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Differences between men and women in percentage of body weight supported during push-up exercise. Mier, C. M., Amasay, T., Capehart, S. and Garner, H. (2014) Level of Evidence : 2c Follow recommendation : 👍 👍 (2/4 thumbs up) Type of study : Therapeutic Topic : Push-up - Resistance This is a cross-sectional study assessing the percentage of body weight lifted during push-up exercises. A total of 37 healthy participants (males = 19, females = 18) were included in the present study. The regular push-up and modified push-up (knee push-up) were assessed during dynamic and static (elbows straight vs elbow flexed) exercises. The results showed that during a dynamic push-up, 80-100% of body weight was lifted. When performing knee push-ups, body weight resistance is reduced to 70-80%. During a static push-up (elbow extension and flexion), resistance equates to 50-75% of body weight. There were differences between males and females during dynamic push-up exercises (see table), however, they were likely due to disparities in push-up speed. 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, during regular push-up exercises, we lift between 80% to 100% of our body weight. When performing knee push-up the resistance reduces to 70-80% of body weight. Static push-up holds (elbow extension/flexion) further reduce resistance to 50-75% of body weight. This information is useful when people want to return to the gym to do bench press exercises. We will be able to estimate their ability to lift weights by asking them to perform a few push-ups and knowing their body weight. Push-ups can also be utilised as a prognostic factor for future health . If you are interested in other ways of assessing upper limb strength and the ability of the upper limb to withstand load, have a look at the push off test . URL : https://digitalcommons.wku.edu/ijes/vol7/iss2/7/ Abstract The purpose of this study was to investigate the effects of push-up method (standard vs modified) and gender on percentage of body weight supported. Thirty seven men and women completed five push-ups in the standard (SPU) and modified (MPU) positions, and 5-sec hold (static) in the up (elbow extension) and down (elbow flexion) positions. Vertical ground reaction forces (expressed as load relative to body weight) were measured using force platforms. From a video-captured image, a computer software distance tool measured vertical range of motion (ROM) achieved in the down position expressed as a percentage of full vertical ROM. Maximal relative load was greater in men than women (SPU: 97.7 ± 8.1% vs 80.0 ± 3.9%; MPU: 79.7 ± 7.4% vs 68.2 ± 3.0%, p < .0001) with a greater effect during SPU (p < .0001). In the static up position, relative load did not differ between men and women (SPU: 67.0 ± 3.8% vs 65.1 ± 3.1%; MPU: 52.5 ± 3.7% vs 51.5 ± 3.1%); however, relative load was greater in men during the static down position (SPU: 74.6 ± 3.6 vs 70.3 ± 3.1%; MPU: 60.1 ± 4.5 vs 56.6 ± 2.7%, p < .0001). Percentage of full vertical ROM was greater in men than women (SPU: 67.7 ± 6.1% vs 50.1 ± 11.4%; MPU: 66.6 ± 6.9% vs 60.1 ± 8.9%, p = .001). These data indicate that women perform the push-up with less relative load and ROM, likely due to gender differences in movement patterns which can be altered by fatigue.

A machine learning algorithm to estimate the probability of a true scaphoid fracture after wrist trauma. Bulstra, A. E. J., et al. (2022) Level of Evidence : 2b Follow recommendation : 👍 👍 (2/4 thumbs up) Type of study : Diagnostic Topic : Scaphoid fractures - Physical tests This is a retrospective study developing a clinical rule to determine who would benefit from advanced imaging (MRI, CT) in clients with radial wrist pain following a fall or injury. A total of 422 participants were included in the study. All participants were included if they were assessed within 72 hrs of a wrist injury. A machine learning model for the detection of scaphoid fractures was developed. The results showed that age, sex, mechanism of injury, and pain at the anatomical snuff box with ulnar deviation were important factors when making a decision for further imaging. The findings also showed that if the risk of having a scaphoid fracture was equal or greater than 10% ( use this tool to calculate it) , patients would have benefitted from undergoing MRI or CT scan. As for previous research on scaphoid fractures, this study has a flaw. When all the physical tests were negative and follow-up x-rays at two weeks were negative, a scaphoid fracture was excluded, which leaves the possibility of occult fractures being undiagnosed. 