Splinting for carpal tunnel syndrome.

BACKGROUND: Carpal tunnel syndrome (CTS) is a compression neuropathy of the median nerve causing pain and numbness and tingling typically in the thumb, index and middle finger. It sometimes results in muscle wasting, diminished sensitivity and loss of dexterity. Splinting the wrist (with or without the hand) using an orthosis is usually offered to people with mild-to-moderate findings, but its effectiveness remains unclear. OBJECTIVES: To assess the effects (benefits and harms) of splinting for people with CTS. SEARCH METHODS: On 12 December 2021, we searched the Cochrane Neuromuscular Specialised Register, CENTRAL, MEDLINE, Embase, AMED, CINAHL, ClinicalTrials.gov, and WHO ICTRP with no limitations. We checked the reference lists of included studies and relevant systematic reviews for studies. SELECTION CRITERIA: Randomised trials were included if the effect of splinting could be isolated from other treatment modalities. The comparisons included splinting versus no active treatment (or placebo), splinting versus another disease-modifying non-surgical treatment, and comparisons of different splint-wearing regimens. We excluded studies comparing splinting with surgery or one splint design with another. We excluded participants if they had previously undergone surgical release. DATA COLLECTION AND ANALYSIS: Review authors independently selected trials for inclusion, extracted data, assessed study risk of bias and the certainty in the body of evidence for primary outcomes using the GRADE approach, according to standard Cochrane methodology. MAIN RESULTS: We included 29 trials randomising 1937 adults with CTS. The trials ranged from 21 to 234 participants, with mean ages between 42 and 60 years. The mean duration of CTS symptoms was seven weeks to five years. Eight studies with 523 hands compared splinting with no active intervention (no treatment, sham-kinesiology tape or sham-laser); 20 studies compared splinting (or splinting delivered along with another non-surgical intervention) with another non-surgical intervention; and three studies compared different splinting regimens (e.g. night-time only versus full time). Trials were generally at high risk of bias for one or more domains, including lack of blinding (all included studies) and lack of information about randomisation or allocation concealment in 23 studies. For the primary comparison, splinting compared to no active treatment, splinting may provide little or no benefits in symptoms in the short term (< 3 months). The mean Boston Carpal Tunnel Questionnaire (BCTQ) Symptom Severity Scale (SSS) (scale 1 to 5, higher is worse; minimal clinically important difference (MCID) 1 point) was 0.37 points better with splint (95% confidence interval (CI) 0.82 better to 0.08 worse; 6 studies, 306 participants; low-certainty evidence) compared with no active treatment. Removing studies with high or unclear risk of bias due to lack of randomisation or allocation concealment supported our conclusion of no important effect (mean difference (MD) 0.01 points worse with splint; 95% CI 0.20 better to 0.22 worse; 3 studies, 124 participants). In the long term (> 3 months), we are uncertain about the effect of splinting on symptoms (mean BCTQ SSS 0.64 better with splinting; 95% CI 1.2 better to 0.08 better; 2 studies, 144 participants; very low-certainty evidence). Splinting probably does not improve hand function in the short term and may not improve hand function in the long term. In the short term, the mean BCTQ Functional Status Scale (FSS) (1 to 5, higher is worse; MCID 0.7 points) was 0.24 points better (95% CI 0.44 better to 0.03 better; 6 studies, 306 participants; moderate-certainty evidence) with splinting compared with no active treatment. In the long term, the mean BCTQ FSS was 0.25 points better (95% CI 0.68 better to 0.18 worse; 1 study, 34 participants; low-certainty evidence) with splinting compared with no active treatment. Night-time splinting may result in a higher rate of overall improvement in the short term (risk ratio (RR) 3.86, 95% CI 2.29 to 6.51; 1 study, 80 participants; number needed to treat for an additional beneficial outcome (NNTB) 2, 95% CI 2 to 2; low-certainty evidence).  We are uncertain if splinting decreases referral to surgery, RR 0.47 (95% CI 0.14 to 1.58; 3 studies, 243 participants; very low-certainty evidence).  None of the trials reported health-related quality of life. Low-certainty evidence from one study suggests that splinting may have a higher rate of adverse events, which were transient, but the 95% CIs included no effect. Seven of 40 participants (18%) reported adverse effects in the splinting group and 0 of 40 participants (0%) in the no active treatment group (RR 15.0, 95% CI 0.89 to 254.13; 1 study, 80 participants).  There was low- to moderate-certainty evidence for the other comparisons: splinting may not provide additional benefits in symptoms or hand function when given together with corticosteroid injection (moderate-certainty evidence) or with rehabilitation (low-certainty evidence); nor when compared with corticosteroid (injection or oral; low certainty), exercises (low certainty), kinesiology taping (low certainty), rigid taping (low certainty), platelet-rich plasma (moderate certainty), or extracorporeal shock wave treatment (moderate certainty). Splinting for 12 weeks may not be better than six weeks, but six months of splinting may be better than six weeks of splinting in improving symptoms and function (low-certainty evidence). AUTHORS' CONCLUSIONS: There is insufficient evidence to conclude whether splinting benefits people with CTS. Limited evidence does not exclude small improvements in CTS symptoms and hand function, but they may not be clinically important, and the clinical relevance of small differences with splinting is unclear. Low-certainty evidence suggests that people may have a greater chance of experiencing overall improvement with night-time splints than no treatment. As splinting is a relatively inexpensive intervention with no plausible long-term harms, small effects could justify its use, particularly when patients are not interested in having surgery or injections. It is unclear if a splint is optimally worn full time or at night-time only and whether long-term use is better than short-term use, but low-certainty evidence suggests that the benefits may manifest in the long term.

