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Determining C5, C6 and C7 myotomes through comparative analyses of clinical, MRI and EMG findings in cervical radiculopathy. Furukawa, Y., et al. (2021). Level of Evidence : 2b Follow recommendation : 👍 👍 👍 Type of study : Diagnostic Topic : Cervical radiculopathy – Myotomes This is a retrospective study assessing the presence of weakness in key upper limb muscles of participants presenting with a single level radiculopathy. Participants (N = 25) were included if they presented with a single level cervical radiculopathy (identified through MRI) at the C5, C6, C7 level, if they had been having symptoms of radiculopathy for at least one month, if they presented with a positive Spurling's, reflex changes, EMG abnormalities of at least one upper limb muscle, and if they reported sensory disturbances. Potential participants were excluded if they presented with multilevel radiculopathy, or if EMG investigations identified no abnormalities. The results showed that weakness of deltoid and infraspinatus muscles were present in all participants with a C5 lesion (n = 10). Wrist extensors were weak in most participants (83%) with a C6 radiculopathy (n = 6). The triceps was weak in all participants with a C7 radiculopathy (See figure below). Clinical Take Home Message : Based on what we know today, manual muscle testing of deltoid (C5), wrist extensors (C6), and triceps (C7) may be useful for a quick myotome assessment in clients who we suspect presenting with a cervical radiculopathy. It is important to remember that dermatomal patterns, which are often suggested as useful in the determination of cervical radiculopathy level, only follow textbooks patterns in 54% of cases . Once we diagnose clients with a cervical radiculopathy, AROM exercises for the neck have been suggested to be useful in its management . Despite evidence of reduced nerve gliding in clients with cervical radiculopathy, nerve gliding techniques do not appear to provide significant pain relief . Open Access URL : https://doi.org/10.1016/j.cnp.2021.02.002 Abstract Objective: There are many myotome charts in the literature, but few studies have presented actual data to support their identification. We aimed to determine C5/C6/C7 myotomes based on clinical and EMG data of patients with cervical spondylotic radiculopathy (CSR) having a single-root lesion confirmed by MRI. Methods: Medical Research Council (MRC) scores and EMG findings were retrospectively reviewed for patients enrolled from our EMG database. Results: Enrolled were 25 patients (10 C5, 6 C6, and 9 C7 CSR). In C5 CSR, weakness or denervation potentials in EMG, or both, were observed in the deltoid (Del) and infraspinatus (Isp) muscles for all patients, and in the biceps brachii (BB) and brachioradialis (BR) muscles for 9/10 and 8/9 patients, respectively. In C6 CSR, weakness of the wrist extensor and/or denervation of the extensor carpi radialis longus (ECRL)/extensor carpi radialis brevis (ECRB), and those of the pronator teres (PT) were observed for all patients. Weakness was not observed for any other muscle in C6 CSR. Denervation potentials of ECRL were found in 5/8 and 3/5 patients with C5 and C6 CSR, respectively, whereas those of ECRB were found in 1/5, 6/6, and 2/5 patients with C5, C6 and C7 CSR, respectively. In C7 CSR, weakness/denervation of the triceps brachii (TB) and denervation potentials of the flexor carpi radialis (FCR) were observed for all patients. Denervation potentials in PT and weakness/denervation of the extensor digitorum (ED) were observed in 2/9 and 4/9 patients, respectively. Conclusion: Suggested dominant myotomes are: C5 for the Del, Isp, BB, and BR, C5/6 for the ECRL, C6 > C7 for the ECRB and PT, and C7 for the TB and FCR. Significance The current study identified dominant myotomes that differ from the existing literature.

Patient expectations about a clinical diagnostic test may influence the clinician's test interpretation. Coppieters, M. W., B. Rehn and M. L. Plinsinga (2021) Level of Evidence : 2b Follow recommendation : 👍 👍 👍 Type of study : Diagnostic Topic : Client's expectations - Physical tests This is an experiment assessing the effect of client's expectations on pain intensity and area during physical tests. A total of 15 healthy participants were included in the present study. All participants were injected with a hypersaline solution in the thenar muscle of the tested hand to cause a pain response. All participants subsequently underwent median nerve neurodynamic test (see Figure 1 below), during which changes in pain intensity and area were recorded. Prior to the injection and testing, all participants received general information regarding the nature of the neurodynamic test (gradual increase in nerve stretch). However, participants randomised to the "nerve pain group" (n = 7) were told that their pain was caused by irritation of nerve receptors (n = 7; "nerve pain group") whilst the participants randomised to the "muscle pain group" (n = 8) were told that the injection would cause muscle pain. The results showed that the "nerve pain group" presented a statistically and clinically relevant increase in pain intensity (1.6 points out of 10) and pain area (80% increase in painful area) from the least stretched (-2) to the most stretched position (+2) during the median nerve neurodynamic test. In contrast, no change in pain intensity or area was noted in the "muscle pain group" (see Figure 2 below). Figure 1 Figure 2 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, expectations of increased pain during physical tests can increase the pain intensity and painful area in our clients. Even if we don't tell them that the test will cause them pain, if they have an understanding of the physical test, their pain response can be influenced. This may be one of the reason why fracture tenderness on palpation is an unreliable indicator or fractures' healing . This study also highlights the importance of the words and behaviors we implement with our clients as they can increase or decrease their pain. We can conclude that expectations not only play role in the treatment but also in the assessment of our clients. URL : https://doi.org/10.1016/j.msksp.2021.102387 Available through EBSCO Health Databases for PNZ members. Abstract Background: With medical information widely available, patients often have preconceived ideas regarding diagnostic procedures and management strategies. Objectives: To investigate whether expectations, such as beliefs about the source of symptoms and knowledge about diagnostic tests, influence pain perception during a clinical diagnostic test. Design: Cross-sectional study. Methods: Pain was induced by intramuscular hypertonic saline infusion in the thenar muscles. In line with sample size calculations, fifteen participants were included. All participants received identical background information regarding basic median nerve biomechanics and basic concepts of differential diagnosis via mechanical loading of painful structures. Based on different explanations about the origin of their induced pain, half of the participants believed (correctly) they had ‘muscle pain’ and half believed (incorrectly) they had ‘nerve pain’. Pain intensity and size of the painful area were evaluated in five different positions of the median nerve neurodynamic test (ULNT1 MEDIAN). Data were analysed with two-way analyses of variance. Results /findings: Changes in pain in the ULNT1 MEDIAN positions were different between the ‘muscle pain’ and ‘nerve pain’ group (p < 0.001). In line with their expectations, the ‘muscle pain’ group demonstrated no changes in pain throughout the test (p > 0.38). In contrast, pain intensity (p ≤ 0.003) and size of the painful area (p ≤ 0.03) increased and decreased in the ‘nerve pain’ group consistent with their expectations and the level of mechanical nerve loading. Conclusion: Pain perception during a clinical diagnostic test may be substantially influenced by pain anticipation. Moreover, pain was more aligned with beliefs and expectations than with the actual pathobiological process.

Increasing incidence of hand and distal upper extremity injuries associated with electric scooter use. LaGreca, M., C. J. Didzbalis, N. C. Oleck, J. S. Weisberger and H. S. Ayyala (2021) Level of Evidence : 2b Follow recommendation : 👍 👍 Type of study : Preventative Topic : Electric scooters - Injury incidence This is a retrospective study on the number of injuries associated with electronic scooters/skateboards from 2010 to 2019. A total of 26,000 injuries were estimated to have occurred due to electronic scooter/skateboard, when the American National Electronic Injury Surveillance System (NEISS) was reviewed (see graph). The number of injuries had increased 240% during this nine years period. The most common injury was fracture (55%) of the upper limb. 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, it appears that the number of electric scooters/skateboards injuries has been increasing in the last 10 years. This appears to be reasonable considering the increased use of these devices. There was however no comparison to the number of injuries from non electric scooters/skateboards. This would have been relevant as it is possible that whilst the number of electric scooters injuries went up (due to greater use), the number of non electric scooters/skateboards injuries may have gone down, potentially leaving the total number of injuries unchanged. URL : https://doi.org/10.1016/j.jhsa.2021.05.021 Available through The Journal of Hand Surgery (American Volume) for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Purpose Electric scooters (e-scooters) have seen an increase in popularity in cities across the United States as a form of recreation and transportation. The advent of ride-sharing applications allows anyone with a smartphone to easily access these devices, without any investment or experience required. In this study, the authors analyze scooter-related injuries of the hand and upper extremity. Methods The National Electronic Injury Surveillance System (NEISS) was queried to look for injuries related to the use of e-scooters between 2010 and 2019. Data collected included demographic information, the location of the injury, the injury diagnosis, and disposition. National estimates (emergency room visits in the United States) were calculated using the weight variable included in the NEISS database. Miscoded reports were excluded. As a corollary, Google Trends data were utilized to establish a correlation between e-scooter-related injuries and the relative number of e-scooter hits on the Google search engine. Results From 2010 to 2019, there were 730 e-scooter-related injuries reported to the NEISS database. This corresponds to an estimated 26,412 injuries nationally during this time period. The incidence of scooter-related injuries increased by over 230% (2,130 national injuries in 2010; 7,213 national injuries in 2019; relative difference 5,083). Injuries most commonly occurred in patients aged 10 to 18 years (30.3%). The most frequent site of injury was the wrist (41.9%). The most common injury diagnosis was fracture (55.3%). Additionally, there was a correlation between the number of Google Trends e-scooter hits and the number of injuries during this time period. Conclusions The incidence of e-scooter-related upper extremity injuries increased dramatically in the United States between 2010 and 2019. Clinical relevance As novel e-scooter-sharing apps become increasingly popular, it is imperative that users are educated about the risk of injury and that use of proper protective equipment is encouraged.

Volar tilt of the lunate after open reduction internal fixation of a distal radius fracture. Bakker, D., et al. (2021) Level of Evidence : 4 Follow recommendation : 👍 Type of study : Aetiology/Diagnostic Topic : Distal radius fracture - is this a VISI? This is a case series assessing the alignment of the lunate post distal radius fracture. A total of five participants were included in the present study. What the x-rays showed was that after a distal radius fracture some people present with a volar tilt of the lunate on lateral x-ray views. This alignment suggested the presence of a volar intercalated segmental instability (VISI) due to a lunotriquetral (LT) injury (See picture). However, on further investigations, a similar alignment was identified on the contralateral side of one of the participants. In the other cases, arthroscopy was completed to "repair" the LT ligament, but no lesion was identified. 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, after a distal radius fracture, we may note a volar alignment of the lunate, which may or may not be associated with a LT ligament injury. Personally, from now on, I will refer clients for bilateral x-rays when I suspect a LT ligament injury. We are already doing this when we suspect a scapholunate (SL) injury by referring clients for a "clenched fist pencil view" . If you want to sharpen your diagnostic skills, look at this previous synopsis on VISI and DISI or this other one on extrinsic wrist ligament injuries . Finally, if you were confused by the imaging shown above, do not despair, even the surgeons that wrote this article were unclear of why some people present with it! URL : https://doi.org/10.1016/j.jhsa.2020.06.016 Available through EBSCO Health Databases for PNZ members. Abstract The pathophysiology of carpal adaptations after fracture of the distal radius is incompletely understood. We report 5 patients who had normal carpal alignment on injury radiographs that developed marked volar angulation of the lunate during recovery from volar plate fixation of a fracture of the distal radius. There were no signs of alteration of the carpal ligaments. Two patients had similar volar tilt on the contralateral side. The cause and optimal treatment of carpal malalignment after restoration distal radial alignment are unclear.

Recovery of grip strength and hand dexterity after distal radius fracture: A two-year prospective cohort study. Bobos, P., G. Nazari, E. A. Lalone, R. Grewal and J. C. MacDermid (2017) Level of Evidence : 1b- Follow recommendation : 👍 👍 👍 Type of study : Prognostic Topic : Distal radius fractures - Strength and dexterity deficits This is a prospective cohort study assessing the level of grip strength and dexterity impairments at short and long term after distal radius fracture. A total of 154 participants with a distal radius fracture were included. In total, 73% of these participants had undergone surgery. In addition, 80% of the whole sample were female and the average age was 54 years old. Grip strength and hand dexterity were measured at 3, 6, 12, and 24 months. Grip strength was assessed through a hand held dynamometer whilst hand dexterity was assessed through the NK dexterity board . The results showed that at 3 and 6 months grip strength was clinically significantly lower than the contralateral side (more than 6.5 kg deficit). These impairments no longer reached a clinically significant level at 12 or 24 months. Hand dexterity was impaired only at 3 months with normalisation at 6, 12, and 24 months. 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, grip strength deficits are no longer clinically relevant at 12 months post distal radius fracture. In addition, hand dexterity seems to improve to a large extent after the 3 months mark without relevant impairments by the 6 months mark. If you are interested in knowing how minimal clinically relevant differences are calculated, head over to this previous synopsis . A synopsis on clinically relevant changes in grip strength will come out in the following weeks. Remember that it may be important to follow clients with a distal radius fracture for longer if they present with diabetes, as this appears to be associated with a slower functional recovery compared to clients without this condition . Also remember that in older female clients with a distal radius fracture, a bone mass density scan is advised as this may reduce the risk of additional fractures . URL : https://doi.org/10.1177/1758998317731436 Available through Hand Therapy for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Introduction Clinicians often evaluate deficits after an injury by comparing the injured and uninjured side. It is important to understand what deficits occur in hand function after distal radius fracture, how they change over time and their clinical relevance. The purpose of this study was to evaluate the differences in grip strength and hand dexterity between the injured and uninjured hands of patients two years following distal radius fracture. Methods Patients with distal radius fracture were recruited in a specialized hand clinic. Grip strength and hand dexterity were examined bilaterally with a Jamar hand-held dynamometer and with the NK dexterity device at 3, 6, 12 and 24 months post-injury respectively. Generalized linear modeling was performed, with age and sex as covariates to assess changes over time, and between sides. Results Patients (n?=?154) exhibited mean differences of grip strength between injured and uninjured side at 3 months (12.09 kg) and 6 months (7.47 kg) follow-up. The associated deficit standardized response means (SRM) were 1.30 and 0.73, respectively. At 2-years follow-up the mean deficit on the injured side was 2.30 kg with SRM=0.22. One hundred and eleven patients who completed dexterity testing demonstrated small to trivial side to side differences across all time points. Conclusions There were clinically important differences in grip strength between the injured and uninjured hands in patients with a distal radius fracture at 3 and 6 months? follow-up. However, at 12 and 24 months, grip strength differences were small and of uncertain clinical importance. Trivial to small differences in hand dexterity can be expected between the injured and uninjured hand by 2 years after distal radius fracture.

A proximal interphalangeal joint custom-made orthosis in trigger finger: Functional outcome. Pataradool, K. and C. Lertmahandpueti (2021) Level of Evidence : 4 Follow recommendation : 👍 👍 👍 Type of study : Therapeutic Topic : Trigger finger conservative treatment - pipj splint This is a non experimental, before-after study assessing the effectiveness of a proximal interphalangeal joint (pipj) splinting regime for A1-pulley trigger finger (TF). Participants were included if they presented with a Green's grade 1 to 2 (I - intermittent, II - actively correctable, III - passively correctable, IV fixed flexion deformity). Participants were provided with a splint to block pipj flexion for six weeks. Participants were excluded if they presented with trigger thumb or if they received prior treatment for trigger finger. Effectiveness of splinting regime was assessed through Green's classification grade 1 to 4 for trigger severity, pain (VAS), and function (QuickDASH). Compliance with splinting was also recorded. A total of 30 participants were included in the prent study. The results showed that the grading of trigger finger reduced by one point, after six weeks of treatment. In addition, pain (3.4 points out of 10) and function (29 points out of 100) reduced to a statistically and clinically significant level after six weeks. There was also a correlation between compliance an improvements in function, with greater compliance being associated with lower disability at the end of the trial (see scatter plot). The results from this study, need to be considered in light of a few limitations. In particular, there was no control group to account for natural history or other non specific effect of treatment. 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, splinting of the pipj joint may lead to significant improvements in pain, function, and triggering grade in trigger finger. In addition, it appears that greater compliance with splinting is associated with larger improvements on QuickDASH, suggesting that this may be a relevant factor in treatment's success. It is important to keep in mind that greater grades off triggering are associated with greater likelihood of developing fixed pipj flexion contractures . Clients with higher triggering grade may therefore require closer supervision. If clients are encouraged to wear splint full time, it may be important to perform passive AROM, to avoid developing pipj stiffness. It is also important to remember that comorbidities such as diabetes have been shown to lead to worst outcomes compared following trigger finger surgery . If you'd like to read more about splinting for trigger finger, please refer to this synopsis, which compared mcpj to pipj splinting . URL : https://doi.org/10.1177/17589983211018717 Available through Hand Therapy for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Introduction Trigger finger is a common and functionally limiting disorder. Finger immobilization using an orthotic device is one of the conservative treatment options for treating this condition. The most common orthosis previously described for trigger finger is metacarpophalangeal joint immobilization. There are limited studies describing the effectiveness of proximal interphalangeal joint orthosis for treatment of trigger finger. Methods This study was a single group pretest-posttest design. Adult patients with single digit idiopathic trigger finger were recruited and asked to wear a full-time orthoses for 6?weeks. The pre- and post-outcome measures included Quick-DASH score, the Stages of Stenosing Tenosynovitis (SST), the Visual Analogue Scale (VAS) for pain, the number of triggering events in ten active fists, and participant satisfaction with symptom improvement. Orthotic devices were made with thermoplastic material fabricated with adjustable Velcro tape at dorsal side. All participants were given written handouts on this disease, orthotic care and gliding exercises. Paired t-tests were used to determine changes in outcome measures before and after wearing the orthosis. Results There were 30 participants included in this study. Evaluation after the use of PIP joint orthosis at 6?weeks revealed that there were statistically significant improvements in Quick-DASH score from enrolment (mean difference ?29.0 (95%CI ?34.5 to ?23.4); p?<?0.001), SST (mean difference ?1.4 (95%CI ?1.8 to ?1.0); p?<?0.001) and VAS (mean difference ?3.4 (95%CI ?4.3 to ?2.5); p?<?0.001). There were no serious adverse events and patient satisfaction with the treatment was high. Conclusions Despite our small study size, the use of proximal interphalangeal joint orthosis for 6?weeks resulted in statistically significant improvements in function, pain and triggering, and also high rates of acceptance in patients with isolated idiopathic trigger finger.

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.