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Prospective cohort study to investigate factors associated with continued immobilization of a nondisplaced scaphoid waist fracture. Bulstra, A. E. J., et al. (2021) Level of Evidence : 2b Follow recommendation : 👍 👍 👍 Type of study : Prognostic Topic : Scaphoid fractures - Length of immobilisation predictors This is a prospective study assessing the correlation between imaging/psychological well being/physical examination findings and duration of immobilisation following a non displaced scaphoid fracture. A total of 46 participants were included. Potential participants were excluded if they presented more than 3 weeks post injury, if they had an undisplaced saphoid waist fracture (assessed trough CT scan when in doubt), or had a previous history of scaphoid fracture. All participants were immobilised for 6 weeks in a below elbow thumb spica cast, after which a surgeon's follow up was completed to decide whether they required a further immobilisation period. Clients psychological well being was assessed through the PROMIS CATs for physical function, depression, and pain interference (score it yourself or use it for your clients - Try the PROMIS CAT Demo>> ). The results of this questionnaire were unavailable to the surgeon at the follow up appointment. In addition, all participants underwent x-ray imaging to assess fracture healing. The results showed that participants presenting with greater depression and what surgeon's identified as a lack of healing on x-ray was associated with prolonged immobilisation. Interestingly, healing vs non-healing on x-ray was associated with immobilisation time rather than time from injury. In addition, as mentioned in the article, x-ray evaluation is unreliable in identifying fracture healing, despite it being commonly utilised for stopping or prolonging immobilisation. There are a couple of limitations to this study. First, this study did not objectively assess fracture's union because there is currently no gold standard that can measure this outcome. Second, the sample size was possibly too small for the type of statistics utilised (Multivariate logistic regression). Clinical Take Home Message : Based on what we know today, non displaced scaphoid waist fracture immobilisation period may depend on psychological comorbidities (e.g. depression) which may unconsciously affect surgeon's decision to prolong casting. In addition, lack of healing on x-rays, which has been suggested as an unreliable marker, is another factor contributing to prolonged immobilisation. This article is a nice reminder that factors other than objective findings may drive our willingness to continue immobilising a fracture. Previous research has also shown that tenderness on palpation may not be a reliable indicator of fracture healing , and it may be better to follow traditional fracture healing times as a guide. If you are interested in having a read through what physical test are currently suggested for occult scaphoid fractures I have previously created a synopsis on the topic. URL : https://doi.org/10.1016/j.jhsa.2021.03.027 Available through The Journal of Hand Surgery (American Volume) for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Purpose: The decision to continue immobilization of a nondisplaced scaphoid waist fracture is often based on radiographic appearance (despite evidence that radiographs are unreliable and inaccurate for diagnosing scaphoid union 6–12 weeks after fracture) and fracture tenderness (even though it is influenced by cognitive biases on pain). This may result in unhelpful additional immobilization. We studied nondisplaced scaphoid waist fractures to determine the factors associated with (1) the surgeon’s decision to continue cast or splint immobilization at the first visit when cast removal was being considered; (2) greater pain on examination; and (3) the surgeon’s concern about radiographic consolidation. Methods: We prospectively included 46 patients with a nondisplaced scaphoid waist fracture treated nonoperatively. At the first visit when cast removal was considered – after an average of 6 weeks of immobilization – patients rated pain during 4 examination maneuvers. The treating surgeon assessed union on radiographs and decided whether to continue or discontinue immobilization. Patients completed measures of the following: (1) the degree to which pain limits activities (Patient-Reported Outcome Measure Interactive System [PROMIS] Pain Interference Computer Adaptive Test [CAT], Pain Self-Efficacy Questionnaire-2); (2) symptoms of depression (PROMIS Depression CAT); and (3) upper extremity function (PROMIS Upper Extremity Function CAT). We used multivariable regression analysis to investigate the factors associated with each outcome. Results: Perceived inadequate radiographic healing and greater symptoms of depression were independently associated with continued immobilization. Pain during the examination was not associated with continued immobilization. Patient age was associated with pain on examination. Shorter immobilization duration was the only factor associated with the surgeon’s perception of inadequate radiographic consolidation. Conclusions: Inadequate radiographic healing and greater symptoms of depression are associated with a surgeon’s decision to continue cast or splint immobilization of a nondisplaced scaphoid waist fracture. Clinical relevance: Overreliance on radiographs and inadequate accounting for psychological distress may hinder the adoption of shorter immobilization times for nondisplaced waist fractures.

Significant significance? Bothe, T. L. and A. Patzak (2021) Level of Evidence : 5 Follow recommendation : 👍 Type of study : Therapeutic Topic : Research implementation Through the HandyEvidence survey, I have discovered that Hand Therapists are interested in tips on how to critique research article. This synopsis is the first of a series (if you find them useful - leave a comment if so) providing tips on how to interpret what research you read. In particular, this synopsis aims at helping you to understand and making sense of what "statistical significant", "p < 0.05", or "p < 0.001" really mean. Below are a few points: 1) "Statistical significance" simply means that there is a low chance that the results reported are due to chance. This is great to know because ideally we want to provide treatments that consistently, or at least most of the time, provide useful outcomes. Keep reading for more important info below. 2) "p < 0.05", or "p < 0.001" simply means that there is less than 5% or 0.1% probability that the results are due to chance. The p value will often get smaller with larger sample sizes, however, it does not mean that the lower the p value the more clinically relevant the findings are. 3) This is probably the most important point of all. If a paper states that the results are "statistical significant", or that the "p < 0.05", or "p < 0.001", this does not tell us how relevant the findings are. In other words, it does not clarify whether the results are clinically relevant. We could have for example a study showing a "statistical significant (p < 0.05)" reduction in pain with an experimental treatment compared to a control. However, the absolute difference between the experimental and control groups could be 0.5 points out of 10 on the Numerical Rating Scale (NRS). In other words, you have a low probability of this finding to be due to chance (less than 5% chance), but the extent of pain relief is small (0.5 out of 10 on NRS). This is a perfect example of a "statistically significant" but not "clinically relevant" finding. I hope this synopsis provides with some useful tips in interpreting research findings. If you found it useful or if you have other topics on research interpretation that you would like me to cover, post a comment. 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 : Evidence guided practice is not easy to implement and at times can cause frustration. Statistical significance may be one of those jargon terms that adds to the confusion and that can potentially lead to misinterpretation of research. All you need to remember is that if something is "statistical significant", "p < 0.05", or "p < 0.001" there is a low probability of the results being due to chance. You then need to take a additional step and ask yourself whether this difference is "clinically relevant". Often you can find this information in tables where the results for each group are reported. If the difference between groups is not "clinically relevant" (e.g. 2 points out of 10 for pain) you can then make an educated guess on whether you should change your practice based on these findings. If you liked this synopsis you may also like other topics such as the implementation of research to clinical practice and how to make evidence guided decisions when limited evidence is available . URL : https://doi.org/10.1111/apha.13665 Available through EBSCO Health Databases for PNZ members. No Abstract available

MRI does not effectively diagnose ulnar-sided wrist pain in elite tennis players. Reid, M., et al. (2020). Level of Evidence : 2b Follow recommendation : 👍 👍 👍 Type of study : Diagnostic Topic : MRI findings ulnar wrist - Elite tennis players This is a cross sectional study assessing the association between changes on MRI and the presence of ulnar wrist pain in elite tennis players. Elite tennis players with (n = 14) and without (n = 14) symptoms in the non-dominant ulnar wrist were compared to healthy non-tennis players controls (n = 12). Participants were on average 20 years old. Wrist MRI were completed for all participants. The only information that we have regarding the symptomatic participants is that they reported non-dominant ulnar pain on at least 7 or more days in the last year. The results showed that the average number of abnormalities was 3.6 (95% CI: 2.8 to 4.8) in symptomatic vs 2.6 (95% CI: 1.9 to 3.7) non symptomatic tennis players. Healthy non symptomatic tennis players presented with and average 2.5 (95%CI: 1.7 to 3.6) abnormalities. There was no significant difference between the number of abnormalities between groups. Secondary analyses revealed that participants with ulnar sided wrist pain were more likely to present with bony or articular abnormalities. Clinical Take Home Message : Based on what we know today, there is no significant correlation between the total amount of abnormalities reported on MRI and wrist pain in the painful non-dominant wrist of elite tennis players. Interestingly, a similar number of changes was reported by healthy non-tennis player control. This suggests that we should be careful in suggesting a correlation between imaging findings and pain. However, it is possible that bony and articular changes contribute, at least in part, to the pain reported by elite tennis players. We should keep in mind that factors other than MRI abnormalities may contribute to pain. These may include changes in training load and volume , poor sleep , and possibly psychological factors such as kinesiophobia . URL : https://doi.org/10.1016/j.jsams.2020.01.001 Available through EBSCO Health Databases for PNZ members. Abstract Objectives: Ulnar-sided injuries of the non-dominant wrist are common in elite tennis players using a double-handed backhand technique. This study investigated the radiological changes of the non-dominant wrist in elite symptomatic and asymptomatic players using this technique as well as healthy controls. We compared clinical findings to radiological abnormalities. Design: Cross-sectional design with blinded radiological assessment, and contemporaneous clinical assessment of symptomatic players. Methods: Magnetic resonance images (MRI) of wrists related to non-dominant ulnar-sided pain, were taken in 14 symptomatic tennis players, 14 asymptomatic tennis players, and 12 healthy controls which were then independently reviewed for abnormalities by blinded radiologists. Total abnormalities and global between-group differences in the triangular fibrocartilage complex (TFC), ulnar collateral ligament (UCL), extensor carpi ulnaris (ECU) and supporting structures, osseous-articular lesions and ganglia were assessed. These were then compared to clinical examinations of the symptomatic players to assess agreement. Results: Symptomatic players reported a mean 3.64 abnormalities, being exactly 1 abnormality greater than asymptomatic players (2.64) and controls (2.50), suggesting similar asymptomatic lesions in all three groups. Players with pain reported significantly more osseous-articular lesions, ECU tendon and dorsal radio-ulnar ligament abnormalities, while changes to the UCL may reflect an isolated problem in specific wrists. There were no between-group differences in the presence of ganglia, most TFC structures nor ECU subsheath tear and subluxation. Conclusions: Clinicians should carefully consider radiological changes alongside their clinical diagnosis of non-dominant wrist pain in tennis players due to possible tennis-related changes and/or asymptomatic findings.

Accuracy of provocative tests for carpal tunnel syndrome. Zhang, D., C. M. Chruscielski, P. Blazar and B. E. Earp (2020) Level of Evidence : 2b Follow recommendation : 👍 👍 Type of study : Diagnostic Topic : Carpal tunnel syndrome - Physical tests This is a prospective study on the specificity and sensitivity of four physical tests for carpal tunnel syndrome (CTS). If a test is very sensitive and its result is negative, you can be more certain that the patient does not have the condition. If the test is specific and its result is positive, you can be more certain that the patient has the condition. A total of 55 participants (85 symptomatic hands) were included in the present study. Nerve conduction studies were utilised as the gold standard to validate the diagnostic accuracy of the CTS tests. The four physical tests assessed were the Tinel's, Phalen's, Durkan's, and the combination of Phalen's and Durkan's test (see picture below). Out of the 55 participants, nine had no impairments on nerve conduction test of the median nerve at the carpal tunnel. The Phalen's and Dhurkan combination (shown in picture D below) was the most sensitive test (90% sensitivity) when utilised in isolation. This test could therefore be utilised for screening purposes, or in other words exclude the presence of CTS. The presence of four positive tests completed one after the other presented the highest specificity (80% specificity). Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message : Based on what we know today, the combination of the Phalen's and Durkan's test into one (see picture D above - Phdurkan test), is useful to exclude the diagnosis of CTS if negative. In contrast, if the Phdurkan test was positive we would probably want to complete the remaining three tests (Tinel, Phalen, Durkan) and find them all positive, to make a diagnosis of CTS with a good degree of confidence. In addition, we can complete the CTS-6 scoring criteria , which will provide us with useful information on the likelihood of our clients suffering from CTS. Open access URL : https://doi.org/10.1016/j.jhsg.2020.03.002 Abstract Purpose: Prior literature on the diagnostic accuracy of commonly used provocative tests for suspected carpal tunnel syndrome (CTS) is affected by research biases. The objectives of our study were to measure and compare the diagnostic accuracy of 4 commonly used provocative tests for CTS using electrodiagnostic study as the reference standard. Methods: We prospectively evaluated 85 hands in 55 patients with suspected CTS. Tinel sign, Phalen’s test, Durkan’s test, and Phdurkan test (a combination of wrist flexion and carpal compression) and subsequent electrodiagnostic testing were performed on all patients. Sensitivity and specificity were calculated using electrodiagnostic findings as the reference standard. McNemar test was used to compare differences in paired outcomes between provocative tests. Results: Tinel sign had a sensitivity of 0.47 and specificity of 0.56. Phalen’s test had a sensitivity of 0.50 and specificity of 0.33. Durkan’s test had a sensitivity of 0.71 and specificity of 0.22. Phdurkan test had a sensitivity of 0.84 and specificity of 0.11. Median time to a positive Phdurkan test result was 3 seconds. McNemar tests showed significant differences (P < .05) in the proportions of positive results among all CTS provocative tests except between Tinel sign and Phalen’s test. Conclusions: Commonly performed provocative tests for suspected CTS differ in sensitivity and specificity. As the examination maneuver becomes more provocative, the test becomes more sensitive and less specific for CTS.

Bizarre parosteal osteochondromatous proliferation (nora lesion) in pediatric phalanges. Martínez Álvarez, S., D. L. Azorín Cuadrillero and K. J. Little (2021). Level of Evidence : 5 Follow recommendation : 👍 Type of study : Diagnostic/Therapeutic This is the answer for the case study from last 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. At surgical removal, the mass appeared to be a combination of cartilage and bone. Biopsy reveled it to be consistent with a Nora lesion (named after Dr. Frederick E. Nora) which is a benign tumor. After excision, the patient experience no recurrence despite the high rate of relapse. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message : Hand therapists should refer young children or teenagers for x-rays and US when there is evidence of a mass which has grown over time. The likelihood of identifying a Nora lesion is rare, however, x-rays and US may help differentiating among different conditions including ganglion cyst, rheumatoid arthritis, infections or other rare forms of cancer. URL : https://doi.org/10.1016/j.jhsa.2020.05.002 Available through The Journal of Hand Surgery (American Volume) for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Bizarre parosteal osteochondromatous proliferation, or Nora tumor, is an uncommon lesion affecting the tubular bones of the hands and feet. Normally arising from the cortical surface and periosteum of these bones, these lesions histologically consist of a hypercellular cartilaginous cap covering a bony stalk that is surrounded by ossified areas and spindle cell stroma. The differential diagnosis includes conditions involving the periosteum such as chondrosarcoma, parosteal osteosarcoma, osteochondroma, turret exostosis, and florid reactive periostitis. The only effective treatment is wide surgical excision; nevertheless, local recurrence rates are extremely high and may necessitate revision surgery. In the present study, we report 3 cases of Nora lesion located in the hand in pediatric patients. The diagnosis in these cases was challenging owing to their presenting symptoms and radiographic findings. The diagnosis was made based on characteristic findings noted on the radiographic images and was confirmed by histological examination following excision.

Nonsurgical treatment for symptomatic carpal tunnel syndrome: A randomized clinical trial comparing local corticosteroid injection versus night orthosis. de Moraes, V. Y., et al. (2021) Level of Evidence : 1b- Follow recommendation : 👍 👍 👍 👍 Type of study : Therapeutic Topic : Carpal tunnel conservative intervention - Cortisone injections vs splinting This is a randomised clinical trial assessing the effectiveness of night splinting vs corticosteroid injections on night paraesthesia, pain, function, and complications in people with carpal tunnel syndrome (CTS). Participants were included (N = 95) if they were over 40 years old and presented with at least 4 of the following six criteria: night paraesthesia in median nerve distribution of the hand, paraesthesia in median nerve distribution of the hand, atrophy of thenar muscles, positive Phalen's and Tinel's test, reduction in two-point discrimination (>6 mm). In addition, participants had to present with moderate to severe nerve conduction impairments on sensory and motor testing. Participants could have unilateral or bilateral symptoms, however, only the most affected limb was treated for the duration of the study. Outcome assessors were blinded to treatment allocation. Participants were randomised to either night splinting (n = 45), or non US guided corticosteroid injection (n = 50). Treatment effectiveness was assessed through self-reported night paraesthesia, pain and function were measured through the Boston-Levine questionnaire (BLQ), and complications were defined as a worsening of numbness at the injection site or skin tissue atrophy. Participants were assessed at baseline, 1 week, 3 and 6 months after treatment initiation. The results showed that corticosteroid injections reduced night paraesthesia to a clinically greater level compared to night splinting (see picture below). The same results were found for pain and function measured through the Boston-Levine questionnaire (BLQ) where corticosteroid injections were superior to splinting. Night splinting improved pain and function (BLQ) to a clinically relevant level but not night paraesthesia. 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 appear to be superior to night splinting for our clients (≥ 40 years old) with moderate/severe carpal tunnel syndrome. This appears to be specially true for improvements in night paraesthesia. If clients decline a referral for a cortisone injections, splinting can still provide with some benefits (reduction in pain and disability) and other approaches such as manual therapy (mobilisation and tendon/nerve glides) directed at the upper limb appear to be as effective as surgery at one and four years follow up. The combination of manual therapy, nerve gliding exercises , night splinting, and education may provide even better results, and a this conservative management approach should be trialed before undergoing surgery. URL : https://doi.org/10.1016/j.jhsa.2020.11.014 Available through The Journal of Hand Surgery (American Volume) for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Purpose: For carpal tunnel syndrome (CTS), local corticosteroid injection (corticosteroid), and/or wrist immobilization with night orthosis (orthosis) are commonly prescribed and are supported by strong evidence. The aim of this study was to compare orthosis versus corticosteroid for patients with CTS. Methods: A CTS diagnosis was made clinically and supported by electrodiagnostic study. Patients were randomly allocated to either orthosis or corticosteroid. Clinical assessments were performed before the intervention, within the first week of the intervention, and 1, 3, and 6 months after the intervention. Primary outcomes were improvement in nocturnal paresthesia and Boston-Levine questionnaire (BLQ) score. Secondary outcomes were pain assessed by visual analog scale and complications. Results: Of 100 patients enrolled in the study, 95 completed the planned follow-up (45 in the orthosis arm and 50 in the corticosteroid arm). Corticosteroid injections were superior to orthosis in remission of nocturnal paresthesia (remission rates at 1 month, 84.6% versus 43.83%; 3 months, 71.1% versus 40.4%; and 6 months, 80.3% versus 28.8%). The BLQ scores (functional and symptom subscales) were also more favorable for corticosteroid at 1, 3, and 6 months (minimal clinically important differences for Function > 0.5 and Symptom > 0.16). Pain scores were lower and favored the corticosteroid group. There were no complications in either group. Conclusions: Both options are effective in the short term. Corticosteroid is superior to orthosis for improving CTS-related nocturnal paresthesia, BLQ scores, and pain.

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 e xtracorporeal 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). E xtracorporeal shock waves were compared to no intervention, sham/placebo, multimodal physiotherapy, PRP, and corticosteroid injections. Low to moderate quality evidence suggests that e xtracorporeal 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. E xtracorporeal shock waves had no effect on elbow disability when compared to other interventions. Clinical Take Home Message : Based on what we know today, e xtracorporeal 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 e xtracorporeal 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 e xtracorporeal 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.