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.
2023 Research Updates
September Research Update
Passive Manipulation for Proximal Interphalangeal Joint Extension Contractures
Summary provided by April Bryant OTD, OTR/L, CHT
Proximal Interphalangeal (PIP) joint extension contractures can result from injuries to bones, muscle and connective tissue. Surgical management of PIP joint extension contractures yields variable results and can increase edema and scar tissues and even decrease PIP ROM. Passive manipulation of PIP joint extension contractures is an alternative option to consider when the patients have plateaued with other conservative measures. This study aimed to evaluation immediate and more long-term ROM changes to the PIP joint following PIP joint manipulation.
Twenty-eight patients (46 fingers) were selected in this retrospective study that used medical records from 2015 to 2019. Inclusion criteria were the patients were at least 12 weeks post injury/incident, adequate PIP joint architecture and pre-manipulation PROM measurements present. Gentle and gradual passive PIP flexion was applied to address both intrinsic and extrinsic tightness by one of three surgeons in either the clinic with a digital nerve block or in the operating room. Post-intervention, patients were educated on ROM exercises and were referred to hand therapy until they were able to transition to a home exercise program.
Passive PIP flexion improved by 50 degrees post manipulation. This decreased to improvements of 26 degrees, 10 degrees and 18 degrees at before six weeks, six to 12 weeks and over 12 weeks, respectively. These improvements are comparable to those seen after surgical intervention.
Limitations of the study include lack of control group, discharge of patients who did not require further intervention after manipulation, small sample size and relatively short length of follow-up.
This study demonstrates that passive manipulation to improve PIP flexion secondary to PIP extension contractures may be a safer and less invasive, yet equally effective option compared to surgical intervention.
Citation: Gary, C. S., Wang, J. S., Shubinets, V., Sanghavi, K. K., Katz, R. D., Giladi, A. M., & Means, K. R. (2023). Passive manipulation for proximal interphalangeal joint extension contractures. The Journal of Hand Surgery, 48(7).
Journal Source: The Journal of Hand Surgery
Access the Journal Article Here
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
A randomized single-blinded trial of early rehabilitation versus immobilization after reverse total shoulder arthroplasty
Summary Provided by Priya Bakshi, OTD, OTR, CHT
This study compared early rehabilitation (therapy initiated at one week post-surgery) to delayed therapy (six weeks post-surgery) following reverse total shoulder arthroplasty (rTSA). Initial enrollment was 107 shoulders; 86 that completed one year follow up were included for analysis (44 shoulders in the delayed therapy group and 42 in the immediate therapy group).
Outcome measures included active and passive ROM (forward flexion, abduction, external rotation at 0 degrees abduction and cross body adduction), American Shoulder and Elbow Surgeons (ASES) scores, radiographic grading of scapular notching (Nerot-Sirveaux classification system) and adverse event recording. Blinded research assistant assessed outcome measures at six weeks, three months, six months, one year and two years postoperatively.
Within group analysis showed clinically significant improvement in active and passive ROM in flexion and abduction by three months post-surgery. No significant improvement in external rotation or cross body adduction occurred, with an initial decline in external rotation from preoperative range at six weeks. The authors report that other studies show optimization of external rotation with positioning of the glenosphere laterally and inferiorly. Statistical and clinical improvement was seen in ASES scores at six weeks post-surgery, but functional component score did not improve until three months postoperatively.
Between group analysis showed no difference between groups in change in ROM from preoperative motion at all time points. Similarly, no difference between groups was seen in ASES scores at any time point except at six months favoring delayed therapy group. A 30-point improvement in ASES score at one year was maintained at two-year follow up. Scapular notching was statistically the same between groups at one year follow up. No difference between groups was found in dislocation rates (2%) and complications were rare.
The authors concluded that both early and delayed therapy groups showed significant improvements in ROM and ASES scores and that the results support the safety of early rehabilitation programs following rTSA to minimize limitations of prolonged immobilization; however, early ROM did not have an immediate impact on ASES scores.
Citation: Hagen, M. S., Allahabadi, S., Zhang, A. L., Feeley, B. T., Grace, T., & Ma, C. B. (2020). A randomized single-blinded trial of early rehabilitation versus immobilization after reverse total shoulder arthroplasty. Journal of Shoulder and Elbow Surgery, 29(3), 442–450.
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 Jenny M. Dorich, PhD, MBA, OTR/L, CHT, ASHT Research Division Director at jenny.dorich@cchmc.org.
