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A systematic review of how daily activities and exercises are recommended following volar plating of distal radius fractures and the efficacy and safety of early versus late mobilisation. Collis, J., Signal, N., Mayland, E., & Clair, V. W.-S. (2020) Level of Evidence : 1a- Follow recommendation : 👍 👍 👍 👍 Type of study : Therapeutic Topic : Radius fracture – Early mobilisation This is a systematic review assessing the effectiveness and safety of early mobilisation following a distal radius fracture treated surgically with a volar plate. Eight studies, for a total of 519 participants (72% females) were included in the review. Of these, 5 were RCTs and 3 were retrospective studies. All the studies were assessed through the Downs and Black Quality Index, which is appropriate for both experimental and non-experimental studies. Each paper was scored as "excellent", "good", "fair", or "poor". Efficacy of intervention was assessed through improvements in pain (e.g. NRS, VAS), function (e.g. DASH, PRWE), and wrist and forearm range of movement (extension/flexion/supination/pronation) in the short-term (6-8/52), midterm (10-12/52), and long-term (24-26/52). Safety was assessed by counting the number of adverse events. Early mobilisation (1-8 days from surgery) was compared to a delayed mobilisation (2-6 weeks post surgery). On average, the studies included were of "good" quality. The results showed that early mobilisation provided a small possibly non clinically relevant differences (see Supplementary file 2) in pain compared to delayed mobilisation. However, function improved to a small/large extent in the early mobilisation group and these differences were clinically relevant. Early mobilisation also led to small/moderate improvement in range of movement, possibly not clinically relevant (I only looked at supination as we know that for this measurement we require at least an 8deg change for it to be clinically meaningful - Reid et al. 2020 ) when compared to delayed mobilisation. There were no differences in the number of adverse events between the early vs delayed mobilisation. Clinical Take Home Message : Based on what we know today, early mobilisation (within 2 weeks from surgery) of distal radius fractures ORIF may provide better functional outcomes compared to delayed mobilisation (more than 2 weeks post surgery). A recent randomised controlled study showed that there was no difference in terms of pain, function, and AROM if mobilisation was started on the day after surgery vs at 2 weeks ( see this synopsis ). It is therefore possible that delaying mobilisation by a max of two weeks is acceptable. However, immobilisation beyond the two weeks mark may lead to sub-optimal functional recovery off our clients. URL : https://journals.sagepub.com/doi/abs/10.1177/1758998320967032 Available through the Hand Therapy for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Introduction: Following surgical repair of distal radius fractures, mobilisation timeframes and interventions vary. Early mobilisation (<2 weeks postoperatively) usually includes range of motion exercises and may include recommendations to perform daily activities. The review investigated (i) how early mobilisation was recommended, particularly with respect to wrist use during daily activities and (ii) the efficacy and safety of early versus delayed mobilisation (< or ≥2 weeks). Methods: The study protocol was registered on PROSPERO (CRD42019136490). Five databases were searched for studies that compared early and delayed mobilisation in adults with volar plating of distal radius fractures. The Downs and Black Quality Index and the Template for Intervention Description and Replication checklist were used for quality evaluation. Effect sizes were calculated for range of movement, function and pain at 6–8, 10–12 and 26 weeks. A descriptive analysis of outcomes and mobilisation regimes was conducted. Results: Eight studies with a mean Quality Index score of 20 out of 28 (SD=5.6) were included. Performing daily activities was commonly recommended as part of early mobilisation. Commencing mobilisation prior to two weeks resulted in greater range of movement, function and less pain at up to eight weeks postoperatively than delaying mobilisation until two weeks or later. Discussion: Performance of daily activities was used alongside exercise to promote recovery but without clearly specifying the type, duration or intensity of activities. In combination with exercise, early daily activity was safe and beneficial. Performing daily activities may have discrete advantages. Hand therapists are challenged to incorporate activity-approaches into early mobilisation regimes.