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, our clinical reasoning may be aided by this online tool to decide whether additional imaging (e.g. MRI, CT) to exclude a scaphoid fracture is advisable in clients who had a wrist injury with a negative x-ray. Considering that advanced imaging is not always available to us, we may decide instead to keep a closer eye on our clients who present a probability of having a scaphoid fracture equal or higher than 10%. Since this tool appears useful for screening purposes (excluding a fracture), the presence of higher probabilities should not necessarily raise red flags. If you are interested in additional information on diagnostic tests for scaphoid fractures, have a look at this synopsis . URL : https://doi.org/10.1016/j.jhsa.2022.02.023 Abstract Purpose: To identify predictors of a true scaphoid fracture among patients with radial wrist pain following acute trauma, train 5 machine learning (ML) algorithms in predicting scaphoid fracture probability, and design a decision rule to initiate advanced imaging in high-risk patients. Methods: Two prospective cohorts including 422 patients with radial wrist pain following wrist trauma were combined. There were 117 scaphoid fractures (28%) confirmed on computed tomography, magnetic resonance imaging, or radiographs. Eighteen fractures (15%) were occult. Predictors of a scaphoid fracture were identified among demographics, mechanism of injury and examination maneuvers. Five ML-algorithms were trained in calculating scaphoid fracture probability. ML-algorithms were assessed on ability to discriminate between patients with and without a fracture (area under the receiver operating characteristic curve), agreement between observed and predicted probabilities (calibration), and overall performance (Brier score). The best performing ML-algorithm was incorporated into a probability calculator. A decision rule was proposed to initiate advanced imaging among patients with negative radiographs. Results: Pain over the scaphoid on ulnar deviation, sex, age, and mechanism of injury were most strongly associated with a true scaphoid fracture. The best performing ML-algorithm yielded an area under the receiver operating characteristic curve, calibration slope, intercept, and Brier score of 0.77, 0.84, −0.01 and 0.159, respectively. The ML-derived decision rule proposes to initiate advanced imaging in patients with radial-sided wrist pain, negative radiographs, and a fracture probability of ≥10%. When applied to our cohort, this would yield 100% sensitivity, 38% specificity, and would have reduced the number of patients undergoing advanced imaging by 36% without missing a fracture. Conclusions: The ML-algorithm accurately calculated scaphoid fracture probability based on scaphoid pain on ulnar deviation, sex, age, and mechanism of injury. The ML-decision rule may reduce the number of patients undergoing advanced imaging by a third with a small risk of missing a fracture. External validation is required before implementation. 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

Using the Tampa Scale for Kinesiophobia short form in patients with upper extremity specific limitations. Kortlever, J. T., et al. (2021) Level of Evidence : 3b Follow recommendation : 👍 👍 (2/4 thumbs up) Type of study : Diagnostic Topic : Kinesiophobia - Short form This was a prospective study assessing the validity and reliability of the Tampa Scale for Kinesiophobia short form (four questions) to assess fear of movement in people with upper limb conditions. A total of 143 participants were included and they presented with traumatic and non-traumatic conditions of the hand, wrist, elbow, or shoulder. These participants completed several questionnaires including the Tampa Scale for Kinesiophobia short and long form. In the short form (see table below) there are four questions compared to 17 in the full form. The results showed that the Tampa Scale for Kinesiophobia short form was valid when compared to the full-length questionnaire and was also reliable. 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 short version of the Tampa Scale for Kinesiophobia (TKS-4) is reliable and valid when compared to the full questionnaire in our clients with upper limb conditions. Considering that kinesiophobia is associated with upper limb function , we may add this outcome to the information we collect from our clients. Other brief and validated forms that we can use to assess pain catastrophising, anxiety, and depression can be found in this synopsis . URL : https://doi.org/10.1177/1558944719898830 Abstract Background: The Tampa Scale for Kinesiophobia (TSK) is used to quantify fear of painful movement. A shorter form with only 4 questions (TSK-4) can be used by physicians to look for fear of movement independent of catastrophic thinking with less responder and survey burden. We assessed the difference explained in amount of variation in the Patient-Reported Outcomes Measurement Information System Physical Function Upper Extremity (PROMIS PF UE) between the TSK and TSK-4. Additionally, we looked for other factors that were associated with the PROMIS PF UE, and we assessed reliability and validity of the TSK and TSK-4 by looking at mean scaled scores, internal consistency, floor and ceiling effects, interquestionnaire correlations, and collinearity with the Pain Catastrophizing Scale short form (PCS-4), PROMIS Depression, and PROMIS Pain Interference (PROMIS PI). Methods: One hundred forty eight new and follow-up patients were seen at 5 orthopedic clinics in a large urban area and given the TSK, PROMIS PF UE, PROMIS Depression, PROMIS PI, and PCS-4 questionnaires. Results: Both long and short measures of greater fear of painful movement were independently associated with less physical function (PROMIS PF UE). The longer version accounted for more of the variation in physical function than the short version (TSK, semipartial R2 = 0.12, adjusted R2 full model 0.25; TSK-4, semipartial R2 = 0.03, adjusted R2 full model = 0.16, respectively). The shorter measure had slight floor and ceiling effects. There was high internal consistency for both the TSK and TSK-4. Conclusions: A short measure of fear of painful movement may be an adequate screen in the care of patients with upper extremity problems. Using this short form can help decrease questionnaire burden while accounting for kinesiophobia along with catastrophic thinking. 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

Changes in body composition and strength after 12 weeks of high-intensity functional training with two different loads in physically active men and women: A randomized controlled study. Kapsis, D. P., et al. (2022) Level of Evidence : 1b Follow recommendation : 👍 👍 👍 👍 (4/4 thumbs up) Type of study : Therapeutic Topic : Weight loss - Resistance training This is a randomised controlled trial assessing weight loss with low load and moderate resistance training interventions compared to a control group. A total of 31 healthy and active (recreational physical activity 2-3/week) participants were included. Participants were randomised to low load or moderate load circuit training (see figure below), which they performed 3 times per week for 12 weeks. The control group continued to perform their normal physical activity routines. Bioelectrical impendence was utilised to assess fat mass at baseline, 6 weeks, and 12 weeks. The results showed that both circuit training interventions led to an increase in strength and fat loss to a greater extent compared to the control group. There were no differences in fat loss between the low load and moderate load circuit training. 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, circuit training for a total of 85 minutes per week appears to be beneficial for weight loss when using either low loads (body weight exercises) or moderate loads. We can reassure our clients who are recovering from a hand or upper limb injury that they will not get out of shape because they are reducing their gym load as long as they increase the number of repetitions. In addition, considering that physical activity reduces the risk of developing depression and depressive symptoms , the likelihood of developing persistent pain and low-grade inflammation (which appears to be a risk factor for persistent pain ) we should encourage it in our clients. Open Access URL : https://doi.org/10.3390/sports10010007 Abstract This study examined the effects of two different resistance loads during high-intensity Functional Training (HIFT) on body composition and maximal strength. Thirty-one healthy young individuals were randomly assigned into three groups: moderate load (ML: 70% 1-RM), low load-(LL: 30% 1-RM), and control (CON). Each experimental group performed HIFT three times per week for 12 weeks with a similar total volume load. Body fat decreased equally in both experimental groups after 6 weeks of training (p < 0.001), but at the end of training it further decreased only in LL compared to ML (-3.19 ± 1.59 vs. -1.64 ± 1.44 kg, p < 0.001), with no change in CON (0.29 ± 1.08 kg, p = 0.998). Lean body mass (LBM) increased after 6 weeks of training (p = 0.019) in ML only, while after 12 weeks a similar increase was observed in LL and ML (1.11 ± 0.65 vs. ML: 1.25 ± 1.59 kg, p = 0.034 and 0.013, respectively), with no change in CON (0.34 ± 0.67 kg, p = 0.991). Maximal strength increased similarly in four out of five exercises for both experimental groups by between 9.5% and 16.9% (p < 0.01) at the end of training, with no change in CON (-0.6 to 4.9%, p > 0.465). In conclusion, twelve weeks of HIFT training with either low or moderate resistance and equal volume load resulted in an equal increase in LBM and maximal strength, but different fat loss. 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

Inflammation, physical activity, and chronic disease: An evolutionary perspective. Burini, R. C., Anderson, E., Durstine, J. L. and Carson, J. A. (2020) Level of Evidence : 5 Follow recommendation : 👍 (1/4 thumbs up) Type of study : Therapeutic Topic : Physical activity - Effect on low-grade inflammation This is a narrative review on the bases of inflammation and the biological repercussions of being inactive/physically activity. The authors suggest that physical inactivity is linked with greater levels of fat accumulation, which contribute to the development of low-grade systemic inflammation. In contrast, the introduction of gradual and regular physical activity reduces systemic inflammation and has the potential to prevent or have an anti-inflammatory effect. 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, regular physical activity has an anti-inflammatory effect. These findings suggest that the addition of physical activity as an intervention may help our clients' hand and upper limb conditions. This may be especially true in those clients who are overweight, inactive and involved in shift work as these factors contribute to low-grade systemic inflammation. If you would like to have a look at what benefits physical activity provides to our clients, have a look at the database . Open Access URL : https://doi.org/10.1016/j.smhs.2020.03.004 Abstract Low-grade inflammation is emerging as a common feature of contemporary metabolic, psychiatric, and neurodegenerative diseases. Both physical inactivity and abdominal adiposity are associated with persistent systemic low-grade inflammation. Thus, the behavioral, biological, and physiological changes that cause a predisposition to obesity and other co-morbidities could have epigenetic underpinnings in addition to various evolutionary scenarios. A key assumption involves the potential for a mismatch between the human genome molded over generations, and the issue of adapting to the modern high calorie diet and common built environments promoting inactivity. This biological mismatch appears to have dire health consequences. Therefore, the goal of this article is to provide a brief overview on the importance of inflammation as part of human survival and how physical activity (PA) and physical inactivity are critical regulators of systemic inflammation. The review will highlight anti-inflammatory effects of PA and exercise training from a metabolic and systemic signaling perspective, which includes skeletal muscle to utilization of fatty acids, TLR4 signaling, and myokine/adipokine effects. The available evidence suggests that PA, regular exercise, and weight loss offer both protection against and treatment for a wide variety of chronic diseases associated with low-grade inflammation through an improved inflammatory profile. 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

A biomechanical analysis of the h-taping method used by rock climbers as prophylactic or stabilizing fixation of partial a2 pulley tears. Salas, C., et al. (2022) Level of Evidence : 4 Follow recommendation : 👍 👍 (2/4 thumbs up) Type of study : Therapeutic Topic : A2 pulley injury - H-tape This is a biomechanical study assessing the effect of H-tape (see picture below) on the force required to rupture A2 pulley during crimping (see crimping hold in pciture below). A total of 14 cadavers were assessed during data collection. The force to rupture of A2 pulley was measured in several fingers with and without H-tape. The tests were performed with both intact and partially torn (50%) pulleys. The results showed that there was no difference in the force required to partially/fully rupture the A2 pulley when H-tape or no tape were implemented. Clinical Take Home Message : Based on what we know today, H-tape does not prevent rupture of A2 pulley in climbers using a crimp hold. To avoid ruptures of partially torn A2 pulleys, it may be best to avoid crimping. If you would like to know more about how to treat A2 pulley injuries, have a look at this synopsis . URL : https://doi.org/10.1016/j.jhsa.2022.05.002 Abstract Purpose: Rock climbing can lead to upper-extremity injuries, such as A2 pulley ruptures, leading to the bowstringing of the flexor tendons. Climbing finger positions are specific and can put undue stress on the pulley systems. This causes severe hand dysfunction and is a difficult problem to treat, and prevention is important. Using a cadaveric, experimental model, we evaluated the effectiveness of the H-taping method, commonly used by rock climbers, to prevent and treat A2 pulley tears. Methods: Using fourteen matched pairs of fresh-frozen cadaveric hands with forearms, four experiments were conducted with 56 paired comparisons evaluating the failure force, fingertip force, and mode of failure (112 total tests). Comparisons were as follows: index fingers- intact versus 50% distal A2 pulley tears without H-taping (control); ring fingers- intact versus H-taping as a prophylactic for A2 pulley tears; little fingers- 50% distal A2 pulley tears with H-tape versus without tape; and middle fingers- H-taping as a prophylactic versus H-taping as a stabilizing treatment of torn pulleys. Results: The mean index finger failure force was significantly higher in intact vs torn A2 pulleys (control). Failure force for intact H-taped fingers was significantly higher than torn H-taped fingers, but no other finger comparisons for failure force were significant. There were no significant findings in comparison of mean fingertip force values in any of the experiments. Conclusions: We found that H-taping is not effective as prophylaxis against A2 pulley ruptures or as a stabilizing treatment method for partially ruptured pulleys. Clinical relevance: While H-taping has not been recommended as prophylaxis for preventing A2 pulley ruptures, the climbing community has embraced this technique as a preventative measure. The present study provides biomechanical evidence against H-taping for this purpose. Furthermore, it does not appear to aid in increasing fingertip force after injury. 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

