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Empirical treatment of uncomplicated septic olecranon bursitis without aspiration. Deal, J., Vaslow, A., Bickley, R., Verwiebe, E., & Ryan, P. (2020) Level of Evidence : 4 Follow recommendation : 👍 Type of study : Prognostic Topic : Conservative and invasive treatment for septic olecranon bursitis - Aspiration followed by antibiotics vs antibiotics only. This is a retrospective study assessing complications following treatment of septic olecranon bursitis with aspiration and antibiotics, or antibiotics alone. This study needs to be considered in light of a few limitations. The sample size was small (n = 30) and it is possible that larger studies could provide different results. In addition, due to the retrospective design of the study it is not possible to exclude the effect of an unknown variable on the results. The results showed that participants undergoing bursal aspiration (n = 11) had a much greater probability of undergoing bursectomy, compared to patients managed through antibiotics only (n = 19). Based on the number needed to treat to harm, out of 3 participants undergoing bursal aspiration, 2 would require a bursectomy due to unresolved complications. None of the participants managed through antibiotics only required a bursectomy. It is important to remember that the patients underwent a particular intervention based on the decision of a clinician, and were not randomised to a treatment. It is possible that those patients undergoing aspiration presented with a more severe clinical picture. A randomised controlled trial would likely clarify the causality, if any, between bursal aspiration and further complications. 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, clients undergoing aspiration due to septic olecranon bursitis are more likely to require bursectomy, compared to those who are managed with antibiotics only. Additional risk factors for poor wound healing and risk of infection in our clients include smoking , mental stress , and diabetes . Knowing the presence of these risk factors in your clients will help predicting what is their likelihood of developing an infection . If you are suspecting an infection, a workup may be useful . URL : https://www.jhandsurg.org/article/S0363-5023(18)30819-0/fulltext Available through The Journal of Hand Surgery (American Volume) for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract PURPOSE Although aspiration of septic olecranon bursitis is recommended in the literature, no high-level evidence exists to support this practice. The purpose of this study was to retrospectively compare the results of traditional bursal aspiration (TBA) with empirical management without aspiration (EM). We hypothesized that EM of uncomplicated septic olecranon bursitis results in resolution, with fewer chronic draining sinuses and less progression to bursectomy. METHODS We performed a retrospective review of all cases of septic olecranon bursitis seen by the orthopedic surgery department at a single tertiary referral center over a 5-year period. Cases were manually reviewed to determine patient demographics, management, and treatment results. The primary outcome was success of nonsurgical management versus requirement for surgical bursectomy. RESULTS Thirty cases of uncomplicated septic olecranon bursitis were identified within the study period. Eleven patients were initially managed with TBA (performed by an emergency or primary care physician prior to orthopedic consultation), resulting in 11 positive cultures. Only 1 of these prompted a change of antibiotic management, and despite this information, 5 patients required a second course of antibiotics for incomplete resolution. Eight of the TBA cases went on to bursectomy. Nineteen patients underwent EM. Sixteen of these cases resolved with a single course of empirical antibiotics, and 3 (16%) cases required a second antibiotic course. One patient had a recurrence of symptoms 2 months after resolution with a single course of empirical antibiotics. This resolved with a second course of oral antibiotics. No patients who underwent EM went on to require bursectomy. The number needed to harm when aspiration was performed was 1.46. CONCLUSIONS We found EM of uncomplicated septic olecranon bursitis to be effective. Although 1 recurrence did occur in the EM group, no other complications occurred. Empirical management without aspiration may be considered in cases of uncomplicated septic olecranon bursitis.

