Development and Validation of a Survey to Measure Patients' Expectations of Wrist Arthritis Surgery.

Background The purpose of this study was to develop and test a patient-derived expectations survey for wrist arthritis surgery. We hypothesized that preoperative patient expectations are higher in people with greater functional impairment and that postoperative fulfilment of patient expectations correlates with functional improvement. Methods The study was conducted in four phases. Development (n = 22) Preoperatively, patients were asked open-ended questions regarding expectations of surgery. A draft survey was then assembled. Reliability (n = 35) The survey was administered twice preoperatively. Concordance was measured with weighted kappa values and intraclass correlations (ICC). Validity (n = 58) Validity was assessed by comparing responses from the Expectations Survey to the patient-rated wrist evaluation (PRWE). Responsiveness (n = 18) Responsiveness was calculated by comparing the proportion of expectations fulfilled to PRWE scores 1-year postoperatively. Results Development Twenty-two distinct items representing the most frequent responses were utilized from the draft survey items of 1,244 expectations volunteered. Reliability Patients had high preoperative expectations of surgery (mean = 76.8); 30% had scores ≥90. Test-retest reliability was high (Cronbach α coefficients = 0.91, 0.93, ICC = 0.86). Endorsement of items = 66 to 100%; and weighted kappa values = 0.39 to 0.96. Validity Patients with greater preoperative expectations (≥63) had more pain, worse function, and worse PRWE scores than those with lower expectations. Responsiveness The proportion of fulfilled expectations was high (mean 0.80, median 0.79), and greater fulfillment (proportion > 0.80, n = 8) was associated with better postoperative PRWE scores. Conclusion The patient-derived expectations survey is reliable, valid, responsive, and addresses a spectrum of expectations for patients undergoing surgery for wrist arthritis. Clinical relevance Understanding patient expectations can contribute to customized care given the range of surgical choices for the arthritic wrist.

Utilization of shear wave elastography to quantify and predict response to upper extremity botulinum toxin injections in patients with cerebral palsy: A pilot study.

OBJECTIVE: Shear wave elastography (SWE) was used to quantify change in upper extremity muscle stiffness in patients with unilateral spastic cerebral palsy (USCP) following botulinum toxin A (BTX-A) therapy. We hypothesized that SWE measures would decrease following ultrasound-guided BTX-A injection, and correlate with functional improvement. METHODS: SWE measures of BTX-A treated muscles were recorded immediately pre-injection, and at 1-, 3- and 6-months post-injection. At the same timepoints, functional assessment was performed using the Modified Ashworth Scale (MAS), and passive and active range of motion (PROM and AROM) measures. Correlation of SWE with MAS, PROM and AROM, as well as the relationship between change in SWE and change in MAS, PROM and AROM was determined using Spearman's rank correlation coefficient and generalized estimating equation modeling. RESULTS: 16 muscles were injected and longitudinally assessed. SWE and MAS scores decreased following BTX-A injection (p = 0.030 and 0.004, respectively), reflecting decreased quantitative and qualitative muscle stiffness. Decreased SWE reached statistical significance at 1- and 3-months, and 1-, 3- and 6-months for MAS. When comparing relative change in SWE to relative change in AROM, larger change in SWE strongly correlated with positive change in AROM (p-value range:<0.001-0.057). BTX-A responders also demonstrated lower baseline SWE (1.4 m/s) vs. non-responders (1.9 m/s), p = 0.035. CONCLUSION: Ultrasound-guided BTX-A injections in patients with USCP resulted in decreased quantitative and qualitative muscle stiffness. Strong correlation between change in SWE and AROM, as well as the significant difference in baseline SWE for BTX-A responders and non-responders, suggests SWE may provide a useful tool to predict and monitor BTX-A response.

Dynamic assessment of the upper extremity: a review of available and emerging technologies.

The purpose of this review article is to provide an update on the realm of emerging technology available for the assessment of dynamic functional movement of the hand and upper limb. A critical overview of the literature and a conceptual framework for use of such technologies is proposed. The framework explores three broad purpose categories including customization of care, functional surveillance and interventions through biofeedback strategies. State-of-the-art technologies are described, from basic activity monitors to feedback-enabled robotic gloves, along with exemplar trials and clinical applications. The future of technologies innovation in hand pathology is proposed in the context of the current obstacles and opportunities for hand surgeons and therapists.

Reliability and agreement between two wearable inertial sensor devices for measurement of arm activity during walking and running gait.

STUDY DESIGN: This is a validation study. BACKGROUND: Tracking limb movement with body worn sensors allows clinicians to measure limb dynamics to guide treatment for patients with movement disorders. The current gold standard, 3-dimensional optical motion capture, is costly, time-consuming, requires specific training, and is conducted in specialized laboratories. PURPOSE: The purpose of our study was to a compare consumer-grade inertial sensor to a laboratory-grade sensor to provide additional methods for capturing limb dynamics. METHODS: The participants wore an Apple Watch and a laboratory-grade Xsens sensor on each wrist during 3 conditions: walk, fast-walk, and run. Acceleration data were collected simultaneously on each device per wrist for all conditions. Intraclass correlation coefficients and Bland-Altman plots were calculated to measure intra-/interdevice reliability, evaluate bias, and limits of agreement. RESULTS: Intradevice ICCs showed good reliability during walk and fast-walk (0.79-0.87) and excellent reliability during run (0.94-0.97) conditions. Inter-device ICCs yielded moderate reliability during walk (0.52 ± 0.22) and excellent reliability in fast-walk and run (0.93 ± 0.02, 1.00 ± 0.01) conditions. Bland-Altman plots showed small biases with 90% or more of the data contained within the limits of agreement. DISCUSSION: Our study demonstrates reliability and agreement between the two devices, suggesting that both can reliably capture upper extremity motion data during gait trials. CONCLUSION: Our findings support further study of consumer-grade motion trackers to measure arm activity for clinical use. These devices are inexpensive, user-friendly, and allow for data collection outside of the laboratory.

The role of hand therapy in facilitating participation in rock wall climbing: A case report of a woman with cerebral palsy.

STUDY DESIGN: This is a case report. BACKGROUND: A woman with hemiplegic cerebral palsy and limited right upper extremity motion, strength, and control was referred to hand therapy to enable participation in adaptive climbing. PURPOSE: The purpose of this case is to describe the role of hand therapy in identifying and addressing barriers to participation in adaptive climbing. Description of the patient's wrist flexion/extension, grip strength, and functional use over the course of eleven months is also included. METHODS: Activity analysis, iterative problem solving, activity simulation, activity modification, and targeted therapeutic exercises were used over the course of eleven sessions. RESULTS: The patient conveyed successful participation in adaptive climbing with reported improvements in overall strength, motion, ability to shift weight, ability to manage digit spasticity, spontaneous right upper extremity use, and body awareness. Active right wrist flexion, wrist extension, and grip strength improved by 33 degrees, eight degrees, and 35 lbs, respectively. CONCLUSIONS: This case highlights an unconventional treatment scenario where outpatient hand therapy was entirely focused on targeting and facilitating the patient's participation in a specific activity-adaptive climbing. Rehabilitation professionals, uniquely suited to helping individuals explore interests, determine "good fit", identify barriers, and navigate obstacles, can advance the promotion of participation in activities that are both meaningful and physically engaging.

The forgotten radial nerve: A conceptual framework for treatment of lateral elbow pain.