Effects of heavy slow resistance training combined with corticosteroid injections or tendon needling in patients with lateral elbow tendinopathy: A 3-arm randomized double-blinded placebo-controlled study. Couppé, C., et al. (2022) Level of Evidence : 1b Follow recommendation : 👍 👍 👍 👍 (4/4 thumbs up) Type of study : Therapeutic Topic : Lateral epicondylalgia - cortisone injections This is a randomised placebo-controlled trial assessing the benefit of adding cortisone injections or placebo tendon needling to a resistance training program for tennis elbow. A total of 58 participants took part in the study. To be included, participants had to be experiencing symptoms for at least three months. Pain had to be unilateral, located at the lateral epicondyle of the elbow, and participants had to present with at least two of the following: pain on resisted supination, resisted middle finger extension, and resisted wrist extension. Participants were excluded if they presented with elbow osteoarthritis, or had received a cortisone injection in the previous three months. Participant were randomised to cortisone injection (n = 21), tendon needling (n = 17), or placebo tendon needling (n = 20). All groups performed resisted exercises for wrist extension, flexion, and forearm supination three times per week for 12 weeks (see figure below). Each concentric and eccentric phase lasted 3-4 seconds. Several outcomes were assessed and they included function (DASH, QuickDASH) and pain (numerical rating scale). The outcomes were assessed at baseline, 3 months, 6 months, and 12 months. The results showed that participants in all groups improved to a clinically relevant level after three months of treatment. No clinically relevant differences between groups in function/pain were noted at any time point. 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, slow resistance training exercises are beneficial for people with tennis elbow. The addition of a corticosteroid injection does not appear to be more effective than placebo needling. In light of previous evidence suggesting that cortisone injections may be associated with a higher likelihood of tennis elbow recurrence at 12 months , we may avoid suggesting this intervention for our clients. In people with tennis elbow, it may also be important to assess the relative strength of wrist extensors and flexors, as this seems to predict the risk of future recurrence . URL : https://doi.org/10.1177/03635465221110214 Abstract BACKGROUND: Lateral elbow tendinopathy is a disabling tendon overuse injury. It remains unknown if a corticosteroid injection (CSI) or tendon needling (TN) combined with heavy slow resistance (HSR) training is superior to HSR alone in treating lateral elbow tendinopathy. PURPOSE/HYPOTHESIS: The purpose was to investigate the effects of HSR combined with either (1) a CSI, (2) TN, or (3) placebo needling (PN) as treatment for lateral elbow tendinopathy. We hypothesized that 12 weeks of HSR in combination with a CSI or TN would have superior effects compared with PN at 12, 26, and 52 (primary endpoint) weeks' follow-up on primary (Disabilities of the Arm, Shoulder and Hand [DASH] score) and secondary outcomes in patients with chronic unilateral lateral elbow tendinopathy. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: A total of 60 patients with chronic unilateral lateral elbow tendinopathy were randomized to perform 12 weeks of home-based HSR with elastic band exercises combined with either (1) a CSI, (2) TN, or (3) PN, and at 12, 26, and 52 weeks, we assessed the primary outcome, the DASH score, and secondary outcomes: shortened version of the DASH (QuickDASH) score, pain (numerical rating scale [NRS] score), pain-free grip strength, and hypervascularization (power Doppler area). RESULTS: A CSI, TN, and PN improved patient outcomes equally based on the DASH (Δ20 points), QuickDASH (Δ21 points), and NRS (Δ2.5 points) scores after 12 weeks. Further, after 12 weeks, a CSI also resulted in decreased hypervascularization (power Doppler area) compared with PN (Δ-2251 pixels, P = .0418). Except for the QuickDASH score (CSI increased score by Δ15 points compared with PN; P = .0427), there were no differences between the groups after 52 weeks. CONCLUSION: These results suggest that 12 weeks of HSR improved symptoms in both the short and the long term and that a CSI or TN did not amplify this effect. In addition, a CSI seemed to impair patient-reported outcomes compared with HSR alone at long-term follow-up. 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

Abbreviated psychologic questionnaires are valid in patients with hand conditions. Bot, A. G. J., Becker, S. J. E., van Dijk, C. N., Ring, D. and Vranceanu, A.-M. (2013) Level of Evidence : 3b Follow recommendation : 👍 👍 (2/4 thumbs up) Type of study : Diagnostic Topic : Catastrophising and depression - Short forms This was a prospective study assessing the validity of shortened forms assessing pain catastrophising, anxiety, and depression. A total of 164 participants with hand and upper limb conditions were included. These participants completed several questionnaires including the Pain Catastrophising Scale (PCS), the Short Health Anxiety Index (SHAI), and the Patient Health Questionnaire (PHQ). A subset of questions was extracted from the longer version of each questionnaire and their (construct) validity was assessed. The results showed that the PCS-4 (including 4 questions), the SHAI-5 (including five questions), and the PHQ-2 (including two questions) were valid when compared to the full-length questionnaires (see figures below for the short form of these questionnaires). The PHQ-2 shown above was obtained from this link . 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 short version of the Pain Catastrophising Scale (PCS-4), the Short Anxiety Health Index (SAHI-5), and the Patient Health Questionnaire (PHQ-2; which assesses depression) are valid when compared to their longer questionnaires counterparts. Considering that psychological factors do appear to be associated with pain and disability in people with hand and upper limb conditions, these short forms may be useful in screening our clients. Open Access URL : https://doi.org/10.1007/s11999-013-3213-2 Abstract Background: The Pain Catastrophizing Scale (PCS) and Short Health Anxiety Inventory (SHAI) can help hand surgeons identify opportunities for psychologic support, but they are time consuming. If easier-to-use tools were available and valid, they might be widely adopted. Questions/purposes: We tested the validity of shorter versions of the PCS and SHAI, the PCS-4 and the SHAI-5, by assessing: (1) the difference in mean scaled scores of the short and long questionnaires; (2) floor and ceiling effects between the short and long questionnaires; (3) correlation between the short questionnaires and the outcome measures (an indication of construct validity); and (4) variability in disability and pain, between the short and long questionnaires. Methods: One hundred sixty-four new or followup adult patients in one hand surgery clinic completed the SHAI-18, SHAI-5, PCS-13, PCS-4, Patient Health Questionnaire (PHQ)-9, PHQ-2, DASH, and QuickDASH questionnaires, and an ordinal pain scale, as part of a prospective cross-sectional study. Mean scores for the short and long questionnaires were compared with paired t-tests. Floor and ceiling effects were calculated. Pearson’s correlation was used to assess the correlation between the short and long questionnaires and with outcome measures. Regression analyses were performed to find predictors of pain and disability. Results: There were small, but significant differences between the mean scores for the DASH and QuickDASH (QuickDASH higher), SHAI-18 and SHAI-5 (SHAI-18 higher), and PCS-13 and PCS-4 (PCS-4 higher), but not the PHQ-9 and PHQ-2. Floor effects ranged between 0% and 65% and ceiling effects between 0% and 3%. There were greater floor effects for the PHQ-2 than for the PHQ-9, but floor and ceiling effects were otherwise comparable for the other short and long questionnaires. All questionnaires showed convergent and divergent validity and criterion validity was shown in multivariable analyses. Conclusions: Content validity, construct convergent validity, and criterion validity were established for the short versions of the PCS and SHAI. Using shorter forms creates small differences in mean values that we believe are unlikely to affect study results and are more efficient and advantageous because of the decreased responder burden. 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

Upper limb position affects pain-free grip strength in individuals with lateral elbow tendinopathy. Cooke, N., Obst, S., Vicenzino, B., Hodges, P. W. and Heales, L. J. (2021) Level of Evidence : 3b Follow recommendation : 👍 👍 (2/4 thumbs up) Type of study : Diagnostic Topic : Tennis elbow - Pain-free grip strength This is a cohort study assessing the effect of elbow and forearm position on pain-free grip (PFG) strength in people with lateral epicondylalgia. Twenty-one participants with tennis elbow were included in the study. Four testing positions, which included elbow flexion/extension in forearm neutral/pronation, were randomly assessed. The results showed that the elbow flexion, forearm neutral position led to the greatest PFG measurement. The other positions showed on average a lower PFG (3 kg lower). These findings were normalised to the contralateral healthy limb and are therefore unlikely to be due to a position effect. 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, pain-free grip (PFG) strength position affects the strength clients can develop. The elbow flexion and forearm neutral position appear to be the most appropriate one. It may also be useful to normalise the PFG to the contralateral grip strength to get an understanding of the relative deficit. If you would like more information on staging and treatment of tendinopathies, have a look at this synopsis . URL : https://doi.org/10.1002/pri.1906 Abstract Background and Purpose: Pain-free grip (PFG) force is commonly used to monitor treatment outcomes in lateral elbow tendinopathy (LET); however, it is unclear whether changes in forearm and elbow position affect PFG force values. This study aims to examine the effect of elbow/shoulder and forearm position on non-normalised and normalised PFG force in individuals with unilateral LET. Methods: A cohort study including 21 subjects with clinically diagnosed unilateral LET (13 females, mean [SD] age 50 [8] years) performed PFG force (symptomatic arm) and maximal grip (asymptomatic arm) tasks