Search Results

Clinical management of tendinopathy: A systematic review of systematic reviews evaluating the effectiveness of tendinopathy treatments. Irby, A., Gutierrez, J., Chamberlin, C., Thomas, S. J., & Rosen, A. B. (2020) Level of Evidence : 1a Follow recommendation : 👍 👍 👍 👍 Type of study : Therapeutic Topic : Tendinopathies – Conservative and surgical interventions This is a systematic review of systematic reviews assessing the effectiveness of conservative and surgical treatments for symptomatic tendinopathies irrespective of location. Twenty-five systematic reviews (Total of 228 RCTs) were included for a total of 15,000 participants. All the systematic reviews included randomised controlled trials (RCT) only. No systematic reviews on pharmacological intervention (e.g. NSAIDs) were included. All the systematic reviews included were assessed through the Assessment of Multiple Systematic Reviews (AMSTAR), which is scored on a scale from 0 to 11 (higher scores reflect higher study quality). Efficacy of intervention was assessed through changes in pain. The visual analogue scale (VAS) was the most common pain outcome recorded (n=22). The average quality score of the reviews was 9 (SD:1), suggesting that more than 50% of the studies were of high quality. Most of the reviews focused on Achilles and patella tendinopathy (n=23) followed by lateral elbow tendinopathy (n=11) and rotator cuff tendinopathy (n=10) (some of the studies included more than one tendinopathy type). Exercise was the only intervention that was shown to consistently reduce pain in tendinopathy. Heavy eccentric exercises appeared to be particularly effective in reducing pain. Low level laser therapy and extracorporeal shock wave therapy showed some effectiveness in the treatment of symptomatic tendinopathies. Injections, needling, and surgery provided mix results for the treatment of tendinopathies. 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, exercise is an important aspect of tendinopathy treatment. Findings across different body sites consistently suggest that "heavy eccentric exercises" are helpful in reducing pain. It is however not clear what "heavy eccentric exercises" represent in terms of exercise intensity. By considering other research in the field of upper limb tendinopathy, a graded approach to resistance training may be the most appropriate, with eccentric exercises providing potential greater analgesia in lateral epicondylalgia . It is important to remember that resistance training for tendinopathy may be most effective in the sub-acute or chronic phase (disrepair and degenerative stage), while reduction in tendon loading (e.g. rest) may be most suitable for an acute reactive tendinopathy (look at synopsis on staging and treatment of tendinopathies ). Open Access URL : https://onlinelibrary.wiley.com/doi/epdf/10.1111/sms.13734 Abstract While the pathoetiology is disputed, a wide array of treatments are available to treat tendinopathy. The most common treatments found in the literature include therapeutic modalities, exercise protocols, and surgical interventions, however their effectiveness remains ambiguous. The purpose of this study was to perform a systematic review of systematic reviews to determine the ability of therapeutic interventions to improve pain and dysfunction in patients with tendinopathy regardless of type or location. Five databases were searched for systematic reviews containing only randomized control trials to determine the effectiveness of treatments for tendinopathies based on pain and patient-reported outcomes. Systematic reviews were assessed via the Assessment of Multiple Systematic Reviews (AMSTAR) for methodological quality. From the database search, 3,295 articles were found, 107 passed the initial inclusion criteria. After further review, 25 systematic reviews were included in the final qualitative analysis. The AMSTAR scores were relatively high (8.8±1.0) across the 25 systematic reviews. Eccentric exercises were the most common and consistently effective treatment for tendinopathy across systematic reviews. Low-level laser therapy and extracorporeal shockwave therapy demonstrated moderate effectiveness, while platelet-rich plasma injections demonstrated inconclusive evidence on their ability to decrease tendinopathy related pain and improve function. Corticosteroids also showed some effectiveness for short-term pain, but for the long-term use deemed ineffective and at times contraindicated. Regarding surgical options, minimally invasive procedures were more effective compared to open surgical interventions. When treating tendinopathy regardless of location, eccentric exercises were the best treatment option to improve tendinopathy related pain and improve self-reported function. 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 qualitative systematic review of effects of provider characteristics and nonverbal behavior on pain, and placebo and nocebo effects. Daniali, H., & Flaten, M. A. (2019) Level of Evidence : 1a- Follow recommendation : 👍👍👍👍 Type of study : Therapeutic Topic : Smiling - Placebo and nocebo This is a systematic review on the effect on non-verbal interactions on placebo and nocebo. Placebo, a positive effect (e.g. pain reduction), and nocebo, a negative effect (e.g. increase in pain), are the result of treatment expectations. Fourteen experimental studies were included for a total of 1,778 participants. Non-verbal interactions were divided in positive and negative. Positive non-verbal interactions included smiling, nodding, making eye contact, and a warm and friendly voice. Negative non-verbal interactions included a flat and cold tone of voice, frowning, and looking away. The findings showed that negative non-verbal interactions led to a reduced placebo effect, or a nocebo effect, resulting in lower pain tolerance, and higher pain. In contrast, positive non verbal interactions (e.g. smiling) led to a boost in the placebo effect leading to a better emotional and physical state of the patients, lower pain, and a reduction in opioid medications use. Clinical Take Home Message : A positive non-verbal attitude of a hand therapist can enhance the effect of the treatment