2022 Research Updates

December Research Update

“The more I do, the more I can do”: Perspectives on how performing daily activities and occupations influences recovery after surgical repair of a distal radius fracture
Summary provided by Corey W. McGee, PhD, MS, OTR/L, CHT

This qualitative study sought to explore clients’ perceptions of the roles and pragmatics of engaging in activity and occupation after surgical fixation of a distal radius fracture. The authors enrolled 21 participants (14 female, average age of 53 years) who were asked to complete activity/exercise logs 2-3 times/week for the first six weeks post-operatively and to engage in a semi-structured interview between weeks six and eight. The authors then used reflexive thematic analysis to interpret the data gathered during the interviews.

By week three, 67% were using their affected arm during light activities such as eating, showering, or grooming and of this 67%, many were also engaging in meal preparation and household tasks without the use of an orthosis. By week six, 100% were engaging in some activities without an orthosis. The analysis of interview data yielded five themes. They are as follows: Occupation/activity 1) was a driver of recovery, 2) offered accessible and gradable challenges, 3) invited intentional doing, 4) habituated the affected extremity to movement, and 5) was supported through use of psychosocial resources.

The results of this study highlight clients’ perceived importance of activity/occupation in recovery after surgically managed distal radius fracture. The findings also reinforce recent evidence suggesting that psychosocial factors such as depression (Goudie et al., 2022) and low self-efficacy (Stern et al.) are barriers to recovery. Another barrier identified by some of the participants was that they received little and/or conflicting guidance on how to engage in occupations during recovery. The authors advocate that exercise and activity be used synergistically to enhance outcomes. Given these findings and some literature suggesting that, when delivering exercise-based interventions, supervised therapy outcomes look similar to the home programs given by surgeons (Souer et al., 2011) or video recordings (Lara et al, 2022), it might behoove us to be more inclusive of occupations/activities. Ohno et al. (2021) offer a framework to guide therapists’ and clients’ therapeutic use of occupations/activities. Future research should investigate the effects of adding occupation/activity-based interventions to exercise.

Lara TR, Kagan RP, Hiratzka SL, Thompson AR, Nazir OF, Mirarchi AJ. Traditional Versus Digital Media-Based Hand Therapy After Distal Radius Fracture [published correction appears in J Hand Surg Am. 2022 Oct;47(10):1011]. J Hand Surg Am. 2022;47(3):291.e1-291.e8. DOI: https://doi.org/10.1016/j.jhsa.2021.06.018
Goudie ST, Broll R, Warwick C, Dixon D, Ring D, McQueen M. The Association Between Psychological Factors and Outcomes After Distal Radius Fracture. J Hand Surg Am. 2022;47(2):190.e1-190.e10. DOI: https://doi.org/10.1016/j.jhsa.2021.04.012
Ohno K, Saito K, Matsumoto H, Tomori K, Sawada T. The clinical utility of a decision-aid to facilitate the use of the hand in real-life activities of patients with distal radius fractures: A case study. J Hand Ther. 2021;34(3):341-347. DOI: https://doi.org/10.1016/j.jht.2020.03.002
Souer JS, Buijze G, Ring D. A prospective randomized controlled trial comparing occupational therapy with independent exercises after volar plate fixation of a fracture of the distal part of the radius. J Bone Joint Surg Am. 2011;93(19):1761-1766. DOI: https://doi.org/10.2106/JBJS.J.01452
Stern BZ, Howe T-H, Njelesani J. Self-Efficacy for Managing Injury After Distal Radius Fracture: A Mixed Methods Exploration. OTJR: Occupation, Participation and Health. 2022;0(0). DOI: https://journals.sagepub.com/doi/abs/10.1177/15394492221086232

Collis JM, Mayland EC, Wright-St Clair V, Signal N. "The more I do, the more I can do": perspectives on how performing daily activities and occupations influences recovery after surgical repair of a distal radius fracture. Disabil Rehabil. 2022;44(19):5440-5449.

