Search Results

The role of physiotherapists in smoking cessation. Luxton, N., & Redfern, J. (2020) Level of Evidence : 5 Follow recommendation : 👍 Type of study : Preventative, Therapeutic Topic : Smoking - Help them quit This is a guideline for health professionals on how to help clients quit smoking. A simple 3 steps process is suggested: 1) Ask if they are smoking and when they stopped smoking. If they stopped smoking in the last 6 months, they may benefit from extra support to avoid a relapse. 2) Advise to stop smoking if they are smoking. The advice should be personalised and refer to the impact of smoking in relation to their personal circumstances. These could include delays in wound healing and increased risk of infections, delays in fracture healing, as well as reduce effectiveness of painkillers. 3) Help by connecting your client with a specialist telephone service like Quitline (0800 778 778), internet interventions , or the QuitNow app. A relapse within the first few weeks from quitting is very common and health professionals should kindly check in on their client's progress. Clinical Take Home Message : The figure below speaks for itself. I feel I should screen my clients more than what I do at the moment, I often stop at the "Asking". If you have time, have a look at the Ministry of Health page on "Stop smokin g" , it has some great resources! Open Access URL : https://www.researchgate.net/profile/Nia_Luxton2/publication/344637357_The_role_of_physiotherapists_in_smoking_cessation/links/5f861c7e92851c14bcc69473/The-role-of-physiotherapists-in-smoking-cessation.pdf No Abstract available

Association between push-up exercise capacity and future cardiovascular events among active adult men. Yang, J., Christophi, C. A., Farioli, A., Baur, D. M., Moffatt, S., Zollinger, T. W., & Kales, S. N. (2019) Level of Evidence : 2b Follow recommendation : 👍 👍 👍 Type of study : Prognostic Topic : Push-up - Mortality prediction This is a retrospective longitudinal cohort study assessing the ability to predict cardiovascular events (CV - e.g. heart failure, coronary hearth disease) in the next 10 years based on the number of push up that somebody can do. A total of 1,562 male firefighters participants were included at baseline. Participants were followed up for 10 years. Participants were on average 40 years old at baseline. The number of push-up was assessed at baseline. Participants had to do as many push ups as possible following the rhythm of a metronome set at 80 beats per minute. The test was interrupted if participants were unable to keep up with the beat for 3 or more consecutive repetitions. The results showed that participants completing less than 10 push-up were at much greater risk of having a CV event in the next 10 years. Participant able to do at least 11 push-up had a 64% reduction in risk at 10 years and those able to complete 40 push-up had a 96% risk reduction. Clinical Take Home Message : Based on what we know today, this push-up test is a quick reference that allows us to assess our clients CV risk at 10 years. This test is however currently applicable to males only. The results do not suggest that just training push-up will reduce your risk as this is just an adaptation to specific training. What this test does however suggest is that by getting people overall stronger, their risk of CV will reduce. This synopsis is a nice addition to the one that was previously completed on grip strength and mortality and walking and mortality . Getting our clients fitter may provide them with a longer lifespan (length of life) and healthspan (years of quality life - free from disease). Open Access URL : https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2724778 Abstract Importance: Cardiovascular disease (CVD) remains the leading cause of mortality worldwide. Robust evidence indicates an association of increased physical fitness with a lower risk of CVD events and improved longevity; however, few have studied simple, low-cost measures of functional status. Objective: To evaluate the association between push-up capacity and subsequent CVD event incidence in a cohort of active adult men. Design, Setting, and Participants: Retrospective longitudinal cohort study conducted between January 1, 2000, and December 31, 2010, in 1 outpatient clinics in Indiana of male firefighters aged 18 years or older. Baseline and periodic physical examinations, including tests of push-up capacity and exercise tolerance, were performed between February 2, 2000, and November 12, 2007. Participants were stratified into 5 groups based on number of push-ups completed and were followed up for 10 years. Final statistical analyses were completed on August 11, 2018. Main Outcomes and Measures: Cardiovascular disease–related outcomes through 2010 included incident diagnoses of coronary artery disease and other major CVD events. Incidence rate ratios (IRRs) were computed, and logistic regression models were used to model the time to each outcome from baseline, adjusting for age and body mass index (BMI) (calculated as weight in kilograms divided by height in meters squared). Kaplan-Meier estimates for cumulative risk were computed for the push-up categories. Results: A total of 1562 participants underwent baseline examination, and 1104 with available push-up data were included in the final analyses. Mean (SD) age of the cohort at baseline was 39.6 (9.2) years, and mean (SD) BMI was 28.7 (4.3). During the 10-year follow up, 37 CVD-related outcomes (8601 person-years) were reported in participants with available push-up data. Significant negative associations were found between increasing push-up capacity and CVD events. Participants able to complete more than 40 push-ups were associated with a significantly lower risk of incident CVD event risk compared with those completing fewer than 10 push-ups (IRR, 0.04; 95% CI, 0.01-0.36). Conclusions and Relevance: The findings suggest that higher baseline push-up capacity is associated with a lower incidence of CVD events. Although larger studies in more diverse cohorts are needed, push-up capacity may be a simple, no-cost measure to estimate functional status.

Challenging the dogma: Severely angulated neck fractures of the fifth metacarpal must be treated surgically. Boeckstyns, M. E. H. (2020) Level of Evidence : 3a Follow recommendation : 👍 👍 Type of study : Therapeutic Topic : 5th metacarpal neck fracture - conservative vs surgical This is a systematic review comparing the effectiveness of different conservative treatment or conservative treatments vs surgical treatment for 5th metacarpal neck fractures. Eighteen studies were included in the systematic review. The studies included were quite heterogeneous and only one author completed the review (usually we have two authors assessing research independently). Efficacy of intervention was assessed by functional outcomes (e.g. DASH), maintenance of fracture reduction, return to work, and complications.The results showed that different types of conservative treatment did not affect any of the outcomes to a significant level. Some of the studies elected to mobilise participants immediately and others utilised a clam shell around the 5th metacarpal without including the mcpj. Return to work was quicker in those participants who were allowed to mobilise early. No clear difference was identified in clients treated surgically or conservatively. Complications appeared to be higher in the surgically treated group. Clinical Take Home Message : Based on what we know today, hand therapists may choose to mobilise early clients with a 5th metacarpal neck fracture. If a form of splinting is chosen, there appears to be no difference between a clam shall including or not the mcpj, or buddy splinting. Surgical treatment seem to lead to worse outcomes. For another great study on this topic, see previous synopsis . URL : https://journals.sagepub.com/doi/abs/10.1177/1753193420968040 Available through EBSCO Health Databases for PNZ members. Abstract Cadaveric studies suggest that the acceptable deformity in fifth metacarpal neck fractures is maximally 30° palmar angulation. This systematic review verifies the validity of these threshold values. Eighteen prospective comparative studies on operative and/or conservative treatment options in adults were included. None of the studies demonstrated any correlation between the residual or initial angulation and the clinical results despite accepting more severe angular deformities. Closed reduction and immobilization without internal fixation improved the palmar angle by 5° to 9° in three studies and 29° in a fourth. Operative treatments compared with non-reducing conservative treatments showed no benefit of the surgery other than aesthetic issues. The synthesis of this review indicates that 90% of fractures of the metacarpal neck with apex angulation up to 70° can be treated successfully with a functional metacarpal brace without reduction. Disability of the Arm, Shoulder and Hand questionnaire scores <10 are uniformly reported. I modified my own practice accordingly a decade ago to treating these fractures conservatively regardless of the palmar angulation, except in patients with exceptional demands or other fracture deformities.

Rehabilitation of elbow instability. Pipicelli, J. G., & King, G. J. W. (2020) Level of Evidence : 5 Follow recommendation : 👍 Type of study : Aetiologic, Therapeutic Topic : Elbow instability - Aetiology and treatment This is a narrative review on aetiology and treatment of elbow stiffness. The aetiology of elbow instability is usually due to a trauma associated with elbow extension. The goal of treatment is to allow time for the ligaments, capsule, and potentially tendinous lesions to heal. Conservative treatment depends on the severity and type of injury. The presence of a "drop sign" on x-ray (more than 4mm distance between the humerus and ulna in 90deg of elbow flexion) suggest significant elbow laxity. If the lateral collateral ligaments (LCL) of the elbow are involved, the forearm should be maintained in pronation to increase the support provided by the common extensor tendons. If the medical collateral ligaments (MCL) have been injured, the forearm should be positioned in supination to increase support from the common flexor tendon. If both LCL and MCL are involved, the forearm should be placed in neutral. Acutely after injury, the elbow is placed in a splint which limits elbow extension to 60deg. Extension is subsequently increased by 10deg per week. Active range of movement exercises can be initiated soon after the injury and they involve flexion/extension of the elbow (within the brace limits) and pronation/supination of the forearm (in 90 deg of elbow flexion) in a supine position with 90deg of shoulder flexion. This position has been suggested to improve joint congruence and reduce instability during the exercises. Elbow x-rays should be repeated at 3 weeks post injury and if a "drop sign" is still present, surgery is indicated. Isometric biceps and triceps exercises should be included within the first 3 weeks if the "drop sign" is present and this may help in reducing instability. At six weeks post injury, isotonic (e.g. dynamic exercises holding a dumbbell) strengthening can generally be initiated. Clinical Take Home Message : Based on what we know today, elbow instability should be treated with ROM brace than can limit AROM to 60deg of extension. The additional positioning of a resting pronation/supination may be used to protect the LCL and MCL respectively. X-rays should be obtained at baseline and at 3 weeks. If a "drop sign" is present, this suggest significant instability and isometric biceps and triceps resistance exercises should be utilised in combination with AROM in supine to reduce instability and maintain range of movement. The development of stiffness following an elbow injury is common and you can take a look at a previous synopsis on the topic . URL : https://www.sciencedirect.com/science/article/abs/pii/S0749071220300871?via%3Dihub Available through Hand Clinics for HTNZ members. Available through EBSCO Health Databases for PNZ members. No Abstract available

Telemedicine in hand and upper-extremity surgery Grandizio, L. C., Foster, B. K., & Klena, J. C. (2020) Level of Evidence : 5 Follow recommendation : 👍 Type of study : Therapeutic Topic : Telemedicine – Implementation and feasibility This narrative review provides advice on the implementation of telemedicine, and its strength/limitations, for upper limb conditions. Written consent should be gathered before any telemedicine session. This can be obtained online before the appointment. When starting a telemedicine consultation, patients should be made aware of any other people present in the room. Radiology referrals and reports are usually available online making it easier for clinicians to make decisions. Range of movement assessments of wrists and fingers appear to be feasible through video calls. One of the limitations is the assessment of sensation (monofilament testing). No evidence has assessed the feasibility of special tests and reliability of special tests through telemedicine. It appears that wound assessment is feasible with telemedicine and that complications are easily assessed. The cost of telemedicine appears to be lower compared to a traditional outpatient visit, and it seems to be as safe as in person assessments. Clinical Take Home Message : Based on what we know today, telemedicine is possible and may be utilised as an alternative to in person appointments. Limited evidence has assessed the validity and reliability of objective assessments performed remotely. For skin sensation, the Ten Test can be performed by the patient independently and may be suitable for telemedicine use. Toothpicks may be used as an alternative to assess pinprick sensation ( assessing nerves' small fibre ). In addition, most splints can be posted to patients without them leaving the comfort (or safety) of their own house. Companies such as @Therapy can organise the delivery, without too much effort from the clinician's point of view. URL : https://www.jhandsurg.org/article/S0363-5023(19)31388-7/fulltext Available through The Journal of Hand Surgery for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Smartphones, computers, and Internet access continue to become more available to both patients and physicians. As these technologies develop with respect to health care, opportunities for telemedicine visits continue to emerge. The purpose of this review article was to analyze the current use and potential applications of telemedicine in hand and upper-extremity surgery. Although the literature pertaining to the use of telemedicine in hand surgery is limited, videoconferencing visits may provide benefits to patients. Particularly in rural and underserved regions, patients can decrease considerable travel burdens. Potential applications for this technology include remote inpatient and emergency room consultations, outpatient clinic visits, and postoperative care. There are unique considerations with respect to confidentiality and security. As with any new technology, it is important to analyze safety concerns. Future randomized, prospective investigations are necessary to define the economic implications of telemedicine programs more clearly within hand and upper-extremity surgery.

Dietary supplements for treating osteoarthritis: a systematic review and meta-analysis. Liu, X., Machado, G. C., Eyles, J. P., Ravi, V., & Hunter, D. J. (2018) Level of Evidence : 1a Follow recommendation : 👍 👍 👍 👍 Type of study : Therapeutic Topic : Dietary supplements – Osteoarthritis This is a systematic review and meta-analysis of randomised placebo-controlled trials assessing the effectiveness of dietary supplements for osteoarthritis (hand, knee, and hip). Sixty-nine randomised placebo-controlled trials were included for a total of 11,586 participants. The results from this systematic review and meta-analysis were assessed through the GRADE approach (suggested by the Cochrane Group), which scores the evidence as "very low", "low", "moderate", or "high" quality. Efficacy of intervention was assessed through changes in pain (other outcomes were included but I decided to keep it simple). Pain was assessed through the visual analogue scale (e.g. VAS). Several supplements were utilised, however, I selected chondroitin (it had the greatest number of studies for a total of 1,822 participants). The results showed that there was "moderate" to "high" quality of evidence suggesting that chondroitin is effective in the short term (less than 3 months) in reducing pain. The authors report these findings as been non clinically meaningful because their overall effect (standardised mean difference - SMD of 0.34) was smaller than the selected threshold of SMD = 0.37. Interestingly, they reported other supplements (e.g. Boswellia serrata extract, Curcuma longa extract) showing large and clinically important findings although the number of participants was relatively small (33 to 427) and the 95% CI of the therapeutic effect was larger compared to chondroitin. Clinical Take Home Message : Based on what we know today, chondroitin and other supplements (see figure below) may relieve pain in osteoarthritis (hand included) in the short term. These supplements may be utilised as an adjunct to other treatments for hand osteoarthritis, which have previously been shown to be effective (see this synopsis ). Although the reported effect sizes (SMD) are small for chondroitin, their effect size is very similar to the one reported by placebo controlled RCTs assessing the effectiveness of Nonsteroidal anti-inflammatory drugs (NSAIDs) . The cost of ongoing supplementation should be considered and if clients are on a restricted budget this intervention should not be advocated. Clients should also be advised to review the appropriateness of these supplements with their GP to avoid negative interactions with prescribed drugs or allergic reactions. Open Access URL : https://bjsm.bmj.com/content/bjsports/52/3/167.full.pdf Abstract Objective: To investigate the efficacy and safety of dietary supplements for patients with osteoarthritis. Design: An intervention systematic review with random effects meta-analysis and meta-regression. Data sources: MEDLINE, EMBASE, Cochrane Register of Controlled Trials, Allied and Complementary Medicine and Cumulative Index to Nursing and Allied Health Literature were searched from inception to April 2017. Study eligibility criteria: Randomised controlled trials comparing oral supplements with placebo for hand, hip or knee osteoarthritis. Results: Of 20 supplements investigated in 69 eligible studies, 7 (collagen hydrolysate, passion fruit peel extract, Curcuma longa extract, Boswellia serrata extract, curcumin, pycnogenol and L-carnitine) demonstrated large (effect size >0.80) and clinically important effects for pain reduction at short term. Another six (undenatured type II collagen, avocado soybean unsaponifiables, methylsulfonylmethane, diacerein, glucosamine and chondroitin) revealed statistically significant improvements on pain, but were of unclear clinical importance. Only green-lipped mussel extract and undenatured type II collagen had clinically important effects on pain at medium term. No supplements were identified with clinically important effects on pain reduction at long term. Similar results were found for physical function. Chondroitin demonstrated statistically significant, but not clinically important structural improvement (effect size −0.30, –0.42 to −0.17). There were no differences between supplements and placebo for safety outcomes, except for diacerein. The Grading of Recommendations Assessment, Development and Evaluation suggested a wide range of quality evidence from very low to high. Conclusions: The overall analysis including all trials showed that supplements provided moderate and clinically meaningful treatment effects on pain and function in patients with hand, hip or knee osteoarthritis at short term, although the quality of evidence was very low. Some supplements with a limited number of studies and participants suggested large treatment effects, while widely used supplements such as glucosamine and chondroitin were either ineffective or showed small and arguably clinically unimportant treatment effects. Supplements had no clinically important effects on pain and function at medium-term and long-term follow-ups.

Early mobilization after volar locking plate osteosynthesis of distal radial fractures in older patients: A randomized controlled trial. Sørensen, T. J., Ohrt-Nissen, S. M. D., Ardensø, K. V., Laier, G. H. M. S., & Mallet, S. K. M. D. (2020). Level of Evidence : 1b Follow recommendation : 👍 👍 👍 Type of study : Therapeutic Topic : Distal radius fracture - Early vs delayed mobilisation This is a randomised single-blind placebo controlled trial assessing the effectiveness of early mobilisation vs late mobilisation on grip strength, range of movement, and function. Participants (N = 85) were treated with volar open reduction and internal fixation (ORIF) of a distal radius fracture. Participants were excluded if they were younger than 50 years old, if they presented with an open fracture, neurological defficits, or if surgery was dealayed more than 14 days. Grip strength was assessed through a hand-held dynamometer, range of movement in pronation-supination, flexion-extension, and radial-ulnar deviation of the wrist was measured through a goniometer. Function was measured through the Disability of the Arm, Shoulder, and Hand (DASH) questionnaire. Outcomes were assessed at 4 weeks, 3, 6, and 12 months post surgery. Treatment allocation was randomised. No information on allocation concealment was provided. Assessors were blinded to treatment allocation. Participants were provided with either early mobilisation (n = 42) or late mobilisation (n = 43). The early mobilisation group initiated wrist and finger exercises the day after surgery and received a removable wrist splint. The late mobilisation group was put in a dorsal cast for two weeks, which was followed by wrist and finger exercises with intermittent immobilisation through a removable wrist splint. Exercise adherence was not measured. The results showed that both groups improved to a statistically and clinically significant level on grip strength, range of movement, and function at six months. However, there were no differences between groups. Clinical Take Home Message : Hand therapists may elect to immobilise clients for two weeks following distal radius fracture or initiate them on early mobilisation. No differences have been shown between the two modalities. However, it is possible that early mobilisation may increase the risk of plate loosening in older people. This may be due osteoporosis and additional screening should be performed in this group of clients. URL : https://www.jhandsurg.org/article/S0363-5023(20)30276-8/fulltext

Modifiable risk factors, cardiovascular disease, and mortality in 155 722 individuals from 21 high-income, middle-income, and low-income countries (PURE): A prospective cohort study. Yusuf, S., Joseph, P., Rangarajan, S., Islam, S., Mente, A., Hystad, P., . . . Dagenais, G. (2020) Level of Evidence : 1b Follow recommendation : 👍 👍 👍 👍 Type of study : Prognostic Topic : Grip strength - Mortality prediction This is a prospective cohort study assessing the effectiveness of a series of risk factors for mortality in countries with high, middle, and low income. In this synopsis we only considered grip strength as a risk factor. A total of 155,722 participants were included at baseline. Participants were followed up for 12 years. Participants were on average 50.2 (SD: 10) years old. High income countries included Saudi Arabia, United Arab Emirates, Canada, and Sweden. Middle income countries included South Africa, Argentina, Chile, Brazil, Colmbia, Iran, Palestine, Poland, Turkey, Malaysia, and Philippines. Low income countries included Zimbawe, Tanzania, India, Pakistan, and Bangladesh. Grip strength was measured through a Jamar hand dynamometer. The results showed that participants with a grip strength below 15-20 kg (1st quintile - calculated based on mean and SD reported) were 1.6 (95%CI: 1.4 to 1.8) times more likely to die compared to participants with greater grip strength within the study time (12 years). This correlation does not suggest causation and there may be other factors that explain this association. Clinical Take Home Message : Mortality appears to be higher in adults with lower grip strength (below 15-20kg). Hand therapists may refer or prescribe whole body exercise (e.g. aerobic, strength training) for patients who present with low grip strength reduce frailty in their patients. URL : https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)32008-2/fulltext

Central sensitization in musculoskeletal pain: Lost in translation? van Griensven, H., Schmid, A., Trendafilova, T., & Low, M. (2020) Level of Evidence : 5 Follow recommendation : 👍 Type of study : Aetiologic, Diagnostic, Therapeutic Topic : Central sensitisation - Presentation and diagnostics This is a view point on the definition of central sensitisation, clinical presentation of central sensitisation, and the challenges associated with the application of this concept in clinical practice. Central sensitisation original definition, referred to neurophysiological changes within the dorsal horn of the spinal cord. These changes could amplify nociceptive stimuli coming from the periphery or allow the translation of mechanical (not nociceptive stimuli) into nociceptive stimuli (leading to allodynia - perception of pain with a non painful stimuli). Currently, clients presenting with widespread, ongoing, severe, and prolonged pain (caused by an "innocuous stimulus"), may present with central sensitisation. The problem with the implementation of this concept in clinical practice is that we do not have biomarkers/tests able to confirm the presence or absence of central sensitisation. In addition, the quantitative sensory testing (QST) utilised in research is far from perfect and records painful responses to stimuli rather than spontaneous pain. The validity of questionnaires for central sensitisation (e.g. Central Sensitisation Inventory) has also recently been questioned, leaving us with limited options. We should also not exclude peripheral drivers (e.g. ongoing nociceptive inputa) to central sensitisation, which may be responsible for allodynia (perception of pain with a non painful stimuli), and hyperalgesia (exaggerated pain response to a usually painful stimuli). Finally, a couple of key concepts which caught my attention were: the need to differentiate between psychological factors and central sensitisation, and the need for knowledge humility. We know that psychological factors (e.g. depression, anxiety) can heighten pain response by reducing pain inhibition (top-down), however, they are not the same thing as central sensitisation (changes within the dorsal horn of the spinal cord). In addition, the concept of epistemic humility (I interpreted it as "knowledge humility") is introduced and suggests that we need to keep an open mind in terms of "truth" provided by scientific research. This means that what is "true" today will most likely be challenged tomorrow and another shade of grey will be introduced. Clinical Take Home Message : Based on what we know today, central sensitisation may amplify nociceptive inputs coming from peripheral joints or soft tissues. Central sensitisation is for most part reversible, and the reduction of nociceptive inputs from the periphery should reverse the neurophysiological processes back to normal. Clients presenting with an extreme pain response, to what is normally not deemed as a particular painful activity, may present with central sensitisation. A diagnosis of central sensitisation is hard, if not impossible, to make with the tools available today. This may question its use in clinical practice, especially with patients. On a final note, central sensitisation is different from psychological factors such as depression, which are known to heighten pain response through top-down pathways. The two concepts (i.e. central sensitisation and psychological factors) should be therefore kept separate. URL : https://www.jospt.org/doi/abs/10.2519/jospt.2020.0610 Available through EBSCO Health Databases for PNZ members. Abstract Central sensitization is a physiological mechanism associated with enhanced sensitivity and pain responses. At present, central sensitization cannot be determined directly in humans, but certain signs and symptoms may be suggestive of it. Although central sensitization has received increasing attention in the clinical literature, there is a risk that certain distinctions are being lost. This paper summarizes current knowledge of the physiology of central sensitization and its possible manifestations in patients, in order to inform a debate about the relevance of central sensitization for physical therapists. It poses 6 challenges associated with the application of central sensitization concepts in clinical practice and makes suggestions for assessment, treatment, and use of terminology. Physical therapists are asked to be mindful of central sensitization and consider potential top-down as well as bottom-up drivers, in the context of a person-centered biopsychosocial approach.

A systematic review of how daily activities and exercises are recommended following volar plating of distal radius fractures and the efficacy and safety of early versus late mobilisation. Collis, J., Signal, N., Mayland, E., & Clair, V. W.-S. (2020) Level of Evidence : 1a- Follow recommendation : 👍 👍 👍 👍 Type of study : Therapeutic Topic : Radius fracture – Early mobilisation This is a systematic review assessing the effectiveness and safety of early mobilisation following a distal radius fracture treated surgically with a volar plate. Eight studies, for a total of 519 participants (72% females) were included in the review. Of these, 5 were RCTs and 3 were retrospective studies. All the studies were assessed through the Downs and Black Quality Index, which is appropriate for both experimental and non-experimental studies. Each paper was scored as "excellent", "good", "fair", or "poor". Efficacy of intervention was assessed through improvements in pain (e.g. NRS, VAS), function (e.g. DASH, PRWE), and wrist and forearm range of movement (extension/flexion/supination/pronation) in the short-term (6-8/52), midterm (10-12/52), and long-term (24-26/52). Safety was assessed by counting the number of adverse events. Early mobilisation (1-8 days from surgery) was compared to a delayed mobilisation (2-6 weeks post surgery). On average, the studies included were of "good" quality. The results showed that early mobilisation provided a small possibly non clinically relevant differences (see Supplementary file 2) in pain compared to delayed mobilisation. However, function improved to a small/large extent in the early mobilisation group and these differences were clinically relevant. Early mobilisation also led to small/moderate improvement in range of movement, possibly not clinically relevant (I only looked at supination as we know that for this measurement we require at least an 8deg change for it to be clinically meaningful - Reid et al. 2020 ) when compared to delayed mobilisation. There were no differences in the number of adverse events between the early vs delayed mobilisation. Clinical Take Home Message : Based on what we know today, early mobilisation (within 2 weeks from surgery) of distal radius fractures ORIF may provide better functional outcomes compared to delayed mobilisation (more than 2 weeks post surgery). A recent randomised controlled study showed that there was no difference in terms of pain, function, and AROM if mobilisation was started on the day after surgery vs at 2 weeks ( see this synopsis ). It is therefore possible that delaying mobilisation by a max of two weeks is acceptable. However, immobilisation beyond the two weeks mark may lead to sub-optimal functional recovery off our clients. URL : https://journals.sagepub.com/doi/abs/10.1177/1758998320967032 Available through the Hand Therapy for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Introduction: Following surgical repair of distal radius fractures, mobilisation timeframes and interventions vary. Early mobilisation (<2 weeks postoperatively) usually includes range of motion exercises and may include recommendations to perform daily activities. The review investigated (i) how early mobilisation was recommended, particularly with respect to wrist use during daily activities and (ii) the efficacy and safety of early versus delayed mobilisation (< or ≥2 weeks). Methods: The study protocol was registered on PROSPERO (CRD42019136490). Five databases were searched for studies that compared early and delayed mobilisation in adults with volar plating of distal radius fractures. The Downs and Black Quality Index and the Template for Intervention Description and Replication checklist were used for quality evaluation. Effect sizes were calculated for range of movement, function and pain at 6–8, 10–12 and 26 weeks. A descriptive analysis of outcomes and mobilisation regimes was conducted. Results: Eight studies with a mean Quality Index score of 20 out of 28 (SD=5.6) were included. Performing daily activities was commonly recommended as part of early mobilisation. Commencing mobilisation prior to two weeks resulted in greater range of movement, function and less pain at up to eight weeks postoperatively than delaying mobilisation until two weeks or later. Discussion: Performance of daily activities was used alongside exercise to promote recovery but without clearly specifying the type, duration or intensity of activities. In combination with exercise, early daily activity was safe and beneficial. Performing daily activities may have discrete advantages. Hand therapists are challenged to incorporate activity-approaches into early mobilisation regimes.

Does Mental Practice or Mirror Therapy help prevent functional loss after distal radius fracture? A randomized controlled trial. Korbus, H., & Schott, N. (2020) Level of Evidence : 2b Follow recommendation : 👍 👍 👍 Type of study : Therapeutic Topic : Radius fracture - motor imagery or mirror therapy vs relaxation This is a randomised single-blind controlled trial assessing the effectiveness of mental practice (Motor Imagery - MI) and mirror therapy (MT) in participants with distal radius fracture. Participants (N = 36) were included if they had undergone a closed fracture reduction or an open reduction internal fixation surgery. Participants were excluded if they had bilateral fracture or had any neurological condition. Effectiveness of each intervention was assessed through several functional measures (I choose to consider the QuickDASH as it is commonly used in clinical practice). Outcomes were measured at baseline and 12 weeks from injury. All participants trained with one therapist 5 times per week for 45 minutes during the first three weeks, and 3 times per week in the last three weeks of training (total of 6 weeks). Treatment allocation was randomised. The assessor was blinded to treatment allocation. Participants were provided with either MI (n = 8), MT (n = 12), or relaxation techniques (control group, n = 9). Participants in the MI mentally rehearsed several wrist movements of the affected wrist, which included wrist flexion, extension, radial and ulnar deviation, pronation, supination, and gripping. The MT group watched the reflection of the healthy hand performing the movements indicated above. The relaxation group was provided with the same duration intervention and relaxation interventions were provided. The results showed that the two intervention groups improved to a larger extent (MI = 43 points improvement; MT = 42 points improvement) compared to the control group (CG = 39 points improvement) in the QuickDASH, however, these differences were not clinically significant (the difference between groups was less than 15 points). Clinical Take Home Message : Based on what we know today, motor imagery or mirror therapy alone do not appear to improve QuickDASH outcomes at 3 months compared to a control group receiving relaxation interventions. A more appropriate approach is to follow a graded motor imagery approach, which has previously been shown to reduce pain and improve funct ion at 8 weeks post distal radius fracture (see synopsis here ). This paper followed a precise series of steps (based on neurophysiological concepts) which included a left/right hand discrimination task (3 weeks), explicit motor imagery (3 weeks), and mirror therapy (2 weeks). This approach may be particularly appropriate in patients presenting with high levels of pain within the first week of injury (these patients are also more likely to develop CRPS ). Open Access URL : https://www.sciencedirect.com/science/article/pii/S0894113020302076 Available through the Journal of Hand Therapy for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Background Therapy results after distal radius fractures (DRF) especially with older patients are often suboptimal. One possible approach for counteracting the problems are motor-cognitive training interventions such as Mental Practice (MP) or Mirror Therapy (MT), which may be applied in early rehabilitation without stressing the injured wrist. Purpose The aim of the study is to investigate the effects of MP and MT on wrist function after DRF. The pilot study should furthermore provide information about the feasibility and efficacy of these methods. Study Design The study was designed as a randomized, single-blinded controlled trial. Methods Thirty-one women were assigned either to one of the two experimental groups (MP, MT) or to a control group (relaxation intervention). The participants completed a training for six weeks, administered at their homes. Measurements were taken at four times (weeks 0, 3, 6 and 12) to document the progression in subjective function (PRWE, QuickDASH) and objective constraints of the wrist (ROM, grip strength) as well as in health-related quality of life (EQ-5D). Results The results indicated that both experimental groups showed higher improvements across the intervention period compared to the control group; e.g. PRWE: MT 74.0%, MP 66.2%, CG 56.9%. While improvements in grip strength were higher for the MP group, the MT group performed better in all other measures. However, time by group interactions approached significance at best; e.g. ROM: p = .076; ηp2 = .141. Conclusion The superiority of MP as well as MT supports the simulation theory. Motor-cognitive intervention programmes are feasible and promising therapy supplements, which may be applied in early rehabilitation to counteract the consequences of immobilization without stressing the injured wrist.

How to proceed when evidence-based practice is required but very little evidence available? Leboeuf-Yde, C., Lanlo, O., & Walker, B. F. (2013) Level of Evidence : 5 Follow recommendation : 👍 Type of study : Therapeutic Topic : Limited evidence - How to proceed? This article presents a discussion on how to manage lack of evidence in clinical practice. You can find an exhaustive figure below the synopsis. The following recommendations were made: - If there is no evidence on a specific topic, use plausibility and experience. - If a treatment/test's plausibility is questioned (i.e. preclinical or basic science studies do not support the mechanism), experience is not enough to justify treatment/test. - If a treatment/test's plausibility is questioned (i.e. preclinical or basic science studies do not support the mechanism) but its use is supported by several high quality clinical studies , use the treatment/test. Clinical Take Home Message : Based on this approach, our clinical decisions should rely on consistent high quality evidence (if available). If not enough evidence (research in clinical populations) is available we should question whether a specific test/treatment is logical and whether its logical assumptions are supported by preclinical/basic science. If not, the specific test/treatment should not be used. On the other hand, if there is limited evidence (research in clinical populations), but the test/treatment is logical and its logical assumptions are supported by preclinical/basic science we should use. In this last case we need to keep an open mind and be ready to change our practice when new evidence arises. Open Access URL : https://chiromt.biomedcentral.com/articles/10.1186/2045-709X-21-24 Abstract Background All clinicians of today know that scientific evidence is the base on which clinical practice should rest. However, this is not always easy, in particular in those disciplines, where the evidence is scarce. Although the last decades have brought an impressive production of research that is of interest to chiropractors, there are still many areas such as diagnosis, prognosis, choice of treatment, and management that have not been subjected to extensive scrutiny. Discussion In this paper we argue that a simple system consisting of three questions will help clinicians deal with some of the complexities of clinical practice, in particular what to do when clear clinical evidence is lacking. Question 1 asks: are there objectively tested facts to support the concept? Question 2: are the concepts that form the basis for this clinical act or decision based on scientifically acceptable concepts? And question three; is the concept based on long-term and widely accepted experience? This method that we call the “Traffic Light System” can be applied to most clinical processes. Summary We explain how the Traffic Light System can be used as a simple framework to help chiropractors make clinical decisions in a simple and lucid manner. We do this by explaining the roles of biological plausibility and clinical experience and how they should be weighted in relation to scientific evidence in the clinical decision making process, and in particular how to proceed, when evidence is missing.