provided. Smiling, making eye contact, and nodding may improve our clinician-client relationship and lead to reduction in pain, enhanced emotional well-being, and a reduction in pain medications consumption. This synopsis is a nice adjunct to the one written about the effect of an empathetic attitude of clinicians and its effect on endogenous analgesia. Open Access URL : https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6476260/pdf/fpsyt-10-00242.pdf Abstract Background Previous research has indicated that the sex, status, and nonverbal behaviors of experimenters or clinicians can contribute to reported pain, and placebo and nocebo effects in patients or research participants. However, no systematic review has been published. Objective: The aim of this study was to investigate the effects of experimenter/clinician characteristics and nonverbal behavior on pain, placebo, and nocebo effects. Methods Using EmBase, Web of Knowledge, and PubMed databases, several literature searches were conducted to find studies that investigated the effects of the experimenter’s/ clinician’s sex, status, and nonverbal behaviors on pain, placebo, and nocebo effects. Results Thirty-four studies were included, 20 on the effects of characteristics of the experimenter/clinician, 11 on the role of nonverbal behaviors, and 3 on the effects of both nonverbal behaviors and characteristics of experimenters/clinicians on pain and placebo/nocebo effects. There was a tendency for experimenters/clinicians to induce lower pain report in participants of the opposite sex. Furthermore, higher confidence, competence, and professionalism of experimenters/clinicians resulted in lower pain report and higher placebo effects, whereas lower status of experimenters/clinicians such as lower confidence, competence, and professionalism generated higher reported pain and lower placebo effects. Positive nonverbal behaviors (e.g., smiling, strong tone of voice, more eye contact, more leaning toward the patient/participant, and more body gestures) contributed to lower reported pain and higher placebo effects, whereas negative nonverbal behaviors (i.e., no smile, monotonous tone of voice, no eye contact, leaning backward from the participant/patient, and no body gestures) contributed to higher reported pain and nocebo effects. Conclusion Characteristics and nonverbal behaviors of experimenters/clinicians contribute to the elicitation and modulation of pain, placebo, and nocebo effects. 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

There is more to pain than tissue damage: Eight principles to guide care of acute non-traumatic pain in sport. Caneiro, J. P., Alaiti, R. K., Fukusawa, L., Hespanhol, L., Brukner, P., & Sullivan, P. P. B. (2020) Level of Evidence : 5 Follow recommendation : 👍 👍 👍 Type of study : Therapeutic Topic : Acute non-traumatic pain – Biopsychosocial approach This is an editorial from the British Journal of Sports Medicine. Eight points on how to better manage acute non-traumatic pain presentations were made. The first one suggested to move away from the assumption that pain is due to tissue trauma. Specifically, it was suggested to avoid wording that implies trauma for non-traumatic cases (e.g. overuse syndrome, microtrauma). Instead we could call it pain associated with a specific activity (e.g. sport-related pain, work related pain). Imaging was also advised against, especially if there are no red flags or if it does not guide treatment. The third advice was to consider biopsychosocial factors such as fatigue, poor sleep, mental health, and pain believes as contributing factors to pain. The importance of providing positive messages was also indicated. Messages suggesting that the body is strong and discussions around tissue sensitivity rather than microtrauma/overuse were encouraged. The fifth point suggested a gradual increase in tissue loading. The sixth point advised against utilising passive modalities as a first line approach. Empowering the client by involving them in our decision making was the seventh point. The eight and last point advised to deliver a consistent message (across different health professionals) regarding the lack of trauma (e.g. overuse, microtrauma) in non-traumatic pain presentations. Clinical Take Home Message : Based on what we know today, we should probably stop talking to our clients about overuse syndromes, repetitive strain injuries, and microtrauma, when no evident trauma is present. We should instead frame it as pain associated with the activity that is exacerbating their symptoms and explain that a recent change in activity levels, stress, lack of sleep, and fatigue may be contributing to an increased sensitivity of their tissue. These explanations are evidence-informed and may help our clients making sense of their non-traumatic pain. URL : https://bjsm.bmj.com/content/early/2020/09/08/bjsports-2019-101705 You can ask the authors for the full text through ResearchGate . May be available through EBSCO Health Databases for PNZ members - you may need to wait a few weeks to get access to this article. Abstract Are you careful with how you label an athlete’s pain? Musculoskeletal pain in athletes is common, but not always associated with injury (ie, tissue damage). Damage occurs when load exceeds tissue tolerance, such as ligament tear or a fracture. However, pain in athletes that occurs in the absence of trauma and tissue damage is still often labelled an ‘injury’ by clinicians, coaches and athletes themselves. This highlights a gap between knowledge (tissue damage is not necessary for pain) and practice (assuming that all pain arises from tissue damage) in our clinical community. This applies particularly in the area of acute non-traumatic pain (such as back and joint pain). To help bridge this gap, we outline eight principles to guide clinicians who manage musculoskeletal pain in sport (see infographic in figure 1). 