The role of diagnostic ultrasound in the examination of carpal tunnel syndrome: an update and systematic review.

BACKGROUND: Diagnostic ultrasound is becoming more available and has potential for identifying carpal tunnel syndrome (CTS), but there is a lack of consensus on optimal measurement parameters and interpretation. PURPOSE: The purpose of this systematic review was to analyze and summarize recent published data evaluating measurement properties of diagnostic ultrasound for use in individuals with CTS. METHODS: Five databases were searched to identify studies reporting on diagnostic measurement in individuals ≥18 years of age. Thirty-four studies underwent critical appraisal using Center for Evidence Based Medicine guidelines for diagnostic study accuracy. Each team member independently reviewed and scored the studies and consensus was reached through discussion. RESULTS: Seventeen studies evaluating 21 unique nerve or tunnel measurements and 9 measurement ratios were included. Measurements of median nerve cross sectional area (CSA) taken at the carpal tunnel inlet consistently demonstrated good to excellent interrater reliability (ICC=0.83-0.93) and good intrarater reliability (r>0.81). All studies supported inlet CSA in differentiating between individuals with and without CTS. Carpal tunnel inlet CSA measurements demonstrated a moderate correlation to the Padua severity classification (r = 0.71), but this varied between studies. Diagnostic accuracy of CSA measured at the carpal tunnel inlet using diagnostic cutoff values ranging from 8.5 mm2 to 12.6 mm2 resulted in a range sensitivity (63%-96.9%) and specificity (67.9%-100%). CONCLUSION: The US measurement most supported was the median nerve CSA measured at the carpal tunnel inlet. There was no evidence supporting the routine use of diagnostic US for individuals with suspected CTS, and no additional evidence to support replacement of electrodiagnostic studies by US. More research is needed to determine use of US for classifying CTS severity or as a differential diagnostic tool for conditions that mimic CTS. LEVEL OF EVIDENCE: N/A.

The Effect of Scapular Muscle Strengthening on Functional Recovery in Patients With Lateral Elbow Tendinopathy: A Pilot Randomized Controlled Trial.

CONTEXT: There is a lack of consensus on the best management approach for lateral elbow tendinopathy (LET). Recently, scapular stabilizer strength impairments have been found in individuals with LET. OBJECTIVE: The purpose of this study was to compare the effectiveness of local therapy (LT) treatment to LT treatment plus a scapular muscle-strengthening (LT + SMS) program in patients diagnosed with LET. DESIGN: Prospective randomized clinical trial. SETTING: Multisite outpatient physical therapy. PATIENTS: Thirty-two individuals with LET who met the criteria were randomized to LT or LT + SMS. INTERVENTIONS: Both groups received education, a nonarticulating forearm orthosis, therapeutic exercise, manual therapy, and thermal modalities as needed. Additionally, the LT + SMS group received SMS exercises. MAIN OUTCOME MEASURE: The primary outcome measure was the patient-rated tennis elbow evaluation; secondary outcomes included global rating of change (GROC), grip strength, and periscapular muscle strength. Outcomes were reassessed at discharge, 6, and 12 months from discharge. Linear mixed-effect models were used to analyze the differences between groups over time for each outcome measure. RESULTS: The average duration of symptoms was 10.2 (16.1) months, and the average total number of visits was 8.0 (2.2) for both groups. There were no significant differences in gender, age, average visits, weight, or height between groups at baseline (P > .05). No statistical between-group differences were found for any of the outcome measures. There were significant within-group improvements in all outcome measures from baseline to all follow-up points (P < .05). CONCLUSION: The results of this pilot study suggest that both treatment approaches were equally effective in reducing pain, improving function, and increasing grip strength at discharge as well as the 6- and 12-month follow-ups. Our multimodal treatment programs were effective at reducing pain and improving function up to 1 year after treatment in a general population of individuals with LET.

Do joint mobilizations assist in the recovery of lateral elbow tendinopathy? A systematic review and meta-analysis.

STUDY DESIGN: Systematic review. INTRODUCTION: No consensus exists as to which are the most effective methods to treat the symptoms associated with lateral elbow tendinopathy (LET). Research has suggested that joint mobilizations may assist in the recovery of patients with LET. PURPOSE OF THE STUDY: To determine if joint mobilizations are effective in improving pain, grip strength, and disability in adults with LET. METHODS: Searches in 3 databases were performed to identify relevant clinical trials. Reviewers independently extracted data and assessed the methodological quality. Summary measures of quantitative data were extracted or calculated where possible. Appropriate data were pooled for meta-analysis using a random-effects model. RESULTS: A total of 20 studies met the inclusion criteria; 7 were included in the meta-analysis. Studies were broadly classified into 3 groups: mobilization with movement (MWM), Mill's manipulation, and regional mobilization techniques. Pooled data across all time periods demonstrated a mean effect size of 0.43 (95% confidence interval [CI]: 0.15-0.71) for MWM on improving pain rating, and 0.31 (95% CI: 0.11-0.51) for MWM on improving grip strength, 0.47 (95% CI: 0.11-0.82) for Mill's manipulation on improving pain rating. A mean effect size of -0.01 (95% CI: -0.27 to -0.26) shows Mill's manipulation did not improve pain free grip strength. Functional outcomes varied considerably among studies. Pain, grip strength, and functional outcomes were improved with regional mobilizations. CONCLUSION: There is compelling evidence that joint mobilizations have a positive effect on both pain and/or functional grip scores across all time frames compared to control groups in the management of LET.

Health promotion, wellness, and prevention in hand therapy: A survey study.

STUDY DESIGN: Descriptive study. INTRODUCTION: Noncommunicable diseases including diabetes and cardiovascular disease are associated with increased complications and cost of health care. PURPOSE OF THE STUDY: To describe beliefs and extent to which hand therapists include health promotion, wellness, and prevention (HPWP) in practice and to elucidate barriers to the incorporation of HPWP. METHODS: A 38-question survey evaluating hand therapists' beliefs, practice of HPWP, and barriers was sent to American Society of Hand Therapists members. RESULTS: About 270 American Society of Hand Therapists members participated. Respondents believed they had a role in HPWP, including occupational (95%), physical (92%), emotional (87%), and psychological (84%) factors and instrumental activities of daily living management (98%). Physical activity is most frequently addressed (42%), whereas other health behaviors are rarely addressed. Time, patient interest, and resources were among identified barriers. DISCUSSION: The importance of health promotion and disease prevention practice is being recognized as critical to successful health outcomes. CONCLUSION: The study results suggest the need to develop HPWP educational programming for hand therapists and the need to consider expansion of understanding of HPWP initiatives and subsequent benefits to patients. LEVEL OF EVIDENCE: 5.

Hand therapist use of patient report outcome (PRO) in practice: a survey study.

PURPOSE: The purpose of this survey was to gain greater insight into hand therapists' use of Patient Report Outcome (PRO) measures. METHODS: An 11-question survey that evaluated therapists' perceptions, preferences, and patterns of use of patient report outcome measures was sent to members of ASHT. RESULTS: A total of 633 ASHT members participated in the survey study. A large majority of participants (92%) responded affirmatively to using a PRO measure in practice. The DASH was reported as the most frequently used measure (90%). The majority of therapists (84%) discuss the results of the outcome measurement score with their patients. Of the participants who use more than one outcome measure, 44% report that this allows them to better establish their patient's functional and physical limitations. CONCLUSION: The findings in this study suggest that a large percentage of hand therapists are currently including a PRO measure in their hand therapy practice.

Physical Therapist Management of Glenohumeral Joint Osteoarthritis: A Clinical Practice Guideline from the American Physical Therapy Association.

A clinical practice guideline on glenohumeral joint osteoarthritis was developed by an American Physical Therapy Association volunteer guideline development group that consisted of physical therapists, an occupational therapist, and a physician. The guideline was based on systematic reviews of current scientific and clinical information and accepted approaches for physical therapist management of glenohumeral joint osteoarthritis. This clinical practice guideline is available in Spanish; see Supplementary Appendix 8.

Lateral Elbow Pain and Muscle Function Impairments.

Although often described as a self-limiting condition and likely to resolve on its own, high recurrence rates and extended sick leave frame a need for effective non-surgical treatment for people with lateral elbow tendinopathy. The interrelationship of histological and structural changes to the tendon, the associated impairments in motor control, and potential changes in pain processing may all drive symptoms. This clinical practice guideline covers the epidemiology, functional anatomy and pathophysiology, risk factors, clinical course, prognosis, differential diagnosis, tests and measures, and interventions for managing lateral elbow tendinopathy in the physical therapy clinic. J Orthop Sports Phys Ther 2022;52(12):CPG1-CPG111. doi:10.2519/jospt.2022.0302.

ANALYSIS OF RANGE OF MOTION IN FEMALE RECREATIONAL TENNIS PLAYERS WITH AND WITHOUT LATERAL ELBOW TENDINOPATHY.

BACKGROUND: Intrinsic factors including altered joint motion in the upper extremity may lead to altered biomechanics in tennis players and could result in symptoms of lateral elbow tendinopathy. PURPOSE: To compare upper extremity passive motion and elbow carrying angle between three groups of women: recreational tennis players with LET, non-symptomatic recreational tennis players, and a control group of non-tennis players. STUDY DESIGN: Cross-sectional. METHODS: A convenience sample of 63 women was recruited and placed into one of the three groups: non-symptomatic tennis players (NSTP), symptomatic tennis players (STP), and a control group. Elbow carrying angle, passive range of motion of the shoulder, elbow, forearm, and wrist were measured during a single session. RESULTS: A significant difference was found between the groups for wrist flexion (p < 0.00), forearm pronation (p = 0.002), elbow flexion (p = 0.020) and extension (p = 0.460), as well as shoulder internal rotation (p < 0.00). No significant differences were found in other motions or carrying angle between the three groups (p =0.059). Post-hoc comparisons indicated that shoulder internal rotation and wrist flexion was less in both STP and NSTP groups compared with the control group. Elbow flexion and forearm pronation were greater in STP than the other two groups. CONCLUSION: Impairments including loss of shoulder internal rotation and wrist flexion and greater motion at the elbow and forearm were found in the UE of symptomatic tennis players. Evaluation of passive motion and muscle length should be performed prior to establishing a rehabilitation plan for symptomatic tennis players. LEVELS OF EVIDENCE: 3.

A COMPREHENSIVE REHABILITATION PROGRAM FOR TREATING LATERAL ELBOW TENDINOPATHY.

Scapular muscle weakness in patients with lateral elbow tendinopathy is an identified impairment and is part of a multimodal rehabilitation approach. The published literature provides little information regarding specific rehabilitation guidelines that address both the proximal scapular muscle weakness and local elbow/wrist dysfunctions common in patients with lateral elbow tendinopathy. The purpose of this clinical commentary is to describe a comprehensive rehabilitation strategy for individuals with lateral elbow tendinopathy. This program emphasizes a phased therapeutic strategy that addresses proximal and local dysfunction along the kinetic chain. This clinical protocol is currently being tested for efficacy as part of a randomized controlled trial. The information in this commentary is intended to provide clinicians with sufficient detail to comprehensively guide the rehabilitation of a patient with lateral elbow tendinopathy. LEVEL OF EVIDENCE: 5.

Comparison of portable handheld versus fixed isokinetic dynamometers in measuring strength of the wrist and forearm.

Purpose: The purpose of this study was to test the concurrent validity of using hydraulic dynamometers in comparison to the gold standard isokinetic dynamometers in measuring wrist and forearm strength. Materials and methods: Healthy adults between the ages of 18-65 participated, including 24 participants, 8 men and 16 women. The examiner used a handheld dynamometer, forearm/wrist dynamometer, and an isokinetic dynamometer to measure force/torque production in forearm rotation and wrist flexion/extension using a standardized protocol of two handle types for each motion. Sequence of testing was randomized. The data were analyzed using Pearson correlation coefficients and paired t-tests. Results: When matched for handle type, three of the four correlations between the strength measurements taken with the different dynamometers were moderate to high with Pearson product moment coefficients ranging from 0.72 to 0.96; the screwdriver handle demonstrated less than acceptable correlation (r = 0.45, 0.67 for wrist flexion and extension, respectively). There were significant differences in most of the force/torque values obtained by different handle types for wrist and forearm motions. Discussion and conclusions: Overall, the dynamometers demonstrated acceptable correlations supporting concurrent validity for measuring forearm and wrist strength, except with the screwdriver handle. However, different tools, positions, and handle interfaces provided different absolute values, therefore the tools cannot be used interchangeably. It is recommended that repeated measurements to monitor patient progress are taken with the same tool and handle type.

CHRONIC UCL INJURY: A MULTIMODAL APPROACH TO CORRECTING ALTERED MECHANICS AND IMPROVING HEALING IN A COLLEGE ATHLETE- A CASE REPORT.

BACKGROUND: Ulnar collateral ligament (UCL) tears and associated Tommy Johns surgical intervention from excessive and poor quality pitching has increased immensely-with more college and professional pitchers undergoing the surgery in 2014 alone than in the 1990s as a whole.(1) Faulty mechanics developed at young ages are often well-engrained by the late adolescent years and the minimal healing ability of the largely avascular UCL often leads to delayed safe return to sport.(2). PURPOSE: The purpose of this case study was to describe an innovative, multimodal approach to conservative management of a chronic UCL injury in a college-aged baseball pitcher. This innovative approach utilizes both contractile and non-contractile dry needling to enhance soft tissue healing combined with standard conservative treatment to decrease pain and improve sport performance as measured by the Disabilities of Arm, Shoulder and Hand (DASH), Numeric Pain Report Scale (NPRS), and return to sport. STUDY DESIGN: Retrospective Case Report. CASE DESCRIPTION: A collegiate athlete presented to an outpatient orthopedic physical therapy clinic for treatment of UCL sprain approximately six weeks post-injury and platelet-rich plasma injection. Diagnostic testing revealed chronic ligamentous microtrauma. Impairments at evaluation included proximal stabilizing strength deficits, myofascial trigger points throughout the dominant upper extremity, improper pitching form, and inability to pitch in game conditions due to severe pain. Interventions included addressing strength deficits throughout the body, dry needling, and sport-specific biomechanical training with pitching form analysis and correction. OUTCOMES: Conventional DASH and Sport-Specific scale on the DASH and the numeric pain rating scale improved beyond both the minimally clinically important difference and minimal detectable change over the 12 week treatment(3,4) At 24-week follow up, conventional DASH scores decreased from 34.20% disability to 3.33% disability while sport-specific DASH scores decreased from 100% disability to 31.25% disability. Although initially unable to compete due to high pain levels, the subject is currently completing his pitching role full-time with 1/10 max pain. DISCUSSION: The approach used in this case study provides an innovative approach to conservative UCL partial tear treatment. Dry needling of both contractile and non-contractile tissue in combination with retraining of faulty mechanics may encourage chronically injured ligamentous tissue healing and encourage safe return to sport. LEVEL OF EVIDENCE: Level 4.

Risk management strategies in physical therapy: documentation to avoid malpractice.

PURPOSE: This article aims to highlight the importance of a complete and accurate medical record as it pertains to potential risk exposure in the outpatient physical therapy profession. DESIGN/METHODOLOGY/APPROACH: Basic charting rules, correction and alteration recommendations, documentation of telephone conversations, informed consent, exculpatory release forms and incident reports are discussed. Basic risk management strategies are reviewed that may reduce outpatient physical therapy practitioners' malpractice exposure. FINDINGS: The authors contend that quality and thorough documentation is as important as the quality of the care that is delivered to patients, since medical records are legal documents and serve as valuable evidence as to what transpired between patients and the healthcare providers. ORIGINALITY/VALUE: Practical documentation strategies are described in a manner that will inform physical therapists of their legal obligations relating to patient care.

Upper extremity strength characteristics in female recreational tennis players with and without lateral epicondylalgia.

STUDY DESIGN: Descriptive, cross-sectional. OBJECTIVES: To compare static strength characteristics of the upper extremity musculature in female recreational tennis players with lateral epicondylalgia to those of nonsymptomatic tennis players and a control group of women who did not play tennis. BACKGROUND: There is a paucity of research describing the relationship between lateral epicondylalgia and strength characteristics of the upper extremity musculature, despite the functional relationship between the shoulder, elbow, and wrist. METHODS: Sixty-three women were recruited into 3 groups (n = 21 per group): symptomatic tennis players (STP) with lateral epicondylalgia, nonsymptomatic tennis players, and controls. Data collection was performed during a single session, during which the strength of selected muscle groups of the dominant upper extremity was measured using a combination of force transducers. Strength ratios of selected muscle groups were then calculated. RESULTS: The STP group reported median pain level of 3/10 on a numeric pain rating scale and a symptom duration of 16 weeks. The STP group had weaker lower trapezius strength (mean difference, -9.0 N; 95% confidence interval [CI]: -13.5, -4.4) and wrist extensor strength (-12.7 N; 95% CI: -24.4, -1.1), and a higher shoulder internal/external rotation strength ratio (0.19; 95% CI: 0.02, 0.35) and upper/lower trapezius strength ratio (1.32; 95% CI: 0.41, 2.23), compared to those of the nonsymptomatic group. Compared to the control group, the STP group demonstrated a significantly higher shoulder internal/external rotation strength ratio (0.21; 95% CI: 0.04, 0.38) and wrist flexion/extension strength ratio (0.14; 95% CI: 0.01, 0.27). CONCLUSION: In this group of recreational female tennis players, significant differences in strength and strength ratio characteristics were identified. Although the design of the study precludes establishing a cause-and-effect relationship, the results suggest further study and treatment of the muscle groups of interest.

Static progressive splinting to improve wrist stiffness after distal radius fracture: a prospective, case series study.

This is the first prospective consecutive case series study that has examined the effectiveness of static progressive splinting in the management of persistent wrist stiffness following distal radius fracture. Eight patients, seven females and one male with a median age of 49 years (range, 43-56 years), participated in the study. Median time from surgical intervention to splint initiation was 77 days (range, 58-148 days). The median duration of splint use was 88 days (range, 21-180). Four subjects were followed for 6 months, and four were followed for 1 year. The median total passive sagittal range of motion of the wrist improved from 65 degrees to a median of 106 degrees at 12 weeks, to 115 degrees at 6 months and to 125 degrees at 1 year after splint initiation. The median disability scores for the arm, shoulder, and hand based on the DASH improved from 42 points to 19 points at 12 weeks, to 14 points at 6 months and at 1 year after splint initiation. The outcome measures of this prospective study indicate that static progressive stretch splints may be useful in treating persistent wrist stiffness following distal radius fracture especially when used early in the rehabilitation process.

Changes in impairment and function after static progressive splinting for stiffness after distal radius fracture.

The purpose of this study was to describe changes in range of motion, grip strength, and function in subjects treated with static progressive splinting for stiffness after distal radius fracture. A retrospective review was conducted on 25 patients; outcomes reviewed included wrist/forearm motion, grip strength and Disability of the Arm, Shoulder, and Hand (DASH) scores. The Wilcoxon-Signed Rank test was used to assess differences between pre-/postsplinting outcome measurements. Spearman correlation coefficients were calculated for the DASH scores with each of the other measurements. Wrist extension and flexion improved 18.6 (p<0.0001) and 11.4 degrees (p<0.0001), respectively. Forearm pronation and supination improved 20.0 (p<0.0001) and 14.5 degrees (p<0.0001), respectively. Grip strength improved 24.5 pounds (p=0.0012). The median DASH score improved from 43 to 19 (p>0.0001). DASH scores demonstrated a significant negative correlation with wrist extension (r=-0.50, p=0.011) and forearm supination (r=-0.47, p=0.02). Increased wrist extension and supination correlated with better functional outcome as reflected by the DASH scores.