Research Updates

The ASHT Research Division offers research updates to increase awareness of emerging research in the field of hand and upper extremity therapy. Each month, the Research Division releases a brief summary of an original published research paper selected by members of the Research Division.

2024 Research Updates

December Research Update

Is there a difference in referral to occupational therapy (OT) or opioid prescription usage after open versus endoscopic carpal tunnel release?

Summary Provided by Melanie Hubbuck, MS, OTD, OTR/L, CHT

A retrospective study of patients with isolated idiopathic carpal tunnel syndrome (CTS) treated by either open surgical release (OCTR) or endoscopic release (ECTR) with a total of 1125 participants. On average, 12.1% of ECTR patients received an OT referral with 4.5 visits required compared to 11.4% after OCTR with 4.2 visits required. This was not statistically significant unadjusted. Multivariable binary regression was performed. Operating surgeon was predictive of referral to post-operative OT with 2 of 6 statistically significantly less likely to refer to OT. After controlling for referring surgeon, patients who underwent OCTR were 4.18 times more likely to be referred to OT compared to those who underwent ECTR. There was no difference in opioid prescription patterns. The authors concluded that both approaches have similar opioid prescription usage patterns, but ECTR is associated with reduced need for post-operative OT.

Citation: Schroeder, M.J., Reddy, N., Rust, A., O’Brien, A.L., Jain, S. A. (2024). Open versus endoscopic carpal tunnel release: A comparison of opioid prescription patterns and occupational therapy referrals. HAND (New York, N.Y.), 19(5), 776-782.

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 Lori Algar, OTD, OTR/L, CHT, ASHT Research Division Director at lori.algar@gmail.com.

November Research Update

When active mobilization therapy is compared to passive mobilization with place-and-hold for flexor tendon repair rehabilitation, which protocol showed better outcomes at a 5-year study follow-up?

Summary Provided by Lori Algar, OTD, OTR/L, CHT

A randomized controlled trial placed 64 participants who had a flexor tendon repair in zone I or zone II into either an active mobilization or a passive mobilization with place-and-hold therapy protocol group. Forty-seven of the participants followed up after five years. The group that performed the passive mobilization with place-and-hold had significantly greater range of motion. Both groups had a decrease in grip strength at the five-year mark (compared to the one-year follow-up), however they did have a significant increase in function via the DASH and ABILHAND. The authors of this RCT concluded that the passive mobilization with place-and-hold protocol had superior results in the long term.

Citation: Chevalley S, Wangberg V, Ahlen M, Stromberg J, Bjorkman A. Passive Mobilization with Place-and-Hold Versus Active Mobilization Therapy after Flexor Tendon Repair: 5-Year Minimum Follow-Up of a Randomized Controlled Trial. J Hand Surg. Article in press.

Journal Source: Journal of Hand Surgery

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October Research Update

Risk factors and predictive models for frozen shoulder

Summary Provided by Ricardo G. Altahif, Jr., OTD, OTR, CHT

This study explored risk factors associated with frozen shoulder (FS) and introduced a predictive model to assist in early detection and diagnosis. This study used a case-control design, comparing 103 patients with frozen shoulder to 309 age- and gender-matched controls, and identified key risk factors for FS including low BMI, diabetes, cervical spondylosis, and hyperlipidemia. The authors developed a predictive model combining these risk factors which showed improved accuracy for early diagnosis. Hand therapists should screen for risk factors such as low BMI, cervical spondylosis, and metabolic conditions (diabetes, hyperlipidemia) during chart review or initial evaluations, and patients with these individual, and especially combined, conditions should be flagged as higher risk for FS and the plan of care adjusted accordingly. Communicating this risk with other members of the healthcare team such the referring provider can help to holistically address underlying metabolic conditions. This research supports the early identification of FS, potentially reducing the occurrence through timely intervention.

Citation: Sun, G., Li, Q., Yin, Y., Fu, W., He, K., & Pen, X. (2024). Risk factors and predictive models for frozen shoulder. Scientific Reports, 14(15261).

Journal Source: Scientific Reports

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September Research Update

Reliability, validity, and responsiveness of pinch strength assessment: A systematic review

Summary Provided by Katherine Loomis, MA, OTR/L, CHT

Introduction:

This systematic review synthesizes the current evidence on the psychometric properties of pinch strength assessments to evaluate their accuracy as outcome measures.

Methodology:

The authors screened 1,002 records to identify studies examining the reliability, validity, and responsiveness of pinch strength assessments. Thirty-three studies were selected for final inclusion and assessed for quality via the COSMIN Risk of Bias Checklist. Reliability measures included intraclass correlation coefficient (ICC), standard error, and minimal detectable change; validity measures included correlation coefficient (r) with other measures of upper extremity function; and responsiveness measures included effect size, standardized response mean, and minimal clinically important difference.

Main results:

Among the included pinch strength studies, most (16/19) measuring reliability and about half (7/12) measuring validity were considered adequate to very good quality, while all (8/8) all measuring responsiveness were adequate. Pinch strength reliability was at least good (ICC > 0.75) for both healthy participants and those with upper extremity conditions. Pinch strength was moderately to strongly correlated with other performance-based outcome measures such as grip strength and dexterity (r = 0.72–0.92), yet was only weakly to moderately correlated with patient-reported outcome measures such as the DASH (r = 0.03-0.50). Results for pinch strength responsiveness were inconclusive.

Implications and conclusion:

Pinch strength assessment is a reliable clinical tool, though further research is needed on responsiveness. While pinch strength assessments are closely related to other performance-based measures, they should be considered as distinct from patient-reported outcome measures of hand function.

Citation: Szekeres, M., Aspinall, D., Kulick, J., Sajid, A., Dabbagh, A., & MacDermid, J. (2024). Reliability, validity, and responsiveness of pinch strength assessment: a systematic review. Disability and Rehabilitation, 1–13.

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.

August Research Update

Commentary: Rehabilitation for Rural and Remote Residents Following a Traumatic Hand Injury

Hand therapy in rural and remote Australia

Summary provided by Tauni Malmgren, OTD, OTR/L

Introduction
This commentary analyzes the barriers and enablers to providing hand therapy rehabilitation in rural and remote areas, emphasizing the unique challenges faced by residents after a traumatic hand injury. Understanding these factors is crucial for developing effective rehabilitation programs.

Methodology
The study reviews existing literature and evidence related to hand therapy practices in rural and remote Australia, highlighting the specific needs and conditions of these regions compared to metropolitan areas.

Results
Key barriers identified include geographical isolation, limited access to healthcare services and rigid postsurgical protocols that do not align with the daily lives of rural patients. Enablers such as focusing on resuming meaningful activities, adopting a shared care approach, maintaining flexibility, fostering resilience and utilizing technology are crucial for improving rehabilitation outcomes.

Implications
For hand therapy in rural areas to be effective, therapists must adopt a person-centered approach that considers the patient's environment and lifestyle. This includes flexible and innovative strategies that prioritize patient needs over rigid protocols, enhancing both adherence and functional recovery.

Conclusion
Providing tailored and flexible rehabilitation programs is essential for addressing the unique challenges of rural and remote residents with traumatic hand injuries. This approach ensures that therapeutic interventions are relevant and accessible, ultimately improving patient care and outcomes.

Citation
Kingston, G. A. (2017). Commentary: Rehabilitation for rural and remote residents following a traumatic hand injury. Rehabilitation Process and Outcome, 6.

Journal Source: Rehabilitation Process and Outcome

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July Research Update

Advancements in de Quervain Tenosynovitis Management: A Comprehensive Network Meta-Analysis

Summary provided by Priya Bakshi, OTD, OTR, CHT

What is the relative efficacy of various nonsurgical treatments for de Quervain tenosynovitis?

This systematic review and network meta-analysis included 14 RCTs up to August 2023. Primary outcome of visual analog scale (VAS) and secondary outcome of QuickDASH or DASH was considered. Eight articles had low risk of bias. Analysis categorized outcomes in three time periods:

Short-term (follow up in six weeks): Extracorporeal shockwave therapy (ECSWT) ranked the highest in treatment effects with statistically significant improvement in VAS compared to placebo. Corticosteroid injection combined with casting (thumb spica cast), laser therapy with removable orthosis had favorable outcomes.

Medium term (six weeks to six months): ECSWT followed by corticosteroid injection with casting were ranked the highest.

Long-term effects (one year follow up): Corticosteroid injection alone, platelet rich plasma injections had sustained pain relief. Corticosteroid injection with orthosis was more promising than corticosteroid injection alone.

Authors concluded that corticosteroid injection with a short duration of immobilization remains primary, effective treatment with ECSWT as a secondary option.

Citation: Chong, H. H., Pradhan, A., Dhingra, M., Liong, W., Hau, M. Y. T., & Shah, R. (2024). Advancements in De Quervain tenosynovitis management: A comprehensive network meta-analysis. The Journal of Hand Surgery, 49(6), 557-569.

Journal Source: The Journal of Hand Surgery

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June Research Update

The Use of Relative Motion Flexion Orthoses for Chronic Boutonniere Deformity

Summary provided by Sophie Goloff, MS, OTR/L, CHT

Boutonniere injuries are a common finger injury that often require a lengthy course of immobilization with subsequent PIP and DIP joint stiffness. Many patients continue to demonstrate a PIP extension lag after treatment. This study examined the effects of a relative motion flexion orthosis (RMFO) on PIP and DIP range of motion (ROM) after boutonniere injury.

This was a prospective cohort study. Participants included 28 patients with chronic boutonniere deformity who were able to fully extend their PIP with the MCP in relative flexion (pencil test) and classified as Stage 1 on the Burton scale (passively correctable). Patients were instructed to wear an RMFO full time for at least six weeks, longer if PIP extension lag did not fully resolve. PIP extension and DIP flexion were measured at a follow up of median 12 weeks but at minimum eight weeks.

The mean initial active DIP joint flexion was 47 (0 to 90) and improved to 66.8 (5 to 110). The mean initial extension lag of the PIP joint was 22.5 (5 to 55) and improved to 12 (0 to 30). PIP joint extension increased in 27/28 patients, although 12 had 5deg or less of improvement. DIP flexion did increase even in patients with minimal functional PIP extension improvement. Median time use of orthosis was 9 weeks, median for follow up after stopping use was 12 weeks (at least 8 weeks). ROM did not change after stopping use of orthosis into follow up.

This study suggests that RMFO can be an effective treatment for this patient population if the PIP joint is passively correctable. Further study is indicated based on small sample size and lack of functional improvement in 12/28 patients. This supports use of RMFO for PIP extension lag, and potentially as a treatment for boutonnière deformity.

Citation: Arslan, Ö. B., Sığırtmaç, İ. C., Ayvalı, C., Baş, C. E., Ayhan, E., Bilgin, S. S., & Öksüz, Ç. (published online 2022). The use of relative motion flexion orthoses for chronic boutonniere deformity. The Journal of Hand Surgery.

Journal Source: The Journal of Hand Surgery

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May Research Update

Fear Avoidance Beliefs in Upper-Extremity Musculoskeletal Pain Conditions: Secondary Analysis of a Prospective Clinical Study on Digital Care Programs

Summary provided by Alyssa Phillips, CScD, MOT, OTR/L

With musculoskeletal pain being the leading cause of disability worldwide, it’s an alarming statistic that 31.8% of all occupational injuries result in upper extremity musculoskeletal pain and the longest periods of absenteeism. The first line of intervention includes exercise-based approaches, which makes empowering patients to adhere to targeted home exercise programs a crucial piece of recovery; however, factors like access to consistent care, fear-avoidance beliefs (FABs) and perception of disability can impact patient adherence and outcomes. How do FABs contribute to participation in exercise programs and how patients can be supported in a way that improves their outcomes through overall adherence?

FABs include for example the perception that pain, even potential pain from activity like exercise is a threat. These beliefs lead to consequences like healing delays and chronic pain, essentially poor prognosis. This research explores Digital Care Programing that integrated exercise, education and cognitive behavioral therapy, to empower patients in their own recovery process. For the analyzed intervention, patients were assigned to a physical therapist that prescribed an individualized home program, which included progressive movement exposure tracked through an app with a camera and wearable motion trackers. In addition to progressive movement and exercise, clients were provided education (via app) on fear-avoidance, pain reconceptualization, active coping, pacing strategies and additional cognitive behavioral concepts.

The combination of graded exercise and education resulted in decreased fear avoidance scores, improvements in QuickDASH scores and reduction in pain. Participants with upper extremity musculoskeletal pain and initially high levels of fear avoidance were able to maintain high levels of exercise adherence which contributed to overall health and decreased disability.

Citation: Janela, D., Costa, F., Molinos, M., Moulder, R. G., Lains, J., Scheer, J. K., Bento, V., Yanamadala, V., Cohen, S. P., Dias Correia, F. (2023) Fear avoidance beliefs in upper-extremity musculoskeletal pain conditions: Secondary analysis of a prospective clinical study on digital care programs. Pain Medicine, 24(4), 451–460.

Journal Source: Pain Medicine, with the American Academy of Pain Medicine

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April Research Update

Factors Influencing the Successful Treatment of Recurrent Trigger Finger with Repeated Corticosteroid Injection: A Prospective Cohort Study

Summary provided by April Bryant, OTD, OTR/L, CHT

Trigger digits are a common and painful hand condition that limits an individual’s functional ability. Corticosteroid injections are a common choice for initial disease episode and for those wishing to avoid surgery. Unfortunately, about 50% of patients will have a recurrent trigger finger, leading them to consider subsequent injections. Grade of disease, higher BMI and a symptom-free period of less than six months were predictors of recurrence. Having all three risk factors decreased efficacy of repeat injections, where having fewer risk factors increased efficacy with 73% without recurrence after a year. This suggests that repeat injections are a viable option, especially for those with fewer risk factors.

Citation: Luangjarmekorn, P., Charoenyothakun, A., Kuptniratsaikul, V., & Kitidumrongsook, P. (2024). Factors influencing the successful treatment of recurrent trigger finger with repeated corticosteroid injections: A prospective cohort study. The Journal of Hand Surgery, 49(3), 253–259.

Journal Source: The Journal of Hand Surgery

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March Research Update

Long-Term Outcomes in Female Patients with Carpometacarpal Arthroplasty and Metacarpophalangeal Fusion Compared with the Unoperated Side of Carpometacarpal Arthroplasty

Summary provided by Lori Algar OTD, OTR/L, CHT

Does a thumb CMC arthroplasty with a thumb MP joint fusion yield improved pinch strength outcomes in comparison to a CMC arthroplasty alone in the treatment of thumb CMC joint osteoarthritis? What should hand therapists’ expectations be regarding long-term pinch strength outcomes for these patients?

Dock, Stone McGraver and McCarthy completed a retrospective review of long-term results for patients who underwent a CMC arthroplasty and compared outcomes to those who underwent a CMC arthroplasty combined with a thumb MP joint fusion. The study included 53 female patients and 70 operated thumbs (29 with CMC arthroplasties and 41 with arthroplasty plus MP joint fusion). There was a statistically significant difference between post-operative long-term pinch strength outcomes with the individuals undergoing the CMC arthroplasty plus MP joint fusion having an average of 11.3 lbs. of pinch strength versus 8.0 lbs. of pinch on average in individuals who underwent CMC arthroplasty alone. There was no difference in QuickDASH scores.

Citation: Dock CC, Stone McGraver R, McCarthy CK. Long-term outcomes in female patients with carpometacarpal arthroplasty and metacarpophalangeal fusion compared with the unoperated side or carpometacarpal arthroplasty. J Hand Surg. 2023; Article in press.

Journal Source: The Journal of Hand Surgery

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February Research Update

The Scope and Distribution of Upper Extremity Nerve Injuries Associated with Combat-Related Extremity Limb Salvage

Summary provided by Mirella Deisher, OTD, MS, OTR/L, CHT

Peripheral nerve injuries following blast trauma and can be overlooked or missed, particularly in warfare conditions which often require multiple hand-offs, and where there is wound contamination, as well as other accompanying injuries that need immediate attention. Delay in diagnosis in severe cases of trauma also occur when decisions on limb salvage versus amputation are primarily driven by infection and bone healing concerns. Thus, concomitant nerve injuries are identified and considered secondarily.

This study’s aim was to define the incidence and locations of upper extremity peripheral nerve injuries as well as pain and functional outcomes in a more recent sample of patients that sustained injuries in combat who underwent limb salvage with flap coverage.

They identified 49 extremities treated with limb salvage and flap coverage, 33 (67%) had associated nerve injuries with a total of 47 injured nerves. Of the 33 extremities with nerve injuries, 18 (55%) underwent surgery to address the nerve injury at a median of 26 days. The most injured nerve was the ulnar nerve (51%), followed by the median nerve (30%) and the radial/posterior interosseous nerve (19%). Of the 14 extremities with multiple nerves injured, the median and ulnar nerves were most often injured together (71%), followed by the median and radial nerves (14%) and the ulnar and radial (14%).

Results of this study further demonstrate the increasing trend of nerve injuries secondary to a blast mechanism with more than 95% of patients in their cohort sustaining their injuries from an IED. The three most injured nerves in their cohort were the ulnar, median, and radial nerves with multiple nerve injuries being relatively common. Chronic pain and patient-reported functional limitations were more common among patients with concomitant peripheral nerve injuries. Operatively managed nerve injuries demonstrated decreased pain scores compared to nonsurgical injured nerves. The median numerical rating scale (NRS) pain score in patients with nerve injuries without operative intervention was 2 compared to a median score of 0 in patients who underwent operative management of the injured nerve.

The authors concluded that surgeons performing limb salvage procedures with flap coverage should anticipate associated peripheral nerve injuries and be prepared to repair or reconstruct the injured nerves, when feasible.

Citation: Harrington, C. J., Dearden, M., McGlone, P., Potter, B.., Tintle, S., Souza, J. (2023). The Scope and Distribution of Upper Extremity Nerve Injuries Associated with Combat-Related Extremity Limb Salvage. The Journal of Hand Surgery, Article in Press.

Journal Source: The Journal of Hand Surgery

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January Research Update

Electrodiagnostic Predictors of Outcomes After In Situ Decompression of the Ulnar Nerve

Summary provided by Katherine Lagasse, MOT, OTR/L

In patients with severe ulnar neuropathy at the elbow (UNE), outward clinical symptoms may not accurately represent the severity of the underlying nerve lesion, necessitating use of objective assessment tools such as electrodiagnostic studies. Timing is often critical, as delayed diagnosis and treatment can lead to irreversible nerve damage and poorer post-operative outcomes. Traditional electrodiagnostic parameters, such as motor nerve conduction velocity (NCV), conduction block and signal latencies, have not been shown to accurately capture the later stages of UNE. Compound muscle action potential (CMAP), an electrodiagnostic parameter that measures the viability of axons at the distal motor target, may offer a more accurate picture. This study aimed to determine whether specific CMAP parameters were able to accurately predict postoperative outcomes after in situ ulnar nerve decompression at the elbow.

Forty-two patients with UNE were selected from five tertiary hand surgery institutions for this prospective, nonrandomized cohort study. The diagnosis of UNE was confirmed via nerve conduction study, with a motor NCV across the elbow segment of <50 m/s required to meet criteria for study participation. Exclusion criteria included post-traumatic UNE, previous ulnar nerve surgery to the affected elbow, additional compressive neuropathies on the ipsilateral side and a history of substance abuse, traumatic brain injury or major psychiatric comorbidity. Study participants underwent in situ ulnar nerve decompression at the elbow, with follow-up reassessments at six weeks, three months, six months and 12 months after surgery.

Outcomes measures were taken both at baseline and at each subsequent post-surgical visit. These included: nerve conduction studies (latency, NCV, and CMAP), motor and sensory function measures (grip and pinch strength, static 2-point discrimination [2-PD] and Semmes Weinstein Monofilaments) and patient-reported outcomes (PROs; Michigan Hand Outcomes Questionnaire [MHQ], Disabilities of the Arm, Shoulder and Hand [DASH] and Carpal Tunnel Questionnaire [CTQ] ).

Controlling for motor NCV and demographic factors, CMAP amplitude was the only electrodiagnostic variable found to predict scores on all three PROs, as well as overall recovery of motor function (both grip and pinch strength). Notably, male sex was also found to correlate with a faster recovery of grip and pinch strength. Motor NCV scores were found to independently predict recovery of 2-PD and pinch strength. Neither CMAP nor NCV scores predicted the MHQ subsections of pain, aesthetics or satisfaction, or the Semmes-Weinstein outcome postoperatively.

The authors concluded that CMAP is a useful electrodiagnostic parameter to identify the severity of UNE and should be utilized to determine timing of treatment for UNE and prognosis. CMAP scores were predictive of post-operative recovery trends of in situ ulnar nerve decompression, particularly for functional PROs and motor function return of grip and pinch strength. Decreased CMAP amplitude pre-operatively was shown to be predictive of poorer treatment outcomes post-operatively.

Citation: Florczynski, M. M., Kong, L., Burns, P. B., Wang, L., & Chung, K. C. (2023). Electrodiagnostic Predictors of Outcomes After In Situ Decompression of the Ulnar Nerve. The Journal of Hand Surgery, 48(1), 28–36.

Journal Source: The Journal of Hand Surgery

2024 Research Updates

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