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 short-term impact of combining pain neuroscience education with exercise for chronic musculoskeletal pain: A systematic review and meta-analysis. Siddall, B., et al. (2021) Level of Evidence : 1a Follow recommendation : 👍 👍 👍 👍 Type of study : Therapeutic Topic : Persistent pain - pain education This is a systematic review and meta-analysis on the effect of pain education plus exercise vs exercise only in participants with persistent musculoskeletal pain. Five RCTs were included in the systematic review, for a total of 460 participants. Participants included presented with a wide range of spinal musculoskeletal pain, which extended beyond 3 months. All the studies were included in the meta-analysis and they were assessed through the PEDro scale. The overall strength of evidence was assessed through the GRADE approach ("low", "very low", "moderate", "high"), which has also been suggested by the Cochrane group for systematic reviews. Pain neuroscience education plus exercise was compared to exercise alone. Pain neuroscience education was largely based on the "Explain pain" book by Butler and Moseley (4/5 studies). The total education time varied from 5 to 120 minutes. The exercises varied significantly across studies and included aquatic exercises, aerobic and/or strength training, or stretching exercises. Efficacy of intervention was assessed through pain intensity (0 to 10) and pain catastrophising. Intervention duration ranged between 6 and 12 weeks, with a maximum training frequency of 7 and a minimum of 2 times per week. The assessment time points ranged from 6 to 12 weeks. There was low quality evidence suggesting that the addition of pain neuroscience education provided a clinically and statistically significant improvement in pain intensity (average change of 2 points out of ten; 95%CI: 1 to 3.4 points). Furthermore, pain catastrophising reduced to a clinically and statistically significant level (8 points out of 52; 95%CI: 3 to 12 points) with the addition of pain education to exercises. 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 neuroscience education can provide a clinically significant boost to your exercises. Currently, I am not aware of similar studies in hand therapy but it is likely that pain neuroscience education could have a similar effect four our clients with persistent pain. Remember to keep your educational sessions simple and that they have a real neurophysiology basis to their effectiveness . If you are interested in additional information on the effectiveness of pain education on persistent pain, have a look at this synopsis . You may also want to rethink the use of some terms such as "overuse injury", which probably needs updating . URL : https://doi.org/10.1097/j.pain.0000000000002308 Available through EBSCO Health Databases for PNZ members. Abstract Exercise and pain neuroscience education (PNE) have both been used as standalone treatments for chronic musculoskeletal pain. The evidence supporting PNE as an adjunct to exercise therapy is growing but remains unclear. The aim of this systematic review and meta-analysis was to evaluate the effect of combining PNE and exercise for patients with chronic musculoskeletal pain, when compared to exercise alone. A systematic search of electronic databases was conducted from inception to November 6, 2020. A quality effects model was used to meta-analyze outcomes where possible. Five high quality randomized controlled studies (n=460) were included in this review. The PEDro scale was used to assess the quality of individual studies and GRADE analysis was conducted to determine the quality of evidence for each outcome. Meta-analyses were performed for pain intensity, disability, kinesiophobia and pain catastrophizing using data reported between 0 and 12 weeks post-intervention. Long-term outcomes (>12 weeks) were only available for two studies and therefore were not suitable for meta-analysis. Meta-analysis revealed a significant difference in pain (WMD, -2.09/10; 95% CI, -3.38 to -0.80; low certainty), disability (SMD, -0.68; 95% CI, -1.17 to -0.20; low certainty), kinesiophobia (SMD, -1.20; CI, -1.84 to -0.57; moderate certainty) and pain catastrophizing (WMD, -7.72; 95% CI, -12.26 to -3.18; very low certainty) that favoured the combination of PNE and exercise. These findings suggest that combining PNE and exercise in the management of chronic musculoskeletal pain results in greater short-term improvements in pain, disability, kinesiophobia and pain catastrophizing relative to exercise alone. publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings

Recovery trajectories in common musculoskeletal complaints by diagnosis contra prognostic phenotypes. Aasdahl, L., et al. (2021) Level of Evidence : 2c Follow recommendation : 👍 👍 👍 Type of study : Prognostic Topic : Pain phenotype – Recovery at one year This is a prospective study assessing the association between different musculoskeletal pain phenotypes (presentations) and recovery at one year. A total of 86 participants completed the study. Participants' average age was 45. Participants with a wide variety of musculoskeletal conditions including shoulder and neck pain were included. Pain phenotypes were classified into 5 different classes (Phenotype 1 to 5) according to pain intensity, frequency, number of painful sites, duration of pain, frequency of pain, sleep and functional impairments, recovery expectations, self-efficacy, fear avoidance, and work disability. Participants in phenotype 1 to 2 reported low levels of pain, limited psychological distress, low disability, and positive thoughts about their recovery. Participants in phenotype 5 presented with greater levels of pain, significant psychological distress, high disability, and negative thoughts about their recovery (See picture below). Recovery was defined as a level of pain below 3 point out of 10, or a level of function on the patient specific functional scale (PSFS) of at least 8 out 10 (greater scores representing better function). The results showed that at one year, recovery was homogeneous across different musculoskelatal conditions presenting the same phenotype. However, different pain phenotypes were associated with different levels of recovery. Of the participants with Phenotype 1 to 3, seventy percent had recovered at one year. Of those with Phenotype 4 to 5, thirty percent had recovered at one year. Clinical Take Home Message : Based