Does Mental Practice or Mirror Therapy help prevent functional loss after distal radius fracture? A randomized controlled trial. Korbus, H., & Schott, N. (2020) Level of Evidence : 2b Follow recommendation : 👍 👍 👍 Type of study : Therapeutic Topic : Radius fracture - motor imagery or mirror therapy vs relaxation This is a randomised single-blind controlled trial assessing the effectiveness of mental practice (Motor Imagery - MI) and mirror therapy (MT) 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 condition. Effectiveness of each intervention was assessed through several functional measures (I choose to consider the QuickDASH as it is commonly used in clinical practice). Outcomes were measured at baseline and 12 weeks from injury. All participants trained with one therapist 5 times per week for 45 minutes during the first three weeks, and 3 times per week in the last three weeks of training (total of 6 weeks). Treatment allocation was randomised. The assessor was blinded to treatment allocation. Participants were provided with either MI (n = 8), MT (n = 12), or relaxation techniques (control group, n = 9). Participants in the MI mentally rehearsed several wrist movements of the affected wrist, which included wrist flexion, extension, radial and ulnar deviation, pronation, supination, and gripping. The MT group watched the reflection of the healthy hand performing the movements indicated above. The relaxation group was provided with the same duration intervention and relaxation interventions were provided. The results showed that the two intervention groups improved to a larger extent (MI = 43 points improvement; MT = 42 points improvement) compared to the control group (CG = 39 points improvement) in the QuickDASH, however, these differences were not clinically significant (the difference between groups was less than 15 points). Clinical Take Home Message : Based on what we know today, motor imagery or mirror therapy alone do not appear to improve QuickDASH outcomes at 3 months compared to a control group receiving relaxation interventions. A more appropriate approach is to follow a graded motor imagery approach, which has previously been shown to reduce pain and improve funct ion at 8 weeks post distal radius fracture (see synopsis here ). This paper followed a precise series of steps (based on neurophysiological concepts) which included a left/right hand discrimination task (3 weeks), explicit motor imagery (3 weeks), and mirror therapy (2 weeks). This approach 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 ). Open Access URL : https://www.sciencedirect.com/science/article/pii/S0894113020302076 Available through the Journal of Hand Therapy for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Background Therapy results after distal radius fractures (DRF) especially with older patients are often suboptimal. One possible approach for counteracting the problems are motor-cognitive training interventions such as Mental Practice (MP) or Mirror Therapy (MT), which may be applied in early rehabilitation without stressing the injured wrist. Purpose The aim of the study is to investigate the effects of MP and MT on wrist function after DRF. The pilot study should furthermore provide information about the feasibility and efficacy of these methods. Study Design The study was designed as a randomized, single-blinded controlled trial. Methods Thirty-one women were assigned either to one of the two experimental groups (MP, MT) or to a control group (relaxation intervention). The participants completed a training for six weeks, administered at their homes. Measurements were taken at four times (weeks 0, 3, 6 and 12) to document the progression in subjective function (PRWE, QuickDASH) and objective constraints of the wrist (ROM, grip strength) as well as in health-related quality of life (EQ-5D). Results The results indicated that both experimental groups showed higher improvements across the intervention period compared to the control group; e.g. PRWE: MT 74.0%, MP 66.2%, CG 56.9%. While improvements in grip strength were higher for the MP group, the MT group performed better in all other measures. However, time by group interactions approached significance at best; e.g. ROM: p = .076; ηp2 = .141. Conclusion The superiority of MP as well as MT supports the simulation theory. Motor-cognitive intervention programmes are feasible and promising therapy supplements, which may be applied in early rehabilitation to counteract the consequences of immobilization without stressing the injured wrist.

