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Advances in the treatment of hand and wrist injuries in the elite athlete. Noble, D. M., Dacus, A. R. and Chhabra, A. B. (2024) Level of Evidence: 4 Follow recommendation: 👍 👍 👍 (3/4 Thumbs up) Type of study: Therapeutic Topic : Return to sport - Hand and wrist injuries This narrative review focused on the treatment of hand and wrist injuries in elite athletes. Common injuries discussed included metacarpal fractures, thumb ulnar collateral ligament (UCL) tears, and scaphoid fractures. These injuries can negatively impact performance and career longevity. Effective treatment must balance accelerated rehabilitation alongside long-term outcomes. For metacarpal fractures, surgical reduction and fixation, including intramedullary screw techniques, facilitate quicker return-to-play with fewer complications than traditional methods. Thumb UCL injuries often necessitate surgical repair for stability with overall positive outcomes. Scaphoid fractures, require prompt, often surgical, intervention, with two-screw or plate fixation. Longer term outcomes of these expedite approaches are lacking and future research is likely going to clarify long term results of these management strategies. 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, recent advances in the surgical and perioperative treatment of metacarpal fractures, thumb ulnar collateral ligament (UCL) injuries, and scaphoid fractures offer promising outcomes for elite athletes. These options support accelerated rehabilitation and earlier return-to-play, which are crucial in the demanding environment of professional sports. Of note, previous research in the National Football League (NFL) has shown that stable metacarpal fractures can be managed conservatively with splinting and early return to competition. In contrast, scaphoid fractures in athletes tend to always be managed surgically unless the athlete can take time off. Thumb ucl injuries appear to have positive outcomes even if surgery is delayed , hence, a conservative trial of a few weeks may be justifiable without significant risks. URL : https://doi.org/10.1016/j.jhsa.2024.03.018 Abstract Caring for hand and wrist injuries in the elite athlete brings distinct challenges, with case-by-case decisions regarding surgical intervention and return-to-play. Metacarpal fractures, thumb ulnar collateral ligament tears, and scaphoid fractures are common upper-extremity injuries in the elite athlete that can be detrimental to playing time and future participation. Treatment should therefore endure the demand of accelerated rehabilitation and return-to-activity without compromising long-term outcomes. Fortunately, the literature has supported emerging management options that support goals specific to the athlete. This review examined the advances in surgical and perioperative treatment of metacarpal fractures, thumb ulnar collateral ligament injuries, and scaphoid fractures in the elite athlete. publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings

Adherence of individuals with shoulder pain to home exercise booklets: Barriers, facilitators, and the impact of disability, self-efficacy, and treatment expectations. Francisco, I. M., Tozzo, M. C., Martins, J. and de Oliveira, A. S. (2024) Level of Evidence: 2c Follow recommendation: 👍 👍 👍 (3/4 Thumbs up) Type of study: Therapeutic Topic : Shoulder exercises - Adherence factors This prospective study assessed barriers, facilitators, and the roles of disability, self-efficacy, and treatment expectations on adherence to exercise in people with persistent shoulder pain. A total of 47 participants were included in the present study and adherence was assessed utilising the Exercise Adherence Assessment Scale. The results showed that 50% of participants adhered to the exercise program. The primary barriers included pain and health issues, time constraints, and other commitments, while facilitators were pain improvement and enjoyment of exercises. Statistical analysis revealed that disability, self-efficacy, and treatment expectations did not significantly predict adherence. 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, half of our patients with upper limb pain adhere to home exercise programs. The main barriers for non-adherence include pain and time constraints, while improvement in symptoms and enjoyment of exercises were facilitators to adherence. Another way to improve exercise adherence may be to limit the number of exercises to two or a maximum of three . In addition, social support and task appreciation appear to be useful in boosting exercise adherence . URL : https://doi.org/10.1016/j.msksp.2024.102956 Abstract Background home exercise booklets offer several benefits to individuals with shoulder pain. However, it is necessary to investigate the factors that determine adherence to home exercises. Objectives 1) To investigate the level of adherence of individuals with chronic shoulder pain to a home exercise booklet conducted without the mediation of a healthcare professional, 2) To describe the barriers and facilitators to adherence, and 3) to determine if shoulder disability, self-efficacy, and treatment expectations are predictors of the level of adherence. Design prospective longitudinal study. Methods A total of 47 individuals with chronic shoulder pain were recruited. The Numeric Pain Rating Scale (NPRS) was used to assess pain intensity, the Shoulder Pain and Disability Index (SPADI) to measure shoulder disability, the Pain Self-Efficacy Questionnaire (PSEQ-10) for self-efficacy, and a likert scale to measure treatment expectations. Adherence was measured by Exercise Adherence Assessment Scale (EAAE-Br). Results A total of 23 individuals (48.93%) adhered to the home exercise program. The most commonly cited barriers were pain and health-related issues, while the most cited facilitators were pain improvement and symptom relief. Barriers associated with adherence were time constraints and other commitments, while the facilitator associated with adherence was enjoying the exercises. Binary logistic regression analysis revealed that shoulder disability, self-efficacy, and treatment expectations were unable to predict adherence to home exercises in individuals with shoulder pain [F (1,47) = 2.384; p = 0.130; R2 = 0.056]. Conclusion The study revealed barriers and facilitators to home exercise in individuals with shoulder pain. Disability, self-efficacy, and treatment expectations were not able to predict adherence. publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings

Are there differences in pain reduction and functional improvement among splint alone, steroid alone, and combination for the treatment of adults with trigger finger? Atthakomol, P., Wangtrakunchai, V., Chanthana, P., Phinyo, P. and Manosroi, W. (2023) Level of Evidence: 1b Follow recommendation: 👍 👍 👍 (3/4 Thumbs up) Type of study: Therapeutic Topic : Splinting alone or with cortisone - Trigger finger This randomised study assessed the effect of three conservative interventions on pain reduction and functional improvement in people with trigger finger. A total of 120 participating were included. Participants were randomised to either splinting alone (see picture below), steroid injection alone, or a combination of both. The outcomes measures included the Visual Analog Scale (VAS) for pain and the Michigan Hand Outcomes Questionnaire (MHQ) assessed at 6, 12, and 52 weeks. The results showed no clinically important differences in pain reduction or functional improvement among the groups at any time point (see graph below). Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message : Based on what we know today, splinting alone is recommended for the initial treatment of trigger finger. Thus, there is a lack of clinically important differences between splinting alone, steroid injection alone, or a combination of the two in terms of pain reduction and functional improvement up to one year. If you want to read more about trigger finger, including splinting options , have a look at the whole database . URL : https://doi.org/10.1097/CORR.0000000000002662 Abstract Background Steroid injection and splinting, which are commonly recommended nonsurgical treatments in adults with trigger finger, have been demonstrated to effectively relieve pain and improve function. However, to our knowledge, there have been no direct comparisons of pain relief and function improvement with splinting alone, steroid injection alone, or a combination of splinting and steroid injection in patients with this diagnosis. Question/purpose Are there differences in pain reduction and functional improvement in adults with trigger finger treated with splinting alone, steroid injection alone, and a combination of splinting and steroid injection at 6, 12, and 52 weeks after the intervention? Methods Between May 2021 and December 2021, we treated 165 adult patients for trigger finger at an academic university hospital. Based on prespecified criteria, all patients we saw during that period were eligible, but 27% (45 of 165) were excluded because they had received a previous local corticosteroid injection (n = 10) or they had concomitant carpal tunnel syndrome (n = 14), first carpometacarpal joint arthritis (n = 3), osteoarthritis of the hand (n = 6), de Quervain disease (n = 3), multiple-digit trigger finger (n = 6), or pregnancy during the study period (n = 3). After screening, 120 patients were randomized to receive either splinting (n = 43), steroid injection (n = 40), or splinting plus steroid injection (n = 37). Patients were randomly assigned to the different treatments using computer-generated block randomization (block of six). Sequentially numbered, opaque, sealed envelopes were used in the allocation concealment process. Both the allocator and the outcome assessor were blinded. Splinting involved the patient wearing a fixed metacarpophalangeal joint orthosis in the neutral position at least 8 hours per day for 6 consecutive weeks. Steroid injection was performed using 1 mL of 1% lidocaine without epinephrine and 1 mL of triamcinolone acetonide (10 mg/mL) injected directly into the flexor tendon sheath. No patients were lost to follow-up or had treatment failure (that is, the patient had persistent pain or triggering with the trigger finger treatment and requested additional medical management including additional splinting, steroid injection, or surgery) at 6 or 12 weeks after the intervention, and at 52 weeks, there was no difference in loss to follow-up among the treatment groups. An intention-to-treat analysis was performed with all 120 patients, and a per-protocol analysis was conducted with 86 patients after excluding patients who were lost to follow-up or had treatment failure. Primary outcomes evaluated were VAS pain reduction and improvement in Michigan