2020 Research Updates

January Research Update

A Prospective, Randomized Trial Comparing Open and Endoscopic Carpal Tunnel Release Within the Same Patient
Summary provided by Nancy Naughton, OTD, OTR/L, CHT

A prospective randomized controlled trial compared open and endoscopic carpal tunnel release techniques. The goal was to prospectively examine various outcomes, patient satisfaction and complications after both ECTR and OCTR in the opposite hands of the same patient. Thirty subjects with bilateral CTS were included and underwent surgical release with both techniques.

Several outcome measures were utilized and included pain score, two-point discrimination, Semmes-Weinstein monofilament testing, thenar strength testing, grip strength, carpal tunnel syndrome functional status score, carpal tunnel syndrome symptom severity score and overall satisfaction.

The results reflected no significant differences in any measure at any of the postoperative time points. Although pain scores were not found with a statistically significant difference, 24 of 30 patients subjectively reported a preference for the endoscopic technique, citing pain as the primary reason. The authors concluded no difference in outcomes with either technique and due to the increased cost and equipment associated with ECTR, the usefulness of ECTR is questionable.

Brett M. Michelotti, Kavita T. Vakharia, Diane Romanowsky, Randy M. Hauck. A Prospective, Randomized Trial Comparing Open and Endoscopic Carpal Tunnel Release Within the Same Patient. HAND Nov. 2017

Journal Source: HAND

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Note: For non Journal of Hand Therapy articles: If you or your institution cannot access the complete article via the link, please contact Cindy Ivy, OTD, CHT, M.Ed, ASHT Research Division Director at Cynthia.Ivy@nau.edu.

February Research Update

Influence of postoperative immobilization on pain control of patients with distal radius fracture treated with volar locked plating: A prospective, randomized clinical trial
Summary provided by Cindy Ivy, OTD, CHT, M.Ed

This prospective RCT of 39 subjects compares pain scores between two groups of patients who underwent volar locked plating for distal radius fractures. One group received a post-operative splint to use for two weeks, whereas the other group had a post-operative bandage. The purpose of the study was to not only compare pain scores, but also compare the use of opioid use in the two groups. The use of Tramadol was tracked while in the hospital through the records and at home through a form that the patient filled out. The Disabilities of the Arm Shoulder and Hand score was assessed at six, 12 and 24 weeks and wrist flexion/extension and forearm rotation were assessed at two, six, 12 and 24 weeks by evaluators who were blinded to the treatment group. In addition, a pain scale, edema, a patient satisfaction scale and radiographs were obtained at set intervals. Although there was not a significant difference in pain scores or in Tramadol use, there was a trend toward higher Tramadol use in the no splint group. The authors determined this to be clinically relevant due to the possible harm from opioid use. They also had one subject in the no splint group who lost the fracture reduction; however, this low number is not significant and does not imply causation. The researchers’ data showed no difference in functional outcomes, edema or patient satisfaction between the two groups. The study shows a trend of increased opioid use in the no splint group/early wrist mobilization group with no difference in pain, satisfaction or functional outcomes between the two groups. The fact that the no splint group was using more Tramadol may influence the comparison of pain scores. The authors point out that reasons for immediate immobilization include osteosynthesis protection and controlling pain caused by active and involuntary movements during the early postoperative phase of healing.

F.B. Andrade-Silva, et al., Influence of postoperative immobilization on pain control of patients with distal radius fracture treated with volar locked plating: A prospective, randomized clinical trial, Injury (2018), Volume 50, Issue 2, Pages 386-391. February 2019

Journal Source: Injury

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March Research Update

Relative Motion Flexion Splinting for Flexor Tendon Lacerations: Proof of Concept
Summary provided by Nancy Naughton, OTD, OTR/L, CHT

A cadaveric study examined the viability of relative motion orthoses following a flexor tendon repair. The researchers examined four fresh frozen cadavers. A tenotomy was made in the FDP tendon of the middle fingers (zone III) and immediately repaired. The researchers measured elongation with and without the relative motion splint as well as accessing gapping of the tendon. The results revealed elongation was restricted to less than 1.3mm in repaired tendons in the relative motion flexion orthosis compared to elongation >2mm in the fingers without an orthosis. Visual inspection revealed no tendon gapping with the relative motion orthosis on. The researchers conclude that relative motion orthosis decreases elongation and eliminates tendon gapping in cadaver models. Therefore, the authors suggest that a relative motion orthosis may be a viable protective option for flexor tendon repairs. This consideration will allow for further research examining early tendon motion and less restricted hand function during the post-operative and rehabilitation phase.

Bryan Chung, David T. W. Chiu, Vishal Thanik. Relative Motion Flexion Splinting for Flexor Tendon Lacerations: Proof of Concept. HAND 2019 14(2):193-196

Journal Source: HAND

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April Research Update

The optimal position for arthrodesis of the proximal interphalangeal joints of the border digits
Summary provided by Lori Algar, OTD, OTR/L, CHT

Is there an optimal position for arthodesis of the PIP joints of the border digits in regards to functional performance?

This study simulated arthrodesis of the PIP joint of the index and small fingers via custom orthoses in healthy individuals. The pseudo fused positions were at 25 degrees, 40 degrees and 55 degrees of flexion for the index digit and at 30 degrees, 55 degrees and 40 degrees of flexion for the small digit. Twenty-three participants performed grip and pinch (key, tripod and pulp) strength testing with and without digit fusions as noted above and 25 participants performed the Jebsen Hand Function Test (JHFT) with and without simulated arthrodesis also as noted above in order to assist with gathering information on preferred positioning for border digit arthrodesis. The authors conclude that no border digit PIP joint fusion position was superior related to grip and pinch strength; however, index digit PIP joint fusion at 40 degrees and small digit PIP joint fusion at 55 degrees might be preferred based on performance on the JHFT.

Fram, BR, Seigerman DA, Cross DE, et al. The optimal position for arthrodesis of the proximal interphalangeal joints of the border digits. J Hand Surg. In press

Journal Source: Journal of Hand Surgery

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May Research Update

Early Versus Late Motion Following Volar Plating of Distal Radius Fractures
Summary provided by Nancy Naughton, OTD, OTR/L, CHT

Following a distal radius fracture, does early motion have better outcomes than late motion?

A prospective clinical trial randomly assigned 33 patients following a distal radius fracture with volar plate fixation to either an early motion or late motion group.

The early motion group began by 14 days post-surgery and included both active and passive ROM. The late motion group received the same treatment but began at five weeks post-surgery. Outcomes of interest included motion, strength, DASH and the PRWE. All outcomes were assessed through one year. The early motion group had improved outcomes up to the six-week interval. There were no differences between groups for long term outcomes.

The late motion group had two complications: one patient developed CRPS and the other developed adhesive capsulitis. This led the authors to question if delayed motion may lead to potential complications not found with patients receiving early motion.

David G. Dennison, Charlene L. Blanchard, Bassem Elhassan, Steven L. Moran, Alexander Y. Shin. Early Versus Late Motion Following Volar Plating of Distal Radius Fractures. HAND (N Y). 2020 Jan;15(1):125-130. Epub 2018 Jul 15.

Journal Source: HAND

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June Research Update

Utility of the iPhone 4 Gyroscope Application in the Measurement of Wrist Motion
Summary provided by Katherine Loomis, MA, OTR/L, CHT

This cross-sectional study evaluates the accuracy and ease of use of the iPhone gyroscope application compared to goniometer measurement to assess wrist range of motion. Measurements were taken of 306 adult wrists without pathology present using both techniques for wrist flexion, extension, radial deviation and ulnar deviation. The measurements were then compared and analyzed. To obtain the gyroscope measurement, the phone was placed against the dorsal hand. The study found that wrist motion measured similarly with both the iPhone gyroscope and goniometer techniques, with the only statistically significant difference being an average of 1 degree of wrist flexion; however, the authors experienced some technical difficulties when using the gyroscope application, such as its inability to detect the position of the forearm relative to the hand, and needing to subtract the initial angle from the measured angle. The authors conclude that these difficulties present a barrier for patient use of the application for self-assessment. The authors recommend additional features that could increase the application’s ease of use, such as a reset button for starting position or a strap to secure the phone to the dorsal hand. Further research is recommended to refine the use of the application in a rehabilitation setting.

Nuphar Lendner, Erik Wells, Idit Lavi, Yan Yan Kwok, Pak-Cheong Ho, Ronit Wollstein. Utility of the iPhone 4 Gyroscope Application in the Measurement of Wrist Motion. HAND 2019 14(3): 352-356

Journal Source: HAND

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July Research Update

A Comprehensive Rehabilitation Program for Treating Lateral Elbow Tendinopathy
Summary provided by Erika Lewis, PT, EdD, MS, CHT

This article discusses the importance of strengthening the scapular muscles in patients with lateral elbow tendinopathy and presents a comprehensive clinical program to treat lateral elbow tendinopathy. Research has shown that patients with lateral elbow tendinopathy have scapular weakness thus increasing the demand on the distal portion of the extremity. There is little published literature on specific rehabilitation guidelines addressing both the scapular muscle weakness and the elbow and wrist issues related to this diagnosis. This very specific program developed by experienced clinicians offers a menu of exercise options, grouped by rehabilitation phases, that addresses both areas of weakness and provides a progression along the rehab continuum. The clinical program includes recommendations on all aspects of treatment such as cryotherapy, soft tissue mobilization and joint mobilization. This clinical commentary is helpful for offering guidance in treating your patients with lateral elbow tendinopathy. A randomized controlled trial is being conducted on this clinical protocol so stay tuned.

Day, JM, Lucado, AM, Uhl, TL. A Comprehensive Rehabilitation Program for Treating Lateral Elbow Tendinopathy. IJSPT. Vol. 14:5. October 2019. pp. 818-834

Journal Source: IJSPT

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August Research Update

Early Results of Surgical Treatment of Triangular Fibrocartilage Complex Tears in Children and Adolescents.
Summary provided by Jenny Dorich, MBA, OTR/L, CHT

This retrospective study evaluated the outcomes of children under 19 years old who underwent surgery for triangular fibrocartilage complex (TFCC) tears. The results of 153 wrists in a 149 patients who had TFCC injury confirmed through arthroscopy were included. All patients had a history of persistent ulnar-sided wrist pain and/or functional limitations after six months of conservative treatment. Treatment prior to surgical intervention included wrist orthoses, activity modification, anti-inflammatory medication, corticosteroid injections and psychical therapy. Fifty-six percent of the patient population had a history of traumatic injury.

The specific surgical procedure used to address the TFCC pathology was dependent upon the classification of the TFCC pathology. Following surgery, patients were immobilized in a long arm cast for four weeks and a short arm cast for an additional two weeks. Six weeks after surgery, therapy was initiated, and intervention included range of motion, scar management, isometric and then isotonic strengthening and proprioceptive retraining.

Outcome measures included the Modified Mayo Wrist Score (MMWS) and the PROMIS Upper Extremity Short Form. Pain at rest and with activity was rated as at rest and during activity as no pain, mild pain, moderate or severe pain. At final clinical follow up (median 15.4 months), patients had significant improvement in pain, DRUJ stability and MMWS scores. MMWS scores at final follow up were distributed as 65 (61%) excellent, 21(20%) good scores, 12 (11%) fair scores and six (6%) poor scores. PROMIS scores were available on at subset of patients (n= 57). The median t-score was 57 (IRQ 45-57). By a median of 4.1 months (IRQ) following surgery, all patients returned to functional/athletic at the following levels full (83%), restricted (7%) or low-demand (9%). Twenty-nine (19%) of the wrists underwent a secondary surgery due to persistent pain.

This study provides contributes to the limited evidence available on the management and treatment outcomes of children with TFCC pathology.

Wu, M., Miller, P. E., Waters, P. M. & Bae, D. (2020). Early Results of Surgical Treatment of Triangular Fibrocartilage Complex Tears in Children and Adolescents. The Journal of Hand Surgery, 45(5), 449 – e1

Journal Source: The Journal of Hand Surgery

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September Research Update

Occupational Neuroplasticity in the Human Brain: A Critical Review and Meta-Analysis of Neuroimaging Studies
Summary provided by Cindy C. Ivy, M.ED, OTD, CHT

Hand therapists rely on the concept of neuroplasticity when rehabilitating upper extremity injuries that have affected mapping in the primary motor and sensory cortices, and other areas of the brain. While the brain continues to reorganize and change throughout life, the concept of neuroplasticity refers to the brain’s adaptation to external and internal factors with changes of structure and function. This meta-analysis introduces the concept of “occupational neuroplasticity.” The authors review studies of the neuroimaging of athletes, taxi drivers, musicians, dancers, simultaneous interpreters, acupuncturists, seafarers, mathematicians, pilots and creative writers to explore neuroplastic changes in the brain that may be driven by these professions. The review excluded studies that did not compare experts with novices, did not report on brain activation as a result or contained fewer than three stereotactic coordinates in imaging.

The results show clusters of changes in the brain when comparing experts to novices. While studying of occupations implies more than repetitive training (i.e. numerous considerations such as environmental, social, genetic, etc.), there are implications for therapists when choosing interventions for generating neuroplasticity. This study enriches our knowledge on neuroplasticity and presents new questions. It remains unclear whether neuroplasticity is principally determined by nature or nurture or both; however, the study of groups (occupational groups in this case) over time adds to the body of knowledge and brings insight and context to the use of purposeful, meaningful and repetitive activities in the hand therapist’s intervention strategies.

Wu H, Yan H, Yang Y, Xu M, Shi Y, Zeng W, Li J, Zhang J, Chang C and Wang N (2020) Occupational Neuroplasticity in the Human Brain: A Critical Review and Meta-Analysis of Neuroimaging Studies. Front. Hum. Neurosci. 14:215.

Journal Source: Frontiers in Human Neuroscience

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October Research Update

Inclusion and Perception of Hand Therapy Content in Occupational Therapy Programs: A Mixed Methods Study
Summary provided by Lisa Kozden, MOT, OTR/L, CHT, COMT

Hand therapy is a specialized area of rehabilitation practiced by both occupational and physical therapists. Of the only 6,228 Certified Hand Therapists worldwide (Hand Therapy Certification Commission, 2020), less than 7 percent are younger than 35 years of age. In the next 10 years, over 25 percent of experienced CHTs will be of retirement age. These statistics emphasize the urgent need for occupational and physical therapy graduates to seek specialization in hand and upper extremity therapy. Researchers have found that specific content of occupational therapy students’ curricula can influence how prepared they are for clinical practice after graduation. Because hand therapists strongly rely on the biomechanical approach to evaluation and treatment of clients, OT students pursuing this specialty practice require a detailed understanding of anatomy and conditions affecting the upper extremity. There is, however, a paucity of research regarding this content in OT educational programs.

The purpose of this mixed methods study was to examine how hand therapy content is included in entry-level occupational therapy programs and to explore the perspectives of the faculty on this matter. Investigators developed surveys that were emailed to all accredited entry-level and doctoral level occupational therapy programs nationwide. Those who responded to the survey were also invited to participate in a semi-structured interview by telephone. Of the 183 surveys sent, 43 were completed and returned to investigators. Of the 43 respondents, two agreed to be interviewed.

Results demonstrated that although most programs included a similar amount of hours dedicated to hand therapy content, the authors found great variability in the type of content, particularly in the subject of anatomy. Respondents disagreed about whether or not hand therapy content was too specific for inclusion in a program designed to prepare students for entry-level practice. This discord may represent a gap in understanding between OT educators and clinicians as to what is expected for students to know as they begin clinical practice. Overall, participants agreed using occupation-based model in teaching hand therapy was necessary to support the philosophy of the profession, which is treatment of the whole person who engages in occupations within a variety of contexts. Focusing on the occupational performance of a client’s upper extremity would benefit OT students as they prepare for entry into general and specialized practice areas, including hand therapy. Lastly, this study emphasized the importance of ongoing communication among educators and clinical instructors in promoting optimal learning opportunities for the future generations of occupational therapists to come.

Short, N., Bain, J., Barker, C., Dammeyer, K., Fahrney, E., Hale, K. & Nieman, C. (2020). Inclusion and perception of hand therapy content in occupational therapy programs: A mixed methods study. Journal of Hand Therapy, 33(1), 112-118.

Journal Source: Journal of Hand Therapy

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November Research Update

Association between upper extremity dysfunction and sleep disturbance in an elderly general population
Summary provided by Sarah B. Doerrer, PhD, OTR/L, CHT, CLT

This study examined if there was a relationship between upper extremity disability measured by the QuickDASH (Japanese version) and sleep disturbance measured by the Athens Insomnia Scale (Japanese version) in the Japanese elderly population. In addition, the authors of this study collected quality of life using the EuroQol-5-dimension-3-level (Japanese version) and bilateral grip strength. The EuroQol-5-dimension-3-level (Japanese version) also included a visual analog scale for individuals to rate their overall health.

The total sample was 159 with there being 56 men and 103 women with a mean age of 66.4 years. No definitive diagnosis was given to subjects in this study. BMI was also collected for each subject.

For data analysis, subjects were grouped by insomnia levels. Subjects who scored more than six on the Athens Insomnia Scale were grouped in the pathological insomnia group, subjects with a score of 4 or 5 were grouped in the suspected insomnia group and the subjects who scored less than 5 were grouped in the no sleep disturbance group. For some analysis, the authors then combined the insomnia group and the suspected insomnia groups (45 subjects total).

Results showed that subjects with insomnia had worse upper extremity disability, worse quality of life and worse self-reported health status. Dominant grip strength was significantly lower in subjects with insomnia compared to subjects with no sleep disturbance. For subjects with pathological insomnia (19), those subjects had significantly worse QuickDASH scores than those subjects with no sleep disturbance.

The authors concluded with results of their study that the self-assessed health status of upper extremities is associated with pathological insomnia in the elderly population.

Tajika, T., Kuboi, T., Endo, F., Shinagawa, S., Kobayashi, H., Hashimoto, S., ... & Shitara, H. (2020). Association between upper extremity dysfunction and sleep disturbance in an elderly general population. SAGE Open Medicine, 8, 2050312120901584.

Journal Source: SAGE Open Medicine

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Note: For non Journal of Hand Therapy articles: If you or your institution cannot access the complete article via the link, please contact Nancy Naughton, OTD, OTR/L, CHT, ASHT Research Division Director at nancynaughton10@gmail.com.

December Research Update

Looking Further When Symptoms Are Disproportionate to Physical Findings
Summary provided by Erika Lewis, PT, EdD, MS, CHT

A 36-year-old man competitive ice hockey player developed ulnar-side wrist pain without acute injury. The pain prevented him from playing ice hockey and golf; however, testing in a position of wrist extension and ulnar deviation revealed only minor pain. The disability appeared disproportionate to the injury. The first author evaluated further and noticed a commonality of supination in the provoking activities. Based on literature, three additional tests were conducted to test the stability of the ECU: ECU Synergy test, The Serpent Head test and the Ice Cream Scoop test. Two out of the three tested positive. They found that by testing with the forearm in supination, they were able to reproduce the pain and had ECU tendon snapping indicating subluxation. The take-home message of the case report was to explore further and not assume secondary gain. This patient was treated with wrist orthosis and was able to return to hockey six months later, although he had to play hockey less frequently. He continued to have residual pain and weakness.

Brief descriptions of the three tests provided by the authors:

The ECU Synergy test is performed with the elbow flexed at 90 degrees and forearm fully supinated. The patient holds the digits in extension and wrist in neutral, then resists the examiner’s attempt to adduct the thumb causing the ECU as a wrist stabilizer. This could cause the tendon to sublux in the presence of instability.
The Serpent Head was briefly described as the patient holding his or her wrist in flexion and the examiner rotates the wrist between full pronation and supination against resistance and watches the ulnar side of the wrist for a sudden clunk of the ECU tendon.
The Ice Cream Scoop test mimics scooping ice cream and requires the patient to be in a pronated, wrist extended and ulnarly deviated position, then moving into full supination and flexion. A positive test is an audible and palpable subluxation, along with pain. Adding resistance is recommended.

Shrier, I., D.R. Morrison and R. Hawkes. Looking Further When Symptoms Are Disproportionate to Physical Findings. Med. Sci. Sports Exerc., Vol. 51, No. 1, PP. 1-3, 2019.

Journal Source: Med. Sci. Sports Exerc.

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