BACKGROUND: Lateral elbow pain is a prevalent musculoskeletal overuse disorder that has serious consequences for musculoskeletal health, occupational performance, and overall healthcare burden. Available treatment options (traditional therapy and steroid injections) have been studied rigorously, yet supporting evidence is weak. The majority of treatment options available are targeted at the local pathology of the common extensor tendon as the apparent source of pain, and do not adequately address the cause, the source of overuse, and mechanism of injury. PURPOSE: The purpose of this paper is to describe a novel approach, a regional interdependence model, to reduce symptoms of upper extremity musculoskeletal overuse in populations at risk by addressing a broader systematic approach versus a localized symptom driven approach for the assessment and treatment of lateral elbow pain. METHODS: The proposed framework - Think in nerve length and layers (TINLL)- accounts for nerve tension and muscle balance in the entire extremity. In this paper we describe the application of the TINLL model for assessment and treatment of SRSN irritation in individuals with lateral elbow pain and propose a method for treatment and for further studies. The proposed treatment approach combines mobilization with movement, elastic taping, and isometric exercises to address impairment at each level: joint alignment, neural tension, and the superficial sensory nervous system. RESULTS: Our findings of reduced pain with a relatively small number of therapy sessions in a small retrospective cohort of patients using the TINLL framework for assessment and treatment supports further formal study of this approach in a larger cohort with longer follow-up to determine effectiveness compared to current treatments. CONCLUSION: Future studies will test and compare the efficacy of the TINLL framework and model of treatment on the short- and long-term outcomes in individuals with chronic lateral elbow pain compared to traditional therapy.

Leveraging implementation science to prevent and reduce musculoskeletal overuse injury in musicians: A proposal for the study of a conceptual framework.

BACKGROUND: Musician health and wellness, a fundamental requirement for safe, effective and optimal musical performance, is not guaranteed. Performance related musculoskeletal disorders (PRMD) affect between 60% and 90% of all musicians, and have serious consequences on musculoskeletal health, performance ability and the overall healthcare burden of musculoskeletal injury. The high prevalence of PRMD in musicians can be prevented and reduced via health-education programs designed to address risk factors and practice habits. Multiple studies demonstrate the efficacy of education and instructional exercises in reducing PRMD symptoms in musicians. Despite the awareness of risk and the substantial consequence of non-adherence, implementation of health-education programs is complex and challenging and is rarely offered in music institutions. For successful adoption of musculoskeletal health programs, it is important to identify system level barriers and facilitators and it is important to develop and pilot effective strategies to guide successful implementation of musculoskeletal health programs for musicians. PURPOSE: This paper proposes a conceptual framework using implementation science methodology to study the factors that influence adoption of musician health education programs to prevent performance related injury. The overall goal of this methodology is to identify determinants of implementation by engaging key stakeholders, developing strategies for adoption of injury prevention programs and generate hypotheses for future studies. METHODS: The research plan is designed to accomplish the specific aims of this study. Through a mixed-method study we will use qualitative and quantitative methods to address potential barriers, and design and test implementation feasibility of health-education programs for musicians. RESULTS/CONCLUSIONS: Our findings will inform the development of a large-scale participant randomized hybrid trial to assess effectiveness and implementation outcomes of health education programs and ultimately reduce injury and promote musculoskeletal longevity and performance in musicians.

Feasibility and impact of a musculoskeletal health for musicians (MHM) program for musician students: A randomized controlled pilot study.

BACKGROUND: There is a high incidence of performance-related musculoskeletal disorders in musicians that may be reduced via education programs. However, the efficacy of formalized injury prevention programs has not been rigorously studied. PURPOSE: To assess the feasibility and effect of a formalized injury prevention education workshop on incidence and severity of musculoskeletal pain in a cohort of musician-students attending an intensive summer music festival compared to controls. STUDY DESIGN: Randomized-controlled-pilot trial. METHODS: Musicians at an 8-week long intensive summer festival were randomized to an intervention (workshop) or control group. Workshop attendees participated in a 90-minute session of injury prevention strategies. Musculoskeletal outcome data were collected at the start and end of the festival. Outcomes included presence of musculoskeletal pain, adherence level, and sub-scales of the Musculoskeletal Pain Intensity and Interference Questionnaire for Musicians. RESULTS: A total of 57 musician-students (ages 17-30, 23 females) participated in the study, and 48(84%) completed the study. Seventy-five percent of workshop participants reported adherence over 8 weeks. At baseline, 84% of participants reported a history of playing-related pain, and 47% recent or current pain. Participants played a range of instruments (50% string, 34% piano, 16% woodwind/brass). At baseline, average weekly reported playing time was 39 hours (±11). At follow-up, reported pain decreased by 32% in the intervention group and increased by 8% in controls (P < .01). Pain interference scores were lower (Post - Pre = -4.58, 95% CI -9.26 to 0.11, P = .055). There was no statistically significant difference between groups for pain intensity. CONCLUSIONS: The high compliance and willingness to participate suggests that injury prevention education implementation is feasible. Our preliminary findings suggest a positive effect on pain incidence and pain interference in the intervention group. Future studies will examine the relationship between adherence levels and injury rates in a larger cohort and identify obstacles to implementation.

Self-identified functional limitations improve in patients with degenerative wrist arthritis after surgery.

STUDY DESIGN: This is a prospective cohort pilot study. BACKGROUND: Degenerative wrist arthritis leads to pain, loss of strength, mobility, function, and impairments in psychological well-being. Accurate assessment of functional limitations that are unique to the individual is essential for successful treatment that best meets those specific needs. PURPOSE OF THE STUDY: To identify and determine if self-identified functional limitations improve in patients who underwent surgery for degenerative wrist arthritis. METHODS: Patients with degenerative wrist arthritis who were scheduled for surgery were prospectively recruited (n = 14, mean age + SD = 42 + 16, 10 males, 4 females) into a pilot study that measured self-identified functional limitations and outcomes. Inclusion criteria included a diagnosis of scapholunate advanced collapse, scaphoid nonunion advanced collapse, scapholunate interosseous ligament tear, or Kienböck disease. Exclusion criteria included a history of neuromuscular disease or concomitant ipsilateral musculoskeletal injury. Data were collected during two 20-minute sessions, preoperatively and one year postoperatively, utilizing the Patient-Rated Wrist Evaluation and the Canadian Occupational Performance Measure. RESULTS: All patients reported significant decreases (P < .001) in total pain (mean change = 17.6, SD = 8.5) and total disability (mean = 17.8, SD = 9.1) on the Patient-Rated Wrist Evaluation from presurgery to postsurgery, with a large effect size of d > 0.8. Patients also reported significant improvements (P < .001) in mean performance (mean = 3.5, SD = 1.5) and mean satisfaction (mean = 4.0, SD = 2.1) with self-identified activities on the Canadian Occupational Performance Measure, with an effect size of d > 0.8. CONCLUSION: Patients with degenerative wrist arthritis reported significant postoperative improvement in both performance and satisfaction in self-identified activities. Consideration of patient-specified goals can inform both patients and clinicians during the surgical decision-making process and allow for more individualized care.

Elbow Kinematics During Gait Improve With Age in Children With Hemiplegic Cerebral Palsy.

BACKGROUND: Children with hemiplegic cerebral palsy (hCP) exhibit a typical posture of elbow flexion during gait. However, the change in elbow kinematics and symmetry during gait across age span in both hCP and typically developing (TD) children is not well described. The aim of this study was to quantify the change in elbow kinematics and symmetry across age span in hCP children compared with TD children. METHODS: Upper extremity kinematic data were extracted and analyzed from a database for gait studies performed between 2009 and 2015. A total of 35 hCP and 51 TD children between the ages of 4 and 18 (mean age: TD=11.2±0.6, hCP=9.8±0.5) met inclusionary criteria. The groups were further subdivided into 3 age categories: 4 to 7, 8 to 11, 12+ years old. Elbow angles were extracted and peak elbow flexion, overall range of motion during gait, and asymmetry indices were calculated. A 1-way analysis of variance was performed on each group with post hoc Tukey honestly significant difference pairwise comparisons. RESULTS: Peak elbow flexion during gait increased with age in TD children (P<0.05) and decreased with age in hCP children on the affected side (P<0.05). There was no change on the less affected side of hCP children. TD children demonstrated significantly less elbow flexion (mean=51.9±2.1 deg.) compared with the affected side in hCP (mean=82.1±3.8 deg.) across all age categories (P<0.05). There was no change in elbow asymmetry index (0=perfect symmetry) across age in either controls or hCP children; however, there were differences between hCP and TD groups in younger age groups (TD=28, hCP=62, P<0.05) that resolved by adolescence (TD=32, hCP=40). CONCLUSIONS: During gait, hCP children have greater peak elbow flexion on the affected side than do TD children. Peak elbow flexion angle converged between the 2 groups with age, decreasing in hCP children and increasing in TD children. Furthermore, elbow symmetry during gait improves with age in hCP children, approximating symmetry of TD children by adolescence. These findings have implications for both consideration and optimal timing of surgical intervention to improve elbow flexion in children with hCP. LEVEL OF EVIDENCE: Level III-retrospective case-control study.

Anatomical and biomechanical framework for shoulder arthroplasty rehabilitation.

This article provides an anatomical and biomechanical framework for the postoperative management and progression of treatment for shoulder arthroplasty. The clinical relevance of normal shoulder anatomy, biomechanics, and pathomechanics related to this surgery is emphasized to provide the reader with an understanding of the rationale for treatment. We review the rehabilitation implications of surgical indications and technique for both traditional total shoulder arthroplasty and reverse total shoulder arthroplasty procedures with an emphasis on biomechanical considerations. Relevant factors that affect rehabilitation outcomes are discussed along with supporting evidence from the literature. Principles to guide and progress treatment are highlighted with a discussion on return to sports with the ultimate objective of providing a comprehensive approach for successful rehabilitation.

Rehabilitation for scapholunate injury: Application of scientific and clinical evidence to practice.

In this article, the development of a rehabilitation approach is describe using scapholunate injury as a model. We demonstrate how scientific and clinical evidence is applied to a treatment paradigm and modified based on emerging evidence. Role of the scapholunate interosseous ligament within the pathomechanics of the carpus, along with the progression of pathology, and specific rehabilitation algorithms tailored to the stage of injury. We review the recent and current evidence on the kinematics of wrist motion during functional activity, role of the muscles in providing dynamic stability of the carpus, and basic science of proprioception. Key relevant findings in each of these inter-related areas are highlighted to demonstrate how together they form the basis for current wrist rehabilitation. Finally, we make recommendations for future research to further test the efficacy of these approaches in improving functional outcomes.

Differentiation of hand posture to object shape in children with unilateral spastic cerebral palsy.

Quantifying hand-shaping in children with unilateral spastic cerebral palsy (USCP) is the first step in understanding hand posture differentiation. To quantify this ability and determine how hand posture evolves during reach toward various object shapes in children with unilateral spastic cerebral palsy (USCP), 2 groups of children (10 typically developing, and 10 USCP, ages 6-13) were studied in a single-session cross-sectional study. Subjects grasped rectangular, concave, and convex objects with each hand. Metacarpal and proximal interphalangeal joint finger flexion and finger abduction angles were calculated. The extent to which hand posture reflects object shape was calculated using a "visuomotor efficiency (VME) index" (a score of 100 reflects perfect discrimination between objects). A mixed design ANOVA with repeated measures on time was used to compare the VME between groups. Children with USCP demonstrated a lower VME than controls in the affected hand, indicating less effective hand-shaping; p<.01. There was also a difference between groups in the evolution of VME throughout reach; p<.01. No difference in hand-shaping in the less affected hand in USCP was observed. Analysis of joint angles at contact and VME throughout reach demonstrated that children with USCP differentiated their hand posture to objects of different shapes, but demonstrated deficits in the timing and magnitude of hand-shaping isolated to the affected side. The present study suggests it may be important to consider the quality of hand activity using quantitative approaches such as VME analyses. Rehabilitation approaches that target these deficits to improve joint mobility and motor control are worth testing.