Search Results

Level of Evidence: 5 Follow recommendation: 👍 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 12 years old boy who presented with a mass on the middle phalanx of the ring finger, which developed after finger trauma six months earlier. The mass was painless and developed on the volar/radial aspect of the finger. The x-rays identified a mass as shown below in the picture. What was it?

Clinical effectiveness of shockwave therapy in lateral elbow tendinopathy: Systematic review and meta-analysis. Karanasios, S., G. K. Tsamasiotis, K. Michopoulos, V. Sakellari and G. Gioftsos (2021) Level of Evidence: 1a Follow recommendation: 👍 👍 👍 👍 Type of study: Therapeutic Topic: Lateral epicondylalgia - Extracorporeal shock waves This is a systematic review and meta-analysis of randomised controlled trials assessing the effectiveness of extracorporeal shock waves for lateral epicondylalgia. Twenty-seven randomised controlled trials were included for a total of 1,871 participants (16 studies were included in the meta-analysis). Each individual paper was scored on the PEDro critiquing tool. The results from this systematic review and meta-analysis were assessed through the GRADE approach (suggested by the Cochrane Group), which scores the evidence as "very low", "low", "moderate", or "high" quality. Efficacy of intervention was assessed through changes in pain, grip strength, pain-free grip strength (PFG), and elbow disability. Pain was assessed through the visual analogue scale (VAS) or the numerical rating scale (NRS), elbow disability was measured through several different outcome measures including the Patient-Rated Tennis Elbow Evaluation (PRTEE) and the Disability of the Arm, Shoulder, and Hand (DASH) questionnaire. Follow-up times ranged between very short term (less than 2 months), short term (2-3 months), mid-term (3-12 months), and long term (more than 12 months). Extracorporeal shock waves were compared to no intervention, sham/placebo, multimodal physiotherapy, PRP, and corticosteroid injections. Low to moderate quality evidence suggests that extracorporeal shock waves provide statistically significant differences in pain in the mid term and grip strength in the very short and short term. However, these results were unlikely to be of clinical relevance due to the small effects. Extracorporeal shock waves had no effect on elbow disability when compared to other interventions. Clinical Take Home Message: Based on what we know today, extracorporeal shock waves may have a small effect on pain and grip strength for clients with lateral epicondylalgia. Their effectiveness appears however small and possibly not clinically relevant. When compared to corticosteroid injections, there were no differences (this comparison was reported in four trials). The benefit of extracorporeal shock waves over corticosteroids may be that they do not appear to increase recurrence at one year. To draw some final conclusions, we may utilise extracorporeal shock waves as a last resort in our clients with severe pain, unresponsive to main stream interventions. A trial of tendon unloading (activity reduction and counterforce splint - see previous synopses on splint effectiveness and biomechanics) followed by graded resistance training (see previous synopsis on tendinopathy grading and treatment) may be trialed first. URL: https://doi.org/10.1177/02692155211006860 Available through EBSCO Health Databases for PNZ members. Abstract Objective: To evaluate the effectiveness of extracorporeal shockwave therapy compared with other interventions on pain, grip strength and disability in patients with lateral elbow tendinopathy. Data Sources: MEDLINE, PubMed, CINAHL, EMBASE, PEDro, ScienceDirect, Cochrane Library and clinical trial registries. Review methods: We included randomized controlled trials assessing the effectiveness of extracorporeal shockwave therapy alone or as an additive intervention compared with sham or other interventions. Pain intensity, grip strength and elbow disability were used as primary outcome measures. We assessed methodological quality with the PEDro score and quality of evidence with the GRADE approach. Results: Twenty-seven studies with 1871 patients were finally included. Extracorporeal shockwave therapy reduced pain intensity at mid-term follow-up (standardized mean difference: 1.21, 95% confidence interval:1.53, 0.89, P<0.001) and improved grip strength at very short- (mean difference:3.92, 95% confidence interval: 0.91, 6.94, P=0.01) and short-term follow-up (mean difference:4.87, 95% confidence interval:2.24, 7.50, P<0.001) compared with sham treatment. However, no clinically significant results were found between comparators in all outcomes and follow-up times. Extracorporeal shockwave therapy presented clinically better compared to Laser in grip strength at short-term (mean difference:3.50, 95% confidence interval:2.40, 4.60, P<0.001) and ultrasound in pain intensity at very-short-term follow-up (standardized mean difference: 1.54, 95% confidence interval: 2.60, 0.48, P=0.005). Conclusion: Low to moderate certainty of evidence suggests that there are no clinical benefits of extracorporeal shockwave therapy compared to sham interventions or corticosteroid injections. Based on very-low and moderate certainty of evidence, extracorporeal shockwave therapy outperforms against Laser and ultrasound, respectively.

The effects of exercise on chemotherapy-induced peripheral neuropathy symptoms in cancer patients: A systematic review and meta-analysis. Lin, W.-L., et al. (2021) Level of Evidence: 1a- Follow recommendation: 👍 👍 👍 👍 Type of study: Therapeutic Topic: Neuropathic pain - Chemotherapy induced neuropathy and exercise This is a systematic review and meta-analysis on exercise interventions for chemotherapy-induced neuropathies. Five RCTs were included in the meta-analysis for a total of 178 participants. Each study was assessed through the CONSORT checklist. No overall quality of evidence assessment was provided, however, I calculated it for you through the GRADE approach ("low", "very low", "moderate", "high"), which is commonly utilised by the Cochrane group for systematic reviews. Several different types of exercises were utilised including resistance training, balance, nerve gliders, or combined exercises (see table below). Frequency ranged from 2 to 7 times per week and duration varied from 6 to 18 weeks. Treatment effectiveness was assessed though the Chemotherapy induced peripheral neuropathy (CIPN) screening tool, a neuropathic pain questionnaire (Leeds Assessment for Neuropathic Symptoms and Signs - S-LANSS), or other questionnaires. The results showed that there is low quality evidence showing statistically significant improvements in symptoms reported by participants. It is unclear whether these improvements were clinically relevant. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message: Based on what we know today, clients presenting with chemotherapy-induced neuropathic pain, may benefit from a wide range of exercises. This seems to reduce neuropathic pain symptoms although we are not sure whether these improvements are clinically relevant. These results are supported by previous basic science research suggesting that exercise has a neuroprotective effect. Exercise not only has the potential to extend cancer survivors healthspan by improving cardiovascular fitness, but has also been shown to improve their quality of life. URL: https://doi.org/10.1007/s00520-021-06082-3 Available through EBSCO Health Databases for PNZ members. Abstract Purpose: To conduct a systematic review and meta-analysis of current studies to determine whether exercise affects chemotherapy-induced peripheral neuropathy (CIPN) symptoms in cancer patients. Design: The Medline, Embase, Cochrane Library, CINAHL, PubMed, and National Central Library databases, and the reference lists of the included studies were surveyed. The Consolidated Standards of Reporting Trials (CONSORT) extension checklist for non-pharmacologic treatment was used to evaluate the literature. Setting and participants: Exercise interventions offered in hospitals or at home. A total of 178 participants from 5 studies were assessed in the meta-analysis, with their mean age ranging from 48.56 to 71.82 years. Methods: The randomized control trials were summarized in a systematic review. The effects of the exercise interventions were compiled for meta-analysis. A forest plot was constructed using a fixed effect model to obtain a pooled mean difference. Results: The pooled results indicated that exercise interventions significantly improved the CIPN symptoms of the participants (mean difference: 0.5319; 95% confidence interval: 0.2295 to 0.8344; Z = 3.45; P = 0.0006). A combination of exercise protocols including a nerve gliding exercise intervention was found to have improved CIPN symptoms. In addition, a sensorimotor-based exercise intervention was found to have reduced CIPN-induced loss of postural stability. Conclusions and implications: The findings indicated that the effects of exercise could improve CIPN symptoms in cancer patients. Nevertheless, further investigations of different exercise protocols and intensity of intervention utilizing larger sample sizes and more specific outcome measures will further inform the best practices for cancer patients.

Central sensitisation in chronic pain conditions: Latest discoveries and their potential for precision medicine. Nijs, J., et al. (2021) Level of Evidence: 5 Follow recommendation: 👍 Type of study: Aetiologic, Diagnostic, Therapeutic Topic: Central sensitisation - Presentation and diagnostics This is a narrative review published in The Lancet Rheumatology on the presentation, diagnosis, and treatment of central sensitisation in people with musculoskeletal conditions. Central sensitisation has been defined as an amplification of nociceptive messages, which could lead to greater pain levels. Changes associated with central sensitisation could lead to the translation of mechanical (not nociceptive stimuli) into nociceptive stimuli (leading to allodynia - perception of pain with a non painful stimuli). Previous studies have suggested that central sensitisation may be a common phenomenon in upper limb conditions, especially in lateral epicondylalgia. The Central Sensitization Inventory (CSI) has been suggested as potentially useful questionnaire to identify people who may present with central sensitisation phenotypes. The results from this questionnaire may also be useful for prognostic purposes as there is some evidence suggesting that clients with central sensitisation may have greater disability in the short and longer term after injury. It was also highlighted that central sensitisation could be maintained by on-going peripheral nociceptive inputs as well as centrally mediated changes (brain and spinal cord functional changes). Unfortunately, at this point in time there is no way of differentiating between the two. Therapeutic interventions aimed at affecting peripheral dysfunctions (joint impairments) as well as moderating other psychological factors (e.g. pain catastrophising) that can contribute to central sensitisation, may be utilised in clinical practice. Therapeutic interventions including manual therapy, exercise, and education have shown to be effective in reducing signs of central sensitisation although they are best not used in isolation in people with persistent pain. 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, central sensitisation may amplify nociceptive inputs coming from peripheral joints or soft tissues. Treatments including pain neurophysiology education, exercise, and manual approaches appear to be effective in reducing signs of central sensitisation. In addition, using words that reduce fear and threat of tissue damage may be useful to reduce central sensitisation. URL: https://doi.org/10.1016/S2665-9913(21)00032-1 Available through EBSCO Health Databases for PNZ members. Abstract Chronic pain is a leading cause of disability globally and associated with enormous health-care costs. The discrepancy between the extent of tissue damage and the magnitude of pain, disability, and associated symptoms represents a diagnostic challenge for rheumatology specialists. Central sensitisation, defined as an amplification of neural signalling within the CNS that elicits pain hypersensitivity, has been investigated as a reason for this discrepancy. Features of central sensitisation have been documented in various pain conditions common in rheumatology practice, including fibromyalgia, osteoarthritis, rheumatoid arthritis, Ehlers-Danlos syndrome, upper extremity tendinopathies, headache, and spinal pain. Within individual pain conditions, there is substantial variation among patients in terms of presence and magnitude of central sensitisation, stressing the importance of individual assessment. Central sensitisation predicts poor treatment outcomes in multiple patient populations. The available evidence supports various pharmacological and non-pharmacological strategies to reduce central sensitisation and to improve patient outcomes in several conditions commonly seen in rheumatology practice. These data open up new treatment perspectives, with the possibility for precision pain medicine treatment according to pain phenotyping as a logical next step. With this view, studies suggest the possibility of matching non-pharmacological approaches, or medications, or both to the central sensitisation pain phenotypes.

A meta-synthesis of carpal tunnel syndrome treatment options: Developing consolidated clinical treatment recommendations to improve practice. Baker, N. A., J. Dole and S. C. Roll (2021) Level of Evidence: 1a- Follow recommendation: 👍 👍 👍 👍 Type of study: Therapeutic Topic: Conservative - pain education This is a meta-synthesis on the effectiveness of most published treatments for carpal tunnel syndrome. A meta-synthesis is the combination of qualitative research to provide new insights into a specific topic. The search focused initially on available information from clinical resources as well as guidelines to make it as relevant as possible for clinicians. The search was not only limited to formal databases but professional institutes worldwide. Only information which had been created by a panel of experts, professional bodies, or that was obtained from formal literature searches was retained. The overall quality of the evidence was assessed through a modified GRADE approach, which was originally suggested by the Cochrane group for systematic reviews. A total of six guidelines were included in this study, including 55 different treatments. The results showed that there was strong evidence for the use of carpal tunnel release, wrist splinting, or corticosteroid injections. 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, immobilisation for carpal tunnel syndrome is strongly advised. This may be trialed for six weeks. Other strongly advised treatments include cortisone injections or surgical release. Other approaches such exercise, education, manual therapy, and workplace changes could be utilised but should not be the mainstream approach. URL: https://doi.org/10.1016/j.apmr.2021.03.034 Available through The Journal of Hand Surgery (American Volume) for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Carpal tunnel syndrome (CTS) treatment contains ambiguities across and within disciplines. This meta-synthesis of professional guidelines consolidates clinical treatment recommendations for CTS treatment and classifies them by strength of evidence. We conducted a search of Google, Google Scholar, and PubMed for published clinical treatment recommendations for CTS. A systematic hand search was completed to identify additional professional organizations with published recommendations. We extracted any mentioned treatment from all sources but developed our final consolidated clinical treatment recommendations only from select rigorous guidelines based on the Institute of Medicine (IOM) criteria for trustworthy guidelines. We translated rating systems of the primary guidelines into a universal rating system to classify recommendations for consolidated clinical treatment recommendations. Our search yielded 30 sources that mentioned a total of 55 CTS treatments. Six of the sources met the IOM inclusion criteria. These primary guidelines provided recommendations for 46 of the 55 treatments, which were consolidated into 12 broad treatment categories. Surgery, positioning, and steroids were strongly supported. Conservative treatments provided by rehabilitation professionals were conditionally supported. Pharmaceuticals, supplements, and alternative treatments were not generally supported. CTS is a complex condition with a wide variety of treatments provided by a multitude of disciplines. Our consolidated clinical treatment recommendations offer a comprehensive outline of available treatments for CTS and contributes to the process of developing best practices for its treatment.

Reframing how we care for people with persistent non-traumatic musculoskeletal pain. Suggestions for the rehabilitation community. Lewis, J. S., et al. (2021) Level of Evidence: 5 Follow recommendation: 👍 👍 Type of study: Therapeutic Topic: Persistent musculoskeletal pain – Reframing care This is an expert opinion piece from a community of rehabilitation clinicians, researchers, and patients on the need to review our approach to persistent musculoskeletal treatment. Patients reported being disappointed and frustrated when undergoing "curative" treatments which provided no solution to their pain. Clients also reported economical issues associated with the time spent off work, which was moderated by their understanding that movement would cause further "damage". Clients reported empowerment as the most useful approach. This was guided by clinicians helping them in taking charge of their own health. In terms of advice for physiotherapists, the list in the box below was suggested. A move away from passive treatments for persistent musculoskeletal was suggested, with a strong bias towards coaching and maintenance of a healthy lifestyle. Clinicians were invited to dedicate more attention to the potential drivers of persistent musculoskeletal pain (e.g. inactivity, deconditioning) and less attention to the specific diagnostic labels and "curative" treatment, which can provide limited help in the treatment of persistent pain. 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 may take a holistic approach to care of our musculoskeletal clients by providing them with neuroscience education, information regarding the importance of staying active, and advice on how stop smoking if they are. In addition, we could probably start talking about tissue sensitivity rather than "wear and tear" or "overuse syndrome". There is in fact evidence suggesting that the words that we use can have either a placebo (reducing pain) or nocebo effect (increasing pain). We may also encourage joint motion for lotion, promote joint movement for amusement, and suggest meditation for elation. URL: https://doi.org/10.1016/j.physio.2021.04.002 Available through EBSCO Health Databases for PNZ members. Abstract There have been repeated calls to re-evaluate how clinicians provide care for people presenting with persistent non-traumatic musculoskeletal conditions. One suggestion is to move away from the ?we can fix and cure you? model to adopting an approach that is more consistent with approaches used when managing other persistent non-communicable diseases; education, advice, a major focus on self-management including lifestyle behavioural change, physical activity and medications as required. Currently the global delivery of musculoskeletal care has many of the elements of a ?super wicked problem?, namely conflict of interest from stake-holders due to the consequences of change, prevailing expectation of a structural diagnosis and concomitant fix for musculoskeletal pain, persistent funding of high risk, more expensive care when low risk more economic viable options that don?t impact on the quality of outcome exist, and an unquestionable need to find a solution now with the failure resulting in a growing social and economic burden for future generations. To address these issues, 100 participants included clinicians, educators and researchers from low-, middle- and high-income countries, 8 presenters representing the physiotherapy, sport medicine and the orthopaedic professions and the insurance industry, together with 3 people who shared their lived experiences of persistent musculoskeletal pain, discussed the benefits and barriers of implementing change to address this problem. This paper presents the results from the stakeholders? contextual analysis and forms the basis for the proposed next steps from an action and advocacy perspective.

Avoiding ring avulsion injuries with silicone rings: A biomechanical study. Jewett, C. A., S. Uppuganti and M. J. Desai (2021) Level of Evidence: 2b Follow recommendation: 👍 👍 Type of study: Preventative Topic: Ring avulsion - How to reduce the risk This is a biomechanical study assessing finger damage associated with traction of metal vs silicone rings in cadavers. A total of 25 fingers were tested in the present study. The speed of traction on the ring was 50 cm/s, which aimed to replicate a fall speed. The results showed that the breaking point for the silicone and metal rings was 495 N (50.5 kg) and 53 N (5.4 kg) respectively See table below). The breaking point for the silicone ring was defined as rupture of the ring itself whilst for the metal ring, the breaking point was defined as slippage or skin rupture. 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, silicone rings may reduce the risk of serious avulsion injuries compared to traditional metal rings. Despite reduced risk, the forces associated with the breaking point of silicone rings, may still cause injury as shown by a previous biomechanical study. URL: https://doi.org/10.1016/j.jhsa.2021.02.025 Available through The Journal of Hand Surgery (American Volume) for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Purpose: Finger avulsion injuries account for 5% of upper extremity injuries requiring evaluation in an emergency room. They are devastating injuries that require microvascular reconstruction or amputation. As public awareness rises, there is a growing market for silicone rings, with limited data on their ability to prevent ring avulsion injuries. Methods: Five cadaver forearms were attached to a custom fixture, allowing for ring avulsion simulations. Specifically designed silicone or metal rings of varying sizes (#4–#11) were assigned to one of five fingers on each forearm, based on fit. The contralateral corresponding finger was tested using a ring of the same size in the other material. A preload of 2 N was applied to each ring, and ultimate failure force was determined by applying an upward force at a loading rate of 500 mm/sec until failure. Additionally, a fifth cadaver forearm was used to determine the ultimate failure force of silicone rings in a clenched fist position. Results: The average ultimate failure force for silicone rings of all sizes was 53.0 N, compared to 495.2 N for metal rings of all sizes. The average ultimate failure force of silicone rings in the clenched fist position was increased across rings of all sizes, with an average of 99.9 N. There were no degloving injuries in the silicone ring avulsion group. Conclusions: Biomechanically, silicone rings have a significantly lower failure force than metal rings and may help prevent ring avulsion injuries. Clinical relevance: The use of silicone rings should be encouraged in professions where ring avulsion injuries are more likely, such as heavy labor.

Association between text neck and neck pain in adults. Correia, I. M. T., et al. (2021) Level of Evidence: 4 Follow recommendation: 👍 👍 👍 Type of study: Symptoms prevalence study Topic: Mobile technology use - symptoms prevalence of neck pain This cross sectional study assessed the association between neck position during mobile phone texting and neck pain in adults. Participants (N = 582) with and without neck pain between the age of 18 and 65 were included. The average age was 27 years old. Neck flexion position during mobile texting (usual comfortable position) was measured through a cervical range of movement inclinometer in standing and sitting. The presence of neck pain (yes/no) and the intensity of it (measured through NRS 0 to 10) were self-reported. The results showed that the average cervical flexion position in standing and sitting was 34° (SD: 12°) and 36° (SD: 14°) respectively. Prevalence of neck pain was 21% (n = 125). The worst neck pain intensity was 4.5 (SD: 2.3) out of 10. There was no association between the degree of cervical flexion during mobile texting and the presence or intensity of neck pain. Older age and poorer sleep were the only factors associated with greater prevalence of neck pain or pain intensity. Increase phone used also appeared to be associated with greater neck pain intensity. Clinical Take Home Message: Based on what we know today, there is no correlation between neck position and the presence or intensity of neck pain. Instead, it appears that older age, poor sleep, and possibly longer periods of time spent on the phone contributed to the presence and intensity of neck pain. Given these findings, we can probably avoid focusing too much on the posture that our clients adopt when utilising mobile phones and invite them instead to follow the World Health Organisation 2020 physical activity guidelines, which may reduce the time spent on their phone and improve sleep quality. URL: https://www.researchgate.net/publication/347846024 Available through The Journal of Hand Surgery (American Volume) for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract STUDY DESIGN: Observational cross-sectional study. OBJECTIVE: The aim of this study was to investigate the association between text neck and neck pain (NP) in adults. SUMMARY OF BACKGROUND DATA: It has been hypothesized that the inappropriate neck posture adopted when texting and reading on a smartphone, called text neck, is related to the increased prevalence of NP. METHODS: The sample was composed of 582 volunteers aged between 18 and 65 years. Sociodemographics, anthropometrics, lifestyle, psychosocial, NP, and smartphone use-related questions were assessed by a self-reported questionnaire. Text neck was assessed by measuring the cervical flexion angle of the participants standing and sitting while typing a text on their smartphones, using the Cervical Range of Motion (CROM) device. RESULTS: Multiple logistic regression analysis and linear regression analysis showed the cervical flexion angle of the standing participant using a smartphone did not associate with the prevalence of NP (odds ratio [OR] = 1.00; 95% confidence interval [CI]: 0.98-1.02; P = 0.66), NP frequency (OR = 1.01; 95% CI: 1.00-1.03; P = 0.056), or maximum NP intensity (beta coefficient = -5.195 × 10-5; 95% CI: -0.02 to 0.02; P = 0.99). Also, the cervical flexion angle of the sitting participant using the smartphone did not associate with NP (OR = 0.99; 95% CI: 0.98-1.01; P = 0.93), NP frequency (OR = 1.01; 95% CI: 0.99-1.02; P = 0.13), or maximum NP intensity (beta coefficient = 0.002; 95% CI: -0.002 to 0.02; P = 0.71). CONCLUSION: Text neck was not associated with prevalence of NP, NP frequency, or maximum NP intensity in adults.

Conservative management of de quervain stenosing tenosynovitis: Review and presentation of treatment algorithm. Abi-Rafeh, J., R. Kazan, T. Safran and S. Thibaudeau (2020) Level of Evidence: 2a Follow recommendation: 👍 👍 👍 Type of study: Treatment Topic: De Quervain - Conservative treatment This is a systematic review reporting a treatment algorithm for De Quervain syndrome. Sixty-six studies (including case studies) were analysed, for a total of 2,306 participants. The studies included were not formally assessed in terms of their quality. The conservative treatments included in the review were cortisone injections, physiotherapy, and splinting. A very limited number of studies assessed the effectiveness of physiotherapy. Cortisone injections alone or in combination with splinting were the most studied approaches and appeared to provide pain relief in participants with De Quervain. 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: There is a significant lack of studies assessing the effectiveness of conservative interventions other than cortisone injections or splinting for De Quervain syndrome. This is unfortunate, considering findings from previous research showing tendon pathology of APL/EPB in participants with De Quervain. If tendinopathy was a significant driver in De Quervain's syndrome, unloading through activity modification/splinting, followed by gradual tendon loading, may be an appropriate treatment (see previous synopsis on different Tendinopathy stages). Currently, for De Quervain tenosynovitis, the use of cortisone injection appears to be an effective treatment option. Future research is needed to determine whether cortisone injections for this condition are the best treatment or whether they provide a short term fix with long term negative repercussions, as it has been shown for tennis elbow. URL: https://doi.org/10.1097/prs.0000000000006901 Available through EBSCO Health Databases for PNZ members. Abstract BACKGROUND: Nonsurgical management of de Quervain disease relies mainly on the use of oral nonsteroidal antiinflammatory drug administration, splint therapy, and corticosteroid injections. Although the latter is most effective, with documented success rates of 61 to 83 percent, there exists no clear consensus pertaining to conservative treatment protocols conferring the best outcomes. This article reports on all present conservative treatment modalities in use for the management of de Quervain disease and highlights specific treatment- and patient-related factors associated with the best outcomes. METHODS: A systematic search was performed using the PubMed database using appropriate search terms; two independent reviewers evaluated retrieved articles using strict inclusion and exclusion criteria. RESULTS: A total of 66 articles met the inclusion criteria for review, consisting of 22 articles reporting on outcomes following a single conservative treatment modality, eight articles reporting on combined treatment approaches, 13 articles directly comparing different conservative treatment regimens, and 23 case reports. CONCLUSIONS: A multimodal approach using splint therapy and corticosteroid injections appears to be more beneficial than either used in isolation. Although there exists some evidence showing that multipoint injection techniques and multiple injections before surgical referral may provide benefit over a single point injection technique and a single injection before surgery, corticosteroid use is not benign and should thus be performed with caution. Ultrasound was proven valuable in the visualization of an intercompartmental septum, and ultrasound-guided injections were shown to both be more accurate and confer better outcomes. Several prior and concurrent medical conditions may affect conservative treatment outcome. A Level I to II evidence-based treatment protocol is recommended for the optimal nonsurgical management of de Quervain disease.

The effect of scapular muscle strengthening on functional recovery in patients with lateral elbow tendinopathy: A pilot randomized controlled trial. Day, J. M., et al. (2021). Level of Evidence: 2b Follow recommendation: 👍 👍 Type of study: Therapeutic Topic: Lateral epicondylalgia - Scapular strengthening This is a pilot randomised controlled trial assessing the effectiveness of local interventions (elbow) vs local interventions plus scapular strengthening for lateral epicondylalgia (LE). A total of 21 participants were included in the study. To be included, participants had to be experiencing symptoms at the lateral elbow during the following test: gripping with the elbow in extension, resisted middle finger or wrist extension, palpation at the lateral epicondyle, or stretching of the wrist extensors. Participants also had to present with a grip strength deficit of at least 8% in elbow extension compared to flexion and pain measured through the patient related tennis elbow evaluation questionnaire (PRTEE) had to be at least 3/50. Participants were excluded if they presented with neck or arm symptoms, if they presented with neurological symptoms, or had received a cortisone injection in the previous three months. Participant were randomised to local interventions (n = 14), or local interventions plus scapular strengthening exercises (n = 7). Local interventions included activity modification, the use of a counterforce brace, manual therapy (mobilisation with movement - see this previous synopsis on their effectiveness), physical modalities (e.g. icing), stretching and wrist extensors strengthening exercises. The group that performed additional scapular strengthening performed serratus anterior exercises (push up position), and an isometric triceps hold in supine while holding light weights (see picture below). Efficacy of intervention was assessed through the PRTEE questionnaire at baseline, after 4-6 weeks of treatment, 6 months, and 12 months. Treatment frequency was not standardised. Compliance with the home exercise program was not reported. The results showed that the average number of treatment provided within 4-6 weeks was 8. No difference between the two treatment groups (local vs local plus shoulder strengthening) was reported on the PRTEE. Both groups improved to the same extent. 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 adjunct of general upper limb exercises provides no additional benefits compared to local elbow treatments in clients with lateral epicondylalgia. During the acute phase of LE, tendon unloading may be more appropriate through rest/activity modification or the use of a counterforce splint (see previous synopses on splint effectiveness and biomechanics). During the disrepair/degenerative phase of LE (sub acute/chronic - see previous synopsis on tendinopathy grading and treatment), graded resistance training of the wrist extensors alone may be enough to improve function and reduce pain. Open access URL: https://doi.org/10.1123/jsr.2020-0203 Abstract CONTEXT: There is a lack of consensus on the best management approach for lateral elbow tendinopathy (LET). Recently, scapular stabilizer strength impairments have been found in individuals with LET. OBJECTIVE: The purpose of this study was to compare the effectiveness of local therapy (LT) treatment to LT treatment plus a scapular muscle-strengthening (LT + SMS) program in patients diagnosed with LET. DESIGN: Prospective randomized clinical trial. SETTING: Multisite outpatient physical therapy. PATIENTS: Thirty-two individuals with LET who met the criteria were randomized to LT or LT + SMS. INTERVENTIONS: Both groups received education, a nonarticulating forearm orthosis, therapeutic exercise, manual therapy, and thermal modalities as needed. Additionally, the LT + SMS group received SMS exercises. MAIN OUTCOME MEASURE: The primary outcome measure was the patient-rated tennis elbow evaluation; secondary outcomes included global rating of change (GROC), grip strength, and periscapular muscle strength. Outcomes were reassessed at discharge, 6, and 12 months from discharge. Linear mixed-effect models were used to analyze the differences between groups over time for each outcome measure. RESULTS: The average duration of symptoms was 10.2 (16.1) months, and the average total number of visits was 8.0 (2.2) for both groups. There were no significant differences in gender, age, average visits, weight, or height between groups at baseline (P > .05). No statistical between-group differences were found for any of the outcome measures. There were significant within-group improvements in all outcome measures from baseline to all follow-up points (P < .05). CONCLUSION: The results of this pilot study suggest that both treatment approaches were equally effective in reducing pain, improving function, and increasing grip strength at discharge as well as the 6- and 12-month follow-ups. Our multimodal treatment programs were effective at reducing pain and improving function up to 1 year after treatment in a general population of individuals with LET.

The effects of taping combined with wrist stabilization exercise on pain, disability, and quality of life in postpartum women with wrist pain: A randomized controlled pilot study. Jung, K. S., et al. (2021) Level of Evidence: 2b Follow recommendation: 👍 👍 👍 Type of study: Therapeutic Topic: De Quervain tenosynovitis - Resistance training This is a pilot randomised controlled trial assessing the effectiveness of taping and exercises in participants with De Quervain tenosynovitis. Participants (N = 45) were diagnosed with De Quervain if they had pain on the radial side of the wrist, pain greater than 3/10 (VAS), and if they had given birth within the past year. Participants were excluded if they were undergoing any other treatments or if they were taking painkillers. Effectiveness of treatment was assessed through the VAS for pain and the DASH score for function. These outcomes were assessed before treatment and at the end of treatment (8 weeks). Participants were not blinded to treatment allocation. Participants were randomised to a resisted isometric exercises plus taping group (n = 15), resisted isometric exercises alone (n = 15), or a control group performing passive range of movement exercise (n = 15). The resisted isometric exercises included wrist extensors, flexors, radial deviators, ulnar deviators (with therabands) as well as shoulder isometric exercises while holding a dumbbell (0.5 to 2 kg) in shoulder flexion, extension, abduction, and adduction (see picture below). All the exercises were performed for three sets of 10 repetitions. Each isometric repetition was held for 10 seconds. Participants in the passive range of movement exercises performed the same movements without any resistance and held the positions for the same length of time. The exercises were performed once per day, 5 days/week for 8 weeks. Participants were reviewed once per week by a physiotherapist. For the exercises plus tape group, kinesiotape was applied to the radial side of the wrist on the volar and ulnar aspect of the forearm and wrist. The results showed that both resisted isometric exercises plus taping and resisted isometric exercises alone significantly improved pain or function from baseline to 8 weeks after treatment. However, only pain improved to a level that would be deemed clinically relevant. In addition, resisted isometric exercises plus taping provided greater pain relief (statistically and clinically significant) compared to isometric exercises alone. No improvements were noted with passive range of movement exercise. 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, resisted exercises of the wrist and shoulder plus wrist taping provide greater pain relief than resistance exercises alone for De Quervain tenosynovitis in postpartum clients. In addition, resistance exercises with or without taping provide greater pain relief than passive ROM exercises. It is possible that taping or splinting would have a similar effect and we could therefore choose whichever modality we prefer. It appears however clear that loading the wrist's tendon with resisted exercises (in this case isometric) is an important aspect of treatment of these clients. This is in line with previous research showing that graded resistance exercises appear to be effective in the treatment of tendinopathies, once the reactive stage (acute phase) has settled. Open access URL: https://www.mdpi.com/1660-4601/18/7/3564 Abstract The purpose of this study was to evaluate the effects of wrist stabilization exercise combined with taping on wrist pain, disability, and quality of life in postpartum women with wrist pain. Forty-five patients with wrist pain were recruited and randomly divided into three groups: wrist stabilization exercise + taping therapy (WSE + TT) group (n = 15), wrist stabilization exercise (WSE) group (n = 15), and control group (n = 15). The WSE + TT and WSE groups performed wrist stabilization exercises for 40 min (once a day, five times a week for eight weeks), and the control group performed passive range of motion (P-ROM) exercise for the same amount of time. Additionally, the WSE + TT group attached taping to the wrist and forearm during the training period. The visual analogue scale (VAS) was used to assess pain level of the wrist. The Disabilities of the Arm, Shoulder and Hand (DASH) and the Short Form-36 (SF-36) were used to evaluate the degree of wrist disability and quality of life, respectively. The WSE + TT group showed a significant decrease in wrist pain and functional disability compared to two groups (p < 0.05). Significant improvement in the SF-36 score was observed in the WSE + TT and WSE groups compared to that in the control group (p < 0.05). However, there was no significant difference between the WSE + TT and WSE groups in the SF-36. Our findings indicate that wrist stabilization exercise combined with taping is beneficial and effective in managing wrist pain and disability in postpartum women with wrist pain.

