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The impact of isometric handgrip exercise and training on health-related factors: A review Yamada, Y., et al. (2022) Level of Evidence: 1a- Follow recommendation: 👍 👍 👍 (3/4 thumbs up) Type of study: Therapeutic Topic: Gripping exercise - additional values This is a systematic review on the effect of gripping exercise (ball squeezing) on blood pressure and pain. Thirteen studies assessed the effect of gripping exercises on blood pressure whilst 22 assessed its effect on pain. A mix of experimental and quasi-experimental studies were included. Both healthy participants and people with persistent pain were included. Blood pressure measurements included systolic and diastolic recordings. These were taken either immediately after a single bout of exercise or a prolonged regime (1 to 3 months, daily or a few times per week). Pain measurements included pain pressure thresholds and pain intensity, usually recorded immediately following the exercises. The results show that overall gripping exercises appear to reduce blood pressure and pain. It is however uncertain whether these changes represent clinically relevant outcomes. Have a look at the picture for potential mechanisms. 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, ball squeeze exercises may have benefits extending beyond the hand. In particular, these exercises may reduce blood pressure and improve pain outcomes, although the clinical relevance of these changes is currently unknown. If you are interested in grip strength and its relevance in other aspects of general health, have a look at this synopsis. URL: https://doi.org/10.1111/cpf.12741 Abstract Isometric handgrip exercise has been suggested to promote some health-related factors (e.g., lowering blood pressure). However, there is a need to evaluate whether this type of exercise can be included as an option to elicit these health-related outcomes. The purpose of the article was to systematically review the acute and chronic effects of isometric handgrip exercise on resting blood pressure, pain sensation, cognitive function and blood lipids and lipoproteins. A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A total of 89 studies met our inclusion criteria. Most randomized controlled trials (17/26) reported reductions in resting blood pressure (mostly systolic blood pressure) following isometric handgrip training. There were inconsistent results in isometric handgrip exercise-induced hypotension (i.e., acute response). There was convincing evidence observed in randomized controlled trials (4/6) for isometric handgrip exercise-induced hypoalgesia. Some randomized controlled trials (2/2) supported an improvement in memory performance, but not interference control (0/2), after a session of isometric handgrip exercise. None of the included studies found any effects of isometric handgrip training on blood lipids and lipoproteins. Isometric handgrip exercise appears to be an effective method to improve certain health-related factors. The acute reductions in pain and blood pressure may share a similar central mechanism. However, training-induced reductions in resting blood pressure may be driven by changes in the periphery. Additional work is needed to better understand if (and to what extent) isometric handgrip exercise (or training) influences cognitive function and blood lipids and lipoproteins. 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

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

Achenbach’s syndrome revisited: The paroxysmal finger hematoma may have a genetic link. Harnarayan, P., M. J. Ramdass, S. Islam and V. Naraynsingh (2021) Level of Evidence: 5 Follow recommendation: 👍 (1/4 thumbs up) Type of study: Diagnostic/Therapeutic This is a narrative review about Achebach's syndrome, which was the pathology described in this week's Sherlock Handy. Achebach's is benign painful syndrome associated with localised bruising in the proximal and middle phalanx. This syndrome was described for the first time by Dr Walter Achebach, who defined it as a paroxysmal hand haematoma. Despite it appearing as a severe traumatic injury, trauma is rarely reported. Haematoma and swelling are usually limited to the two proximal phalanges and mainly to the volar aspect of the finger. They can involve more than one finger (see figure) and this presentation does not usually recur, making it once in a lifetime presentation (although recurrent cases have been described). All vascular investigations and blood tests are usually normal. The symptoms and haematoma usually resolve within 2 to 14 days and females appear to be more predisposed to develop this syndrome. There is a growing body of evidence suggesting that genetic factors contribute to the likelihood of developing this condition. Thus, it has been described in familial clusters. 