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- Does treatment optimisation for CEO tendinopathy provide better outcomes compared to usual care?
Optimising physiotherapy for people with lateral elbow tendinopathy – Results of a mixed-methods pilot and feasibility randomised controlled trial (OPTimisE). Bateman, M., et al. (2024). Level of Evidence: 2b Follow recommendation: 👍 👍 👍 (3/4 Thumbs up) Type of study: Therapeutic Topic: Lateral epicondylalgia – Personalised treatment This randomised feasibility controlled study focused on optimising physiotherapy for lateral elbow tendinopathy (LE) using the OPTimisE intervention and comparing it to usual care. The OPTimisE treatment included condition specific information, the use of a commercial digital grip dynamometer that patients could use at home, and a counterforce brace. The usual care group received general advice on the condition, exercise did not follow a precise prescription, and no splinting was provided. A total of 50 participants in the UK were recruited. Outcomes included upper limb subjective function and objective measures such as pain free grip strength and time off work. The results showed that both patients and physiotherapists found these intervention acceptable. There were no between groups differences on pain, function, or objective measurements and all participants improved to a clinically relevant level. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message: Based on what we know today, the OPTimisE intervention or usual care provide similar outcomes for people with lateral elbow pain due to a common extensor tendinopathy. If you would like to have a wider view of what treatments have been assessed in research settings for lateral epicondylalgia, have a look at the whole dataset which now contains more than 45 articles on the topic. URL: https://doi.org/10.1016/j.msksp.2023.102905 Abstract Background: The OPTimisE intervention was developed to address uncertainty regarding the most effective physiotherapy treatment strategy for people with Lateral Elbow Tendinopathy (LET). Objectives To assess the feasibility of conducting a fully-powered randomised controlled trial (RCT) evaluating whether the OPTimisE intervention is superior to usual physiotherapy treatment for adults with LET. Design: A mixed-methods multi-centred, parallel pilot and feasibility RCT, conducted in three outpatient physiotherapy departments in the UK. Method: Patients were independently randomised 1:1 in mixed blocks, stratified by site, to the OPTimisE intervention or usual care. Outcomes were assessed using pre-defined feasibility progression criteria. Results: 50 patients were randomised (22 Female, 28 Male), mean age 48 years (range 27–75). Consent rate was 71% (50/70), fidelity to intervention 89% (16/18), attendance rate in the OPTimisE group 82% (55/67) vs 85% (56/66) in usual care, outcome measure completion 81% (39/48) at six-month follow-up. There were no related adverse events. Patients and physiotherapists reported that the OPTimisE intervention was acceptable but suggested improvements to the trial design. 49 patients were recruited from physiotherapy referrals vs one from primary care records. Outcome measure return rates were higher when completed online (74%) compared to postal questionnaire (50%). Exploratory analysis showed improvements in both groups over time. Conclusions: It is methodologically feasible to conduct a fully powered RCT comparing the clinical and cost-effectiveness of the OPTimisE intervention versus usual physiotherapy treatment. Considering the similar improvements observed in both groups, careful consideration is needed regarding the priority research question to be addressed in future research. publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings
- How long do patients need to use RMF splints for chronic Boutonnière deformities?
The use of relative motion flexion orthoses for chronic boutonniere deformity. Arslan, Ö. B., et al. (2022) Level of Evidence: 2b Follow recommendation: 👍 👍 (2/4 Thumbs up) Type of study: Therapeutic Topic: Relative motion flexion splint for chronic Boutonnière - Outcomes This retrospective study assessed the effectiveness of a relative motion flexion splint in treating chronic boutonniere deformity. The study included 28 patients with chronic boutonniere deformity. Chronic was defined as a duration more than four weeks. To be included, patients had also be able to achieve 0 degrees of pipj extension during the pencil test (see picture below). The orthosis was prescribed for full time wear (except for hand hygiene) for at least six weeks. The results showed that pipj extension improved by an average of 10 degrees and dipj flexion improved by 20 degrees. The average total wearing time for the splint was 12 weeks. 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, a relative motion flexion splint has been shown to be effective in improving active pipj extension and dipj flexion in patients with chronic Boutonnière deformity. The average duration of splint wearing was 12 weeks. If you are interested in the use of relative motion flexion splints for acute Boutonnière deformity, have a look at this synopsis. URL: https://doi.org/10.1016/j.jhsa.2022.08.007 Abstract Purpose: This study investigated the effectiveness of a relative motion flexion orthosis (RMFO) for increasing the range of motion for boutonniere deformity. Methods: We included 28 patients aged 13–62 years with chronic boutonniere deformity who could complete 0° proximal interphalangeal (PIP) joint extension with the pencil test and were stage 1 according to the Burton classification of boutonniere deformity. At the initial hand therapy appointment, the RMFO was made. The duration of the orthosis usage at the initial therapy session, after stopping the use of the orthosis (posttreatment), and at the follow-up period were noted. Results: The mean time for orthosis usage of all patients was 11.7 weeks (6–40 weeks). The mean initial active distal interphalangeal joint flexion was 47° (0° to 90°) and improved to 66.8° (5° to 110°). The mean initial extension lag of the PIP joint was 22.5° (5° to 55°) and improved to 12° (0° to 30°). This did not change between discontinuation of the orthosis and final follow-up. Conclusions: The use of RMFO is effective in increasing active distal interphalangeal joint flexion and improving PIP extension in patients with Burton stage 1 chronic boutonniere deformity. publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings
- Do we have good quality evidence for the assessment and management of non-traumatic wrist conditions?
A scoping review to map evidence regarding key domains and questions in the management of non-traumatic wrist disorders. Mitchell, T., et al. (2023). Level of Evidence: 4 Follow recommendation: 👍 (1/4 thumbs up) Type of study: Diagnostic/Therapeutic Topic: Non-traumatic wrist conditions - Management and treatment The scoping review focused on mapping evidence regarding the diagnosis, management, pathways of care, and outcome measures for non-traumatic wrist disorders (NTWD) in the United Kingdom. An interdisciplinary team of clinicians and academic researchers conducted the review following specific guidelines and checklists, with input from a mixed stakeholder group of patients and healthcare professionals who identified 16 key research questions. The study found common diagnoses such as wrist pain, De Quervain’s syndrome, and ulna-sided pain, along with available best practice guidelines for some NTWD conditions, but noted substantial gaps in evidence throughout the patient journey. Various conservative management options and patient-reported outcome measures for NTWD were identified. The review emphasized the need for rigorous primary studies to address the identified evidence gaps and highlighted opportunities for further research and improvements in non-traumatic wrist disorder management. The text also discussed the importance of utilizing patient-reported outcomes to measure treatment effectiveness, exploring trends in musculoskeletal management towards patient-centered care and shared decision-making, and the limitations of pathoanatomical diagnosis in explaining pain and disability in non-traumatic conditions. 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, non-traumatic wrist disorders (NTWD) such as wrist pain, De Quervain’s syndrome, and ulna-sided pain are commonly encountered in clinical practice. The existing literature on NTWD highlights the use of subjective questioning, self-reported pain, palpation, and special tests for diagnosing these conditions. Unfortunately, few of these tests have gone through appropriate diagnostic accuracy assessment. As a way of compensating this lack of specific hand research, considering new trends in musculoskeletal management, such as patient-centered care and shared decision-making may be useful stategies may be useful strategies. This article also points out that pathoanatomical diagnosis may have limitations in explaining pain and disability in non-traumatic conditions, and other psychosocial factors should be taken into consideration. URL: https://doi.org/10.1177/17589983231219595 Abstract Introduction: Non-traumatic wrist disorders (NTWD) are commonly encountered yet sparse resources exist to aid management. This study aimed to produce a literature map regarding diagnosis, management, pathways of care and outcome measures for NTWDs in the United Kingdom. Methods: An interdisciplinary team of clinicians and academic researchers used Joanna Briggs Institute guidelines and the PRISMA ScR checklist in this scoping review. A mixed stakeholder group of patients and healthcare professionals identified 16 questions of importance to which the literature was mapped. An a-priori search strategy of both published and non-published material from five electronic databases and grey literature resources identified records. Two reviewers independently screened records for inclusion using explicit eligibility criteria with oversight from a third. Data extraction through narrative synthesis, charting and summary was performed independently by two reviewers. Results: Of 185 studies meeting eligibility criteria, diagnoses of wrist pain, De Quervain?s syndrome and ulna-sided pain were encountered most frequently, with uncontrolled non-randomised trial or cohort study being the most frequently used methodology. Diagnostic methods used included subjective questioning, self-reported pain, palpation and special tests. Best practice guidelines were found from three sources for two NTWD conditions. Seventeen types of conservative management, and 20 different patient-reported outcome measures were suggested for NTWD. Conclusion: Substantial gaps in evidence exist in all parts of the patient journey for NTWD when mapped against an analytic framework (AF). Opportunities exist for future rigorous primary studies to address these gaps and the preliminary concerns about the quality of the literature regarding NTWD. publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings
- RMF splints for Boutonnière, do they work for acute and chronic injuries?
A paradigm shift in managing acute and chronic Boutonniere deformity: Anatomic rationale and early clinical results for the relative motion concept permitting immediate active motion and hand use. Merritt, W. H. and Jarrell, K. (2020) Level of Evidence: 4 Follow recommendation: 👍 👍 (2/4 Thumbs up) Type of study: Therapeutic Topic: Relative motion flexion splint for Boutonnière - Is it useful? This expert opinion and case series discusses the use of relative motion splinting for the management of both acute and chronic boutonniere deformities. The authors present their clinical results and provide anatomical rationale for this treatment approach. For acute injuries, relative motion flexion splinting is utilized, allowing for immediate active motion and hand use while maintaining full range of motion. This technique has shown promising results in acute cases, with good range of motion and no recurrences. For chronic deformities, serial casting is used to obtain as much PIP extension as possible (6 weeks), followed by relative motion flexion splinting for 12 weeks. This method has been successful in all of their chronic cases, with all patients achieving flexion to their palm and good pipj extension. Overall, the authors conclude that relative motion flexion splinting is an effective technique for managing both acute and chronic boutonniere deformities. It allows for early active motion and hand use, with excellent range of motion achieved. This approach has the advantage of lower morbidity compared to conventional surgical management techniques. 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, relative motion flexion splinting is an effective treatment technique for both acute and chronic boutonniere deformities. For acute injuries, the use of relative motion flexion splinting has shown promising results, with good range of motion and no recurrences. For chronic deformities, serial casting to obtain full passive PIP extension followed by relative motion flexion splinting has been successful in all cases reported by the article. The use of relative motion flexion splints may be particularly useful in those patients who are not keen to undergo finger immobilisation because of work reasons. Relative motion splints have been tested across a series of conditions including extensors tendon repair and flexors tendon repair. If you are interested in the topic, have a look at the full database. URL: https://doi.org/10.1097/SAP.0000000000002307 Abstract Background: We have utilized relative motion splinting for early motion following acute repair of boutonniere injuries, and we have developed nonoperative orthosis-based therapy for the treatment of chronic injuries. We offer our early clinical experience using relative motion flexion splinting for boutonniere deformities and explain the anatomic rationale that permits immediate active motion and hand use following acute injury or repair. For chronic boutonniere deformity, we offer a nonsurgical management method with low morbidity as a safe alternative to surgery. Methods: Our understanding of the extrinsic-intrinsic anatomic interrelationship in boutonniere deformity offers rationale for relative motion flexion splinting, which is confirmed by cadaver study. Our early clinical results in 5 closed and 3 open acute and 15 chronic cases have encouraged recommending this management technique. For repaired open and closed acutely injured digits, we utilize relative motion flexion orthoses that place the injured digits in 15° to 20° greater metacarpophalangeal flexion than its neighboring digits and otherwise permit full active range of motion and functional hand use maintaining the 15° to 20° greater metacarpophalangeal flexion for 6 weeks. In fixed chronic boutonniere cases, serial casting is utilized to obtain as much proximal interphalangeal extension as possible (at least −20°), and then relative motion flexion splinting and hand use is instituted for 12 weeks. Results: Our acute cases obtained as good as, or better range of motion than, conventional management techniques, with early full flexion and maintenance of extension without any recurrences. The most significant difference is morbidity, with ability to preserve hand function during healing and the absence of further therapy after 6 weeks of splinting. Patients with chronic boutonniere deformity presented from 8 weeks to 3 years following injury (averaging 31 weeks) and were 15 to 99 years of age (averaging 42 years). All were serially casted to less than −20° (averaging −4°) and maintained that level of extension after 3 months of relative motion flexion splinting. All achieved flexion to their palm, and all met the Steichen-Strickland chronic boutonniere classification of “excellent.” There were no recurrent progressive boutonniere deformities in either acute or chronic cases and no instances of reflex sympathetic dystrophy/chronic regional pain syndrome (RSD/CRPS). Conclusions: Relative motion flexion splinting affords early active motion and hand use with excellent range of motion achieved following acute open boutonniere repair or closed boutonniere rupture with less morbidity than conventional management. Chronic boutonniere deformity will respond to relative motion flexion splinting if serial casting can place the proximal interphalangeal joint in less than −20° extension, and the patient actively uses the hand in a relative motion flexion orthosis for 3 months, recovering flexion. No further therapy was needed in our cases. We believe this management technique should be attempted for chronic boutonniere deformity as a preferable alternative to surgery, which remains an option if needed. publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings
- Does early mobilisation post surgery make a difference for "manageable triad" injuries (otherwise known as "terrible triad")?
Postoperative mobilization after terrible triad injury: Systematic review and single-arm meta-analysis. Ahmed Kamel, S., et al. (2023) Level of Evidence: 2a Follow recommendation: 👍 👍 👍 (3/4 Thumbs up) Type of study: Therapeutic Topic: Terrible triad early mobilisation – Outcomes This systematic review and meta-analysis assessed the effect of early vs late postoperative mobilisation in patients with terrible triad injuries of the elbow. A total of 11 prospective and retrospective cohort studies were included. No RCTs were available for inclusion in this review. The Mayo Elbow Performance Index was utilised to assess improvements in function, pain, and elbow stability. The results showed that there was a statistically significant trend towards better function with early mobilisation approaches (see figure below), however, this was not clinically relevant. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message: Based on what we know today, early postoperative mobilisation may lead to better functional outcomes in patients with manageable triad (otherwise known as "terrible triad") injuries of the elbow without an increased risk of instability. Nevertheless, these improvements appear to be marginal and appear to be of little clinical importance. URL: https://doi.org/10.1016/j.jse.2023.10.012 Abstract Background: Terrible triad is a complex injury of the elbow, involving elbow dislocation with associated fracture of the radial head, avulsion or tear of the lateral ulnar collateral ligament and fracture of the coronoid. These injuries are commonly managed surgically with fixation or replacement of the radial head, repair of collateral ligaments, with or without fixation of the coronoid. Postoperative mobilization is a significant factor that may affect patient outcomes; however the optimal postoperative mobilization protocol is unclear. This study aims to systematically review the available literature regarding postoperative rehabilitation of terrible triad injuries to aid clinical decision-making. Methods: We systematically reviewed PubMed, Embase, Cochrane and CINAHL in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Inclusion criteria were studies with populations aged 16 years or over with terrible triad injury, underwent operative treatment, defined a clear postoperative mobilization protocol and reported the Mayo Elbow Performance Score (MEPS). Secondary outcomes were pain, instability, and range of motion (ROM). Postoperative mobilization was classified as ‘early’, defined as active ROM commenced up to 14 days, or ‘late’, defined as active ROM commenced after 14 days. Results: A total of 119 articles were identified from the initial search, of which 11 (301 patients) were included in the final review. The most common protocols (6 studies) favored early mobilization, whilst 5 studies undertook late mobilization. Meta-regression analysis including mobilization as covariate showed an estimated mean difference of pooled mean MEPS between early and late mobilization of 6.1 points (95% CI 0.2 – 12) with higher pooled mean MEPS in early mobilization (MEPS 91.2) compared to late mobilization (MEPS 85), p = 0.041. Rate of instability reported ranged from 4.5 – 19%, (8-11.5% early mobilization, 4.5-19% late mobilization). Conclusion: Our findings suggest that early postoperative mobilization may confer a benefit in terms of functional outcome following surgical management of terrible triad injuries, without appearing to confer an increased instability risk. Further research in the form of randomized controlled trials between early and late mobilization is advised to provide a higher level of evidence. publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings
- How does grip force change with cubital tunnel syndrome?
Force loss and distribution of load in the hands of patients with cubital tunnel syndrome. Garkisch, A., Rohmfeld, K., Fischer, D.-C., Prommersberger, K.-J. and Mühldorfer-Fodor, M. (2023). Level of Evidence: 2b Follow recommendation: 👍 👍 👍 (3/4 Thumbs up) Type of study: Symptoms prevalence Topic: Cubital tunnel – Grip strength changes This prospective study aimed to assess grip force and load distribution in patients with cubital tunnel syndrome using manugraphy with three different cylinder sizes. A total of 27 participants who were planned to undergo cubital tunnel release surgery were assessed. Significant differences of up to 29% in grip forces between affected and healthy hands were found, with similar forces noted when gripping smaller handles despite ulnar nerve palsy. Contact area with cylinders was reduced by 5%-9% and correlated with grip force, atrophy, and impaired sensibility. Load distribution varied significantly, with weakness in thumb positioning and stabilisation when gripping large objects, and weakness in intrinsic finger muscles when gripping small objects. 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, cubital tunnel leads to reduction in gripping surface and force production compared to healthy hands. The reduction in grip force was about 30%, which is similar to what has been shown when nerve blocks are applied to the Guyon's canal during laboratory testing. It is likely that this reduction in grip strength is due to a combination of motor and sensory fibre impairments. URL: https://doi.org/10.1177/17531934231198660 Abstract Manugraphy with three different cylinder sizes was used to quantify the contribution of fingers, thumb and palm to grip force in patients with unilateral cubital tunnel syndrome. Forces in the affected and contralateral hands differed by up to 29%. Although grip force is usually maximal when gripping small handles, ulnar nerve palsy resulted in similar absolute grip forces using the 100-mm and 200-mm cylinders. The contact area between the affected hand and the cylinders was reduced by 5%-9%. We noted a high correlation between the contact area and grip force, visible atrophy and permanently impaired sensibility. The load distribution differed significantly between both hands for all cylinder sizes. When gripping large objects, the main functional impairment in cubital tunnel syndrome is weakness in positioning and stabilizing the thumb. Weak intrinsic finger muscles are responsible for loss of force when gripping small objects. publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings
- Is the inclusion of mobilisation with movement to treatment for carpal tunnel syndrome useful?
The effectiveness of mobilization with movement on patients with mild and moderate carpal tunnel syndrome: A single-blinded, randomized controlled study. Ceylan, İ., et al. (2023). Level of Evidence: 2b Follow recommendation: 👍 👍 👍 (3/4 Thumbs up) Type of study: Therapeutic Topic: Carpal tunnel syndrome - Mobilisation with movement This is a randomised controlled trial on the effectiveness of mobilisation with movement (MWM) technique in patients with carpal tunnel syndrome (CTS). A total of 45 participants with CTS diagnosed based on symptoms presentation, positive response to provocative tests, and mild to moderate median nerve compression as shown by nerve conduction studies, were included. Participants were randomised to either physiotherapy plus MWM (see picture below) or physiotherapy alone. Each group received three sessions per week for four weeks. The primary outcome was pain measured through the visual analogue scale. The results showed that all participants improved to a clinically relevant level. Furthermore, the study showed that the addition of MWMs did not provide statistically significant or clinically relevant improvements in pain compared to physiotherapy alone. 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, mobilisation with movement (MWM) does not provide additional pain relief when compared to physiotherapy alone for people with CTS. However, it appears that a combination of multiple manual therapy interventions and exercise may be beneficial for carpal tunnel syndrome. Other interventions that have a much larger body of evidence supporting their use include surgery, corticosteroid injections, and night splinting. Have a look at the whole database to get a full picture of the most recent papers on the topic. URL: https://doi.org/10.1016/j.jht.2023.02.004 Abstract Study design: Single-blinded, randomized controlled study. Introduction Carpal Tunnel Syndrome (CTS) causes pain and loss of function in the affected hand. The mobilization with movement (MWM) technique is a manual therapy method applied to correct joint movement limitation and to relieve pain and functional disorders. Purpose of the study: This study aimed to examine the effectiveness of MWM technique on pain, grip strength, range of motion, edema, hand reaction, nerve conduction, and functional status in patients with CTS. Methods: A total of 45 patients enrolled in the study. The MWM group (n = 18) completed a 4-week combined conservative physiotherapy and MWM program, whereas the control group (n = 18) received only the 4 weeks of conservative physiotherapy. Pain severity according to the numerical rating scale was used as primary outcome. Results: We found an improvement within the subjects in resting pain (MWMG:5.1 ± 3.6 vs 1.1 ± 2.4, Effect Size (ES)=1.3; CG:4.5 ± 3.3 vs 1.0 ± 2.2, ES=1.1), in activity pain (MWMG:6.5 ± 3.7 vs 1.1 ± 2.4, ES=1.5; CG:4.8 ± 3.4 vs 2.2 ± 2.3, ES=1) and in night pain (MWMG:5.9 ± 3.2 vs 1.8 ± 2.5, ES=1.2; CG:5.3 ± 4.2 vs ± 2.3 ± 3.5, ES=0.9). For between the groups, a statistical difference was found for the activity pain, Disabilities of the Arm Shoulder and Hand Questionnaire score (MWMG:52.2 ± 23.8 vs 27 ± 24.7, ES=1.3; CG:47.0 ± 24.8 vs 41.5 ± 22.1, ES=0.2), Michigan Hand Outcomes Questionnaire (MHQ-1), (MWMG:44.4 ± 23.7 vs 74.7 ± 24.5, ES=1.3; CG:44.8 ± 17.4 vs 57.4 ± 21.7, ES=0.9) and MHQ-5 (MWMG:68.8 ± 13.1 vs 82.5 ± 11.5, ES=0.9; CG:63.4 ± 26.7 vs 59.3 ± 25.8, ES=0.1) parameters in favour of MWM group. Discussion: This study showed that MWM compared to conservative physiotherapy might be more effective in reducing perceived symptoms in mild and moderate CTS patients. Conclusions: MWM produced a small benefit to recovery of activity pain and upper extremity functionality level outcomes of patients with mild to moderate CTS when added to a traditional CTS physical therapy program. publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings
- Is driving a low load activity following total elbow arthroplasty?
Elbow joint loads during simulated activities of daily living: Implications for formulating recommendations after total elbow arthroplasty. Duijn, R. G. A., et al. (2023). Level of Evidence: 5 Follow recommendation: 👍 (1/4 thumbs up) Type of study: Therapeutic Topic: Loading - Elbow arthroplasty This is a lab based biomechanics study assessing elbow joint loading during activities of daily living (ADL) after total elbow arthroplasty (TEA). The study assessed joint moments during ADL and their relationship to the failure limits of a prosthesis. A total of eight cadavers were included in the present study. Eight different tasks, described in the figure below, were assessed. The results showed that peak joint moments significantly differed between tasks and movement directions, with the most demanding tasks being steering a wheel and rising from a chair. In addition, lifting 1 kg was one of the least biomechanically taxing activities. 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, driving and pushing off a chair with your arms are amongst the activities that put the highest loading through the elbow. As a result, it may be useful to avoid doing so for the first few weeks post total elbow arthroplasty. In addition, pushing and pulling, such as lifting and opening doors, put significant stress on the elbow joint, particularly in the flexion-extension and varus-valgus directions. Interestingly, the study questions the effectiveness of the current postoperative instruction of not lifting more than 1 kg as this does not appear to put excessive stress on the prosthesis. This article is an interesting addition to a recent one assessing the amount of upper limb ROM required to return to driving. URL: https://doi.org/10.1016/j.jse.2023.07.042 Abstract Background: Overloading of the elbow joint prosthesis following total elbow arthroplasty can lead to implant failure. Joint moments during daily activities are not well-contextualized for a prosthesis’ failure limits and the effect of the current postoperative instruction on elbow joint loading is unclear. This study investigates the difference in elbow joint moments between simulated daily tasks and between flexion-extension, pronation-supination, varus-valgus movement directions. Additionally, the effect of the current postoperative instruction on elbow joint load is examined. Methods: Nine healthy participants (age 45.8 ± 17 years, 3 males) performed eight tasks; driving a car, opening a door, rising from chair, lifting, sliding, combing hair, drinking, emptying cup, without and with the instruction “not lifting more than 1 kg”. Upper limb kinematics and hand contact forces were measured. Elbow joint angles and net moments were analyzed using inverse dynamic analysis, where the net moments are estimated from movement data and external forces. Results: Peak elbow joint moments differed significantly between tasks (p < 0.01) and movement directions (p < 0.01). The most and least demanding tasks were, rising from a chair (13.4 Nm extension, 5.0 Nm supination, 15.2 Nm valgus) and sliding (4.3 Nm flexion, 1.7 Nm supination, 2.6 Nm varus). Net moments were significantly reduced after instruction only in the chair task (p < 0.01). Conclusion: This study analyzed elbow joint moments in different directions during daily tasks. The outcomes question whether postoperative instruction can lead to decreasing elbow loads. Future research might focus on reducing elbow loads in the flexion-extension and varus-valgus directions. publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings
- Is self-efficacy strongly associated with function in people with hand pathologies?
The association between pain self-efficacy and patient-reported outcome measures for hand disorders: A cross-sectional study. Overduin, I., Allen, C. and Aret, J. (2023) Level of Evidence: 2b Follow recommendation: 👍 👍 👍 (3/4 thumbs up) Type of study: Symptoms prevalence study Topic: Self efficacy - Hand function This retrospective study assessed the correlation between pain self-efficacy and patient-reported outcome measures for hand and wrist disorders. A total of 229 participants were included in the present study The outcomes measured included the Dutch translations of the Pain Self-Efficacy Questionnaire Short Form (PSEQ-2) and the Patient Rated Wrist Hand Evaluation (PRWHE). The results showed a strong and significant correlation between the PSEQ-2 and the PRWHE, indicating that a higher pain self-efficacy was associated with less pain and disability as measured by the PRWHE. Pain self-efficacy independently predicted 28% of the PRWHE. 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, pain self-efficacy is an important psychological factor that may be assessed in patients with hand conditions. There is a growing amount of evidence suggesting that self-efficacy is an important aspect mediating not only pain and function but also the effect of exercise on patients anxiety/depression and their compliance. URL: https://doi.org/10.1177/17589983231174800 Abstract Introduction: Multiple psychological factors influence the functioning of patients with hand disorders. Pain self-efficacy is a positive psychological factor, which concerns an individual’s confidence to function despite experiencing pain. This study aimed to analyse the association between pain self-efficacy and a patient-reported outcome measure (PROM) for hand and wrist disorders. Methods: Cross-sectional data from patient records were collected prior to hand therapy to analyse the correlation between pain self-efficacy and a PROM for hand and wrist disorders. The assessment tools consisted of the Dutch translations of the Pain Self-Efficacy Questionnaire Short Form (PSEQ-2) and the Patient Rated Wrist Hand Evaluation (PRWHE). Results: The findings were reported for the entire sample of 185 respondents (61% women). The PSEQ-2 and the PRWHE were strongly and significantly correlated, which signifies that a higher pain self-efficacy was associated with less pain and disability as measured by the PRWHE. Within a multivariable regression model which accounted for confounding variables, pain self-efficacy independently predicted 28% of the PRWHE scores. Conclusions: A strong association between the Dutch PSEQ-2 and the PRWHE was found in this sample of hand therapy patients. This study was limited by the use of retrospective data and by the lack of validation of the Dutch PSEQ-2. The findings were consistent with existing research which reported similar correlations between upper extremity PROM scores and pain self-efficacy. The positively worded PSEQ presents a chance to routinely assess pain self-efficacy as a key psychological factor while also affirming a positive coping strategy. publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings
- Thumb OA: What psychosocial factors affect pain?
Biopsychosocial factors associated with pain severity and hand disability in trapeziometacarpal osteoarthritis and non-surgical management. Hamasaki, T., et al. (2023). Level of Evidence: 2c Follow recommendation: 👍 👍 👍 (3/4 Thumbs up) Type of study: Symptoms prevalence Topic: Thumb osteoarthritis - Psychological factors This is a cross-sectional study assessing the correlation between biopsychosocial factors and pain intensity/disability as well as the most common forms of interventions utilised by people with cmcj osteoarthritis. A total of 228 participants with an average age of 63 were included in the present study. Eighty percent of the participants reported having experienced average pain of moderate to severe intensity during the last 7 days, with a mean pain intensity of 6/10 and a moderate level of disability. Disability was associated with pain catastrophizing, depressive symptoms, and age. Non-surgical cmcj management included acetaminophen, oral NSAIDs, intra-articular cortisone injections, splinting, hand exercises, ergonomic techniques, and assistive devices. Several interventions, which may be useful to reduce depression/pain catastrophising (see graph below) had not been trialed by the majority of patients. The results suggest that a multidisciplinary approach is necessary to adequately tackle patients' specific needs. 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, cmcj can cause severe pain, disability, disturbed emotional well-being, limited quality of life, and reduced productivity. Working on modifiable factors such as pain frequency, disability, depression, and pain catastrophising may help reduce the severity of cmcj symptoms. A multidisciplinary approach should also be employed in patients with severe distress to identify opportunities to improve mental health and increase levels of physical activity in those who are sedentary. URL: https://doi.org/10.1016/j.jht.2022.10.001 Abstract Background: Trapeziometacarpal osteoarthritis (TMO) is one of the most prevalent and painful forms of hand osteoarthritis. Purpose: This study aimed at (1) describing the TMO pain experience, (2) identifying biopsychosocial factors associated with pain intensity and disability, and 3) documenting the use of non-surgical management modalities. Study Design: Cross-sectional. Methods: Participants who presented for care for TMO were recruited from 15 healthcare institutions. They completed a questionnaire addressing sociodemographic, pain, disability, psychological well-being, quality of life (QoL), productivity, and treatment modalities employed. Multivariable regression analyses identified biopsychosocial factors associated with pain intensity and magnitude of disability. Results: Among our 228 participants aged 62.6 years, 78.1% were women. More than 80% of the participants reported average pain of moderate to severe intensity in the last 7 days. Nearly 30 % of them scored clinically significant levels of anxiodepressive symptoms. The participants’ norm-based physical QoL score on the SF-12v2 was 41/100. Among the 79 employed respondents, 13 reported having missed complete or part of workdays in the previous month and 18 reported being at risk of losing their job due to TMO. Factors independently associated with more intense pain included higher pain frequency and greater disability, accounting for 59.0% of the variance. The mean DASH score was 46.1 of 100, and the factors associated with greater magnitude of disability were higher pain intensity, greater levels of depression, female sex, and lower level of education, explaining 60.1% of the variance. Acetaminophen, oral non-steroid anti-inflammatory drugs, cortisone injections, orthoses, hand massage/exercises, and heat/cold application were the most frequently employed modalities. Most participants never used assistive devices, ergonomic techniques, and psychosocial services. Conclusions: Patients with TMO can experience severe pain, disability, disturbed emotional well-being, limited QoL and reduced productivity. As disability is associated with TMO pain, and depressive symptoms with disability, reducing such modifiable factors should be one of the clinicians’ priorities. publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings
- A new splint design for radial nerve palsy!
A new orthotic solution for radial nerve injury. Copuaco, M. and Csajko, A. (2023). Level of Evidence: 5 Follow recommendation: 👍 (1/4 thumbs up) Type of study: Therapeutic Topic: Radial palsy - Splint This article outlines a new orthotic solution for radial nerve injury which is low-profile, simple, and time-efficient. It requires a limited amount of materials/tools, and the most time consuming aspect involves attaching finger loops to a thermoplastic component. The elastics are threaded through the thermoplastic and finger loops, and finished with a knot on the thermoplastic side. This design is adjustable and easy to apply. It is also simpler and faster to fabricate than a typical dynamic orthosis. The cost would also be much lower compare to an off the shelf radial palsy splint. 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, this new splint design for radial nerve palsy appears to be of low-profile, simple, and time-efficient. This approach to splinting may be also useful for hand therapists in training, who may find a full radial nerve palsy splinting design daunting. URL: https://doi.org/10.1016/j.jht.2022.09.008 No Abstract available publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings
- Are stabilisation exercises more effective than standard care for thumb OA?
Effect of a stabilization exercise program versus standard treatment for thumb carpometacarpal osteoarthritis: A randomized trial. Pisano, K., Wolfe, T., Lubahn, J. and Cooney, T. (2023) Level of Evidence: 1b Follow recommendation: 👍 👍 👍 (3/4 Thumbs up) Type of study: Therapeutic Topic: Thumb osteoarthritis - Real vs Sham thumb splint This randomised controlled study assessed the effect of adding stabilisation exercises to standard care in people with thumb OA. A total of 190 participants with symptomatic thumb OA were recruited. Participants were randomised to either standar care or standard care plus thumb stabilisation exercises. Standard care included the provision of an orthosis, joint protection advice, and heat modalities. The stabilisation exercises aimed at improving flexibility/strength of the thumb and some of the exercises have been shown in the pictures below. The exercises were to be performed 2-3 times per day for about 10 minutes each time. Objective and subjective measurements were recorded at baseline, 3, 6, and 12 months. The results showed that the addition of stabilisation exercises program did not improve objective or subjective outcomes more than standard care. Both groups had decreased pain with activity and improved PSFS scores, with no statistical significance between the two groups. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message: Based on what we know today, a home exercise program for thumb stability may not provide added benefits compared to standard care in people with thumb thumb OA. Pain can significantly decrease with the provision of standard care with or without the addition of stabilisation exercises. It appears that symptoms and disability in thumb OA are affected by several psychosocial variables and that the thumb stability may play a limited role in symptoms presentation. URL: https://doi.org/10.1016/j.jht.2022.03.009 Abstract Study Design: Randomized, interventional trial with 1 year follow-up. Introduction: Though recommended, evidence is lacking to support specific exercises to stabilize and strengthen the first carpometacarpal (CMC) joint for cases of osteoarthritis (OA). Purpose of the Study: To determine in a naturalistic setting, whether standard treatment plus a home exercise program (ST+HEP) is more effective than standard treatment (ST) alone in improving Quick Disabilities of Arm, Shoulder and Hand (qDASH) scores, and secondarily, in other patient-centered (pain, function) and clinical outcomes (range of motion, strength). Methods: A total of 190 patients from a hand therapy practice in northwestern PA were enrolled by informed consent and randomized into ST or ST+HEP groups. Average age was 60 years, most were female (78%) with sedentary occupations most common (36%). ST group received orthotic interventions, modalities, joint protection education and adaptive equipment recommendations, while the ST+HEP group received a home exercise program in addition to ST for 6-12 months. Follow-up occurred at 3, 6, and 12 months. Outcomes included grip strength, pinch strength, range of motion (ROM), qDASH, Patient Specific Functional Scale (PSFS) and pain ratings. At the 6 month mark, all subjects could change groups if desired. Efficacy data analysis included both parametric and non-parametric tests. The threshold for statistical significance was 0.05 and adjusted for multiple comparisons. Results: Repeated measures ANOVA failed to show a statistically significant difference in strength and ROM assessments between treatment groups over the 12 month follow-up (P ≥ .398). Differences between groups did not exceed 13%. Both the ST and ST+HEP groups evidenced improvement over time in most patient-focused assessments (P ≤ .011), including improvements exceeding reported clinically important differences in pain with activity and PSFS scores. Scores for these measures were similar at each follow-up period (P ≥ .080) in each group. The presence of CTS exerted no effect on outcomes; longer treatment time was weakly related to poorer qDASH and PSFS scores initially. Of those enrolled, 48% of subjects completed the study. Conclusions: The addition of a high-frequency home exercise program did not improve clinical or patient-centered outcomes more so than standard care in our sample however, study limitations are numerous. Both groups had decreased pain with activity and improved PSFS scores, meeting the established minimally clinically important difference (MCID) of each at 6 and 12 months. Adherence with the home program was poor and/or unknown. publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings