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Diagnostic accuracy of clinical tests to rule out elbow fracture: A systematic review. Breda, G., De Marco, G., Cesaraccio, P. and Pillastrini, P. (2023) Level of Evidence: 1a- Follow recommendation: 👍 👍 (2/4 Thumbs up) Type of study: Diagnostic Topic : Elbow fractures - Objective testing This is as a systematic review on the diagnostic accuracy of clinical tests for detecting or excluding elbow fractures. A total of 12 studies involving 4,485 participants were included. Three tests were assessed and they included the elbow full range of motion test, the elbow extension test, and the elbow extension combined with point tenderness test. The results demonstrated high sensitivity for these tests, with values reaching up to 99%, but specificity varied widely from 24% to 70%. While these tests are useful, particularly in ruling out fractures in adults when results are negative, their specificity is quite low. 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, clinical tests for elbow fractures, such as the elbow full range of motion test, elbow extension test, and elbow extension combined with point tenderness test, present high sensitivity values, making them potentially useful to exclude fractures when results are negative. Keep in mind that factors like depression and catastrophising can significantly modulate pain in patients with upper limb fractures and that tenderness on palpation of fractures is not a reliable indicator. URL : https://doi.org/10.5397/cise.2022.00948 Abstract Elbow traumas represent a relatively common condition in clinical practice. However, there is a lack of evidence regarding the most accurate tests for screening these potentially serious conditions and excluding elbow fractures. The purpose of this investigation was to analyze the literature concerning the diagnostic accuracy of clinical tests for the detection or exclusion of suspected elbow fractures. A systematic review was performed using the Preferred Reporting Items for a Systematic Review and Meta-analysis of Diagnostic Test Accuracy Studies (PRISMA-DTA) guidelines. Literature databases including PubMed, Cumulative Index to Nursing and Allied Health Literature, Diagnostic Test Accuracy, Cochrane Library the Web of Science, and ScienceDirect were searched for diagnostic accuracy studies of subjects with suspected traumatic elbow fracture investigating clinical tests compared to imaging reference tests. The risk of bias in each study was assessed independently by two reviewers using the Quality Assessment of Diagnostic Accuracy Studies 2 checklist. Twelve studies (4,485 patients) were included. Three different types of index tests were extracted. In adults, these tests were very sensitive, with values up to 98.6% (95% confidence interval [CI], 95.0%–99.8%). The specificity was very variable, ranging from 24.0% (95% CI, 19.0%–30.0%) to 69.4% (95% CI, 57.3%–79.5%). The applicability of these tests was very high, while overall studies showed a medium risk of bias. Elbow full range of motion test, elbow extension test, and elbow extension and point tenderness test appear to be useful in the presence of a negative test to exclude fracture in a majority of cases. The specificity of all tests, however, does not allow us to draw useful conclusions because there was a great variability of results obtained. 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 your bedside neurological examination for suspected peripheral neuropathies measure up? Bender, C., Dove, L. and Schmid, A. B. (2022) Level of Evidence : 5 Follow recommendation : 👍 (1/4 Thumbs up) Type of study : Diagnostic Topic : Neurological testing - Peripheral neuropathies This is an expert opinion on neurological testing for peripheral neuropathies. Six recommendations are provided based on the available evidence: 1 - Assess light touch sensation in the upper limb in a circular pattern. This will allow you to differentiate between a dermatomal vs a peripheral nerve numbness presentation. 2 - Test small fibre neuropathy through pin-prick in a circular pattern 3 - If there are motor or sensory deficits in both upper limbs, do not consider that "normal". 4 - When performing myotome testing, fatigue may incur more quickly in the affected muscles compared to other myotomes. Instead of a single maximal strength test, repeated testing may be required. 5 - Reflex testing is independent of patients' pain, use them. 6 - Monitor progress/deterioration as accurately as possible. Have a look at: Upper limb sensory testing - The video is also on JOSPT but it keeps buffering Upper limb motor and reflex testing - The video is also on JOSPT  but it keeps buffering 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, light touch, pin-prick, myotomes , and reflex testing may be useful in the assessment of people with peripheral neuropathies. Light touch, myotome, and reflex testing assess the gross integrity of nerves and they may be affected when there are moderate/large entrapment neuropathies. If the entrapment is mild, you may only identify impairments on pin-prick (small fibre neuropathy) . Pin-prick can be easily tested with a neuropen, which consistently delivers 40g of pin-prick (This is what I use in the clinic). If clients report muscle fatigue and you are testing myotomes, you may want to perform a few repetitions and compare their endurance to unaffected muscles of the same limb. In terms of dermatomes remember that they are inconsistent across people and the best you could do is differentiate between a radicular presentation vs a peripheral nerve entrapment. URL : https://doi.org/10.2519/jospt.2022.11281 Abstract Neurological testing is essential for screening and diagnosing suspected peripheral neuropathies. Detecting changes in somatosensory and motor nerve function can also have direct implications for management decisions. Nevertheless, there is considerable variation in what is included in a bedside neurological examination, and how it is performed. Neurological examinations are often used as screening tools to detect neurological deficits, but not used to their full potential for monitoring progress or deterioration. Here, we advocate for better use of the neurological examination within a clinical reasoning framework. Constrained by the lack of research in this field, our viewpoint is based on neuroscientific principles. We highlight six challenges for clinicians when conducting neurological examinations, and propose ways to overcome these challenges in clinical practice. We challenge widely held ideas about how the results of neurological examinations for peripheral neuropathies are interpreted and how the examinations are performed in practice. 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

Observed patterns of cervical radiculopathy: how often do they differ from a standard, “Netter diagram” distribution? McAnany, S., Rhee, J., Baird, E., Shi, W., Konopka, J., Neustein, T., & Arceo, R. (2019) Level of Evidence : 2b Follow recommendation : 👍 👍 👍 (3/4 thumbs up) Type of study : Symptoms prevalence study Topic : Cervical radiculopathy – Dermatomal patterns This is a retrospective study assessing the agreement between radiculopathy symptoms reported by patients and standard textbook patterns of radiculopathy. Patients were selected if they presented with a single level cervical radiculopathy (identified through MRI/CT scan), if they had been unresponsive to conservative treatment, and if they had a 75% improvement of symptoms at 6 months after anterior cervical discectomy and fusion (ACDF) surgery. The results showed that ipsilateral neck pain was present in 80% of patients before surgery. Shoulder pain on the side of the radiculopathy was present in 60% of the cases before surgery. Any spinal level from C3-C4 to C7-T1 could present with symptoms beyond the shoulder before surgery. The pain/numbness patterns described by the patients significantly deviated from the patterns described in textbooks and only 54% of patients presented with a standard pain/numbness pattern. 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, radiculopathies may present with a dermatomal pattern as described in textbooks in 54% of the cases. The presence or lack of symptoms beyond the neck/shoulder is not useful in identifying the level of cervical compression. URL : https://doi.org/10.1016/j.spinee.2018.08.002 Abstract BACKGROUND CONTEXT Traditionally, cervical radiculopathy is thought to present with symptoms and signs in a standard, textbook, reproducible pattern as seen in a “Netter diagram.” To date, no study has directly examined cervical radicular patterns attributable to single level pathology in patients undergoing ACDF. PURPOSE The purpose of this study is to examine cervical radiculopathy patterns in a surgical population and determine how often patients present with the standard textbook (ie, Netter diagram) versus nonstandard patterns. STUDY DESIGN/SETTING A retrospective study. PATIENT SAMPLE Patients who had single-level radiculopathy with at least 75% improvement of preoperative symptoms following ACDF were included. OUTCOME MEASURES Epidemiologic variables were collected including age, sex, weight, body mass index, laterality of symptoms, duration of symptoms prior to operative intervention, and the presence of diabetes mellitus. The observed pattern of radiculopathy at presentation, including associated neck, shoulder, upper arm, forearm, and hand pain and/or numbness, was determined from chart review and patient-derived pain diagrams. METHODS We identified all patients with single level cervical radiculopathy operated on between March 2011 and March 2016 by six surgeons. The observed pattern of radiculopathy was compared to a standard textbook pattern of radiculopathy that strictly adheres to a dermatomal map Fisher exact test was used to analyze categorical data and Student t test was used for continuous variables. A one-way ANOVA was used to determine differences in the observed versus expected radicular pattern. A logistic regression model assessed the effect of demographic variables on presentation with a nonstandard radicular pattern. RESULTS Overall, 239 cervical levels were identified. The observed pattern of pain and numbness followed the standard pattern in only 54% (129 of 239; p=.35). When a nonstandard radicular pattern was present, it differed by 1.68 dermatomal levels from the standard (p<.0001). Neck pain on the radiculopathy side was the most prevalent symptom; it was found in 81% (193 of 239) of patients and did not differ by cervical level (p=.72). In a logistic regression model, none of the demographic variables of interest were found to significantly impact the likelihood of presenting with a nonstandard radicular pattern. CONCLUSIONS Observed patterns of cervical radiculopathy only followed the standard pattern in 54% of patients and did not differ by the cervical level involved. Cervical radiculopathy often presents with a nonstandard pattern. Surgeons should think broadly when identifying causative levels because they frequently may not adhere to textbook descriptions in actual clinical practice. We observed III 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

Advancing the understanding of placebo effects in psychological outcomes of exercise: Lessons learned and future directions. Lindheimer, J. B., A. Szabo, J. S. Raglin and C. Beedie (2020) Level of Evidence : 5 Follow recommendation : 👍 (1/4 Thumbs Up) Type of study : Therapeutic Topic : Placebo and nocebo – What are they? This is a narrative review on the effect of placebo and nocebo with exercise interventions. Placebo can be defined as a positive effect (e.g. pain reduction), nocebo instead can be described as a negative effect (e.g. increase in pain) resulting from your treatment or interaction with clients. The findings from this review suggest that 50% of the benefits provided by exercise may be due to a placebo effect (see picture). It also appears that clients' expectations largely contribute to exercise effectiveness. Interestingly, these expectations can be influenced by the client-clinician interaction. 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, up to 50% of the positive response to exercise may be due to placebo. This may also suggest that a large proportion of the negative responses to exercise or activities may be due to the nocebo effect (wait for next week synopsis, you are in for a treat). This is consistent with prior research suggesting that the words that we use can increase or decrease our clients' pain . Telling clients that doing certain activities will increase their pain, will therefore increase their likelihood of reporting pain during such activities at next appointment . This will probably lead to a confirmation bias on our side, contributing to a self-fulfilling prophecy. If we instead take an approach that reduces threats associated with movement and exercise, we may be able to boost the placebo effect. Being empathetic and smiling has also been shown to reduce pain in our clients . This placebo boosting activity may be especially useful once we encounter clients with ongoing symptoms long after expected healing time frames. To conclude: Test your pain science knowledge and check whether the placebo is with you! URL : https://doi.org/10.1080/17461391.2019.1632937 Abstract Despite the apparent strength of scientific evidence suggesting that psychological benefits result from both acute and chronic exercise, concerns remain regarding the extent to which these benefits are explained by placebo effects. Addressing these concerns is methodologically and at times conceptually challenging. However, developments in the conceptualisation and study of placebo effects from the fields of psychology, neuroscience, pharmacology, and human performance offer guidance for advancing the understanding of placebo effects in psychological responses to exercise. In clinical trials, expectations can be measured and experimentally manipulated to better understand the influence of placebo effects on treatment responses. Further, compelling evidence has shown that the contribution of placebo effects and their underlying neurobiological mechanisms to treatment effects can be measured without administering a traditional placebo (e.g. inert substance) by leveraging psychological factors such as expectations and conditioning. Hence, the purpose of this focused review is to integrate lessons such as these with the current body of literature on placebo effects in psychological responses to exercise and provide recommendations for future research 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

The magnitude of nocebo effects in pain: A meta-analysis. Petersen, G. L., et al. (2014) Level of Evidence : 1a Follow recommendation : 👍 👍 👍 👍 (4/4 Thumbs Up) Type of study : Therapeutic Topic : Nocebo – No touching needed This is a systematic review and meta-analysis on the effect of verbal communication and nocebo. Nocebo can be described as a negative effect (e.g. increase in pain) resulting from your treatment or interaction with clients. Ten experimental studies for a total of 334 participants were included in the present study. The participants included either had persistent pain or were healthy subjects to whom pain was induced experimentally (e.g. saline injection). The results showed that verbal nocebo (suggesting that an activity/treatment will be painful) combined with an activity, significantly increased pain with a moderate to large effect size. The clinical relevance of this finding was not provided by the paper, however, I calculated it for you. To give you an estimate, with verbal nocebo and activity conditioning, there was an increase in pain of at least 1 point out of 10 (I calculated this by utilising Hedges' g of 0.62, which was the lowest effect size, on the standard deviation reported in Figure 3 of the paper by Colloca et al. published in 2008 ). The results also showed that the magnitude of the nocebo effect is similar to the one of the placebo effect, yet in the opposite direction. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message : Based on what we know today, we can increase clients' pain just by telling them that a specific activity is going to be painful. In particular, the minimum increase in pain appears to be 1 point out of 10 on a visual analogue pain scale. In addition, the size of the nocebo effect appears to be similar to that of the placebo effect but in the opposite direction. What this means is that within the same client, we can make the pain better or worse by at least 1 point out of 10. In other words, a client presenting with a baseline pain level of 4/10, can come back to you at the next appointment with a pain level of 3/10 or 5/10 according to your placebo or nocebo conditioning approach respectively. This is a clinically relevant difference! Which approach should we choose? I will go with the placebo approach, which has been suggested to boost the effect of exercise , and I will be smiling, which has been shown to reduce pain in our clients . Remember, if you tell your clients that an activity is going to hurt, that increases the chances that it will . URL : https://www.sciencedirect.com/science/article/pii/S030439591400195X Abstract The investigation of nocebo effects is evolving, and a few literature reviews have emerged, although so far without quantifying such effects. This meta-analysis investigated nocebo effects in pain. We searched the databases PubMed, EMBASE, Scopus, and the Cochrane Controlled Trial Register with the term “nocebo.” Only studies that investigated nocebo effects as the effects that followed the administration of an inert treatment along with verbal suggestions of symptom worsening and that included a no-treatment control condition were eligible. Ten studies fulfilled the selection criteria. The effect sizes were calculated using Cohen’s d and Hedges’ g. The overall magnitude of the nocebo effect was moderate to large (lowest g=0.62 [0.24–1.01] and highest g=1.03 [0.63–1.43]) and highly variable (range of g=−0.43 to 4.05). The magnitudes and range of effect sizes was similar to those of placebo effects (d=0.81) in mechanistic studies. In studies in which nocebo effects were induced by a combination of verbal suggestions and conditioning, the effect size was larger (lowest g=0.76 [0.39–1.14] and highest g=1.17 [0.52–1.81]) than in studies in which nocebo effects were induced by verbal suggestions alone (lowest g=0.64 [−0.25 to 1.53] and highest g=0.87 [0.40–1.34]). These findings are similar to those in the placebo literature. As the magnitude of the nocebo effect is variable and sometimes large, this meta-analysis demonstrates the importance of minimizing nocebo effects in clinical practice. 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

Pain can be conditioned to voluntary movements through associative learning: An experimental study in healthy participants Alaiti, R., Zuccolo, P., Leite Hunziker, M., Caneiro, J., Vlaeyen, J., & Fernandes da Costa, M. (2020) Level of Evidence : 5 Follow recommendation : 👍(1/4 Thumbs Up) Type of study : Aetiologic Topic : Acute pain - Movement conditioning This is an experimental study assessing the effect of shoulder movement associated with a painful stimulus on the likelihood of perceiving pain in the presence of a non painful stimulus after the conditioning. A total of 34 healthy participants were included in the study. The assessment took place immediately before and after the pain conditioning. During the assessment, a non painful stimulus was delivered through an electrocutaneous current of low intensity at the acromion of the tested shoulder. During the assessment, participants were asked to report whether two shoulder movements (shoulder flexion/shoulder flexion with horizontal adduction) paired with the non painful stimuli were painful or not. During the conditioning, a painful stimuli (electrocutaneous current of high intensity) was delivered consistently to one of the shoulder movements described above (randomised among participants) for 50% of the trials. The conditioning phase lasted on average 2 minutes. The results showed that the painfully conditioned movement was reported as painful more often (85%; SD: 25%) compared to the non conditioned movement (73%; SD: 32%) when paired with the non painful stimuli after the conditioning. Clinical Take Home Message : Based on what we know today, our clients can develop a learned association between a specific movement and the perception of pain. It is possible that this leads to the experience of pain in the absence of tissue damage. Therapeutic interventions aiming to dissociate movement from pain may be useful in reducing the pain experience. URL : https://journals.lww.com/pain/Abstract/9000/zain_can_be_conditioned_to_voluntary_movements.98406.aspx 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

Platelet-rich plasma injection versus operative treatment for lateral elbow tendinosis: A systematic review and meta-analysis. Kim, C.-H., Y.-B. Park, J.-S. Lee and H.-S. Jung (2021) Level of Evidence : 1a- Follow recommendation : 👍 👍 👍 👍(4/4 Thumbs up) Type of study : Therapeutic Topic : Lateral epicondylalgia – surgery vs platelet-rich plasma injections This is a systematic review and meta-analysis assessing the effectiveness of platelet-rich plasma (PRP) vs surgery for lateral epicondylalgia. Two randomised controlled trials (RCT) and two retrospective studies were included for a total of 340 participants. All the studies were assessed through a critiquing tool suitable for experimental and non-experimental studies. Intervention efficacy was assessed through improvements in pain (visual analogue scale - VAS) and function (patient-related tennis elbow evaluation - PRTEE). To be included in the review, studies had to compare PRP injections to surgery. Surgery involved in all cases debridement with decortication. Follow-up periods ranged between 3 and 12 months. The results showed that there was no statistical or clinically significant difference between PRP and surgery in terms of pain or function at any time point. 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, surgery for tennis elbow does not appear to be more effective than PRP injections. In addition, PRP injections do not appear to be more effective than placebo saline injections for tennis elbow . Surgery for tennis elbow is therefore unlikely to be more effective than placebo. Considering the high cost of surgery and PRP injections, we may be better of telling our clients to adopt other less expensive alternatives such as initial rest followed by graded resistance training . If you would like to get a more complete picture about lateral epicondylalgia, have a look at the whole collection . URL : https://www.sciencedirect.com/science/article/pii/S1058274621007242 Available through EBSCO Health Databases for PNZ members. Abstract Background Although surgical treatment is considered reliable for lateral elbow tendinosis, local injection therapy may be preferable, as it avoids surgery. Among a number of local injections, platelet-rich plasma has been used successfully to treat lateral elbow tendinosis. The purpose of this study was to compare the outcomes in patients treated with either platelet-rich plasma injections or surgery for lateral elbow tendinosis using a systematic literature review and meta-analysis. Methods MEDLINE, Embase, and Cochrane Library databases were systematically searched for studies published before March 1, 2021, that compared platelet-rich plasma with operative treatment for lateral elbow tendinosis. The pooled analysis was designed to compare the visual analog scale scores and the Patient-Related Tennis Elbow Evaluation scores between the platelet-rich plasma and surgical treatment groups at serial time points. Results We included five studies involving 340 patients with lateral elbow tendinosis, comprising of 154 patients treated with platelet-rich plasma and 186 patients who underwent surgical treatment. The pooled analysis showed no statistically significant differences in the visual analog scale scores at any of the follow-up time points, namely post-intervention 2 months (mean difference = 1.11, 95% confidence interval: −2.51 to 4.74, P = 0.55, I2 = 94%), 6 months (mean difference = 0.80, 95% confidence interval: −2.83 to 4.42, P = 0.67, I2 = 92%), and 12 months (mean difference = −0.92, 95% confidence interval: −4.63 to 2.80, P = 0.63, I2 = 93%) and in the Patient-Related Tennis Elbow Evaluation scores at post-intervention 12 weeks (mean difference = −1.86, 95% confidence interval: −22.30 to 18.58, P = 0.86, I2 = 81%), 24 weeks (mean difference = −3.33, 95% confidence interval: −21.82 to 15.17, P = 0.72, I2 = 74%), and 52 weeks (mean difference = −3.64, 95% confidence interval: −19.65 to 12.37, P = 0.66, I2 = 69%). Conclusions Local platelet-rich plasma injections and surgical treatment produced equivalent pain scores and functional outcomes in patients with lateral elbow tendinosis. Thus, platelet-rich plasma injections may represent a reasonable alternative treatment for patients who are apprehensive to proceed with surgery or for poor surgical candidates. 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

Clinical efficacy of platelet-rich plasma in the treatment of lateral epicondylitis: A systematic review and meta-analysis of randomized placebo-controlled clinical trials. Simental-Mendía, M., Vilchez-Cavazos, F., Álvarez-Villalobos, N., Blázquez-Saldaña, J., Peña-Martínez, V., Villarreal-Villarreal, G., & Acosta-Olivo, C. (2020) Level of Evidence : 1a- Follow recommendation : 👍 👍 👍 👍(4/4 Thumbs Up) Type of study : Therapeutic Topic : Lateral epicondylalgia – platelet-rich plasma injections This is a systematic review and meta-analysis assessing the effectiveness of platelet-rich plasma (PRP) vs placebo injections for lateral epicondylalgia. Five randomised placebo-controlled trials (RCT) were included for a total of 276 participants (PRP = 153; Placebo injection = 123). 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) and function (patient-rated tennis elbow evaluation - PRTEE). To be included in the review, RCTs had to compare PRP injections to placebo injections (saline). Follow-up periods ranged between 2 to 6 months. The results showed that all the RCTs presented a low risk of bias. There was no difference between PRP or placebo injections on pain (Mean difference: -0.51; 95%CI: -1.32 to 0.3) or function (Standardised mean difference: -0.07; 95%CI: -0.46 to 0.33). Pain improved to a clinically significant level in both placebo and PRP injections groups (median reduction in pain of 5 points out of 10 in both groups). Neither the placebo nor the PRP injection group improved to a clinically significant level in the functional outcomes (1 point change on DASH). Clinical Take Home Message : PRP injections do not appear to show any additional benefit on pain or function when compared to placebo (saline) injections. Both interventions appeared to provide a clinically meaningful improvement in pain, which is most likely due to the contextual effect of the injection treatment. URL : https://link.springer.com/article/10.1007/s10067-020-05000-y

Discussing conflicting explanatory approaches in flexibility training under consideration of physiology: A narrative review. Warneke, K., et al. (2024) Level of Evidence: 4 Follow recommendation: 👍 👍 👍 (3/4 Thumbs up) Type of study: Therapeutic Topic : Flexibility - Mechanisms This narrative review discussed the efficacy of common flexibility training techniques including stretching and foam rolling. All the techniques/approaches show similar improvements in range of movement due to increased muscle temperature and decreased stiffness. A point is made that a simple warm-up regime may obtain similar short-term flexibility improvements as static stretching/foam rolling. For long-term flexibility, both stretching and resistance training through full joint range of movement can induce comparable structural adaptations, likely attributable to mechanical tension at extended muscle lengths, which stimulates protein synthesis and potentially sarcomerogenesis. Despite limited direct evidence of sarcomerogenesis in humans, the proposed mechanisms align with known physiological responses from animal studies. 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, effective flexibility training does not rely solely on traditional stretching methods. In particular, other physical training routines, such as full range of motion resistance training or general warm-ups, can induce similar flexibility gains. These findings are in line with previously published research showing that resistance training through range alone , without the addition of stretching , can improve flexibility. Therefore, if you or your patients don't have much time, you can avoid stretching . URL : https://doi.org/10.1007/s40279-024-02043-y Abstract The mechanisms underlying range of motion enhancements via flexibility training discussed in the literature show high heterogeneity in research methodology and study findings. In addition, scientific conclusions are mostly based on functional observations while studies considering the underlying physiology are less common. However, understanding the underlying mechanisms that contribute to an improved range of motion through stretching is crucial for conducting comparable studies with sound designs, optimising training routines and accurately interpreting resulting outcomes. While there seems to be no evidence to attribute acute range of motion increases as well as changes in muscle and tendon stiffness and pain perception specifically to stretching or foam rolling, the role of general warm-up effects is discussed in this paper. Additionally, the role of mechanical tension applied to greater muscle lengths for range of motion improvement will be discussed. Thus, it is suggested that physical training stressors can be seen as external stimuli that control gene expression via the targeted stimulation of transcription factors, leading to structural adaptations due to enhanced protein synthesis. Hence, the possible role of serial sarcomerogenesis in altering pain perception, reducing muscle stiffness and passive torque, or changes in the optimal joint angle for force development is considered as well as alternative interventions with a potential impact on anabolic pathways. As there are limited possibilities to directly measure serial sarcomere number, longitudinal muscle hypertrophy remains without direct evidence. The available literature does not demonstrate the necessity of only using specific flexibility training routines such as stretching to enhance acute or chronic range of motion. 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

Posterior interosseous nerve compression in the forearm, AKA radial tunnel syndrome: A clinical diagnosis. Patterson, J. M. M., Medina, M. A., Yang, A. and Mackinnon, S. E. (2024) Level of Evidence: 4 Follow recommendation: 👍 👍 👍 (3/4 Thumbs up) Type of study: Diagnostic, Therapeutic Topic : Radial tunnel syndrome - Assessment and treatment This retrospective study assessed the clinical characteristics of radial tunnel syndrome. A total of 182 patients who underwent posterior interosseous nerve decompression between 2000 and 2020 were screened. After exclusion of patients who presented with polyneuropathy, motor palsy, and common extensor origin tendinopathy, 14 patients were included in the study. Clinical presentation commonly involved dorsal forearm pain with a somewhat heterogeneous presentation of symptoms (see pain drawings below). Surgical decompression led to significant improvements in pain, quality of life, and DASH scores. Overall, the authors suggested that surgery should be used as a last resort for those patients not responding to conservative treatment. 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, radial tunnel syndrome is predominantly a pain syndrome without motor paralysis of the posterior inteosseous nerve. Pain is often reported in the dorsal forearm and surgical intervention should be considered for patients resistant to conservative management. Radial tunnel syndrome is not an easy diagnosis to make as it appears to be common in people presenting with common extensor origin tendinopathy . The evidence for treatment is scarce , however, on a positive note, radial tunnel syndrome is easily differentiated from posterior interosseous nerve syndrome as radial tunnel syndrome does not present with motor impairments . URL : https://doi.org/10.1177/15589447221122822 Abstract Background: Posterior interosseous nerve (PIN) compression in the forearm without motor paralysis is a challenging clinical diagnosis. This retrospective study evaluated the clinical assessment, diagnostic studies, and outcomes following surgical decompression of the PIN in the forearm. Methods: This study reviewed 182 patients’ medical charts following PIN decompression between 2000 and 2020 by a single surgeon. After exclusion of combined nerve entrapments, polyneuropathy, motor palsy, or lateral epicondylitis, the study included 14 patients. Data collected included: clinical presentation and pain drawings, provocative testing, functional outcomes, and Disabilities of the Arm, Shoulder, and Hand (DASH) scores. Results: There were 15 PIN decompressions (14 patients, mean follow-up = 11.9 months). Clinical presentation included pain (n = 14) (proximal dorsal forearm, n = 14; distal forearm over radial sensory nerve, n = 3) and positive clinical tests (sensory collapse test over the radial tunnel, n = 8; pain with forearm pronation and compression over the radial tunnel, n = 10; Tinel sign, n = 5). Postoperatively, there were significant improvements in Visual Analog Scale pain scores (6.7 to 3.3, P = .0006), quality-of-life scores (74.7 to 32.7, P = .0001), and DASH scores (46.3 to 33.6, P = .02). Conclusions: The PIN compression in the forearm without motor paralysis is a clinical diagnosis supported by pain drawings, pain quality, and provocative tests. Patients with persistent, therapy-resistant dorsal forearm pain should be evaluated for PIN compression. Surgical decompression provides statistically significant quantifiable improvement in pain and quality of life. 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