Search Results

An exploratory investigation into the longevity of pain reduction following multisensory illusions designed to alter body perception. Barnard, A., Jansen, V., Swindells, M., Arundell, M., & Burke, F. (2020) Level of Evidence : 4 Follow recommendation : 👍 👍 Type of study : Therapeutic Topic : Hand osteoarthritis - Illusory resizing This is a case-series study assessing the effectiveness of illusory sensory resizing of the hand on pain in participants with hand osteoarthritis (OA). Participants (N = 38) were diagnosed with hand OA through clinical criteria. The illusory visual resizing was achieved through cameras and screens which the participants looked at. The visual resizing could either give the illusion of stretching or shrinking the hand. This visual illusion was coupled with either a gentle traction (for the stretching illusion) or compression (for the shrinking illusion) of the most painful finger to boost the illusion effect. Pain was assessed on a Numerical Rating Scale (NRS) immediately before and after the intervention. The intervention provided participants with an illusory sensory resizing (visual and traction/compression) lasting two minutes. Participants were also asked to report how long pain-relief lasted after the illusory resizing. The choice of which illusion (shrinking vs stretching) to utilise, was based on a baseline test identifying which provided the most pain relief. Out of 38 participants, 28 (74%) reported pain relief with one of the illusions. Of these 28 participants, 17 (60%) reported improvement with the stretching illusion and 11 (40%) with the shrinking illusion. The results showed that after two minutes of illusory resizing, the stretching illlusion improved pain by 1.5 points out of 10, and the shrinking illusion improved pain by 0.5 out of 10 points (difference between medians provided). The effect of the intervention lasted for four minutes in 16% of participants, 20 minutes in 68% of participants, and between 7 hours and 10 weeks in 16% of participants. There was no statistical difference between the two illusions on pain. Clinical Take Home Message : Hand therapists may trial imagery resizing coupled with gentle traction or compression of the most painful finger in people with hand OA. This intervention, may provide immediate small and short lasting pain relieving effects in people with hand OA. This regime may be trialled in patients that are unable to undergo other interventions supported by higher quality evidence (e.g. NSAIDs). URL : https://www.mskscienceandpractice.com/article/S2468-7812(19)30119-5/pdf

Radial tunnel syndrome: definition, distinction and treatments. Bo Tang, J. (2020) Level of Evidence : 5 Follow recommendation : 👍 Type of study : Diagnostic, Therapeutic Topic : Posterior interosseous nerve entrapment - Radial tunnel syndrome vs PIN syndrome This is a narrative review on radial tunnel syndrome (RTS) and posterior interosseous nerve syndrome (PINS). These two presentations are both entrapment neuropathies of the posterior interosseous nerve, however, RTS is a mild entrapment neuropathy while PIN is a severe entrapment neuropathy (similar to mild vs severe carpal tunnel syndrome). The clinical presentations of RTS and PINS are different. RTS presents with pain in the lateral aspect of forearm 4-5 cm distal from the lateral epicondyle. PINS presents with no pain but with palsy of the wrist, finger, and thumb extensors, except for extensor carpi radialis longus. Clients with PINS will therefore present with painless weak wrist extension associated with radial deviation. Investigations for people with RTS or PINS may include x-rays and US, which will be able to exclude the presence of radiocapitellar joint osteoarthritis or space invading lesions which may be responsible for the entrapment. The differential diagnosis includes lateral epicondylalgia, cervical radiculopathy, high radial nerve palsy (e.g. Saturday night palsy), and extensive tendon ruptures of the extensors compartment. If a diagnosis of RTS is made, conservative treatment should be trialed for at least 6 months before surgery is considered. Overall, entrapment of the posterior interosseous nerve, especially severe entrapment, appears to be rare compared to median and ulnar nerve entrapment neuropathies (e.g. carpal tunnel syndrome, cubital tunnel syndrome). Clinical Take Home Message : A mild (RTS) or severe (PINS) entrapment neuropathy of the posterior interosseous nerve is rare. A mild entrapment neuropathy (RTS) usually presents with pain 4-5 cm distal to the lateral epicondyle. A severe entrapment neuropathy (PINS) presents with no forearm pain but significant motor weakness of the extensors compartment of the forearm. The key characteristic discriminating PINS from a higher nerve palsy (e.g. Saturday night palsy) or cervical radiculopathy with motor impairments, is that PINS will present with weak wrist extension associated with radial deviation (ECRL is intact). In addition, cervical radiculopathies present with neck pain in 80% of cases and often present with pain above the elbow . When differentiating between RTS and lateral epicondylalgia, the location of pain is the most useful indicator, with lateral epicondylalgia presenting with more proximal symptoms. URL : https://journals.sagepub.com/doi/10.1177/1753193420953990 Available through EBSCO Health Databases for PNZ members. Abstract Radial tunnel syndrome (RTS) is a disease causing lateral elbow and proximal dorsolateral forearm pain that may radiate to the wrist and dorsum of the fingers without obvious extensor muscle weakness. An epidemiological study shows an incidence of nine new cases of radial neuropathy per 100,000 population for men and six per 100,000 for women in a 10-year period (Hulkkonen et al., 2020). These incidences are far less than entrapments of the median and ulnar nerves. There are ambiguous descriptions of RTS in relation to posterior interosseous nerve (PIN) compression. This article intends to discuss the anatomy of the radial tunnel and the clinical distinctions between two entities.

