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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.

Strength training is as effective as stretching for improving range of motion: A systematic review and meta-analysis. Afonso, J., et al. (2021). Level of Evidence : 1a- Follow recommendation : 👍 👍 👍 👍 Type of study : Therapeutic Topic : Resistance training and stretching - Range of movement improvements This is a systematic review and meta-analysis assessing the effectiveness of resistance training and stretching exercises on joint range of movement. Eleven RCTs were included in the systematic review, for a total of 452 participants. Participants included had a wide age range, health status (healthy and persistent pain). All the studies were included in the meta-analysis and they were assessed through the Risk of Bias criteria recommended by the Cochrane Review Group. 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. Resistance training exercises were compared to stretching exercises. Efficacy of intervention was assessed through active and passive range of movement of lower and upper limb joints. Interventions duration ranged betwee 5 and 16 weeks, with a maximum training frequency of 5 and a minimum of 2. The assessment time points varied significantly, and they ranged from 6 to 24 weeks. Moderate quality evidence showed that stretching or resistance training provided similar range of movement improvements by the end of the training regime. 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 or stretching interventions appear to be equally effective in improving range of movement. Either intervention can be used if the goal of treatment is to improve range of movement in our clients. However, if resistance training is well tolerated, it may be the best option. Thus, the international guidelines for physical activity advise on the implementation of resistance training across all ages. Stretching is only mentioned as an adjunct to aerobic and resistance training for pregnant women. Open access URL : https://osf.io/preprints/metaarxiv/2tdfm/ Abstract Background: Range of motion (ROM) is an important feature of sports performance and health. Stretching is usually prescribed to improve promote ROM gains, but evidence has suggested that strength training (ST) also improves ROM. However, it is unclear if its efficacy is comparable to stretching. Objective: To perform a systematic review and meta-analysis of randomized controlled trials (RCTs) assessing the effects of ST and stretching on ROM. Protocol: INPLASY: 10.37766/inplasy2020.9.0098. Data sources: Cochrane Library, EBSCO, PubMed, Scielo, Scopus, and Web of Science were consulted in early October 2020, followed by search within reference lists and consultation of four experts. No constraints on language or year. Eligibility criteria (PICOS): (P) humans of any sex, age, health or training status; (I) ST interventions; (C) stretching interventions (O) ROM; (S) supervised RCTs. Data extraction and synthesis: Independently conducted by multiple authors. Quality of evidence assessed using GRADE; risk-of-bias assessed with RoB 2. Results: Eleven articles (n = 452 participants) were included. Pooled data showed no differences between ST and stretching on ROM (ES = -0.22; 95% CI = -0.55 to 0.12; p = 0.206). Sub-group analyses based on RoB, active vs. passive ROM, and specific movement-per-joint analyses for hip flexion and knee extension showed no between-protocol differences in ROM gains. Conclusion: ST and stretching were not different in improving ROM, regardless of the diversity of protocols and populations. Barring specific contra-indications, people who do not respond well or do not adhere to stretching protocols can change to ST programs, and vice-versa.

Pain during physical examination of a healing upper extremity fracture. Gonzalez, A. I., Kortlever, J. T. P., Crijns, T. J., Ring, D., Reichel, L. M., & Vagner, G. A. (2020) Level of Evidence : 2c Follow recommendation : 👍 👍 👍 Type of study : Prognostic Topic : Fracture tenderness - Healing This is a prospective study assessing the correlation between clients ability to cope with pain in daily life and tenderness on palpation of a hand or wrist fracture. A total of 117 participants were included. Of these participants 33% had a distal radius fracture, 21% had a metacarpal fracture, (18%) and phalanx fracture (the remaining 34% had other upper limb fractures). All of the participants included, presented with fractures which were unlikely to present complications or prolonged healing times (e.g. displaced). Clients ability to cope with pain in daily life was assessed through the Pain Self-Efficacy Questionnaire - Two-Item Short Form (PSEQ-2) ( scroll to the bottom of the link to find this handy questionnaire), and the PROMIS CATs for physical function, depression, and pain interference (score it yourself or use it for your clients - Try the PROMIS CAT Demo>> ). Tenderness on palpation at the fracture site was scored on a 0 to 10 numerical rating scale. Participants were assessed 3 to 6 weeks post injury. On average, participants were over 48 years old. The results showed that participants presenting with greater pain interference and lower self efficacy, presented with greater tenderness on palpation at the fracture site. This study did not objectively assess fracture's union because there is currently no gold standard that can measure this outcome. It is possible that delayed union affected participants' pain and as a results this affected their ability to cope with pain (this is a limitation of the study). This last option is however unlikely due to the type of fractures assessed, which usually heal fast without complications. Clinical Take Home Message : Based on what we know today, hand therapists may not decide on extending or reducing a fracture's immobilisation period based on tenderness on palpation of the fracture site. It appears that clients presenting with limited coping strategies report greater pain with fracture palpation. Traditional fracture healing times may be a better guide, compared to pain, in deciding how long a fracture should be immobilised. URL : https://journals.sagepub.com/doi/abs/10.1177/1753193420952010 You can ask the authors for the full text through Research Gate Available through EBSCO Health Databases for PNZ members. Abstract The evidence that symptom intensity and magnitude of limitations correlate with thoughts and emotions means that subjective signs, such as pain with physical examination, reflect both physical and mental health. During a 1-month evaluation of a rapidly healing upper extremity fracture with no risk of nonunion, 117 people completed measures of adaptiveness to pain and pain during the physical examination. Greater pain during examination correlated with less adaptive responses to pain and older age. This finding raises questions about using tenderness to assess fracture union.

Effect of neural mobilization on nerve-related neck and arm pain: A randomized controlled trial. Basson, C. A., A. Stewart, W. Mudzi and E. Musenge (2020). Level of Evidence : 1b Follow recommendation : 👍 👍 👍 👍 Type of study : Therapeutic Topic : Nerve pain - Usual care vs usual care plus neural mobilisation This is a randomised, single-blind, controlled trial assessing the effectiveness of nerve gliding on pain, function, and quality of life in participants with nerve-related neck and arm pain. Participants (N = 78) were included if they presented with clinical signs of neck pain associated with nerve-related symptoms (participants had to had positive neurodynamic tests and allodynia on peripheral nerve palpation). Pain was assessed through the Numerical Rating Scale (NRS), function through the Patient Specific Functional Scale (PSFS), and quality of life through the EuroQol-5. Participants were randomised (2:1) to either usual care (n = 25), or usual care plus neural mobilisation (n = 53). The usual care included cervical and thoracic mobilisation, exercises and the advice to keep active. The experimental group received the usual care plus mobilisation of the tissues surrounding the peripheral nerve involved (e.g. pronator teres for median nerve). On average, participants were treated over 4 sessions. Outcomes were measured at baseline, 3, 6 weeks, 6 months, and one year. The results showed that participants in all groups improved by one year. There were no differences between groups in function and quality of life. Pain was significantly better at 6 months for the usual care plus neural mobilisation, however, this difference was not clinically relevant (see picture below). Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message : Based on what we know today, the addition of neural mobilisation to an evidence based program for people with nerve-related cervical and arm pain does not provide better results. In contrast, neural mobilisation may be helpful for clients presenting with isolated carpal tunnel syndrome . If you are interested, you can also r educe the likelihood of clients undergoing carpal tunnel surgery by adding a night splint and education to your intervention. Finally, have a look at what is the most effective and safe nerve gliding approach for carpal tunnel syndrome . URL : https://www.utpjournals.press/doi/abs/10.3138/ptc-2018-0056 Available through EBSCO Health Databases for PNZ members. Abstract Purpose: Neural mobilization (NM) is often used to treat nerve-related conditions, and its use is reasonable with nerve-related neck and arm pain (NNAP). The aims of this study were to establish the effect of NM on the pain, function, and quality of life (QOL) of patients with NNAP and to establish whether high catastrophizing and neuropathic pain influence treatment outcomes. Method: A randomized controlled trial compared a usual-care (UC; n = 26) group, who received cervical and thoracic mobilization, exercises, and advice, with an intervention (UCNM; n = 60) group, who received the same treatment but with the addition of NM. Soft tissue mobilization along the tract of the nerve was used as the NM technique. The primary outcomes were pain intensity (rated on the Numerical Pain Rating Scale), function (Patient-Specific Functional Scale), and QOL (EuroQol-5D) at 3 weeks, 6 weeks, 6 months, and 12 months. The secondary outcomes were the presence of neuropathic pain (using the Neuropathic Diagnostic Questionnaire) and catastrophizing (Pain Catastrophising Scale). Results: Both groups improved in terms of pain, function, and QOL over the 12-month period (p < 0.05). No between-groups differences were found at 12 months, but the UCNM group had significantly less pain at 6 months (p = 0.03). Patients who still presented with neuropathic pain (p < 0.001) and high pain catastrophizing (p = 0.02) at 6- and 12-mo follow-ups had more pain. Conclusions: Both groups had similar improvements in function and QOL at 12-month follow-up. The UCNM group had significantly less pain at 6-month follow-up and a lower mean pain rating at 12-month follow-up, although the difference between groups was not significant. Neuropathic pain is common among this population and, where it persisted, patients had more pain and functional limitations at 12-mo follow-up.

Excursion of the median nerve during a contra-lateral cervical lateral glide movement in people with and without cervical radiculopathy. Thoomes, E., R. Ellis, A. Dilley, D. Falla and M. Thoomes-de Graaf (2021) Level of Evidence : 3b Follow recommendation : 👍 👍 Type of study : Aetiologic, Prognostic Topic : Cervical radiculopathy - Median nerve gliding This is a case-control study assessing differences in median nerve gliding in participants with and without cervical radiculopathy during a contralateral cervical lateral glide. A total of 40 participants were included in the study. Cervical radiculopathy was diagnosed through clinical examination through a positive upper limb neurodynamic test (ULNT of median/ulnar/radial nerve) and/or Spurling's test and confirmed through MRI. Controls were participants who did not present with neck/arm pain and had a negative Spurling's or ULNT tests. Median nerve gliding was assessed just proximal to the wrist and elbow through an ultrasound machine. The contralateral cervical lateral glide was performed within a pain-free range and the amount of movement was recorded by a machine in which the head was positioned. The results showed that there was no difference in the amount of pain free contralateral cervical lateral glide between cervical radiculopathy and healthy participants. In other words, the range of movement was similar. There was a significant difference in the amount of median nerve gliding between the participants with and without cervical radiculopathy. In particular, healthy participants had a median glide of 2-3.5 mm vs 0.5-1.2 mm in participants with cervical radiculopathy. This difference resolved after three months. During these three months, the cervical radiculopathy was treated conservatively with exercises, manual therapy, nerve glides, and medications. Unfortunately, we are not sure whether these intervention contributed or not to the improvement in medial nerve glide recovery because no wait and see group with radiculopathy was included in 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, clients with cervical radiculopathy present with reduced median nerve gliding in the upper limb compared to healthy controls. It is possible that these impairments may contribute to pain and functional deficits. Currently, there is no evidence supporting the use of specific neural mobilisation interventions for upper limb nerve related pain and active range of movement and resistance exercises for the neck may suffice to provide clinically significant improvements . URL : https://doi.org/10.1016/j.msksp.2021.102349 Available through EBSCO Health Databases for PNZ members. Abstract Background: A segmental, contra-lateral cervical lateral glide (CCLG) mobilization technique is effective for patients with cervical radiculopathy (CR). The CCLG technique induces median nerve sliding in healthy individuals, but this has not been assessed in patients with CR. Objective This study aimed to 1) assess longitudinal excursion of the median nerve in patients with CR and asymptomatic participants during a CCLG movement, 2) reassess nerve excursions following an intervention at a 3-month follow-up in patients with CR and 3) correlate changes in nerve excursions with changes in clinical signs and symptoms. Design Case-control study. Methods: During a computer-controlled mechanically induced CCLG, executed by the Occiflex™, longitudinal median nerve excursion was assessed at the wrist and elbow with ultrasound imaging (T0) in 20 patients with CR and 20 matched controls. Patients were re-assessed at a 3-month follow-up (T1), following conservative treatment including neurodynamic mobilization. Results: There was a significant difference between patients and controls in the excursion of the median nerve at both the wrist (Mdn = 0.50 mm; IQR = 0.13–1.30; 2.10 mm (IQR = 1.42–2.80, p < 0.05)) and elbow (Mdn = 1.21 mm (IQR = 0.85–1.94); 3.49 mm (IQR = 2.45–4.24, p < 0.05)) respectively at T0. There was also a significant increase in median nerve excursion at both sites between T0 and T1 in those with CR (Mdn = 1.96, 2.63 respectively). Wilcoxon Signed-Ranks Test indicated median pre-test ranks (Mdn = 0.5, 1.21; Z = - 3.82, p < 0.01; Z = −3.78, p < 0.01 respectively) and median post-test ranks. There was a strong correlation between improvement in median nerve excursion at the elbow at T1 and improvement in pain intensity (r = 0.7, p < 0.001) and functional limitations (r = 0.6, p < 0.01). Conclusion: Longitudinal median nerve excursion differs significantly between patients with CR and asymptomatic volunteers at baseline, but this difference is no longer present after 3 months of conservative physiotherapy management. Improvement in nerve excursion correlates with improvement in clinical signs and symptoms.

The effect of exercise on cervical radiculopathy: A systematic review and meta-analysis. Irby, A., Gutierrez, J., Chamberlin, C., Thomas, S. J., & Rosen, A. B. (2020) Level of Evidence : 1a- Follow recommendation : 👍 👍 👍 👍 Type of study : Therapeutic Topic : Cervical radiculopathy – Conservative treatment This is a systematic review and meta-analysis of randomised controlled trials assessing the effectiveness of exercise for cervical radiculopathy. Ten randomised controlled trials were included for a total of 751 participants. The results from this systematic review and meta-analysis were assessed through the GRADE approach (suggested by the Cochrane Group), which scores the evidence as "very low", "low", "moderate", or "high" quality. Efficacy of intervention was assessed through changes in pain and function. Pain was assessed through the visual analogue scale (VAS) (9 studies) and function was assessed through the Neck Disability Index (NDI) (5 studies). The quality of evidence was "low", suggesting that there is limited confidence in the estimated effect of exercise on pain and function for cervical radiculopathies. Exercises included range of movement and graded resistance exercises for the superficial and deep neck muscles. There was however a lack of detailed description in the interventions. The control groups either provided no exercises or conservative interventions other than exercise. The results showed that exercises provided a statistically and clinically significant change in pain of 2.8 ( 95%CI : 1.4 to 4.2) points out of 10 (this change was calculated from the study by Kuijper et al. (2009) based on the standardised mean difference provided). There was also a statistically significant but not clinically relevant change in function, showing a 3.6 point ( 95%CI : 6.3 to 1) point change in the NDI. The minimal clinically important change for the NDI is 10 points, which was not achieved through exercise. 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 : Clients often present to hand therapists with symptoms that suggest a double crush syndrome (e.g. carpal tunnel syndrome and cervical radiculopathy). In these cases, it may be beneficial to include cervical exercises if there are symptoms and signs suggesting a cervical radiculopathy. Exercises may be useful to improve pain but not function. Open Access URL : https://journals.lww.com/md-journal/Fulltext/2019/11080/The_effect_of_exercise_on_cervical_radiculopathy_.18.aspx

Diagnostic accuracy of patient interview items and clinical tests for cervical radiculopathy. Sleijser-Koehorst, M. L. S., et al. (2020) Level of Evidence : 2b Follow recommendation : 👍 👍 Type of study : Diagnostic Topic : Cervical radiculopathy – Interview items and physical tests This is a prospective study assessing the usefulness of subjective information and physical tests in making a diagnosis of cervical radiculopathy. A total of 134 participants who were referred to a multidisciplinary team with a suspicion of cervical radiculopathy by their doctors were included in the study. Participants with rehumatological, diabetes, polineuropathies, or other neurological comorbidities were excluded. The variables of interest were the sensitivity and specificity of subjective information provided by participants and the result of physical tests. If a test is very sensitive and its result is negative, you can be more certain that the patient does not have the condition. If the test is specific and its result is positive, you can be more certain that the patient has the condition. The physical tests assessed were the Spurling, upper limb neurodynamic for median nerve, shoulder abduction test for pain relief, cervical distraction, and neurological examination including muscle, sensory, and reflex testing. The gold standard against which these tests were compared was the combination of a neurosurgeon diagnosis of cervical radiculopathy and MRI imaging confirming a root encroachment consistent with the symptoms reported. The average age of the participants was 50 with 68% of participants between the age of 40 and 60. Out of the 134 participants, 66 had a confirmed cervical radiculopathy whilst 68 did not. The ones with a cervical radiculopathy most often presented with a radiculopathy of C6 or C7. The results of the study showed that the absence of paraesthesia and/or numbness on subjective examination reduced the probability of participants presenting with a cervical radiculopathy (sensitive). No physical tests were useful in the exclusion of cervical radiculopathy. The presence of arm pain being worse than neck pain, a positive Spurling test, and reduced reflexes increased the probability of a cervical radiculopathy (specific). Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message : Based on what we know today, hand therapists may use a combination subjective (see in synopsis above) and objective tests to reduce or increase the probability of a cervical radiculopathy in their clients. The arm squeeze test has previously shown to be useful as a screening and diagnostic test. In addition, the present study confirmed one more time that the Spurling test is useful in making a diagnosis of cervical radiculopathy (see previous synopsis ). In addition, this is the first study (that I am aware of) assessing the usefulness of deep tendon reflexes for cervical radiculopathy. The results suggest that a reduction in upper limb reflexes increases the probability of cervical radiculopathy. Have a look at this previous synopsis on myotomes testing for cervical radiculopathy. URL : https://www.sciencedirect.com/science/article/pii/S003194062030393X Available through EBSCO Health Databases for PNZ members. Abstract Objective: To determine the diagnostic accuracy of patient interview items and clinical tests to diagnose cervical radiculopathy. Design: A prospective diagnostic accuracy study. Participants Consecutive patients (N=134) with a suspicion of cervical radiculopathy were included. A medical specialist made the diagnosis of cervical radiculopathy based on the patient's clinical presentation and corresponding Magnetic Resonance Imaging findings. Participants completed a list of patient interview items and the clinical tests were performed by a physiotherapist. Main outcome measures: Diagnostic accuracy was determined in terms of sensitivity, specificity, and positive (+LR) and negative likelihood ratios (−LR). Sensitivity and specificity values ≥0.80 were considered high. We considered +LR≥5 and −LR≤0.20 moderate, and +LR≥10 and −LR≤0.10 high. Results: The history items ‘arm pain worse than neck pain’, ‘provocation of symptoms when ironing’, ‘reduction of symptoms by walking with your hand in your pocket’, the Spurling test and the presence of reduced reflexes showed high specificity and are therefore useful to increase the probability of cervical radiculopathy when positive. The presence of ‘paraesthesia’ and ‘paraesthesia and/or numbness’ showed high sensitivity, indicating that the absence of these patient interview items decreases the probability of cervical radiculopathy. Although most of these items had potentially relevant likelihood ratios, none showed moderate or high likelihood ratios. Conclusions: Several patient interview items, the Spurling test and reduced reflexes are useful to assist in the diagnosis of cervical radiculopathy. Because there is no gold standard for cervical radiculopathy, caution is required to not over-interpret diagnostic accuracy values.