How to proceed when evidence-based practice is required but very little evidence available? Leboeuf-Yde, C., Lanlo, O., & Walker, B. F. (2013) Level of Evidence : 5 Follow recommendation : 👍 Type of study : Therapeutic Topic : Limited evidence - How to proceed? This article presents a discussion on how to manage lack of evidence in clinical practice. You can find an exhaustive figure below the synopsis. The following recommendations were made: - If there is no evidence on a specific topic, use plausibility and experience. - If a treatment/test's plausibility is questioned (i.e. preclinical or basic science studies do not support the mechanism), experience is not enough to justify treatment/test. - If a treatment/test's plausibility is questioned (i.e. preclinical or basic science studies do not support the mechanism) but its use is supported by several high quality clinical studies , use the treatment/test. Clinical Take Home Message : Based on this approach, our clinical decisions should rely on consistent high quality evidence (if available). If not enough evidence (research in clinical populations) is available we should question whether a specific test/treatment is logical and whether its logical assumptions are supported by preclinical/basic science. If not, the specific test/treatment should not be used. On the other hand, if there is limited evidence (research in clinical populations), but the test/treatment is logical and its logical assumptions are supported by preclinical/basic science we should use. In this last case we need to keep an open mind and be ready to change our practice when new evidence arises. Open Access URL : https://chiromt.biomedcentral.com/articles/10.1186/2045-709X-21-24 Abstract Background All clinicians of today know that scientific evidence is the base on which clinical practice should rest. However, this is not always easy, in particular in those disciplines, where the evidence is scarce. Although the last decades have brought an impressive production of research that is of interest to chiropractors, there are still many areas such as diagnosis, prognosis, choice of treatment, and management that have not been subjected to extensive scrutiny. Discussion In this paper we argue that a simple system consisting of three questions will help clinicians deal with some of the complexities of clinical practice, in particular what to do when clear clinical evidence is lacking. Question 1 asks: are there objectively tested facts to support the concept? Question 2: are the concepts that form the basis for this clinical act or decision based on scientifically acceptable concepts? And question three; is the concept based on long-term and widely accepted experience? This method that we call the “Traffic Light System” can be applied to most clinical processes. Summary We explain how the Traffic Light System can be used as a simple framework to help chiropractors make clinical decisions in a simple and lucid manner. We do this by explaining the roles of biological plausibility and clinical experience and how they should be weighted in relation to scientific evidence in the clinical decision making process, and in particular how to proceed, when evidence is missing.

Upper extremity fragility fractures. Shoji, M. M., Ingall, E. M., & Rozental, T. D. (2020) Level of Evidence : 5 Follow recommendation : 👍 👍 Type of study : Preventative Topic : Fragility fractures - Prevention of secondary osteoporotic fractures This is a narrative review on screening and prevention of fragility fractures in patients presenting with a distal radius fracture (DRF). Fragility fractures are defined as fractures associated with low energy trauma. Interestingly, older clients presenting with a DRF, are 5 times more likely to have a fragility fracture within one year compared to their peers. The presence of a DRF in people older than 50 can suggest the presence of bone weakness (osteopenia or osteoporosis) and a Bone Mass Density (BMD) assessment is therefore indicated in these clients. A BMD assessment can be combined with the Fracture Risk Assessment Tool ( FRAX ) to provide a 10 years risk of hip fracture or other osteoporotic type fractures. If the results of the FRAX suggest that there is ≥ 3% risk of hip fracture or ≥ 20% risk of osteoporotic fractures in patients older than 50, bisphosphonate therapy should be initiated. In addition, a balance and strength training exercise program should be started. Clinical Take Home Message : Hand therapists have a great opportunity to reduce the risk of fragility fractures among their clients by screening them through tools such as the FRAX . Hand therapists may also refer their clients with a distal radius fracture, who are older than 50, to their GP suggesting a bone mass density assessment. Hand therapist can also assess lower limb strength and balance in people with distal radius fracture through simple tests such as the Chair Stand Test and the Timed up and Go test. Recently, an mobile app called Nymbl has been sponsored by ACC and can be used by our older clients to keep active and reduce their risk of falls. If clients are provided with medications such as bisphosphonate, hand therapists should encourage them to take them as prescribed and provide educational resources on osteoporosis (e.g. NIH , NOF , IOF ). For further information on our key role in fragility fracture screening, see this synopsis . URL : https://www.jhandsurg.org/article/S0363-5023(20)30407-X/fulltext Available through the Journal of Hand Surgery (American volume) for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract The population of elderly patients is rapidly increasing in the United States and worldwide, leading to an increased prevalence of osteoporosis and a concurrent rise in fragility fractures. Fragility fractures are defined as fractures involving a low-energy mechanism, such as a fall from a standing height or less, and have been associated with a significant increase in the risk of a future fragility fracture. Distal radius fractures in the elderly often present earlier than hip and vertebral fractures and frequently involve underlying abnormalities in bone mass and microarchitecture. This affords a unique opportunity for upper extremity surgeons to aid in the diagnosis and treatment of osteoporosis and the prevention of secondary fractures. This review aims to outline current recommendations for orthopedic surgeons in the evaluation and treatment of upper extremity fragility fractures.