Hand Outcomes Questionnaire (MHQ) scores at 6, 12, and 52 weeks after the intervention. The minimum clinically important difference (MCID) values were 1 and 10.9 for the VAS and MHQ, respectively. Results There were no clinically important differences in VAS pain scores among the three treatment groups at any timepoint, in either the intention-to-treat or the per-protocol analyses. Likewise, there were no clinically important differences in MHQ scores at any timepoint in either the intention-to-treat or the per-protocol analyses. Conclusion Splinting alone is recommended as the initial treatment for adults with trigger finger because there were no clinically important differences between splinting alone and steroid injection alone in terms of pain reduction and symptom or functional improvement up to 1 year. The combination of steroid injection and splinting is disadvantageous because the benefits in terms of pain reduction and symptom or functional improvement are not different from those achieved with steroid injection or splinting alone. publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings

Value of physical tests in diagnosing cervical radiculopathy: A systematic review Thoomes, E., van Geest, S., van der Windt, D., Falla, D., Verhagen, A., Koes, B., Thoomes-de Graaf, M., Kuijper, B., Scholten-Peeters, W., & Vleggeert-Lankamp, C. (2018) Level of Evidence : 1a Follow recommendation : 👍 👍 👍 👍(4/4 Thumbs Up) Type of study : Diagnostic Topic : Cervical radiculopathy – Physical tests This is a systematic review assessing the usefulness of physical tests in making a diagnosis of cervical radiculopathy in patients with a disk herniation or osteoarthritic changes. Five papers, which compared physical test results against MRI/CT scans or surgical findings were included. The variables of interest were the sensitivity and specificity of physical tests. 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. Spurling’s test and cervical distraction test showed high specificity and low sensitivity. Upper limb neurodynamic tests showed high sensitivity and low specificity. The arm squeeze test showed high sensitivity and high specificity. The arm squeeze test is performed by compressing the anterior and posterior mid portion of the patient’s arm. The test is considered positive if compression of the arm is 3/10 points more painful than squeezing the patient’s shoulder joint. The cervical distraction test showed high specificity and low sensitivity. The cervical distraction test is considered positive when manual cervical traction relieves symptoms in the upper limb. Clinical Take Home Message : Based on what we know today, hand therapists may use a combination upper limb neurodynamic test, and arm squeeze test to rule out a radiculopathy. If neurodynamic tests do not elicit pain and the arm squeeze test is negative, the presence of a radiculopathy is less likely. A diagnosis of cervical radiculopathy can be made if the arm squeeze test and Spurling’s test are positive, and if the cervical distraction test relieves pain. URL : https://www.thespinejournalonline.com/article/S1529-9430(17)30918-X/fulltext

Diagnostic accuracy of clinical tests to rule out elbow fracture: A systematic review. Breda, G., De Marco, G., Cesaraccio, P. and Pillastrini, P. (2023) Level of Evidence: 1a- Follow recommendation: 👍 👍 (2/4 Thumbs up) Type of study: Diagnostic Topic : Elbow fractures - Objective testing This is as a systematic review on the diagnostic accuracy of clinical tests for detecting or excluding elbow fractures. A total of 12 studies involving 4,485 participants were included. Three tests were assessed and they included the elbow full range of motion test, the elbow extension test, and the elbow extension combined with point tenderness test. The results demonstrated high sensitivity for these tests, with values reaching up to 99%, but specificity varied widely from 24% to 70%. While these tests are useful, particularly in ruling out fractures in adults when results are negative, their specificity is quite low. 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, clinical tests for elbow fractures, such as the elbow full range of motion test, elbow extension test, and elbow extension combined with point tenderness test, present high sensitivity values, making them potentially useful to exclude fractures when results are negative. Keep in mind that factors like depression and catastrophising can significantly modulate pain in patients with upper limb fractures and that tenderness on palpation of fractures is not a reliable indicator. URL : https://doi.org/10.5397/cise.2022.00948 Abstract Elbow traumas represent a relatively common condition in clinical practice. However, there is a lack of evidence regarding the most accurate tests for screening these potentially serious conditions and excluding elbow fractures. The purpose of this investigation was to analyze the literature concerning the diagnostic accuracy of clinical tests for the detection or exclusion of suspected elbow fractures. A systematic review was performed using the Preferred Reporting Items for a Systematic Review and Meta-analysis of Diagnostic Test Accuracy Studies (PRISMA-DTA) guidelines. Literature databases including PubMed, Cumulative Index to Nursing and Allied Health Literature, Diagnostic Test Accuracy, Cochrane Library the Web of Science, and ScienceDirect were searched for diagnostic accuracy studies of subjects with suspected traumatic elbow fracture investigating clinical tests compared to imaging reference tests. The risk of bias in each study was assessed independently by two reviewers using the Quality Assessment of Diagnostic Accuracy Studies 2 checklist. Twelve studies (4,485 patients) were included. Three different types of index tests were extracted. In adults, these tests were very sensitive, with values up to 98.6% (95% confidence interval [CI], 95.0%–99.8%). The specificity was very variable, ranging from 24.0% (95% CI, 19.0%–30.0%) to 69.4% (95% CI, 57.3%–79.5%). The applicability of these tests was very high, while overall studies showed a medium risk of bias. Elbow full range of motion test, elbow extension test, and elbow extension and point tenderness test appear to be useful in the presence of a negative test to exclude fracture in a majority of cases. The specificity of all tests, however, does not allow us to draw useful conclusions because there was a great variability of results obtained. publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings

Do therapeutic exercises impact supraspinatus tendon thickness? Secondary analyses of the combined dataset from two randomised controlled trials in patients with rotator cuff-related shoulder pain. Dubé, M.-O., et al. (2024) Level of Evidence: 2b Follow recommendation: 👍 👍 (2/4 Thumbs up) Type of study: Therapeutic Topic : Tendon thickness - Exercise This study is a secondary analysis of two existing randomised controlled trials assessing whether supraspinatus tendon thickness changes with therapeutic exercises in people with rotator cuff pathology. The primary focus was on comparing high-load and low-load strengthening exercises, while secondary aims included examining variations in tendon thickness among different tendinopathy subgroups (reactive vs. degenerative) and their associations with clinical outcomes like disability. A total of 159 participants were included in the study. The results showed that tendon thickness changed over time differently based on the type of tendinopathy. In particular, thickness increased in degenerative tendons, decreased in reactive tendons, and remained unchanged in normal tendons. However, no significant differences in tendon thickness were observed based on exercise modality. The study found no association between changes in tendon thickness and disability scores, suggesting that tendon behavior over time might normalise irrespective of intervention type. 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 type of therapeutic exercise does not appear to impact supraspinatus tendon thickness in patients with rotator cuff-related shoulder pain. However, tendon thickness changes over time depending on the tendinopathy type. These findings seem to be supported by recent studies showing that any form of exercise seems to be useful for tendinopathy without a specific approach being superior. URL : https://doi.org/10.1016/j.jse.2024.03.055 Abstract Background: The mechanistic response of rotator cuff tendons to exercises within the context of rotator cuff-related shoulder pain (RCRSP) remains a significant gap in current research. A greater understanding of this response can shed light on why individuals exhibit varying responses to exercise interventions. It can also provide information on the influence of certain types of exercise on tendons. The primary aim of this article is to explore if changes in supraspinatus tendon thickness (SSTT) ratio differ between exercise interventions (high load vs. low load). The secondary aims are to explore if changes in SSTT ratio differ between ultrasonographic tendinopathy subgroups (reactive vs. degenerative) and if there are associations between tendinopathy subgroups, changes in tendon thickness ratio, and clinical outcomes (disability). Methods: This study comprises secondary analyses of the combined dataset from two randomized controlled trials that compared high and low-load exercises in patients with RCRSP. In those trials, different exercise interventions were compared: 1) progressive high-load strengthening exercises, and 2) low-load strengthening with or without motor control exercises. In one trial, there was also a third group that was not allocated to exercises (education only). Ultrasound-assessed SSTT ratio, derived from comparing symptomatic and asymptomatic sides, served as the primary measure in categorizing participants into tendinopathy subgroups (reactive, normal and degenerative) at baseline. Results: Data from 159 participants were analyzed. Two-way repeated measures ANOVAs revealed significant Group (p<0.001) and Group X Time interaction (p<0.001) effects for the SSTT ratio in different tendinopathy subgroups, but no Time effect (p=0.63). Following the interventions, SSTT ratio increased in the "Degenerative" subgroup (0.14 [95% CI: 0.09 to 0.19]), decreased in the "Reactive" subgroup (-0.11 [95% CI: -0.16 to -0.06]), and remained unchanged in the "Normal" subgroup (-0.01 [95% CI: -0.04 to 0.02]). There was no Time (p=0.21), Group (p=0.61), or Group X Time interaction (p=0.66) effect for the SSTT ratio based on intervention allocation. Results of the linear regression did not highlight any significant association between the tendinopathy subgroup (p=0.25) or change in SSTT ratio (p=0.40) and change in disability score. Conclusion: Findings from this study suggest that, over time, SSTT in individuals with RCRSP tends to normalize, compared to the contralateral side, regardless of the exercise intervention. Different subgroups of symptomatic tendons behave differently, emphasizing the need to potentially consider tendinopathy subtypes in RCRSP research. Future adequately powered studies should investigate how those different tendinopathy subgroups may predict long-term clinical outcomes. publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings

Does thermoplastics' thickness influence joint stabilization and movement coordination? An inferential study of wrist orthoses. de Almeida, P., Santos, B. B., Bernardo, L. D. and MacDermid, J. C. (2022) Level of Evidence: 2c Follow recommendation: 👍 👍 👍 (3/4 Thumbs up) Type of study: Therapeutic Topic : Thermoplastic thickness - Wrist splint stability This cross-sectional study investigated whether the thickness of low-temperature thermoplastics in wrist splints impacted joint stability and movement coordination. A total of 10 participants performed a task whilst either wearing a 1.6 mm, a 3.2 mm, or no splint. The task involved pouring some water from a jar into a cup and drinking from the cup. The kinematic assessment was completed through motion analysis and showed that both splints similarly restricted wrist mobility, maintaining approximately 15 degrees of wrist extension without significant differences between them. Proximal joint movements (shoulder, elbow, forearm) showed no substantial changes across conditions. While task performance time increased when using the splints, movement smoothness and coordination showed no significant differences. 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, wrist splints made from 1.6 mm thick thermoplastic provide joint stability similar to those made from 3.2 mm thick material during a low load task. This may not be necessary true when heavier tasks (e.g. manual work) is required by patients. URL : https://doi.org/10.1097/PXR.0000000000000162 Abstract Background: Given the existence of multiple low-temperature thermoplastics, clinicians fabricating can readily modify an orthoses' thickness, weight and flexibility, among other properties. However, there is limited evidence on the impact of such different materials on upper extremities' biomechanics. Objective: Our study aimed to investigate differences in joint stabilization and movement coordination provided by upper extremity orthotics fabricated with low-temperature thermoplastics of different thicknesses. Study Design: Inferential, cross-sectional study Method: We conducted a kinematic analysis of a standardized task through a three-dimensional motion capture system. Ten participants (5 female) performed the same task under three circumstances: 1) wearing a volar wrist immobilization orthosis, made with a 3.2-mm thick low-temperature thermoplastic; 2) using the same orthotic fabricated with a 1.6-mm thick material; and (3) without orthoses. We divided the standardized task into five logical phases for data analysis, obtaining the active range of motion of the shoulder, elbow, forearm, and wrist joints as the primary outcome. Secondary outcomes included movement smoothness and coordination, measured by the number of motor units, time, and distance travelled by the upper extremity. Results: Despite changes in thermoplastic thickness, both orthotics significantly restricted the wrist motion during task performance (F(2,16) = 14.32, P < .01, and η2p = 0.797), with no difference between the 2 devices and no significant changes to proximal joints' active range of motion. Although orthoses use increased the time required for task performance (F(2,16) = 23.05, P < .01, and η2p = 0.742), no significant differences in movement smoothness or coordination were noted. Conclusion: Our results indicate that wrist orthoses fabricated with a 1.6-mm thick low-temperature thermoplastic can provide joint stabilization similar to a device made from a 3.2-mm thickness material, suggesting thinner thermoplastics' efficacy to stabilize joints in the absence of contractures or preexisting chronic conditions. publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings

Does your bedside neurological examination for suspected peripheral neuropathies measure up? Bender, C., Dove, L. and Schmid, A. B. (2022) Level of Evidence : 5 Follow recommendation : 👍 (1/4 Thumbs up) Type of study : Diagnostic Topic : Neurological testing - Peripheral neuropathies This is an expert opinion on neurological testing for peripheral neuropathies. Six recommendations are provided based on the available evidence: 1 - Assess light touch sensation in the upper limb in a circular pattern. This will allow you to differentiate between a dermatomal vs a peripheral nerve numbness presentation. 2 - Test small fibre neuropathy through pin-prick in a circular pattern 3 - If there are motor or sensory deficits in both upper limbs, do not consider that "normal". 4 - When performing myotome testing, fatigue may incur more quickly in the affected muscles compared to other myotomes. Instead of a single maximal strength test, repeated testing may be required. 5 - Reflex testing is independent of patients' pain, use them. 6 - Monitor progress/deterioration as accurately as possible. Have a look at: Upper limb sensory testing - The video is also on JOSPT but it keeps buffering Upper limb motor and reflex testing - The video is also on JOSPT  but it keeps buffering 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, light touch, pin-prick, myotomes , and reflex testing may be useful in the assessment of people with peripheral neuropathies. Light touch, myotome, and reflex testing assess the gross integrity of nerves and they may be affected when there are moderate/large entrapment neuropathies. If the entrapment is mild, you may only identify impairments on pin-prick (small fibre neuropathy) . Pin-prick can be easily tested with a neuropen, which consistently delivers 40g of pin-prick (This is what I use in the clinic). If clients report muscle fatigue and you are testing myotomes, you may want to perform a few repetitions and compare their endurance to unaffected muscles of the same limb. In terms of dermatomes remember that they are inconsistent across people and the best you could do is differentiate between a radicular presentation vs a peripheral nerve entrapment. URL : https://doi.org/10.2519/jospt.2022.11281 Abstract Neurological testing is essential for screening and diagnosing suspected peripheral neuropathies. Detecting changes in somatosensory and motor nerve function can also have direct implications for management decisions. Nevertheless, there is considerable variation in what is included in a bedside neurological examination, and how it is performed. Neurological examinations are often used as screening tools to detect neurological deficits, but not used to their full potential for monitoring progress or deterioration. Here, we advocate for better use of the neurological examination within a clinical reasoning framework. Constrained by the lack of research in this field, our viewpoint is based on neuroscientific principles. We highlight six challenges for clinicians when conducting neurological examinations, and propose ways to overcome these challenges in clinical practice. We challenge widely held ideas about how the results of neurological examinations for peripheral neuropathies are interpreted and how the examinations are performed in practice. publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings

Observed patterns of cervical radiculopathy: how often do they differ from a standard, “Netter diagram” distribution? McAnany, S., Rhee, J., Baird, E., Shi, W., Konopka, J., Neustein, T., & Arceo, R. (2019) Level of Evidence : 2b Follow recommendation : 👍 👍 👍 (3/4 thumbs up) Type of study : Symptoms prevalence study Topic : Cervical radiculopathy – Dermatomal patterns This is a retrospective study assessing the agreement between radiculopathy symptoms reported by patients and standard textbook patterns of radiculopathy. Patients were selected if they presented with a single level cervical radiculopathy (identified through MRI/CT scan), if they had been unresponsive to conservative treatment, and if they had a 75% improvement of symptoms at 6 months after anterior cervical discectomy and fusion (ACDF) surgery. The results showed that ipsilateral neck pain was present in 80% of patients before surgery. Shoulder pain on the side of the radiculopathy was present in 60% of the cases before surgery. Any spinal level from C3-C4 to C7-T1 could present with symptoms beyond the shoulder before surgery. The pain/numbness patterns described by the patients significantly deviated from the patterns described in textbooks and only 54% of patients presented with a standard pain/numbness pattern. 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, radiculopathies may present with a dermatomal pattern as described in textbooks in 54% of the cases. The presence or lack of symptoms beyond the neck/shoulder is not useful in identifying the level of cervical compression. URL : https://doi.org/10.1016/j.spinee.2018.08.002 Abstract BACKGROUND CONTEXT Traditionally, cervical radiculopathy is thought to present with symptoms and signs in a standard, textbook, reproducible pattern as seen in a “Netter diagram.” To date, no study has directly examined cervical radicular patterns attributable to single level pathology in patients undergoing ACDF. PURPOSE The purpose of this study is to examine cervical radiculopathy patterns in a surgical population and determine how often patients present with the standard textbook (ie, Netter diagram) versus nonstandard patterns. STUDY DESIGN/SETTING A retrospective study. PATIENT SAMPLE Patients who had single-level radiculopathy with at least 75% improvement of preoperative symptoms following ACDF were included. OUTCOME MEASURES Epidemiologic variables were collected including age, sex, weight, body mass index, laterality of symptoms, duration of symptoms prior to operative intervention, and the presence of diabetes mellitus. The observed pattern of radiculopathy at presentation, including associated neck, shoulder, upper arm, forearm, and hand pain and/or numbness, was determined from chart review and patient-derived pain diagrams. METHODS We identified all patients with single level cervical radiculopathy operated on between March 2011 and March 2016 by six surgeons. The observed pattern of radiculopathy was compared to a standard textbook pattern of radiculopathy that strictly adheres to a dermatomal map Fisher exact test was used to analyze categorical data and Student t test was used for continuous variables. A one-way ANOVA was used to determine differences in the observed versus expected radicular pattern. A logistic regression model assessed the effect of demographic