Advancing the management of upper extremity musculoskeletal conditions: Insights from the field of implementation science. Juckett, L. A., L. DeMott and H. V. Oliver (2021) Level of Evidence : 5 Follow recommendation : 👍 Type of study : Research Implementation Topic : Making the jump from research to practice - Implementation This paper revolved around strategies to help clinicians implementing valuable research into clinical practice. The reason why this is important, is that it takes on average 17 years for research to be implemented in clinical practice. This means that concepts relevant to Hand Therapists published this year, may be applied in clinical practice in 2036. Why does this process take so long? Time is one factor. We are busy: looking, critiquing, and interpreting research is not something that we get paid for, although we are supposed to. Second, the papers we may want to read are often closed access and that makes it harder, if not impossible to read the full text. People may also feel that they lack confidence in applying new findings and this is likely to make them go back to what they were doing before reading the paper. The usefulness of different strategies to improve the uptake of research is called "implementation science". Currently, there are steps that have been suggested to help improving research uptake. These include: 1) Identification of barriers to evidence implementation by talking with Clinicians 2) Creation of a team of Clinicians and people interested in research to help reducing barriers and move forward. 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 : I would like to take the first step identified above. I would like to hear from you rather than provide you with a clinical take home message: What are the barriers that you face when you try and implement evidence based practice? URL : https://doi.org/10.1016/j.jht.2021.04.004 Available through The Journal of Hand Therapy for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Introduction The development of effective interventions in hand and upper extremity rehabilitation is critically important; yet even the most promising interventions may not successfully be implemented in practice. Occupational and physical therapists who provide specialized hand and upper extremity rehabilitation services (“hand therapists”) can face extensive, multi-level barriers when attempting to use research findings in real-world settings, widening the long-standing research-to-practice gap. Concepts from the field of implementation science can be leveraged to address this gap and expedite the application of research discoveries that can maximize treatment outcomes of the musculoskeletal upper extremity client. As the intersection of hand and upper extremity rehabilitation and implementation science draws growing attention, there is a great need for researchers and clinicians to infuse implementation science into the hand and upper extremity rehabilitation research and practice contexts. Purpose The purpose of this article is to define implementation science and synthesize several studies from the hand and upper extremity rehabilitation field that have examined the effect of implementation strategies (eg, chart audit and feedback techniques; implementation teams) on implementation outcomes (eg, acceptability, fidelity). We also present recommendations for how (1) hand and upper extremity rehabilitation researchers can design studies to examine both patient outcomes and implementation outcomes relative to interventions for the musculoskeletal upper extremity and (2) hand and upper extremity rehabilitation specialists and administrators can develop implementation teams to facilitate the use of evidence in practice. Conclusion Collaboration between researchers and clinicians has great potential to advance the entirety of the hand and upper extremity rehabilitation profession, especially when such collaborations are guided by the implementation science field.

Surgery versus cast immobilisation for adults with a bicortical fracture of the scaphoid waist (swifft): A pragmatic, multicentre, open-label, randomised superiority trial. Dias, J. J., et al. (2020) Level of Evidence : 1b Follow recommendation : 👍 👍 👍 👍 Type of study : Therapeutic Topic : Scaphoid waist fractures - Surgery vs casting This is a randomised controlled trial assessing the outcomes of surgical fixation vs casting for non displaced waist scaphoid fractures . Only participants who presented with a bicortical fracture (through the waist of the scaphoid) with a step of 2 mm or less in any radiographic view were included. A total of 408 participants were included. Outcome measures included the patient-rated wrist evaluation (PRWE) at 0, 6,12, 26, and 52 weeks post randomisation. Secondary outcomes included adverse events associated with casting, surgery, or other medical issues. Casting was applied below the elbow and involved the thumb in some but not all participants. X-rays were repeated at 6-12 weeks and if non union was identified participants underwent surgery. The results showed that there was no statistically or clinically relevant difference in PRWE scores across all times (see graph). No differences were identified in rates of non-union. 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, non displaced scaphoid waist fracture of 2 mm or less can be managed with a below elbow cast (with or without thumb inclusion). The outcomes associated with casting immobilisation do not appear to be superior or inferior to screw fixation. Non union complications do not appear to be higher with conservative management compared to surgery. If you are interested in knowing what physical tests appear to be useful for identification of occult scaphoid fractures have a look at this synopsis . Also, remember that tenderness on palpation may not be a reliable indicator of fracture healing , and it may be better to follow traditional fracture healing times as a guide for weaning of casting/splint. Interestingly, it appears that the duration of immobilisation for scaphoid fractures not only depends on radiographic evidence of healing, which has been shown not to be a reliable indicator, but also on client's depressive symptoms . Once again, it may be best to judge immobilisation duration on timeframes from injury rather than subjective factors such as tenderness on palpation. Open Access URL : https://eprints.whiterose.ac.uk/161086/1/Final_SWIFFT_Manuscript_accepted_2020.04.16_3_.pdf Abstract Background Scaphoid fractures account for 90% of carpal fractures and occur predominantly in young men. The use of immediate surgical fixation to manage this type of fracture has increased, despite insufficient evidence of improved outcomes over non-surgical management. The SWIFFT trial compared the clinical effectiveness of surgical fixation with cast immobilisation and early fixation of fractures that fail to unite in adults with scaphoid waist fractures displaced by 2 mm or less. Methods This pragmatic, parallel-group, multicentre, open-label, two-arm, randomised superiority trial included adults (aged 16 years or older) who presented to orthopaedic departments of 31 hospitals in England and Wales with a clear bicortical fracture of the scaphoid waist on radiographs. An independent remote randomisation service used a computer-generated allocation sequence with randomly varying block sizes to randomly assign participants (1:1) to receive either early surgical fixation (surgery group) or below-elbow cast immobilisation followed by immediate fixation if non-union of the fracture was confirmed (cast immobilisation group). Randomisation was stratified by whether or not there was displacement of either a step or a gap of 1–2 mm inclusive on any radiographic view. The primary outcome was the total patient-rated wrist evaluation (PRWE) score at 52 weeks after randomisation, and it was analysed on an available case intention-to-treat basis. This trial is registered with the ISRCTN registry, ISRCTN67901257, and is no longer recruiting, but long-term follow-up is ongoing. Findings Between July 23, 2013, and July 26, 2016, 439 (42%) of 1047 assessed patients (mean age 33 years; 363 [83%] men) were randomly assigned to the surgery group (n=219) or to the cast immobilisation group (n=220). Of these, 408 (93%) participants were included in the primary analysis (203 participants in the surgery group and 205 participants in the cast immobilisation group). 16 participants in the surgery group and 15 participants in the cast immobilisation group were excluded because of either withdrawal, no response, or no follow-up data at 6, 12, 26, or 52 weeks. There was no significant difference in mean PRWE scores at 52 weeks between the surgery group (adjusted mean 11·9 [95% CI 9·2–14·5]) and the cast immobilisation group (14·0 [11·3 to 16·6]; adjusted mean difference −2·1 [95% CI −5·8 to 1·6], p=0·27). More participants in the surgery group (31 [14%] of 219 participants) had a potentially serious complication from surgery than in the cast immobilisation group (three [1%] of 220 participants), but fewer participants in the surgery group (five [2%]) had cast-related complications than in the cast immobilisation group (40 [18%]). The number of participants who had a medical complication was similar between the two groups (four [2%] in the surgery group and five [2%] in the cast immobilisation group). Interpretation Adult patients with scaphoid waist fractures displaced by 2 mm or less should have initial cast immobilisation, and any suspected non-unions should be confirmed and immediately fixed with surgery. This treatment strategy will help to avoid the risks of surgery and mostly limit the use of surgery to fixing fractures that fail to unite.

Clinical evaluation of a wrist sensorimotor rehabilitation program for triangular fibrocartilage complex injuries. Chen, Z. (2021) Level of Evidence : 4 Follow recommendation : 👍 👍 Type of study : Therapeutic Topic : Triangular Fibrocartilage Complex (TFCC) rehabilitation - Four stages treatment over three months This case series reported the effectiveness of a four stage approach to the rehabilitation of TFCC injuries. Ten patients were included in the present study. The four stage approach has been previously described in this other synopsis . Effectiveness of treatment was assessed through pain during motion (0-10 Numerical Rating Scale - NRS), Pus Off Test , and hand function (Patient Rated Wrist Hand Evaluation - PRWHE). On average it took three months for participants to complete the four stages. The results showed that 100% of participants reported a clinically relevant improvement in pain (at least 2 points out of 10 on NRS). In addition, 70% of participants reported a clinically important change on the Pus Off Test (at least 4.4 kg improvement), and PRWHE (at least 14 points change). One of the limitations of this study is that it did not present with a control group undergoing some other form of treatment or standard care. It is therefore possible that the improvements noted are due to the natural history of the condition rather than the four stage approach treatment. Clinical Take Home Message : Based on what we know today, a graded exercise program may be effective in people with symptomatic TFCC injuries. However, a randomised controlled trial will be required to determine whether the changes noted in this study are simply due to natural history or a specific component of this four stages approach. In addition, progressing exercises based on pain may be appropriate in some clients but not in others. Thus, there is evidence showing that a large proportion of pain intensity is mediated by psychological factors such as pain catastrophising . Considering also that other factors such as kinesiophobia mediate disability in people with upper limb musculoskeletal conditions , a more holistic approach including pain neurophysiology education in addition to exercise may provide better outcomes. URL : https://doi.org/10.1177/17589983211033313 Available through Hand Therapy for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Introduction Triangular fibrocartilage complex (TFCC) injuries are associated with distal radioulnar joint (DRUJ) instability and impaired wrist proprioception. Sensorimotor training of extensor carpi ulnaris (ECU) and pronator quadratus (PQ) can enhance DRUJ stability. With limited evidence on effectiveness of TFCC sensorimotor rehabilitation, this study aimed to evaluate the effects and feasibility of a novel wrist sensorimotor rehabilitation program (WSRP) for TFCC injuries. Methods Patients diagnosed with TFCC injuries were recruited from May 2018 to January 2020 at an outpatient hand clinic in Singapore General Hospital. There are four stages in WSRP: (1) pain control, (2) muscle re-education and joint awareness, (3) neuromuscular rehabilitation, and (4) movement normalization and function. WSRP also incorporated dart throwing motion and proprioceptive neuromuscular facilitation. Outcome measures included grip strength measured with grip dynamometer, numerical pain rating scale, joint position sense (JPS) measurement, weight bearing measured with the "push-off" test, and wrist function reported on the Patient Rated Wrist Hand Evaluation. Results Ten patients completed the WSRP. Mean changes were compared with minimal clinically important differences (MCID) for outcomes. All patients achieved MCID on pain, 70% of patients achieved MCID on grip strength, weight bearing and wrist function. Paired t-tests and Cohen?s D for outcome measures were calculated. There were large effect sizes of 2.47, 1.35, and 2.81 for function, grip strength and pain respectively, and moderate effect sizes of 0.72 and 0.39 for axial loading and JPS respectively. Discussion WSRP presents a potential treatment approach in TFCC rehabilitation. There is a need for future prospective clinical trials with control groups.