using four upper limb positions: (1) shoulder neutral, elbow flexed (90°), forearm pronated; (2) shoulder neutral, elbow flexed (90°), forearm neutral; (3) shoulder flexed (90°), elbow extended, forearm pronated; and (4) shoulder flexed (90°), elbow extended, forearm neutral. PFG force was normalised to the maximal grip of the asymptomatic side. Repeated-measures analyses of variance were used to compare non-normalised and PFG force normalised to maximal grip between positions. Results: Both non-normalised and normalised PFG forces were greater in position 2 than position 1, position 3 and position 4 (elbow-by-forearm interaction non-normalised p = 0.002, normalised p = 0.004). There were no differences between positions 1, 3 and 4 for either non-normalised or normalised PFG strength. Discussion: This study shows that PFG force was higher when performed with forearm neutral supination/pronation, elbow flexion and shoulder neutral than other tested positions, and irrespective of whether PFG force was normalised to the maximal grip force of the contralateral limb. This indicates that arm position should be standardised for comparison. 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

A structured exercise programme combined with proprioceptive neuromuscular facilitation stretching or static stretching in posttraumatic stiffness of the elbow: A randomized controlled trial. Birinci, T., A. Razak Ozdincler, S. Altun and C. Kural (2019) Level of Evidence : 1b Follow recommendation : 👍 👍 👍 👍 (4/4 thumbs up) Type of study : Therapeutic Topic : Post-fracture elbow rehab - Static stretching vs PNF This is a randomised single-blind trial assessing the effectiveness of proprioceptive neuromsucular facilitation (PNF) and static stretching in participants with post-traumatic elbow stiffness following a fracture. Participants (N = 40) were included if they were between 18 and 55, had confirmed fracture healing as per surgeon and imaging review, and had a flexion or extension limitation. Participants were excluded if they had an infection, heterotopic ossification, malunion, or nerve lesions. The effectiveness of each intervention was assessed through the Disability of Arm, Shoulder, and Hand (DASH) questionnaire, elbow range of movement, and several other outcomes, which were not included in this synopsis. The outcomes were measured at baseline, after 6, and 10 weeks. All participants attended two sessions with a physiotherapist each week for 6 weeks. Treatment allocation was randomised. The assessor was blinded to treatment allocation. Participants were provided with either PNF (n = 20) or static stretching (n = 20). The PNF was performed by getting participants to actively resist the stretch for 15 seconds, followed by passive stretching of the joint; this was repeated 10 times with 10 seconds of rest. The static stretching followed a similar routine with a passive stretching held for 20 seconds; this was repeated 10 times with 10 seconds rest. Participants in both groups completed additional exercises, which are available at the following link . Of interest, the PNF and stretching regimes were performed with pain starting from 4/10 and progressed to 7/10. The results showed that both groups improved to a clinically relevant level at 6 weeks on both DASH and elbow range of movement. The between-group difference for the DASH score was not clinically relevant and the improvement in range of movement was similar for both interventions. 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, static stretching or PNF appear to equally improve function and range of movement in those who present with elbow stiffness due to a fracture. It appears important to push these interventions into pain and not shy away from it (starting at 4/10 and gradually building up to a max of 7/10), once the fracture has healed. An alternative to these interventions is graded motor imagery , if elbow pain is very high. It is useful to remember that once the client is able to introduce resistance exercises, eccentric training is useful to improve range of movement . URL : https://doi.org/10.1177/0269215518802886 Abstract OBJECTIVES: To compare the different stretching techniques, proprioceptive neuromuscular facilitation (PNF) stretching and static stretching, in patients with elbow stiffness after a treated elbow fracture. DESIGN: Randomized-controlled, single-blind study. SETTING: Department of physiotherapy and rehabilitation. SUBJECTS: Forty patients with posttraumatic elbow stiffness (24 women; mean age, 41.34 ± 7.57 years). INTERVENTION: PNF stretching group ( n = 20), hold-relax PNF stretching combined with a structured exercise programme (two days per week for six weeks); static stretching group ( n = 20), static stretching combined with a structured exercise programme (two days per week for six weeks). MAIN MEASURES: The primary outcome is the Disabilities of the Arm, Shoulder and Hand (DASH). The secondary outcomes are active range of motion (AROM), visual analogue scale (VAS), Tampa Scale for Kinesiophobia, Short Form-12 and Global Rating of Change. Participants were assessed at baseline, after a six-week intervention period and one-month later (follow-up). RESULTS: After treatment, improvement in the mean DASH score was slightly better in the PNF stretching group (8.66 ± 6.15) compared with the static stretching group (19.25 ± 10.30) ( p = 0.03). The overall group-by-time interaction for the 2 × 3 mixed-model analysis of covariance (ANCOVA) was also significant for elbow flexion AROM (mean change for PNF stretching group; static stretching group; 41.10, 34.42, p = 0.04), VAS-rest (-1.31, -1.08, p = 0.03) and VAS-activity (-3.78, -3.47, p = 0.01) in favour of PNF stretching group. The other outcomes did not differ significantly between the two groups. CONCLUSION: The study demonstrated that the structured exercise programme combined with PNF stretching might be effective in patients with posttraumatic elbow stiffness with regard to improving function, elbow flexion AROM, pain at rest and during activity. 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

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

Revisiting the continuum model of tendon pathology: What is its merit in clinical practice and research? Cook, J. L., E. Rio, C. R. Purdam and S. I. Docking (2016). Level of Evidence : 5 Follow recommendation : 👍 Type of study : Aetiology, Therapeutic Topic : Lateral epicondylalgia - Staging and treatment This is a narrative review on tendinopathy staging and their respective treatments. Although this narrative review is 5 years old, I decided to include it in HandyEvidence as it provides useful information for tendinopathy treatment. Staging of tendinopathies has been suggested as a useful way to treat these conditions and these include: reactive, disrepair, and degenerative stages (see picture below). In terms of treatment, during the reactive stage (acute phase), unloading of the tendon is advised. During disrepair and degenerative stages, graded tendon loading has been suggested as an effective approach. The difference between the disrepair and degenerative stage is simply related to the structural reversibility (disrepair) vs non-reversibility (degenerative) of the tendon structure. From a clinical point of view, the distinction between disrepair and degenerative stage may be less relevant as both stages can be treated with good outcomes. One last comment was made in relation to treatments aiming at improving tendon cell proliferation through injections (e.g. PRP injections). In particular, the rationale for the use of these interventions was questioned due to an already excessive proliferation of cells across all the three tendinopathy stages (reactive, disrepair, and degenerative). 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, tendinopathies can be classified and treated according to their pathological stage. Treatments can vary from unloading (during the reactive stage) to graded loading (during the disrepair or degenerative stage). These concepts can be applied to several conditions such as lateral epicondylalgia (i.e. tennis elbow) or De Quervain tenosynovitis. If we consider for example lateral epicondylalgia, for an acute reactive tendinopathy, we may provide our clients with a counterforce brace, which appears to reduce loading at the common extender tendon during daily activities and improve pain-free grip strength . Once the acute reactive stage has settled and the irritability has improved (reduction in pain intensity and duration of symptoms after mechanical loading), graded loading may be appropriate. During this stage, graded resistance training has been suggested as an effective approach without one form of loading (e.g. eccentric, concentric, isometric) deemed superior to another . It is however possible that for lateral epicondylalgia, eccentric resistance training may provide better analgesia . Open access URL : https://bjsm.bmj.com/content/50/19/1187 Abstract The pathogenesis of tendinopathy and the primary biological change in the tendon that precipitates pathology have generated several pathoaetiological models in the literature. The continuum model of tendon pathology, proposed in 2009, synthesised clinical and laboratory-based research to guide treatment choices for the clinical presentations of tendinopathy. While the continuum has been cited extensively in the literature, its clinical utility has yet to be fully elucidated. The continuum model proposed a model for staging tendinopathy based on the changes and distribution of disorganisation within the tendon. However, classifying tendinopathy based on structure in what is primarily a pain condition has been challenged. The interplay between structure, pain and function is not yet fully understood, which has partly contributed to the complex clinical picture of tendinopathy. Here we revisit and assess the merit of the continuum model in the context of new evidence. We (1) summarise new evidence in tendinopathy research in the context of the continuum, (2) discuss tendon pain and the relevance of a model based on structure and (3) describe relevant clinical elements (pain, function and structure) to begin to build a better understanding of the condition. Our goal is that the continuum model may help guide targeted treatments and improved patient 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