Horner Syndrome With Ipsilateral Wing Paresis in a Wild, Juvenile Yellow-Tailed Black Cockatoo (Calyptorhynchus funereus).

A juvenile yellow-tailed black cockatoo (Calyptorhynchus funereus) was presented with paresis of the right wing, ptosis, and miosis of the right eye; feather erection of the right side of the head and neck; and a penetrating injury over the right pectoral muscle. Temporary reversal of ptosis, miosis, and feather erection after administration of phenylephrine drops confirmed a diagnosis of Horner syndrome. Computed tomographic imaging revealed a fractured rib, traumatic lung lesions, and subcutaneous emphysema. The right-sided Horner syndrome and wing paresis were attributed to a sympathetic nerve trauma of the eye and feathers and to the brachial plexus, respectively. This report describes the diagnosis and resolution of ptosis and miosis within 8 weeks and recovery of feather symmetry and wing function within 11 weeks of the cockatoo's initial presentation with a conservative-management treatment plan.

The cerebral basal arterial network: morphometry of inflow and outflow components.

The aim of this project was to study how the morphology of the incoming and outgoing arterial components of the cerebral basal arterial network influence the blood flow to the brain. The cerebral basal arterial network consists of the circulus arteriosus cerebri anteriorly and the basilar artery posteriorly. Diameters of inflow vessels (bilateral vertebral and internal carotid arteries), connecting vessels (anterior communicating, basilar and bilateral posterior communicating arteries) and outflow vessels (anterior, middle and posterior cerebral arteries) were measured and cross-sectional areas calculated in 51 cadaveric brain specimens. The individual and the average cross-sectional areas of inflow arteries (51.43 mm2 ) were significantly bigger than the major outflow arteries (37.76 mm2 ) but smaller than the combined cross-sectional areas of outflow (37.76 mm2 ) and connecting (25.33 mm2 ) arteries. The difference in the size of arterial cross-sectional area and the presence of the connecting arteries in the cerebral basal arterial network provides a mechanism for lowering peaks in pressure, and demonstrates a function of the cerebral basal arterial network.

Variability in the distance between the suprascapular notch with the spine of the scapulae and the acromion.

INTRODUCTION: The suprascapular notch lies in the superior border of the scapula and is a passageway for the suprascapular nerve that is sensory to the shoulder joint. Suprascapular nerve block involves injection of local anaesthetic into the suprascapular notch, either ultrasound guided or blind, using the spine of scapula and/or the medial border of the acromion as surface landmarks. AIM: To investigate the anatomic variations that exist between the distance of the notch from the spine of scapula and acromion. METHOD: Ninety-two dry scapulae were measured with a digital calliper for their length of the spine, distance between the midpoint of the spine and base of the suprascapular notch and distance between the medial border of the acromion and the base of the suprascapular notch. These measurements were compared for variations in the scapular bony landmarks, the spine and the acromion to determine the site for the injection. RESULTS: Measurement reliability was assessed by intraclass correlation, Cronbach's alpha being 0.99, 0.97 and 0.91 for length of spine, distance from spine and distance from acromion respectively. The distance from the acromion had less variation in measurement (3.73 ± 0.42 cm) but a flatter distribution when compared to distance from the spine of the scapula (3.32 ± 0.39 cm). CONCLUSION: Length of the spine of the scapula appeared not to influence either distance from the acromion or distance from the spine of scapula. There is potential for greater variability in placement of nerve blocks that use acromion as the bony reference. Key Points • Dry scapular measurement using electronic Vernier callipers is accurate (0.91-0.97). • There is potential for greater variability in placement of blind nerve blocks that use acromion as the bony reference to locate the suprascapular notch.

Exploring anthropometric and functional factors that influence working adult's handgrip strength in north Australia.

BACKGROUND: Handgrip strength (HGS) is a reliable assessment of hand function. Interpretation of HGS is commonly done using normative data. Normative HGS data HGS considers the influence of age and gender without adjustment for anthropometric measurements or functional factors known to influence HGS. OBJECTIVE: To determine the potential relationship of select anthropometric measurements (height, weight, hand length and width, forearm length and circumference) and functional factors (hand dominance, work and lifestyle category) to HGS. METHODS: This study included a sample of 119 males and 96 female workers from North Queensland. HGS and six anthropometric measurements were obtained using calibrated instruments and reliable measurement protocols. Age and gender along with three functional factors were documented by self-report. RESULTS: Right and left mean HGS was greater for individuals who performed heavy/very heavy work (58.1±10.1 kg and 54.1±10.9 kg respectively) compared to light (38.5±12.3 kg and 35.5±11.8 kg) or medium work (44.1±10.8 kg and 40.0±12.9 kg). Mean HGS was greater for individuals who performed heavy/very heavy activity (right 48.5±13.6 kg and left 44.5±13.7 kg) compared to light activity (right 36.3±11.2 kg and left 33.9±11.3 kg) within their lifestyle. HGS positively correlated with gender (p = 0.0001), work (p = 0.001) and anthropometric measurements of forearm circumference (p = 0.001), hand length (p = 0.006) and hand width (p = 0.052). CONCLUSIONS: Easy to measure anthropometric measurements of forearm circumference, hand length and width are the strongest predictors of HGS in addition to an individual's physical activity at work and in their lifestyle. Consideration of these factors could lead to improved evaluation of HGS scores.

A dose response analysis of exercise prescription variables for lateral abdominal muscle thickness and activation: A systematic review.

BACKGROUND: Various exercise programs are used to treat lateral abdominal muscle (LAM) impairments in people with low back pain. Factors comprising these programs include exercise type, session time, frequency, and program duration. However, specific clinical guidance about optimal exercise prescription is lacking. OBJECTIVES: To perform a dose-response analysis on exercise prescription variables for LAM thickness and activation as measured by ultrasound imaging. DESIGN: Systematic review METHOD: Databases were searched from their inception for studies examining the association between exercise interventions and LAM thickness/activation measured by ultrasound imaging in healthy individuals. Risk of bias was assessed using the Joanna Brigg's Institute critical appraisal tools. For each muscle, subgroup analyses were performed to determine the dose response of exercise prescription variables for LAM thickness and activation. Where there was insufficient data for subgroup analyses, data was narratively synthesised. RESULTS: Fourteen studies comprising 395 participants were included. Statistical and narrative synthesis revealed specific local abdominal exercises, programs from four weeks duration, three sessions per week and sessions of ≥30 min were associated with greatest improvements to LAM thickness. Only the variables exercise type, program duration and session frequency showed a significant between groups difference for the subgroup analysis. The main limitation was inability to perform subgroup analyses for all variables across all muscles measured at rest and during contraction, due to non-reporting of data. CONCLUSION: This review provides preliminary guidance to practitioners on how the LAM respond to different exercise dosages. Future research should trial these findings.

Therapeutic ultrasound for carpal tunnel syndrome.

BACKGROUND: Therapeutic ultrasound may be offered to people experiencing mild to moderate symptoms of carpal tunnel syndrome (CTS). The effectiveness and duration of benefit of this non-surgical intervention remain unclear. OBJECTIVES: To review the effects of therapeutic ultrasound compared with no treatment, placebo or another non-surgical intervention in people with CTS. SEARCH METHODS: On 27 November 2012, we searched the Cochrane Neuromuscular Disease Group Specialized Register, CENTRAL (2012, Issue 11 in The Cochrane Library), MEDLINE (January 1966 to November 2012), EMBASE (January 1980 to November 2012), CINAHL Plus (January 1937 to November 2012), and AMED (January 1985 to November 2012). SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing any regimen of therapeutic ultrasound with no treatment, a placebo or another non-surgical intervention in people with CTS. DATA COLLECTION AND ANALYSIS: Two review authors independently selected trials for inclusion, extracted data and assessed the risk of bias in the included studies. We calculated risk ratio (RR) and mean difference (MD) with 95% confidence intervals (CIs) for primary and secondary outcomes. We pooled results of clinically homogenous trials in a meta-analysis using a random-effects model, where possible, to provide estimates of the effect. MAIN RESULTS: We included 11 studies including 414 participants in the review. Two trials compared therapeutic ultrasound with placebo, two compared one ultrasound regimen with another, two compared ultrasound with another non-surgical intervention, and six compared ultrasound as part of a multi-component intervention with another non-surgical intervention (for example, exercises and splint). The risk of bias was low in some studies and unclear or high in other studies, with only two reporting that the allocation sequence was concealed and six reporting that participants were blinded. Overall, there is insufficient evidence that one therapeutic ultrasound regimen is more efficacious than another. Only two studies reported the primary outcome of interest, short-term overall improvement (any measure in which patients indicate the intensity of their complaints compared with baseline, for example, global rating of improvement, satisfaction with treatment, within three months post-treatment). One low quality trial with 68 participants found that when compared with placebo, therapeutic ultrasound may increase the chance of experiencing short-term overall improvement at the end of seven weeks treatment (RR 2.36; 95% CI 1.40 to 3.98), although losses to follow-up and failure to adjust for the correlation between wrists in participants with bilateral CTS in this study suggest that this data should be interpreted with caution. Another low quality trial with 60 participants found that at three months post-treatment therapeutic ultrasound plus splint increased the chance of short-term overall improvement (patient satisfaction) when compared with splint alone (RR 3.02; 95% CI 1.36 to 6.72), but decreased the chance of short-term overall improvement when compared with low-level laser therapy plus splint (RR 0.87; 95% CI 0.57 to 1.33), though participants were not blinded to treatment, it was unclear if the random allocation sequence was adequately concealed, and there was a potential unit of analysis error. Differences between groups receiving different frequencies and intensities of ultrasound, and between ultrasound as part of a multi-component intervention versus other non-surgical interventions, were generally small and not statistically significant for symptoms, function, and neurophysiologic parameters. No studies reported any adverse effects of therapeutic ultrasound, but this outcome was only measured in three studies. More adverse effects data are required before any firm conclusions on the safety of therapeutic ultrasound can be made. AUTHORS' CONCLUSIONS: There is only poor quality evidence from very limited data to suggest that therapeutic ultrasound may be more effective than placebo for either short- or long-term symptom improvement in people with CTS. There is insufficient evidence to support the greater benefit of one type of therapeutic ultrasound regimen over another or to support the use of therapeutic ultrasound as a treatment with greater efficacy compared to other non-surgical interventions for CTS, such as splinting, exercises, and oral drugs. More methodologically rigorous studies are needed to determine the effectiveness and safety of therapeutic ultrasound for CTS.

Normative Values for Pinch Strength-Relationship With Joint Hypermobility as Measured With the Beighton Criteria.

Purpose: This study aimed to determine normative ranges of static pinch strength as measured with a spring gauge in adults of working age and investigate whether pinch strength is associated with hand hypermobility. A secondary aim was to explore whether the Beighton criteria for hypermobility are associated with hypermobility in joints of the hand during forceful pinching. Methods: A convenience sample of healthy men and women aged 18-65 years were recruited for measurement of lateral pinch, 2-point pinch, 3-point pinch, and joint hypermobility according to the Beighton criteria. Regression analysis was used to determine the effect of age, sex, and hypermobility on pinch strength. Results: Two hundred and fifty men and 270 women participated in this study. Men were stronger than women at all ages. Lateral and 3-point pinch were greatest for all participants and 2-point pinch was the least strong. There were no statistically significant differences between age groups, but a trend for the lowest pinch strength to occur before the mid-thirties was seen in both sexes. Thirty-eight percent of women and 19% of men were hypermobile; however, these participants statistically insignificant differ in pinch strength compared with other participants. The Beighton criteria corresponded strongly with hypermobility in other joints of the hand as observed and photographed during pinch. Hand dominance did not show clear relationships with pinch strength. Conclusions: Normative lateral, 2-point, and 3-point pinch strength data for adults of working age are presented with men having greatest pinch strength at all ages. The Beighton criteria for hypermobility are associated with hypermobility in other joints of the hand. Clinical Relevance: Benign joint hypermobility is not related to pinch strength. Men have greater pinch strength at all ages than women.

Therapeutic ultrasound for carpal tunnel syndrome.

BACKGROUND: Therapeutic ultrasound may be offered to people experiencing mild to moderate symptoms of carpal tunnel syndrome (CTS). The effectiveness and duration of benefit of this non-surgical intervention remain unclear. OBJECTIVES: To review the effects of therapeutic ultrasound compared with no treatment, placebo or another non-surgical intervention in people with CTS. SEARCH METHODS: We searched the Cochrane Neuromuscular Disease Group Specialized Register (22 February 2011), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2011, Issue 1), MEDLINE (January 1966 to February 2011), EMBASE (January 1980 to February 2011), CINAHL Plus (January 1937 to February 2011), and AMED (January 1985 to February 2011). SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing any regimen of therapeutic ultrasound with no treatment, a placebo or another non-surgical intervention in people with CTS. DATA COLLECTION AND ANALYSIS: Two review authors independently selected trials for inclusion, extracted data and assessed the risk of bias in the included studies. We calculated risk ratio (RR) and mean difference (MD) with 95% confidence intervals (CIs) for primary and secondary outcomes. We pooled results of clinically homogenous trials in a meta-analysis using a random-effects model, where possible, to provide estimates of the effect. MAIN RESULTS: We included 11 studies randomising 443 patients in the review. Two trials compared therapeutic ultrasound with placebo, two compared one ultrasound regimen with another, two compared ultrasound with another non-surgical intervention, and six compared ultrasound as part of a multi-component intervention with another non-surgical intervention (for example, exercises and splint). The risk of bias was low in some studies and unclear or high in other studies, with only three reporting that the allocation sequence was concealed and six reporting that participants were blinded. Overall, there is insufficient evidence that one therapeutic ultrasound regimen is more efficacious than another. Only two studies reported the primary outcome of interest, short-term overall improvement (any measure in which patients indicate the intensity of their complaints compared with baseline, for example, global rating of improvement, satisfaction with treatment, within three months post-treatment). One low quality trial with 68 participants found that when compared with placebo, therapeutic ultrasound may increase the chance of experiencing short-term overall improvement at the end of seven weeks treatment (RR 2.36; 95% CI 1.40 to 3.98), although losses to follow-up in this study suggest that these data should be interpreted with caution. Another low quality trial with 60 participants found that at three months, post-treatment therapeutic ultrasound plus splint increased the chance of short-term overall improvement (patient satisfaction) when compared with splint alone (RR 3.02; 95% CI 1.36 to 6.72), but decreased the chance of short-term overall improvement when compared with low-level laser therapy plus splint (RR 0.87; 95% CI 0.57 to 1.33), though participants were not blinded to treatment and it was unclear if the random allocation sequence was adequately concealed. Differences between groups receiving different frequencies and intensities of ultrasound, and between ultrasound as part of a multi-component intervention versus other non-surgical interventions, were generally small and not statistically significant for symptoms, function, and neurophysiologic parameters. Only four studies measured adverse effects, none of which identified adverse effects due to therapeutic ultrasound. However, more data on this outcome are required before any firm conclusions on the safety of this intervention can be made. AUTHORS' CONCLUSIONS: There is only poor quality evidence from very limited data to suggest that therapeutic ultrasound may be more effective than placebo for either short- or long-term symptom improvement in people with CTS. There is insufficient evidence to support the greater benefit of one type of therapeutic ultrasound regimen over another or to support the use of therapeutic ultrasound as a treatment with greater efficacy compared to other non-surgical interventions for CTS, such as splinting, exercises, and oral drugs. More methodologically rigorous studies are needed to determine the effectiveness and safety of this intervention for CTS.

Exercise and mobilisation interventions for carpal tunnel syndrome.

BACKGROUND: Non-surgical treatment, including exercises and mobilisation, has been offered to people experiencing mild to moderate symptoms arising from carpal tunnel syndrome (CTS). However, the effectiveness and duration of benefit from exercises and mobilisation for this condition remain unknown. OBJECTIVES: To review the efficacy and safety of exercise and mobilisation interventions compared with no treatment, a placebo or another non-surgical intervention in people with CTS. SEARCH METHODS: We searched the Cochrane Neuromuscular Disease Group Specialised Register (10 January 2012), CENTRAL (2011, Issue 4), MEDLINE (January 1966 to December 2011), EMBASE (January 1980 to January 2012), CINAHL Plus (January 1937 to January 2012), and AMED (January 1985 to January 2012). SELECTION CRITERIA: Randomised or quasi-randomised controlled trials comparing exercise or mobilisation interventions with no treatment, placebo or another non-surgical intervention in people with CTS. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed searches and selected trials for inclusion, extracted data and assessed risk of bias of the included studies. We calculated risk ratios (RR) and mean differences (MD) with 95% confidence intervals (CIs) for primary and secondary outcomes of the review. We collected data on adverse events from included studies. MAIN RESULTS: Sixteen studies randomising 741 participants with CTS were included in the review. Two compared a mobilisation regimen to a no treatment control, three compared one mobilisation intervention (for example carpal bone mobilisation) to another (for example soft tissue mobilisation), nine compared nerve mobilisation delivered as part of a multi-component intervention to another non-surgical intervention (for example splint or therapeutic ultrasound), and three compared a mobilisation intervention other than nerve mobilisation (for example yoga or chiropractic treatment) to another non-surgical intervention. The risk of bias of the included studies was low in some studies and unclear or high in other studies, with only three explicitly reporting that the allocation sequence was concealed, and four reporting blinding of participants. The studies were heterogeneous in terms of the interventions delivered, outcomes measured and timing of outcome assessment, therefore, we were unable to pool results across studies. Only four studies reported the primary outcome of interest, short-term overall improvement (any measure in which patients indicate the intensity of their complaints compared to baseline, for example, global rating of improvement, satisfaction with treatment, within three months post-treatment). However, of these, only three fully reported outcome data sufficient for inclusion in the review. One very low quality trial with 14 participants found that all participants receiving either neurodynamic mobilisation or carpal bone mobilisation and none in the no treatment group reported overall improvement (RR 15.00, 95% CI 1.02 to 220.92), though the precision of this effect estimate is very low. One low quality trial with 22 participants found that the chance of being 'satisfied' or 'very satisfied' with treatment was 24% higher for participants receiving instrument-assisted soft tissue mobilisation compared to standard soft tissue mobilisation (RR 1.24, 95% CI 0.89 to 1.75), though participants were not blinded and it was unclear if the allocation sequence was concealed. Another very low-quality trial with 26 participants found that more CTS-affected wrists receiving nerve gliding exercises plus splint plus activity modification had no pathologic finding on median and ulnar nerve distal sensory latency assessment at the end of treatment than wrists receiving splint plus activity modification alone (RR 1.26, 95% CI 0.69 to 2.30). However, a unit of analysis error occurred in this trial, as the correlation between wrists in participants with bilateral CTS was not accounted for. Only two studies measured adverse effects, so more data are required before any firm conclusions on the safety of exercise and mobilisation interventions can be made. In general, the results of secondary outcomes of the review (short- and long-term improvement in CTS symptoms, functional ability, health-related quality of life, neurophysiologic parameters, and the need for surgery) for most comparisons had 95% CIs which incorporated effects in either direction. AUTHORS' CONCLUSIONS: There is limited and very low quality evidence of benefit for all of a diverse collection of exercise and mobilisation interventions for CTS. People with CTS who indicate a preference for exercise or mobilisation interventions should be informed of the limited evidence of effectiveness and safety of this intervention by their treatment provider. Until more high quality randomised controlled trials assessing the effectiveness and safety of various exercise and mobilisation interventions compared to other non-surgical interventions are undertaken, the decision to provide this type of non-surgical intervention to people with CTS should be based on the clinician's expertise in being able to deliver these treatments and patient's preferences.

Splinting for carpal tunnel syndrome.

BACKGROUND: Carpal tunnel syndrome (CTS) is a condition where one of two main nerves in the wrist is compressed, which can lead to pain in the hand, wrist and sometimes arm, and numbness and tingling in the thumb, index and long finger. Splinting is usually offered to people with mild to moderate symptoms. However, the effectiveness and duration of the benefit of splinting for this condition remain unknown. OBJECTIVES: To compare the effectiveness of splinting for carpal tunnel syndrome with no treatment, placebo or another non-surgical intervention. SEARCH METHODS: We searched the Cochrane Neuromuscular Disease Group Specialized Register (10 January 2011), CENTRAL, NHSEED and DARE (The Cochrane Library 2011, Issue 4), MEDLINE (January 1966 to December 2011), EMBASE (January 1980 to January 2012), AMED (January 1985 to January 2012), and CINAHL Plus (January 1937 to January 2012), using no time limits. We searched the reference lists of all included trials and relevant reviews for further relevant studies. SELECTION CRITERIA: All randomised and quasi-randomised trials comparing splinting with no treatment (or a placebo) or with other non-surgical treatments were eligible for inclusion. We also included studies comparing one splint type or regimen versus another. We excluded studies comparing splinting with surgical treatment. There were no language restrictions. We included all patients diagnosed with carpal tunnel syndrome unless they had undergone surgical release. DATA COLLECTION AND ANALYSIS: Two review authors independently selected trials for inclusion, and performed data extraction. Two authors also independently performed the assessment of risk of bias. We calculated measures of effect as risk ratios (RR) for dichotomous outcomes and mean differences (MD) for continuous outcomes, with 95% confidence intervals (CI) reported and statistical significance set at P < 0.05 for all outcome comparisons. MAIN RESULTS: The review included 19 studies randomising 1190 participants with carpal tunnel syndrome. Two studies compared splinting with no treatment, five compared different splint designs, one compared different splint-wearing regimens, seven compared splint delivered as a single intervention with another non-surgical intervention, and five compared splint delivered alongside other non-surgical interventions with another non-surgical intervention. Only three studies reported concealing the allocation sequence, and only one reported blinding of participants. Three studies measured the primary outcome, short-term overall improvement at three months or less. One low quality study with 80 wrists found that compared to no treatment, splints worn at night more than tripled the likelihood of reporting overall improvement at the end of four weeks of treatment (RR 3.86, 95% CI 2.29 to 6.51). However, the lack of patient blinding and unclear allocation concealment suggests this result should be interpreted with caution. A very low quality quasi-randomised trial with 90 wrists found that wearing a neutral splint more than doubled the likelihood of reporting 'a lot or complete relief' at the end of two weeks of treatment compared with an extension splint (RR 2.43, 95% CI 1.12 to 5.28). The third study which measured short-term overall improvement did not report outcome data separately per group. Nine studies measured adverse effects of splinting and all found either no or few participants reporting discomfort or swelling due to splinting; however, the precision of all RRs was very low. Differences between groups in the secondary outcomes - symptoms, function, and neurophysiologic parameters - were most commonly small with 95% CIs incorporating effects in either direction. AUTHORS' CONCLUSIONS: Overall, there is limited evidence that a splint worn at night is more effective than no treatment in the short term, but there is insufficient evidence regarding the effectiveness and safety of one splint design or wearing regimen over others, and of splint over other non-surgical interventions for CTS. More research is needed on the long-term effects of this intervention for CTS.

Ergonomic positioning or equipment for treating carpal tunnel syndrome.

BACKGROUND: Non-surgical treatment, including ergonomic positioning or equipment, are sometimes offered to people experiencing mild to moderate symptoms from carpal tunnel syndrome (CTS). The effectiveness and duration of benefit from ergonomic positioning or equipment interventions for treating CTS are unknown. OBJECTIVES: To assess the effects of ergonomic positioning or equipment compared with no treatment, a placebo or another non-surgical intervention in people with CTS. SEARCH METHODS: We searched the Cochrane Neuromuscular Disease Group Specialized Register (14 June 2011), the Cochrane Central Register of Controlled Trials (CENTRAL) (2011, Issue 2, in The Cochrane Library), MEDLINE (1966 to June 2011), EMBASE (1980 to June 2011), CINAHL Plus (1937 to June 2011), and AMED (1985 to June 2011). We also reviewed the reference lists of randomised or quasi-randomised trials identified from the electronic search. SELECTION CRITERIA: Randomised or quasi-randomised controlled trials comparing ergonomic positioning or equipment with no treatment, placebo or another non-surgical intervention in people with CTS. DATA COLLECTION AND ANALYSIS: Two review authors independently selected trials for inclusion, extracted data and assessed risk of bias of included studies. We calculated risk ratios (RR) and mean differences (MD) with 95% confidence intervals (CI) for the primary and secondary outcomes. We pooled results of clinically and statistically homogeneous trials, where possible, to provide estimates of the effect of ergonomic positioning or equipment. MAIN RESULTS: We included two trials (105 participants) comparing ergonomic versus placebo keyboards. Neither trial assessed the primary outcome (short-term overall improvement) or adverse effects of interventions. In one small trial (25 participants) an ergonomic keyboard significantly reduced pain after 12 weeks (MD -2.40; 95% CI -4.45 to -0.35) but not six weeks (MD -0.20; 95% CI -1.51 to 1.11). In this same study, there was no difference between ergonomic and standard keyboards in hand function at six or 12 weeks or palm-wrist sensory latency at 12 weeks. The second trial (80 participants) reported no significant difference in pain severity after six months when using either of the three ergonomic keyboards versus a standard keyboard. No trials comparing (i) ergonomic positioning or equipment with no treatment, (ii) ergonomic positioning or equipment with another non-surgical treatment, or (iii) different ergonomic positioning or equipment regimes, were found. AUTHORS' CONCLUSIONS: There is insufficient evidence from randomised controlled trials to determine whether ergonomic positioning or equipment is beneficial or harmful for treating carpal tunnel syndrome.

Reliability and validity of indices of hand-grip strength and endurance.

BACKGROUND/AIM: Grip strength is useful in clinical practice for the assessment of disease and/or rehabilitation progression. Brief maximal gripping is seldom required in everyday occupations, with repeated or sustained gripping at sub-maximal power more commonly involved. It has been proposed that assessment of both maximal hand-grip force and endurance is utilised. While the suitability of maximal contraction measures has been clearly established, the reliability and validity of other hand-grip indices have not been investigated. This study examined the reliability of various hand-grip indices and their validity in relation to distance walked during the six-minute walk test, a standardised exercise capacity test. METHODS: Subjects undertook static sub-maximal (50%) and maximal force contraction hand-grip testing from which various indices were derived, and six-minute walk testing from which distance walked was determined. Testing was repeated on three separate occasions for determination of test-retest reliability. RESULTS: Pre- and post-fatigue maximal contraction measurements demonstrated excellent test-retest reliability and validity. Conversely, other hand-grip indices were shown to be unreliable and exhibited no relationship with distance walked and hence concurrent validity could not be established. CONCLUSIONS: Based on the results of this study, it is recommended that pre- and post-fatigue maximal contraction may be utilised for the assessment of client ability and progression due to their established validity and test-retest reliability. However, previously proposed measures of fatigue such as endurance (duration of sustained contraction), Strength Decrement Index and work performed (function of endurance and force of contraction) are unreliable and invalid and may have limited use in clinical practice.

Adding to the Allied Health Student Experience: Motivators, Deterrents, and How to Get More from Peer Teaching.

Volunteering as a peer tutor offers teaching experience to allied health students who will one day teach patients and colleagues. It also provides an opportunity for students to extend themselves personally and academically. Medical and nursing literature supports peer teaching, yet fewer publications describe the experience of allied health students. This study investigated the effects of cross-level peer tutoring in anatomy, for the peer tutors and their students. Peer tutors revealed their primary concern as lacking anatomical knowledge; however, students valued the currency of their student experience and the opportunity to discuss learning processes with a peer. Recommendations from peer tutors and students included: recognition of the value of interactions between students and peer tutors; value of teaching how to learn, rather than content; and for academics to introduce peer tutors as peers, which clarifies the students' expectations of the peer tutor.

The reliability of rehabilitative ultrasound to measure lateral abdominal muscle thickness: A systematic review and meta-analysis.

BACKGROUND: Variations in rehabilitative ultrasound imaging (RUSI) protocols may alter lateral abdominal muscle (LAM) thickness measurements. A standardised protocol is required for clinicians to accurately compare LAM thickness changes. OBJECTIVE: In healthy and lower back pain (LBP) populations, to assess the 1) overall reliability of RUSI to diagnose LAM thickness via meta-analysis, 2) reliability of ultrasound variables to diagnose LAM thickness via systematic review, and 3) propose a RUSI protocol for the LAM using variables associated with excellent reliability (intraclass correlation coefficient [ICC] >0.9). DESIGN: Systematic review and meta-analysis. METHOD: Databases were searched from January 2000 for studies reporting the reliability of RUSI on the LAM at rest. Title, abstract and full-text screening were performed. Reference lists of reviews and included full-text articles were scanned for further articles. Study characteristic, ultrasound procedure and reliability data were extracted, and article quality assessed. Data was synthesised using meta-analysis to determine the overall reliability for RUSI in different subgroups; calculation of the mean ICCs and standard error of measurements of protocol variables; and narrative synthesis of protocols to contrast those of differing reliability. RESULTS: Twenty-seven articles, involving 884 participants were included. Reliability ranged from good-to-excellent (ICC 0.859-0.958) in all subgroups. Protocols ranged in subject selection and position, examiner experience, transducer position with the comprehensiveness of protocol description the main limitation of the reviewed literature. Based on the findings an ultrasound protocol was proposed. CONCLUSIONS: RUSI variables for the LAM at rest show moderate-to-excellent reliability; future research should explore reliability following the proposed protocol.

Intact tactile anisotropy despite altered hand perception in complex regional pain syndrome: rethinking the role of the primary sensory cortex in tactile and perceptual dysfunction.

Complex Regional Pain Syndrome (CRPS) is characterised by pain, autonomic, sensory and motor abnormalities. It is associated with changes in the primary somatosensory cortex (S1 representation), reductions in tactile sensitivity (tested by two-point discrimination), and alterations in perceived hand size or shape (hand perception). The frequent co-occurrence of these three phenomena has led to the assumption that S1 changes underlie tactile sensitivity and perceptual disturbances. However, studies underpinning such a presumed relationship use tactile sensitivity paradigms that involve the processing of both non-spatial and spatial cues. Here, we used a task that evaluates anisotropy (i.e., orientation-dependency; a feature of peripheral and S1 representation) to interrogate spatial processing of tactile input in CRPS and its relation to hand perception. People with upper limb CRPS (n = 14) and controls with (n = 15) or without pain (n = 19) judged tactile distances between stimuli-pairs applied across and along the back of either hand to provide measures of tactile anisotropy. Hand perception was evaluated using a visual scaling task and questionnaires. Data were analysed with generalised estimating equations. Contrary to our hypotheses, tactile anisotropy was bilaterally preserved in CRPS, and the magnitude of anisotropic perception bias was comparable between groups. Hand perception was distorted in CRPS but not related to the magnitude of anisotropy or bias. Our results suggest against impairments in spatial processing of tactile input, and by implication S1 representation, as the cause of distorted hand perception in CRPS. Further work is warranted to elucidate the mechanisms of somatosensory dysfunction and distorted hand perception in CRPS.

Average grip strength: a meta-analysis of data obtained with a Jamar dynamometer from individuals 75 years or more of age.

BACKGROUND AND PURPOSE: Although strength diminishes with age, average values for grip strength have not been available heretofore for discrete strata after 75 years. The purpose of this meta-analysis was to provide average values for the left and right hands of men and women 75-79, 80-84, 85-89, and 90-99 years. METHODS: Contributing to the analysis were 7 studies and 739 subjects with whom the Jamar dynamometer and standard procedures were employed. RESULTS: Based on the analysis, average values for the left and right hands of men and women in each age stratum were derived. CONCLUSIONS: The derived values can serve as a standard of comparison for individual patients. An individual whose grip strength is below the lower limit of the confidence intervals of each stratum can be confidently considered to have less than average grip strength.

A new versatile hand dynamometer.

This paper describes the design and testing of a new hand strain-gauge based dynamometer. The design is portable and capable of measuring grip strengths from 12.5 to 800N. The dynamometer is independent of point of application of the grip force. Finite element modelling and experimental testing were used to verify the mechanical system's suitability. The dynamometer was designed for input to a PDA to allow full portability of the device.

A systematic review of the content of critical appraisal tools.

BACKGROUND: Consumers of research (researchers, administrators, educators and clinicians) frequently use standard critical appraisal tools to evaluate the quality of published research reports. However, there is no consensus regarding the most appropriate critical appraisal tool for allied health research. We summarized the content, intent, construction and psychometric properties of published, currently available critical appraisal tools to identify common elements and their relevance to allied health research. METHODS: A systematic review was undertaken of 121 published critical appraisal tools sourced from 108 papers located on electronic databases and the Internet. The tools were classified according to the study design for which they were intended. Their items were then classified into one of 12 criteria based on their intent. Commonly occurring items were identified. The empirical basis for construction of the tool, the method by which overall quality of the study was established, the psychometric properties of the critical appraisal tools and whether guidelines were provided for their use were also recorded. RESULTS: Eighty-seven percent of critical appraisal tools were specific to a research design, with most tools having been developed for experimental studies. There was considerable variability in items contained in the critical appraisal tools. Twelve percent of available tools were developed using specified empirical research. Forty-nine percent of the critical appraisal tools summarized the quality appraisal into a numeric summary score. Few critical appraisal tools had documented evidence of validity of their items, or reliability of use. Guidelines regarding administration of the tools were provided in 43% of cases. CONCLUSIONS: There was considerable variability in intent, components, construction and psychometric properties of published critical appraisal tools for research reports. There is no "gold standard' critical appraisal tool for any study design, nor is there any widely accepted generic tool that can be applied equally well across study types. No tool was specific to allied health research requirements. Thus interpretation of critical appraisal of research reports currently needs to be considered in light of the properties and intent of the critical appraisal tool chosen for the task.

Therapy gloves for patients with rheumatoid arthritis: a review.

Rheumatoid arthritis is a chronic inflammatory disease that causes pain, joint stiffness and swelling leading to impaired hand function and difficulty with daily activities. Wearing therapy gloves has been recommended by occupational therapists as one of the alternative treatment methods for rheumatoid arthritis. This study aims to review the available literature on the effects of wearing therapy gloves on patients' hand function and symptoms as well as to discuss the attributes of gloves that might influence the glove performance. An electronic databases search of MEDLINE, Physiotherapy Evidence Database, Occupational Therapy Systematic Evaluation of Evidence, Wiley Online Library, ScienceDirect and Cochrane Central Register of Controlled Trial was performed. Eight articles met the inclusion criteria, and covered seven clinical trials and one case study. Seven outcome measures were identified from the included studies and were then classified into two categories: hand function and hand symptoms. The hand symptoms such as pain, stiffness and swelling improve substantially when the therapy gloves are used. However, marginal or no improvement in hand function (with the exception of grip strength) linked to the use of therapy gloves is being reported. Further research is needed to quantify the effectiveness of therapy gloves, especially in improvement of hand function and in patients' interest in wearing therapy gloves. Furthermore, future studies should include parameters which might influence therapy gloves' performance, such as duration of trials, interface pressure generated by the gloves on the underlying skin and tissue, glove fit and construction, as well as thermophysiological comfort.