A novel staged wrist sensorimotor rehabilitation program for a patient with triangular fibrocartilage complex injury: A case report. Chen, Z. B. (2019) Level of Evidence : 5 Follow recommendation : 👍 Type of study : Therapeutic Topic : Triangular Fibrocartilage Complex (TFCC) rehabilitation - Four stages treatment over three months This case study reported the rehabilitation phases of a young patient (20s) presenting with two months’ history of wrist ulnar sided pain in the dominant hand. The pain developed while carrying a heavy object and it impaired their ability to work in a sedentary job (computer typing and answering phone calls). No information was provided on hobbies or sport activities. The patient presented with a pain of 4/10 on wrist movements at baseline. The diagnosis of TFCC was based on a positive fovea sign. The assessment also included self-reported measures of function (QuickDASH and Patient-Related Wrist Evaluation), active range of movement, grip strength, wrist joint position sense, and weight bearing ability through the Push Off test . Treatment was provided in four stages, each lasting one month. In the first stage, active range of movement exercises, splinting, and laser therapy were provided. If pain at rest and during exercises was less than 2/10, the next phases was initiated. This included isometric strengthening of pronator quadratus and extensor carpi ulnaris, light weightbearing wrist extension and flexion, and gradual splint weaning. Progression to the third phase initiated when wrist extension with overpressure was not painful and when pain was less than 2/10 with the exercises. This phase included progression of strength training intensity and introduction of wrist and upper limb perturbations. The fourth and last phase included graded return to functional activities with more complex tasks. 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 : Progression of exercises for patients with TFCC injury may be based on symptoms. It appears that 2/10 pain may be the maximum advisable pain for patients to experience during or after exercises. A wrist splint may be worn for the first six weeks, after which a weaning process could commence according to pain irritability. The Push Off test might be a good assessment tool to assess patients at 8 weeks. URL : https://www.jhandtherapy.org/article/S0894-1130(17)30404-0/abstract Available through The Journal of Hand Therapy for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Study Design Case report. Introduction Studies have highlighted the sensory innervations and stabilizing role of forearm muscles on wrist joint and implications to wrist sensorimotor rehabilitation. This case explored the novel incorporation of dart-throwing motion and proprioceptive neuromuscular facilitation in wrist sensorimotor rehabilitation. Purpose of the Study To describe and evaluate a staged wrist sensorimotor rehabilitation program for a patient with triangular fibrocartilage complex (TFCC) injury. Methods The patient participated in the staged program for 9 sessions over a 3-month period. Treatment involved neuromuscular strengthening at the wrist and movement normalization of the upper extremity. Outcome measures were grip strength, visual analog scale, joint position sense, Quick Disabilities of the Arm, Shoulder and Hand, and patient-rated wrist evaluation. Results The patient showed improvement in all outcome measures. Most outcomes exceeded the established minimal clinically important difference values. Discussion The results suggest that dart-throwing motion and proprioceptive neuromuscular facilitation are beneficial in rehabilitation of TFCC injury. Conclusions This is the first study that incorporated dart-throwing motion and proprioceptive neuromuscular facilitation in the sensorimotor rehabilitation of TFCC injury and yielded promising results. There is a need to further evaluate the program in prospective randomized controlled trial recruiting a larger group of patients with TFCC injury.

Self-guided web-based pain education for people with musculoskeletal pain: A systematic review and meta-analysis. de Oliveira Lima, L., et al. (2021) Level of Evidence : 1a- Follow recommendation : 👍 👍 👍 👍 Type of study : Therapeutic Topic : Persistent pain - online pain education This is a systematic review and meta-analysis on the effect of pain education alone in participants with persistent musculoskeletal pain. Six RCTs were included in the systematic review, for a total of 1664 participants. Participants included presented with a wide range of spinal musculoskeletal pain, which extended beyond 3 months. Five of the six 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 education was compared to no intervention. Pain education included cognitive behavioral strategies aimed at changing behavior as well as strategies aimed at improving coping strategies and reduce stress levels. All the educational sessions were delivered through different online platforms. Efficacy of intervention was assessed through pain intensity (0 to 10) and self-reported disability. Intervention duration ranged between 3 and 8 weeks, with a maximum training frequency of 7 and a minimum of 2 times per week. The assessment time points ranged from short-term (less than 3 months from inclusion in the trial) to intermediate-term (3 to 6 months after inclusion). There is moderate quality evidence suggesting that pain education provided statistically significant but not clinically relevant improvements in pain intensity (average change of 0.6 points out of ten; 95%CI: 1 to 3.4 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, pain education alone does not provide clinically significant improvements in pain intensity or disability in people with musculoskeletal conditions. However, it appears that the combination of pain neurophysiology education and exercise is more effective than exercise alone . Remember to keep your educational sessions simple and that they have a real neurophysiology basis to their effectiveness . You may also want to rethink the use of some terms such as "overuse injury", which probably needs updating . URL : https://doi.org/10.1093/ptj/pzab167 Available through EBSCO Health Databases for PNZ members. Abstract Objective We aimed to investigate the effectiveness of Web-based pain education programs without clinical support in patients with musculoskeletal pain. Methods We searched on PubMed, Scopus, CINAHL, Web of Science, Cochrane Library and PsycINFO from inception to February 2020. Included studies were randomized clinical trials in which people with musculoskeletal pain were allocated to an experimental group that received Web-based pain education as a standalone approach. Three review authors performed data extraction. PEDro scale was used to assess the methodological quality of the studies. The primary outcomes were pain intensity and disability. Results We included six trials with a total of 1664 participants. There is moderate quality evidence with small effect size that Web-based pain education programs, as a standalone approach, is better than minimal intervention (no intervention or booklets) for pain intensity (SMD = −0.23, 95% CI = −0.43 to −0.04) at short-term and at intermediate-term (SMD = −0.26, 95% CI = −0.42 to −0.10). Regarding to disability, there is low quality evidence that Web-based pain education programs is better than minimal intervention (SMD = −0.36, CI 95% = −0.64 to −0.07) at short-term. Web-based pain education added to usual care was no better than usual care alone at intermediate or long-term for primary outcomes. Conclusions Web-based pain education for adults with musculoskeletal pain, as a standalone approach, showed to be better than minimal intervention for pain intensity and disability at short-term, and for pain intensity at intermediate-term. Web-based pain education added to usual care did not provide additional benefits for primary oucomes at intermediate or long-term. Impact Web-based pain education as a standalone intervention provided small improvements in pain intensity and disability in patients with chronic musculoskeletal pain. Scarcely resourced contexts and overburdened health systems should consider this delivery method in the management of chronic musculoskeletal pain. Lay summary If you have chronic musculoskeletal pain, your physical therapist might recommend web-based pain education as treatment to help you reduce pain intensity and disability.

Radiographic comparison of bony and tendinous mallet injuries. Giddins, G. E. (2021) Level of Evidence : 4 Follow recommendation : 👍 👍 Type of study : Diagnostic Topic : Bony vs tendinous mallet – Extension lag This is a non-peer reviewed restrospective study assessing whether finger mallet lag (at the first assessment) is determined by the type of injury (bony vs soft tissue) or bony fragment size. A total of 131 participants were included in the study. Of these 52 presented with tendinous and 89 with bony mallet injuries. Lag was measured through lateral view radiographs. Bony mallet size was measured as a percentage of the base of the distal phalanx on lateral radiographs. The results showed that bony mallets presented with a smaller lag (average 13°; range 0-38°), whilst tendinous mallets presented with a larger lag (average 33°; range 24-57°). This difference was statistically significant. The average size of the bony mallets fragment was 50% of the articular surface (range 25-80%). Of note, only 5% of the participants included in this study presented with a fragment size smaller than 1/3 of the joint size. There was no correlation between the bony fragment size and lag (see graph). 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, tendon mallet injuries present with larger extension lags compared to bony mallets injuries at the first assessment. In bony mallets, the fragment size is not correlated with the amount of extension lag. This synopsis is a nice addition to an existing one on the treatment of bony mallets greater than 1/3 of the joint surface with or without subluxation . URL : https://doi.org/10.1177/17531934211028133 Available through EBSCO Health Databases for PNZ members. No abstract available

Why do ineffective treatments seem helpful? A brief review. Hartman, S. E. (2009) Level of Evidence : 5 Follow recommendation : 👍 Type of study : Therapeutic Topic : Logical fallacies This article presents with potential explanations to why treatments shown to have no specific effect, may appear to be effective in clinical practice. The following are some of the explanations: - Regression to the mean: Clients often seek treatment when symptoms exacerbate beyond levels usually experienced. What this means is that over time, there is a high likelihood that their symptoms will return to what they used to be before coming to see you (return to their average symptoms = regression to the mean). - Natural history: For acute injuries, no matter what treatment is provided, there is usually an improvement in symptoms over time. - Placebo effect: Your smile , the fact that you are caring for them or providing some sort of therapeutic touch , will boost the client's endogenous analgesia. - Confirmation bias: Imagine that you have been measuring QuickDASH, pain, AROM, PROM, grip strength, and pinch strength. At follow up there is a small improvement in AROM only. It is likely that we will take that as an improvement as we want to confirm that whatever has been done is actually having an effect. - Hope: Imagine that the client has spent 1,500 NZD for three PRP injection for tennis elbow . They are really hoping that they have not been wasting money. They may be looking for some changes, although small and possibly clinically irrelevant, that can justify the money spent rather than recognizing that treatment was ineffective. This is not even to mention that some clients may not even want to tell the health care provider that despite all their efforts, nothing has changed. All these factors may bring us to think that what we have been doing is responsible for the improvements. This logical fallacy is called Post Hoc, Ergo Propter Hoc and has been covered in a previous synopsis . Clinical Take Home Message : Based on what we know today, it is hard, if not impossible, to determine whether our therapeutic intervention is really the cause of improvements in our clients. It is highly probable that other factors, such as the ones identified above, may be responsible (at least in part) for the improvements identified. Keeping an open mind, utilising sound clinical reasoning, and implementing treatments that have been shown to be more effective than placebo, if available, may provide better outcomes for our clients. If you are interested in being aware of other logical fallacies, have a look at this previous synopsis . Last but not least I think that the combination of all the factors mentioned in the article and the use of evidence based treatments will provide the best outcomes. URL : https://www.sciencedirect.com/science/article/abs/pii/S0306987720302437 Possibly available through EBSCO Health Databases for PNZ members. Abstract After any therapy, when symptoms improve, healthcare providers (and patients) are tempted to award credit to treatment. Over time, a particular treatment can seem so undeniably helpful that scientific verification of efficacy is judged an inconvenient waste of time and resources. Unfortunately, practitioners' accumulated, day-to-day, informal impressions of diagnostic reliability and clinical efficacy are of limited value. To help clarify why even treatments entirely lacking in direct effect can seem helpful, I will explain why real signs and symptoms often improve, independent of treatment. Then, I will detail quirks of human perception, interpretation, and memory that often make symptoms seem improved, when they are not. I conclude that healthcare will grow to full potential only when judgments of clinical efficacy routinely are based in properly scientific, placebo-controlled, outcome analysis.

Effects of a progressive resistance exercise program in patients with hand osteoarthritis: A randomized, controlled trial with a blinded assessor. Nery, M., et al. (2021) Level of Evidence : 1b- Follow recommendation : 👍 👍 👍 👍 Type of study : Therapeutic Topic : Resistance training - application in hand OA This is a randomised controlled trial assessing the effectiveness of resistance training exercises for hand OA. A total of sixty participants were included in this study. Participants were included if they presented with the American College of Rheumatology classification criteria, and if their pain was between 3 and 8 points out of 10 on a Numerical Rating Scale at the interphalangeal joints of the hand. Resistance training exercises were compared to control groups undergoing no exercise. Efficacy of intervention was assessed through improvements in pain, function (i.e., AUSCAN), grip and pinch strength. Participants in the training and control group received one educational session on hand OA at baseline. Participants in the control group received no additional interventions. In contrast, participants in the training group also performed resistance exercises for gross grip and intrinsic muscles of the hand, twice a week for twelve weeks. Exercises were performed in groups of up to 5 participants. During each training session, participants performed three sets of 10 repetitions for each exercise in both hands. Unfortunately, the training intensity is unknown as participants were working against elastic resistance. The results showed that there was no statistically significant difference between the exercise and control group on pain, grip or pinch strength. These variables were unchanged from baseline in both groups. Function appeared to improve to a statistically significant level in the resistance training group, however the clinical relevance is unclear because of the scoring method utilised. 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, resistance training interventions do not appear to improve pain or hand strength in clients with interphalangeal OA. At the same time resistance training does not appear to worsen symptoms compared to no exercise in people with symptomatic hand OA. Resistance exercises may improve hand function, however, the extent of these improvements is unclear. These results are consistent with a systematic review and meta analysis covered in a previous synopsis . Considering these results, a multimodal approach to the treatment of hand OA may be more effective to reduce pain (see previous synopsis on the topic). It is also important to remember that clients' expectations on the type of treatment provided will affect treatment results . The good news is that since resistance training does not worsen hand pain, we may be even more inclined to suggest our clients with symptomatic hand OA to follow the World Health Organisation guidelines for physical activity . Thus, people with symptomatic hand OA are at greater risk of cardiovascular disease and physical activity may extend their life span and health span. URL : https://doi.org/10.1177/02692155211030622 Available through EBSCO Health Databases for PNZ members. Abstract Objective To assess the effectiveness of a progressive resistance strength program on pain, function and strength in hand osteoarthritis patients. Design Randomized controlled trial.Settings:Outpatients, University Hospital.Subjects:Sixty hand osteoarthritis patients were randomly allocated to exercise group (n?=?30) or control group (n?=?30).Intervention:The exercise group performed a progressive resistance strength program for hand muscles over 12?weeks. Both groups had a single education session. Main measures The primary outcome was pain intensity (numeric pain scale). The secondary outcomes were the AUSCAN Hand Osteoarthritis Index, Cochin Hand Functional Scale for function and grip and pinch strength. A blinded evaluator performed the evaluations at baseline, 6 and 12 weeks. Results The mean age were 68.9 (8.8) and 64.7 (8.9) for control and exercise groups, respectively. No significant differences between-group was observed for pain after 12 weeks (mean difference between groups was 1.30 (0.02 to 2.62) for dominant hand and 1.33 (0.01 to 2.65) for non-dominant hand at T12, with P=0.085 and 0.295, respectively). Regarding secondary outcomes, statistically significant differences between groups were found in exercise group: AUSCAN index total score (P=0.005), pain (P=0.006), function (P=0.047), and Cochin scale (P=0.042) with the following mean difference between groups: 9.9 (4.07 to 15.73), 3.26 (1.06 to 5.46), 5.03 (1.20 to 8.86), and 6.27 (0.18 to 12.36), respectively. Conclusion No difference was observed for pain (numerical pain scale) after the progressive resistance exercise program performed, however in exercise group, an improvement was observed on secondary outcomes such as pain during activities and function for patients with hand osteoarthritis.

Level of Evidence : 5 Follow recommendation : 👍 Type of study : Diagnostic/Therapeutic Have a think about this case study. Leave a diagnostic comment if you like. I will publish the diagnosis reported by the paper next week. The patient was a 55 years old presenting with right side pain on the lateral antecubital area of elbow/forearm and elbow flexion weakness, which developed over the course of 7 months. They reported cramps in the anterior portion of their arm. Pain was reproduced with elbow flexion in forearm pronation, or in full elbow extension. There was atrophy of the brachialis but biceps function was retained (see picture). Neurological examination identified no central nervous system pathology. Age related changes where identified on cervical MRI. What was it?

Hand osteoarthritis in relation to mortality and incidence of cardiovascular disease: Data from the Framingham heart study. Haugen, I. K., Ramachandran, V. S., Misra, D., Neogi, T., Niu, J., Yang, T., . . . Felson, D. T. (2015) Level of Evidence : 2b Follow recommendation : 👍 👍 👍 Type of study : Prognostic Topic : Symptomatic hand OA - Mortality prediction This is a prospective cohort study assessing the risk of cardiovascular disease and associated mortality in people with symptomatic hand OA. A total of 1,348 participants were included at baseline (1948-1953) and followed up for 60 years (2008-2011). Participants' offspring were included as well in this study. Participants were 50 to 75 years old at baseline. Participants were divided into two groups: participants with symptomatic and radiographic evidence of hand OA, and participants with radiographic hand OA only. The results showed that participants with symptomatic hand OA were at least twice as likely to present with a significant cardiovascular condition (e.g. coronary heart disease) during the course of their life compared to the rest of the sample. People with radiographic but not symptomatic hand OA were at no greater risk that the rest of the population. 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, people with symptomatic hand OA are at least 2 times more likely to develop cardiovascular disease. We should therefore encourage our clients with this condition to keep as active as possible. Remember that previous research showed a relation between grip strength and mortality and walking and mortality . Have a look at the recent WHO 2020 guidelines on physical activity , which will give you an idea of the level and type of exercise that we should recommend to our clients. Clients who do not present with symptomatic hand OA but x-ray evidence of OA do not seem to be at greater risk then other people to develop cardiovascular disease. Open Access URL : https://ard.bmj.com/content/annrheumdis/74/1/74.full.pdf Abstract Objectives: To study whether hand osteoarthritis (OA) is associated with increased mortality and cardiovascular events in a large community based cohort (Framingham Heart Study) in which OA, mortality and cardiovascular events have been carefully assessed. Methods: We examined whether symptomatic (≥1 joint(s) with radiographic OA and pain in the same joint) and radiographic hand OA (≥1 joint(s) with radiographic OA without pain) were associated with mortality and incident cardiovascular events (coronary heart disease, congestive heart failure and/or atherothrombotic brain infarction) using Cox proportional hazards models. In the adjusted models, we included possible confounding factors from baseline (eg, metabolic factors, medication use, smoking/alcohol). We also adjusted for the number of painful joints in the lower limb and physical inactivity. Results: We evaluated 1348 participants (53.8% women) with mean (SD) age of 62.2 (8.2) years, of whom 540 (40.1%) and 186 (13.8%) had radiographic and symptomatic hand OA, respectively. There was no association between hand OA and mortality. Although there was no significant relation to incident cardiovascular events overall or a relation of radiographic hand OA with events, we found a significant association between symptomatic hand OA and incident coronary heart disease (myocardial infarction/coronary insufficiency syndrome) (HR 2.26, 95% CI 1.22 to 4.18). The association remained after additional adjustment for pain in the lower limb or physical inactivity. Conclusions: Symptomatic hand OA, but not radiographic hand OA, was associated with an increased risk of coronary heart disease events. The results suggest an effect of pain, which may be a possible marker of inflammation.

Risk of infection in thumb carpometacarpal surgery after corticosteroid injection. Qin, M. M., C. D. Qin, D. J. Johnson and D. M. Kalainov (2021) Level of Evidence : 4 Follow recommendation : 👍 👍 👍 Type of study : Prognostic Topic : 1st cmcj OA injections - Are they worth it? This is a retrospective study assessing post-surgical complications in clients who underwent cortisone injection (3 months prior to surgery) vs those who did not (for a least 6 months prior to surgery), before surgery for symptomatic 1st cmcj OA. Different surgical procedures were provided across the sample (e.g. suspension arthroplasty). A total of 3,733 participants, took part in this study. Of these, 3,047 (82%) did not receive a cortisone injection in the 1st cmcj for at least 6 months prior to surgery, and 686 (18%) received at least one 1st cmcj cortisone injection three months prior to surgery. The outcome assessed was the number of infections at the surgical site or the presence of additional surgery for wound complications within 90 days from surgery. The results showed that there was no difference between groups in terms of number of wound complications within 90 days from surgery. However, the number of participants that required surgery for those complications was statistically significant higher in the group who received a 1st cmcj cortisone injection within 3 months prior to surgery (n = 15; 2.2% of sample), compared to those who did not receive one in the 6 month prior (n = 32; 1.1% of the sample). We need to keep in mind that this is a retrospective study and the association between recent cortisone injections and surgery for wound complications may be mediated by a third variable which was not measured. This is therefore a limitation of the study. 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, cortisone injections for 1st cmcj OA provided 3 months prior to surgery may increase the probability of requiring a second surgery for wound complications. In particular, it appears that 1 person in 50 will require a second surgery surgery for wound complication if they received a cortisone injections in the 3 months prior surgery. In contrast, it appears that 1 person in 100 will require a second surgery surgery for wound complication if they did not have a cortisone injections for at least 6 months prior to surgery. The findings from this study are consistent with previous research in 1st cmcj OA and research showing an increase risk of post surgical infections in other joint (e.g. hip ). Considering that the effectiveness of cortisone injections for 1st cmcj OA is not superior to placebo , their use may be questionable. Our clients should be provided with this information and the risks vs benefits of having an injection just prior to surgery may be discussed. This may provide them with a chance to make an informed decision about the most suitable therapeutic option for their needs. URL : https://doi.org/10.1016/j.jhsa.2021.04.010 Available through The Journal of Hand Surgery (American Volume) for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Purpose The purpose of this study was to determine whether patients who had an intra-articular corticosteroid injection into the thumb carpometacarpal (CMC) joint for the treatment of arthritis within the 3 months before CMC joint arthroplasty or arthrodesis were at increased risk for wound complication/infection and/or repeat surgery for wound complication/infection in comparison with patients who did not receive an injection within 6 months or who received an injection between 3 and 6 months before surgery. Methods We identified 5,046 patients in the Humana claims database who underwent surgery for CMC joint arthritis. The patients were stratified into 3 groups: (1) no thumb injection within 6 months of CMC joint surgery, (2) thumb injection between 3 and 6 months before CMC joint surgery, and (3) thumb injection within 3 months before CMC joint surgery. The primary outcome was wound complication/infection within 90 days after surgery. The secondary outcome was repeat surgery for wound complication/infection within 90 days after surgery. Multivariable logistic regression was performed to assess the associations between the timing of injection and wound complication/infection and repeat surgery for wound complication/infection. Results The rates of wound complication/infection within 90 days after surgery were similar among the 3 study groups. However, patients who received an intra-articular corticosteroid injection within 3 months before surgery had a 2.2 times greater likelihood of repeat surgery for a wound complication/infection compared with patients who did not have an injection within 6 months before surgery. Conclusions Patients who receive an intra-articular corticosteroid injection within the 3 months before surgery for CMC joint arthritis may be at increased risk of repeat surgery to treat a wound complication/infection in the 90-day postoperative period.