Management of radial tunnel syndrome: A therapist's clinical perspective. Cleary, C. K. (2006) Level of Evidence : 5 Follow recommendation : 👍 Type of study : Therapeutic Topic : Posterior interosseous nerve entrapment - Conservative treatment This is a expert opinion article on conservative interventions for radial tunnel syndrome (RTS). Unfortunately, I was unable to find a more recent paper on conservative interventions for RTS. I have excluded from this synopses modalities such as ultrasound treatment (US) described in the paper. The author's recommendation is based on animal studies showing improvements in nerve conduction (NC) following US. I am not however convinced about the clinical relevance of these findings, as changes in clients' symptoms are not always correlated with improvements in NC (see this synopsis ). If you are really interested in US modalities and the author's opinion on the topic, you can always read the paragraph yourself (page 186-187), it is a 5-10 minutes read. The other treatment approach, which has recently been shown to be effective in other entrapment neuropathies, includes radial/median nerve glides. In addition, a wrist splint may limit the amount of wrist flexion, which may otherwise contribute to nociception in mechanosensitive radial nerves. It was also suggested to do sensorimotor training (e.g. graphesthesia, mirror therapy) to address potential cortical remapping, which can be present in clients with entrapment neuropathies. Clinical Take Home Message : Currently there is very limited evidence supporting the use of any conservative intervention for radial tunnel syndrome (RTS), which is a mild entrapment neuropathy of the posterior interosseous nerve . This may be due to the extremely low incidence of this condition which affects 1 in 10,000 people . The current best approach is therefore based on indirect evidence from other entrapment neuropathies (e.g. carpal tunnel syndrome) and preclinical science. In particular, it appears that nerve glides may be helpful in reducing symptoms in RTS. In addition, the treatment of other potential compression points along the radial nerve, may be useful ( see this synopsis on carpal tunnel syndrome ). Finally, there appears to be preclinical evidence of a neuroprotective and neuroregenerative effect of mild to moderate aerobic exercise (e.g. walking, swimming, jogging) for peripheral entrapment neuropathies ( Jesson et al. 2020 - I will make a synopsis on this). Due to the very low incidence of RTS, other more common conditions such as cervical radiculopathy and lateral epicondylalgia should be excluded first. Open Access URL : https://www.jhandtherapy.org/article/S0894-1130(06)00060-3/fulltext Abstract Current best evidence for the conservative management of radial tunnel syndrome (RTS) consists primarily of expert opinion and inferences taken from studies on other nerve compressions and related syndromes. There are limited data reported in the literature of this particular disorder. This article reviews literature on modalities, therapeutic exercise, ergonomic interventions, and cortical reorganization, and how they may be considered for intervention with RTS. The author's preferred method of treatment, as based on theoretical constructs, for RTS is presented. Definitive evidence in the literature to support the conservative interventions suggested is lacking. Suggestions for clinical management and study are included in this therapist's clinical perspective.

Median and ulnar nerve anastomoses in the upper limb: A meta-analysis. Roy, J., Henry, B. M., PĘkala, P. A., Vikse, J., Saganiak, K., Walocha, J. A., & Tomaszewski, K. A. (2016) Level of Evidence : 1a Follow recommendation : 👍 👍 👍 👍 Type of study : Anatomical Topic : Median nerve variations - Relevance in carpal tunnel syndrome This is a systematic review and meta-analysis assessing the prevalence of median nerve variations in the forearm and hand. There were a total of 58 studies assessing 10,562 upper limbs (from cadavers and nerve conduction studies in living participants). All the studies were pooled in a prevalence meta-analysis. The three most common median nerve anatomical variations in the forearm were described and their prevalence reported (I excluded the Marinacci anastomosis as it is rare 0.7% of the population). These included Martin‐Gruber anastomosis (MGA), Riche‐Cannieu anastomosis (RCA), and Berrettini anastomosis (BA). The Martin‐Gruber anastomosis (MGA) is described as a communicating branch from the median nerve to ulnar nerve in the forearm. Through this anastomosis, the median nerve innervates the thenar eminence bypassing the carpal tunnel. The pooled prevalence of this anastomosis (which is mainly motor) has been shown to be 20% ( 95%CI : 16% to 23%). The Riche‐Cannieu anastomosis (RCA) is defined as a communicating branch from the ulnar nerve to the median nerve in the palm of the hand. Through this anastomosis the ulnar nerve