on what we know today, the recovery of our clients with upper limb musculoskeletal conditions strongly depends on their pain levels, mental health, and believes that they have regarding their recovery. A person-centered model rather than a biomedical approach (e.g. diagnosis based) may be more useful in providing a recovery probability for our clients with musculoskeletal hand conditions. More specifically, people with low levels of pain and very limited psychological distress have 70% chance of recovery (pain below 3/10) at one year. Clients with higher levels of pain and/or high psychological distress have less than 30% change of recovery at one year. This research is in line with previous papers suggesting that fear of movement , depression , and psychosocial factors have an important role in mediating disability and recovery. Open Access URL : https://doi.org/10.1186/s12891-021-04332-3 Abstract Background: There are large variations in symptoms and prognostic factors among patients sharing the same musculoskeletal (MSK) diagnosis, making traditional diagnostic labelling not very helpful in informing treatment or prognosis. Recently, we identified five MSK phenotypes across common MSK pain locations through latent class analysis (LCA). The aim of this study was to explore the one-year recovery trajectories for pain and functional limitations in the phenotypes and describe these in relation to the course of traditional diagnostic MSK groups. Methods: We conducted a longitudinal observational study of 147 patients with neck, back, shoulder or complex pain in primary health care physiotherapy. Data on pain intensity and function were collected at baseline (week 0) and 1, 2, 3, 4, 6, 8, 12, 26 and 52 weeks of follow up using web-based questionnaires and mobile text messages. Recovery trajectories were described separately for the traditional diagnostic MSK groups based on pain location and the same patients categorized in phenotype groups based on prognostic factors shared among the MSK diagnostic groups. Results: There was a general improvement in function throughout the year of follow-up for the MSK groups, while there was a more modest decrease for pain intensity. The MSK diagnoses were dispersed across all five phenotypes, where the phenotypes showed clearly different trajectories for recovery and course of symptoms over 12 months follow-up. This variation was not captured by the single trajectory for site specific MSK diagnoses. Conclusion: Prognostic subgrouping revealed more diverse patterns in pain and function recovery over 1 year than observed in the same patients classified by traditional diagnostic groups and may better reflect the diversity in recovery of common MSK disorders. 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 effect of manual therapy to the thoracic spine on pain-free grip and sympathetic activity in patients with lateral epicondylalgia humeri Zunke, P., Auffarth, A., Hitzl, W., & Moursy, M. (2020) Level of Evidence : 1b Follow recommendation : 👍 👍 Type of study : Therapeutic Topic : Lateral epicondylalgia - Thoracic spine manual therapy This is a randomised placebo controlled trial assessing the acute effect of one session of thoracic mobilisations on pain-free grip strength and sympathetic nervous system activation in participants with lateral epicondilalgia (LE). Participants (N = 30) were diagnosed with LE if they presented with pain on either gripping, resisted contraction of the wrist extensors, or pain at the lateral epicondyle during palpation. If the clinical picture suggested the presence of any other pathology (e.g. cervical radiculopathy, posterolateral instability of the elbow), participants were excluded. Participants' pain-free grip strength was assessed immediately before and after the intervention on the pathological and on the healthy side. Sympathetic nervous system activation was measured through finger skin conductance and skin temperature tests. Greater skin conductance (due to sweating) and lower skin temperature (due to vasoconstriction) suggest a greater activation of the sympathetic nervous system. Adverse events were recorded. Participants were randomised to either a thoracic mobilisation or sham ultrasound. For the experimental group (n = 15), a grade III thoracic mobilisation of T5 was delivered for 2 minutes and was directed in a postero-anterior direction with the participant in prone. The placebo group (n= 15) received 2 minutes of sham ultrasound at the T5 level in prone. The results showed that the thoracic mobilisation group improved in pain-free grip strength on the affected side by 25% (95%CI: 10%-40% - 4.4 kg improvement). This improvement was statistically significant and borderline clinically relevant (an absolute improvement of 5 kg in grip strength and 20% improvement from baseline in grip strength would be defined clinically significant). In the placebo group, no statistically significant improvement in pain-free grip strength of the affected side was detected. There were no differences between the two groups in grip strength. Sympathetic nervous system activity was statistically significantly greater after the thoracic mobilisation compared to the placebo intervention. No adverse events were reported. 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, thoracic mobilisations in patients with lateral epicondilalgia may provide acute pain-free grip strength improvements. However, there were quite a few limitations in this study and there is limited previous evidence to support these findings. It is possible that thoracic mobilisations, have, if any, a non-specific effect on pain through a neurophysiological effect. Currently, the mainstream interventions for tennis elbow has been suggested to be reduced loading in the acute phase (reactive tendinopathy phase) followed by gradual loading . Cortisone injections are advised against , PRP injections do not appear to be more effective than saline , and MWMs do not appear to be more effective than placebo . Open Access URL : https://doi.org/10.1186/s12891-020-3175-y Abstract Background: The treatment of first choice for lateral epicondylalgia humeri is conservative therapy. Recent findings