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, Achenbach syndrome is a benign rare condition that usually resolves within 2 to 14 days. Differential diagnoses include Raynaud's phenomenon, vascular compromise (e.g. closed ring avulsion), polycythemia, and vasoconstriction secondary to the use of some headache medications (e.g. ergot alkaloids). If these and other traumatic conditions can be excluded, the condition is likely to be Achenbach syndrome and it will resolve with no treatment. URL: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8684606/ Abstract Achenbach’s syndrome describes the sudden occurrence of bruising, pain and swelling of one or more digits of the hand involving the volar aspect of the proximal and middle phalanges. Also known as the paroxysmal finger hematoma, it presents in dramatic fashion, sometimes with a prodrome of tingling, itching or numbness but despite its dramatic presentation, all investigations are normal. Routine blood investigations, as well as coagulation and thrombophilia screens are all negative as are vascular imaging and echocardiography. The diagnosis is solely clinical. Due to the nature of its presentation, almost all patients are referred for an urgent vascular consultation but the condition resolves spontaneously usually within 2–3 days, although the discoloration may persist for longer. Its appearance usually leads clinicians to start anticoagulation in the belief that it may progress but, in fact, it settles as quickly as it appears. Though there are episodic cases which recur years later, it is generally self-resolving with no complications nor residual morbidity. Although the etiology was previously unknown, there is now a recognized genetic link. Genes related to the acute phase reactive proteins and the coagulation and complement cascades appear to be linked to Achenbach’s syndrome. This evidence may explain why only certain individuals seem prone to this acutely painful, bruising disorder. We review this interesting disorder and compare patients from the tropical Caribbean region with similar cases from the temperate United Kingdom and discuss whether there are climatic variations in presentations. publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings

Does aerobic exercise effect pain sensitisation in individuals with musculoskeletal pain? A systematic review. Tan, L., et al. (2022) Level of Evidence: 1a- Follow recommendation: 👍 👍 👍 👍 (4/4 thumbs up) Type of study: Therapeutic Topic: Persistent pain - aerobic exercise This is a systematic review on the effect of aerobic exercise on pain sensitisation in people with persistent musculoskeletal pain. Of note, studies on fibromyalgia or chronic fatigue syndrome were excluded. This is important as previous reviews have included more heterogeneous persistent pain conditions making the results less clear. A total of 11 studies were included with a large variety of study designs including observational, experimental, and quasi-experimental approaches. Aerobic exercise was defined as cycling, walking, or stepping. All other forms of exercise such as stretching, strengthening, or a combination of these were excluded. Pain sensitisation was measured through pressure or thermal pain thresholds. An adapted Cochrane Risk of Bias criteria was utilised to score each individual paper. Pain sensitivity was measured either after one bout of exercise or 2-12 weeks of aerobic exercise. The results showed that overall the studies included in the review presented with low to moderate risk of bias. All 11 studies showed an improvement in pain sensitisation with an increase of 10% in the pain thresholds. On average the aerobic training was performed in hearth rate training zone 1 (50-60% of heart rate reserve), zone 2 (60-70% of heart rate reserve), zone 3 (70-80%) for 4-60 minutes up to 3-5 times per week for 2-12 weeks. 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, aerobic exercise may reduce pain sensitivity in people with persistent musculoskeletal pain. The median improvement in sensitivity is 10% suggesting that our clients may be able to withstand 10% extra activity after an aerobic training period. This is only a theoretical estimate of the improvements. Further trials assessing the impact of aerobic exercise for musculoskeletal pain on clinical outcomes are needed. In the meanwhile, for your clients with persistent pain, pain neuroscience education has been shown to provide a clinically significant boost to your exercises. In addition, if you want to provide them with an estimate of the heart rate at which aerobic exercise may be effective, you can estimate it through the calculator below, which was created by MDapp. The maximum heart rate is calculated as 220 minus the person's age (e.g. age = 34, max hearth rate = 220-34 = 186). The resting heart rate can be measured while you lie down relaxing. Open Access URL: https://doi.org/10.1186/s12891-022-05047-9 Abstract Background: Pain sensitisation plays a major role in musculoskeletal pain. However, effective treatments are limited, and although there is growing evidence that exercise may improve pain sensitisation, the amount and type of exercise remains unclear. This systematic review examines the evidence for an effect of aerobic exercise on pain sensitisation in musculoskeletal conditions. Methods: Systematic searches of six electronic databases were conducted. Studies were included if they examined the relationship between aerobic physical activity and pain sensitisation in individuals with chronic musculoskeletal pain, but excluding specific patient subgroups such as fibromyalgia. Risk of bias was assessed using Cochrane methods and a qualitative analysis was conducted. Results: Eleven studies (seven repeated measures studies and four clinical trials) of 590 participants were included. Eight studies had low to moderate risk of bias. All 11 studies found that aerobic exercise increased pressure pain thresholds or decreased pain ratings in those with musculoskeletal pain [median (minimum, maximum) improvement in pain sensitisation: 10.6% (2.2%, 24.1%)]. In these studies, the aerobic exercise involved walking or cycling, performed at a submaximal intensity but with incremental increases, for a 4-60 min duration. Improvement in pain sensitisation occurred after one session in the observational studies and after 2-12 weeks in the clinical trials. Conclusions: These findings provide evidence that aerobic exercise reduces pain sensitisation in individuals with musculoskeletal pain. Further work is needed to determine whether this translates to improved patient outcomes, including reduced disability and greater quality of life. 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

Achenbach syndrome: A report of three familial cases. Helm, R. H. (2021) 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 48 years old right-handed woman. They reported recurrent (years) haematomas and pain on the volar aspect of all fingers (except thumbs) with sparring of the fingertip (see picture). These haematomas occurred every few weeks and were not always associated with trauma/handling of heavy objects. Objectively, they did not present with temperature changes in the fingers. They reported that the symptoms and bruising usually resolved within a few days. Overall they were healthy, and they were not taking blood-thinning medications. Considering the lack of objective neurovascular impairments and haematomas presentation, the patient was diagnosed with Achenbach syndrome which is a benign condition requiring no medical attention. 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, Achenbach syndrome is a rare condition presenting with bruising and pain on the volar aspect of the fingers except for the distal phalanx. If you would like to know more about this condition, have a look at this synopsis, which provides further information about the syndrome. URL: https://doi.org/10.1177/17531934211024567 No Abstract available 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 48 years old right-handed woman. They reported recurrent (years) haematomas and pain on the volar aspect of all fingers (except thumbs) with sparring of the fingertip (see picture). These haematomas occurred every few weeks and were not always associated with trauma/handling of heavy objects. Objectively, they did not present with temperature changes in the fingers. They reported that the symptoms and bruising usually resolved within a few days. Overall they were healthy, and they were not taking blood-thinning medications. What is it?

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

Closed ring avulsion injury with isolated arterial insufficiency. Bouz, A., Y. Liu, K. T. Yamaguchi and J. B. Friedrich (2021) Level of Evidence: 5 Follow recommendation: 👍 (1/4 thumbs up) Type of study: Preventative Topic: Closed ring avulsion - Presentation This is a case report of 68 years old male with a close ring avulsion injury. The patient was working on his boat at the time of the accident. They slipped and ended up hanging off their wedding ring for a few seconds before being able to disengage the ring from a hook. They immediately went to the emergency department where they presented without fractures/major cutaneous lesions. However, there was a haematoma, paleness (see figure 1), numbness and objective evidence of reduced temperature in the left ring finger. There was full active range of movement in the finger. The patient was immediately referred for further specialist assessment. Pencil doppler revealed the presence of a pulse at the base of the finger but a total absence of it beyond the proximal interphalangeal joint. In the meanwhile, symptoms had improved but the haematoma had extended to the distal phalanx (see figure 2). Surgical exploration revealed a complete transection of the ulnar digital artery and a thrombus in the radial digital artery. Both radial and digital nerves were intact. The ulnar and radial digital artery lesions were surgically resolved and over the course of three months of rehabilitation, the patient regained full active range of movement of the finger. Figure 1 Figure 2 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, ring avulsion injuries could occur without cutaneous involvement. Despite lack of cutaneous involvement, this injury may be associated with damage to the neurovascular bundle. To reduce the risk of ring avulsion injuries, the use of silicon rings may be advisable. Thus, these rings have a breaking point of around 1/10 of metal rings. URL: https://doi.org/10.1016/j.jhsg.2021.07.004 Abstract Ring avulsion injuries are an uncommon, often catastrophic, pattern of digit injuries that result from sudden traction onto a ring-bearing digit. The reconstructive treatment of these injuries can be complex because of the characteristic involvement of nerves, muscles, vasculature, and bone. There is paucity of literature describing isolated arterial injuries in the absence of overlying soft tissue and underlying bone involvement. We present an unusual case of a closed ring avulsion injury, wherein a patient initially presented to his local urgent care center with a cool and pale digit without wounds or fractures, and abnormal pulse oximetry readings prompted his transfer to a tertiary care center for further evaluation. Surgical exploration demonstrated isolated disruption of both digital arteries and the preservation of both digital nerves. The digit was successfully revascularized with venous autografting and stripping of arterial thrombi. 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

Greater efficacy of a combination of conservative therapies for thumb base OA in individuals with lower radial subluxation – a pre-planned subgroup analysis of the COMBO trial. Deveza, L. A., et al. (2021) Level of Evidence: 2b Follow recommendation: 👍 👍 👍 (3/4 thumbs) Type of study: Prognostic Topic: Thumb osteoarthritis - thumb base radial deviation and treatment response This is a subgroup analysis of a previously published randomised controlled trial. This subgroup analysis aimed at assessing whether base of thumb radial subluxation, Kellgren Lawrence grade (KL), presence of interphalangeal joint OA, and presence of erosive hand OA affected response to conservative treatment. The two treatment types have been previously reported in the trial and included education alone or a combination of multiple conservative treatments. There were a series of outcomes being collected to assess response to treatment with the primary being pain (visual analogue scale - VAS) and function (functional index of hand OA - FIHOA) measured at six weeks. The results showed a multimodal treatment was associated with better outcomes in people with lower levels of thumb base radial deviation. Despite this finding, the improvements were quite heterogeneous and may not be clinically relevant. No other factors appeared to mediate treatment response. 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, lower levels of thumb base subluxation may predict better treatment outcomes in people with thumb OA. Radiologic findings (e.g. erosive OA) do not appear to largely affect treatment. This appears to be supported by previous evidence showing that pain catastrophising (rather than x-ray findings) is associated with pain intensity in thumb OA. An additional factor that appears to mediate treatment response in thumb OA is treatment expectations. In particular, more positive treatment expectations are associated with better treatment outcomes. URL: https://doi.org/10.1016/j.joca.2021.07.010 Abstract Objective: To investigate heterogeneous effects of a combination of conservative therapies compared with an education comparator for thumb base (TB) osteoarthritis (OA) according to clinically relevant characteristics. Methods: Pre-planned subgroup analysis of the COMBO trial (n = 204) which compared a combination of education on self-management and ergonomic principles, a prefabricated neoprene splint, hand exercises, and diclofenac sodium gel, with education alone for radiographic and symptomatic TB OA. Primary outcomes were change in pain (visual analogue scale [VAS], 0–100 mm) and hand function (Functional Index for Hand Osteoarthritis questionnaire, 0–30) from baseline to week-6. Other outcomes were grip and tip-pinch strength and patient's global assessment (PGA) (VAS, 0–100 mm). Possible treatment effect modifiers were the presence of interphalangeal joint pain, erosive hand OA, radiographic thumb carpometacarpal joint subluxation (higher vs equal or lower than the sample mean), and baseline radiographic OA severity (Kellgren Lawrence grade). Linear regression models were fitted, adding interaction terms for each subgroup of interest. Results: The treatment effects of the combined intervention at 6 weeks were greater in participants with lower joint subluxation compared with those with greater subluxation (pain −11.6 [95%CI −22.2, −9.9] and 2.6 [−5.5, 10.7], respectively, difference between the subluxation groups 14.2 units (95% CI 2.3, 26.1), p-value 0.02; and PGA −14.0 [−22.4, −5.5] and 1.5 [−6.2, 9.3), respectively, difference between the subluxation groups 15.5 units (95% CI 4.2, 26.8), p-value 0.03). There was no statistically significant heterogeneity for the other subgroups. Conclusion: A combination of conservative therapies may provide greater benefits over 6 weeks in individuals with lower joint subluxation, although the clinical relevance is uncertain given the wide confidence intervals. Treatment strategies may need to be customized for those with greater joint subluxation. Trial registration number ACTRN 12616000353493. 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

Physical inactivity is associated with a higher risk for severe COVID-19 outcomes: A study in 48 440 adult patients. Sallis, R., et al. (2021) Level of Evidence: 2b Follow recommendation: 👍 👍 👍 (3/4 thumbs) Type of study: Preventative Topic: Physical activity and COVID-19 - Risk reduction This is a retrospective study assessing the correlation between pre-infection physical activity and severity of COVID-19 infection. A total of 103,337 participants were included. The severity of COVID-19 infection was measured by rate of hospitalisation, admission to ICU, and deaths associated with it. The results showed that of the total sample, 8.6% were hospitalised, 2.4% had to be admitted to ICU, and 1.6% died. Patients who were consistently inactive (did not meet the physical activity guidelines) were a greater odds of been hospitalised, being admitted to ICU, and dying compared to patients who consistently met the physical activity guidelines. These findings were retained even with analyses that adjusted for several confounding variables (e.g. age) - see forest plot below. 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, physical activity appears to reduce the risk of COVID-19 severity. This is important to remember because many of our clients undergo periods of reduced activity due to their upper limb injuries. If possible, we should therefore find alternative exercising strategies that maintain them active whilst avoiding loading of healing tissues. Ideally we would suggest them to follow the physical activity guideline that were discussed in a previous synopsis (See picture below for further information). Following the WHO physical activity guidelines will not only improve prognosis for COVID-19 infection, but also improve wound healing, bone mass density, and mental health status, which is a factor influencing our clients recovery. Open Access URL: http://bjsm.bmj.com/content/early/2021/04/07/bjsports-2021-104080.abstract Abstract Objectives: To compare hospitalisation rates, intensive care unit (ICU) admissions and mortality for patients with COVID-19 who were consistently inactive, doing some activity or consistently meeting physical activity guidelines. Methods: We identified 48 440 adult patients with a COVID-19 diagnosis from 1 January 2020 to 21 October 2020, with at least three exercise vital sign measurements from 19 March 2018 to 18 March 2020. We linked each patient’s self-reported physical activity category (consistently inactive=0–10 min/week, some activity=11–149 min/week, consistently meeting guidelines=150+ min/week) to the risk of hospitalisation, ICU admission and death after COVID-19 diagnosis. We conducted multivariable logistic regression controlling for demographics and known risk factors to assess whether inactivity was associated with COVID-19 outcomes. Results: Patients with COVID-19 who were consistently inactive had a greater risk of hospitalisation (OR 2.26; 95% CI 1.81 to 2.83), admission to the ICU (OR 1.73; 95% CI 1.18 to 2.55) and death (OR 2.49; 95% CI 1.33 to 4.67) due to COVID-19 than patients who were consistently meeting physical activity guidelines. Patients who were consistently inactive also had a greater risk of hospitalisation (OR 1.20; 95% CI 1.10 to 1.32), admission to the ICU (OR 1.10; 95% CI 0.93 to 1.29) and death (OR 1.32; 95% CI 1.09 to 1.60) due to COVID-19 than patients who were doing some physical activity. Conclusions: Consistently meeting physical activity guidelines was strongly associated with a reduced risk for severe COVID-19 outcomes among infected adults. We recommend efforts to promote physical activity be prioritised by public health agencies and incorporated into routine medical care. 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 functional outcomes after brachial plexus injury. Quick, T. J. and H. Brown (2020) Level of Evidence: 4 Follow recommendation: 👍 (1/4 thumbs) Type of study: Diagnostic Topic: Assessment of brachial plexus injuries - Motor, sensory, and functional tests to assess brachial plexus injuries This narrative review focused on the available outcomes to assess motor, sensory, pain, and functional impairments in people with brachial plexus injuries. For motor outcomes, the use of dynamometers instead of traditional manual muscle testing has been advised. Thus, they appear to be more reliable and valid to assess muscle strength. Detection of stimuli can be assessed through monofilament testing, which appears to be a good outcome to measure change over time. In addition, the Shape Texture Identification (STI) for stereognosis and the locognosia test for touch localisation can both be used to assess further sensory impairments. Pain can be assessed through multiple outcomes and there is no specific measure for brachial plexus injuries. The visual analogue scale (VAS), the Numerical Rating Scale (NRS), and McGill Pain Questionnaire are only a few of several outcomes available. Finally, the DASH is commonly utilised in brachial plexus injuries, however, it has not been validated in this group of patients. The Brachial plexus Assessment Tool (BrAT) can be used as an alternative to the DASH, however, this is a new scale and requires further research supporting its use. 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, when assessing brachial plexus injuries, motor, sensory, and functional aspects need to be measured. Hand-held dynamometers can be purchased by hand therapists (roughly $1,600) and can provide more valid measurements than manual muscle testing. Monofilaments appear to be a good starting point to assess touch detection. Further assessment of sensibility can be performed through the test for touch localisation, which is free. The Shape Texture Identification test appears to be a great tool but it is not free (roughly $1,115). In regard to pain assessment, we are spoiled for choice. I would personally use both the NRS for pain intensity and the Douleur Neuropathique 4 (DN4), a quick questionnaire that includes three objective tests for the identification of neuropathic pain. URL: https://doi.org/10.1177%2F1753193419879645 Abstract Major nerve injuries such as those of the brachial plexus present a significant challenge for both rehabilitation and evaluation of outcome. With these often complex and multi-faceted injuries, correct selection of outcome measures is important. Healthy nerve function in humans heightens our interactions with the world, creating quality and enjoyment through our experiences of movement and touch. Therefore, assessments should be holistic and representative of all of these features. This article considers the assessment and evaluation of all of the features of nerve injury: sensorimotor, sensation (including that of pain), function and the psychosocial aspects. Current practice is described and combined with clinical experience and research findings to provide suggestions and recommendations for the selection of the most appropriate tools for use with this patient group. 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