Somatosensory rehabilitation for allodynia in complex regional pain syndrome of the upper limb: A retrospective cohort study.

STUDY DESIGN: Retrospective cohort study. INTRODUCTION: Somatosensory rehabilitation is a standardized method of evaluation and conservative treatment of painful disorders of vibrotactile sensation, including the mechanical allodynia and burning pain of complex regional pain syndrome (CRPS). PURPOSE OF THE STUDY: The purpose of this study was to examine the effectiveness of somatosensory rehabilitation for reducing allodynia in persons with CRPS of 1 upper limb in a retrospective consecutive cohort of patients. METHODS: An independent chart review of all client records (May 2004-August 2015) in the Somatosensory Rehabilitation Centre (Fribourg, Switzerland) identified 48 persons meeting the Budapest criteria for CRPS of 1 limb who had undergone assessment and treatment. Outcomes of interest were the French version of the McGill Pain Questionnaire (Questionnaire de la Douleur St-Antoine [QDSA]), total area of allodynia as recorded by mapping the area of skin where a 15-g monofilament was perceived as painful, and the allodynia threshold (minimum pressure required to elicit pain within the allodynic territory). RESULTS: This cohort was primarily women (70%), with a mean age of 45 years (range: 18-74). Mean duration of burning pain was 31 months (range: 1 week-27.5 years), and baseline QDSA core was 48. The average primary area of allodynia was 66 cm2 (range: 2.6-320), and the most common allodynia threshold was 4.0 g. The average duration of treatment was 81 days. At cessation of treatment, the average QDSA score was 20 (effect size Cohen's d = 1.64). Allodynia completely resolved in 27 persons (56% of the total sample where only 58% completed treatment). DISCUSSION: This uncontrolled retrospective study suggests that somatosensory rehabilitation may be an effective treatment with a large effect size for reducing the allodynia and painful sensations associated with CRPS of the upper limb. More work is in progress to provide estimates of reliability and validity for the measurement tools for allodynia employed by this method. LEVEL OF EVIDENCE: 2c.

Cross cultural adaptation and refinement of an English version of a Dutch patient-reported questionnaire for hand sensitivity: The Radboud Evaluation of Sensitivity.

STUDY DESIGN: Longitudinal clinical measurement. INTRODUCTION: Sensory alterations in the hand can present as both decreased sensation or numbness, and hyperesthesia, including mechanical allodynia and cold intolerance. However, few patient-reported outcomes have been developed and validated for evaluation, particularly for increased sensitivity. The Radboud Evaluation of Sensitivity was developed in the Netherlands for patient-reported evaluation of hand sensitivity in complex regional pain syndrome. PURPOSE OF THE STUDY: The purpose of this study was to translate into English and culturally validate the Radboud Evaluation of Sensitivity for the North American context. METHODS: Forward and backward translation, followed by a psychometric evaluation of the synthesized version of the translated tool, was undertaken in a heterogeneous group of persons after hand injury, including nerve injuries, hand trauma, and complex regional pain syndrome. RESULTS: Thirty-six persons completed test-retest reliability testing, yielding an intraclass correlation coefficient of 0.92 (95% CI 0.85 to 0.96) for single measures. Internal consistency was also high at α = 0.96 in a larger sample (n = 56). Although some support for construct validity was generated, several validity hypotheses were not confirmed. Of interest, there appeared to be significant differences in the scores between persons with hypoesthesia as compared with those with hyperesthesia. CONCLUSIONS: The Radboud Evaluation of Sensitivity, English version appears to be a reliable tool for the self-reported evaluation of sensory alterations in the hand, including both hypoesthesia and hyperesthesia. More research is needed to add to the extent of and confidence in the validity and responsiveness of this assessment. LEVEL OF EVIDENCE: Level II.

Rehabilitation strategies for wrist sensorimotor control impairment: From theory to practice.

UNLABELLED: This clinical review discusses the organization, neuroanatomy, assessment, clinical relevance, and rehabilitation of sensorimotor (SM) control impairment after wrist trauma. The wrist SM control system encompasses complex SM pathways that control normal wrist active range of motion and mediate wrist joint neuromuscular stability for maintaining joint function. Among various known assessment methods of wrist SM control impairment, the active wrist joint position sense test is determined to be a clinically meaningful and responsive measure for wrist SM control impairment after wrist fracture. Wrist trauma may involve significant soft tissue injury (ie, skin, ligament, muscle), which could disrupt the generation and transmission of adequate proprioceptive input from wrist mechanoreceptors, thus leading to significant joint SM impairment. Various clinical examples of wrist trauma (eg, distal radius fracture, scapholunate joint injury) along with known prognostic factors (eg, pain) that may influence wrist SM control impairment recovery are discussed to illustrate this point. This article proposes promising rehabilitation strategies toward restoring wrist joint conscious and unconscious SM control impairments, integrating current research evidence with clinical practice. These strategies require more rigorous evaluation in clinical trials. LEVEL OF EVIDENCE: 5.

Responsiveness of the active wrist joint position sense test after distal radius fracture intervention.

STUDY DESIGN: Prospective cohort study. INTRODUCTION: The active wrist joint position sense (JPS) test has been determined to be a clinically useful test for assessing wrist sensorimotor (SM) status after distal radius fracture (DRF). Its responsiveness is yet to be determined. PURPOSE OF THE STUDY: Primary study aim was to determine the active wrist JPS test responsiveness to detect change in wrist SM status at 8 and 12 weeks after DRF treatment intervention. Secondary aims were to compare group (nonsurgical, surgical, high, and low pain) test responsiveness; compare pain-level group participants test scores; determine the relationship between test minimal clinically important difference (MCID) value and function; compare functional outcomes across assessment times; and determine the Patient Global Impression of Change Scale intrarater reliability. METHODS: A total of 33 male and female participants were tested at baseline, 8, and 12 weeks after nonsurgical (n = 13) and surgical (n = 20) DRF treatment interventions. Distribution-based analysis encompassed both group- (ie, effect size, standardized response mean) and individual-based (ie, minimum detectable change) statistical indices. Anchor-based analysis determined the MCID value by linking test scores to the Patient Global Impression of Change Scale. RESULTS: The active wrist JPS test is highly responsive based on effect size (8 weeks = 1.53 and 12 weeks = 2.36) and standardized response mean (8 weeks = 1.57 and 12 weeks = 2.14). Statistically significant minimum detectable change values were 4.28° and 4.94° at 8 and 12 weeks, respectively. Clinically meaningful MCID values were 5.00° and 7.09° at 8 and 12 weeks, respectively. Between treatment type and pain-level group responsiveness levels were not significantly different. High-pain participants demonstrated significantly greater JPS deficit. Test MCID values and function were significantly associated. DISCUSSION: This is the first study to determine the active wrist JPS test responsiveness as reflected by its group- and individual-based statistical indices following DRF surgical and non-surgical interventions among low- and high-pain level participants. The statistical analysis approach, which was used to determine the aforementioned variables of the active wrist JPS test, is consistent with current research. This study's strengths included its design, methodology, and statistical approach. The study findings must be interpreted, however, within the content of several methodological limitations. CONCLUSIONS: The active wrist JPS test was determined to be highly responsive to detect wrist SM status change at 8 and 12 weeks regardless of treatment type or pain level. Clinicians can use this test with confidence to measure clinically meaningful SM impairment after DRF treatment. LEVEL OF EVIDENCE: 2b.

Therapist supervised clinic-based therapy versus instruction in a home program following distal radius fracture: a systematic review.

PURPOSE: The primary purpose of this systematic review is to determine the effectiveness of a home program or a structured therapy program for patients following distal radius fracture. METHODS: A search was performed using terms wrist fracture, supervised therapy, occupational therapy, physical therapy, splint, orthosis, distal radius fracture, exercise, and home program. Studies that met the inclusion criteria were evaluated for research quality using The Structured Effectiveness for Quality Evaluation of Study (SEQES). RESULTS: Five of the seven trials found no difference between outcomes for their subjects that had uncomplicated distal radius fractures. The population that has complications following distal radius fractures was not represented in the studies reviewed. CONCLUSION: The available evidence from randomized controlled trials is insufficient to support a home program or therapist supervised clinic-based program as a superior method of treatment for adults following a distal radius fracture without complications or the presence of comorbidities.

The push-off test: development of a simple, reliable test of upper extremity weight-bearing capability.

STUDY DESIGN: Longitudinal clinical measurement study. INTRODUCTION: The push-off test (POT) is a novel and simple measure of upper extremity weight-bearing that can be measured with a grip dynamometer. There are no published studies on the validity and reliability of the POT. The relationship between upper extremity self-report activity/participation and impairment measures remain an unexplored realm. PURPOSE: The primary purpose of this study is to estimate the intra and inter-rater reliability and construct validity of the POT. The secondary purpose is to estimate the relationship between upper extremity self-report activity/participation questionnaires and impairment measures. METHODS: A convenience sample of 22 patients with wrist or elbow injuries were tested for POT, wrist/elbow range of motion (ROM), isometric wrist extension strength (WES) and grip strength; and completed two self-report activity/participation questionnaires: Disability of the Arm, Shoulder and the Hand (DASH) and Work Limitations Questionnaire (WLQ-26). POT's inter and intra-rater reliability and construct validity was tested. Pearson's correlations were run between the impairment measures and self-report questionnaires to look into the relationship amongst them. RESULTS: The POT demonstrated high inter-rater reliability (ICC affected = 0.97; 95% C.I. 0.93-0.99; ICC unaffected = 0.85; 95% C.I. 0.68-0.94) and intra-rater reliability (ICC affected = 0.96; 95% C.I. 0.92-0.97; ICC unaffected = 0.92; 95% C.I. 0.85-0.97). The POT was correlated moderately with the DASH (r = -0.47; p = 0.03). While examining the relationship between upper extremity self-reported activity/participation questionnaires and impairment measures the strongest correlation was between the DASH and the POT (r = -0.47; p = 0.03) and none of the correlations with the other physical impairment measures reached significance. At-work disability demonstrated insignificant correlations with physical impairments. CONCLUSION: The POT test provides a reliable and easily administered quantitative measure of ability to bear the load through an injured arm. Preliminary evidence supports a moderate relationship between loading bearing measured by the POT and upper extremity function measured by the DASH. LEVEL OF EVIDENCE: 1b.

Distal Radius Fracture Rehabilitation.

Distal radius fracture (DRF) is arguably the most common upper extremity fracture resulting from a fall accident. These clinical practice guidelines (CPG) were developed to guide all aspects of the management of DRF by physical therapists and other rehabilitation practitioners, such as certified hand therapists. This CPG employed a systematic review methodology to locate, appraise, and synthesize contemporary evidence while developing practice recommendations for determining the prognosis of outcomes, examination, and interventions while managing individuals with DRF. The quality of the primary studies found in the literature search was appraised using standardized tools. The strength of the available evidence for a particular practice domain (e.g., prognosis or intervention) was graded as strong, moderate, weak, or conflicting, where such gradings guided the level of obligation for each practice recommendation. Lastly, the CPG also provided the gaps in the evidence pool for the rehabilitation of DRF that future research efforts can address. J Orthop Sports Phys Ther 2024;54(9):CPG1-CPG78. doi:10.2519/jospt.2024.0301.

A descriptive study on wrist and hand sensori-motor impairment and function following distal radius fracture intervention.

STUDY DESIGN: Descriptive cross-sectional design. INTRODUCTION: Wrist and hand sensori-motor impairment have been observed after distal radius fracture (DRF) treatment. This impairment and its relationship to function lack research. PURPOSE OF THE STUDY: The primary aim of this exploratory study was to determine the magnitude of wrist and hand sensori-motor impairment following surgical and non-surgical treatment among older patients following DRF. Secondary aims were to determine the relationship between wrist and hand sensori-motor impairment with function and pain as well as the relationships among wrist and hand sensori-motor impairment and function and age following DRF. METHODS: Ten Test (TT), active joint position sense (JPS), electromyography (EMG), computerized hand-grip dynamometer (CHD), and the Patient-Rated Wrist Evaluation (PRWE) were used to assess twenty-four female participants 8 weeks following DRF treatment and their 24 matched-control healthy counterparts on wrist and hand sensibility, proprioception, muscle recruitment, grip force, muscle fatigue, and functional status. RESULTS: Participants following DRF demonstrated significantly (p < .05) greater sensory (i.e., JPS, TT), and motor (i.e., EMG, CHD) deficits than their control counterparts. A significantly higher functional deficit (i.e., PRWE) also existed among participants following DRF than the control group. Participants following surgical and non-surgical DRF treatment were found to be statistically different only on total grip force. Group differences on JPS and total grip force revealed the strongest effect size with the highest correlations to PRWE. EMG and muscle fatigue ratio group differences revealed a weaker effect size with a fair degree of correlation to PRWE. Pain significantly correlated with sensori-motor function. Age did not correlate with any measured variable. CONCLUSIONS: Significant wrist and hand sensori-motor impairment and functional deficits among older females 8 weeks following DRF surgical and non-surgical interventions were revealed. JPS and total grip force were the most clinically meaningful tests for assessing the sensori-motor status as well as explaining functional disability and pain levels for these patients. LEVEL OF EVIDENCE: 2c.

Content validation of the Patient-Reported Hamilton Inventory for Complex Regional Pain Syndrome: Validité de contenu du Hamilton Inventory for Complex Regional Pain Syndrome, une mesure des résultats déclarés par le patient.

BACKGROUND: Complex regional pain syndrome (CRPS) is a perplexing neurological condition, and persons with CRPS experience substantial loss of daily roles and activities. A condition-specific measure is being developed to evaluate CRPS. PURPOSE: We describe the use of cognitive interviews to examine content validity of this patient-reported outcome measure for CRPS. METHOD: Interviews with 44 persons with CRPS were analyzed to identify problems with wording and support content validation. Item-total correlations were calculated for proposed subscales, and scores were plotted to consider floor/ceiling effects. FINDINGS: Interviews identified questions where respondents considered factors unrelated to the construct of interest or were underaddressed by the questionnaire, including depression and skin temperature. The symptoms, daily function, and coping/social impact scales demonstrated satisfactory correlations (Cronbach's alpha 0.76-0.86). Despite a sampling bias of severity, no frank floor/ceiling effects were noted. IMPLICATIONS: This study builds a foundation for continuing development and evaluation of the measurement properties of the Patient-Reported Hamilton Inventory for CRPS. It makes explicit the iterative decisions involved in rigorous instrument development.

Conservative interventions for carpal tunnel syndrome.

The assessment and conservative interventions in patients with carpal tunnel syndrome (CTS) are described in this paper. Information about surgical procedures and postoperative care has also been included. It is difficult to make definitive conclusions about the literature regarding success of treatment for CTS due to variations in outcome measures, severity of CTS, and inconsistencies in duration, dosage, and follow-up time for interventions. Based on what is known to date, this author recommends that patients with mild or moderate CTS be provided with a conservative program of splinting the wrist in neutral for nocturnal wear. In addition, intermittent exercise (nerve-gliding exercises) and activity modification, including avoidance of protracted periods of sustained gripping activities and awkward wrist positions, can be useful. This conservative program may be complemented by pain-relieving modalities during times of activity and supplemental participation in other exercise such as yoga. If symptoms are not relieved to the satisfaction of the patient, or they recur, then it is incumbent upon the therapist to refer the patient to a hand surgeon for injection or possible surgical decompression.

Reliability of 2 functional goniometric methods for measuring forearm pronation and supination active range of motion.

STUDY DESIGN: Test-retest reliability study. OBJECTIVES: To determine intra- and intertester reliability of the hand-held pencil (HHP) and the plumbline goniometer (PLG) methods for measuring active forearm pronation and supination motions in individuals with and without injuries. BACKGROUND: The distal forearm method has been considered the gold standard for measuring forearm pronation and supination motion. The HHP and PLG, however, are 2 more functional methods for measuring forearm motions, though limited information on the psychometric properties of these tests is currently available. METHODS AND MEASURES: Intra- and intertester reliability of the HHP and PLG methods were determined in 40 subjects of convenience (20 injured and 20 noninjured). Two testers performed 3 repeated measurements for each motion and method on all subjects. Intraclass correlation coefficients (ICC3,1 for intratester reliability, ICC2,3 for intertester reliability) and standard error of measurements (SEMs) were determined. RESULTS: The ICCs for the measurements of pronation and supination using the HHP and PLG methods were high (range, 0.86-0.98) for individuals with and without injuries, with the reliability for the PLG method being equal or slightly greater than the HHP method for the majority of pronation and supination measurements. Intratester ICCs were higher (SEMs were conversely lower) than intertester ICCs for nearly all measurements. The ICC values were generally the same or higher for individuals with injuries compared to individuals without injuries. CONCLUSIONS: The HHP and PLG are highly reliable methods for measuring functional forearm pronation and supination. Because plumbline goniometers are not commercially available and the instrumentation for the HHP method is readily accessible, clinicians should consider the latter as their method of choice for measuring functional forearm pronation and supination.

Use of a Delphi panel to establish consensus for recommended uses of selected balance assessment approaches.

The Delphi survey is a useful mechanism to make recommendations for clinical judgments in the absence of practice guidelines for evidence-based decision making. Although there is a great deal of literature about the topic of various methods of balance assessment, decisions about application of research evidence for clinical practice may be subject to personal interpretation and/or biases of the reader. In this study, a panel of informed experts was used through a Delphi process to establish consensus regarding the recommended use of selected balance assessment methods based on the literature. Selective recruitment of experienced faculty members with advanced degrees and/or specialist certification in the content area identified seven knowledgeable informants. The panel participated in three rounds of discussion to develop a consensus-based summary of the recommended use of balance assessment methods commonly used in clinical practice and suggest how those measures fit within the framework of the Patient/Client Management Model of physical therapy practice. The outcomes of the Delphi process form a basis for recommended practice in the examination of patients with balance deficits and serve as a starting point in the development of evidence-based practice guidelines.

Using evidence-based practice to select diagnostic tests.

Diagnosis is a primary activity of hand surgeons and therapists. Diagnostic tests can be used to assist in "ruling in" or "ruling out" a condition to best direct prognosis and treatment. However, the assigning of the diagnostic label is not always obvious. Principles of evidence-based practice may help hand care professionals improve their practice in the diagnosis of their patients. Evidence-based practice can be defined in terms of five steps that serve the structure for decision making and ensure optimum use of clinicians' expertise in the diagnosis.

Factors that influence the clinical decision making of physical therapists in choosing a balance assessment approach.

BACKGROUND: Many methods for examining patients with balance deficits are supported by the literature. How or why therapists choose specific balance assessment methods during examination of patients remains unclear. OBJECTIVES: The aims of this study were: (1) to explore decision making during examination of patients with balance deficits, (2) to understand the selection and use of assessment methods from the clinician's perspective, and (3) to explore why specific methods were selected. DESIGN: A qualitative design using a grounded theory approach permitted exploration of clinical decision making. METHODS: Eleven therapists were purposefully selected (6 from outpatient offices, 5 from inpatient rehabilitation settings) to participate in repeated interviews. Credibility of the findings was established through low-inference data, member check, and triangulation among participants and multiple data sources. RESULTS: A highly individualized approach to patient examination based on therapists' practical knowledge emerged from the data, with limited influence of the literature. Movement observation was the primary assessment and diagnostic tool. When selecting assessment approaches for specific patients, the perceived value of information gathered mattered more than testing time. A 3-stage model of assessment decision making portrayed both the process and reasons influencing therapists' choices. CONCLUSIONS: In the context of the complex and busy nature of clinical practice, therapists gathered data that they considered meaningful during patient examination. The findings provide insight into factors influencing assessment decisions and suggest mechanisms to foster translation of research into clinical practice.

Examination of the elbow: linking diagnosis, prognosis, and outcomes as a framework for maximizing therapy interventions.

A conceptual framework for examination of the elbow by the therapist is presented. The role of history taking including patient life-style factors, comorbidities and goals; pain assessment; utility of provocative maneuvers and range of motion analysis are presented. Assessment of strength using hand-held dynamometry is described. Pain and disability measures relevant to patients with elbow pathology are discussed and one patient self report instruments is appended (the Patient-rated Elbow Evaluation). The psychometrics properties of tests for the elbow, when available, are reviewed. A template for recording an elbow examination is provided.

Is there a role for ultrasound and electrical stimulation following injury to tendon and nerve?

Ultrasound (US) and electrical stimulation have been widely used in hand therapy to promote recovery after nerve and tendon injuries. There is support for the use of low-dosage continuous wave and pulsed US for carpal tunnel syndrome and tendonitis. Iontophoresis with dexamethasone sodium phosphate can relieve pain in acute elbow tendonitis, but there is no support for phonophoresis for any tendonitis. Animal model research supports the use of low-dosage US to improve the mechanical properties of the Achilles tendon when initiated immediately after tenorrhaphy. There are no studies available which have examined US applied to tendons in humans after repair. Electrical stimulation has been extensively studied in animal models after nerve axonotmesis and neurotmesis with nerve repair, with some support of enhancing recovery. There is a void in the literature on the use of electrical stimulation for humans after nerve transection and repair.

Therapy interventions for improving joint range of motion: A systematic review.

The authors conducted a systematic review of the published evidence on conservative interventions for loss of upper extremity joint range of motion following selected musculoskeletal conditions. Several databases (Medline, CINAHL, PEDRO, PubMed, and Cochrane) were searched for articles that met inclusion criteria. Two reviewers determined abstract selection; two reviews performed critical appraisal of 26 articles. Level of evidence and quality on a 24-item quantitative critical appraisal form were determined for all articles meeting selection criteria. The primary outcome considered was range-of-motion measurement. Overall, the quantity and quality of evidence were moderate to low. Sackett's levels 2b, 3, and 4 evidence has shown that joint mobilization, a supervised exercise program, and splinting can all increase joint range of motion. There were no studies found in the literature that examined techniques of physical agent or electrotherapeutic modalities. Future studies are needed to delineate selection of appropriate candidates for these techniques and effective dosage.