January Research Update
A Medical Mystery of Complex Regional Pain Syndrome
Summary provided by Cynthia Ivy, M.ED, OTD, CHT
The authors use a systematic approach to reviewing the literature on complex regional pain syndrome (CRPS) reviewing 95 papers on diagnosis and treatment, making a nice go-to piece to review the theories on the disease, the diagnostic criteria and evidence-based research on interventions.
Of note, the authors point out that mechanisms of CRPS may be both peripherally and centrally involved, and differ among patients and within the same patient over time. Fractures and sprains represent 60% of CRPS patients. They discuss clinical trials showing that the most commonly used therapeutic intervention of sympathetic ganglion nerve blocks are probably ineffective for average patients. Furthermore, they describe a shift toward a focus on functional abilities over pain control as the primary goal of treatment. A treatment algorithm explains therapeutic interventions and approaches based on the severity of the condition, including physical and occupational therapy in all stages. They do not recommend mirror therapy and graded motor imagery until the chronic stage. The article includes two tables outlining the International Association for the Study of Pain diagnostic criteria for CRPS and a modified version that may be helpful for the hand therapist.
The pathophysiology of CRPS is described as initial tissue trauma and/or nerve injury inciting peripheral sensitization and inflammation and nociceptive neuron density. Together, along with genetic susceptibility, there is spinal central sensitization, which will affect the limb’s representation in the somatosensory cortex. In addition, the peripheral sensitization will stimulate the adrenal glands to circulate catecholamine and cause sympathetic outflow causing a cycle of emotional arousal and increased sympathetic outflow and adrenal gland stimulation.
The role of brain plasticity is described in that neuroimaging studies show a significant decrease in a region of the somatosensory cortex that represents the CRPS-affected body part compared to unaffected body parts, with the notion that these alterations would return with proper control of pain.
At the conclusion of this review, it is clear that increased study of the purpose and effectiveness of therapeutic interventions used in hand therapy are crucial to the advancement of our management of this complex disease.
Citation: Jabril Eldufani, Nyruz Elahmer, Gilbert Blaise, A medical mystery of complex regional pain syndrome, Heliyon, Volume 6, Issue 2, 2020, e03329, ISSN 2405-8440
Journal Source: Heliyon
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February Research Update
Effects of Virtual Reality-Based Rehabilitation on Burned Hands: A Prospective, Randomized, Single-Blind Study
Summary provided by Lori Algar, OTD, OTR/L, CHT
Does virtual reality-based rehabilitation improve hand function after a hand burn more effectively than conventional rehabilitation?
Fifty-seven individuals with hand burns were randomized to either receive virtual reality-based therapy or conventional rehabilitation after re-epithelialized split thickness skin grafting. Conventional therapy included range of motion and strengthening exercises, desensitization and manual lymphatic drainage. The virtual reality therapy involved the use of a smart glove to virtually complete tasks with the involved hand, such as squeezing an orange and casting a fishing pole in addition to some components of conventional therapy. Researchers found that the Jebsen-Taylor hand function test and MHQ scores (for hand function, functional ADL, work, pain, aesthetics and patient satisfaction) were significantly higher in the virtual reality group than in the conventional treatment group following four weeks of intervention. Grip and pinch strengths improved in both groups without a significant difference between groups after treatment. This study suggests that virtual reality treatment should be considered for individuals with hand burns.
Citation: So Young Joo, Yoon Soo Cho, Seung Yeol Lee, Hyun Seok, Cheong Hoon Seo, Effects of Virtual Reality-Based Rehabilitation on Burned Hands: A Prospective, Randomized, Single-Blind Study, J. Clin. Med. 2020, 9, 731
Journal Source: Journal of Clinical 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.
March Research Update
Predictors of Hand Function Following Digit Replantation: Quantitative Review and Meta-Analysis
Summary provided by Katherine Loomis, MA, OTR/L, CHT
This quantitative review and meta-analysis evaluates functional outcomes following digit replantation to identify predictors of hand function. The review was performed using PubMed and resulted in a sample of 28 studies with a total of 618 replanted digits. Inclusion criteria selected studies that evaluated functional status after replantation, focused on digital amputation, had a sample size of at least four patients and studies that presented individual patient data. Studies characterized as reviews, meta-analyses or care reports and studies that examined more proximal amputations or heterotopic replantations were excluded. Using statistical analysis across the pooled data set, patient attributes and injury details were compared to the outcome measures of sensation, grip strength and disabilities of the arm, shoulder and hand (DASH) score. Grip strength and sensation were chosen based on the results of previous studies showing them to be reliable measures of hand function for patients after hand injury. The study found that more proximal digital injuries were correlated with lower grip strength outcomes, and that two-point discrimination scores differed based on age, mechanism of injury and level of amputation. Mechanism of injury and amputation level were found to predict DASH scores. Factors that did not significantly impact outcome measures include gender, tobacco use, ischemia time and which digit was replanted. The authors suggest that these results can be used to inform the decision for replantation and expectations of function after replantation.
Citation: Shaterian, A., Sayadi, L.R., Tiourin, E., Gardner, D. J., Evans, G. R. D., Leis, A. (2021). Predictors of Hand Function Following Digit Replantation: Quantitative Review and Meta-Analysis. HAND (New York, N.Y.), 16(1), 11–17.
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 Nancy Naughton, OTD, OTR/L, CHT, ASHT Research Division Director at nancynaughton10@gmail.com.
April Research Update
The Effect of Orthoses on the Kinematics of the Trapeziometacarpal, Scaphotrapeziotrapezoidal, and Radioscaphoid Joints
Summary provided by Corey McGee, PhD, OTR/L, CHT
Vanneste, Stockmans, and Vereeckee (2021) used a within-subjects design to measure the effects of orthotic design (custom vs. prefabricated) and orthosis base location (forearm vs. hand) on the kinematics of the 1st carpometacarpal (CMC), scaphotrapeziotrapezoidal (STT) and radioscaphoid (RS) joints in the dominant hands of healthy participants. The purpose of the study was to investigate if and how commonly used orthoses for persons with osteoarthritic thumb and wrist joints reduce motion differently.
Joint motion was quantified via CT and 3D motion analysis. Participants were randomized to a custom-design group (n=6) and a prefabricated design group (n=12) and joint mechanics were measured in each participant during selected physiologic joint movements of the wrist (i.e. maximal active flexion-extension and maximal active ulnar-radial deviation) and thumb CMC (i.e. maximal palmar abduction-adduction and maximal flexion and extension) 1) without an orthosis, 2) when wearing a hand-based thumb immobilization orthosis and 3) when wearing a forearm-based wrist and thumb CMC/MP mobilization orthosis. The two prefabricated orthoses were the Push MetaGrip CMCTM Thumb Brace and Thuasne Ligaflex ManuTM and the two custom orthoses were volar hand-based thumb CMC/MP immobilization and radial forearm-based wrist and thumb CMC/MP immobilization designs.
This was the first study of its kind and it offers evidence to support the validity of our assumptions on the mechanical benefits of orthotic devices. Moreover, it offers some evidence to support the unique skills of the hand therapist in that a customized thumb orthosis offers greater stability to a thumb CMC joint during abduction/adduction than does a commercial device and customized forearm-based thumb wrist, thumb MP and CMC stabilization orthosis offers better radiocarpal joint immobilization than does the prefabricated comparator. However, when attempting to immobilize only the STT joint, the immobilizing effects of the custom and prefabricated forearm-based orthoses did not statistically differ.
The study does, however, raise some questions and concerns. The author’s choice of experimental design was curious and the groups were small and unbalanced. Additionally, these findings may not translate to those with OA in these joints and they may not generalize to other custom or prefabricated designs. Lastly, the designs of the hand-based orthoses were different in that the custom orthosis immobilized the MP joint whereas the prefabricated orthosis did not. For this reason, the more appropriate comparator to the Push MetaGrip CMCTM would have been a custom orthosis which only immobilized the thumb CMC.
Citation: Vanneste M, Stockmans F, Vereecke EE. The Effect of Orthoses on the Kinematics of the Trapeziometacarpal, Scaphotrapeziotrapezoidal, and Radioscaphoid Joints. Journal of Orthopaedic Research. 2021;39(1):196-203. doi:10.1002/jor.24700.
Journal Source: Journal of Orthopaedic Research
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May Research Update
The Effect of Orthoses on the Kinematics of the Trapeziometacarpal, Scaphotrapeziotrapezoidal, and Radioscaphoid Joints
Summary provided by Lori Algar, OTD, OTR/L, CHT
Is there a role for extracorporeal shock wave therapy in the treatment of hypertrophic scars caused by hand burns?
Extracorporeal shock wave therapy (ESWT) is a therapeutic modality gaining some momentum in treating skeletal and orthopedic injuries. This particular study involved 48 individuals with hypertrophic hand scars who were less than six months from sustaining a burn to the right dominant hand that required split thickness skin grafting and admission to the therapy department. All study participants received routine occupational therapy services and either ESWT or a sham one time per week for four weeks. The individuals in the ESWT group had a greater improvement in pain score, scar thickness, scar vascularity and hand function for turning cards and picking up small objects. The authors concluded that ESWT is effective for decreasing pain, suppressing hypertrophic scarring and improving hand function for individuals with symptomatic hand scarring following a burn.
Citation: Joo SY, Lee SY, Cho YS, Seo CH. Clinical utility of extracorporeal shock wave therapy on hypertrophic scars of the hand caused by burn injury: a prospective, randomized, double-blinded study. J Clin Med. 2020; 9, 1376.
Journal Source: Journal of Clinical 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.
June Research Update
Delayed Extension Block Pinning in 27 Patients with Mallet Fracture
Summary provided by April Bryant, M.S., OTR/L, CHT
How does delayed surgical treatment (<21 days) of bony mallet finger affect patient-reported functional outcomes and complication rate?
Untreated mallet fingers have been shown to cause extension lag, osteoarthritis, swan neck deformity and persistent joint stiffness. This single-center retrospective cohort study examined the effects of delayed surgical treatment of mallet fingers. Twenty-seven patients with 27 bony mallet fingers were treated with either closed or open reduction of mallet finger with K-wire. Patients reported a median pain score of zero at rest and under pressure. Numbness and cold intolerance were also reported by 15 percent and 41 percent of patients, respectively. Patient-Rated Wrist and Hand evaluation (PRWHE) found that patients' overall function was adequate, though 67 percent of patients indicated limited ROM. Patients were overall pleased with the appearance of the finger and would recommend the surgery to family and friends. None of the patients exhibited signs of non-union or contacted the office with complaints post-operatively. This study suggests that delayed surgical treatment of mallet fingers results in adequate function and a low complication rate.
Citation: Kootstra, T. J., Keizer, J., van Heijl, M., Ferree, S., Houwert, M., & van der Velde, D. (2019). Delayed Extension Block Pinning in 27 Patients With Mallet Fracture. HAND, 16(1), 61–66.
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 Nancy Naughton, OTD, OTR/L, CHT, ASHT Research Division Director at nancynaughton10@gmail.com.
July Research Update
Complex Regional Pain Syndrome
Summary provided by Gretchen Bachman, OTD, OTR/L, MBA, CHT and April Bryant, M.S., OTR/L, CHT
This article describes complex regional pain syndrome (CRPS), reviews the diagnostic criteria for CRPS and proposes an algorithm for the management of CRPS based on the current literature. The Budapest Criteria has been commonly used to diagnosis of CRPS. In 2017, the CRPS Severity Score (CSS) was validated and is a hopeful tool to help streamline further clarification of CRPS diagnosis. The etiology of CRPS is still not clearly understood and a multidisciplinary approach to the treatment of CRPS is recommended. CRPS treatment methodology can be separated into acute and chronic stages, and physical and occupational therapy is beneficial in each stage. Research related primarily to therapy purports graded motor imagery, mirror therapy, manual therapy and biofeedback to reduce pain and improve the use of the extremity. Additionally, acupuncture, pharmacologics and spinal cord or dorsal root ganglion stimulators are also evidence-based modalities used in the management of CRPS. Varied therapeutic strategies unique to the individual and in concert with additional multi-modal interventions are critical to the recovery.
Citation: Neumeister MW, Romanelli MR. Complex Regional Pain Syndrome. Clin Plast Surg. 2020;47(2):305-310.
Journal Source: Clin Plast Surg.
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August Research Update
Shared decision making in youth with brachial plexus birth injuries and their families: A qualitative study.
Summary provided by Jenny Dorich, MBA, OTR/L, CHT
The objective of this qualitative interpretive study was to elucidate the decision-making experiences of youth with brachial plexus birth injuries (BPBI) when examining treatment options for elbow flexion contractures, a common sequela of BPBI. Findings from this study are intended to inform the development of a shared decision-making support tool for youth with a BPBI who are seeking treatment for elbow flexion contractures.
Data collection was achieved through semi-structured interviews with patients and their parents. Interview participants included five young adults and 14 youth, mean age 17.6 +/- 3.9 years (8.3 – 23.9 years) at the time of the study, and nine mothers and four pairs of parents who were interviewed alongside their children. Additionally, field notes and researcher-created drawings from observations of clinicians and families engaged in treatment consultation were included in the data analysis. Fifteen treatment consultations with children 2-16 years were observed. Treatment consultations included the patients and their families and a multidisciplinary healthcare team. Data collection and analysis was performed iteratively until saturation of themes.
The study elucidated four related themes pertaining the youths’ decision-making experiences. First, the youth possessed trust in the expertise of the clinician. This trust serves as either a facilitator or a barrier in the shared decision-making experience. The second theme was the youth’s role in the shared decision. Parents’ perceptions of their child’s developmental maturity affect the extent to which the youth are involved in the decision making. Further, the nature of the decision further impacts parents’ acknowledgement of the child’s assent or dissent. The third theme, parental perceived responsibility, provides insight into the parent perspective. Some parents expressed dedication to accepting any intervention that could reduce elbow flexion contractures. Further, parents identified that declining rehabilitation treatment could become a source of parental regret. The final theme was youth-parent decision discord. Often, parents desire treatment to address elbow flexion contractures more than their children. This conflict between parents and the youth was not always openly expressed during the shared decision-making experience. Parents desired exhausting all treatment options in hope of future medical advancements. Conversely, some youth expressed being content with their contractures and experiencing negative social consequences from undergoing treatment.
Study findings illustrate the complexity of the shared decision-making experience for youth with BPBI and their families when exploring treatment options for elbow flexion contractures. Youth require opportunities during the shared decision-making experience to express their perspectives. Clinicians can facilitate elucidating youths’ voices in the shared decision-making experience by using a decisional support tool and employing a strengths- and needs-based approach during the treatment consultation.
Citation: Ho, E. S., Parsons, J. A., Davidge, K. M., Clarke, H. M., & Wright, F. V. (2021). Patient Education and Counseling. In Press.
Journal Source: Patient Education and Counseling
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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.
September Research Update
Radiographic Healing and Functional Outcomes of Untreated Ulnar Styloid Fractures Following Volar Plate Fixation of Distal Radius Fractures: A Prospective Analysis
Summary provided by Sophie Goloff, MS, OTR/L, CHT
This prospective cohort study compares functional outcomes following distal radius fracture (DRFs) treated with a volar locking plate either with or without a concomitant ulnar styloid fracture (USF). There is no current consensus on the ideal treatment strategy for USFs, or whether they affect functional outcomes. The authors hypothesized that there would be no difference in clinical outcome or reoperation rate between DRF patients with or without an associated USF of any type or union status.
Participants included 134 patients who sustained a DRF that was treated with open reduction internal fixation via volar locking plate with (n=70) or without (n=64) a concomitant USF. Patients completed the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) and the Patient-Rated Wrist Evaluation (PRWE) at intake, three months, and one year postoperatively. USFs were classified as base or tip fractures, and union or non-union.
There were no statistically significant differences in QuickDASH or PRWE functional outcome scores between the DRF only and DRF + USF groups or between different types of USF. This study suggests that the presence of an untreated USF will not significantly change patients’ functional outcome and strengthens the body of evidence for nonsurgical treatment of this concomitant injury.
Citation: Okoli M, Silverman M, Abboudi J, et al. Radiographic Healing and Functional Outcomes of Untreated Ulnar Styloid Fractures Following Volar Plate Fixation of Distal Radius Fractures: A Prospective Analysis. HAND. 2019;(3):332-337.
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 Nancy Naughton, OTD, OTR/L, CHT, ASHT Research Division Director at nancynaughton10@gmail.com.
October Research Update
Effectiveness of Nighttime Orthoses in Controlling Pain for Women with Hand Osteoarthritis: A Randomized Controlled Trial
Summary provided by Melanie Hubbuck, MS, OTD, OTR/L
Osteoarthritis (OA) is common musculoskeletal condition characterized by joint pain and often secondary functional limitations, especially when present in the hand. Therapeutic management has traditionally included use of orthotics, adaptive strategies/equipment, patient education and modalities to improve pain and function; however, the use of custom orthoses for management of symptoms associated with OA of the IP joints has not been well-studied. This research study served to fill the gap in the literature, investigating the efficacy of custom orthosis use in treatment of pain in PIP and DIP joints of the hand in women with symptomatic OA.
This study was a randomized control trial with a masked assessor including 52 final eligible participants with confirmed diagnosis of OA, and pain present in the second or third fingers on the dominant hand randomly assigned to the treatment or control group. Both groups received education on OA, pathology, treatment options, energy conservation and joint protection. The intervention group was fabricated a custom, finger-based volar gutter orthosis with the IP joints in neutral positioning for nighttime wear while the control group used no orthosis over a six-month test period.
The authors found a statistically significant reduction in pain as well as increase in hand function in the intervention compared to control group. This study overall indicates that nighttime orthosis use is beneficial in symptom management for women with OA impacting IP joints of the hand.
Silva, P. G., de Carvalho Silva, F., da Rocha Corr ˆea Fernandes, A., & Natour, J. (2020). Effectiveness of nighttime orthoses in controlling pain for women with hand osteoarthritis: A randomized controlled trial. American Journal of Occupational Therapy, 74, 7403205080.
Journal Source: American Journal of Occupational Therapy
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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.
November Research Update
Association of Sleep and Hand Function in People with Carpal Tunnel Syndrome
Summary provided by Melanie Hubbuck, MS, OTD, OTR/L
The carpal tunnel is the most common site for median nerve entrapment with 3% of the general population experiencing carpal tunnel syndrome (CTS). CTS is associated with poor sleep, specifically, disturbed or fragmented sleep. Sleep disturbance has been identified as a health crisis by the Centers for Disease Control and Prevention with recognition of the systemic health consequences caused by sleep interruption. This study utilized a cross-sectional design to investigate and describe the relationship between sleep quality and hand function in patients with CTS, indicating a further area for intervention within the scope of occupation-centered practice.
This study included 53 adult participants who were diagnosed with CTS (confirmed with EMG) seeking treatment. Participants were majority female with a mean age of 58.4. Data collection included results from an EMG and a nerve conduction study, as well as hand function as measured by the Manual Ability Measure-20 (MAM-20), and sleep quantity/quality as measured by the Pittsburgh Sleep Quality Index (PSQI). Data analysis included hierarchical multiple regression to test the association between measures while controlling for other variables including pain and severity.
The authors found that increase in sleep disturbance was significantly associated with decline in manual ability, or hand function, as well as with increase in pain. They propose this forward feedback loop creates a detrimental cycle that perpetuates diminished sleep quality, hand function and increased pain. Interventions to improve sleep hygiene—such as bed positioning, sleep preparation routines and proactive pain control—in addition to positioning to minimize median nerve compression at the wrist may be beneficial to include in managing pain, and improving hand function for patients with CTS.
Goorman, A. M., Dawson, S., Schneck, C., & Pierce, D. (2019). Association of sleep and hand function in people with carpal tunnel syndrome. American Journal of Occupational Therapy, 73, 7306205050.
Journal Source: American Journal of Occupational Therapy
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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
Paraffin bath therapy in De Quervain’s tenosynovitis a single-blind randomized control trial
Summary provided by Stephanie Strouse, OTD, OTR/L, CHT
Does utilization of paraffin with those with De Quervain’s make a significant difference on the functional outcomes?
This prospective, single-blind randomized controlled clinical study was performed to investigate the effectiveness of the use of paraffin bath therapy on pain, functional status, muscle strength and overall improving the quality of life in those suffering from De Quervain’s tenosynovitis. The study population consisted of patients between the age of 18 and 65 with hand pain on the visual analogue scale > 4, a pain duration > than 4 weeks, swelling, and tenderness around the radial styloid, and diagnosed with De Quervain’s tenosynovitis with a positive Finklestein’s test.
Sixty patients fit the inclusion criteria and were randomized into two groups. Group one received paraffin bath, splint and a home-based exercise program, while group two received a splint and home-based exercise program. All treatments were standardized with both groups receiving both exercise and orthotic use; however, one group additionally received paraffin treatment.
There was significant improvement of those in group two comparing pre-treatment to post treatment in both the second and eighth weeks. A comparison difference between the scores in both groups consisting of pain, QDASH, HGS and SF-12 the statistics were more favorable of group one at the second and eighth week compared to pre-treatment; however, there were no significant difference between both groups in all parameters.
This study showed that paraffin therapy combined with home exercise program and thumb spica orthosis provided effective pain control and is more effective in improving functional status, hand grip strength and quality of life than the combination of exercise program and thumb spica orthosis.
Study limitations were identified and included the short length of time the patients were evaluated, a small group size and utilized the DASH to evaluate functionality of the hand. It was noted the DASH is not specific for the hand.
Karlibel, I. A., Aksoy, M. K., & Alkan, A. (2021). Paraffin bath therapy in De Quervain’s tenosynovitis: a single-blind randomized controlled trial. International Journal of Biometeorology, 65, 1391-1398.
Journal Source: International Journal of Biometeorology
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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.