indicate that spinal manual therapy is effective in the treatment of lateral epicondylalgia. We hypothesized that thoracic spinal mobilization in patients with epicondylalgia would have a positive short-term effect on pain and sympathetic activity. Methods: Thirty patients (all analyzed) with clinically diagnosed (physical examination) lateral epicondylalgia were enrolled in this randomized, sample size planned, placebo-controlled, patient-blinded, monocentric trial. Pain-free grip, skin conductance and peripheral skin temperature were measured before and after the intervention. The treatment group (15 patients) received a one-time 2-min T5 costovertebral mobilization (2 Hz), and the placebo group (15 patients) received a 2-min one-time sham ultrasound therapy. Results: Mobilization at the thoracic spine resulted in significantly increased strength of pain-free grip + 4.6 kg ± 6.10 (p = 0.008) and skin conductance + 0.76 μS ± 0.73 (p = 0.000004) as well as a decrease in peripheral skin temperature by - 0.80 °C ± 0.35 (p < 0.0000001) within the treatment group. Conclusion: A thoracic costovertebral T5 mobilization at a frequency of 2 Hz shows an immediate positive effect on pain-free grip and sympathetic activity in patients with lateral epicondylalgia. 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

Isolated entrapment of the brachialis branch of the musculocutaneous nerve: A case report. Ryhänen, J., E. Waris and S. Kujala (2021) Level of Evidence : 5 Follow recommendation : 👍 Type of study : Diagnostic/Therapeutic This is the answer to last week Sherlock Handy. The client was 55 years old presenting with right side pain at the lateral antecubital area of the elbow/forearm. They reported developing elbow flexion weakness over the course of 7 months. Subjectively they also presented with cramps in the anterior portion of their arm. Pain was reproduced with resisted elbow flexion and forearm pronation, or full active elbow extension. There was atrophy of the brachialis, however, biceps function was retained (see picture). Neurological examination identified no central nervous system pathology. Age-related changes were identified on cervical MRI. Nerve conduction studies identified no sensory impairments or motor impairments at the level of the brachial plexus or main branch of the musculocutaneous nerve. However, a significant impairment at the level of the brachialis branch of the musculocutaneous nerve was identified. During surgical exploration, entrapment of the brachialis branch was identified at the level of the coracobrachialis fascia (nerve entrance - see picture), and this was released. Follow up at one year showed completed resolution of pain, however, atrophy had not resolved and weakness in elbow flexion was still present. 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, entrapment of the musculocutaneous branch to the brachialis muscle is a rare presentation. The differential diagnosis for this presentation included cervical entrapment radiculopathy, a peripheral entrapment neuropathy, a large brachialis tear, or central nervous system pathology. To screen for cervical radiculopathy (exclude it), we can utilise upper limb nerve tension tests and the arm squeeze test . To make a diagnosis of cervical radiculopathy, the presence of a positive Spurling's test, arm squeeze test , single-level myotomes weakness , and reduced reflexes may increase the likelihood of cervical radiculopathy. With a cervical entrapment radiculopathy, we would expect weakness of most muscles innervated by the cervical level affected. In contrast, a peripheral entrapment neuropathy (like in this case), is likely to affect only the muscles distal to the affected branch. Central nervous system pathology may be excluded in absence of signs of central nervous system involvement (e.g. multilevel weakness), however, a referral is warranted if we suspect the presence of a central nervous system pathology. URL: https://doi.org/10.1177/17531934211008795 Available through EBSCO Health Databases for PNZ members. No Abstract available 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 minimal important change for the QuickDASH in patients with thumb carpometacarpal arthritis. Jørgensen, R. W. and M. R. K. Nyring (2021) Level of Evidence : 1b Follow recommendation : 👍 👍 👍 Type of study : Diagnostic Topic : Minimal clinically important difference - QuickDASH Through HandyEvidence surveys, I have discovered that Hand Therapists are interested in tips on how to critique research article. This synopsis is the second of a series (if you find them useful - leave a comment) providing tips on how to interpret the research that you read. In particular, this synopsis revolves around the minimally clinically important difference concept. By minimal clinical important difference, we refer to the smallest change in a measure (e.g. QuickDASH) which can be considered as a real improvement in the clinical presentation of our clients. There are at least a couple of methods that can be used to estimate this value, and they are called "anchor-based" and "distribution-based" method. The anchor-based method calculates the minimal clinical important difference by determining the score of those participants who report benefiting from an intervention/treatment. The distribution-based methods instead does not take into account participants' opinion of improvement and simply calculates the minimal clinical important difference based on the error of the measure utilised. In the paper that I read this week, a group of surgeons calculated the minimal clinically important difference for the QuickDASH in a group of participants with thumb OA. In this paper, they assessed clients at baseline and 6 months after surgery for thumb OA (e.g. trapeziotomy). The results showed that the minimal clinically important difference calculated through an anchor-based method (utilising clients' feedback) was 18 points out of 100. When they calculated it through a distribution-based method, the minimal clinically important difference was 10 points out of 100. 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 minimal clinically important difference for the QuickDASH ranges between 10 to 18 points out of 100. Personally, I prefer the anchor-based method, hence I would suggest that a change of 18 points is clinically meaningful. This means that if one our clients scored 50/100 on the QuickDASH at the first assessment and 32/100 on discharge, we would have achieved a clinically meaningful improvement. Once again, it is possible that this change could be either due to our treatment, other people's treatment (e.g. GP medications) , regression to the mean , variables that we have not considered (e.g. reduction in kinesiophobia ), or natural history of the condition. If you liked this synopsis you may also like other topics such as the relevance of statistical significance or p<0.05 , implementation of research to clinical practice , and how to make evidence guided decisions when limited evidence is available . URL : https://doi.org/10.1177/17531934211034749 Available through EBSCO Health Databases for PNZ members. Abstract Evaluating the effect of treatment through change in patient-reported outcomes requires an understanding of the minimal important change. The aim of this study was to report the minimal important change for the Quick Disability of the Arm, Shoulder and Hand questionnaire (QuickDASH) in patients receiving surgical treatment for thumb carpometacarpal joint osteoarthritis. Three hundred and fifteen patients were seen before and 6 months following surgery. Two methods were used to calculate the minimal important change: a distribution-based method calculating the standard error of measurement and an anchor-based method based on the receiver operating characteristic curve. The minimal important change for QuickDASH was estimated to be 18.2 points using the anchor-based method. The area under the receiver operating curve was 0.82, indicating a satisfactory accuracy. The minimal important change was estimated to be 10.3 points using the distribution-based method. These values may be useful in future research on thumb carpometacarpal joint osteoarthritis. 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

Placebo and nocebo effects. Colloca, L., & Barsky, A. J. (2020) Level of Evidence : 5 Follow recommendation : 👍 Type of study : Therapeutic Topic : Placebo and nocebo – What are they? This is a narrative review on placebo and nocebo for clinical practice. Placebo, a positive effect (e.g. pain reduction), and nocebo, a negative effect (e.g. increase in pain), are the result of treatment expectations. Words can induce a placebo or a nocebo effect. Verbal hyperalgesia (hyperalgesia = a nociceptive stimulus usually perceived as a little pain is perceived as a high intensity pain) is an example of nocebo effect. Verbal hyperalgesia is induced in patients when we suggest that something that we are going to do (e.g. ligament testing) or that they are already doing (e.g. activity or movement) will be painful. This nocebo effect has been suggested to be due to an increase in anxiety and inhibition of endogenous analgesic pathways. Classical conditioning (Pavlovian conditioning) is another mechanism that can induce a placebo or nocebo response. For example, repeatedly associating a movement with a highly nociceptive stimulus has been shown to increase the likelihood of perceiving pain in the presence of a mild nociceptive stimulus after the conditioning . In clinical practice, breaking down the association with movement and pain, as well as providing a realistic and positive explanation of the treatment, have both been shown to reduce the pain experience. In addition, an empathetic attitude and smiling have been shown to reduce the experience of pain by improving the endogenous analgesic response of our patients. Clinical Take Home Message : Based on what we know today, the positive attitude of a hand therapist can boost the effect of the treatment provided. It may be useful to avoid suggesting that a specific activity or movement will cause pain. This may set up patients to feel more pain than what they would otherwise experience. Hand therapists should also be aware that patients may associate a specific activity or movement with pain. This may cause ongoing symptoms even after the tissues have healed. URL : https://www.nejm.org/doi/full/10.1056/NEJMra1907805 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

Psychological factors are more strongly associated with pain than radiographic severity in non-invasively treated first carpometacarpal osteoarthritis. Hoogendam, L., et al. (2019) Level of Evidence : 2b Follow recommendation : 👍 👍 👍 Type of study : Aetiology Topic : Thumb osteoarthritis - Pain and psychological factors This is a cross-sectional study assessing the association between psychological variables and pain in participants with thumb osteoarthritis (OA). Participants (N = 255) with thumb OA underwent a radiological assessment and were then recruited for the study. Psychological variables included pain catastrophising, anxiety, and depression. Pain intensity was measured through the pain section of the Michigan Hand Outcomes Questionnaire. Other variables such as radiological severity of thumb OA were included in the statistical analyses. The results showed that pain catastrophising was the most important predictor of pain intensity and it explained 29% of the pain variance. In contrast, radiological findings only explained 1% of pain variability (see figure). 