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Accuracy of provocative tests for carpal tunnel syndrome. Zhang, D., C. M. Chruscielski, P. Blazar and B. E. Earp (2020) Level of Evidence : 2b Follow recommendation : 👍 👍 Type of study : Diagnostic Topic : Carpal tunnel syndrome - Physical tests This is a prospective study on the specificity and sensitivity of four physical tests for carpal tunnel syndrome (CTS). If a test is very sensitive and its result is negative, you can be more certain that the patient does not have the condition. If the test is specific and its result is positive, you can be more certain that the patient has the condition. A total of 55 participants (85 symptomatic hands) were included in the present study. Nerve conduction studies were utilised as the gold standard to validate the diagnostic accuracy of the CTS tests. The four physical tests assessed were the Tinel's, Phalen's, Durkan's, and the combination of Phalen's and Durkan's test (see picture below). Out of the 55 participants, nine had no impairments on nerve conduction test of the median nerve at the carpal tunnel. The Phalen's and Dhurkan combination (shown in picture D below) was the most sensitive test (90% sensitivity) when utilised in isolation. This test could therefore be utilised for screening purposes, or in other words exclude the presence of CTS. The presence of four positive tests completed one after the other presented the highest specificity (80% specificity). Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message : Based on what we know today, the combination of the Phalen's and Durkan's test into one (see picture D above - Phdurkan test), is useful to exclude the diagnosis of CTS if negative. In contrast, if the Phdurkan test was positive we would probably want to complete the remaining three tests (Tinel, Phalen, Durkan) and find them all positive, to make a diagnosis of CTS with a good degree of confidence. In addition, we can complete the CTS-6 scoring criteria , which will provide us with useful information on the likelihood of our clients suffering from CTS. Open access URL : https://doi.org/10.1016/j.jhsg.2020.03.002 Abstract Purpose: Prior literature on the diagnostic accuracy of commonly used provocative tests for suspected carpal tunnel syndrome (CTS) is affected by research biases. The objectives of our study were to measure and compare the diagnostic accuracy of 4 commonly used provocative tests for CTS using electrodiagnostic study as the reference standard. Methods: We prospectively evaluated 85 hands in 55 patients with suspected CTS. Tinel sign, Phalen’s test, Durkan’s test, and Phdurkan test (a combination of wrist flexion and carpal compression) and subsequent electrodiagnostic testing were performed on all patients. Sensitivity and specificity were calculated using electrodiagnostic findings as the reference standard. McNemar test was used to compare differences in paired outcomes between provocative tests. Results: Tinel sign had a sensitivity of 0.47 and specificity of 0.56. Phalen’s test had a sensitivity of 0.50 and specificity of 0.33. Durkan’s test had a sensitivity of 0.71 and specificity of 0.22. Phdurkan test had a sensitivity of 0.84 and specificity of 0.11. Median time to a positive Phdurkan test result was 3 seconds. McNemar tests showed significant differences (P < .05) in the proportions of positive results among all CTS provocative tests except between Tinel sign and Phalen’s test. Conclusions: Commonly performed provocative tests for suspected CTS differ in sensitivity and specificity. As the examination maneuver becomes more provocative, the test becomes more sensitive and less specific for CTS.

Bizarre parosteal osteochondromatous proliferation (nora lesion) in pediatric phalanges. Martínez Álvarez, S., D. L. Azorín Cuadrillero and K. J. Little (2021). Level of Evidence : 5 Follow recommendation : 👍 Type of study : Diagnostic/Therapeutic This is the answer for the case study from last week. The patient was a 12 years old boy who presented with a mass on the middle phalanx of the ring finger, which developed after finger trauma six months earlier. The mass was painless and developed on the volar/radial aspect of the finger. The x-rays identified a mass as shown below in the picture. At surgical removal, the mass appeared to be a combination of cartilage and bone. Biopsy reveled it to be consistent with a Nora lesion (named after Dr. Frederick E. Nora) which is a benign tumor. After excision, the patient experience no recurrence despite the high rate of relapse. 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 : Hand therapists should refer young children or teenagers for x-rays and US when there is evidence of a mass which has grown over time. The likelihood of identifying a Nora lesion is rare, however, x-rays and US may help differentiating among different conditions including ganglion cyst, rheumatoid arthritis, infections or other rare forms of cancer. URL : https://doi.org/10.1016/j.jhsa.2020.05.002 Available through The Journal of Hand Surgery (American Volume) for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Bizarre parosteal osteochondromatous proliferation, or Nora tumor, is an uncommon lesion affecting the tubular bones of the hands and feet. Normally arising from the cortical surface and periosteum of these bones, these lesions histologically consist of a hypercellular cartilaginous cap covering a bony stalk that is surrounded by ossified areas and spindle cell stroma. The differential diagnosis includes conditions involving the periosteum such as chondrosarcoma, parosteal osteosarcoma, osteochondroma, turret exostosis, and florid reactive periostitis. The only effective treatment is wide surgical excision; nevertheless, local recurrence rates are extremely high and may necessitate revision surgery. In the present study, we report 3 cases of Nora lesion located in the hand in pediatric patients. The diagnosis in these cases was challenging owing to their presenting symptoms and radiographic findings. The diagnosis was made based on characteristic findings noted on the radiographic images and was confirmed by histological examination following excision.

Nonsurgical treatment for symptomatic carpal tunnel syndrome: A randomized clinical trial comparing local corticosteroid injection versus night orthosis. de Moraes, V. Y., et al. (2021) Level of Evidence : 1b- Follow recommendation : 👍 👍 👍 👍 Type of study : Therapeutic Topic : Carpal tunnel conservative intervention - Cortisone injections vs splinting This is a randomised clinical trial assessing the effectiveness of night splinting vs corticosteroid injections on night paraesthesia, pain, function, and complications in people with carpal tunnel syndrome (CTS). Participants were included (N = 95) if they were over 40 years old and presented with at least 4 of the following six criteria: night paraesthesia in median nerve distribution of the hand, paraesthesia in median nerve distribution of the hand, atrophy of thenar muscles, positive Phalen's and Tinel's test, reduction in two-point discrimination (>6 mm). In addition, participants had to present with moderate to severe nerve conduction impairments on sensory and motor testing. Participants could have unilateral or bilateral symptoms, however, only the most affected limb was treated for the duration of the study. Outcome assessors were blinded to treatment allocation. Participants were randomised to either night splinting (n = 45), or non US guided corticosteroid injection (n = 50). Treatment effectiveness was assessed through self-reported night paraesthesia, pain and function were measured through the Boston-Levine questionnaire (BLQ), and complications were defined as a worsening of numbness at the injection site or skin tissue atrophy. Participants were assessed at baseline, 1 week, 3 and 6 months after treatment initiation. The results showed that corticosteroid injections reduced night paraesthesia to a clinically greater level compared to night splinting (see picture below). The same results were found for pain and function measured through the Boston-Levine questionnaire (BLQ) where corticosteroid injections were superior to splinting. Night splinting improved pain and function (BLQ) to a clinically relevant level but not night paraesthesia. 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, corticosteroid injections appear to be superior to night splinting for our clients (≥ 40 years old) with moderate/severe carpal tunnel syndrome. This appears to be specially true for improvements in night paraesthesia. If clients decline a referral for a cortisone injections, splinting can still provide with some benefits (reduction in pain and disability) and other approaches such as manual therapy (mobilisation and tendon/nerve glides) directed at the upper limb appear to be as effective as surgery at one and four years follow up. The combination of manual therapy, nerve gliding exercises , night splinting, and education may provide even better results, and a this conservative management approach should be trialed before undergoing surgery. URL : https://doi.org/10.1016/j.jhsa.2020.11.014 Available through The Journal of Hand Surgery (American Volume) for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Purpose: For carpal tunnel syndrome (CTS), local corticosteroid injection (corticosteroid), and/or wrist immobilization with night orthosis (orthosis) are commonly prescribed and are supported by strong evidence. The aim of this study was to compare orthosis versus corticosteroid for patients with CTS. Methods: A CTS diagnosis was made clinically and supported by electrodiagnostic study. Patients were randomly allocated to either orthosis or corticosteroid. Clinical assessments were performed before the intervention, within the first week of the intervention, and 1, 3, and 6 months after the intervention. Primary outcomes were improvement in nocturnal paresthesia and Boston-Levine questionnaire (BLQ) score. Secondary outcomes were pain assessed by visual analog scale and complications. Results: Of 100 patients enrolled in the study, 95 completed the planned follow-up (45 in the orthosis arm and 50 in the corticosteroid arm). Corticosteroid injections were superior to orthosis in remission of nocturnal paresthesia (remission rates at 1 month, 84.6% versus 43.83%; 3 months, 71.1% versus 40.4%; and 6 months, 80.3% versus 28.8%). The BLQ scores (functional and symptom subscales) were also more favorable for corticosteroid at 1, 3, and 6 months (minimal clinically important differences for Function > 0.5 and Symptom > 0.16). Pain scores were lower and favored the corticosteroid group. There were no complications in either group. Conclusions: Both options are effective in the short term. Corticosteroid is superior to orthosis for improving CTS-related nocturnal paresthesia, BLQ scores, and pain.

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 12 years old boy who presented with a mass on the middle phalanx of the ring finger, which developed after finger trauma six months earlier. The mass was painless and developed on the volar/radial aspect of the finger. The x-rays identified a mass as shown below in the picture. What was it?

Clinical effectiveness of shockwave therapy in lateral elbow tendinopathy: Systematic review and meta-analysis. Karanasios, S., G. K. Tsamasiotis, K. Michopoulos, V. Sakellari and G. Gioftsos (2021) Level of Evidence : 1a Follow recommendation : 👍 👍 👍 👍 Type of study : Therapeutic Topic : Lateral epicondylalgia - Extracorporeal shock waves This is a systematic review and meta-analysis of randomised controlled trials assessing the effectiveness of e xtracorporeal shock waves for lateral epicondylalgia. Twenty-seven randomised controlled trials were included for a total of 1,871 participants (16 studies were included in the meta-analysis). Each individual paper was scored on the PEDro critiquing tool. The results from this systematic review and meta-analysis were assessed through the GRADE approach (suggested by the Cochrane Group), which scores the evidence as "very low", "low", "moderate", or "high" quality. Efficacy of intervention was assessed through changes in pain, grip strength, pain-free grip strength (PFG), and elbow disability. Pain was assessed through the visual analogue scale (VAS) or the numerical rating scale (NRS), elbow disability was measured through several different outcome measures including the Patient-Rated Tennis Elbow Evaluation (PRTEE) and the Disability of the Arm, Shoulder, and Hand (DASH) questionnaire. Follow-up times ranged between very short term (less than 2 months), short term (2-3 months), mid-term (3-12 months), and long term (more than 12 months). E xtracorporeal shock waves were compared to no intervention, sham/placebo, multimodal physiotherapy, PRP, and corticosteroid injections. Low to moderate quality evidence suggests that e xtracorporeal shock waves provide statistically significant differences in pain in the mid term and grip strength in the very short and short term. However, these results were unlikely to be of clinical relevance due to the small effects. E xtracorporeal shock waves had no effect on elbow disability when compared to other interventions. Clinical Take Home Message : Based on what we know today, e xtracorporeal shock waves may have a small effect on pain and grip strength for clients with lateral epicondylalgia. Their effectiveness appears however small and possibly not clinically relevant. When compared to corticosteroid injections, there were no differences (this comparison was reported in four trials). The benefit of e xtracorporeal shock waves over corticosteroids may be that they do not appear to increase recurrence at one year . To draw some final conclusions, we may utilise e xtracorporeal shock waves as a last resort in our clients with severe pain , unresponsive to main stream interventions. A trial of tendon unloading (activity reduction and counterforce splint - see previous synopses on splint effectiveness and biomechanics ) followed by graded resistance training ( see previous synopsis on tendinopathy grading and treatment ) may be trialed first. URL : https://doi.org/10.1177/02692155211006860 Available through EBSCO Health Databases for PNZ members. Abstract Objective: To evaluate the effectiveness of extracorporeal shockwave therapy compared with other interventions on pain, grip strength and disability in patients with lateral elbow tendinopathy. Data Sources: MEDLINE, PubMed, CINAHL, EMBASE, PEDro, ScienceDirect, Cochrane Library and clinical trial registries. Review methods: We included randomized controlled trials assessing the effectiveness of extracorporeal shockwave therapy alone or as an additive intervention compared with sham or other interventions. Pain intensity, grip strength and elbow disability were used as primary outcome measures. We assessed methodological quality with the PEDro score and quality of evidence with the GRADE approach. Results: Twenty-seven studies with 1871 patients were finally included. Extracorporeal shockwave therapy reduced pain intensity at mid-term follow-up (standardized mean difference: 1.21, 95% confidence interval:1.53, 0.89, P<0.001) and improved grip strength at very short- (mean difference:3.92, 95% confidence interval: 0.91, 6.94, P=0.01) and short-term follow-up (mean difference:4.87, 95% confidence interval:2.24, 7.50, P<0.001) compared with sham treatment. However, no clinically significant results were found between comparators in all outcomes and follow-up times. Extracorporeal shockwave therapy presented clinically better compared to Laser in grip strength at short-term (mean difference:3.50, 95% confidence interval:2.40, 4.60, P<0.001) and ultrasound in pain intensity at very-short-term follow-up (standardized mean difference: 1.54, 95% confidence interval: 2.60, 0.48, P=0.005). Conclusion: Low to moderate certainty of evidence suggests that there are no clinical benefits of extracorporeal shockwave therapy compared to sham interventions or corticosteroid injections. Based on very-low and moderate certainty of evidence, extracorporeal shockwave therapy outperforms against Laser and ultrasound, respectively.

The effects of exercise on chemotherapy-induced peripheral neuropathy symptoms in cancer patients: A systematic review and meta-analysis. Lin, W.-L., et al. (2021) Level of Evidence : 1a- Follow recommendation : 👍 👍 👍 👍 Type of study : Therapeutic Topic : Neuropathic pain - Chemotherapy induced neuropathy and exercise This is a systematic review and meta-analysis on exercise interventions for chemotherapy-induced neuropathies. Five RCTs were included in the meta-analysis for a total of 178 participants. Each study was assessed through the CONSORT checklist . No overall quality of evidence assessment was provided, however, I calculated it for you through the GRADE approach ("low", "very low", "moderate", "high"), which is commonly utilised by the Cochrane group for systematic reviews. Several different types of exercises were utilised including resistance training, balance, nerve gliders, or combined exercises (see table below). Frequency ranged from 2 to 7 times per week and duration varied from 6 to 18 weeks. Treatment effectiveness was assessed though the Chemotherapy induced peripheral neuropathy (CIPN) screening tool , a neuropathic pain questionnaire ( Leeds Assessment for Neuropathic Symptoms and Signs - S-LANSS ), or other questionnaires. The results showed that there is low quality evidence showing statistically significant improvements in symptoms reported by participants. It is unclear whether these improvements were clinically relevant. 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 presenting with chemotherapy-induced neuropathic pain, may benefit from a wide range of exercises. This seems to reduce neuropathic pain symptoms although we are not sure whether these improvements are clinically relevant. These results are supported by previous basic science research suggesting that exercise has a neuroprotective effect . Exercise not only has the potential to extend cancer survivors healthspan by improving cardiovascular fitness , but has also been shown to improve their quality of life . URL : https://doi.org/10.1007/s00520-021-06082-3 Available through EBSCO Health Databases for PNZ members. Abstract Purpose: To conduct a systematic review and meta-analysis of current studies to determine whether exercise affects chemotherapy-induced peripheral neuropathy (CIPN) symptoms in cancer patients. Design: The Medline, Embase, Cochrane Library, CINAHL, PubMed, and National Central Library databases, and the reference lists of the included studies were surveyed. The Consolidated Standards of Reporting Trials (CONSORT) extension checklist for non-pharmacologic treatment was used to evaluate the literature. Setting and participants: Exercise interventions offered in hospitals or at home. A total of 178 participants from 5 studies were assessed in the meta-analysis, with their mean age ranging from 48.56 to 71.82 years. Methods: The randomized control trials were summarized in a systematic review. The effects of the exercise interventions were compiled for meta-analysis. A forest plot was constructed using a fixed effect model to obtain a pooled mean difference. Results: The pooled results indicated that exercise interventions significantly improved the CIPN symptoms of the participants (mean difference: 0.5319; 95% confidence interval: 0.2295 to 0.8344; Z = 3.45; P = 0.0006). A combination of exercise protocols including a nerve gliding exercise intervention was found to have improved CIPN symptoms. In addition, a sensorimotor-based exercise intervention was found to have reduced CIPN-induced loss of postural stability. Conclusions and implications: The findings indicated that the effects of exercise could improve CIPN symptoms in cancer patients. Nevertheless, further investigations of different exercise protocols and intensity of intervention utilizing larger sample sizes and more specific outcome measures will further inform the best practices for cancer patients.

Central sensitisation in chronic pain conditions: Latest discoveries and their potential for precision medicine. Nijs, J., et al. (2021) Level of Evidence : 5 Follow recommendation : 👍 Type of study : Aetiologic, Diagnostic, Therapeutic Topic : Central sensitisation - Presentation and diagnostics This is a narrative review published in The Lancet Rheumatology on the presentation, diagnosis, and treatment of central sensitisation in people with musculoskeletal conditions. Central sensitisation has been defined as an amplification of nociceptive messages, which could lead to greater pain levels. Changes associated with central sensitisation could lead to the translation of mechanical (not nociceptive stimuli) into nociceptive stimuli (leading to allodynia - perception of pain with a non painful stimuli). Previous studies have suggested that central sensitisation may be a common phenomenon in upper limb conditions, especially in lateral epicondylalgia. The Central Sensitization Inventory (CSI) has been suggested as potentially useful questionnaire to identify people who may present with central sensitisation phenotypes. The results from this questionnaire may also be useful for prognostic purposes as there is some evidence suggesting that clients with central sensitisation may have greater disability in the short and longer term after injury. It was also highlighted that central sensitisation could be maintained by on-going peripheral nociceptive inputs as well as centrally mediated changes (brain and spinal cord functional changes). Unfortunately, at this point in time there is no way of differentiating between the two. Therapeutic interventions aimed at affecting peripheral dysfunctions (joint impairments) as well as moderating other psychological factors (e.g. pain catastrophising) that can contribute to central sensitisation, may be utilised in clinical practice. Therapeutic interventions including manual therapy, exercise, and education have shown to be effective in reducing signs of central sensitisation although they are best not used in isolation in people with persistent pain. 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, central sensitisation may amplify nociceptive inputs coming from peripheral joints or soft tissues. Treatments including pain neurophysiology education , exercise, and manual approaches appear to be effective in reducing signs of central sensitisation. In addition, using words that reduce fear and threat of tissue damage may be useful to reduce central sensitisation . URL : https://doi.org/10.1016/S2665-9913(21)00032-1 Available through EBSCO Health Databases for PNZ members. Abstract Chronic pain is a leading cause of disability globally and associated with enormous health-care costs. The discrepancy between the extent of tissue damage and the magnitude of pain, disability, and associated symptoms represents a diagnostic challenge for rheumatology specialists. Central sensitisation, defined as an amplification of neural signalling within the CNS that elicits pain hypersensitivity, has been investigated as a reason for this discrepancy. Features of central sensitisation have been documented in various pain conditions common in rheumatology practice, including fibromyalgia, osteoarthritis, rheumatoid arthritis, Ehlers-Danlos syndrome, upper extremity tendinopathies, headache, and spinal pain. Within individual pain conditions, there is substantial variation among patients in terms of presence and magnitude of central sensitisation, stressing the importance of individual assessment. Central sensitisation predicts poor treatment outcomes in multiple patient populations. The available evidence supports various pharmacological and non-pharmacological strategies to reduce central sensitisation and to improve patient outcomes in several conditions commonly seen in rheumatology practice. These data open up new treatment perspectives, with the possibility for precision pain medicine treatment according to pain phenotyping as a logical next step. With this view, studies suggest the possibility of matching non-pharmacological approaches, or medications, or both to the central sensitisation pain phenotypes.

A meta-synthesis of carpal tunnel syndrome treatment options: Developing consolidated clinical treatment recommendations to improve practice. Baker, N. A., J. Dole and S. C. Roll (2021) Level of Evidence : 1a- Follow recommendation : 👍 👍 👍 👍 Type of study : Therapeutic Topic : Conservative - pain education This is a meta-synthesis on the effectiveness of most published treatments for carpal tunnel syndrome. A meta-synthesis is the combination of qualitative research to provide new insights into a specific topic. The search focused initially on available information from clinical resources as well as guidelines to make it as relevant as possible for clinicians. The search was not only limited to formal databases but professional institutes worldwide. Only information which had been created by a panel of experts, professional bodies, or that was obtained from formal literature searches was retained. The overall quality of the evidence was assessed through a modified GRADE approach, which was originally suggested by the Cochrane group for systematic reviews. A total of six guidelines were included in this study, including 55 different treatments. The results showed that there was strong evidence for the use of carpal tunnel release, wrist splinting, or corticosteroid injections. 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, immobilisation for carpal tunnel syndrome is strongly advised. This may be trialed for six weeks . Other strongly advised treatments include cortisone injections or surgical release. Other approaches such exercise , education , manual therapy , and workplace changes could be utilised but should not be the mainstream approach. URL : https://doi.org/10.1016/j.apmr.2021.03.034 Available through The Journal of Hand Surgery (American Volume) for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Carpal tunnel syndrome (CTS) treatment contains ambiguities across and within disciplines. This meta-synthesis of professional guidelines consolidates clinical treatment recommendations for CTS treatment and classifies them by strength of evidence. We conducted a search of Google, Google Scholar, and PubMed for published clinical treatment recommendations for CTS. A systematic hand search was completed to identify additional professional organizations with published recommendations. We extracted any mentioned treatment from all sources but developed our final consolidated clinical treatment recommendations only from select rigorous guidelines based on the Institute of Medicine (IOM) criteria for trustworthy guidelines. We translated rating systems of the primary guidelines into a universal rating system to classify recommendations for consolidated clinical treatment recommendations. Our search yielded 30 sources that mentioned a total of 55 CTS treatments. Six of the sources met the IOM inclusion criteria. These primary guidelines provided recommendations for 46 of the 55 treatments, which were consolidated into 12 broad treatment categories. Surgery, positioning, and steroids were strongly supported. Conservative treatments provided by rehabilitation professionals were conditionally supported. Pharmaceuticals, supplements, and alternative treatments were not generally supported. CTS is a complex condition with a wide variety of treatments provided by a multitude of disciplines. Our consolidated clinical treatment recommendations offer a comprehensive outline of available treatments for CTS and contributes to the process of developing best practices for its treatment.

Reframing how we care for people with persistent non-traumatic musculoskeletal pain. Suggestions for the rehabilitation community. Lewis, J. S., et al. (2021) Level of Evidence : 5 Follow recommendation : 👍 👍 Type of study : Therapeutic Topic : Persistent musculoskeletal pain – Reframing care This is an expert opinion piece from a community of rehabilitation clinicians, researchers, and patients on the need to review our approach to persistent musculoskeletal treatment. Patients reported being disappointed and frustrated when undergoing "curative" treatments which provided no solution to their pain. Clients also reported economical issues associated with the time spent off work, which was moderated by their understanding that movement would cause further "damage". Clients reported empowerment as the most useful approach. This was guided by clinicians helping them in taking charge of their own health. In terms of advice for physiotherapists, the list in the box below was suggested. A move away from passive treatments for persistent musculoskeletal was suggested, with a strong bias towards coaching and maintenance of a healthy lifestyle. Clinicians were invited to dedicate more attention to the potential drivers of persistent musculoskeletal pain (e.g. inactivity, deconditioning) and less attention to the specific diagnostic labels and "curative" treatment, which can provide limited help in the treatment of persistent pain. 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 may take a holistic approach to care of our musculoskeletal clients by providing them with neuroscience education , information regarding the importance of staying active , and advice on how stop smoking if they are. In addition, we could probably start talking about tissue sensitivity rather than "wear and tear" or "overuse syndrome" . There is in fact evidence suggesting that the words that we use can have either a placebo (reducing pain) or nocebo effect (increasing pain) . We may also encourage joint motion for lotion , promote joint movement for amusement , and suggest meditation for elation . URL : https://doi.org/10.1016/j.physio.2021.04.002 Available through EBSCO Health Databases for PNZ members. Abstract There have been repeated calls to re-evaluate how clinicians provide care for people presenting with persistent non-traumatic musculoskeletal conditions. One suggestion is to move away from the ?we can fix and cure you? model to adopting an approach that is more consistent with approaches used when managing other persistent non-communicable diseases; education, advice, a major focus on self-management including lifestyle behavioural change, physical activity and medications as required. Currently the global delivery of musculoskeletal care has many of the elements of a ?super wicked problem?, namely conflict of interest from stake-holders due to the consequences of change, prevailing expectation of a structural diagnosis and concomitant fix for musculoskeletal pain, persistent funding of high risk, more expensive care when low risk more economic viable options that don?t impact on the quality of outcome exist, and an unquestionable need to find a solution now with the failure resulting in a growing social and economic burden for future generations. To address these issues, 100 participants included clinicians, educators and researchers from low-, middle- and high-income countries, 8 presenters representing the physiotherapy, sport medicine and the orthopaedic professions and the insurance industry, together with 3 people who shared their lived experiences of persistent musculoskeletal pain, discussed the benefits and barriers of implementing change to address this problem. This paper presents the results from the stakeholders? contextual analysis and forms the basis for the proposed next steps from an action and advocacy perspective.

Avoiding ring avulsion injuries with silicone rings: A biomechanical study. Jewett, C. A., S. Uppuganti and M. J. Desai (2021) Level of Evidence : 2b Follow recommendation : 👍 👍 Type of study : Preventative Topic : Ring avulsion - How to reduce the risk This is a biomechanical study assessing finger damage associated with traction of metal vs silicone rings in cadavers. A total of 25 fingers were tested in the present study. The speed of traction on the ring was 50 cm/s, which aimed to replicate a fall speed. The results showed that the breaking point for the silicone and metal rings was 495 N (50.5 kg) and 53 N (5.4 kg) respectively See table below). The breaking point for the silicone ring was defined as rupture of the ring itself whilst for the metal ring, the breaking point was defined as slippage or skin rupture. 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, silicone rings may reduce the risk of serious avulsion injuries compared to traditional metal rings. Despite reduced risk, the forces associated with the breaking point of silicone rings, may still cause injury as shown by a previous biomechanical study . URL : https://doi.org/10.1016/j.jhsa.2021.02.025 Available through The Journal of Hand Surgery (American Volume) for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Purpose: Finger avulsion injuries account for 5% of upper extremity injuries requiring evaluation in an emergency room. They are devastating injuries that require microvascular reconstruction or amputation. As public awareness rises, there is a growing market for silicone rings, with limited data on their ability to prevent ring avulsion injuries. Methods: Five cadaver forearms were attached to a custom fixture, allowing for ring avulsion simulations. Specifically designed silicone or metal rings of varying sizes (#4–#11) were assigned to one of five fingers on each forearm, based on fit. The contralateral corresponding finger was tested using a ring of the same size in the other material. A preload of 2 N was applied to each ring, and ultimate failure force was determined by applying an upward force at a loading rate of 500 mm/sec until failure. Additionally, a fifth cadaver forearm was used to determine the ultimate failure force of silicone rings in a clenched fist position. Results: The average ultimate failure force for silicone rings of all sizes was 53.0 N, compared to 495.2 N for metal rings of all sizes. The average ultimate failure force of silicone rings in the clenched fist position was increased across rings of all sizes, with an average of 99.9 N. There were no degloving injuries in the silicone ring avulsion group. Conclusions: Biomechanically, silicone rings have a significantly lower failure force than metal rings and may help prevent ring avulsion injuries. Clinical relevance: The use of silicone rings should be encouraged in professions where ring avulsion injuries are more likely, such as heavy labor.

Association between text neck and neck pain in adults. Correia, I. M. T., et al. (2021) Level of Evidence : 4 Follow recommendation : 👍 👍 👍 Type of study : Symptoms prevalence study Topic : Mobile technology use - symptoms prevalence of neck pain This cross sectional study assessed the association between neck position during mobile phone texting and neck pain in adults. Participants (N = 582) with and without neck pain between the age of 18 and 65 were included. The average age was 27 years old. Neck flexion position during mobile texting (usual comfortable position) was measured through a cervical range of movement inclinometer in standing and sitting. The presence of neck pain (yes/no) and the intensity of it (measured through NRS 0 to 10) were self-reported. The results showed that the average cervical flexion position in standing and sitting was 34° (SD: 12°) and 36° (SD: 14°) respectively. Prevalence of neck pain was 21% (n = 125). The worst neck pain intensity was 4.5 (SD: 2.3) out of 10. There was no association between the degree of cervical flexion during mobile texting and the presence or intensity of neck pain. Older age and poorer sleep were the only factors associated with greater prevalence of neck pain or pain intensity. Increase phone used also appeared to be associated with greater neck pain intensity. Clinical Take Home Message : Based on what we know today, there is no correlation between neck position and the presence or intensity of neck pain. Instead, it appears that older age, poor sleep, and possibly longer periods of time spent on the phone contributed to the presence and intensity of neck pain. Given these findings, we can probably avoid focusing too much on the posture that our clients adopt when utilising mobile phones and invite them instead to follow the World Health Organisation 2020 physical activity guidelines , which may reduce the time spent on their phone and improve sleep quality. URL : https://www.researchgate.net/publication/347846024 Available through The Journal of Hand Surgery (American Volume) for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract STUDY DESIGN: Observational cross-sectional study. OBJECTIVE: The aim of this study was to investigate the association between text neck and neck pain (NP) in adults. SUMMARY OF BACKGROUND DATA: It has been hypothesized that the inappropriate neck posture adopted when texting and reading on a smartphone, called text neck, is related to the increased prevalence of NP. METHODS: The sample was composed of 582 volunteers aged between 18 and 65 years. Sociodemographics, anthropometrics, lifestyle, psychosocial, NP, and smartphone use-related questions were assessed by a self-reported questionnaire. Text neck was assessed by measuring the cervical flexion angle of the participants standing and sitting while typing a text on their smartphones, using the Cervical Range of Motion (CROM) device. RESULTS: Multiple logistic regression analysis and linear regression analysis showed the cervical flexion angle of the standing participant using a smartphone did not associate with the prevalence of NP (odds ratio [OR] = 1.00; 95% confidence interval [CI]: 0.98-1.02; P = 0.66), NP frequency (OR = 1.01; 95% CI: 1.00-1.03; P = 0.056), or maximum NP intensity (beta coefficient = -5.195 × 10-5; 95% CI: -0.02 to 0.02; P = 0.99). Also, the cervical flexion angle of the sitting participant using the smartphone did not associate with NP (OR = 0.99; 95% CI: 0.98-1.01; P = 0.93), NP frequency (OR = 1.01; 95% CI: 0.99-1.02; P = 0.13), or maximum NP intensity (beta coefficient = 0.002; 95% CI: -0.002 to 0.02; P = 0.71). CONCLUSION: Text neck was not associated with prevalence of NP, NP frequency, or maximum NP intensity in adults.

Conservative management of de quervain stenosing tenosynovitis: Review and presentation of treatment algorithm. Abi-Rafeh, J., R. Kazan, T. Safran and S. Thibaudeau (2020) Level of Evidence : 2a Follow recommendation : 👍 👍 👍 Type of study : Treatment Topic : De Quervain - Conservative treatment This is a systematic review reporting a treatment algorithm for De Quervain syndrome. Sixty-six studies (including case studies) were analysed, for a total of 2,306 participants. The studies included were not formally assessed in terms of their quality. The conservative treatments included in the review were cortisone injections, physiotherapy, and splinting. A very limited number of studies assessed the effectiveness of physiotherapy. Cortisone injections alone or in combination with splinting were the most studied approaches and appeared to provide pain relief in participants with De Quervain. 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 : There is a significant lack of studies assessing the effectiveness of conservative interventions other than cortisone injections or splinting for De Quervain syndrome. This is unfortunate, considering findings from previous research showing tendon pathology of APL/EPB in participants with De Quervain . If tendinopathy was a significant driver in De Quervain's syndrome, unloading through activity modification/splinting, followed by gradual tendon loading, may be an appropriate treatment ( see previous synopsis on different Tendinopathy stages ). Currently, for De Quervain tenosynovitis, the use of cortisone injection appears to be an effective treatment option. Future research is needed to determine whether cortisone injections for this condition are the best treatment or whether they provide a short term fix with long term negative repercussions, as it has been shown for tennis elbow . URL : https://doi.org/10.1097/prs.0000000000006901 Available through EBSCO Health Databases for PNZ members. Abstract BACKGROUND: Nonsurgical management of de Quervain disease relies mainly on the use of oral nonsteroidal antiinflammatory drug administration, splint therapy, and corticosteroid injections. Although the latter is most effective, with documented success rates of 61 to 83 percent, there exists no clear consensus pertaining to conservative treatment protocols conferring the best outcomes. This article reports on all present conservative treatment modalities in use for the management of de Quervain disease and highlights specific treatment- and patient-related factors associated with the best outcomes. METHODS: A systematic search was performed using the PubMed database using appropriate search terms; two independent reviewers evaluated retrieved articles using strict inclusion and exclusion criteria. RESULTS: A total of 66 articles met the inclusion criteria for review, consisting of 22 articles reporting on outcomes following a single conservative treatment modality, eight articles reporting on combined treatment approaches, 13 articles directly comparing different conservative treatment regimens, and 23 case reports. CONCLUSIONS: A multimodal approach using splint therapy and corticosteroid injections appears to be more beneficial than either used in isolation. Although there exists some evidence showing that multipoint injection techniques and multiple injections before surgical referral may provide benefit over a single point injection technique and a single injection before surgery, corticosteroid use is not benign and should thus be performed with caution. Ultrasound was proven valuable in the visualization of an intercompartmental septum, and ultrasound-guided injections were shown to both be more accurate and confer better outcomes. Several prior and concurrent medical conditions may affect conservative treatment outcome. A Level I to II evidence-based treatment protocol is recommended for the optimal nonsurgical management of de Quervain disease.