilating hand injury. Results: We located 10 previously reported cases of fluoroquinolone-associated tendinopathy in the hand or wrist ranging from 1983 to 2015. Unlike Achilles tendinopathy, women were no more likely than men to have tendon rupture affecting the hands or wrists. Our patient was a 59-year-old man with prior tendon repair but otherwise noncontributory medical history who experienced spontaneous tendon rupture on an extended course of levofloxacin and required extensive pulley and boutonnière repair. Conclusions: Given the extensive damage that may be caused to weakened tissue, clinicians should maintain a high index of suspicion of tendinopathy in patients taking fluoroquinolones who have had previous tendon repairs, particularly in the setting of unexplained changes in recovery trajectory. 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

Post-traumatic elbow stiffness: Pathogenesis and current treatments. Zhang, D., Nazarian, A., & Rodriguez, E. (2018) Level of Evidence : 5 Follow recommendation : 👍 Type of study : Aetiologic, Therapeutic Topic : Post traumatic elbow stiffness - Aetiology and treatment This is a narrative review on aetiology and treatment of post-traumatic elbow stiffness. The aetiology of elbow stiffness is usually classified as intrinsic (e.g. osteophytes), extrinsic (e.g. heterotopic ossification), or mixed (intrinsic + extrinsic). The goal of treatment for elbow stifness is the re-establishment of 100° to 30° of elbow flexion/extension and 100° of pronation (50°) and supination (50°). Conservative treatment should aim at starting active mobilisation as soon as possible after the injury and introducing passive range of motion exercises at 6-12 weeks after injury/surgery. Delayed movemement interventions result in worse outcomes. Very little evidence supports the use of manual therapy in the recovery range of movement in post-traumatic elbow stiffness. Level 2b evidence (systematic review of cohort studies) supports the use of static progressive or dynamic bracing for post-traumatic elbow stiffness. It has been suggested that after 4 to 6 weeks of bracing, range of movement should improve by 30-40°. During the bracing period, care should be taken to avoid pressure sores and ulnar neuropathies (when splinting to regain elbow flexion). Surgical treatment is utilised when nonoperative treatments fails. Improvements following surgery range between 18° to 66° of elbow flexion/extension. Traumatic elbow osteoarthritis is a negative predicting factor for surgical success (surgery is less likely to be effective). The presence of heterotopic ossification is a positive predicting factor for surgical success (surgery is more likely to be effective). Clinical Take Home Message : Hand therapists may use a conservative trial of static progressive or dynamic bracing to treat post traumatic elbow stiffness. This should be trialled for 4-6 weeks to assess its effectiveness. Surgical intervention may be required if no improvements are noted with conservative treatment. URL : https://journals.sagepub.com/doi/abs/10.1177/1758573218793903

At the intersection of anger, chronic pain, and the brain: A mini-review. Yarns, B. C., J. T. Cassidy and A. M. Jimenez (2022). Level of Evidence : 5 Follow recommendation : 👍 (1/4 thumbs up) Type of study : Therapeutic Topic : Anger - Pain perception This is a narrative review on the effect of anger on pain. Several studies were included and the authors suggested that anger suppression and unhealthy anger expression (e.g. shouting) contribute to heightened levels of pain. Some research has also shown that anger can lead to unconscious increases in muscle recruitment, which may contribute to nociception. Interventions aimed at regulating anger such as awareness of anger as well as modifying unhealthy anger expression can reduce pain. In addition, being able to say "no" rather than suppresing anger appears to be a useful strategy in managing these issues. The association between increased levels of anger and pain may be mediated by areas of the brain that appear to be upregulated both during anger states and in persistent pain conditions. 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, anger management may reduce pain intensity in clients with anger suppression or unhealthy anger expression. Strategies aimed at increasing awareness as anger (such as meditation/yoga ) or learning to create boundaries by saying "no" may be helpful. This synopsis is a nice adjunct to the one written about the effect of an empathetic attitude of clinicians and its effect on endogenous analgesia. URL : https://doi.org/10.1016/j.neubiorev.2022.104558 Abstract Chronic pain remains one of the most persistent healthcare challenges in the world. To advance pain treatment, experts have recently introduced research-driven subtypes of chronic pain based on proposed underlying mechanisms. Nociplastic pain (e.g., nonspecific chronic low back or fibromyalgia) is one such subtype which may involve a greater etiologic role for brain plasticity, painful emotions induced by life stress and trauma, and unhealthy emotion regulation. In particular, correlational and behavioral data link anger and the ways anger is regulated with the presence and severity of nociplastic pain. Functional neuroimaging studies also suggest nociplastic pain and healthy anger regulation demonstrate inverse patterns of activity in the medial prefrontal cortex and amygdala; thus, improving anger regulation could normalize activity in these regions. In this Mini-Review, we summarize these findings and propose a unified, biobehavioral model called the Anger, Brain, and Nociplastic Pain (AB-NP) Model, which can be tested in future research and may advance pain care by informing new treatments that address anger, anger regulation, and brain plasticity for nociplastic 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

Exploring indicators of extremity pain of spinal source as identified by Mechanical Diagnosis and Therapy (MDT): A secondary analysis of a prospective cohort study. Rastogi, R., et al. (2022) Level of Evidence : 2b Follow recommendation : 👍 👍 (2/4 thumbs) Type of study : Diagnostic Topic : Peripheral vs spinal referred pain - Diagnosis This is a secondary analysis of a prospective multicentre cohort study with the aim of identifying factors helping in differentiating between peripheral and spinal referred pain. A total of 369 participants were included. Potential participants were included if they presented with upper limb or lower limb pain. In particular, 145 participants presented with either wrist/hand/forearm/elbow/shoulder symptoms. Participants underwent an extensive subjective and objective examination by physiotherapists trained in Mechanical Diagnosis and Therapy (MDT) and classified participants as presenting with either a peripheral source of pain or spinal referred pain. After the assessment, participants were provided with exercises for a peripheral or spinal dysfunction. At the follow-up visit, participants were classified as presenting with a spinal source of impairment if symptoms improve with spinal treatment only. The results showed that a diagnostic model based on the presence of paresthesia, symptoms presentation in association with a specific posture or postural change, limitations in range of movement of the spine, and the presence or not of peripheral joint limitations, was moderately accurate in predicting those people who would respond to spinal interventions or peripheral interventions alone. Unfortunately, this model has not been validated on an external population and should therefore be utilised keeping in mind this limitation. 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 combination of a few subjective and objective factors provides us with a probability estimate of upper limb pain originating from a peripheral or spinal dysfunction. Clinical reason will be (as always) important in supporting your conclusions and the use of other information such as dermatomal presentations , myotomes , anastomoses , and neurodynamic tests will help you interpret what are the likely causes and/or origin of symptoms. URL : https://doi.org/10.1080/10669817.2022.2030625 Abstract Objective: To explore indicators that predict whether patients with extremity pain have a spinal or extremity source of pain. Methods: The data were from a prospective cohort study (n = 369). Potential indicators were gathered from a typical Mechanical Diagnosis and Therapy (MDT) history and examination. A stepwise logistic regression with a backward elimination was performed to determine which indicators predict classification into spinal or extremity source groups. A Receiver Operating Characteristic (ROC) curve was constructed to examine the number of significant indicators that could predict group classification. Results: Five indicators were identified to predict group classification. Classification into the spinal group was associated with the presence of paresthesia [odds ratio (OR) 1.984], change in symptoms with sitting/neck or trunk flexion/turning neck/when still (OR 2.642), change in symptoms with posture change (OR 3.956), restrictions in spinal movements (OR 2.633), and no restrictions in extremity movements (OR 2.241). The optimal number of indicators for classification was two (sensitivity = 0.638, specificity = 0.807). Discussion: This study provides guidance on clinical indicators that predict the source of symptoms for isolated extremity pain. The clinical indicators will allow clinicians to supplement their decision-making process in regard to spinal and extremity differentiation so as to appropriately target their examinations and interventions. 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. I will publish the diagnosis reported by the paper next week. The patient was a 46 years old right-handed woman. They reported previous surgery for carpal tunnel syndrome 6 years prior. This was followed by a second surgery for ongoing symptoms where additional fibrotic tissue was removed from the volar aspect of the wrist. After the second surgery, a mass on the volar aspect of the wrist slowly developed. Subjectively, the patient presented with numbness in all fingers. Objectively, there was a hard, non-mobile mass in the volar aspect of the distal forearm. They also presented with limited wrist range of movement, a positive Allen's test, and reduced 2-points discrimination ability in all fingers. An x-ray was taken and is shown below. What is it?

Persistent pain after wrist or hand fracture: Development and validation of a prognostic model. Cashin, A. G., et al. (2018) Level of Evidence : 1b Follow recommendation : 👍 👍 👍 (3/4 thumbs) Type of study : Prognostic Topic : Persistent wrist pain - Prediction This is a secondary analysis of a prospective multicentre cohort study with the aim of identifying risk factors for the development of persistent pain following a hand or wrist fracture. A total of 715 participants were included. Potential participants were included if they presented with a unilateral fracture of the hand and/or wrist. The potential fractures included metacarpal or carpal bones fractures as well as a distal third fracture of the ulna or radius. Several potential predictors were utilised and they included, amongst others, pain intensity (0-10 NRS) and participants' age. Persistent pain was defined as pain equal to or greater than 3/10 on NRS at four months post-injury. The results showed that 20% of the sample presented with persistent pain at four months. A simple prediction model with age and pain as factors had low prediction ability. 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, in our clients with a hand or wrist fracture, higher levels of baseline pain and older age increase the chance of presenting with persistent pain four months post-injury. This model is similar to the one created to estimate the probability of developing complex regional pain syndrome following a distal radius fracture . Strategies aimed at making splinting or casting comfortable and increasing compliance with pain killers should therefore be implemented as soon as possible to avoid persistent pain once the fracture has healed. Also, remember that tenderness on palpation of a fracture does not appear to be a good indicator of fractures healing . The use of bone healing timeframes may be more useful. URL : https://doi.org/10.2519/jospt.2019.8342 Abstract Background: Worldwide, the incidence of wrist fracture is increasing. There are currently no externally validated prognostic models to inform early decision making for these patients. Objectives: To develop and validate a prognostic model from a comprehensive range of candidate prognostic factors that can identify patients who are at risk of developing persistent pain following wrist or hand fracture. Methods: We developed and validated a prognostic model using secondary data derived from a prospective cohort study (n = 715), with recruitment sites in 3 metropolitan hospitals in Sydney, Australia. The primary outcome was persistent pain 4 months following the injury. The current study used a backward stepwise regression analysis to develop the model in 2 hospitals (n = 408) and externally validate it in a third hospital (n = 307). To determine the accuracy of the model, we assessed calibration and discrimination in accordance with the PROGnosis RESearch Strategy framework. Results: Complete data were available for 95% of the cohort. Of 14 candidate variables, the final model contained 2 prognostic factors: patient age and pain intensity reported at initial presentation. The area under the receiver operating characteristic curve was 0.63 (95% confidence interval: 0.56, 0.69) in the development sample and 0.61 (95% confidence interval: 0.51, 0.70) in the validation sample. The model systematically overestimated risk (intercept, ?1.13; slope, 0.73). Conclusion: We developed and externally validated a prognostic model to predict persistent pain 4 months after a wrist or hand fracture. Future studies are needed to assess whether the accuracy of this model can be improved by updating and validating it in local settings. 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

Development of an optimised physiotherapist-led treatment protocol for lateral elbow tendinopathy: A consensus study using an online nominal group technique. Bateman, M., B. Saunders, C. Littlewood and J. C. Hill (2021) Level of Evidence : 5 Follow recommendation : 👍 (1/4 thumbs up) Type of study : Therapeutic Topic : Lateral epicondylalgia – Treatment consensus This is a clinicians consensus statement on the treatment of lateral epicondylalgia.. Only randomised controlled trials (RCT) were included. All the potential interventions were discussed, independently considered, discussed in a group, and then voted and ranked. Ten physiotherapists with a special interest in lateral epicondylalgia and 3 patients affected by this condition took part in this study. During vote 1, the treatment options were assessed. Those interventions which only received 30- 70% of agreement underwent a second vote. The results showed that in order of importance, advice and education, exercise, and orthotics were the treatment of choice. In addition, they suggested that exercise should cause some pain, to an acceptable level for clients. Of interest, the use of a counterforce brace was agreed upon by 80% of people compared to 7% for a wrist immobilisation splint. In the figure, you can see the ranking of the most important interventions for lateral epicondylalgia. 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 core interventions for lateral epicondylalgia should include advice and education, exercises, and orthotics. The use of exercises is currently supported by several research papers . In addition, the advice of exercises being painful to improve pain is also supported by some research. Counterforce braces are supported by a reasonable amount of evidence and they appear to be more effective than wrist splints . If you would like to predict who is more likely to have a recurrence of tennis elbow within one year, have a look at this synopsis . Open Access URL : https://doi.org/10.1136/bmjopen-2021-053841 Abstract Objectives: There are a wide range of physiotherapy treatment options for people with lateral elbow tendinopathy (LET); however, previous studies have reported inconsistent approaches to treatment and a lack of evidence demonstrating clinical effectiveness. This study aimed to combine the best available research evidence with stakeholder perspectives to develop key components of an optimised physiotherapist-led treatment protocol for testing in a future randomised controlled trial (RCT). Design: Online consensus groups using nominal group technique (NGT), a systematic approach to building consensus using structured multistage meetings.Setting UK National Health Service (NHS).Participants 10 physiotherapists with special interest in LET, 2 physiotherapy service managers and 3 patients who had experienced LET. Interventions: Two consensus groups were conducted; the first meeting focused on agreeing the types of interventions to be included in the optimised treatment protocol; the second meeting focused on specific details of intervention delivery. Participants were sent an evidence summary of available treatments for LET prior to the first meeting. All treatment options were discussed before anonymous voting and ranking of priority. Consensus for inclusion of each treatment option was set at ≥70% based on OMERACT guidelines. Options with 30%–69% agreement were discussed again, and a second vote was held, allowing for a change of opinion. Results: The optimised physiotherapist-led treatment package included: advice and education, exercise therapy and orthotics. Specific components for each of these interventions were also agreed such as: condition-specific advice, health-promotion advice, exercise types, exercise into ‘acceptable’ levels of pain, exercise dosage and type of orthoses. Other treatment options including electrotherapy, acupuncture and manual therapy were excluded. Conclusion: An optimised physiotherapist-led treatment protocol for people with LET was successfully developed using an online NGT consensus approach. This intervention is now ready for testing in a future pilot/feasibility RCT to contribute much needed evidence about the treatment of LET.Trial registration number This is the pre-cursor to the OPTimisE Pilot and Feasibility Randomised Controlled Trial. 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 American stem cell sell in 2021: U.S. businesses selling unlicensed and unproven stem cell interventions. Turner, L. (2021) Level of Evidence : 5 Follow recommendation : 👍 (1/4 thumbs up) Type of study : Therapeutic Topic : Stem cells – pain and orthopaedic conditions This is an expert opinion about the growing use of stem cells therapies for pain and orthopaedic conditions in the USA. The authors have reported how in the last few years the number of clinics providing these therapies has grown exponentially. The main conditions that these clinics say to treat are pain and orthopaedic conditions (e.g. osteoarthritis) (see graph). Despite the current lack of evidence for these interventions, clinics have been marketing stem cells as a very effective treatment and they provide injections at very high prices. The lowest price for a course of injection was 1,000 USD. However, some clinics got to higher prices up to 30,000 USD. The downside of promoting these interventions so strongly is that patients may choose them instead of evidence-based approaches which have higher odds of providing clinical benefits. 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, stem cells injections for pain and orthopaedic conditions present limited evidence supporting their effectiveness and are highly priced. These injections are likely to provide pain relief in clinical settings, not necessarily due to their active principle (e.g. stem cells), but because all sorts of injections, including placebo ones, provide pain relief . You may think that stem cells injections are used for pain in the USA only. A quick google search will however reveal that there are quite a few clinics in Australasia providing too. URL : https://doi.org/10.1016/j.stem.2021.10.008 Abstract In March 2021, 1,480 U.S. businesses operating 2,754 clinics were found selling purported stem cell treatments for various indications. More than four times as many businesses than were identified 5 years ago are selling stem cell products that are not FDA-approved and lack convincing evidence of safety and efficacy. 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

Can we reduce the incidence of complex regional pain syndrome type I in distal radius fractures? The Liverpool experience. Gillespie, S., F. Cowell, G. Cheung and D. Brown (2016) Level of Evidence : 2c Follow recommendation : 👍 👍 👍 (3/4 thumbs) Type of study : Therapeutic Topic : CRPS - Prevention strategies This is a study collecting data from several audits and knowledge translation interventions in the UK with the aim of reducing the incidence of complex regional pain syndrome type I (CRPS-I) following distal radius fracture. A total of 490 participants with a distal radius fracture were included across all audits. People requiring open reduction internal fixation (ORIF) procedures were excluded. In addition, participants presenting with additional neurologic or orthopaedic pathologies were excluded. Participants were diagnosed with CRPS if they presented with signs and symptoms described in the table. A series of progressive interventions, which included patient leaflets and the implementation of specific interventions for patients (e.g. modification of cast if uncomfortable - see table) were utilised. The results showed that over time, with the use of these strategies, the incidence of CRPS reduced from 25% of clients with a conservatively managed distal radius fracture to 1%. 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 is possible to reduce the incidence of CRPS in our clients through several different measures. These include making sure that their cast is comfortable and it is not limiting hand/finger movements beyond what is strictly necessary (see table). You could also provide your clients with a leaflet, similar to what has been published at this link (page 43 of the document), which provides them with useful information to reduce the likelihood of developing CRPS. In addition, a high daily dose of vitamin C (500mg to 1g) for 40-50 days post-fracture has been shown to reduce the risk of CRPS . If you would like to be able to estimate the probability of your clients developing CRPS following a conservatively managed distal radius fracture, have a look at the prediction model which has been published in this synopsis . URL : https://doi.org/10.1177/1758998316659676 Abstract Introduction: Complex regional pain syndrome is a multifaceted condition, which is relatively common after distal radius fracture. Method: A series of audits and service evaluations were conducted from 2004 to 2013 to investigate the incidence of complex regional pain syndrome type I and any correlation to tight, restrictive, over-flexed casts. Simple subsequent clinical and patient management changes were implemented and impact re-evaluated. Results: These audits have contributed to organisational learning and a subsequent reduction in the incidence of complex regional pain syndrome type I in non-operatively managed distal radius fracture from 25%, in keeping with expected incidence in the relevant literature, to a rare event (<1%). Conclusion: The authors suggest that careful attention to the prevention of complex regional pain syndrome through staff and patient awareness, vigilance for warning signs and minor modifications to the traditional management of distal radius fractures can significantly reduce the incidence of complex regional pain syndrome type I after distal radius fracture. 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

Intense pain soon after wrist fracture strongly predicts who will develop complex regional pain syndrome: Prospective cohort study. Moseley, G. L., et al. (2014) Level of Evidence : 2a Follow recommendation : 👍 👍 👍 (3/4 thumbs) Type of study : Prognostic Topic : CRPS - Predicting occurrence This is a prospective cohort study with the aim of identifying risk factors for the development of complex regional pain syndrome (CRPS) following distal radius fracture. A total of 1,549 participants with a distal radius fracture were included. People requiring open reduction internal fixation (ORIF) procedures were excluded. In addition, participants presenting with additional neurologic or orthopaedic pathologies were excluded. Several outcomes were measured a baseline, including pain. The average pain intensity over the last 2 days was assessed on a numerical rating scale (NRS) within the first week post fracture. At four months, people presenting with pain were assessed to determine whether they presented with CRPS as described by the International Association for the Study of Pain (IASP). The results showed that about 4% of participants developed CRPS. A simple prediction model, which included pain only as a predictor was able to accurately discriminate people developing CRPS vs those who would not. In particular, an average pain intensity of more than 5/10 during the first week from fracture greatly increased the chances of developing CRPS. This model has however not been validated on a different group of participants and it is therefore likely that it would not perform as well when applied to different people. 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, in our clients with a conservatively managed distal radius fracture, levels of pain equal to or greater than 5/10 greatly increase the likelihood of developing CRPS. Casting must therefore be modified if it is the reason contributing to their pain. In addition, we should encourage them to take painkillers as prescribed. Finally, a high daily dose of vitamin C (500mg to 1g) for 40-50 days post-fracture has been shown to reduce the risk of CRPS . URL : https://doi.org/10.1016/j.jpain.2013.08.009 Abstract Complex regional pain syndrome (CRPS) is a distressing and difficult-to-treat complication of wrist fracture. Estimates of the incidence of CRPS after wrist fracture vary greatly. It is not currently possible to identify who will go on to develop CRPS after wrist fracture. In this prospective cohort study, a nearly consecutive sample of 1,549 patients presenting with wrist fracture to 1 of 3 hospital-based fracture clinics and managed nonsurgically was assessed within 1 week of fracture and followed up 4 months later. Established criteria were used to diagnose CRPS. The incidence of CRPS in the 4 months after wrist fracture was 3.8% (95% confidence interval = 2.9-4.8%). A prediction model based on 4 clinical assessments (pain, reaction time, dysynchiria, and swelling) discriminated well between patients who would and would not subsequently develop CRPS (c index .99). A simple assessment of pain intensity (0-10 numerical rating scale) provided nearly the same level of discrimination (c index .98). One in 26 patients develops CRPS within 4 months of nonsurgically managed wrist fracture. A pain score of ≥5 in the first week after fracture should be considered a "red flag" for CRPS. PERSPECTIVE: This study shows that excessive baseline pain in the week after wrist fracture greatly elevates the risk of developing CRPS. Clinicians can consider a rating of greater than 5/10 to the question "What is your average pain over the last 2 days?" to be a "red flag" for CRPS. 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