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Agreement between hand therapists and hand surgeons in the management of adults with closed metacarpal fractures. Wong, J., L. Chipchase and A. Gupta (2022) Level of Evidence : 2b Follow recommendation : 👍 👍 (2/4 thumbs up) Type of study : Therapeutic Topic : Metacarpal fractures management - Hand therapists vs surgeons This is a prospective study assessing whether hand therapists and surgeons make similar therapeutic decisions when assessing closed metacarpal fractures. One hand therapist's decision (12 years of experience) was judged against that of a hand surgeon. In addition, the decision of the more experienced hand therapist was compared to that of less experienced hand therapists (5 and 6 years of experience). A total of 90 participants with closed metacarpal fractures, 50% of which included the 5th metacarpal, were assessed independently by the clinicians. The agreement between the experienced hand therapist and surgeon, as well as between experienced hand therapists and less experienced therapists was moderate to good. The main disagreements were identified when there was no clear indication for conservative or surgical management and a trial of conservative management could have been appropriate (see figure 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, hand therapists are able to make independent decisions regarding the need for conservative/surgical management for people with closed metacarpal fractures. If you are interested in metacarpal shaft or 5th metacarpal fractures management, have a look at our previous synopses. If you are interested in hand, wrist, and elbow fractures in general, have a look at the full fractures database . URL : https://doi.org/10.1016/j.msksp.2022.102560 Abstract Background: Hand therapists often work in roles which require an advanced level of experience as Advanced Scope Practitioners (ASP). However, it is not known whether clinical decisions are similar between hand therapists and surgeons when managing simple hand fractures. Objectives: To determine the level of agreement between (i) a hand therapist and five hand surgeons and (ii) three hand therapists, for the management of adults with closed metacarpal fracture(s). Design: A prospective, blinded, crossover inter-rater reliability study. Method: Patient volunteers with closed metacarpal fracture(s) were assessed independently in the first study (n = 90) by a hand therapist and one of five hand surgeons and in the second study (n = 57) by three hand therapists in a randomised order, with each practitioner recording whether the patient participant should be managed conservatively, trialled with conservative or offered surgical treatment. The level of agreement between the hand therapist and hand surgeons was calculated using Cohen's kappa coefficient and between the three hand therapists by calculating Fleiss' Kappa. The observed agreement was also calculated as the proportion of cases for which the assessors had agreement for management. Results: There was good agreement between the hand therapist and surgeons (k = 0.68; 95% CI: 0.537–0.831) and amongst the three hand therapists (k = 0.663; 95% CI: 0.554–0.773) in determining the management of adults with closed metacarpal fracture(s). Conclusions: Hand therapists and surgeons make similar management decision for patients with metacarpal fractures supporting the role of hand therapists as ASP. 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 genetic contribution to carpal tunnel syndrome in women: A twin study. Hakim, A. J., L. Cherkas, S. El Zayat, A. J. MacGregor and T. D. Spector (2002) Level of Evidence : 2b Follow recommendation : 👍 👍 👍 (3/4 thumbs up) Type of study : Aetiologic Topic : Carpal tunnel syndrome - Genetic determinants This retrospective study assessed the contribution of genetic factors on the presence of carpal tunnel syndrome (CTS) in women twins. The study included a total of 4,488 participants who were either monozygotic (sharing 100% of DNA) or dizygotic (sharing 50% of DNA). The presence of CTS was defined as per table 1 below. The results showed that genetic influences contributed to 46% of the probability to develop CTS (See Table 3). It is unclear whether the increased risk associated with genotype is due to structural impairments (e.g. reduced size of the carpal tunnel), pain mechanism, and/or molecular factors. 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 probability of developing CTS in females is largerly dependent on genetic factors. Additional evidence has shown that biomechanical exposure appears to contribute to the development of CTS , albeit, to a lower extent. If you are interested in CTS, you can have a look at several other synopses on the topic . Open Access URL : https://doi.org/10.1002/art.10395 Abstract Objective: To assess the relative genetic and environmental contribution to carpal tunnel syndrome (CTS) using a classic twin study of monozygotic (MZ) and dizygotic (DZ) twins. Methods: The study group comprised unselected female twin pairs, between 20 and 80 years of age, from the St Thomas' UK Adult Twin Registry. Individuals completed a questionnaire that included details on potential risk factors for CTS. The diagnosis of CTS was made using a standardized hand pain diagram and validated criteria. The genetic contribution to CTS was assessed using variance component and regression methods, the heritability was adjusted for environmental confounders. The role of individual risk factors was assessed by a nested case-control study. Results: An overall prevalence of 14.2% for CTS was found in a population of 4,488 females, comprising 867 MZ and 970 DZ twin pairs, and 814 singletons. The concordance for CTS was significantly higher in MZ compared with DZ twins (case-wise concordance values of 0.35 and 0.24 respectively, with a significantly increased MZ:DZ ratio of 1.48; P = 0.03). Modeling produced a heritability estimate of 0.46 (95% CI 0.34–0.58) that was essentially unchanged after adjustment for environmental risk factors including age, body mass index, physical activities, and hormonal/reproductive factors. No major influence of any individual risk factor was seen in the case-control analysis of 520 cases and 3,154 controls, apart from a modest association with menopausal status with an increased risk of 1.53 and 1.43 in the peri and postmenopausal groups. There was no overall effect of age or body mass index. Conclusion: This is the first study to explore the genetic component of CTS. Our data show that up to half of the liability to CTS in women is genetically determined, and this appears to be the single strongest risk factor, with only minor contributions from known environmental factors. Further studies should focus on genetic mechanisms that may lead to tests for susceptibility and detection of those at risk of developing CTS. 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

Selective denervation of the wrist for chronic pain: A systematic literature review Chin, K., Engelsman, A., van Gulik, T., & Strackee, S. (2020) Level of Evidence : 3a Follow recommendation : 👍 👍 (2/4 thumbs up) Type of study : Therapeutic Topic: Wrist denervation for chronic pain – Effect on pain and strength This is a systematic literature review assessing the effectiveness of complete or partial wrist denervation on pain and grip strength in people with chronic wrist pain. Chronic wrist pain was defined as pain lasting for more than 3 months. Wrist pain was associated with a range of conditions including SLAC, SNAC, carpal bone necrosis, OA, CRPS, TFCC injuries, and carpal instabilities. Outcomes were assessed 13 to 146 months post-surgery and included pain (visual analogue scale) and grip strength. Twelve studies were included for a total of 440 participants. The results suggested that there is low-quality evidence showing reductions in pain (36% to 60% reduction) and improvements in grip strength (7% to 64%) following wrist denervation. 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 denervation appears to be useful in reducing symptoms and improving grip strength in a wide variety of conditions associated with persistent pain. If your clients suffer from generalised hand osteoarthritis (OA), they may benefit from a structured resistance training program . Alternatively, in presence of thumb OA, a self-management program may be useful . Also, aerobic exercise appears to have positive effects in people with persistent musculoskeletal pain and you may want to try this before proceeding with more invasive interventions such as surgery. URL : https://journals.sagepub.com/doi/full/10.1177/1753193419886777 Abstract Selective denervation of sensory nerve branches to the wrist is a palliative surgical treatment option for patients with chronic wrist pain when preserving the range of motion and function is preferred. Treatment varies from partial isolated denervation of the posterior interosseous nerve to extensive 'complete' denervations. This study aimed to provide an overview of the literature regarding treatment outcomes in the domains of pain, grip strength, patient satisfaction and return to work. MEDLINE (PubMed), EMBASE and Cochrane databases were systematically searched and identified 993 studies, of which 12 were eligible for analysis. Denervation resulted in high 'return to work' rates (up to 94%), patient satisfaction (up to 92%), increased grip strength (7%-64%) and improved average pain scores (36%-92%). Treatment outcomes of both partial and complete denervations were favourable; however, variations in outcomes suggest the need for improving evidence regarding surgical technique and nerve identification. 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

Adding mobilisation with movement to exercise and advice hastens the improvement in range, pain and function after non-operative cast immobilisation for distal radius fracture: A multicentre, randomised trial Reid, S. A., Andersen, J. M., & Vicenzino, B. (2020) Level of Evidence : 1b- Follow recommendation : 👍 👍 👍 (3/4 thumbs up) Type of study : Therapeutic Topic : Distal radius fracture - Education, exercises, and MWMs This is a two-group randomised trial assessing the added benefit of Mobilisation With Movement (MWM) on range of movement and function after distal radius fractures treated non-surgically. A total of 67 participants took part in the study. After six weeks of cast immobilisation, participants were randomised to either an education, exercise, and MWM group (n = 33), or an education and exercise-only group (n=34). The education involved information on skin care, pain, and swelling management. The exercises involved making a full fist, wrist and elbow flexion and extension, forearm supination and pronation, and shoulder flexion. Two additional MWM exercises were taught to the participants in the experimental group. The first MWM involved the patient holding the affected distal radio-ulnar joint with the healthy hand and providing an antero-posterior glide to the radius while supinating. The second MWM required participants to perform a passive wrist extension mobilisation while a radially directed carpal glide was provided. To achieve this, participants were advised to relax the affected hand on a table and wrap a strap around the wrist, just distally to the ulnar styloid. Once this was achieved, the radial glide was provided by pulling the strap with the healthy hand whilst the trunk moved forward to achieve passive wrist extension. All the exercises were performed six times, twice daily. The MWM exercises had to be performed pain-free. The treatment lasted four weeks. A total of four face-to-face physiotherapy consultations were provided. During these sessions, 1 to 3 sets of 6-10 MWMs were performed. The outcomes measured included supination range of movement and the QuickDASH. The results showed that immediately after the intervention (4 weeks after randomisation) the experimental group presented a larger supination range of movement (difference between groups: 12°; 95%CI: 5° to 20°) and greater function (QuickDASH difference between groups: -11; 95%CI: -18 to -3). Both the MWM group (mean: 18°; SD:±15) and the control group (mean: 8°; SD:±20) improved to a clinically significant level in supination ( MCID = 8° ). Both the MWM group (mean: 31; SD:±17) and the control group (mean: 23; SD:±14) improved to a clinically significant level on the QuickDASH questionnaire ( MCID = 16 points ). 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, self-directed MWMs for wrist supination and extension can improve range of movement and function following a distal radius fracture. In addition, we should encourage our clients to take part in daily activities as this has been shown to increase wrist joint excursion and psychological well-being following a distal radius fracture. This is important because pain catastrophising and depression are associated with pain intensity and disability independently of upper limb fracture severity . URL : https://doi.org/10.1016/j.jphys.2020.03.010 Abstract Question: Does adding mobilisation with movement (MWM) to usual care (ie, exercises plus advice) improve outcomes after immobilisation for a distal radius fracture? Design: A prospective, multicentre, randomised, clinical trial with concealed allocation, blinding and intention-to-treat analysis. Participants Sixty-seven adults (76% female, mean age 60 years) treated with casting after distal radius fracture. Intervention: The control group received exercises and advice. The experimental group received the same exercises and advice, plus supination and wrist extension MWM. Outcome measures: The primary outcome was forearm supination at 4 weeks (immediately post-intervention). Secondary outcomes included wrist extension, flexion, pronation, grip strength, QuickDASH (Disabilities of Arm, Shoulder and Hand), Patient-Rated Wrist Evaluation (PRWE) and global rating of change. Follow-up time points were 4 and 12 weeks, with patient-rated measures at 26 and 52 weeks. Results: Compared with the control group, supination was greater in the experimental group by 12 deg (95% CI 5 to 20) at 4 weeks and 8 deg (95% CI 1 to 15) at 12 weeks. Various secondary outcomes were better in the experimental group at 4 weeks: extension (14 deg, 95% CI 7 to 20), flexion (9 deg, 95% CI 4 to 15), QuickDASH (−11, 95% CI −18 to −3) and PRWE (−13, 95% CI −23 to −4). Benefits were still evident at 12 weeks for supination, extension, flexion and QuickDASH. The experimental group were more likely to rate their global change as ‘improved’ (risk difference 22%, 95% CI 5 to 39). There were no clear benefits in any of the participant-rated measures at 26 and 52 weeks, and no adverse effects. Conclusion: Adding MWM to exercise and advice gives a faster and greater improvement in motion impairments for non-operative management of distal radius fracture. 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

Personal, biomechanical, psychosocial, and organizational risk factors for carpal tunnel syndrome: A structural equation modeling approach Roquelaure, Y., Garlantezec, R., Evanoff, B., Descatha, A., Fassier, J., & Bodin, J. Level of Evidence : 2b Follow recommendation : 👍 👍 👍 Type of study : Aetiologic Topic : Carpal tunnel syndrome - Demographic, biomechanical, psychological, and work pace factors This prospective study assessed the effect of age, gender, BMI, work-related biomechanical exposure, work-related psychological distress, and machine- vs customer-paced jobs on carpal tunnel syndrome (CTS) development. The study included a large sample ( n = 1367) of participants involved in several different occupations. Work-related biomechanical exposure was defined as repetitive or sustained wrist movements for prolonged periods of time, exposure to vibration hand tools, activities involving pinching, and work requiring physical exertion. Work-related psychological distress factors included the inability to make autonomous decisions. Working pace was either set by machine production (machine-paced) or dependent on customer demands (customer-paced). All of the participants were healthy at baseline. At follow up (average 5 years), 3.7% of sample ( n =51) participants presented with symptomatic CTS (pain/paraesthesia in the 2nd and 3rd digit) and of these, 2.3% of sample ( n = 32) presented with signs of CTS (positive on either wrist flexion and compression, carpal compression, Phalen, or Tinel test). The results showed that older age and female gender were risk factors for CTS in this cohort. Biomechanical exposure was the main risk factor leading to CTS. Work-related psychological distress (inability to make autonomous decisions) indirectly increased the risk of CTS by increasing biomechanical exposure. Both biomechanical exposure and psychological distress (inability to make autonomous decisions) were increased when involved in machine-paced jobs. Customer-paced jobs appeared to reduce biomechanical exposure and reduce psychological distress, which reduced the risk of CTS. No direct link was found between psychological distress and CTS development. BMI was not associated with an increased risk of developing CTS. Clinical Take Home Message : Biomechanical exposure appears to be a key risk factor in the development of CTS. Hand therapists might liaise with the workplace supervisor to find strategies to limit extreme wrist position, repetitive motions, use of vibration hand tools, pinching activities, and physical exertion in patients presenting with CTS, or to prevent the development of this condition. Increasing the number of breaks or reducing the work load may be effective strategies. Hand therapists should be aware that workers in a machine-paced job are at higher risk of developing CTS. URL : https://journals.lww.com/pain/Fulltext/2020/04000/Personal,_biomechanical,_psychosocial,_and.11.aspx

Risk factors and outcomes in carpal tunnel syndrome following distal radius open reduction internal fixation. McEntee, R. M., Tulipan, J., & Beredjiklian, P. K. (2022) Level of Evidence : 2b Follow recommendation : 👍 👍 (2/4 thumbs up) Type of study : Prognostic Topic : Distal radius fractures - Carpal tunnel syndrome This is a retrospective study assessing factors associated with greater carpal tunnel syndrome (CTS) incidence following surgery for distal radius fracture (ORIF). A total of 4,487 participants with a distal radius fracture were included. Of these, 1.5% (n = 68) developed CTS six months post-surgery. Carpal tunnel syndrome was diagnosed clinically by the surgeon. A series of factors including age, sex, kidney disease, and psychological characteristics were included in the analyses. The results showed that older age was associated with a greater risk of developing CTS following a distal radius ORIF. The graph below gives you an idea of what the association looks like if somebody is 60 years old, they have 4 times the odds of getting CTS after distal radius fracture compared to a 20 years old. If somebody is 80 years old, they have 9 time the odds of getting CTS compared to a 20 years old, after a distal radius fracture. 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, older people are more likely to develop carpal tunnel syndrome following a distal radius fracture ORIF. Additional factors impairing functional recovery following a distal radius fracture include diabetes and smoking . Extra care should be taken in people presenting with these comorbidities and habits. URL : https://doi.org/10.1016/j.jhsa.2022.03.016 Abstract Purpose: Carpal tunnel syndrome (CTS) is a common complication following the operative repair of distal radius fractures. It is unclear who is at risk of developing this complication in the postoperative period. This study sought to identify risk factors for developing CTS and to evaluate patient-reported outcomes in patients who develop postoperative CTS. Methods: A retrospective review of all distal radius fractures treated surgically at a single private academic center was performed from January 2007 to October 2019. Of the 4,487 patients, 68 were identified to have an ipsilateral carpal tunnel release within 6 months of the distal radius injury. Collected data comprised patient demographics, medical history, and functional outcome scores. Results: Carpal tunnel syndrome was more likely to develop in older patients (62.9 years vs 57.4 years). Sex, body mass index, smoking history, and the type of insurance were not found to be significantly different between the groups. Medical history of kidney disease, psychiatric conditions, and peripheral vascular disease were found to be associated with developing CTS. Patients who developed CTS had higher average Disabilities of the Arm, Shoulder, and Hand scores than patients without CTS (28.1 vs 20.0) at the final follow-up. In a multivariable analysis, patients who developed CTS were found to be older (Odds ratio, 1.03) and less likely to be smokers (Odds ratio, 0.46). Conclusions: In our cohort, we observed that older patients were more likely to require carpal tunnel release following distal radius fracture. In addition, nonsmokers were more likely to require subsequent carpal tunnel release, probably as a result of confounding effects. Special care should be taken to monitor these patients for CTS in the postoperative period following a distal radius open reduction and internal fixation. 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

Surgical excision of a thrombosed persistent median artery in a professional hockey player. Sheridan, J., G. Waslewski and D. Sheridan (2022) Level of Evidence : 5 Follow recommendation : 👍 (1/4 thumbs up) Type of study : Diagnostic/Therapeutic This is the answer to last week's Sherlock Handy. The patient was a 29 years old, right-handed, male professional hockey player presenting with two months insidious onset of pain at the carpal tunnel, which also presented with intermittent median nerve distribution paraesthesia. On objective examination there was no obvious deformity, range of movement was full, and Allen’s test was normal. However, Tinel’s, Phalen’s, and Durkan’s tests were positive. There was also a slight reduction in two-point discrimination at the median compared to the ulnar nerve distribution of the hand. The MRI imaging is shown below. The report identified the presence of a median artery (present in 10% of the population), which was associated with thrombosis. Surgery debrided the thrombosis and removed the median nerve artery after the surgeon had confirmed the evidence of a sufficient vascular supply from the radial and ulnar artery. After surgery, the patient wore a wrist splint for 4 weeks after which a strengthening regime was initiated. They resumed playing hockey at 6 weeks. Several months after surgery, they still presented with minor pain in the wrist, but no paraesthesias in the median nerve distribution. 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, carpal tunnel syndrome is a clinical presentation with several potential causes. An ultrasound investigation may be useful to exclude the presence of space invading lesions or other anatomical variations such as the one described in this article. Imaging to exclude the presence of space invading lesions is often utilised to assess people with cubital tunnel syndrome and may be useful for the assessment of carpal tunnel syndrome too. Furthermore, ultrasound imaging is often required prior to the delivery of a cortisone injection, which has been shown to be quite effective for people with carpal tunnel syndrome . I f you are interested in tests for carpal tunnel syndrome, have a look at this synopsis . URL : https://doi.org/10.1016/j.jhsa.2021.01.002 Abstract A persistent median artery is a rare anatomical variant found in approximately 10% of the population. Carpal tunnel syndrome due to a thrombosed persistent median artery is exceptionally rare. A 29-year-old professional hockey player presented with a 2 months history of hand pain and intermittent paresthesias without vascular symptoms. Magnetic resonance imaging and angiography demonstrated a 2-cm thrombosis in a persistent median artery at the level of the carpal tunnel, with otherwise normal vascular anatomy. He was treated with surgical excision of the thrombus and carpal tunnel decompression. The patient's symptoms resolved rapidly and he was able to return to sport without restrictions. Incidental imaging performed several months after surgery demonstrated a normal vascular pattern in the treated hand. 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

Arm sling after carpal tunnel surgery: Myth or evidence based? Kroeze, M., Rakhorst, H., & Houpt, P. (2020) Level of Evidence : 2c Follow recommendation : 👍 👍 (2/4 thumbs up) Type of study : Therapeutic Topic : Carpal tunnel release post-surgical care - sling vs no sling This is a quasi-experimental study (no randomisation) assessing the effect of an arm sling for elevation vs no sling use following carpal tunnel (CT) release surgery on swelling, full fist range of movement, pain, and function. All patients underwent an open CT release and the sling group was advised to wear it for 3-4 days while the no sling group kept their hands in their preferred position. The results showed no difference between groups on swelling, full fist range of movement, or pain 3-4 days post-surgery. At six weeks there was no difference in function when measured through the Boston Carpal Tunnel Questionnaire. 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, there is no need to wear an arm sling following carpal tunnel release. Arm slings do not appear to provide benefits in terms of swelling, range of movement, pain, or function in this group of patients. If you would like to have a look at the full collection of synopses on carpal tunnel syndrome, you can find it here . URL : https://doi.org/10.1177%2F1753193419880312 Abstract Arm sling elevation is widely used after hand surgery to prevent swelling and pain. This prospective cohort study investigated whether arm sling elevation has any value after carpal tunnel release surgery. Patients were assigned to one of two groups after carpal tunnel release: with or without arm sling elevation. The primary outcome was postoperative swelling. Secondary outcomes were pain and symptom relief and functional outcome. Volumetric analysis showed no significant difference between the sling and non-sling group. Pain scores and improvement of symptom severity and functional status scores were similar for both groups. Thirty-eight per cent found the sling uncomfortable. These results do not support routine use of arm sling elevation after carpal tunnel release. 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

Stress, non-restorative sleep, and physical inactivity as risk factors for chronic pain in young adults: A cohort study. Lindell, M. and A. Grimby-Ekman (2022) Level of Evidence : 2b Follow recommendation : 👍 👍 (2/4 thumbs up) Type of study : Prognostic Topic : Persistent pain risk factors - Young adults This is a longitudinal study assessing the association between risk factors and the development of persistent pain in young adults. A total of 1,759 participants without pain at baseline were included. Participants’ age ranged from 19 to 25. Participants filled out a series of questionnaires which included self-reports of stress, sleep quality, and weekly physical activity. People were defined as stressed if they reported this feeling for more than seven consecutive days in a row. Disturbed sleep was defined as consistently waking up not feeling rested for more than two times a week. Participants who did not take part in any physical activity in the week prior to baseline assessment were defined as inactive. At one and four years follow up, researchers asked participants whether they presented with persistent pain (more than 90 days per year). The results showed that people who were stressed, had non-restorative sleep, and were inactive were more likely to have persistent pain at one year. In particular, stress in the past year increased the odds of presenting with persistent pain by 60%, bad sleep twice weekly/everyday increased the odds by 50%, and those people who participated in no physical activity had 80% increased odds. At four years follow up, only stress was associated with persistent pain (90% increase in odds). 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, young adults who are stressed, don’t get good sleep, and are physically inactive, have a greater chance of presenting with persistent pain at one year (including upper limb persistent pain). This study adds to the growing amount of evidence suggesting that factors other than biomechanics contribute to the development of persistent pain. This does not mean that biomechanics are not important, but that they play a smaller role in the development of persistent pain compared to what clinicians and researchers used to believe. Open Access URL : https://doi.org/10.1371/journal.pone.0262601 Abstract Background: Chronic pain is a common condition which causes patients much suffering and is very costly to society. Factors known to be associated with chronic pain include female gender, acute pain, depression, and anxiety. This study investigated whether stress, sleep disturbance, and physical inactivity were risk factors for developing chronic pain among young adults, and whether there were any interactions between these. Methods: This retrospective longitudinal study was based on an existing database from a cohort study on IT use and health, called Health 24 Years. A questionnaire was sent to students aged 19–24 in Sweden for five consecutive years, containing questions on pain, stress, sleep, physical activity, technology use, health, and more. In logistic regressions, stress, sleep, and physical activity at baseline were potential predictors of chronic pain one and four years later. In addition, a new variable including all possible interactions between potential predictors was created to test for effect modification between risk factors. Results: At the one-year follow-up, stress, non-restorative sleep, and physical inactivity showed odds ratios of 1.6 (95% CI: 1.0–2.4), 1.5 (95% CI: 1.0–2.3), and 1.8 (95% CI: 1.1–3.0) respectively after adjusting for confounders, the reference being non-stressed, having restorative sleep and being active. At the four-year follow-up, stress showed an adjusted odds ratio of 1.9 (95% CI: 1.3–2.9), while non-restorative sleep and physical inactivity were statistically insignificant. At the one-year follow-up, the interaction between risk factors were significant. The most clear example of this effect modification was to be inactive and not have -restorative sleep, compared to individuals who were active and had restorative sleep, showing an adjusted odds ratio of 6.9 (95% CI: 2.5–19.2) for developing chronic pain one year after baseline. This in comparison of odds ratios for only inactive respectively only non-restorative sleep being 1.7 (95% CI: 0.6–5.3) respectively 1.6 (95% CI: 0.7–3.5). Conclusions: Stress, non-restorative sleep, and physical inactivity were risk factors for developing chronic pain one year after baseline, and stress were also a risk factor four years after baseline. These findings suggest that non-restorative sleep and inactivity are risk factors in the short term while stress is a risk factor in both the short and the long term. In addition to the independent effects of non-restorative sleep and inactivity, their combination seems to further increase the odds of chronic pain. 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

Boxer's elbow: Internal impingement of the coronoid and olecranon process. A report of seven cases. Robinson, P. M., Loosemore, & M., Watts, A. C. (2017) Level of Evidence : 5 Follow recommendation : 👍 (1/4 thumb up) Type of study : Diagnostic/Therapeutic Topic : Boxer's elbow - Locking This is a case series describing Boxer's elbow syndrome, which is characterised by anterior or posterior elbow pain. The onset of this syndrome is characterised by hyperextension or hyperflexion injuries that occur when missing a punch or pushing off the opponent following a clinch. Mechanical impingement is produced by olecranon vs posterior fossa or coronoid process vs anterior fossa. Objectively, patients present with pain on palpation of the postero-lateral joint line, swelling, pain with full elbow flexion or extension, but with symptomless pronation-supination. X-ray imaging to exclude loose bodies may be required if patients report locking. This investigation will detect, if present, osteophytes, which can be responsible for objective limitations in extension or flexion. Conservative treatment may be appropriate, however, if symptoms do not resolve and locking is present, referral to an orthopaedic surgeon is required. 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, Boxer's elbow is characterised by anterior or posterior elbow pain following a hyperflexion or hyperextension injury respectively. Despite its name, gymnasts and weightlifters can present with the same syndrome. Imaging may be required to exclude the presence of osteophytes and/or loose bodies. Referring to an orthopaedic surgeon is appropriate if there are no improvements with conservative treatment or if the elbow is locking, which is suggestive of loose bodies. If we encounter a similar presentation in kids, we should exclude other conditions such as osteochondritis dissecans . URL : https://doi.org/10.1016/j.jse.2016.09.035 Abstract Background: Boxer's elbow has been described in the literature as an extension and hyperextension injury. However, in our experience, there is a coexisting impingement lesion in the anterior compartment of the elbow that has not previously been described. We report a series of professional boxers with elbow disease treated arthroscopically. The aim of the paper was to accurately describe the pathoanatomy of the condition, the key points in its diagnosis, and the outcomes of surgical treatment. Methods: Seven professional boxers were treated for symptomatic elbow disease. Clinical evaluation included range of motion and Disabilities of the Arm, Shoulder, and Hand score. The arthroscopic findings and procedures were documented. Results: Symptoms were mainly those of anterior and posterior impingement; 6 elbows had an anterior impingement lesion and 6 had a posterior impingement lesion. Postoperatively, the mean Disabilities of the Arm, Shoulder, and Hand score was 2.7 (range, 0-13.3) at a median of 15 (range, 6-36) months postoperatively. All boxers returned to their previous level of competition and 5 won their next bout. All of the boxers used an orthodox stance, and in all but 1 case the left elbow was the pathologic elbow. Conclusion: Boxers are prone to development of anterior and posterior elbow impingement. The side of the pathologic process is related to the boxer's stance, with the lead arm being more vulnerable. Arthroscopic débridement is an effective treatment, enabling return to a high competitive level. Surgeons, sports medicine physicians, and physiotherapists should be aware of the condition. 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

Level of Evidence : 5 Follow recommendation : 👍 (1/4 thumbs up) Type of study : Diagnostic/Therapeutic Have a think about this case study. Leave a diagnostic comment if you like. The patient was a 29 years old, right-handed, male professional hockey player presenting with two months insidious onset of pain at the carpal tunnel, which also presented with intermittent median nerve distribution paraesthesia. On objective examination there was no obvious deformity, range of movement was full, and Allen’s test was normal. However, Tinel’s, Phalen’s, and Durkan’s tests were positive. There was also a slight reduction in two-point discrimination at the median compared to the ulnar nerve distribution of the hand. The MRI imaging is reported below. What is it?

Effectiveness of the graded motor imagery to improve hand function in patients with distal radius fracture: A randomized controlled trial. Dilek, B., Ayhan, C., Yagci, G., & Yakut, Y. (2018) Level of Evidence : 2b Follow recommendation : 👍 👍 👍 (3/4 thumbs up) Type of study : Therapeutic Topic : Radius fracture - graded motor imagery This is a randomised single-blind controlled trial assessing the effectiveness of Graded Motor Imagery (GMI) and traditional rehabilitation in participants with distal radius fracture. Participants (N = 36) were included if they had undergone a closed fracture reduction or an open reduction internal fixation surgery. Participants were excluded if they had bilateral fracture or had any neurological/rheumatological condition. Effectiveness of each intervention was assessed through pain at rest (VAS), range of movement (degrees of wrist movement), and function (DASH). The outcomes were measured at baseline and after 8 weeks of treatment. All participants attended two session (1 hour each) with a physiotherapist each week for 8 weeks. Participants in every group received a home exercise program. Treatment allocation was randomised. The assessor was blind to treatment allocation. Participants were provided with either GMI (n = 17) or traditional rehabilitation (n = 19). Participants in the GMI completled 3 weeks of left/right hand discrimination (10 minutes each waking hour). This was followed by 3 weeks of explicit motor imagery in which participants had to look at a hand picture and imagining moving their own hand (10 minutes each waking hour). The last phase of the GMI (2 weeks) involved mirror therapy (10 minutes each waking hour). The traditional rehabilitation group included a gradual AROM home exercise program which was then progressed into resistance exercises towards the end of the intervention program. There were no differences between groups in the number of participant that undervent a conservative or surgical intervention for their fracture. All the participants reported high adherence to the physiotherapy intervention (100%) and home exercise program (90-100%), although the latter was self-reported. The results showed that GMI improved pain at rest (GMI - Mean difference: 2.2, SD: 2.1; Control - Mean difference: 1,1, SD: 1.2) and function (GMI - Mean difference: 38, SD: 14.3; Control - Mean difference: 27, SD: 17) to a statistically and clinically significant level compared to the traditional rehabilitation group. From a practical poin of view, these results suggest that there is an average improvement in pain at rest of 2 points out of 10 with GMI (clinically significant change) and 1 point out of 10 with traditional physiotherapy (non clinically significant change). For function, there is an improvement of 38 points on the DASH with GMI and 27 points with traditional physiotherapy (both clinically significant changes). Contrasting results were reported in text and in the tables for range of movement. It is therefore not possible to comment on these findings with certainty. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message : Hand therapists may choose GMI training if the main goal of rehabilitation is to reduce pain and improve function. This may be particularly appropriate in patients presenting with high levels of pain within the first week of injury (these patients are also more likely to develop CRPS ). It is unclear whether GMI can lead to improvements in range of movement. Open Access URL : https://doi.org/10.1016/j.jht.2017.09.004 Abstract Background: Physiotherapy improves the movement range after the onset of post-traumatic elbow stiffness and reduces the pain, which is a factor limiting elbow range of motion. However, no results have been reported for motor-cognitive intervention programs in post-traumatic elbow stiffness management. The objective was to investigate the efficacy of Graded Motor Imagery (GMI) in post-traumatic elbow stiffness. Methods: Fifty patients with post-traumatic elbow stiffness (18 female; mean age, 41.9±10.9 years) were divided into two groups. The GMI group (n=25) received a program consisting of left/right discrimination, motor imagery, and mirror therapy (twice a week for six weeks); the structured exercise (SE) group (n=25) received a program consisting of the range of motion, stretching, and strengthening exercises (twice a week for six weeks). Both groups received a 6-week home exercise program. The primary outcome was the Disabilities of the Arm, Shoulder and Hand (DASH). The secondary outcomes were the active range of motion (AROM), Visual Analogue Scale (VAS), Tampa Scale for Kinesiophobia (TSK), muscle strength of elbow flexors and extensors, grip strength, left/right discrimination, and Global Rating of Change. Patients were assessed at baseline, at the end of treatment (12 sessions), and a 6-week follow-up. Results: The results indicated that both GMl and SE interventions significantly improved outcomes (p<0.05). After a 6-week intervention, the DASH score was significantly improved with a medium effect size in the GMI group compared to the SE group and improvement continued at the 6-week follow-up (F1,45=3.10, p=0.01). The results with a medium to large effect size were also significant for elbow flexion AROM (p=0.02), elbow extension AROM (p=0.03), VAS-activity (p=0.001), TSK (p=0.01), muscle strength of elbow flexors and elbow extensors (p=0.03) in favor of GMI group. Conclusion: The GMI is an effective motor-cognitive intervention program that might be applied to the rehabilitation of post-traumatic elbow stiffness to improve function, elbow AROM, pain, fear of movement-related pain, and muscle strength. 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