variables on presentation with a nonstandard radicular pattern. RESULTS Overall, 239 cervical levels were identified. The observed pattern of pain and numbness followed the standard pattern in only 54% (129 of 239; p=.35). When a nonstandard radicular pattern was present, it differed by 1.68 dermatomal levels from the standard (p<.0001). Neck pain on the radiculopathy side was the most prevalent symptom; it was found in 81% (193 of 239) of patients and did not differ by cervical level (p=.72). In a logistic regression model, none of the demographic variables of interest were found to significantly impact the likelihood of presenting with a nonstandard radicular pattern. CONCLUSIONS Observed patterns of cervical radiculopathy only followed the standard pattern in 54% of patients and did not differ by the cervical level involved. Cervical radiculopathy often presents with a nonstandard pattern. Surgeons should think broadly when identifying causative levels because they frequently may not adhere to textbook descriptions in actual clinical practice. We observed III level of evidence. publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings

Advancing the understanding of placebo effects in psychological outcomes of exercise: Lessons learned and future directions. Lindheimer, J. B., A. Szabo, J. S. Raglin and C. Beedie (2020) Level of Evidence : 5 Follow recommendation : 👍 (1/4 Thumbs Up) Type of study : Therapeutic Topic : Placebo and nocebo – What are they? This is a narrative review on the effect of placebo and nocebo with exercise interventions. Placebo can be defined as a positive effect (e.g. pain reduction), nocebo instead can be described as a negative effect (e.g. increase in pain) resulting from your treatment or interaction with clients. The findings from this review suggest that 50% of the benefits provided by exercise may be due to a placebo effect (see picture). It also appears that clients' expectations largely contribute to exercise effectiveness. Interestingly, these expectations can be influenced by the client-clinician interaction. 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, up to 50% of the positive response to exercise may be due to placebo. This may also suggest that a large proportion of the negative responses to exercise or activities may be due to the nocebo effect (wait for next week synopsis, you are in for a treat). This is consistent with prior research suggesting that the words that we use can increase or decrease our clients' pain . Telling clients that doing certain activities will increase their pain, will therefore increase their likelihood of reporting pain during such activities at next appointment . This will probably lead to a confirmation bias on our side, contributing to a self-fulfilling prophecy. If we instead take an approach that reduces threats associated with movement and exercise, we may be able to boost the placebo effect. Being empathetic and smiling has also been shown to reduce pain in our clients . This placebo boosting activity may be especially useful once we encounter clients with ongoing symptoms long after expected healing time frames. To conclude: Test your pain science knowledge and check whether the placebo is with you! URL : https://doi.org/10.1080/17461391.2019.1632937 Abstract Despite the apparent strength of scientific evidence suggesting that psychological benefits result from both acute and chronic exercise, concerns remain regarding the extent to which these benefits are explained by placebo effects. Addressing these concerns is methodologically and at times conceptually challenging. However, developments in the conceptualisation and study of placebo effects from the fields of psychology, neuroscience, pharmacology, and human performance offer guidance for advancing the understanding of placebo effects in psychological responses to exercise. In clinical trials, expectations can be measured and experimentally manipulated to better understand the influence of placebo effects on treatment responses. Further, compelling evidence has shown that the contribution of placebo effects and their underlying neurobiological mechanisms to treatment effects can be measured without administering a traditional placebo (e.g. inert substance) by leveraging psychological factors such as expectations and conditioning. Hence, the purpose of this focused review is to integrate lessons such as these with the current body of literature on placebo effects in psychological responses to exercise and provide recommendations for future research directions. publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings

The magnitude of nocebo effects in pain: A meta-analysis. Petersen, G. L., et al. (2014) Level of Evidence : 1a Follow recommendation : 👍 👍 👍 👍 (4/4 Thumbs Up) Type of study : Therapeutic Topic : Nocebo – No touching needed This is a systematic review and meta-analysis on the effect of verbal communication and nocebo. Nocebo can be described as a negative effect (e.g. increase in pain) resulting from your treatment or interaction with clients. Ten experimental studies for a total of 334 participants were included in the present study. The participants included either had persistent pain or were healthy subjects to whom pain was induced experimentally (e.g. saline injection). The results showed that verbal nocebo (suggesting that an activity/treatment will be painful) combined with an activity, significantly increased pain with a moderate to large effect size. The clinical relevance of this finding was not provided by the paper, however, I calculated it for you. To give you an estimate, with verbal nocebo and activity conditioning, there was an increase in pain of at least 1 point out of 10 (I calculated this by utilising Hedges' g of 0.62, which was the lowest effect size, on the standard deviation reported in Figure 3 of the paper by Colloca et al. published in 2008 ). The results also showed that the magnitude of the nocebo effect is similar to the one of the placebo effect, yet in the opposite direction. 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 can increase clients' pain just by telling them that a specific activity is going to be painful. In particular, the minimum increase in pain appears to be 1 point out of 10 on a visual analogue pain scale. In addition, the size of the nocebo effect appears to be similar to that of the placebo effect but in the opposite direction. What this means is that within the same client, we can make the pain better or worse by at least 1 point out of 10. In other words, a client presenting with a baseline pain level of 4/10, can come back to you at the next appointment with a pain level of 3/10 or 5/10 according to your placebo or nocebo conditioning approach respectively. This is a clinically relevant difference! Which approach should we choose? I will go with the placebo approach, which has been suggested to boost the effect of exercise , and I will be smiling, which has been shown to reduce pain in our clients . Remember, if you tell your clients that an activity is going to hurt, that increases the chances that it will . URL : https://www.sciencedirect.com/science/article/pii/S030439591400195X Abstract The investigation of nocebo effects is evolving, and a few literature reviews have emerged, although so far without quantifying such effects. This meta-analysis investigated nocebo effects in pain. We searched the databases PubMed, EMBASE, Scopus, and the Cochrane Controlled Trial Register with the term “nocebo.” Only studies that investigated nocebo effects as the effects that followed the administration of an inert treatment along with verbal suggestions of symptom worsening and that included a no-treatment control condition were eligible. Ten studies fulfilled the selection criteria. The effect sizes were calculated using Cohen’s d and Hedges’ g. The overall magnitude of the nocebo effect was moderate to large (lowest g=0.62 [0.24–1.01] and highest g=1.03 [0.63–1.43]) and highly variable (range of g=−0.43 to 4.05). The magnitudes and range of effect sizes was similar to those of placebo effects (d=0.81) in mechanistic studies. In studies in which nocebo effects were induced by a combination of verbal suggestions and conditioning, the effect size was larger (lowest g=0.76 [0.39–1.14] and highest g=1.17 [0.52–1.81]) than in studies in which nocebo effects were induced by verbal suggestions alone (lowest g=0.64 [−0.25 to 1.53] and highest g=0.87 [0.40–1.34]). These findings are similar to those in the placebo literature. As the magnitude of the nocebo effect is variable and sometimes large, this meta-analysis demonstrates the importance of minimizing nocebo effects in clinical practice. publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings

Pain can be conditioned to voluntary movements through associative learning: An experimental study in healthy participants Alaiti, R., Zuccolo, P., Leite Hunziker, M., Caneiro, J., Vlaeyen, J., & Fernandes da Costa, M. (2020) Level of Evidence : 5 Follow recommendation : 👍(1/4 Thumbs Up) Type of study : Aetiologic Topic : Acute pain - Movement conditioning This is an experimental study assessing the effect of shoulder movement associated with a painful stimulus on the likelihood of perceiving pain in the presence of a non painful stimulus after the conditioning. A total of 34 healthy participants were included in the study. The assessment took place immediately before and after the pain conditioning. During the assessment, a non painful stimulus was delivered through an electrocutaneous current of low intensity at the acromion of the tested shoulder. During the assessment, participants were asked to report whether two shoulder movements (shoulder flexion/shoulder flexion with horizontal adduction) paired with the non painful stimuli were painful or not. During the conditioning, a painful stimuli (electrocutaneous current of high intensity) was delivered consistently to one of the shoulder movements described above (randomised among participants) for 50% of the trials. The conditioning phase lasted on average 2 minutes. The results showed that the painfully conditioned movement was reported as painful more often (85%; SD: 25%) compared to the non conditioned movement (73%; SD: 32%) when paired with the non painful stimuli after the conditioning. Clinical Take Home Message : Based on what we know today, our clients can develop a learned association between a specific movement and the perception of pain. It is possible that this leads to the experience of pain in the absence of tissue damage. Therapeutic interventions aiming to dissociate movement from pain may be useful in reducing the pain experience. URL : https://journals.lww.com/pain/Abstract/9000/zain_can_be_conditioned_to_voluntary_movements.98406.aspx publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings