Tailored exercise program reduces symptoms of upper limb work-related musculoskeletal disorders in a group of metalworkers: A randomized controlled trial. Rasotto, C., et al. (2015) Level of Evidence : 2b Follow recommendation : 👍 👍 Type of study : Therapeutic Topic : Work-related musculoskeletal conditions - How to reduce symptoms This is a randomised controlled study assessing the effectiveness of a personalised exercise program on upper limb symptoms in people who are at high risk of work-related musculoskeletal disorders. A total of 68 healthy metalworkers were included in the present study. By healthy, the researchers meant that they did not present with neurological conditions or uncontrolled cardiovascular disease. Participants were randomised to the intervention group (n = 34) or the control group (n = 34). The intervention group performed 2 sessions per week of 30 minutes during which they performed movement exercises of the neck and upper limb (if they reported pain) or resistance exercises of the upper limb (if they did not report pain). Effectiveness of intervention was assessed through the visual analogue scale (VAS) for pain (neck, shoulders, elbow, wrist, and hand) and active range of movement (AROM) of the neck, shoulders, elbows and wrists. These measures were assessed at baseline, 5 and 10 months since initiation of the exercise program. The results showed that the intervention group presented with statistically significant but clinically irrelevant improvements in pain and mobility across several upper limb joints from baseline. There were some statistically significant differences between groups but these were not clinically relevant. A limitation of the present study was that the control group underwent no intervention at all, leaving the potential effect shown in the intervention group possibly due to a contextual effect. 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, any form of exercise introduced in the workplace may have some small clinically irrelevant effect on pain and mobility. Overall being active appears to have some effect that may be non-specific. As hand therapists, we always have the opportunity to remind our clients to try and be as active as possible and follow the international guidelines for physical activity . Following the guidelines may not only have the benefit of getting our clients to live longer and a healthier but also indirectly benefit their upper limb conditions by reducing mental health symptoms such as depression . As you probably remember, depression is a mediator of upper limb recovery and it may hinder recovery as it has been shown in these people with scaphoid fractures . If you would like to know how to reduce other workplace-related injuries, have a look at this synopsis . URL : https://www.sciencedirect.com/science/article/pii/S1356689X14001258 Alternative URL : https://doi.org/10.1016/j.math.2014.06.007 Available through EBSCO Health Databases for PNZ members. Abstract Work-related musculoskeletal disorders (WRMDs) are a leading cause of work-related disability and loss of productivity in the developed countries; these disorders may concur with the indirect costs of an illness or injury included losses of potential output. Literature on workplace physical activity program provided a mixed but positive impact on health and important worksite outcomes. Therefore, programs of physical activity organized and performed in the workplace could reveal as essential tool to reduce musculoskeletal symptoms. This investigation aimed to assess the effectiveness of a tailored physical activity program, performed in a work-environment, to reduce the symptoms in upper extremities and neck with the novelty in personalizing the approach applied to the exercise protocol, basing on pain and disability levels, to reduce the onset and symptoms in upper extremity and neck WRMDs increasing upper-limb strength and flexibility. 68 metalworkers were recruited, 34 were randomly allocated to an intervention group (IG), while the other 34 to a control group. Primary outcomes concerned pain symptoms measured with visual analog scales while disability was measured by DASH (Disability of the Arm, Shoulder and Hand), and NPDS-I (Neck Pain and Disability Scale) questionnaires. Grip strength, upper-limb mobility, neck and shoulder range of motion were also assessed. After the 9-month intervention, IG reduced pain symptoms on neck, shoulders, elbows and on wrists. Grip strength and upper-limb mobility improved as well as scores on questionnaires. This protocol suggests that performing a tailored physical activity program is beneficial to reduce pain and disability on upper-limb WRMDs. 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

Joint position sense, motor imagery and tactile acuity in lateral elbow tendinopathy: A cross-sectional study. Wiebusch, M., B. K. Coombes and M. F. Silva (2021) Level of Evidence : 3b Follow recommendation : 👍 👍 Type of study : Aetiology Topic : Lateral epicondylalgia - Joint position sense This is a cross-sectional study assessing the effect of lateral epicondylalgia on joint position sense and brain changes. A total of 28 participants were included. Of these, 14 had unilateral tennis elbow whilst the other 14 were healthy controls. Lateral epicondylalgia was diagnosed if participants presented with tenderness at the lateral elbow, pain with gripping, pain on resisted wrist extension or middle finger extension. Joint position sense of the wrist was assessed bilaterally in all participants. Participants' wrist was passively positioned in either 20° of extension or flexion and held there for 5 seconds. Participants were then asked to reproduce the wrist position actively. Brain changes were assessed by getting participants to perform a motor imagery tasks (left/right hand discrimination) and tactile acuity tests at the lateral elbow (two-point discrimination assessment with digital callipers). The results showed that participants with lateral epicondylalgia presented with joint position sense impairments. In particular, they reproduced lower levels of wrist extension on the affected side compared to the unaffected side (roughly 3° less extension compared to the unaffected side) and also when compared to controls (roughly 3° less extension compared to the matched side of the controls). In terms of motor imagery and tactile acuity, there were no differences between groups. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message : Based on what we know today, people with lateral epicondylalgia (LE) may present with reduced wrist proprioception compared to healthy controls. During the acute phase of LE we may introduce exercises of wrist repositioning with eyes closed as a form of treatment (see figure). In addition, during the acute phase of LE, it may be useful to provide rest/activity modification or advise on the use of a counterforce splint (see previous synopses on splint effectiveness and biomechanics ). During the disrepair/degenerative phase of LE (sub acute/chronic - see previous synopsis on tendinopathy grading and treatment ), graded resistance training of the wrist extensors alone may be enough to improve function and reduce pain. URL : https://www.sciencedirect.com/science/article/pii/S2468781221001065 Available through EBSCO Health Databases for PNZ members. Abstract Background Impairments of sensorimotor function are evident in individuals with lateral elbow tendinopathy (LET), although understanding of the mechanisms for this is lacking. Objectives To determine if motor imagery, tactile acuity and wrist joint position sense (JPS) are impaired in participants with unilateral LET compared to controls, whether deficits are localised to the affected side, and whether deficits relate to severity of pain. Design Cross-sectional study with control group. Methods 14 participants with unilateral LET of 6 weeks or longer and 14 matched control participants were assessed bilaterally for motor imagery (left/right hand judgement task), tactile acuity (two-point discrimination test) and wrist JPS (reposition test for flexion and extension). Pain levels were measured using a numeric rating scale. Results Significant differences in JPS were observed for wrist extension only, such that participants with LET adopted less extended postures with their affected side when compared to their unaffected side (MD = 2.97°; p = 0.01) and to the matched-affected side of controls (MD = 4.89°; p < 0.01). No differences in tactile acuity or motor imagery were observed. Conclusion Altered wrist extension JPS, but not motor imagery or tactile acuity, was found in the affected side of patients with unilateral LET when compared to non-injured side and asymptomatic controls. publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings

Level of Evidence : 5 Follow recommendation : 👍 Type of study : Diagnostic/Therapeutic Have a think about this case study. Leave a diagnostic comment if you like. I will publish the diagnosis reported by the paper next week. The patient was a 46 years old male presenting with ulnar side wrist pain, which developed following a volleyball injury 9 weeks prior to examination. They presented with a positive fovea sign. A trial of conservative management with splinting lead to no improvements. As a matter of fact, pain got worse over time despite splinting. You have x-rays and MRI images below. What was it?

Therapist's practice patterns for subsequent fall/osteoporotic fracture prevention for patients with a distal radius fracture Dewan, N., MacDermid, J., MacIntyre, N., & Grewal, R. Level of Evidence : 5 Follow recommendation : 👍 Type of study : Preventative Topic : Fracture prevention - Prevention of further falls/fractures after distal radius fracture. This survey study assessed clinicians' knowledge on prevention of subsequent falls/osteoporotic fractures in patients over 45 years old who presented to the clinic after a distal radius fracture. The results showed that there is a lack of attention towards assessment, treatment, and prevention in these patients with only 30% of therapists assessing either balance, lower limb strength, levels of physical activity, or fear of falling. These findings are despite compelling evidence that fall prevention treatments reduce the risks of falls by 50% in older adults. Outcomes measures such as the Chair Stand Test, the Timed up and Go test, the Rapid Assessment of Physical Activity scale, and Fracture Risk Assessment Tool ( FRAX ) can be used as simple screening tools. Several treatments including Tai Chi, progressive strength training, and aerobic exercises can be promoted to improve bone health. Clinical Take Home Message : Hand therapists should assess risk of falls in people over 45 years old who present to the clinic with a distal radius fracture. A quick assessment tool, which only requires demographic data and minimal history taking, is the FRAX . This is a freely available validated online tool which can predict risk of falls within the next 10 years. If interested, hand therapists can use the Chair Stand Test and the Timed up and Go test, which both take 1-4 minutes to complete. Once screened, patients could be provided with educational resources (e.g. NIH , NOF , IOF ) or referred to other health practitioners for fall prevention programs and medical treatment for osteoporosis (e.g. Physiotherapists, community exercise classes, GPs). URL : https://www.jhandtherapy.org/article/S0894-1130(17)30270-3/fulltext

Median nerve compression: Lacertus syndrome versus superficialis-pronator syndrome. Tang, J. B. (2021) Level of Evidence : 5 Follow recommendation : 👍 Type of study : Diagnostic, Therapeutic Topic : Median nerve compression - Lacertus fibrosus, flexor digitorum superficialis and pronator teres This is a narrative review on median nerve compression sites proximal and distal to the elbow. Firstly, compression of the median nerve at the Struthers ligament (proximally to the elbow) and compression of the Anterior Interosseous Nerve are defined as rare events. Much more common are median nerve entrapment neuropathies at the lacertus fibrosus, and at the flexor digitorum superficialis arch/pronator teres. Clinically the first author reports differentiating between the lacertus fibrosus and superficialis/pronator entrapment via palpation. They report lacertus fibrosus entrapment presenting with exquisite tenderness just proximally to the proximal border of the lacertus. In contrast, clients with superficialis/pronator entrapment tend to present with pain slightly more distally. The first author suggests that differentiating between a flexor digitorum superficialis vs pronator teres median nerve entrapment is very hard, if not impossible without performing surgery, hence the reference to superficialis/pronator entrapment. 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, we could possibly attempt to differentiate between a lacertus fibrosus and a superficialis/pronator entrapment of the median nerve in our clients presenting with forearm and hand symptoms. The severity of the entrapment will lead to the involvement of sensory/motor fibres (moderate to severe entrapment) or only cause pain (mild entrapment) . The differential diagnosis for a peripheral median nerve entrapment may include cervical radiculopathy, brachial neuritis, thoracic outlet syndrome, and carpal tunnel syndrome (CTS). Clients with cervical radiculopathy are likely to report neck pain . In addition, they are likely to test positive on all upper limb neurodynamic tests and present with positive spurling's, distraction, and arm squeeze test . They may have weakness in key upper limb muscles and have reduced deep tendon reflexes . Remember that dermatomal patterns are not reliable. Brachial neuritis and thoracic outlet syndrome present with limited special tests available because a gold standard for their diagnosis does not exist (similar to pronator teres syndrome). If you are interested in a deep dive on carpal tunnel syndrome, look at the comments in this synopsis . You will find links to several other diagnostic, therapeutic, and prognostic topics related to carpal tunnel syndrome. URL : https://doi.org/10.1177/17531934211024092 Available through EBSCO Health Databases for PNZ members. Abstract Median nerve compression in the forearm may occur at several sites, and descriptions in major textbooks and that of personal surgical experience vary. I feel frustrated by these, some of which do not coincide with each other or with what I have seen. Therefore, I set out to contact a few surgeons who often discuss these disorders. I tried to come away with an easy approach to understanding these disorders for myself and perhaps for others. 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 effects of an 8-week knitting program on osteoarthritis symptoms in elderly women: A pilot randomized controlled trial. Leonard, G., et al. (2021) Level of Evidence : 2b- Follow recommendation : 👍 👍 👍 Type of study : Therapeutic Topic : Knitting - Hand OA This is a pilot randomised controlled trial assessing the effectiveness of knitting for symptomatic hand OA. A total of thirty participants took part in this study. Participants were included if they presented with the American College of Rheumatology classification criteria, had never knitted or had not knitted in the six months prior to inclusion, had not had surgery or cortisone injections to their hands. Knitting was compared to a control group who continued with their normal routine. Both groups received advice on hand OA through a pamphlet. The feasibility of the trial was assessed through adherence to the intervention and dropout rate. Clinically, the intervention was assessed through improvements in stiffness/pain, function (i.e., AUSCAN), grip strength, and several other outcomes. Data collection took place at baseline, at 4 weeks, 8 weeks, and 12 weeks (4 weeks upon completion of the study). Participants in the experimental group knitted in groups twice a week and knitted at home alone on the remaining days for 20 minutes each time. Participants in the control group continued with their normal routine. Both groups received a pamphlet on hand OA. The results showed that adherence (participants attended 80% of the knitting sessions) and drop out (80% of participants were retained at follow up) were reasonable. The results also showed that there were no differences between groups on clinical outcomes. Statistical analyses were also reported, however, they should be interpreted with caution due to the pilot nature of the study . Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message : Based on what we know today, knitting appears to be a feasible intervention for people with symptomatic hand OA. Currently, we can advise clients with symptomatic hand OA that knitting for 20 minutes each day seems to be reasonable, especially if they enjoy the activity. At the moment, it is not possible to comment on the effect of knitting on clinical outcomes as a fully powered trial has not been completed. A therapeutic alternative to knitting could be resistance exercises for the hand, as this appears to be safe . General physical exercise may also be useful for our clients with symptomatic hand OA, as they appear to be at greater risk of cardiovascular disease compared to their healthy counterparts . URL : https://www.sciencedirect.com/science/article/abs/pii/S1360859221000759 Alternative URL : https://savoirs.usherbrooke.ca/bitstream/handle/11143/18425/Leonard_Guillaume_JBMT_vol27no2021_p410-419_2021.pdf?sequence=3 Available through EBSCO Health Databases for PNZ members. Abstract BACKGROUND: Exercise therapy is effective in reducing symptoms and disability associated with hand osteoarthritis (HOA) but often has low adherence. An intervention consisting in a meaningful occupation, such as knitting, may improve adherence to treatment. This pilot randomized controlled trial (RCT) studied the adherence and clinical effectiveness of a knitting program in older females suffering from HOA to evaluate the acceptability of this intervention and assess the feasibility of a larger-scale RCT. METHODS: Single-blind, two-arm pilot RCT with a parallel group design with 37 participants (18 control, 19 intervention). Control participants were given an educational pamphlet and assigned to a waiting list. The knitting program (8-week duration) had two components: bi-weekly 20-min group knitting sessions and daily 20-min home knitting session on the 5 remaining weekdays. Measures included knitting adherence (implementation outcomes) as well as stiffness, pain, functional status, hand physical activity level, patient's global impression of change, health-related quality of life, self-efficacy, and grip strength (clinical outcomes measured throughout the 8-week program and 4 weeks after the intervention). RESULTS: Our protocol is feasible and the intervention was acceptable and enjoyable for participants, who showed high adherence. No difference was observed between the two groups for any of the clinical outcome measures (all p > .05). CONCLUSION: Knitting is a safe and accessible activity for older women with HOA. However, our 8-week knitting program did not result in improvements in any of our outcome measures. Knitting for a longer period and/or with higher frequency may yield better outcomes. 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

Wrist flexion and extension strength in patients suffering from work-related chronic elbow pain: The isokinetic effort factor and its implications. Chaler, J., et al. (2021) Level of Evidence : 1b- Follow recommendation : 👍 👍 Type of study : Prognostic Topic : Elbow pain recurrence - Prognostic factors This is a longitudinal study assessing what factors predict pain recurrence within one year in people with elbow pain, including lateral epicondylalgia. A total of 30 participants were included in the present study. Most of these participants presented with tennis elbow (n=20, 66%), and a minority presented with elbow fractures (n=5, 16%), golfers elbow (n=2, 7%), or other unspecified conditions of the elbow (n=3, 11%). Participants were excluded if they presented with bilateral elbow pathology. Recurrence was defined as a worsening of symptoms that led to sick leave within one year after discharge. The prognostic (predicting) factors analysed included maximum strength of the wrist flexors and extensors as well as the wrist flexors/extensors strength ratio of the involved and uninvolved sides. Of note, these strength measurements were maximal efforts rather than pain-free efforts. The results showed that the wrist flexors/extensors strength ratio on the affected side predicted correctly 80% of the recurrence, which is a reasonable predictive ability. In particular, if the wrist flexors/extensors strength ratio was equal or above 1.37, flexors stronger than extensors, the clients had a higher recurrence at one year. One of the limitations of this study is that the predictive ability of this strength ratio was tested on the same sample on which the predictive factor was developed. This often leads to an overestimation of the predictive ability of the test. Testing this predictive factor on a different sample of people with elbow pain will lead to a better estimation of the predictive ability of this ratio. 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, if our clients with elbow conditions, especially tennis elbow, present with wrist extensors that are 37% weaker or more compared to wrist flexors, we may expect them to present with a recurrence within one year from discharge. This may suggest that providing them with an appropriate graded resistance training program after the acute phase (reactive phase of tendinopathy) , and following them up until their wrist flexors/extensors ratio is smaller than 1.37 before discharging them, may be useful in avoiding recurrence. This approach would be consistent with what currently has been shown to be the most effective conservative approach for tennis elbow . It is however unknown at this stage whether strength deficits are mediating recurrence as other factors such as pain intensity or psychosocial factors may be important contributors to recurrence. A practical way in which you could measure wrist extensor and flexor strength in the clinic is by utilising dumbbells to test slow concentric wrist flexors/extensors strength. It is possible that instead of calling tennis elbow an "overuse injury" we may need to call it an "underuse injury", especially if recurrences occur well beyond the rehabilitation acute phase. Further research will clarify these points. URL : https://doi.org/10.1016/j.jse.2021.06.005 Available through EBSCO Health Databases for PNZ members. Abstract Background The validity of isokinetic strength findings relating to forearm muscles in patients suffering from chronic elbow pain and/or epicondylitis is not well established. Furthermore, given the nature of this disorder, ensuring maximal effort in performing the tests is an essential prerequisite. The isokinetic-based DEC parameter has been shown to efficiently detect maximal effort. The purpose of the present study was therefore to assess the validity of isokinetic strength tests in chronic elbow pain/epicondylitis patients. Methods A cohort consisting of 44 male patients suffering from chronic elbow pain (average evolution time: 262 ± 193.04 days) was recruited. Wrist extensor (E) and flexor (F) concentric and eccentric isokinetic strength of the involved (I) and uninvolved (U) side was measured. The I/U and F/E ratios as well as the DEC were computed based on peak moment (PM) values. Work disability and relapse within the first year were registered. In maximal performers associations between deficits, F/E ratios, work disability and symptom relapse were explored applying multiple comparisons. Results 68.2% of the patients met maximal effort criteria with the I side muscles being significantly weaker than their U counterparts in most cases. While the mean deficit in this group was not associated with either work disability or relapse, patients with relapse of symptoms within the first year had a significant higher F/E ratio than those without relapse. Conclusion In patients presenting with chronic elbow pain who perform at maximal level of effort, high wrist F/E strength ratios may predict symptom relapse. 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

Enrollment in treatment at a specialized pain management clinic at a tertiary referral center after surgery for ulnar nerve compression: Patient characteristics and outcome. Giöstad, A., R. Räntfors, T. Nyman and E. Nyman (2021) Level of Evidence : 2b Follow recommendation : 👍 👍 👍 Type of study : Symptoms prevalence study Topic : Cubital tunnel syndrome - chronic pain This study is a retrospective analysis of patients who had undergone ulnar nerve entrapment release and were referred to a persistent pain clinic. A total of 173 participants were included, 26 of which were referred for persistent pain management. The remaining 147 participants were included as a control group. Several outcomes such as kinesiophobia, anxiety and depression, health status, and life satisfaction were collected. The results showed that participants referred to the persistent pain clinic had clinically higher levels of functional impairments (see Figure). In addition, a high percentage of people in the persistent pain group presented high levels of kinesiophobia. A limitation of the present study is that due to the retrospective nature of the design it is not possible to comment on whether kinesiophobia was responsible for higher levels of functional impairments or whether another variable (e.g. pain intensity) was responsible for 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, 15% of people undergoing a cubital tunnel nerve release present with persistent pain after surgery. This means that 1 to 2 people in 10 will present with persistent pain after cubital tunnel release. These clients also present with clinically relevant higher levels of disability (QuickDASH) . It is important to remember that kinesiophobia, which was higher in this group, has also been previously shown to be highly correlated with upper limb function . It is therefore possible that pain neurophysiology education in combination with graded exercise exposure may be useful to reduce symptoms in this subgroup of clients. In addition, if clients are unresponsive to conservative treatment, prompt referral to a surgeon may be appropriate. Thus, surgery in people with long term cubital tunnel seems less effective than when performed at an earlier stage . A workup of elbow x-ray and US may be useful in identifying space-occupying lesions (causing cubital tunnel in 7% of all cases) and providing a more complete clinical picture. Open Access URL : https://doi.org/10.1016/j.jhsg.2021.02.001 Abstract Purpose To study patients who enroll in treatment at a specialized pain management clinic at a tertiary referral center following ulnar nerve decompression. Methods Data from medical charts and postoperative questionnaires were collected for all patients after surgery for ulnar nerve compression at the elbow from 2011 to 2014 (n = 173) at a tertiary referral center. Differences in characteristics between patients who enrolled in treatment at the pain management clinic (study group, n = 26) and the rest of the patients (reference group, n = 147) were analyzed. The study group was further evaluated using questionnaires from the Swedish Quality Registry for Pain Rehabilitation (SQRP) and regarding outcome of pain treatment. Results The study group was characterized by prior pain conditions, earlier contact with a pain management clinic, and high degrees of kinesiophobia, depression/anxiety, low quality of life, and low life satisfaction. These patients had significantly higher postoperative Disabilities of the Arm, Shoulder, and Hand (DASH) scores, were significantly younger, and had bilateral surgery significantly more often than the reference group. For patients with unilateral surgery, simple decompression was significantly more common in the reference group. The most common treatments at the clinic were antidepressants and anticonvulsants for neurogenic pain. In 5 of 26 patients, pain relief, or pain reduction was the documented reason for discharge. Conclusions Pain is a relevant outcome measure for ulnar nerve decompression among complicated cases at a referral center. Severe postoperative pain is connected to higher disability, reduced life satisfaction, and overall low health status. This study maps out characteristics of patients who postoperatively enroll in treatment at a specialized pain management clinic following ulnar nerve decompression. Further studies are needed to define predictive factors for such pain. publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings

Associations between insurance type and the presentation of cubital tunnel syndrome Cheng, C., & Rodner, C. Level of Evidence : 4 Follow recommendation : 👍 👍 Type of study : Symptoms prevalence study Topic : Cubital tunnel syndrome (CuTS) progression - Disease stage in privately vs publicly insured patients in USA. This retrospective study analysed Cubital tunnel syndrome (CuTS) stages and time to first surgeon’s visit in American patients who were either privately or publicly insured. The results showed the odds of publicly insured patient to have intrinsic hand muscles weakness, atrophy, mild to severe disturbances on moving two-point discrimination, and nerve conduction impairments, were 4.4 times larger than patients who were privately insured. In addition, the wait time in the publicly insured patients was twice (7yrs) as long as the one for privately insured patients (3.5yrs). It can be speculated that greater disease severity in the publicly insured group were due to longer time with the condition, lower socio-economic status and health literacy, and inability to take leave from work. Further studies need to verify whether any causality between these factors and disease severity exists. Clinical Take Home Message : Based on what we know today, patients with longer standing CuTS may present with worse signs and symptoms. To avoid long term consequences, a prompt referral to a hand surgeon may be useful when conservative treatment for CuTS fails. In the United States, therapists should be aware that publicly insured patients may present with a worse clinical condition compared to privately insured patients. URL: https://www.jhandsurg.org/article/S0363-5023(18)31402-3/fulltext 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

Clinical management of tendinopathy: A systematic review of systematic reviews evaluating the effectiveness of tendinopathy treatments. Irby, A., Gutierrez, J., Chamberlin, C., Thomas, S. J., & Rosen, A. B. (2020) Level of Evidence : 1a Follow recommendation : 👍 👍 👍 👍 Type of study : Therapeutic Topic : Tendinopathies – Conservative and surgical interventions This is a systematic review of systematic reviews assessing the effectiveness of conservative and surgical treatments for symptomatic tendinopathies irrespective of location. Twenty-five systematic reviews (Total of 228 RCTs) were included for a total of 15,000 participants. All the systematic reviews included randomised controlled trials (RCT) only. No systematic reviews on pharmacological intervention (e.g. NSAIDs) were included. All the systematic reviews included were assessed through the Assessment of Multiple Systematic Reviews (AMSTAR), which is scored on a scale from 0 to 11 (higher scores reflect higher study quality). Efficacy of intervention was assessed through changes in pain. The visual analogue scale (VAS) was the most common pain outcome recorded (n=22). The average quality score of the reviews was 9 (SD:1), suggesting that more than 50% of the studies were of high quality. Most of the reviews focused on Achilles and patella tendinopathy (n=23) followed by lateral elbow tendinopathy (n=11) and rotator cuff tendinopathy (n=10) (some of the studies included more than one tendinopathy type). Exercise was the only intervention that was shown to consistently reduce pain in tendinopathy. Heavy eccentric exercises appeared to be particularly effective in reducing pain. Low level laser therapy and extracorporeal shock wave therapy showed some effectiveness in the treatment of symptomatic tendinopathies. Injections, needling, and surgery provided mix results for the treatment of tendinopathies. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message : Based on what we know today, exercise is an important aspect of tendinopathy treatment. Findings across different body sites consistently suggest that "heavy eccentric exercises" are helpful in reducing pain. It is however not clear what "heavy eccentric exercises" represent in terms of exercise intensity. By considering other research in the field of upper limb tendinopathy, a graded approach to resistance training may be the most appropriate, with eccentric exercises providing potential greater analgesia in lateral epicondylalgia . It is important to remember that resistance training for tendinopathy may be most effective in the sub-acute or chronic phase (disrepair and degenerative stage), while reduction in tendon loading (e.g. rest) may be most suitable for an acute reactive tendinopathy (look at synopsis on staging and treatment of tendinopathies ). Open Access URL : https://onlinelibrary.wiley.com/doi/epdf/10.1111/sms.13734 Abstract While the pathoetiology is disputed, a wide array of treatments are available to treat tendinopathy. The most common treatments found in the literature include therapeutic modalities, exercise protocols, and surgical interventions, however their effectiveness remains ambiguous. The purpose of this study was to perform a systematic review of systematic reviews to determine the ability of therapeutic interventions to improve pain and dysfunction in patients with tendinopathy regardless of type or location. Five databases were searched for systematic reviews containing only randomized control trials to determine the effectiveness of treatments for tendinopathies based on pain and patient-reported outcomes. Systematic reviews were assessed via the Assessment of Multiple Systematic Reviews (AMSTAR) for methodological quality. From the database search, 3,295 articles were found, 107 passed the initial inclusion criteria. After further review, 25 systematic reviews were included in the final qualitative analysis. The AMSTAR scores were relatively high (8.8±1.0) across the 25 systematic reviews. Eccentric exercises were the most common and consistently effective treatment for tendinopathy across systematic reviews. Low-level laser therapy and extracorporeal shockwave therapy demonstrated moderate effectiveness, while platelet-rich plasma injections demonstrated inconclusive evidence on their ability to decrease tendinopathy related pain and improve function. Corticosteroids also showed some effectiveness for short-term pain, but for the long-term use deemed ineffective and at times contraindicated. Regarding surgical options, minimally invasive procedures were more effective compared to open surgical interventions. When treating tendinopathy regardless of location, eccentric exercises were the best treatment option to improve tendinopathy related pain and improve self-reported function. publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings

A qualitative systematic review of effects of provider characteristics and nonverbal behavior on pain, and placebo and nocebo effects. Daniali, H., & Flaten, M. A. (2019) Level of Evidence : 1a- Follow recommendation : 👍👍👍👍 Type of study : Therapeutic Topic : Smiling - Placebo and nocebo This is a systematic review on the effect on non-verbal interactions on placebo and nocebo. Placebo, a positive effect (e.g. pain reduction), and nocebo, a negative effect (e.g. increase in pain), are the result of treatment expectations. Fourteen experimental studies were included for a total of 1,778 participants. Non-verbal interactions were divided in positive and negative. Positive non-verbal interactions included smiling, nodding, making eye contact, and a warm and friendly voice. Negative non-verbal interactions included a flat and cold tone of voice, frowning, and looking away. The findings showed that negative non-verbal interactions led to a reduced placebo effect, or a nocebo effect, resulting in lower pain tolerance, and higher pain. In contrast, positive non verbal interactions (e.g. smiling) led to a boost in the placebo effect leading to a better emotional and physical state of the patients, lower pain, and a reduction in opioid medications use. Clinical Take Home Message : A positive non-verbal attitude of a hand therapist can enhance the effect of the treatment provided. Smiling, making eye contact, and nodding may improve our clinician-client relationship and lead to reduction in pain, enhanced emotional well-being, and a reduction in pain medications consumption. This synopsis is a nice adjunct to the one written about the effect of an empathetic attitude of clinicians and its effect on endogenous analgesia. Open Access URL : https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6476260/pdf/fpsyt-10-00242.pdf Abstract Background Previous research has indicated that the sex, status, and nonverbal behaviors of experimenters or clinicians can contribute to reported pain, and placebo and nocebo effects in patients or research participants. However, no systematic review has been published. Objective: The aim of this study was to investigate the effects of experimenter/clinician characteristics and nonverbal behavior on pain, placebo, and nocebo effects. Methods Using EmBase, Web of Knowledge, and PubMed databases, several literature searches were conducted to find studies that investigated the effects of the experimenter’s/ clinician’s sex, status, and nonverbal behaviors on pain, placebo, and nocebo effects. Results Thirty-four studies were included, 20 on the effects of characteristics of the experimenter/clinician, 11 on the role of nonverbal behaviors, and 3 on the effects of both nonverbal behaviors and characteristics of experimenters/clinicians on pain and placebo/nocebo effects. There was a tendency for experimenters/clinicians to induce lower pain report in participants of the opposite sex. Furthermore, higher confidence, competence, and professionalism of experimenters/clinicians resulted in lower pain report and higher placebo effects, whereas lower status of experimenters/clinicians such as lower confidence, competence, and professionalism generated higher reported pain and lower placebo effects. Positive nonverbal behaviors (e.g., smiling, strong tone of voice, more eye contact, more leaning toward the patient/participant, and more body gestures) contributed to lower reported pain and higher placebo effects, whereas negative nonverbal behaviors (i.e., no smile, monotonous tone of voice, no eye contact, leaning backward from the participant/patient, and no body gestures) contributed to higher reported pain and nocebo effects. Conclusion Characteristics and nonverbal behaviors of experimenters/clinicians contribute to the elicitation and modulation of pain, placebo, and nocebo effects. publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings

There is more to pain than tissue damage: Eight principles to guide care of acute non-traumatic pain in sport. Caneiro, J. P., Alaiti, R. K., Fukusawa, L., Hespanhol, L., Brukner, P., & Sullivan, P. P. B. (2020) Level of Evidence : 5 Follow recommendation : 👍 👍 👍 Type of study : Therapeutic Topic : Acute non-traumatic pain – Biopsychosocial approach This is an editorial from the British Journal of Sports Medicine. Eight points on how to better manage acute non-traumatic pain presentations were made. The first one suggested to move away from the assumption that pain is due to tissue trauma. Specifically, it was suggested to avoid wording that implies trauma for non-traumatic cases (e.g. overuse syndrome, microtrauma). Instead we could call it pain associated with a specific activity (e.g. sport-related pain, work related pain). Imaging was also advised against, especially if there are no red flags or if it does not guide treatment. The third advice was to consider biopsychosocial factors such as fatigue, poor sleep, mental health, and pain believes as contributing factors to pain. The importance of providing positive messages was also indicated. Messages suggesting that the body is strong and discussions around tissue sensitivity rather than microtrauma/overuse were encouraged. The fifth point suggested a gradual increase in tissue loading. The sixth point advised against utilising passive modalities as a first line approach. Empowering the client by involving them in our decision making was the seventh point. The eight and last point advised to deliver a consistent message (across different health professionals) regarding the lack of trauma (e.g. overuse, microtrauma) in non-traumatic pain presentations. Clinical Take Home Message : Based on what we know today, we should probably stop talking to our clients about overuse syndromes, repetitive strain injuries, and microtrauma, when no evident trauma is present. We should instead frame it as pain associated with the activity that is exacerbating their symptoms and explain that a recent change in activity levels, stress, lack of sleep, and fatigue may be contributing to an increased sensitivity of their tissue. These explanations are evidence-informed and may help our clients making sense of their non-traumatic pain. URL : https://bjsm.bmj.com/content/early/2020/09/08/bjsports-2019-101705 You can ask the authors for the full text through ResearchGate . May be available through EBSCO Health Databases for PNZ members - you may need to wait a few weeks to get access to this article. Abstract Are you careful with how you label an athlete’s pain? Musculoskeletal pain in athletes is common, but not always associated with injury (ie, tissue damage). Damage occurs when load exceeds tissue tolerance, such as ligament tear or a fracture. However, pain in athletes that occurs in the absence of trauma and tissue damage is still often labelled an ‘injury’ by clinicians, coaches and athletes themselves. This highlights a gap between knowledge (tissue damage is not necessary for pain) and practice (assuming that all pain arises from tissue damage) in our clinical community. This applies particularly in the area of acute non-traumatic pain (such as back and joint pain). To help bridge this gap, we outline eight principles to guide clinicians who manage musculoskeletal pain in sport (see infographic in figure 1). publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings