Search Results

The value of magnetic resonance imaging and ultrasound in diagnosing displaced rupture of the thumb ulnar collateral ligament. Hamborg-Petersen, E., Torfing, T., & Viberg, B. (2020) Level of Evidence : 4 Follow recommendation : 👍 👍 Type of study : Diagnostic Topic : Thumb UCL – Ultrasound and MRI diagnostic This is a non-peer reviewed prospective study assessing the usefulness of MRI and Ultrasound (US) in identifying thumb UCL (mcpj) ruptures. A total of 49 participants were included in the study. Only participants with a ruptured UCL identified clinically and with fluoroscopic diagnsosis were included. UCL rupture was confirmed if there was a greater than 35° of mcpj medial gapping on stress test (in 0° to 30° of mcpj flexion) or if there was more than 10° difference between sides. Potential participants were excluded if trauma had occured longer than 6 weeks before assessment. The variables of interest were the sensitivity of MRI and US. If a test is very sensitive and its result is negative, you can be more certain that the patient does not have the condition (good for screening purposes). Diagnostic accuracy of MRI and US was based on the intraoperative findings (gold standard). The results showed that median time from injury to MRI and US was 6 and 9 days respectively (range 1-20). Median time from injury to surgery was 9 days (range 1-33). The sensitivity of MRI was 65% and 73% for UCL rupture and Stener lesion respectively. The sensitivity of US was 65% and 36% for UCL rupture and Stener lesion respectively. Clinical Take Home Message : Hand therapists may not refer patients for US scans to screen for an UCL rupture or a Stener lesion. The sensitivity of this test is too low and does not appear to be useful in excluding these pathologies when the scans are negative. URL : https://journals.sagepub.com/doi/abs/10.1177/1753193420932496

Are you translating research into clinical practice? What to think about when it does not seem to be working. Murphy, M. C., W. Gibson, G. L. Moseley and E. K. Rio (2021). Level of Evidence : 5 Follow recommendation : 👍 Type of study : Therapeutic Topic : Research implementation This article presents a potential few reasons of why evidence based practice does not always work in clinical practice: 1) Participants included in a study may be different from the ones that you are seeing. Furthermore, the diagnostic criteria for participants inclusion may be different from the ones that you use. 2) Are your clients presenting with comorbidities that were utilised as exclusion criteria in research? If this is the case, the effectiveness of treatment in clinical practice may not be as significant. 3) Is there any placebo effect that has not been controlled for in research or in clinical practice? Consider potential confounding variables that could contribute to the findings - Take home message - "believe nothing, question everything, trust nobody" 4) Case series are not answering questions. They provide a story about clients' presentation, treatment, and outcomes. Causality cannot be ascertained. Same goes for clinical experience. 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 : Evidence guided practice is not easy to implement and at times can cause frustration. I still think that we should try to implement research while keeping an eye on the characteristics of the research sample (participants may be different from the clients we see in clinical practice). It is good practice to keep questioning what we read and hear, not out of disrespect, but to get closer to what actually works. I reviewed another article that you may find useful to take decisions when there is a lack of research available. URL : http://bjsm.bmj.com/content/early/2021/01/11/bjsports-2020-102369.abstract Available through EBSCO Health Databases for PNZ members. Abstract The value of clinical research can be lost in translation and implementation. One often overlooked issue is whether clinicians can determine if their patient is similar to research participants and, ipso facto, whether the clinician treating that patient will have the same effects as what was reported in a research study. We present five questions and clinical tips for clinicians.

Acute bilateral compartment syndrome of the forearms. Wrafter, P., O. Kelly and M. O’Shaughnessy (2020). Level of Evidence : 5 Follow recommendation : 👍 Type of study : Diagnostic Incidence : Rare Topic : What is the differential diagnosis? – Case study This is the answer for the case study from last week. The patient was a 43 year old female who had been experiencing 4 hours of forearm pain and paraesthesia in both hands. She was on angiotensin II medications (for hypertension treatment) and she had probably been dehydrated after sunbathing for the whole day. Objectively, there was no evidence of sunburn. Forearms were swollen. Fingers' position was in flexion and excruciating pain was reproduced when an attempting to passively extend the fingers. Pulses were palpable, capillary refill time was 2 seconds. A diagnosis of bilateral forearm compartment syndrome was made, possibly secondary to rhabdomyolysis. Rhabdomyolysis is a pathology leading to muscle break down. This condition is often caused by unaccustomed overexertion, dehydration and myotoxic medications (medications toxic to muscle), which include statins and angiotensin inhibitors. The patient was treated with bilateral forearm fasciotomy, which relieved pressure and lead to a good overall recovery. 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 : Compartment syndrome may be considered as a differential diagnosis in clients who report: taking statins or angiotensin inhibitors, recently having overexerted themselves, being dehydrated, or consuming alcohol. Objectively they would present with swollen painful muscles, which cause extreme pain when stretched. If acute compartment syndrome is suspected, clients should immediately be referred to ED. URL : https://www.jhandsurg.org/article/S0363-5023(18)31003-7/fulltext Available through The Journal of Hand Surgery (American Volume) for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract A 43-year-old woman presented to our emergency department with severe bilateral forearm pain. On examination, both forearms were tense and swollen and the patient had excruciating pain, made much worse on passive extension of the fingers. The pain did not resolve with analgesia. The symptoms and clinical examination were highly suspicious for compartment syndrome. However, there was no history of trauma, strenuous physical activity, or any other obvious factor that might have precipitated the onset of a compartment syndrome. The serum creatinine kinase at presentation was greater than 37,000. The patient, however, did have a history of hypertension and was taking losartan, an angiotensinogen II antagonist that has been associated with rhabdomyolysis. The patient was brought to surgery for emergency fasciotomies and made an excellent recovery after surgery. The etiology of this patient’s bilateral compartment syndrome is uncertain but may be a manifestation of drug-induced rhabdomyolysis.

Clinical and cost effectiveness of arthritis gloves in rheumatoid arthritis (A-GLOVES): randomised controlled trial with economic analysis. Hammond, A., et al. (2021). Level of Evidence : 1b Follow recommendation : 👍 👍 👍 👍 Type of study : Therapeutic Topic : Rheumatoid Arthritis - Gloves This is a randomised, multicentre, double-blind, placebo controlled trial assessing the effectiveness of compression gloves on pain in participants with rheumatoid arthritis (RA) affecting the hand. Participants (N = 206) were included if they were diagnosed with rheumatoid arthritis by a Rheumatology consultant and if they had difficulty sleeping due to hand pain or using their hands during the day. Importantly, participants were excluded if they had previously tried arthritis gloves. Pain was assessed through the numerical rating scale (NRS) at baseline and 12 weeks. Participants and assessors were blinded to treatment allocation. Participants were randomised to either wear arthritis gloves providing between 23 to 32 mmHg of compression (real gloves), or loose fitting gloves providing 15 to 25 mmHg of compression (placebo gloves). Participants were advised to wear the gloves for most of the day but less than 24 hours per day. Participants in both groups were also provided with joint protection advice and hand exercises. The results showed that participants in all groups used the gloves for an average of 5 hours during the day and 6 hours at night. Both groups had minor improvements in pain (1 point out of 10) at 12 weeks, which was not statistically or clinically different between groups. The arthritis gloves increased the cost of care by £129 without providing any significant benefit. 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, arthritis gloves do not provide any additional benefit than loose fitting gloves. Providing gloves is more pricey and the expense does not appear to be justified. Instead of providing gloves, it may be more useful to use those resources (money) for an additional session of hand therapy where we can provide them with exercise interventions which have been shown to be effective through the SARAH trial ( See previous synopsis with links to free online course ). Open access URL : https://doi.org/10.1186/s12891-020-03917-8 Abstract Arthritis (or compression) gloves are widely prescribed to people with rheumatoid arthritis and other forms of hand arthritis. They are prescribed for daytime wear to reduce hand pain and improve hand function, and/or night-time wear to reduce pain, improve sleep and reduce morning stiffness. However, evidence for their effectiveness is limited. The aims of this study were to investigate the clinical and cost effectiveness of arthritis gloves compared to placebo gloves on hand pain, stiffness and function in people with rheumatoid arthritis and persistent hand pain.

Joint position sense impairments in older adults with carpometacarpal osteoarthritis: A descriptive comparative study. Ouegnin, A. and K. Valdes (2020). Level of Evidence : 3b Follow recommendation : 👍 👍 Type of study : Aetiologic Topic : Symptomatic thumb osteoarthritis - Proprioception This is a multicentre case-control study assessing differences on proprioception (joint position test) in participants with thumb OA (cases) and healthy participants (controls). A total of 29 participants were included in the study. Thumb OA was diagnosed through clinical examination (e.g. positive grind test) and confirmed through x-ray in some participants but not all. Proprioception (joint position sense) was assessed through a hand held goniometer by asking participants to reproduce a specific thumb position (30 degrees of abduction) after moving the thumb through the full range of abduction. The difference between the target angle and the angle reproduced (error) was recorded. The results showed that participants with thumb OA presented with an average error of 10 degrees while the healthy participants presented with 1 degree error in joint repositioning. This finding was statistically and potentially clinically significant. There are however, a couple of limitations in this study. First, not all participants with thumb OA were matched to a healthy participant. In some cases, when thumb OA was unilateral, the controlateral thumb of the same participant was assessed. This leads to the second limitation, which is a statistical one. For the data analysis, an independent t-test was used, although this test can only be utilised when the two groups (thumb OA and controls) do not include the same participants. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message : Based on what we know today, clients with thumb OA may present with proprioception deficit. It is possible that these impairments may contribute to functional deficits. Currently, there is no evidence supporting the use of specific proprioceptive training and other multidisciplinary approaches , supported by higher quality evidence, may be implemented first. URL : http://www.sciencedirect.com/science/article/pii/S0894113018302904 Available through The Journal of Hand Therapy for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Study Design This study has a descriptive-comparative, cross-sectional design. Introduction Sensorimotor (SM) impairments have been observed after common wrist and hand injuries such as distal radius fractures. However, there is a lack of research regarding SM impairments in patients with carpometacarpal (CMC) osteoarthritis (OA). Purpose of the Study This study sought to quantify proprioception deficits in older adults with CMC OA as compared with healthy adults using the joint position sense (JPS) test. Methods The active JPS test was used to measure proprioception function in 29 thumbs with CMC OA and their 29 matched-control healthy counterparts. For comparison, participants with unilateral CMC OA were matched against themselves, whereas those with lateral CMC OA were age matched with a healthy participant. Data analysis was performed to compute the mean error of JPS; an unpaired t test was used to compare the mean error of the non–CMC OA group with the healthy control group. Results The mean positional error measured from subjects with CMC OA was 9.53° compared with 1.32° for the age-matched healthy subjects. The effect size for the difference in means was D = 1.96. Conclusions Thumb SM impairments were found to be greater in subjects with CMC OA than in their healthy counterparts when using the JPS test to assess proprioception.

Level of Evidence : 5 Follow recommendation : 👍 Type of study : Diagnostic Incidence : Rare Topic : What is the differential diagnosis? – Case study Have a think about this case study. Leave a diagnostic comment if you like. I will publish the diagnosis and treatment reported by the paper next week. The patient was a 43 year old female who had been experiencing 4 hours of forearm pain and paraesthesia in both hands. She was on angiotensin II medications (for hypertension treatment) and she had probably been dehydrated after sunbathing for the whole day. Objectively, there was no evidence of sunburn. Forearms were swollen. Fingers' position was in flexion and excruciating pain was reproduced when an attempting to passively extend the fingers. Pulses were palpable, capillary refill time was 2 seconds. What is it? 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.

Customary physical activity and odds of depression: A systematic review and meta-analysis of 111 prospective cohort studies. Dishman, R. K., C. P. McDowell and M. P. Herring (2021). Level of Evidence : 1a- Follow recommendation : 👍 👍 👍 👍 Type of study : Therapeutic Topic : Mental health - Physical activity This is a systematic review and meta-analysis assessing the effectiveness of physical activity in reducing symptoms of depression. Hundred and eleven observational studies were included in the systematic review, for a total of 1,404 participants. All the studies were included in the meta-analysis and they were assessed through the Risk of Bias criteria recommended by the Cochrane Review Group. The overall strength of evidence was based on some aspects of the GRADE approach, although the evidence was classified as "good", "acceptable", or "poor". Studies were included if physical activity was quantified and comparable to a guideline threshold. The results showed that there is moderate quality evidence showing that physical activity, when performed according to international guidelines, reduces the odds of presenting with depression by 20%. Importantly, there is a dose-response between physical activity and symptoms of depression. A limitation of this study is the inclusion of observational studies, which limits the extrapolation of causality between physical activity and depression. 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, physical activity has the potential to reduce depression symptoms. Interesting, effectiveness appears to be dependent on exercise dosage, which needs to follow international guidelines . The type of activity does not appear to matter as long as we meet a sufficient intensity and volume of exercise. Among the many forms of exercise available, a previous meta-analysis has shown that yoga , can reduce depression (see contraindications of yoga classes with a significant amount of meditation ). Considering the relationship between depressive symptoms and upper limb recovery as well as mental health and post surgical satisfaction , it may be worthwhile encouraging our clients to follow the international guidelines for physical activity. URL : http://bjsm.bmj.com/content/early/2021/01/04/bjsports-2020-103140.abstract Available through EBSCO Health Databases for PNZ members. Abstract Objective: To explore whether physical activity is inversely associated with the onset of depression, we quantified the cumulative association of customary physical activity with incident depression and with an increase in subclinical depressive symptoms over time as reported from prospective observational studies. Design: Systematic review and meta-analysis. Data sources MEDLINE, PsycINFO, PsycARTICLES and CINAHL Complete databases, supplemented by Google Scholar.Eligibility criteria Prospective cohort studies in adults, published prior to January 2020, reporting associations between physical activity and depression.Study appraisal and synthesis Multilevel random-effects meta-analysis was performed adjusting for study and cohort or region. Mixed-model meta-regression of putative modifiers. Results: Searches yielded 111 reports including over 3 million adults sampled from 11 nations in five continents. Odds of incident cases of depression or an increase in subclinical depressive symptoms were reduced after exposure to physical activity (OR, 95% CI) in crude (0.69, 0.63 to 0.75; I2=93.7) and adjusted (0.79, 0.75 to 0.82; I2=87.6) analyses. Results: were materially the same for incident depression and subclinical symptoms. Odds were lower after moderate or vigorous physical activity that met public health guidelines than after light physical activity. These odds were also lower when exposure to physical activity increased over time during a study period compared with the odds when physical activity was captured as a single baseline measure of exposure. Conclusion: Customary and increasing levels of moderate-to-vigorous physical activity in observational studies are inversely associated with incident depression and the onset of subclinical depressive symptoms among adults regardless of global region, gender, age or follow-up period.

Reliability of clinical tests for prediction of occult scaphoid fractures and cost benefit analysis of a dedicated scaphoid pathway. Kodumuri, P., A. McDonough, V. Lyle, Z. Naqui and L. Muir (2020). Level of Evidence : 3b Follow recommendation : 👍 👍 Type of study : Diagnostic Topic : Scaphoid fractures - Physical tests This is a retrospective study on the specificity and sensitivity of physical tests for occult schapoid fractures. 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. Only participants (n = 920) presenting with a negative x-ray for scaphoid fracture (occult fracture) were included in the present study. The diagnostic tests utilised were: tenderness on palpation at the snuff box or scaphoid tubercle, pain on axial compression of the thumb, pinch test, and ulnar deviation. The pinch test simply consisted in a tip to tip pinch between the thumb and index. The test was deemed positive when it caused pain in the client (see table 1 below). MRI was used as the gold standard against which the physical tests were assessed. The results showed that the absence of tenderness on palpation of the snuff box, moderately reduced the probability of an occult scaphoid fracture (see table 2 below - I calculated likelihood ratios for you, which are useful in assessing the diagnostic ability of a test). Tenderness on palpation of the snuff box increased the probability of an occult scaphoid fracture by a small degree (see table 2 below). The combination of multiple tests did not improve diagnostic accuracy. There was however a flaw within the study. When all the physical tests were negative, participants were not referred for an MRI, which is the gold standard against which all the tests were supposed to be assessed against (Thanks Dr. Steve White for pointing out this limitation and having a look at my likelihood ratio calculations). Table 2. Test specificity, sensitivity, and likelihood ratios (I calculated the LR+ and LR-, they were not provided in the article) 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, assessment of snuff box tenderness may be the most useful test for excluding an occult scaphoid fracture. However, given the limitations of the study analysed, it may be still worth repeating a hand x-ray at two weeks to exclude the presence of an occult scaphoid fracture. If you would like more information, look at the previous synopsis on scaphoid fractures requiring surgery . URL : https://doi.org/10.1177/1753193420979465 Available through EBSCO Health Databases for PNZ members. Abstract We reviewed the outcomes of our dedicated clinic for suspected scaphoid fractures. The primary outcome measure was to test the reliability of accurately diagnosing an occult scaphoid fracture with a combination of anatomical snuff box, scaphoid tubercle, longitudinal compression tenderness, ulnar deviation and the pinch test. Cost savings of the new patient pathway was our secondary outcome measure. Between December 2016 and March 2020, 922 patients were recruited at a mean of 12 days post-injury. Sixty-five per cent (n=602) with a low clinical suspicion were discharged and 35% (n=320) with a high clinical suspicion had same day MRI scan. Fifty-eight scaphoid fractures were diagnosed and treated with no nonunions reported. Anatomical snuff box tenderness was the most sensitive test (90%). A combination of five tests better excluded an occult fracture (80% accuracy). The dedicated scaphoid clinic pathway resulted in 350 fewer follow-up visits and an overall saving of £59,666.

Cupping for patients with chronic pain: A systematic review and meta-analysis. Cramer, H., et al. (2020) Level of Evidence : 1a- Follow recommendation : 👍 👍 👍 👍 Type of study : Therapeutic Topic : Cupping effectiveness - Chronic pain This is a systematic review and meta-analysis assessing the effectiveness of cupping for persistent pain. Eighteen RCTs were included in the systematic review, for a total of 1,172 participants. All the studies were included in the meta-analysis and they were assessed through the Risk of Bias criteria recommended by the Cochrane Review Group. The overall strength of evidence was not assessed in the paper but I decided to assess it through the GRADE approach ("low", "very low", "moderate", "high"), which has also been suggested by the Cochrane group for systematic reviews. The effectiveness of cupping was applied to several different musculoskeletal conditions (e.g. lower back pain, osteoarthritis). Efficacy of intervention was assessed through improvements in function or pain intensity (i.e. NRS, VAS). Cupping was compared to no intervention, sham cupping, or an active treatment. In this synopsis I just focused on the results of sham cupping (very low negative pressure or no negative pressure), which provide a reasonable placebo comparison. The treatment duration varied between 3 to 4 weeks, with biweekly treatment frequency. There is low quality evidence suggesting that sham cupping is as effective as cupping (both groups improved), without any statistically significant difference between the two interventions for both pain intensity and disability. Clinical Take Home Message : Based on what we know today, cupping is no more effective than placebo in clients with persistent pain. If you have applied it in clinical practice with significant success, it may be due to the contextual effect of your treatment session rather than any specific mechanism associated with cupping. Similar results have been shown when comparing cortisone injections or acupuncture for thumb OA, PRP or MWMs for tennis elbow to placebo interventions. They all work in clinical practice but the results is probably due to the placebo effect. URL : http://www.sciencedirect.com/science/article/pii/S1526590020300031 Available through EBSCO Health Databases for PNZ members. Abstract There is a growing interest in nonpharmacological pain treatment options such as cupping. This meta-analysis aimed to assess the effectiveness and safety of cupping in chronic pain. PubMed, Cochrane Library, and Scopus were searched through November 2018 for randomized controlled trials on effects of cupping on pain intensity and disability in patients with chronic pain. Risk of bias was assessed using the Cochrane risk of bias tool. Of the 18 included trials (n =1,172), most were limited by clinical heterogeneity and risk of bias. Meta-analyses found large short-term effects of cupping on pain intensity compared to no treatment (standardized mean difference [SMD] = −1.03; 95% confidence interval [CI] = −1.41, −.65), but no significant effects compared to sham cupping (SDM = −.27; 95% CI = −.58, .05) or other active treatment (SMD = −.24; 95% CI = −.57, .09). For disability, there were medium-sized short-term effects of cupping compared to no treatment (SMD = −.66; 95% CI = −.99, −.34), and compared to other active treatments (SMD = −.52; 95% CI = −1.03, −.0028), but not compared to sham cupping (SMD = −.26; 95% CI = −.57,.05). Adverse events were more frequent among patients treated with cupping compared to no treatment; differences compared to sham cupping or other active treatment were not statistically significant. Cupping might be a treatment option for chronic pain, but the evidence is still limited by the clinical heterogeneity and risk of bias. Perspective: This article presents the results of a meta-analysis aimed to assess the effectiveness and safety of cupping with chronic pain. The results suggest that cupping might be a treatment option; however, the evidence is still limited due to methodical limitations of the included trials. High-quality trials seem warranted.

Physiotherapy for people with painful peripheral neuropathies: A narrative review of its efficacy and safety. Jesson, T., Runge, N., & Schmid, A. (2020) Level of Evidence : 5 Follow recommendation : 👍 Type of study : Therapeutic Topic : Neuropathic pain - Chemotherapy induced and focal neuropathies This is a narrative review on physiotherapy interventions for chemotherapy-induced neuropathic pain and focal entrapment neuropathies (e.g. carpal tunnel, cervical radiculopathy). The results suggest that for established chemotherapy-induced neuropathic pain, an 8 weeks exercise program (participants trained at a perceived rate of exertion of "somewhat hard" to "hard" three times per week) can reduce symptoms. However, these findings were based on one study only with a small sample size. The following few sentences are only based on the preclinical science section of the paper, which I really liked. These findings suggested that aerobic training of low to moderate intensity may have "neuroprotective" and "neuroregenerative" effects independently of the form of exercise (e.g. walking, swimming, cycling). In addition, aerobic training may be more beneficial than resistance training in neuropathic pain. The perpetrated mechanism of pain relief is suggested to be due to modulation of inflammatory markers and the release of a soup of chemical that reduces nociceptive stimuli reaching the brain as well as reducing the firing thresholds of peripheral nociceptors. Clinical Take Home Message : Based on what we know today, clients presenting with chemotherapy-induced neuropathic pain, may benefit from an eight weeks program of moderate aerobic exercise performed three times per week. This is great as there is otherwise not much that we can otherwise offer to these clients. In addition, you may suggest you next client with a focal peripheral entrapment neuropathy (e.g. cervical radiculopathy, carpal tunnel syndrome) to go for a walk every day in addition to your mainstream treatment. This form of exercise would be defined as low to moderate intensity and it may help reducing symptoms. In addition, you may extend their healthspan by a few years ! Why don't you give it a try? Open Access URL : https://journals.lww.com/painrpts/Fulltext/2020/10000/Physiotherapy_for_people_with_painful_peripheral.14.aspx Abstract Pharmacological treatment for peripheral neuropathic pain has only modest effects and is often limited by serious adverse responses. Alternative treatment approaches including physiotherapy management have thus gained interest in the management of people with peripheral neuropathies. This narrative review summarises the current literature on the efficacy and safety of physiotherapy to reduce pain and disability in people with radicular pain and chemotherapy-induced peripheral neuropathy, 2 common peripheral neuropathies. For chemotherapy-induced peripheral neuropathy, the current evidence based on 8 randomised controlled trials suggests that exercise may reduce symptoms in patients with established neuropathy, but there is a lack of evidence for its preventative effect in patients who do not yet have symptoms. For radicular pain, most of the 21 trials investigated interventions targeted at improving motor control or reducing neural mechanosensitivity. The results were equivocal, with some indication that neural tissue management may show some benefits in reducing pain. Adverse events to physiotherapy seemed rare; however, these were not consistently reported across all studies. Although it is encouraging to see that the evidence base for physiotherapy in the treatment of peripheral neuropathic pain is growing steadily, the mixed quality of available studies currently prevents firm treatment recommendations. Based on promising preliminary data, suggestions are made on potential directions to move the field forward.

The lumbricals are not the workhorse of digital extension and do not relax their own antagonist. Crowley, J. S., M. Meunier, R. L. Lieber and R. A. Abrams (2020) Level of Evidence : 5 Follow recommendation : 👍 Type of study : Anatomical Topic : Lumbricals' action - Action and interaction This is biomechanical study on the role of lumbricals in the hand. The major points of this article are reported below: - Lumbricals are not able to produce enough force to counteract flexor digitorum profondus (FDP) or superficialis (FDS) at the pipj or dipj. This is due to their small cross sectional area when compared to FDP or FDS. - Lumbricals are weak mcpj flexors compared to the interossei muscles as their cross sectional area is 1/15 of the interossei - Lumbricals present the greatest number of muscle spindles (used for proprioception) among all the muscles of the upper limb Considering these facts, it is hypothesised that lumbricals have a proprioceptive role important for finger dexterity. Clinical Take Home Message : Based on what we know today, the lumbricals are more likely to have a sensory function rather than a force or movement generating capability in healthy clients. A possible exception is the presence of paradoxical flexion following laceration or avulsion of FDP. Knowing that lumbricals are also involved in proprioception may direct us to include a dexterity treatment component in those clients presenting with a grade III or IV lumbrical strain or tear . This injury may occur in climbers following a forced middle or ring finger extension while having the other fingers curled in your hand (Fall while on a mono or small ledge holds). URL : https://doi.org/10.1016/j.jhsa.2020.10.022 Available through The Journal of Hand Surgery (American Volume) for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract That the lumbrical muscles are the workhorse of digital extension and that they can relax their own antagonist have been time-honored principles. However, we believe this dogma is incorrect and an oversimplification. We base our assertion on anatomy, innervation, and the notion that muscle architecture is the most important determinant of muscle function. Wang and colleagues proposed the lumbrical to be a sophisticated tension monitoring device. We elaborate on their well-supported thesis, further proposing that the lumbricals also function as a constant tension spring within the closed loop composed of the digital flexors and the extensor mechanism.

A potential classification schema and management approach for individuals with A2 flexor pulley strain. Cooper, C. and P. LaStayo (2020). Level of Evidence : 5 Follow recommendation : 👍 Type of study : Therapeutic Topic : A2 pulley injury - Assessment and treatment This is an expert opinion article on assessment and treatment of A2 pulley injury. These injuries are very common in rock climbers and they do occur most often while crimping (see picture below). The classification suggested in this article (i.e. severe, moderate, and mild - see table below) is based on assessment of pain, active range of movement, resisted tests, and palpation. According to this classification system, severe pulley injury should be immobilised except for gentle active range of movement exercises and climbing training should be significantly modified. A mild injury should be managed with progressive resistance training and hang board training (avoiding crimping). With a moderate injury, the routine would be similar to a mild injury, however, the intensity would be lower. Additionally, H tape and pulley orthoses may be utilised to control symptoms in adjunct to climbing volume modification. Clinical Take Home Message : Based on what we know today, we may decide to classify A2 pulley injuries according to the assessment procedures described in this article. The only issue with a symptomatic driven assessment is that several factors can increase or decrease pain intensity independently of tissue damage (see the overuse injury and fracture TOP synopses). Triangulation of clinical presentation with investigations such as ultrasound and x-ray may help in the differential diagnosis (e.g. stress fractures) and may provide a more objective assessment of tissue damage (if any). If you are interested in other climbing injuries, see this previous synopsis . URL : https://doi.org/10.1016/j.jht.2019.01.002 Available through the Journal of Hand Therapy for HTNZ members. Available through EBSCO Health Databases for PNZ members. No abstract available