Effect of corticosteroid injection, physiotherapy, or both on clinical outcomes in patients with unilateral lateral epicondylalgia: A randomized controlled trial. Coombes, B. K., L. Bisset, P. Brooks, A. Khan and B. Vicenzino (2013). Level of Evidence: 1b Follow recommendation: 👍 👍 👍 👍 Type of study: Therapeutic Topic: Lateral epicondylalgia - cortisone injections This is a randomised placebo controlled trial assessing the effectiveness of cortisone injections for lateral epicondylalgia (LE). A total of 165 participants were included in the study. To be included, participants had to been experiencing symptoms for at least six weeks. Pain had to be unilateral, intensity of at least 3/10, had to be located at the lateral epicondyle of the elbow and participants had to present with at least two of the following: pain on gripping, resisted middle finger or wrist extension, palpation at the lateral epicondyle, or stretching of the wrist extensors. Participants were excluded if they presented with neck or arm symptoms, if they presented with neurological symptoms, had receive cortisone injections or physiotherapy in the previous six and three months respectively for LE. Participant were randomised to cortisone injection alone (n = 43), saline injection alone (placebo) (n = 41), physiotherapy with cortisone injection (n = 40), or physiotherapy with saline injection (n = 41). Physiotherapy included 8 sessions of thirty minutes each over the course of 8 weeks. These included manual therapy (mobilisation with movement - see this previous synopsis on their effectiveness) or graded progression of concentric and eccentric exercises for the wrist extensors. Efficacy of intervention was assessed by self reported complete recovery and recurrence at one year. The results showed that 93% of participants had recovered in the placebo group compared to 83% in the corticosteroid injection group. In addition, participants undergoing corticosteroid injections had a significant improvement at 4-8 weeks followed by a greater recurrence of symptoms at one year (55% recurrence) compared to the placebo injection group (20%). Both these results were statistically significant. There was no difference between the physiotherapy vs no physiotherapy groups at one year follow up. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message: Based on what we know today, corticosteroid injections for lateral epicondylalgia hinder our clients' recovery and increase the recurrence rate in the long term (one year). It may be better to provide our clients with a course of physiotherapy, which does not hinder recovery and may facilitate return to function in clients with severe pain. Graded resistance training may be appropriate in the disrepair/degenerative phase of LE (sub acute/chronic - see previous synopsis on tendinopathy grading and treatment). During the acute phase, tendon unloading may be more appropriate through rest or the use of a counterforce splint (see previous synopses on splint effectiveness and biomechanics). Open access URL: https://jamanetwork.com/journals/jama/fullarticle/1568252 Abstract Importance: Corticosteroid injection and physiotherapy, common treatments for lateral epicondylalgia, are frequently combined in clinical practice. However, evidence on their combined efficacy is lacking. Objective: To investigate the effectiveness of corticosteroid injection, multimodal physiotherapy, or both in patients with unilateral lateral epicondylalgia. Design, setting, and patients: A 2 × 2 factorial, randomized, injection-blinded, placebo-controlled trial was conducted at a single university research center and 16 primary care settings in Brisbane, Australia. A total of 165 patients aged 18 years or older with unilateral lateral epicondylalgia of longer than 6 weeks' duration were enrolled between July 2008 and May 2010; 1-year follow-up was completed in May 2011. Interventions: Corticosteroid injection (n = 43), placebo injection (n = 41), corticosteroid injection plus physiotherapy (n = 40), or placebo injection plus physiotherapy (n = 41). Main outcome measures: The 2 primary outcomes were 1-year global rating of change scores for complete recovery or much improvement and 1-year recurrence (defined as complete recovery or much improvement at 4 or 8 weeks, but not later) analyzed on an intention-to-treat basis (P < .01). Secondary outcomes included complete recovery or much improvement at 4 and 26 weeks. Results: Corticosteroid injection resulted in lower complete recovery or much improvement at 1 year vs placebo injection (83% vs 96%, respectively; relative risk [RR], 0.86 [99% CI, 0.75-0.99]; P = .01) and greater 1-year recurrence (54% vs 12%; RR, 0.23 [99% CI, 0.10-0.51]; P < .001). The physiotherapy and no physiotherapy groups did not differ on 1-year ratings of complete recovery or much improvement (91% vs 88%, respectively; RR, 1.04 [99% CI, 0.90-1.19]; P = .56) or recurrence (29% vs 38%; RR, 1.31 [99% CI, 0.73-2.35]; P = .25). Similar patterns were found at 26 weeks, with lower complete recovery or much improvement after corticosteroid injection vs placebo injection (55% vs 85%, respectively; RR, 0.79 [99% CI, 0.62-0.99]; P < .001) and no difference between the physiotherapy and no physiotherapy groups (71% vs 69%, respectively; RR, 1.22 [99% CI, 0.97-1.53]; P = .84). At 4 weeks, there was a significant interaction between corticosteroid injection and physiotherapy (P = .01), whereby patients receiving the placebo injection plus physiotherapy had greater complete recovery or much improvement vs no physiotherapy (39% vs 10%, respectively; RR, 4.00 [99% CI, 1.07-15.00]; P = .004). However, there was no difference between patients receiving the corticosteroid injection plus physiotherapy vs corticosteroid alone (68% vs 71%, respectively; RR, 0.95 [99% CI, 0.65-1.38]; P = .57). Conclusion and relevance: Among patients with chronic unilateral lateral epicondylalgia, the use of corticosteroid injection vs placebo injection resulted in worse clinical outcomes after 1 year, and physiotherapy did not result in any significant differences.