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 catastrophising is one of the strongest contributors to pain intensity in thumb OA. This study adds to the growing amount of evidence suggesting that mental health is an important factor to consider in our clients with hand and upper limb conditions. In particular, mental health issues have been shown to be associated with a greater number of hand clinic visits across a wide range of upper limb conditions as well as delay recovery in clients post carpal tunnel release . In addition, kinesiophobia has been shown to be associated with upper limb disability and we may be able to utilise a pain phenotype classification to predict recovery in our clients . Open access URL : https://doi.org/10.1080/09638288.2019.1685602 Abstract Background: The aim of this study was to investigate to what extent psychological factors are related to pain levels prior to non-invasive treatment in patients with osteoarthritis of the first carpometacarpal joint. Methods: We included patients (n = 255) at the start of non-invasive treatment for osteoarthritis of the first carpometacarpal joint who completed the Michigan Hand Outcome Questionnaire. Psychological distress, pain catastrophizing behavior and illness perception was measured. X-rays were scored on presence of scaphotrapeziotrapezoid osteoarthritis. We used hierarchical linear regression analysis to determine to what extent pain levels could be explained by patient characteristics, X-ray scores, and psychological factors. Results: Patient characteristics and X-ray scores accounted for only 6% of the variation in pre-treatment pain levels. After adding the psychological factors to our model, 47% of the variance could be explained. Conclusions: Our results show that psychological factors are more strongly related to pain levels prior to non-invasive treatment in patients with osteoarthritis of the first carpometacarpal joint than patient characteristics and X-ray scores, which implies the important role of these factors in the reporting of symptoms. More research is needed to determine whether psychological factors will also affect treatment outcomes for patients treated non-invasively for osteoarthritis of the first carpometacarpal joint. IMPLICATIONS FOR REHABILITATION: Pain is the most important complaint for patients with osteoarthritis of the first carpometacarpal joint. Psychological factors are strongly associated with pain levels prior to treatment. Pain catastrophizing behavior appears to be a promising target for complementary treatment in patients with osteoarthritis of the first carpometacarpal joint.

A scoping review of the use of exercise-based upper extremity injury prevention programs for industrial workers. Boyette, J. and J. Bell (2021) Level of Evidence : 1a- Follow recommendation : 👍 👍 👍 👍 Type of study : Therapeutic/Preventative Topic : Injury prevention - Industrial workers This is a systematic review and meta-analysis on the effect of upper limb injury prevention programs for industrial workers. Fourteen studies, of which 10 were RCTs were included in the systematic review, for a total of 2682 participants. Participants included were from an industrial population and the outcomes analysed varied significantly across the studies included. The overall strength of evidence was not assessed and a meta-analysis was not completed. Despite exercise programs varying quite significantly, the most common exercise frequency was three times per week. Exercises included stretching and strengthening programs. Overall the results suggest that exercise in any form appears to be beneficial from a pain, function, and return to work point of view. It is not possible to comment on the clinical relevance of these findings. 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, exercise in any form (stretching/strengthening) appears to be useful in preventing and/or reducing symptoms and improving function in people with upper limb conditions working in industrial settings. Currently, it is not possible to comment on which exercises are most effective. Overall, I would suggest for clients to follow the World Health Organisation guidelines for physical activity , which are likely to induce physical as well as mental health benefits. In addition to exercise, our clients may benefit from the adjunct of pain neurophysiology education , which seems to boost the effect of exercise. Remember that pain neurophysiology education alone does not appear to be enough to reduce pain and it needs to be combined with exercises to have a clinically relevant effect. If you are interested in additional information on the effectiveness of pain education on persistent pain, have a look at this synopsis . You may also want to rethink the use of some terms such as "overuse injury", which probably needs updating . URL : https://doi.org/10.1016/j.jht.2021.04.020 Available through The Journal of Hand Therapy for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Study Design This study is a scoping review. Introduction Exercise-based upper extremity injury prevention programs are used by employers to reduce the cost of work-related injuries in the industrial work setting. Purpose of the Study The purpose of the study was to identify, report, and evaluate all published literature that describes exercise-based upper extremity injury prevention programs used with an industrial workforce. Methods A systematic search of Medline, ProQuest, Pubmed, and Worldcat databases was performed. Data extracted included the type of outcome tool used, the outcome that was measured, the components of the exercise program, and the effectiveness toward reducing injury. Results 14 studies were included in the final analysis and summary. 12 articles included strengthening (85%) 10 included stretching (71%), 2 included health coaching (14%), and 2 included work simulation (14%). The most prevalent treatment approach was combined stretching and strengthening which accounted for 5 of the 14 studies, or 36%. The intervention period ranged from 4 weeks to 1 year and the program frequency ranged from before every work shift to weekly performance. There were 22 different outcome measures with health condition reported in 12 of 14 studies (86%) and function reported in 7 of 14 studies (50%). Discussion and Conclusions Although many of the studies showed positive benefits to the exercise program, there is a wide variance in the current literature regarding the implementation, supervision, and exercise components of an upper extremity injury prevention program in an industrial work setting. Because there is no commonly-accepted exercise program, a conclusion regarding effectiveness cannot be generalized outside of the environment, supervision requirements, frequency, and duration in which the research was performed. There is a need for improved reporting techniques and a preferred program to be replicated across multiple work settings in order to allow generalizability of findings.

Diagnostic accuracy of upper limb neurodynamic tests in the diagnosis of cervical radiculopathy. Grondin, F., et al. (2021). Level of Evidence : 2b Follow recommendation : 👍 👍 👍 Type of study : Diagnostic Topic : Neurodynamic tests - cervical radiculopathy diagnosis This is a prospective study assessing the diagnostic accuracy (sensitivity and specificity) of upper limb nerve tension (ULNT) tests in the identification or exclusion of a cervical radiculopathy. If a test is very sensitive and its result is negative, you can be more certain that the patient does not have the condition. If the test is specific and its result is positive, you can be more certain that the patient has the condition. To be included in the study, potential participants had to present with arm pain with or without neck pain. A total of 85 participants were included in the present study. Of these, 27 presented with cervical radiculopathy, 42 with non-radicular arm pain, 12 with peripheral nerve entrapment, and 4 with widespread shoulder pain. Radiculopathy was defined by clinical diagnosis from a neurosurgeon and confirmation of such pathology was made through MRI findings. The MRI findings had to be consistent with the clinical examination for a diagnosis of cervical radiculopathy. In other words, the level of root compression had to be consistent with the reported subjective symptoms distributions and motor/sensory/reflex deficits. A musculoskeletal physiotherapist blinded to the neurosurgeon's diagnosis and MRI, completed all the ULNTs (median, radial, ulnar nerve). An ULNT test was defined positive if the participant reported familiar symptoms (e.g. burning pain/tingling) in the arm and/or neck and if structural differentiation (movement of a joint distant from the pain – e.g. neck for forearm pain or wrist for arm pain) reduced or increased symptoms. An ULNT test was defined negative in it did not reproduce familiar symptoms or structural differentiation was not possible. The result showed that when all three tests were negative, sensitivity was high (81%). In addition, when all three tests were positive, specificity was high (93%). These findings suggest that the greatest diagnostic accuracy is achieved when the tests are combined. Clinical Take Home Message : Based on what we know today, the combination of upper limb neurodynamic tests appears to be useful in making or excluding a diagnosis of cervical radiculopathy. In particular, if none of the neurodynamic tests (median, radial, and ulnar) reproduces the client's symptoms, a cervical radiculopathy is unlikely. In contrast, if all the upper limb neurodynamic tests reproduce the clients' symptoms, they are likely to present with a cervical radiculopathy. The novelty of this study is that it looked at the combination of these tests rather than their diagnostic ability in isolation. It is important to remember that client's prior knowledge of the purpose of these tests can significantly bias the outcomes of the tests . Other tests that have been shown to be useful in the diagnosis of cervical radiculopathy are: manual muscle testing of key muscle groups , assessment of deep tendon reflexes , Spurling's, cervical distraction, and arm squeeze test . Also, keep in mind that clients with a cervical radiculopathy present with ipsilateral neck pain in 80% of cases , arm pain is often worse than neck pain , and that pain/numbness follows dermatomal patterns in 54% of clients only. In terms of treatment, neck AROM exercises appear to be useful in c ervical radiculopathy. Despite evidence of reduced nerve gliding in clients with cervical radiculopathy, nerve gliding techniques do not appear to provide significant pain relief . URL : https://doi.org/10.1016/j.msksp.2021.102427 Available through EBSCO Health Databases for PNZ members. Abstract Background Upper limb neurodynamic tests (ULNT) are used to diagnose neuropathic conditions such as cervical radiculopathy (CR). Within the literature, a positive ULNT is defined in markedly variable ways, which is likely why the diagnostic accuracy of these tests lacks consistency across studies. Objectives To determine the diagnostic accuracy of single and combined upper limb neurodynamic tests ((ULNT)1, 2a, 2b and 3) for cervical radiculopathy using test findings that are similar to those used in practice. Design Diagnostic accuracy study (prospective) design following the updated STARD 2015 reporting guideline. Method From 109 consecutively enrolled individuals with suspected CR. Of the 85 participants included, 27 (31.7%) were diagnosed with CR (mean age, 43.9 years; Neck Disability Index 38,16%). ULNTs test were performed by a blind examiner to a CR reference standard of clinical diagnosis and magnetic resonance imaging verification provided by a neurosurgeon. Results In general, the single tests were better at ruling in CR versus ruling out. Of the single ULNT, the ULNT3 demonstrated the strongest post-test probability change with a positive finding (73.28%). Three of four test combinations demonstrated the highest clinical utility for changing the post-test probability with a positive finding at 83.29% and with LR+=12.89 (95%CI:3.10-53.62). Having none of the test’s positive was able to rule out CR with LR-=0.08 (95%CI:0.01-0.56). Conclusion ULNTs fail to significantly alter post-test probability when used singularly for diagnosis of CR. However, combinations of ULNT (3 out of 4 positive) can rule in CR, and rule out CR when all ULNT are negative.