Journal Source: Disability and Rehabilitation

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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 Jenny M. Dorich, PhD, MBA, OTR/L, CHT, ASHT Research Division Director at jenny.dorich@cchmc.org.

November Research Update

The Impact of Therapeutic Camp on Children with Congenital Hand Differences
Summary provided by Jenny M. Dorich, PhD, MBA, OTR/L, CHT

This study examined upper extremity function, peer relationship and self-esteem outcomes among a group of pre-adolescent children (age 10-13) with congenital hand differences who participated in a therapeutic hand camp. Measures were administered prior to the children attending camp, immediately following camp and six months after attending camp.

Thirty-six children (61% female) with congenital hand differences who attended hand camp participated in this study. All children completed the following patient reported outcome measures: the PROMIS Peer Relations scale, the PROMIS Physical Function Upper Extremity Function scale and the Rosenberg Self-Esteem Scale. Significant gains in participant scores from pre-camp to immediately post-camp were assessed across all measures. Additionally, a significant increase in the six-month post camp score compared to pre-camp scores was assessed for the PROMIS Physical Function Upper Extremity Function scale and the Rosenberg Self-Esteem Scale; however, the PROMIS Peer Relations scale score had returned to be like the pre-camp score at the six-month post-camp reassessment.

Study findings highlight the value of a therapeutic hand camp in improving upper extremity function and self-esteem among children age 10-13 with congenital hand differences. Findings that the gains in peer relationships assessed immediately following camp returned to baseline six-month post camp suggest the potential need for ongoing interactive experiences with other children with congenital hand differences that extend beyond camp for this population.

Amy Lake, Shelby Parker Cerza, Lesley Butler, Scott Oishi & Andrea Brown | (2021) The impact of therapeutic camp on children with congenital hand differences, Cogent Psychology, 8:1, 1938439

Journal Source: Cogent Psychology

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October Research Update

Comparison of Orthosis Management Failure Rates for Mallet Injuries
Summary provided by Sophie Goloff, MS, OTR/L, CHT

This study examined mallet finger failure rates after treatment with different orthoses and aimed to identify factors associated with treatment failure.

Records of 328 patients who sustained a closed mallet finger injury (IF-SF) were retrospectively reviewed for this study. Treatment failure was defined as any three of the following: DIP extensor lag >20 after 4+ weeks of continuous immobilization, unplanned conversion to surgical intervention or initiation of a second course of orthosis use during the treatment period. Median length of initial immobilization was seven weeks. Orthosis types included: soft cast, custom thermoplastic, Stack, alumafoam and unspecified.

The overall failure rate was 32%. The most common reason was extensor lag >20deg, followed by an additional course of orthosis wear, followed by unplanned surgical intervention. There was no statistically significant difference in failure rates amongst digits, although a trend suggested higher failure rates in the SF (40% failure). Other risk factors for failure include a higher age at injury or a tendinous vs bony mallet injury. Orthosis type was associated with failure rate – it was highest in patients treated with the Stack orthosis (57%), then alumafoam (42%), soft cast (28%), custom thermoplastic (26%) and unspecified (3%) orthoses.

This study supports hypotheses of previous researchers that Stack and dorsal-padded alumafoam are associated with the highest failure rates. Additionally, this study strengthens previous findings in the literature that age is a risk factor for lag and failure. These findings suggest age is a factor to consider with treatment planning and expectation counseling after this injury. This study reports tendinous mallet injures as a risk factor for failure, although the greater literature regarding bony vs tendinous mallet fingers is not conclusive. Further study is warranted to strengthen the statistical significance of findings.

Brush M, Dick NR, Rohman EM, Bohn DC. Comparison of Orthosis Management Failure Rates for Mallet Injuries. Journal of Hand Surgery Global Online. 2022;(4):220-225.

Journal Source: Journal of Hand Surgery Global Online

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September Research Update

Associations between range of motion, strength, tear size, patient-reported outcomes, and glenohumeral kinematics in individuals with symptomatic isolated supraspinatus tears
Summary provided by Priya Bakshi, OTD, OTR, CHT

This study described the clinical presentation of individuals with a symptomatic isolated supraspinatus tear; examined the relationship between passive glenohumeral range of motion (ROM), isometric rotator cuff (RTC) muscle strength, tear size and glenohumeral (GH) kinematics; and examined the relationship between GH kinematics and patient reported outcome (PROs) measures.

One hundred and one individuals with isolated symptomatic supraspinatus tears were recruited with ages ranging from 40.1 to 80.6 years. Tear size ranged from .5mm to 28.3 mm.

The participants had decreased isometric strength with deficit of strength being the most for ER at 90-degree abduction. Minimal restrictions in passive glenohumeral ROM were found with minimal pain and disability scores on the PROs.

The authors did not find any association between passive glenohumeral ROM, isometric RTC strength, supraspinatus tear size and GH kinematics during scaption. Those participants with higher RTC strength did not have less superior translation, indicating that various magnitudes of strength of the subscapularis, infraspinatus and teres minor can maintain joint stability.

Those participants with larger size tears did not have lower ER and IR strength, indicating that functional strength of infraspinatus, subscapularis and teres minor was not affected by tear size of the supraspinatus.

No association was found between GH kinematics with PROs. The authors concluded that from a biomechanical perspective, individuals with isolated supraspinatus tears do not present with significant differences in GH kinematics that would likely affect PROs.

Mattar, L. T., Popchak, A. J., Anderst, W. J., Musahl, V., Irrgang, J. J., & Debski, R. E. (2022). Associations between range of motion, strength, tear size, patient-reported outcomes, and glenohumeral kinematics in individuals with symptomatic isolated supraspinatus tears. Journal of Shoulder and Elbow Surgery, 31(6), 1261-1271.

Journal Source: Journal of Shoulder and Elbow Surgery

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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.

August Research Update

Passive Mobilization with Place and Hold Versus Active Motion Therapy After Flexor Tendon Repair: A Randomized Trial
Summary provided by Stephanie Strouse, OTD, OTR/L, CHT

The treatment of flexor tendon injuries on the digits have undergone many changes over the past years and has been an area for debate as to what is best practice for rehabilitative intervention. This study investigated whether true active mobilization after flexor tendon repair results in a superior ROM and strength compared with passive mobilization with place and hold with the author’s hypothesizing active motion results improved ROM.

A total of 64 patients with a zone I or II flexor tendon injury who underwent a primary repair of an FDP laceration in digits II – IV ages > 16 years of age. Exclusion criteria were associated fractures, joint injuries, crush injuries, soft tissue defects or those with functional limitations prior to injury. Randomization treatment between either active or passive mobilization with place and hold was performed and patients were followed up for 12 months using outcome measurements including ROM, strength, rupture frequency, DASH, ABILHAND questionnaire and Purdue Pegboard. Median values were used for sample size because the values were not normally distributed. Mann-Whitney U test was used for ROM, grip strength and key pinch measures and chi-square test was used for Strickland categories.

The results did not yield significant differences between the two groups for any of the outcome measurement tools at either three-, six- or 12-month follow-ups. The authors were unable find evidence to support that early active mobilization is better than passive mobilization post flexor tendon repair of FDP in zones I or II. The authors speculated it may be beneficial for patients to have protected AROM between sessions verses simply protected passive motion, which could potentially reduce the opportunity for adherence.

CHevalley, S., Tenfalt, M., Ahlen, M., Stromberg, J. “Passive Mobilization with Place and Hold Versus Active Motion Therapy After Flexor Tendon Repair: A Randomized Trial”. The Journal of Hand Surgery (American ed.) Vol 47 (2022): 348-357.

Journal Source: The Journal of Hand Surgery

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July Research Update

The Impact of Social Deprivation and Hand Therapy Attendance on Range of Motion After Flexor Tendon Repair
Summary provided by Mirella Deisher, OTD, MS, OTR/L, CHT

This study aims to understand the impact of social circumstances on outcomes after flexor tendon repair – specifically how social deprivation might be associated with poorer digital motion outcomes. They hypothesized that social deprivation would be associated with decreased therapy attendance and thus result in inferior ROM outcomes.

The Area Deprivation Index (ADI) was utilized to measure social factors that may facilitate or impede on access to care. Strickland Percentage, a clinical measure for flexor tendon outcome, was the calculated for digital motion outcome. The study included a retrospective cohort of 109 patients with a mean ADI of 53, and a mean of 13 visits attended. They identified a correlation between a higher ADI and fewer therapy sessions, and that each was associated with decreased Strickland’s Percentage.

The authors of this study concluded that socially deprived patients attend fewer therapy sessions and obtain poorer AROM after flexor tendon repair; however, they noted it would be an oversimplification not to consider other variables of ADI that may relate to outcomes, such as their understanding of home programs, the need for patients to return to wage-earning or the need attend to family responsibilities. The authors identified the need for further study in this area, including gaining a better understanding willingness and ability to comply with home programs to improve outcomes, particularly vulnerable patients.

Stonner, M., Keane, G., Berlet, L., Goldfarb, C., Pet, M.. “The Impact of Social Deprivation and Hand Therapy Attendance on Range of Motion After Flexor Tendon Repair”. The Journal of Hand Surgery (American ed.) Article In Press (2022): 1-7.

Journal Source: The Journal of Hand Surgery

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June Research Update

Comparison of 2 Postoperative Therapy Regimens After Trapeziectomy Due to Osteoarthritis: A Randomized, Controlled Trial
Summary provided by Renee McDade, OT, CHT

The current standard of care for postoperative trapeziectomy in the first carpometacarpal joint is rigid orthosis and mobilization after six weeks, but is early mobilization inferior to that or should it be considered? Fifty-five participants with a mean age of 65 were assessed at baseline, three, six and 12 months after surgery.

The participants were randomly assigned to either the control group (standard care) or the intervention group (early mobilization). Each participant was informed of the content of the intervention but not on whether it was standard care vs the new regimen. The primary outcomes were activity performance using the COPM, and a patient-reported effect of surgery on a six-point scale ranging from “much worse” to “completely recovered.” Secondary outcomes of pain, grip and pinch strengths, and joint mobility were also included. No significant differences were found between the groups in primary or secondary outcomes, except for decreased pain at rest in the intervention group.

The authors of this study concluded that a postoperative regimen with early mobilization after trapeziectomy is as safe and effective as a regimen with longer immobilization.

Hermann-Eriksen, Merete et al. “Comparison of 2 Postoperative Therapy Regimens After Trapeziectomy Due to Osteoarthritis: A Randomized, Controlled Trial.” The Journal of Hand Surgery (American ed.) 47.2 (2022): 120–129.e4. Web.

Journal Source: The Journal of Hand Surgery

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May Research Update

Efficacy of Hand Therapy After Volar Locking Plate Fixation of Distal Radius Fracture in Middle-Aged to Elderly Women: A Randomized Controlled Trial
Summary provided by Lori Algar, OTD, OTR/L, CHT

What are the differences in outcomes for middle-aged to elderly women who attend skilled hand therapy versus those who perform independent exercises post volar locking plate for distal radius fracture?

Fifty-seven patients who were treated with a volar locking plate for a distal radius fracture were randomized to either attend skilled hand therapy or perform independent exercises. The participants included females over the age of 40. At six weeks post-surgery, functional disability according to the DASH was statistically significantly less in the skilled hand therapy group. At the two-, four-, and six-week follow up, pain according to the VAS was statistically significantly less in the skilled hand therapy group and range of motion for the wrist and forearm was statistically significantly greater in the skilled hand therapy group at the two-, four-, six- and eight-week mark and the six- and eight-week mark, respectively. The authors conclude that hand therapy improved outcomes for the participants at eight weeks post-surgery.

Gamo K, Baba N, Kakimoto T, Kuratsu S. Efficacy of hand therapy after volar locking plate fixation of distal radius fracture in middle-aged to elderly women: a randomized controlled trial. J Hand Surg. 2022; 47: 62-68.

Journal Source: Journal of Hand Surgery

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April Research Update

Surgical and Nonoperative Management of Olecranon Fractures in the Elderly: A Systematic Review and Meta-Analysis
Summary provided by Cynthia Ivy, M.ED, OTD, CHT

With baby boomers currently in the 57-75-year-old age range, we will continue to see an uptick in upper extremity conditions related to age and low energy falls. One of these conditions is olecranon fractures. This systematic review and meta-analysis explores surgical versus non-surgical care of closed olecranon fractures without elbow instability. An olecranon fracture can have dire effects on function during the healing process, and complications of surgery can prolong the time that their upper extremity must be protected.

I found this study while searching point-of-care resources and clinical practice guidelines for a 95-year-old independent woman who fell in her home two days ago.

The results of this metanalysis found that high reoperation rates can be expected in patients treated with tension band wire or plate fixation (the only operations that were included in the study) compared to the nonoperative group that had no subsequent surgeries to address the high rate (86%) of nonunion. Functional flexion arcs were achieved in all groups. Functional outcome scores were comparably excellent across all groups.

The authors propose that fibrous pseudoarthrosis of the olecranon in the low-demand patient may provide adequate elbow function for activities of daily living (ADLs), and they cite five other authors who suggest the same due to good outcomes with minimal complications in nonoperative management of displaced stable olecranon fractures.

Although there were some limitations with the research, including poor methodology noted in the studies and high heterogeneity amongst the studies, there appears to be decent evidence to consider conservative management of stable, displaced olecranon fractures in the low-demand elderly as a first line of treatment.

It is important for hand therapists to be aware of studies such as this one so we can be prepared to help manage our patients conservatively and problem solve with them adaptive techniques and alternative methods of completing their ADLs safely while healing.

Chen MJ, Campbell ST, Finlay AK, Duckworth AD, Bishop JA, Gardner MJ. Surgical and Nonoperative Management of Olecranon Fractures in the Elderly: A Systematic Review and Meta-Analysis. J Orthop Trauma. 2021 Jan 1;35(1):10-16.

Journal Source: J Orthop Trauma

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March Research Update

The Association Between Psychological Factors and Outcomes After Distal Radius Fracture
Summary provided by Katherine J. Loomis, MA, OTR/L, CHT

Investigations into the specific impact of psychosocial factors on recovery from common upper extremity conditions are still relatively preliminary despite acknowledgement from medical professionals that these factors can greatly impact patient experience and outcomes. This prospective study examines associations between patient demographic and psychosocial factors and functional and pain outcomes for patients with distal radius fractures. The study followed patients post distal radius fracture (n = 216), collecting demographic, psychological, pain, functional data at baseline and pain and functional outcome data at intervals of 10 weeks and nine months. Patient psychosocial data was collected using the Hospital Anxiety and Depression Scale (HADS), Pain Catastrophizing Scale, Posttraumatic Stress Disorder Checklist-Civilian, Tampa Scale for Kinesiophobia, Illness Perception Questionnaire Brief (IPQB), General Self-Efficacy Scale and Recovery Locus of Control (RLOC). Functional outcomes were assessed with the Disabilities of the Arm, Shoulder and Hand Questionnaire (DASH) and pain outcomes with a numeric pain scale. Data from these measures was examined using linear regression analysis to identify patient factors significantly associated with functional and pain outcomes at the two follow-up measurements.

Significant associations were observed between higher DASH scores and increased age, the presence of nerve pathology, increased HADS Depression subscale scores, increased IPQB scores and decreased RLOC scores at the 10-week time point. At the nine-month time point, DASH scores were associated with increased age, increased deprivation scores, higher numbers of medical comorbidities, greater radial shortening, increased HADS Depression subscale scores and lower RLOC scores. Pain had far fewer associations at both time points. Increased pain was only associated with increased deprivation and IPQB scores at 10 weeks and increased medical comorbidities at nine months.

Patient psychological factors measured early in the recovery process from distal radius fractures can be associated with functional and pain outcomes for up to nine months after injury. Certain psychosocial factors such as illness perception may be addressed and/or modified over the course of therapy or through patient referrals to improve patient outcomes. Further investigation is needed to better understand the impact of these factors on patient recovery for a wider variety of patient populations, how patient psychological states prior to injury influence these results and optimal strategies to address these factors during recovery and condition management.

Goudie, S. T., Broll, R., Warwick, C., Dixon, D., Ring, D., & Mcqueen, M. (2022). The Association Between Psychological Factors and Outcomes After Distal Radius Fracture. Journal of Hand Surgery, 47(2), 190.e1-190.e10.

Journal Source: Journal of Hand Surgery

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February Research Update

Comparison of the Short-Term and Long-Term Effects of Surgery and Nonsurgical Intervention in Treating Carpal Tunnel Syndrome: A Systematic Review and Meta-Analysis
Summary provided by April Bryant OTD, OTR/L, CHT

Carpal tunnel syndrome (CTS) affects up to 12% of American adults. Symptoms of CTS can range from pain, numbness and weakness to sensory loss and thenar paralysis. The authors of this systematic review and meta-analysis evaluated the efficacy of surgical versus non-surgical (splint, steroid injection, physical therapy) intervention. The researchers conducted a review from 1980 to September 2017, finding 10 trials with 1,028 participants met inclusion criteria. The authors compared functional status and symptom severity and one, three, six and 12-month post-intervention or post-operatively.

Limited data found conservative treatment to be superior to surgical treatment one-month post-operatively. At three months, there was no significant difference between the surgical and conservative groups. Functional status as well as symptom severity were superior in the surgical versus non-surgical group at six-months post-operatively. This effect, however, declined at 12 months for both functional status and symptom severity. The authors do note that distal sensory latency improved more significantly in the surgical group at the 12-week mark. The authors suggest that longer-term follow up would help researchers gain a better understanding of the course of surgical outcomes. The authors also suggest a larger-scale randomized controlled trial comparing surgical and non-surgical interventions would be beneficial.

Shi, Q., Bobos, P., Lalone, E. A., Warren, L., & MacDermid, J. C. (2018). Comparison of the short-term and long-term effects of surgery and nonsurgical intervention in treating carpal tunnel syndrome: A systematic review and meta-analysis. HAND, 15(1), 13–22.

Journal Source: HAND

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January Research Update

Proprioceptive Neuromuscular Facilitation Protocol for Thumb Osteoarthritis A Pilot Study
Summary provided by Nancy Naughton, OTD, OTR/L, CHT

The authors conducted a double-blind experimental trial with a pre-test/post-test design to assess participants with Grade I or II thumb CMC joint OA in the dominant hand with a pain rating >4.

The 12 participants were divided into two groups with the control group receiving traditional treatment and the experimental group receiving standard treatment along with proprioceptive training. Traditional treatment included a short opponens orthosis for sleeping hours, self-massage of the thumb muscles, first dorsal interossei active resistive exercise and instruction for functional inclusion of the thumb for ADLs. The proprioceptive training was a previously designed three-phase proprioceptive rehabilitation program designed by the primary investigator. The outcomes of interest were lateral pinch strength, pain intensity during activities and proprioceptive response via Joint Position Sense (JPS) Testing.

Lateral pinch and pain improved and achieved statistical significance as well as a large effect size for both groups, although there was not a statistically significant difference between groups. Specific to JPS testing, only the experimental group experienced a large effect size. There was also a statistically significant difference between groups for JPS testing.

The authors findings reveal the importance for further study of the effects of proprioception for individuals with thumb CMC OA with further high-level studies with larger sample sizes.

Raquel Cantero-Tellez, Nancy Naughton, Lori A. Algar, Ivan Medina-Porqueres , Leire Cruz-Gambero, and Kristin A. Valdes. Proprioceptive Neuromuscular Facilitation Protocol for Thumb Osteoarthritis A Pilot Study. HAND. First Published May 6, 2021.

Journal Source: HAND

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