The Effect of Proprioceptive Training on Hand Function and Activity Limitation After Open Carpal Tunnel Release Surgery: A Randomized Controlled Study.

OBJECTIVE: To investigate the effect of proprioceptive training on hand function and activity limitation in patients undergoing open carpal tunnel release surgery. DESIGN: Randomized controlled study. SETTING: A university hospital. PARTICIPANTS: Thirty patients were included in the study and randomized to proprioceptive training (PT) and conventional rehabilitation (CR) groups. INTERVENTION: One week after surgery, both groups received CR for 6 weeks. All participants were asked to perform home-based exercises daily in 3 sets with 10 repetitions. For the PT group, a 6-step PT program was conducted starting from Week 6. Both groups received face-to-face interventions twice a week for 12 weeks. MAIN OUTCOME MEASURES: The outcome measures included the Purdue Pegboard Test (PPT), the joint position sense test (JPST), the Boston Carpal Tunnel Questionnaire, and the Patient-Specific Functional Scale. In total, 3 assessments were performed (at 1, 6 and 12 weeks postoperatively). RESULTS: In the PT group, the results for PPT were statistically significant (P<.05). Although there was a greater decrease in the absolute angular error value (JPST) of the PT group compared to the CR group, the difference was nonsignificant (P>.05). Similar reductions in activity limitation were seen in both groups (PT: 176%, CR: 175%). Symptom severity decreased by 40% in the PT group vs 32% in the CR group. The effect sizes were larger for the changes between the second and third assessments in the PT group compared to the CR group in all parameters tested. CONCLUSION: When applied after carpal tunnel release surgery, PT may potentially to improve hand functions, reduce activity limitation, increase participation in activities of daily living, and thus improve quality of life.

Use of relative motion orthoses from the perspective of hand-injured patients: A qualitative study.

BACKGROUND: Relative motion (RM) orthoses have gained popularity with therapists as their versatility lends to "protective," "exercise," and "adaptive" uses. PURPOSE OF THE STUDY: To ask for comments from patients wearing RM orthoses for protective or exercise reasons. STUDY DESIGN: Interpretive descriptive qualitative study. METHODS: Semi-structured face-to-face interviews comprised of nine open-ended questions were conducted with 20 hand injured patients who were advised to wear a protective or exercise RM orthosis for at least 4 weeks. RESULTS: Twenty patients participated in the interviews. Thirteen patients wore the protective RM orthoses had a mean age of 28 years (range,16-54) and the mean age was 34 years (range, 20-51) for 7 patients using exercise RM orthoses. Interviews generated 4 major themes: physical characteristics of the orthoses, challenges in daily living activities, emotional response to orthotic wear, and impact of social environment. DISCUSSION: Comments from both groups of patients suggested the small size of the orthosis contributed to wearing the orthosis as advised. Most found the orthosis comfortable, when not, comments were related to rubbing of the orthosis causing pain and rigidity of the orthosis resulting in finger swelling. A few were impacted by the orthosis drawing attention to their injured hand. Those wearing the exercise RM orthosis often removed it instead of using it for nonintentional exercise. CONCLUSIONS: Comments obtained from the limited structured interview of 20 patients wearing protective or exercise RM orthosis may offer therapists with some understanding from the patient's perspective. Additional study is worthwhile.

The Use of Relative Motion Flexion Orthoses for Chronic Boutonniere Deformity.

PURPOSE: This study investigated the effectiveness of a relative motion flexion orthosis (RMFO) for increasing the range of motion for boutonniere deformity. METHODS: We included 28 patients aged 13-62 years with chronic boutonniere deformity who could complete 0° proximal interphalangeal (PIP) joint extension with the pencil test and were stage 1 according to the Burton classification of boutonniere deformity. At the initial hand therapy appointment, the RMFO was made. The duration of the orthosis usage at the initial therapy session, after stopping the use of the orthosis (posttreatment), and at the follow-up period were noted. RESULTS: The mean time for orthosis usage of all patients was 11.7 weeks (6-40 weeks). The mean initial active distal interphalangeal joint flexion was 47° (0° to 90°) and improved to 66.8° (5° to 110°). The mean initial extension lag of the PIP joint was 22.5° (5° to 55°) and improved to 12° (0° to 30°). This did not change between discontinuation of the orthosis and final follow-up. CONCLUSIONS: The use of RMFO is effective in increasing active distal interphalangeal joint flexion and improving PIP extension in patients with Burton stage 1 chronic boutonniere deformity. TYPE OF STUDY/LEVEL OF EViDENCE: Therapeutic IV.

Investigation of reliability, validity, and cutoff value of the Jebsen-Taylor Hand Function Test.

STUDY DESIGN: This is a cross-sectional study. INTRODUCTION: The Jebsen-Taylor Hand Function Test (JTHFT) evaluate the efficacy of treatment and assess a broad range of hand functions. PURPOSE OF THE STUDY: The purpose of this study was to investigate the psychometric properties of the JTHFT and to determine cutoff values. METHODS: The test-retest reliability was assessed by determining intraclass correlation coefficient (ICC), the hypothesis testing validity was assessed by using Spearman rho coefficient, and the receiver operating characteristic curve, area under the curve of the receiver operating characteristic, sensitivity, and specificity were calculated to determine the cutoff values. We administered JTHFT, Disabilities of Arm, Shoulder and Hand Questionnaire (DASH) and assessed grip strength with Jamar dynamometer. We included 162 healthy participants and 143 patients with hand injuries. RESULTS: The JTHFT subtests and total score have a good to excellent test-retest reliability (except lifting large light object for dominant hand-ICC: 0.77) for both dominant and nondominant hand (ICCs = 0.84-0.97). There was a statistically significant, weak positive correlation between the JTHFT total score and DASH-T (r = 0.39, P < .001 for the injured hand; r = 0.35, P < .001 for the uninjured hand) and also statistically significant weak negative correlation between grip strength for injured hand and JTHFT total score for injured hand (r = -0.33; P < .001). The cutoff value of the total score was found to be 37.08 s for injured hand. DISCUSSION AND CONCLUSION: JTHFT is a reliable and valid instrument. Clinicians and researchers may use this test with confidence to assess the dexterity of hand injury patients.

Systematic review of the quality of the cross-cultural adaptations of Disabilities of the Arm, Shoulder and Hand (DASH).

BACKGROUND: The Disabilities of the Arm, Shoulder and Hand (DASH) Outcome Measure is a widely used patient reported outcome measure. OBJECTIVE: The aim of this study is to evaluate the quality of translation procedures and assessment of the psychometric properties of cross-cultural adaptations of the DASH. METHODS: We reviewed the literature to identify all published studies of cultural adaptations of the DASH questionnaire. For the quality assessment, we used Guidelines for the Process of Cross-Cultural Adaptation of Self-Report Measures, Quality Criteria for Psychometric Properties of Health Status Questionnaire and COSMIN Checklist for Cross-Cultural Validity. RESULTS: We included 25 articles with 26 versions of the DASH. Only the Puerto Rican version followed all six of the processes of cross-cultural adaptation. None of the versions assessed all eight measurement properties for Quality Criteria for Psychometric Properties of Health Status Questionnaire and none of them had a positive rating from agreement, internal consistency, responsiveness and interpretability. All the studies got a poor rating according to the COSMIN checklist. DISCUSSION: None of the versions got a good rating from all three checklists. We observed that supplementary tests for the adaptations are necessary, especially for assessing agreement, responsiveness and interpretability. We concluded that all versions need more research on psychometric properties.

Sensory processing patterns of young adults with preterm birth history.

PURPOSE/AIM: This study aimed to evaluate the sensory processing abilities of young adults with a history of preterm birth and the factors affecting these abilities. MATERIALS AND METHODS: Thirty-seven young adults with preterm birth history were included. After recording their sociodemographic data, sensory processing functions were evaluated using the Adolescent/Adult Sensory Profile. The participants' data were compared to normative samples. RESULTS: Mean score was 43.51 ± 8.29 for sensory sensitivity, 44.45 ± 9.19 for sensation avoiding, 33.43 ± 8.45 for low registration, and 47.97 ± 9.91 for sensation seeking. Compared to normative samples, 78% of participants in sensation avoiding quadrant, 62% of participants in sensory sensitivity quadrant, 40% of participants in low registration quadrant and sensation seeking quadrant had atypical scores. When sensory profile scores were analysed according to mode of birth, percentages of typical sensory sensitivity and sensation avoiding were low in both the normal vaginal and caesarean delivery subgroups. When analysed by gestational age at birth, ratios of abnormality in sensation avoiding were similar between individuals with very early, early, and late preterm delivery history. Statistically significant difference was found in low registration and sensation avoiding quadrants according to mode of birth (p < .05). There were no statistically significant sex-based and gestational age at birth differences in any of the four quadrants of the sensory profile in the preterm group (p > .05). CONCLUSION: These results showed that young adults with preterm birth history have differences in sensory processing compared to the general population and should be evaluated for sensory processing patterns.

Evaluation of Load Distributions and Contact Areas in 4 Common Grip Types Used in Daily Living Activities.

PURPOSE: Grip analysis systems, with sensors quantifying load distributions and contact areas applied by the hand while grasping objects, are useful for collecting and recording instant data; these systems are popular in hand assessment. The purpose of this study was to determine the load distribution (LD) and contact area (CA) size of the palmar surface of the hand during 4 common grip types used in activities of daily living (standard, lateral, pinch, and tripod grips). METHODS: A convenience sample of 80 right-handed subjects were enrolled in this study. Participants wore special gloves equipped with sensors and grasped a variety of objects. Contact area size and LD were determined for the 4 grip types. RESULTS: The CA and the LD were different for each grip. For standard grip, although the largest CA occurred at the metacarpophalangeal joint level, the largest LD was over the middle finger pulp. For standard grip, index, middle, and ring fingers appear to be loaded with almost the same frequency as the thumb. Although CA on the thumb was maximum in the pinch, lateral and tripod grip types, the LD on the thumb was not. CONCLUSIONS: This study shows that the LD and CA patterns differ widely among standard, pinch, lateral, and tripod grips. The percentage of CA occurring on the thumb was maximum in all grip types. CLINICAL RELEVANCE: This information is important to optimize the design of artificial manipulators or assistive devices and to optimize the hand rehabilitation process. In addition, results of the study can be used to guide the design of prostheses and biomedical implants better.

Ring orthosis design and production by rapid prototyping approach.

STUDY DESIGN: In this study, ring orthosis design and manufacturing was performed by using rapid prototyping technology. INTRODUCTION: Swan neck and boutonniere deformities may occur because of various reasons such as tendon injuries, sharp object injuries, or rheumatic diseases. Although the ring orthoses are the most commonly used conservative treatment method for swan neck and buttonhole deformities, they cannot be widely used because they are both difficult to produce and esthetically unsatisfied with the patients. PURPOSE OF THE STUDY: In this study, it was aimed to manufacture with an orthosis design that is fully compatible, more esthetic, faster, and easily produced. METHODS: 3D printing technologies are used in design and manufacturing. The 3D scanner is used in the measurement process, and the 3D printer is used in the manufacturing process. RESULTS: As a result of the study, a more esthetically pleasing and comfortable orthosis was made faster. DISCUSSION AND CONCLUSIONS: As a result of the study, the thickness of the material should not be less than 5 mm.

Bimanual ability for brachial plexus birth injury: a validity and reliability study of the ABILHAND-Kids.

PURPOSE: ABILHAND-Kids is a structured parent report that assesses manual ability in activities of daily living in children with cerebral palsy, and also brachial plexus birth injury (BPBI). This study investigated the validity, test-retest reliability, and internal consistency of the ABILHAND-Kids in children with BPBI. MATERIALS AND METHODS: The ABILHAND-Kids was administered to parents of 119 children with BPBI between 6 and 15 years for validity and internal consistency, also 92 parents were re-interviewed after two weeks to establish test-retest reliability. Its concurrent validity was examined by correlating scores on the ABILHAND-Kids with Active Movement Scale-Total Score. RESULTS: ABILHAND-Kids were strongly correlated with AMS-Total score (p < 0.001, r = 0.87) ABILHAND-Kids test-retest reliability was excellent (ICC: 0.93, %95 CI: 0.90-0.95). The internal consistency for the total score of ABILHAND-Kids was excellent (alpha = 0.94). For 20 items, item-total correlations were adequate (corrected item-total correlations, 0.27-0.85), one item which was "switching on a bedside lamb" had no adequate correlation (corrected item-total correlations, 0.011). The ABILHAND-Kids score showed a statistically significant difference between the Narakas types (p < 0.001). CONCLUSION: The ABILHAND-Kids has excellent reliability and strong validity for measuring manual ability or bimanual performance in activities of daily living in children with BPBI.

ABILHAND-Kids is a valuable tool for assessing bimanual activities in children with Brachial Plexus Birth Injury.ABILHAND-Kids is valid in both concurrent and discriminative validity in children with Brachial Plexus Birth Injury.ABILHAND-Kids is reliable in children with Brachial Plexus Birth Injury.ABILHAND-Kids assesses bimanual performance in real-life activities and offers valuable insights for treatment planning in Brachial Plexus Birth Injury.

Relative Motion Extension Splint after Extensor Tendon Reconstruction.

Recently, the wide-awake local anesthesia no tourniquet (WALANT) technique and relative motion extension (RME) splint changed practice in extensor tendon reconstruction and therapy. We wanted to share our approach for zones 5 to 8 extensor tendon management following the up-to-date developments. The impacts of surgery under WALANT and early active motion therapy with RME splinting were explained frankly and shown in several videos throughout the article.

Health-related quality of life in children with obstetrical brachial plexus palsy.

PURPOSE: We aimed to determine the health-related quality of life (HRQL) of children with obstetrical brachial plexus palsy (OBPP) and examine its association with gender, age, injury level, injured side, and functional status. METHODS: We conducted a controlled, cross-sectional study including 70 children with OBPP. Fifty-two age-matched children without any health problems were included as controls. HRQL was assessed with the short parent form of the Child Health Questionnaire (CHQ-PF28), and functional status was measured using the active movement scale (AMS). RESULTS: Children with OBPP scored significantly lower on most of the CHQ-PF28 subscales than the healthy controls (p < 0.05). Gender or age did not significantly affect scores in any domain (p > 0.05). CHQ-PF28 scores showed that there were significant differences according to the side of injury between groups, especially in the "parental impact-time" and "family activities" domains (p < 0.05). There were no statistically significant differences in CHQ-PF28 scores between groups that had an upper trunk involvement and total injury groups (p > 0.05), except in the "bodily pain/discomfort" domain (p < 0.05). The AMS score was weakly to moderately correlated with the "mental health" and "parental impact-time" and "general health perceptions" domains. CONCLUSION: The study demonstrated that children with OBPP have a poorer HRQL than their healthy peers. Side of injury, limitations in shoulder flexion, shoulder internal rotation, elbow flexion, elbow extension, and forearm supination were important factors affecting the HRQL of the children. The health concepts and factors discussed in the study can guide clinicians aiming to improve QoL of children with OBPP.

Early active movement with relative motion flexion splint for the management of zone 1-2 flexor tendon repairs: Case series.

BACKGROUND: There is limited literature evidence on the use of relative motion flexion splint after flexor tendon repairs. OBJECTIVES: We aimed to report the clinical use of early active movement with a relative motion flexion splint and to determine the outcomes of a consecutive series in patients with zone 1-2 flexor tendon repair. METHODS: We included 14 patients with one-stage flexor tendon repair. An active rehabilitation program was initiated in the first week with a static dorsal block splint, which was removed in the third week, and patients started to use the relative motion flexion splint. Total active motion (TAM) of the injured finger at 8, 12, and 16 weeks after surgery was assessed as described by Strickland and Glogovac. RESULTS: The mean TAM of the injured fingers was as follows: 102.5 ± 41.49° (25°-180°) at week 8; 123.42 ± 40.94° (45°-190°) at week 12; and 148 ± 38.18° (90°- 200°) at week 16. Final TAM grades of the patients at week 16 were as follows: excellent (six patients); good (five patients); and fair (three patients). There were no tendon ruptures and secondary surgeries. CONCLUSION: Early active movement and the use of relative motion flexion splint seem to be promising strategies for flexor tendon zone 1-2 repair management.

Impact of obstetrical brachial plexus injury on parents.

BACKGROUND: The aim of this study was to describe the impact of obstetrical brachial plexus palsy (OBPP) on parents and to investigate the effect of the severity of OBPP and the age of the children on parents. METHODS: A total of 106 parents (with a mean age of 30.14 ± 5.01 years) of children with OBPP were included in the study. The functional level of the children was assessed by the Active Movement Scale, whereas the impact of OBPP on the parents was assessed by the Turkish version of the Impact on Family Scale. RESULTS: The parents appeared to be moderately affected by their child's disorder. Financial, social, personal, mastery parameters and total impact values were 52% (27-77%), 65% (46-114%), 49% (31-67%), 51% (28-74%) and 56% (40-72%), respectively. Root involvement and the age of the children did not make a statistically significant difference in the level of impact. CONCLUSIONS: Detailed knowledge of the impact of OBPP on families might provide a chance to support affected families in coping with the situation and decrease their burden in providing care for the children. It is crucial to evaluate and provide social support to parents of children with OBPP.

Quality of life in mothers of children with obstetrical brachial plexus palsy.

BACKGROUND: The aim of this study was to explore impairment in quality of life (QOL) of the mothers who were primarily responsible for taking care of children with obstetrical brachial plexus palsy (OBPP) and to state its association with the age, sex and functional status of the child with OBPP. METHODS: Ninety-three mothers of children with OBPP and 88 mothers of children without any health problems were included in the study. Children's demographic characteristics were recorded and the functional status of the upper extremity was determined with the active movement scale. The QOL of the mothers was assessed with the Turkish version of the Nottingham Health Profile (NHP). RESULTS: There were significant differences between mothers of children with OBPP and the control group in total, physical activity, energy expenditure, and pain score of the NHP. A decrease in energy expenditure and physical activity levels were found to be related to children's active movement scale results in elbow flexion and extension, and forearm supination. A statistically meaningful difference was found between mothers of children aged 0-2 and mothers of children aged 2-7 years in emotional reaction, social isolation and total score of NHP. CONCLUSIONS: The results of this study revealed that mothers of children with OBPP have poor QOL compared with mothers of healthy children. The limitation in elbow joint movements was found to be important for the mothers. The strongest impact of the illness is on the emotional reactions and social isolation of the mothers. Professionals involved in the care of children with OBPP should also help parents to cope with the burden of caregiving.

Manufacturing an assistive device with 3D printing technology - a case report.

Our aim is to define the design and procedure of a 3D printed assistive device and to produce a prototype assistive device for an individual with quadriplegia in order to enable him/her to independently conduct daily living activities. For the design and production of the 3D assistive device, we followed six steps. In the first step-determination of problematic activity/client-centered approach-writing activity was determined as the most problematic activity as a result of the interview with a paraplegic patient. Then, 2D drawings of the assistive device were created as the second step. For the third step the 3D scan of the individual's right hand was obtained. 3D scan of the right hand was transferred to CATIA program and the 3D printer is used in the manufacturing process for the fourth step. In the fifth step, we produced a low-cost novel writing assistive device. The writing device was introduced to the disabled individual and training was given regarding its practical use in the final step teaching the use of the device. As 3D printing technology progresses and becomes more reliable, we believe that the production of assistive devices will become much easier and their use will become more prevalent.

Cross-cultural adaptation, validation, and reliability process of the Michigan Hand Outcomes Questionnaire in a Turkish population.

PURPOSE: The Michigan Hand Outcomes Questionnaire (MHQ) is a domain-specific questionnaire that was developed to be used as a standardized instrument capable of measuring outcomes for patients with all types of hand disorders. The purpose of this study was to develop the Turkish version of the MHQ and to examine whether it is a valid and reliable tool for assessing the outcomes in hand disorders. METHODS: Translation and back-translation of the MHQ were performed, according to published guidelines. A total of 70 patients with hand complaints completed the final version of the MHQ and the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire Turkish version (DASH-T) twice, on their first visit and after an interval of 7 days. Visual analog scale (VAS) results for pain intensity and grip strength measurements of the individuals were also taken in both assessments consecutively. RESULTS: Translation and back-translation revealed no major difficulties. The Turkish version of the MHQ met set criteria of reliability and validity. The intraclass correlation coefficient of the test-retest reliability for the 6 subscales ranged from 0.79 to 0.96. The internal consistency of the MHQ, estimated by Cronbach's alpha, ranged from 0.85 to 0.96 for all subscale scores. There were high to moderate correlations between MHQ and DASH scores and VAS and grip strength scores of the injured side. CONCLUSIONS: The Turkish version of the MHQ has excellent test-retest reliability and validity, and it is an adequate and useful instrument for measuring functional disability in hand disorders of Turkish-speaking patients.

Getting Better Results in Flexor Tendon Surgery and Therapy.

Recently, better outcomes have been reported when up-to-date developments in flexor tendon surgery and therapy were followed. Slightly tensioned multistrand repairs, judicious venting of pulleys, and early active motion are widely accepted principles. In addition to these principles, tailoring of the repair according to intraoperative active movement with wide awake local anesthesia no tourniquet (WALANT) surgical setting is recommended for better results. We aimed to describe our up-to-date approach to flexor tendon surgery and therapy with the help of visual communication tools of this age. The ideal primary repair of flexor tendons, the management of delayed presentation flexor tendon injuries, the key steps to achieve better results with flexor tendon therapy, and the tele-rehabilitation experience during COVID-19 pandemic will be highlighted. Zone 2 flexor tendon injuries are the most demanding part and will be focused on.

Association between 6 min pegboard and ring test and arm performance in GOLD stage II-III patients.

BACKGROUND: The 6 min pegboard and ring test (6PBRT) is a valid and reproducible test of unsupported arm exercise endurance. The aim of this study was to determine the associations between the 6PBRT, activities of daily living (ADL) and hemoglobin levels in chronic obstructive pulmonary disease (COPD). METHODS: This study included 40 stable patients with COPD. All participants underwent the 6PBRT, peripheral venous blood sampling, arm ergometer test and the Glittre-ADL and ADL simulation tests for the ADLs performance. RESULTS: An average 172.51 ± 25.94 rings were moved in 6 min. The number of rings in 6PBRT was significantly positively correlated with the number of cycles in ADL simulation test (r = 0.553, p < 0.001), peak oxygen consumption in arm ergometer (r = 0.381, p = 0.024) and serum hemoglobin level (r = 0.411, p = 0.011). CONCLUSION: The number of rings moved in the 6PBRT is associated with ADL simulation test performance that reflects upper extremity ADLs. Therefore, the 6PBRT can be used for estimating limitation in upper extremity ADLs as a simple and quick evaluation in patients with GOLD stage II-III COPD.

Mothers' depression and health-related quality of life in neuromuscular diseases: role of functional independence level of the children.

BACKGROUND: In the literature there have been studies about quality of life of parents who have children with chronic diseases. Most of these studies have focused on the stress of parents of children with neuromuscular disease (NMD), and there was no evidence to support hypothesized relationships between caregiving demands and health-related quality of life (HRQOL). The aim of the present study was therefore to evaluate the relations between maternal depression and HRQOL and functional limitations of the children with NMD. METHODS: Forty children with a diagnosis of NMD and their mothers were included in the study. HRQOL of the mothers was assessed on the Turkish version of the Nottingham Health Profile (NHP); potential cases of depressive illness were identified on Beck Depression Inventory (BDI); and Wee-Functional Independence Measure (Wee-FIM) was used to evaluate of functional independence level of the children. RESULTS: It was found that mean total NHP score of the mothers was moderately correlated with the total FIM score and sphincter control of the child, and weakly correlated with the locomotion of the child (P < 0.001). There was moderate correlation between mothers' social isolation and children's sphincter control, social integration and total Wee-FIM score and a weak correlation between mobility and communication scores (P < 0.001). In contrast there was no correlation between BDI scores of mothers and Wee-FIM scores of children (P > 0.05). CONCLUSION: The functional level of children with NMD is one of the factors that affect the quality of life of mothers.

More severe cold intolerance is associated with worse sensory function after peripheral nerve repair or decompression.

The aim of the study is to investigate the correlation between cold intolerance and sensory function after repair of nerve transection or decompression of peripheral neuropathy in the upper extremity. We included patients with abnormal cold sensitivity who had a score of 30 or more in the Cold Intolerance Symptom Severity Questionnaire. There were 30 individuals after surgery to repair nerve transection and 30 with compression neuropathy, aged between 18-65 years. We used the Cold Intolerance Symptom Severity Questionnaire to evaluate cold intolerance and the Rosen Score to evaluate sensory function. There was a significant negative correlation between cold intolerance and sensory function in both peripheral nerve transections and compression neuropathies. We conclude that greater cold intolerance is associated with worse sensory function in peripheral nerve injuries. Interventions for sensory function in cold intolerance treatment may reduce the severity of cold intolerance. Level of evidence: III.