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

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

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

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

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

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

An exploratory investigation into the longevity of pain reduction following multisensory illusions designed to alter body perception. Barnard, A., Jansen, V., Swindells, M., Arundell, M., & Burke, F. (2020) Level of Evidence : 4 Follow recommendation : 👍 👍 Type of study : Therapeutic Topic : Hand osteoarthritis - Illusory resizing This is a case-series study assessing the effectiveness of illusory sensory resizing of the hand on pain in participants with hand osteoarthritis (OA). Participants (N = 38) were diagnosed with hand OA through clinical criteria. The illusory visual resizing was achieved through cameras and screens which the participants looked at. The visual resizing could either give the illusion of stretching or shrinking the hand. This visual illusion was coupled with either a gentle traction (for the stretching illusion) or compression (for the shrinking illusion) of the most painful finger to boost the illusion effect. Pain was assessed on a Numerical Rating Scale (NRS) immediately before and after the intervention. The intervention provided participants with an illusory sensory resizing (visual and traction/compression) lasting two minutes. Participants were also asked to report how long pain-relief lasted after the illusory resizing. The choice of which illusion (shrinking vs stretching) to utilise, was based on a baseline test identifying which provided the most pain relief. Out of 38 participants, 28 (74%) reported pain relief with one of the illusions. Of these 28 participants, 17 (60%) reported improvement with the stretching illusion and 11 (40%) with the shrinking illusion. The results showed that after two minutes of illusory resizing, the stretching illlusion improved pain by 1.5 points out of 10, and the shrinking illusion improved pain by 0.5 out of 10 points (difference between medians provided). The effect of the intervention lasted for four minutes in 16% of participants, 20 minutes in 68% of participants, and between 7 hours and 10 weeks in 16% of participants. There was no statistical difference between the two illusions on pain. Clinical Take Home Message : Hand therapists may trial imagery resizing coupled with gentle traction or compression of the most painful finger in people with hand OA. This intervention, may provide immediate small and short lasting pain relieving effects in people with hand OA. This regime may be trialled in patients that are unable to undergo other interventions supported by higher quality evidence (e.g. NSAIDs). URL : https://www.mskscienceandpractice.com/article/S2468-7812(19)30119-5/pdf

Radial tunnel syndrome: definition, distinction and treatments. Bo Tang, J. (2020) Level of Evidence : 5 Follow recommendation : 👍 Type of study : Diagnostic, Therapeutic Topic : Posterior interosseous nerve entrapment - Radial tunnel syndrome vs PIN syndrome This is a narrative review on radial tunnel syndrome (RTS) and posterior interosseous nerve syndrome (PINS). These two presentations are both entrapment neuropathies of the posterior interosseous nerve, however, RTS is a mild entrapment neuropathy while PIN is a severe entrapment neuropathy (similar to mild vs severe carpal tunnel syndrome). The clinical presentations of RTS and PINS are different. RTS presents with pain in the lateral aspect of forearm 4-5 cm distal from the lateral epicondyle. PINS presents with no pain but with palsy of the wrist, finger, and thumb extensors, except for extensor carpi radialis longus. Clients with PINS will therefore present with painless weak wrist extension associated with radial deviation. Investigations for people with RTS or PINS may include x-rays and US, which will be able to exclude the presence of radiocapitellar joint osteoarthritis or space invading lesions which may be responsible for the entrapment. The differential diagnosis includes lateral epicondylalgia, cervical radiculopathy, high radial nerve palsy (e.g. Saturday night palsy), and extensive tendon ruptures of the extensors compartment. If a diagnosis of RTS is made, conservative treatment should be trialed for at least 6 months before surgery is considered. Overall, entrapment of the posterior interosseous nerve, especially severe entrapment, appears to be rare compared to median and ulnar nerve entrapment neuropathies (e.g. carpal tunnel syndrome, cubital tunnel syndrome). Clinical Take Home Message : A mild (RTS) or severe (PINS) entrapment neuropathy of the posterior interosseous nerve is rare. A mild entrapment neuropathy (RTS) usually presents with pain 4-5 cm distal to the lateral epicondyle. A severe entrapment neuropathy (PINS) presents with no forearm pain but significant motor weakness of the extensors compartment of the forearm. The key characteristic discriminating PINS from a higher nerve palsy (e.g. Saturday night palsy) or cervical radiculopathy with motor impairments, is that PINS will present with weak wrist extension associated with radial deviation (ECRL is intact). In addition, cervical radiculopathies present with neck pain in 80% of cases and often present with pain above the elbow . When differentiating between RTS and lateral epicondylalgia, the location of pain is the most useful indicator, with lateral epicondylalgia presenting with more proximal symptoms. URL : https://journals.sagepub.com/doi/10.1177/1753193420953990 Available through EBSCO Health Databases for PNZ members. Abstract Radial tunnel syndrome (RTS) is a disease causing lateral elbow and proximal dorsolateral forearm pain that may radiate to the wrist and dorsum of the fingers without obvious extensor muscle weakness. An epidemiological study shows an incidence of nine new cases of radial neuropathy per 100,000 population for men and six per 100,000 for women in a 10-year period (Hulkkonen et al., 2020). These incidences are far less than entrapments of the median and ulnar nerves. There are ambiguous descriptions of RTS in relation to posterior interosseous nerve (PIN) compression. This article intends to discuss the anatomy of the radial tunnel and the clinical distinctions between two entities.

Does diabetes mellitus change the carpal tunnel release outcomes? Evidence from a systematic review and meta-analysis. Moradi, A., Sadr, A., Ebrahimzadeh, M. H., Hassankhani, G. G., & Mehrad-Majd, H. (2020) Level of Evidence : 1a Follow recommendation : 👍 👍 👍 👍 Type of study : Therapeutic Topic : Surgical decompression of the carpal tunnel - Outcomes in diabetic vs healthy clients This is a systematic review and meta-analysis assessing outcomes in participants with and without diabetes following surgical decompression of the carpal tunnel. Ten studies were included for a total of 2,869 participants. Of these participants, 2423 were healthy and 446 presented with diabetes. Seventy percent of these participants were females. On average, participants were 56 years old. Outcomes included function, sensory, and motor nerve conduction studies. The results showed that there were no functional differences between clients with or without diabetes. Sensory nerve conduction improved to a greater extent in the healthy compared to diabetic participants. However, considering the multiple statistical tests undertaken, 23% of the results are due to chance. This reduces our confidence in these findings, especially considering that these differences did not have clinical repercussions in terms of function. Clinical Take Home Message : Hand therapists may reassure clients that diabetes does not appear to affect the results of surgery for carpal tunnel syndrome. However, hand therapists should remember that depression and mental health do affect post surgical satisfaction and the amount of health care resources required following carpal tunnel decompression. URL : https://www.sciencedirect.com/science/article/pii/S0894113020300235 Available through the Journal of Hand Therapy for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Study Design: A systematic review and meta-analysis. Introduction: Carpal tunnel syndrome (CTS) is one of the most common upper extremity conditions which mostly affect women. Management of patients suffering from both CTS and diabetes mellitus (DM) is challenging, and it was suggested that DM might affect the diagnosis as well as the outcome of surgical treatment. Purpose of the Study: This meta-analysis was aimed to compare the response with CTS surgical treatment in diabetic and nondiabetic patients. Methods: Electronic databases were searched to identify eligible studies comparing the symptomatic, functional, and neurophysiological outcomes between diabetic and nondiabetic patients with CTS. Pooled MDs with 95% CIs were applied to assess the level of outcome improvements. Results: Ten articles with 2869 subjects were included. The sensory conduction velocities in the wrist-palm and wrist–middle finger segments showed a significantly better improvement in nondiabetic compared with diabetic patients (MD = −4.31, 95% CI = −5.89 to −2.74, P  < .001 and MD = −2.74, 95% CI = −5.32 to −0.16, P  = .037, respectively). However, no significant differences were found for the improvement of symptoms severity and functional status based on the Boston Carpal Tunnel Questionnaire and Quick Disabilities of the Arm, Shoulder, and Hand questionnaire as well as motor conduction velocities and distal motor latencies. Conclusion: Metaresults revealed no significant difference in improvements of all various outcomes except sensory conduction velocities after CTS surgery between diabetic and nondiabetic patients. A better diabetic neuropathy care is recommended to achieve better sensory recovery after CTS surgery in diabetic patients.

The effect of digital sensory loss on hand dexterity. Luukinen, P., Leppänen, O. V., & Jokihaara, J. (2020) Level of Evidence : 4 Follow recommendation : 👍 👍 Type of study : Diagnostic Topic : DIgital nerve anaesthesia - Grip and pinch strength This is a study assessing dexterity, grip, and pinch strength before and after digital nerve blocks at the thumb, index, and middle finger (within-subject design). Twelve healthy participants were recruited for this study. Hand dexterity was measured through the Moberg pick-up test. Grip and pinch strength were assessed through a Jamar hand dynamometer (power grip) and pinch dynamometer (tripod and key pinch). The measurement were taken before and after the injection. The results showed that thumb anaesthesia led to the greatest loss of dexterity while it did not affect grip or pinch strength. Index or middle finger anaesthesia, led to a significant loss of grip (25% reduction) and tripod pinch strength (30% reduction). Clinical Take Home Message : Hand therapists should be aware that a digital nerve lesion can contribute to grip and tripod pinch weakness as well as lack of dexterity. In addition, these findings may also suggest that grip or pinch strength deficits in entrapment neuropathies (e.g. carpal tunnel syndrome) may be due to a combination of motor and sensory rather than just motor impairments. This synopsis is a nice addition to the previous one on the effect of anaesthesia to the ulnar nerve at the Guyon's canal . URL : https://journals.sagepub.com/doi/10.1177/1753193420936598 You can ask the authors for the full text through ResearchGate . Available through EBSCO Health Databases for PNZ members. Abstract The purpose of this study is to determine how loss of sensation affect hand dexterity. In this study, digital nerve block anaesthesia was performed in different stages of timing for thumb, index and middle fingers of 12 volunteers. The Moberg pick-up test was conducted in the assessment of hand dexterity. Grip and pinch forces were also measured. Loss of thumb sensation had the greatest effect on dexterity, increasing average timing by at least 10.5 seconds (range 3.4 to 32.4). Loss of sensation to the index and middle fingers has a lesser impact, but decreased hand grip and chuck pinch forces (grip –25% or –33%, chuck pinch –31% or –32% depending on the timing of injections). We concluded that loss of thumb sensation has the greatest impact on hand dexterity. Index and middle finger sensory loss had less of an impact on hand dexterity but decreased grip and chuck pinch forces.

The effectiveness of joint-protection programs on pain, hand function, and grip strength levels in patients with hand arthritis: A systematic review and meta-analysis. Bobos, P., Nazari, G., Szekeres, M., Lalone, E. A., Ferreira, L., & MacDermid, J. C. (2019) Level of Evidence : 1a- Follow recommendation : 👍 👍 👍 Type of study : Therapeutic Topic : Hand RA and OA – Joint protection vs no intervention This is a systematic review and meta-analysis assessing the effectiveness of joint protection vs control interventions for RA and OA of the hand. Seventeen RCTs were included in the systematic review, for a total of 1,847 participants (80% were diagnosed with RA). Only nine of these studies were included in the meta-analysis. All the RCTs were assessed through the Risk of Bias criteria recommended by the Cochrane Review Group. The overall strength of evidence was assessed through the GRADE approach ("low", "very low", "moderate", "high"), which has also been suggested by the Cochrane group for systematic reviews. Joint protection with an exercise component was compared to a control group undergoing either standard care, advice, no treatment, or patient education. Efficacy of intervention was assessed through improvements in pain (e.g. NRS, VAS), and function (e.g. Michigan Hand Questionnaire, AUSCAN), at short-term (3-4/12), midterm (6-8/12), and long-term (1 year). The results showed that publication bias was present (low sample size studies were more likely to over-inflate the effectiveness of joint protection interventions). There was very low to low quality of evidence showing that joint protection may have a small, unlikely to be clinically relevant, positive effectiveness in people with RA. In OA, joint protection had no effect compared to the control groups. Overall, due to multitude of statistical tests performed (16 tests) and the number of significant findings (4 test - all in RA) there is a 20% probability that the results are just due to chance. Clinical Take Home Message : Hand therapists should be aware that joint protection interventions appear to have a small, not clinically relevant effect in hand RA. Considering these results, other interventions such as stretching and strengthening may be more appropriate as they have been shown to have relevant effectiveness in a large RCT and a recent implementation study . No effect was shown for joint protection interventions in hand OA. Therefore, other approaches (see previous synopsis on the topic) for hand OA may be more effective. URL : https://www.jhandtherapy.org/article/S0894-1130(18)30164-9/fulltext Available through the Journal of Hand Therapy for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Study Design: Systematic review with meta-analysis. Introduction Joint protection (JP) has been developed as a self-management intervention to assist people with hand arthritis to improve occupational performance and minimize joint deterioration over time. Purpose of the Study: We examined the effectiveness between JP and usual care/control on pain, hand function, and grip strength levels for people with hand osteoarthritis and rheumatoid arthritis. Methods: A search was performed in 5 databases from January 1990 to February 2017. Two independent assessors applied Cochrane's risk of bias tool, and a Grading of Recommendations Assessement, Development and Evaluation (GRADE) approach was adopted. Results: For pain levels at short term, we found similar effects between JP and control standardized mean difference (SMD; −0.00, 95% confidence interval [CI]: −0.42 to 0.42, I2 = 49%), and at midterm and long-term follow-up, JP was favored over usual care SMD (−0.32, 95% CI: −0.53 to −0.11, I2 = 0) and SMD (−0.27, 95% CI: −0.41 to −0.12, I2 = 9%), respectively. For function levels at midterm and long-term follow-up, JP was favored over usual care SMD (−0.49, 95% CI: −0.75 to −0.22, I2 = 34%) and SMD (−0.31, 95% CI: −0.50 to −0.11, I2 = 56%), respectively. For grip strength levels, at long term, JP was inferior over usual care mean difference (0.93, 95% CI: −0.74 to 2.61, I2 = 0%). Conclusions: Evidence of very low to low quality indicates that the effects of JP programs compared with usual care/control on pain and hand function are too small to be clinically important at short-, intermediate-, and long-term follow-ups for people with hand arthritis.

Translating the strengthening and stretching for rheumatoid arthritis of the hand programme from clinical trial to clinical practice: An effectiveness–implementation study. Williamson, E., Srikesavan, C., Thompson, J., Tonga, E., Eldridge, L., Adams, J., & Lamb, S. E. (2020) Level of Evidence : 2c Follow recommendation : 👍 👍 👍 Type of study : Therapeutic Topic : Rheumatoid arthritis - Stretching and strengthening This is a pragmatic trial, assessing the effectiveness of a hand exercise program for people with rheumatoid arthritis (RA) affecting their hands. A total of 448 hand therapists were trained through an online course. The hand exercise program taught in the online course, has previously been shown to be effective for RA in a randomised controlled trial published in the Lancet . Hand therapists were then asked to collect data from their patients with RA during the first visit and at discharge. In addition, a four months follow up was completed. Function was assessed through the Michigan Hand Questionnaire, pain was assessed through a 5-points likert scale, and grip strength was measured through a hand dynamometer. Data were collected from 118 clients with RA. All of these clients were guided in the implementation of the hand exercise program, although compliance with the original exercises program varied significantly. The results showed that hand function improved to a statistically significant level at discharge and at four months follow up. It is however unclear whether the results were clinically relevant (a minimal clinical important change threshold for the total score of the Michigan Hand Questionnaire has not been published yet). Pain was unchanged, however, grip strength improved to a clinically and statistically significant level (25-30%) from baseline (14kg). Clinical Take Home Message : Hand therapists treating clients with hand RA may benefit from completing the training course created for this study. The course is accessible online ( iSARAH ) and it is entirely free. Both this study and the original RCT were completed in participants with an average grip strength close to 14kg. It is possible that clients presenting with higher grip strength (i.e. 25kg) may benefit less from this hand exercise program. Thus, a grip strength of 25kg appears to be sufficient to complete most of the daily tasks . URL : https://journals.sagepub.com/doi/abs/10.1177/1758998320948538 Available through Hand Therapy for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Introduction: The Strengthening and Stretching for Rheumatoid Arthritis of the Hand programme is a hand exercise programme for people with rheumatoid arthritis. It was clinically effective when delivered during a clinical trial but there was a need to evaluate translation into routine care. Methods:We conducted an effectiveness–implementation study. We adapted the trial training into an online format for National Health Service hand therapists. Educational outcomes included confidence and capability to deliver the programme. Implementation outcomes included training reach and adoption. Therapists were invited to collect clinical outcomes. Patients receiving the programme provided data on function (Michigan Hand Questionnaire function scale), pain and grip strength at baseline, treatment discharge and four-month follow-up. Results: A total of 790 therapists (188 National Health Service organizations) enrolled in the training; 584/790 (74%) therapists (162 National Health Service organizations) completed the training; 448/790 therapists (145 National Health Service organizations) (57%) evaluated the training and were confident (447/448, 99.8%) and capable (443/448, 99%) to deliver the programme with 85% intending to adopt it (379/448). Follow-up data were provided by 116/448 (26%) therapists. Two-thirds (77/116; 51 National Health Service organizations) reported adopting the programme. One hundred and eighteen patients (15 National Health Service trusts) participated. Patients reported improved function (mean change Michigan Hand Questionnaire scores: 10 (95% CI 6.5–13.6) treatment discharge; 7 (95% CI 3.8–10.2) 4-month follow-up). Grip strength increased 24.5% (left) and 31% (right). Pain was stable. Discussion: Online training was an effective way to train therapists with good reach. Clinical outcomes were similar to the clinical trial providing preliminary evidence of successful translation into routine care.