Does diabetes mellitus change the carpal tunnel release outcomes? Evidence from a systematic review and meta-analysis. Moradi, A., Sadr, A., Ebrahimzadeh, M. H., Hassankhani, G. G., & Mehrad-Majd, H. (2020) Level of Evidence : 1a Follow recommendation : 👍 👍 👍 👍 Type of study : Therapeutic Topic : Surgical decompression of the carpal tunnel - Outcomes in diabetic vs healthy clients This is a systematic review and meta-analysis assessing outcomes in participants with and without diabetes following surgical decompression of the carpal tunnel. Ten studies were included for a total of 2,869 participants. Of these participants, 2423 were healthy and 446 presented with diabetes. Seventy percent of these participants were females. On average, participants were 56 years old. Outcomes included function, sensory, and motor nerve conduction studies. The results showed that there were no functional differences between clients with or without diabetes. Sensory nerve conduction improved to a greater extent in the healthy compared to diabetic participants. However, considering the multiple statistical tests undertaken, 23% of the results are due to chance. This reduces our confidence in these findings, especially considering that these differences did not have clinical repercussions in terms of function. Clinical Take Home Message : Hand therapists may reassure clients that diabetes does not appear to affect the results of surgery for carpal tunnel syndrome. However, hand therapists should remember that depression and mental health do affect post surgical satisfaction and the amount of health care resources required following carpal tunnel decompression. URL : https://www.sciencedirect.com/science/article/pii/S0894113020300235 Available through the Journal of Hand Therapy for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Study Design: A systematic review and meta-analysis. Introduction: Carpal tunnel syndrome (CTS) is one of the most common upper extremity conditions which mostly affect women. Management of patients suffering from both CTS and diabetes mellitus (DM) is challenging, and it was suggested that DM might affect the diagnosis as well as the outcome of surgical treatment. Purpose of the Study: This meta-analysis was aimed to compare the response with CTS surgical treatment in diabetic and nondiabetic patients. Methods: Electronic databases were searched to identify eligible studies comparing the symptomatic, functional, and neurophysiological outcomes between diabetic and nondiabetic patients with CTS. Pooled MDs with 95% CIs were applied to assess the level of outcome improvements. Results: Ten articles with 2869 subjects were included. The sensory conduction velocities in the wrist-palm and wrist–middle finger segments showed a significantly better improvement in nondiabetic compared with diabetic patients (MD = −4.31, 95% CI = −5.89 to −2.74, P  < .001 and MD = −2.74, 95% CI = −5.32 to −0.16, P  = .037, respectively). However, no significant differences were found for the improvement of symptoms severity and functional status based on the Boston Carpal Tunnel Questionnaire and Quick Disabilities of the Arm, Shoulder, and Hand questionnaire as well as motor conduction velocities and distal motor latencies. Conclusion: Metaresults revealed no significant difference in improvements of all various outcomes except sensory conduction velocities after CTS surgery between diabetic and nondiabetic patients. A better diabetic neuropathy care is recommended to achieve better sensory recovery after CTS surgery in diabetic patients.

The effect of digital sensory loss on hand dexterity. Luukinen, P., Leppänen, O. V., & Jokihaara, J. (2020) Level of Evidence : 4 Follow recommendation : 👍 👍 Type of study : Diagnostic Topic : DIgital nerve anaesthesia - Grip and pinch strength This is a study assessing dexterity, grip, and pinch strength before and after digital nerve blocks at the thumb, index, and middle finger (within-subject design). Twelve healthy participants were recruited for this study. Hand dexterity was measured through the Moberg pick-up test. Grip and pinch strength were assessed through a Jamar hand dynamometer (power grip) and pinch dynamometer (tripod and key pinch). The measurement were taken before and after the injection. The results showed that thumb anaesthesia led to the greatest loss of dexterity while it did not affect grip or pinch strength. Index or middle finger anaesthesia, led to a significant loss of grip (25% reduction) and tripod pinch strength (30% reduction). Clinical Take Home Message : Hand therapists should be aware that a digital nerve lesion can contribute to grip and tripod pinch weakness as well as lack of dexterity. In addition, these findings may also suggest that grip or pinch strength deficits in entrapment neuropathies (e.g. carpal tunnel syndrome) may be due to a combination of motor and sensory rather than just motor impairments. This synopsis is a nice addition to the previous one on the effect of anaesthesia to the ulnar nerve at the Guyon's canal . URL : https://journals.sagepub.com/doi/10.1177/1753193420936598 You can ask the authors for the full text through ResearchGate . Available through EBSCO Health Databases for PNZ members. Abstract The purpose of this study is to determine how loss of sensation affect hand dexterity. In this study, digital nerve block anaesthesia was performed in different stages of timing for thumb, index and middle fingers of 12 volunteers. The Moberg pick-up test was conducted in the assessment of hand dexterity. Grip and pinch forces were also measured. Loss of thumb sensation had the greatest effect on dexterity, increasing average timing by at least 10.5 seconds (range 3.4 to 32.4). Loss of sensation to the index and middle fingers has a lesser impact, but decreased hand grip and chuck pinch forces (grip –25% or –33%, chuck pinch –31% or –32% depending on the timing of injections). We concluded that loss of thumb sensation has the greatest impact on hand dexterity. Index and middle finger sensory loss had less of an impact on hand dexterity but decreased grip and chuck pinch forces.

The effectiveness of joint-protection programs on pain, hand function, and grip strength levels in patients with hand arthritis: A systematic review and meta-analysis. Bobos, P., Nazari, G., Szekeres, M., Lalone, E. A., Ferreira, L., & MacDermid, J. C. (2019) Level of Evidence : 1a- Follow recommendation : 👍 👍 👍 Type of study : Therapeutic Topic : Hand RA and OA – Joint protection vs no intervention This is a systematic review and meta-analysis assessing the effectiveness of joint protection vs control interventions for RA and OA of the hand. Seventeen RCTs were included in the systematic review, for a total of 1,847 participants (80% were diagnosed with RA). Only nine of these studies were included in the meta-analysis. All the RCTs were assessed through the Risk of Bias criteria recommended by the Cochrane Review Group. The overall strength of evidence was assessed through the GRADE approach ("low", "very low", "moderate", "high"), which has also been suggested by the Cochrane group for systematic reviews. Joint protection with an exercise component was compared to a control group undergoing either standard care, advice, no treatment, or patient education. Efficacy of intervention was assessed through improvements in pain (e.g. NRS, VAS), and function (e.g. Michigan Hand Questionnaire, AUSCAN), at short-term (3-4/12), midterm (6-8/12), and long-term (1 year). The results showed that publication bias was present (low sample size studies were more likely to over-inflate the effectiveness of joint protection interventions). There was very low to low quality of evidence showing that joint protection may have a small, unlikely to be clinically relevant, positive effectiveness in people with RA. In OA, joint protection had no effect compared to the control groups. Overall, due to multitude of statistical tests performed (16 tests) and the number of significant findings (4 test - all in RA) there is a 20% probability that the results are just due to chance. Clinical Take Home Message : Hand therapists should be aware that joint protection interventions appear to have a small, not clinically relevant effect in hand RA. Considering these results, other interventions such as stretching and strengthening may be more appropriate as they have been shown to have relevant effectiveness in a large RCT and a recent implementation study . No effect was shown for joint protection interventions in hand OA. Therefore, other approaches (see previous synopsis on the topic) for hand OA may be more effective. URL : https://www.jhandtherapy.org/article/S0894-1130(18)30164-9/fulltext Available through the Journal of Hand Therapy for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Study Design: Systematic review with meta-analysis. Introduction Joint protection (JP) has been developed as a self-management intervention to assist people with hand arthritis to improve occupational performance and minimize joint deterioration over time. Purpose of the Study: We examined the effectiveness between JP and usual care/control on pain, hand function, and grip strength levels for people with hand osteoarthritis and rheumatoid arthritis. Methods: A search was performed in 5 databases from January 1990 to February 2017. Two independent assessors applied Cochrane's risk of bias tool, and a Grading of Recommendations Assessement, Development and Evaluation (GRADE) approach was adopted. Results: For pain levels at short term, we found similar effects between JP and control standardized mean difference (SMD; −0.00, 95% confidence interval [CI]: −0.42 to 0.42, I2 = 49%), and at midterm and long-term follow-up, JP was favored over usual care SMD (−0.32, 95% CI: −0.53 to −0.11, I2 = 0) and SMD (−0.27, 95% CI: −0.41 to −0.12, I2 = 9%), respectively. For function levels at midterm and long-term follow-up, JP was favored over usual care SMD (−0.49, 95% CI: −0.75 to −0.22, I2 = 34%) and SMD (−0.31, 95% CI: −0.50 to −0.11, I2 = 56%), respectively. For grip strength levels, at long term, JP was inferior over usual care mean difference (0.93, 95% CI: −0.74 to 2.61, I2 = 0%). Conclusions: Evidence of very low to low quality indicates that the effects of JP programs compared with usual care/control on pain and hand function are too small to be clinically important at short-, intermediate-, and long-term follow-ups for people with hand arthritis.

Translating the strengthening and stretching for rheumatoid arthritis of the hand programme from clinical trial to clinical practice: An effectiveness–implementation study. Williamson, E., Srikesavan, C., Thompson, J., Tonga, E., Eldridge, L., Adams, J., & Lamb, S. E. (2020) Level of Evidence : 2c Follow recommendation : 👍 👍 👍 Type of study : Therapeutic Topic : Rheumatoid arthritis - Stretching and strengthening This is a pragmatic trial, assessing the effectiveness of a hand exercise program for people with rheumatoid arthritis (RA) affecting their hands. A total of 448 hand therapists were trained through an online course. The hand exercise program taught in the online course, has previously been shown to be effective for RA in a randomised controlled trial published in the Lancet . Hand therapists were then asked to collect data from their patients with RA during the first visit and at discharge. In addition, a four months follow up was completed. Function was assessed through the Michigan Hand Questionnaire, pain was assessed through a 5-points likert scale, and grip strength was measured through a hand dynamometer. Data were collected from 118 clients with RA. All of these clients were guided in the implementation of the hand exercise program, although compliance with the original exercises program varied significantly. The results showed that hand function improved to a statistically significant level at discharge and at four months follow up. It is however unclear whether the results were clinically relevant (a minimal clinical important change threshold for the total score of the Michigan Hand Questionnaire has not been published yet). Pain was unchanged, however, grip strength improved to a clinically and statistically significant level (25-30%) from baseline (14kg). Clinical Take Home Message : Hand therapists treating clients with hand RA may benefit from completing the training course created for this study. The course is accessible online ( iSARAH ) and it is entirely free. Both this study and the original RCT were completed in participants with an average grip strength close to 14kg. It is possible that clients presenting with higher grip strength (i.e. 25kg) may benefit less from this hand exercise program. Thus, a grip strength of 25kg appears to be sufficient to complete most of the daily tasks . URL : https://journals.sagepub.com/doi/abs/10.1177/1758998320948538 Available through Hand Therapy for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Introduction: The Strengthening and Stretching for Rheumatoid Arthritis of the Hand programme is a hand exercise programme for people with rheumatoid arthritis. It was clinically effective when delivered during a clinical trial but there was a need to evaluate translation into routine care. Methods:We conducted an effectiveness–implementation study. We adapted the trial training into an online format for National Health Service hand therapists. Educational outcomes included confidence and capability to deliver the programme. Implementation outcomes included training reach and adoption. Therapists were invited to collect clinical outcomes. Patients receiving the programme provided data on function (Michigan Hand Questionnaire function scale), pain and grip strength at baseline, treatment discharge and four-month follow-up. Results: A total of 790 therapists (188 National Health Service organizations) enrolled in the training; 584/790 (74%) therapists (162 National Health Service organizations) completed the training; 448/790 therapists (145 National Health Service organizations) (57%) evaluated the training and were confident (447/448, 99.8%) and capable (443/448, 99%) to deliver the programme with 85% intending to adopt it (379/448). Follow-up data were provided by 116/448 (26%) therapists. Two-thirds (77/116; 51 National Health Service organizations) reported adopting the programme. One hundred and eighteen patients (15 National Health Service trusts) participated. Patients reported improved function (mean change Michigan Hand Questionnaire scores: 10 (95% CI 6.5–13.6) treatment discharge; 7 (95% CI 3.8–10.2) 4-month follow-up). Grip strength increased 24.5% (left) and 31% (right). Pain was stable. Discussion: Online training was an effective way to train therapists with good reach. Clinical outcomes were similar to the clinical trial providing preliminary evidence of successful translation into routine care.

Injection therapy for base of thumb osteoarthritis: a systematic review and meta-analysis. Riley, N., Vella-Baldacchino, M., Thurley, N., Hopewell, S., Carr, A. J., & Dean, B. J. F. (2019) Level of Evidence : 1a- Follow recommendation : 👍 👍 👍 Type of study : Therapeutic Topic : 1st cmcj OA – cortisone vs other types of injections This is a systematic review and meta-analysis assessing the effectiveness of cortisone injections vs other types of injections for 1st cmcj OA. Nine RCTs were included in the present review, for a total of 504 participants. Only three of these (cortisone vs hyaluronic acid) were included in the meta-analysis. All the RCTs were assessed through the Risk of Bias criteria recommended by the Cochrane Review Group. Efficacy of intervention was assessed through improvements in pain (VAS), pinch and grip strength. The results showed that most of the studies presented with a high risk of bias, large heterogeneity, and small sample sizes. There was very low quality of evidence showing that cortisone injections were not more effective in improving pain, pinch or grip strength when compared to hyaluronic acid injections. Interestingly, when cortisone or hyaluronic acid injections where compared to placebo injections (narrative review of 3 RCTs), there were no differences in pain, pinch or grip strength. Similar findings were reported when hyaluronic acid was compared to placebo injections. The authors reported that corticosteroid injections provided statistically significant improvements in the medium term compared to hyaluronic acid injections. However, due to multitude of statistical tests performed (11 tests) and the number of significant findings (1 test) there is a 55% probability that this result is just due to chance. Clinical Take Home Message : Corticosteroid injections do not appear to provide any additional benefit on pain, pinch, or grip strength when compared to hyaluronic acid injections for 1st cmcj OA. From the results of two RCTs it appears that neither cortisone nor hyluronic acid injections are superior to placebo (saline) injections. As shown by another study , most of the clinical effect shown by cortisone or hyaluronic acid injections may be due to contextual factors associated with the therapeutic intervention. Hand therapists may refer clients for cortisone or hyluronic acid injections if other conservative interventions have failed, and if surgery is not viable due to comorbidities. If clients may be eligible for 1st cmcj OA surgery, cortisone or hyaluronic acid injections may actually increase the odds of post surgical complications. Open Access URL: https://bmjopen.bmj.com/content/bmjopen/9/9/e027507.full.pdf Abstract Objective: To evaluate the effectiveness of injection-based therapy in base of thumb osteoarthritis. Design: Systematic review and meta-analysis. Data sources: MEDLINE and EMBASE via OVID, CINAHL and SPORTDiscus via EBSCO were searched from inception to 22 May 2018. Study selection: Randomised controlled trials (RCTs) and non-RCTs of adults with base of thumb osteoarthritis investigating an injection-based intervention with any comparator/s. Data extraction and analysis: Data were extracted and checked for accuracy and completeness by pairs of reviewers. Primary outcomes were pain and function. Comparative treatment effects were analysed by random-effects model for short-term and medium-term follow-up. Results: In total, 9 RCTs involving 504 patients were identified for inclusion. All compared different injection-based therapies with each other, no studies compared an injection-based therapy with a non-injection-based intervention. Twenty injection-based intervention groups were present within these nine trials, consisting of hyaluronic acid (n=9), corticosteroid (n=7), saline placebo (n=3) and dextrose (n=1). Limited meta-analysis was possible due to the heterogeneity in the injections and outcomes used, as well as incomplete outcome data. Meta-analysis of two RCTs (92 patients) demonstrated reduced Visual Analogue Scale pain on activity with corticosteroid versus hyaluronic acid (mean difference (MD) −1.32, 95% CI −2.23 to −0.41) in the medium term, but no differences in other measures of pain or function in the short term and medium term. Overall, the available evidence does not suggest that any of the commonly used injection therapies are superior to placebo, one another or a non-injection-based comparator. Conclusion: Current evidence is equivocal regarding the use of injection therapy in base of thumb osteoarthritis, both in terms of which injection-based therapy is the most effective and in terms of whether any injection-based therapy is more effective than other non-injection-based interventions. Given limited understanding of both the short-term and long-term effects, there is a need for a large, methodologically robust RCT investigating the commonly used injection therapies and comparing them with other therapeutic options and placebo. PROSPERO registration number CRD42018095384.

Ronald Melzack Award Lecture: Putting the brain to work in cognitive behavioral therapy for chronic pain. Thorn, B. E. (2020) Level of Evidence : 5 Follow recommendation : 👍 👍 Type of study : Therapeutic Topic : Chronic pain – Biopsychosocial approach This is a invited lecture for the Ronald Melzack Award (IASP). The Ronald Melzack Award was established by the International Association for the Study of Pain in honour of Ronald Melzack who contributed exceptionally to the study of pain. In this invited lecture, Dr. Beverly Thorn highlights how pain can be modulated by getting our clients' brain to work. It was made clear from the beginning that psychosocial interventions for chronic pain are not targeted for people affected by mental health. This is often one of the main barriers that hinder patients' or clinicians' adoption of this model. By embracing the ability of the brain to modulate the response of thoughts and emotions, pain can be more amenable. A key word appeared multiple times: simplicity. Simplicity in terms of the explanations that we provide to clients on the link between psychosocial factors, and pain. Simplicity in terms of treatments provided. Other key concepts included the lack of association between pain and tissue damage in chronic pain conditions, and the fact that thoughts and emotions can worsen the suffering associated with pain. In addition, it was clarified that psychosocial interventions and pain education do not aim to distract or be an academic exercise. They aim to get people better by understanding how pain works. Clinical Take Home Message : Psychosocial and pain education interventions are useful for chronic pain clients. They have a very real biological effects and we should clarify that to our clients. We have plenty of evidence showing that a positive attitude of a clinician can boost the effect of the treatment provided, pain conditioning can influence future pain experiences, and that our words can increase or decrease clients' pain perception. The brain is responsible for the pain experience, and it can be used to reduce it. Open Access URL : https://journals.lww.com/pain/Fulltext/2020/09001/Ronald_Melzack_Award_Lecture__Putting_the_brain_to.4.aspx No abstract available.

Rumple-Leede phenomenon after tourniquet application in acute hand surgery: A case report. Imran, R., & Jose, R. M. (2020) Level of Evidence : 5 Follow recommendation : 👍 Type of study : Diagnostic Incidence : Rare Topic : Skin rash – proximal compression This is a case report of unilateral Rumple-Leede phenomenon. The patient was a 65 year old male who had undergone terminalisation of a finger and wound closure following a traumatic injury. A tourniquet was applied to the proximal arm for 75 minutes during surgery. Upon tourniquet release, a circumferential rash, which was non-blanching, developed in the whole arm below the tourniquet level. The patient was neurovascularly intact at the level of the hand. The patient was discharged following two hours of observation with a diagnosis of Rumple-Leede phenomenon. This condition is due to an acute rupture of skin capillaries following the application of a limb compression (pressure cuff or tourniquet). This is a benign condition which resolves withing 2-3 weeks and it is unrelated to the time of tourniquet application. It is however important to exclude the presence of other conditions such as diabetes, trombocytopenia (low number of platelets), hypertension, and connective tissue disorders, which may increase the likelihood of this condition to occur or mimicker such as vasculitis (vessels inflammation). In this case, no predisposing factors were identified. The patient was reassured and the condition resolved within two weeks. Clinical Take Home Message : Clients may present with Rumple-Leede phenomenon following surgery, blood pressure measurements, application of any type of limb compression (e.g. counterforce brace at the forearm), or blood flow restriction training. Hand therapist should reassure clients and refer them to their GP for follow up testing, which aims at excluding other mimickers or contributing factors to the phenomenon (e.g. emathological or connective tissue conditions). Although this condition has been described in the literature several times, it is quite rare and it is unlikely to occur. URL : https://journals.sagepub.com/doi/abs/10.1177/1753193420930595 You can ask the authors for the full through ResearchGate Available through EBSCO Health Databases for PNZ members. No Abstract available.

The long term effect of neurodynamics vs exercise therapy on pain and function in people with carpal tunnel syndrome: A randomized parallel-group clinical trial. Hamzeh, H., Madi, M., Alghwiri, A. A., & Hawamdeh, Z. (2020) Level of Evidence : 1b- Follow recommendation : 👍 👍 👍 Type of study : Therapeutic Topic : Carpal tunnel conservative intervention - Neurodynamic vs general exercise This is a randomised controlled trial assessing the effectiveness of neurodynamic exercise vs general exercises on function, pain, range of movement (ROM), and grip strength in people with carpal tunnel syndrome (CTS). All the participants included (n = 41) were diagnosed with CTS through subjective reports of paraesthesia in the median nerve distribution at the hand, a positive Phalen's test, and impairments on nerve conduction studies. Potential participants were excluded if they presented with a history of neck pain radiating to the upper limb and/or previous hand trauma. Participants were randomised to a neurodynamic exercise group (n = 26), or to a general exercise group (n = 25). Both groups received four individual supervised sessions of one hour each. The neurodynamic group underwent neurodynamic exercises and they were progressed to the next level of exercise when the symptoms were no longer elicited by previous week neurodynamic testing. They also completed neurodynamic exercises at home. The general exercise group received tendon gliding exercises, active range of movement, stretching, and strengthening exercises. Both groups were asked to perform the exercises twice daily. Treatment effectiveness was assessed through the Boston Carpal Tunnel Syndrome Questionnaire (Primary outcome), QuickDASH, numerical pain rating scale (NRS), wrist ROM, and grip strength (All secondary outcomes). Participants were assessed at baseline, one month, and six months. Both groups improved to a statistically and clinically significant level for most outcomes. Considering the multiple statistical tests undertaken, 25% of the results are due to chance. Nevertheless, neurodynamic testing appeared to provide statistically and clinically relevant greater improvements in pain and function (QuickDASH) at 1 month compared to the general exercise group. Thus, the difference between the two groups was close to 2 ( 95%CI : -3.45 to -0.41) points out of 10, and 13 ( 95%CI : -24.5 to -0.7) points out of 100 for the NRS and QuickDASH respectively. No adverse events were reported. The confidence intervals for both outcomes were quite wide, suggesting that the effect of the intervention was not consistent. Clinical Take Home Message : Hand therapists may use either neurodynamic or general exercises to improve the clinical presentation of people with CTS. Neurodynamic exercises may be more effective in improving pain and function compared to general exercises in the short term. Hand therapists should be aware that the improvements reported with neurodynamic exercises are substantially variable and range from large, beyond clinically relevant improvements, to the same improvement as with general exercises. URL : https://www.sciencedirect.com/science/article/abs/pii/S0894113020301447 Available through the Journal of Hand Therapy for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Introduction: Carpal tunnel syndrome (CTS) is a common disorder that limits function and quality of life. Little evidence is available on the long-term effect of neurodynamics and exercise therapy. Purpose of the Study: This study aimed to examine the long-term effect of neurodynamic techniques vs exercise therapy in managing patients with CTS. Study Design: Parallel group randomized clinical trial. Methods: Of 57 patients screened, 51 were randomly assigned to either receiving four sessions of neurodynamics and exercise or home exercise therapy alone as a control. Blinded assessment was performed before treatment allocation, at treatment completion, and 6 months posttreatment. Outcome measures included Symptom Severity Scale (SSS), Functional Status Scale (FSS), Shortened version of the Disabilities of the Arm, Shoulder, and Hand (DASH), Numerical Pain Rating Scale, grip strength and range of motion. Results: Data from 41 individuals (52 hands) were analyzed. The neurodynamics group demonstrated significant improvement in all outcome measures at 1 and 6 months ( P  < .05). Mean difference in SSS was 1.4 (95% CI= 0.9-1.4) at 1 month and 1.6 (95% CI = 0.9-2.2) at 6 months. Mean difference in FSS was 0.9 (95% CI = 0.4-1.4) at 1 month and 1.4 (95% CI = 0.7-2.0) at 6 months. Significant between-group differences were found in pain score at 1 month (−1.93) and in FSS (−0.5) and Shortened version of DASH (−12.6) at 6 months ( P  < .05). No patient needed surgery 1 year after treatment. Conclusions: Although both treatments led to positive outcomes, neurodynamics therapy was superior in improving function and strength and in decreasing pain.

Manual therapy versus surgery for carpal tunnel syndrome: 4-year follow-up from a randomized controlled trial. Fernández-de-las-Peñas, C., Arias-Buría, J. L., Cleland, J. A., Pareja, J. A., Plaza-Manzano, G., & Ortega-Santiago, R. (2020) Level of Evidence : 1b- Follow recommendation : 👍 👍 👍 👍 Type of study : Therapeutic Topic : Carpal tunnel conservative intervention - Manual therapy and exercise This is a randomised controlled trial assessing the effectiveness of a manual therapy approach vs surgery on pain in people with carpal tunnel syndrome (CTS). All the participants included (n = 120) were females on a waiting list for CTS surgery. Diagnosis of CTS was made through clinical findings (e.g. pain/paraesthesia in median nerve distribution and positive findings on Phalen's/Tinel's signs) and confirmed by nerve conduction studies. Participants were excluded if they had diabetes or thyroid conditions (which are known to worsen treatment prognosis), depression, if they were pregnant, or if they had other musculoskeletal conditions. Participants were randomised to a manual therapy and exercise program group (n = 60), or carpal tunnel decompression surgery (n = 60). The manual therapy and exercise program was delivered over the course of three sessions (one per week), each lasting 30 minutes. These sessions involved soft tissue mobilisation of potential entrapment sites af the median nerve. These included the pronator teres, biceps brachii, pectoralis minor, and scalene muscles. Lateral glides of the cervical spine and tendon/ nerve gliding exercises were also completed. If interested, participants were also provided with an information sheet on how to perform tendon and nerve gliding. Treatment effectiveness was assessed through pain intensity (current and worst pain in the last week) on a numerical rating scale. Participants were assessed at baseline, one year, and 4 years. The results showed no difference between manual therapy and surgery at one year, and at 4 years. During the 4 years follow up, 9 participants (15%) in the manual therapy group, and 8 participants (13%) in the surgical group underwent surgery or a second surgery respectively (no differences between groups). Clinical Take Home Message : A manual therapy approach (mobilisation and tendon/nerve glides) directed at the upper limb appears to be as effective as surgery in the treatment of clients with carpal tunnel syndrome at one and four years follow up. Considering the low cost of three sessions of manual therapy compared to surgery, hand therapists should offer this treatment to clients. 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://www.jpain.org/article/S1526-5900(15)00816-0/fulltext Available through EBSCO Health Databases if you have access ( PNZ )

The title will be provided next week. Imran, R., & Jose, R. M. (2020) Level of Evidence : 5 Follow recommendation : 👍 Type of study : Diagnostic Topic : Skin rash – proximal compression Have a think about it this case study. If you like, you can leave a comment indicating what the diagnosis may be. I will publish the diagnosis and treatment reported by the paper next week. The patient was a 65 year old male who had undergone terminalisation of a finger and wound closure following a traumatic injury. A tourniquet was applied to the arm proximally for 75 minutes during surgery. Upon tourniquet release, a circumferential rash, which was non-blanching, developed in the whole arm below the tourniquet level. The patient was neurovascularly intact at the level of the hand. What is it? URL : N ext week