innervates the thenar eminence muscles. The pooled prevalence of this anastomosis (which is motor) has been shown to be 60% ( 95%CI : 30% to 80%). Last but not least, Berrettini anastomosis (BA) is a sensory connection between median and ulnar nerve in the palm that innervate the middle and ring finger (digital nerves). Through this anastomosis, both the ulnar and median nerve provide sensory innervation to the ulnar aspect of the middle finger and radial aspect of the ring finger. The pooled prevalence of this anastomosis (which is sensory) has been shown to be 60% ( 95%CI : 40% to 80%). Clinical Take Home Message : Based on what we know today, at least three median nerve variations in the forearm and hand are common or normal in our clients. These variations may explain why a limited number of people presenting with severe carpal tunnel compression (significant numbness with or without pain) do not present with motor impairments in the thenar muscles (MGA and RCA anastomosis). In addition, sensory changes involving the middle and ring finger in clients with carpal tunnel syndrome may depend on the presence of communicating branches between median and ulnar nerve (BA anastomosis). This last anastomosis may explain why there is significant variance in the textbooks description of sensory changes associated with carpal tunnel syndrome (involvement or not of ring finger). URL : https://onlinelibrary.wiley.com/doi/epdf/10.1002/mus.24993 You can ask the authors for the full text through Research Gate . Available through EBSCO Health Databases for PNZ members. Abstract Introduction: The most frequently described anomalous neural connections between the median and ulnar nerves in the upper limb are: Martin‐Gruber anastomosis (MGA), Marinacci anastomosis (MA), Riche‐Cannieu anastomosis (RCA), and Berrettini anastomosis (BA). The reported prevalence rates and characteristics of these anastomoses vary significantly between studies. Methods: A search of electronic databases was performed to identify all eligible articles. Anatomical data regarding the anastomoses were pooled into a meta‐analysis using MetaXL 2.0. Results: A total of 58 (n = 10,562 upper limbs) articles were included in the meta‐analysis. The pooled prevalences were: MGA, 19.5% (95% confidence interval [CI], 16.2%–23.1%); MA, 0.7% (95% CI, 0.1%–1.7%); RCA, 55.5% (95% CI, 30.6%–79.1%); and BA, 60.9% (95% CI, 36.9%–82.6%). The results also showed that MGA was more commonly found unilaterally (66.8%), on the right side (15.7%), following an oblique course (84.8%), and originating from the anterior interosseous nerve with a prevalence of 57.6%. Conclusions: As anastomoses between the median and ulnar nerves occur commonly, detailed anatomical knowledge is essential for accurate interpretation of electrophysiological findings and reducing the risk of iatrogenic injuries during surgical procedures.

Why are assumptions passed off as established knowledge? Weisman, A., Quintner, J., Galbraith, M., & Masharawi, Y. (2020) Level of Evidence : 5 Follow recommendation : 👍 Type of study : Therapeutic Topic : Logical fallacies This article presents a discussion on logical fallacies in medicine. These fallacies apply to both expert opinions and published articles introducing new hypotheses rather than established theories. The following recommendations were made: - Avoid assuming that the achieved outcomes are the result of what preceded it (fallacy - post hoc ergo propter hoc). For example, you have given your clients "stabilisation" exercises for symptomatic 1st cmcj OA and their pain improved. You therefore assume that the issue is 1st cmcj instability when in fact pain may have improved with general thumb exercises. - Avoid assuming that incidental findings associated with a certain pathology are the cause of that pathology (e.g. repetitive strain injury, central sensitisation). For example, one of your clients is an athlete doing high exercise volume and you assume that the symptoms that they developed are due to repetitive strain injury. High loads and repetitive activities may not be the only cause of their pain and other factors such as poor sleep, fatigue, and mental health may be large contributing factors to their pain ( see this synopsis ). Clinical Take Home Message : This paper suggests keeping an open mind and challenging the concepts guiding our treatment approach, as well as the opinion of experts in the field. By assuming that we are wrong and logically test the potential alternatives (e.g. diagnostic, therapeutic) we can increase the likelihood of doing what is best for our patients. Challenging one's own practice is difficult and it has always been throughout history. URL : https://www.sciencedirect.com/science/article/abs/pii/S0306987720302437 Possibly available through EBSCO Health Databases for PNZ members. Abstract “What can be asserted without evidence can also be dismissed without evidence.” (Christopher Hitchens, 2007).

A randomized clinical trial comparing early active motion programs: Earlier hand function, TAM, and orthotic satisfaction with a relative motion extension program for zones V and VI extensor tendon repairs. Collocott, S. J. F., Kelly, E., Foster, M., Myhr, H., Wang, A., & Ellis, R. F. (2020) Level of Evidence : 1b Follow recommendation : 👍 👍 👍 👍 Type of study : Therapeutic Topic : RME - Zone V and VI extensor repair This is a randomised controlled trial assessing the effectiveness of controlled active motion (CAM) and relative motion extension (RME) splinting program following zone V and VI extensor tendon repair. Participants (N = 42) were included if they presented with a primary repair of maximum two digits in zone V and VI. Participants were excluded if they presented with additional injuries (e.g. fractures). Effectiveness of each intervention was assessed through the Sollerman Hand Function Test (SHFT - primary outcome), QuickDASH, total active motion (TAM), days to return to full work duties, grip strength, compliance with splinting regime, and participants' satisfaction (all secondary outcomes). The outcomes were measured at 4 and 8 weeks after surgery, except for grip strength, which was measured at 8 weeks only. Treatment allocation was randomised. The assessor was blinded to treatment allocation. Participants were provided with either a RME splint of the affected finger/s (n = 21) or CAM protocol (n = 21). The RME splint group was advised to wear the RME splint all day and a volar block at night. Advice was given to avoid composite flexion during the day. At 10 days, participants could return to work lifting a maximum of 5 kg. The splint was gradually weaned from week 4 post surgery (RME off for light tasks), and at week 6 participants used the RME for heavy tasks only without the need to wear a volar block at night. From week 8, any splint was to be discontinued. The RME group did not have to do any exercises unless they presented with range of movement limitations at week 4. The CAM splint group had to wear a volar block (except for pipj and dipj) during the day, which was reinforced at night (including pipj and dipj). In addition, they had to perform several exercises during the day. Return to work was similar to the RME splint group, although the CAM group was advised not to resume heavy duties at work until week 8 (two weeks later than CAM splint). The results showed that participants in the RME group recovered more quickly in terms of function (SHFT, QuickDASH) and TAM compared to the CAM group at 4 weeks. These results were both statistically and clinically significant. Overall, participants were more satisfied with the RME compared to the CAM approach. At 8 weeks TAM was still statistically and clinically significant greater in the RME splint group, however, function was no longer different between groups. No differences were noted in return to work, adherence, or complications between the two groups. Overall there was a 10% probability that these group differences were due to chance (10 group comparisons were performed, 5 of these were significant). Clinical Take Home Message : Based on what we know today, hand therapists may choose to use an RME over the CAM splinting program for extensor tendon repair in zone V and VI. The RME protocol provides greater improvement in function and finger range of movement at four weeks without the need to do a home exercise program. In addition, the number of complications (e.g. tendon rupture) was as low as in the CAM group, making the RME a safe protocol. URL : https://www.jhandtherapy.org/article/S0894-1130(18)30082-6/abstract Available through the Journal of Hand Therapy for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Study Design: Randomized clinical trial with parallel groups. Introduction: Early active mobilization programs are used after zones V and VI extensor tendon repairs; two programs used are relative motion extension (RME) orthosis and controlled active motion (CAM). Although no comparative studies exist, use of the RME orthosis has been reported to support earlier hand function. Purpose of the Study: This randomized clinical trial investigated whether patients managed with an RME program would recover hand function earlier postoperatively than those managed with a CAM program. Methods: Forty-two participants with zones V-VI extensor tendon repairs were randomized into either a CAM or RME program. The Sollerman Hand Function Test (SHFT) was the primary outcome measure of hand function. Days to return to work, QuickDASH (Disabilities of Arm, Shoulder and Hand) questionnaire, total active motion (TAM), grip strength, and patient satisfaction were the secondary measures of outcome. Results: The RME group demonstrated better results at four weeks for the SHFT score ( P  = .0073; 95% CI: −10.9, −1.8), QuickDASH score ( P  = .05; 95% CI: −0.05, 19.5), and TAM ( P  = .008; 95% CI: −65.4, −10.6). Days to return to work were similar between groups ( P  = .77; 95% CI: −28.1, 36.1). RME participants were more satisfied with the orthosis ( P  < .0001; 95% CI: 3.5, 8.4). No tendon ruptures occurred. Discussion: Participants managed using an RME program, and RME finger orthosis demonstrated significantly better early hand function, TAM, and orthosis satisfaction than those managed by the CAM program using a static wrist-hand-finger orthosis. This is likely due to the less restrictive design of the RME orthosis. Conclusions: The RME program supports safe earlier recovery of hand function and motion when compared to a CAM program following repair of zones V and VI extensor tendons.

Use of a relative motion flexion orthosis for postoperative management of zone I/II flexor digitorum profundus repair: A retrospective consecutive case series. Henry, S. L., & Howell, J. W. (2020) Level of Evidence : 4 Follow recommendation : 👍 👍 Type of study : Therapeutic Topic : RMF - Flexor tendon zone I and II This is a retrospective case series assessing the effectiveness of a relative motion flexion (RMF) splinting program following zone I and II flexor tendon repair. Participants (N = 10) were included if they presented with a single digit lesion in zone I and II. Surgical interventions included a four strand repair of flexor digitorum profundus (FDP) with pulley venting. Flexor digitorum superficialis (FDS) was not repaired if injured. The RMF splint placed the affected finger in 30°-40° of relative flexion compared to the other fingers. A wrist orthosis was utilised in combination with the RMF splint 24/7 for the first 3 weeks. After 3 weeks, the RMF was worn full time while the wrist splint was used at night and during at risk tasks (e.g. jogging) only. Lifting light objects with both hands was allowed at the three weeks mark. At six weeks, the RMF splint was still worn 24/7 and patients could lift a maximum of 3.5 kg. Use of the wrist splint was discontinued at this point. All restrictions, which included the use of the RMF splint, were lifted between week 8 and 10. Effectiveness of the intervention was assessed through ipj range of movement (total active range of movement - %TAM), grip strength, and rupture rate. The results showed that 4 participants had an excellent, 1 had a good, and 3 had a fair range of movement at the end of the rehabilitation (% of contralateral TAM outcome). Grip strength ranged from 63% to 100% of the contralateral. No ruptures were reported. Clinical Take Home Message : In the future, a RMF splint in combination with a wrist splint may be an alternative to more traditional flexor tendon repair in zone I and II when only one digit is involved. There is however not enough high quality research (at this point in time) to allow the implementation of this approach according to an evidence based approach. The risk of tendon ruptures has not been formally assessed through randomised controlled trials and there is a possibility of it being higher than the currently adopted protocols. URL : https://www.jhandtherapy.org/article/S0894-1130(18)30389-2/fulltext Available through the Journal of Hand Therapy for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Study Design: A retrospective, single-center, consecutive case series. Introduction: In concept, a relative motion flexion (RMF) orthosis will induce a “quadriga effect” on a given flexor digitorum profundus (FDP) tendon, limiting its excursion and force of flexion while still permitting a wide range of finger motion. This effect can be exploited in the rehabilitation of zone I and II FDP repairs. Purpose of the Study: To describe the use of RMF orthoses to manage zone I and II FDP 4-strand repairs. Methods: Medical record review of 10 consecutive zone I and II FDP tendon repairs managed with RMF orthosis for 8 to 10 weeks in combination with a static dorsal blocking or wrist orthosis for the initial 3 weeks. Results: Indications included sharp lacerations (n = 6), ragged lacerations (n = 2), staged flexor tendon reconstruction (n = 1), and type IV avulsion (n = 1). In 8 of the 10 cases that completed follow-up, the mean arc of proximal interphalangeal/distal interphalangeal active motion were as follows: sharp, 0° to 106°/0° to 75°; ragged, 0° to 90°/0° to 25°; reconstruction, 0° to 90°/10° to 45°; and avulsion, 0° to 95°/0° to 20°. Grip performance available for 6 of 10 cases was 62% to 108% of the dominant hand. There were no tendon ruptures, secondary surgeries, or proximal interphalangeal joint contractures. Conclusion: Based on this small series, the RMF approach appears to be safe and effective. It can lead to similar mobility and functional recovery as other early active motion protocols, with certain practical advantages and without major complications. Further investigation with larger, multicenter, prospective, longitudinal cohorts and/or randomized clinical trials is necessary.

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

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

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