July Research Update
Role of Health Equity Research and Policy for Diverse Populations Requiring Hand Surgery Care
Summary Provided by Sophie Goloff, MS, OTR/L, CHT
Health equity and health equality are often used interchangeably; however, each represents a different concept. Health equity is “an ethical principle driven by social justice, which means that everyone has a fair and just opportunity to be as healthy as possible.” Health equality is defined by equal resources provided to all. Health equity must target systemic disparities in healthcare that affect marginalized groups. Currently, populations such as racial/ethnic minority groups, rural residents and socio-economically disadvantaged families have reduced quality and access to healthcare.
Research regarding social determinants of health in hand surgery is limited, but showed that race, socioeconomic status and rural location all are associated with poorer surgical outcomes. Community based barriers to health equity can arise due to poor Medicaid reimbursements, leading to fewer community-based hand surgeons accepting Medicaid. This increases the travel burden, out-of-pocket costs and time required to receive adequate care. Rural and socioeconomically disadvantaged areas similarly are less likely to be served by specialty hand surgeons. Although there is extensive research regarding social, environmental and economic factors that serve as barriers for health equity, we still do not have conclusive strategies to reduce health inequities. Research has shown a collaborative, interdisciplinary approach is necessary.
Opportunities to advance health equity are present at an institutional level. Awareness is important – a 2016 cross sectional study showed only 37% of surgeons believe health disparities exist, and only 5% recognize them in their own practice. All medical professionals must be educated regarding cultural competence and antiracism education, and more research is required on how to reduce implicit bias. Greater diversity in hand surgery is required to improve health equity and must start at the education level.
There is a need for improved pre- and post-operative care for vulnerable patients. Hand therapy is important for optimal surgical outcomes; however, patients insured by Medicaid are less likely to receive hand therapy services. Insurance limitations, geographical location, care coordination and decreased health literacy all contribute to this disparity. Public policy contributes to surgeon willingness to accept insurance, improving reimbursement and accuracy of success metrics can contribute to more equitable healthcare.
Health equity will be best achieved through addressing research and policy at individual, community, institutional and healthcare system levels.
Citation: Myers, Paige L., and Kevin C. Chung. “Role of Health Equity Research and Policy for Diverse Populations Requiring Hand Surgery Care.” Hand Clinics, no. 1, Elsevier BV, Feb. 2023, pp. 17–24. Crossref.
Journal Source: Hand Clinics
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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.
June Research Update
A prospective clinical trial comparing denervation with suspension arthroplasty for treatment of carpometacarpal arthritis of the thumb.
Summary Provided by Stephanie Strouse, OTD, OTR/L, CHT
One of the most popular treatments for thumb carpometacarpal arthritis is a trapeziectomy with suspensionplasty; however, a recent procedure involving denervation of the carpometacarpal joint has been found to be favorable in reducing pain in a younger population and to “buy time” until they progressed to the point where they needed to have a suspension arthroplasty. Those who underwent this procedure not only reported decreased pain but also reported improved quality of life as noted in functional outcome surveys.
For this study, the authors performed a prospective clinical trial between June 2020 and December 2021 to compare the functional outcomes of subjects who underwent denervation versus arthroplasty. All 48 participants underwent procedures by the same surgeon and the study was designed as a “patient choice” comparative study. Inclusion criteria to participate in the study included a diagnosis of CMC arthritis as well and failure of non-surgical management with anti-inflammatories, bracing, or corticosteroid injections. Exclusions to the study were those individuals who were concurrently diagnosed with peripheral neuropathy or cervical radiculopathy. The subjects were provided with the options of surgical denervation or arthroplasty with suture suspensionplasty. A total of 34 patients underwent denervation and 14 underwent suspension arthroplasty of the thumb CMC joint.
Hand function was determined by the Michigan Hand Outcomes Questionnaire (MHQ), pain using the visual analog scale (VAS), and quality of life was determined by the EuroQol-5D (EQ-5D). These scales are considered patient-reported outcome measure and data was collected pre- and post-surgery. In addition to the above outcome measures, each subject was asked several qualitative questions after surgery. The questions included “Compared to before surgery, how is your hand pain currently?” and “compared to before surgery, how well does your hand function?” Responses were limited to “slightly worse,” “about the same,” “slightly better” or “much better.” In addition to questions regarding pain, subjects were also asked about sensation. These questions included “Do you have numbness around the incision site?” and “Do you have numbness over the distal thumb?” Reponses to these two questions were limited to “yes” or “no.” One final questions regard function included “How long after surgery did you return to full function?” Responses for this question ranged from “never,” “worse” or “several weeks.”
Results of the study found similar short-term surgical outcomes in patient treatment with denervation and suspensionplasty. Both groups had improvements in MHQ function scores, decreased pain as reflected by VAS scores. There was a difference in the length of time the subjects reported improved symptoms, denervation patients generally noted a decrease in symptoms in 3-4 weeks compared to the arthroplasty patients reported improvement in 4-5 months. Another difference was the absence of post-operative paresthesia throughout the dorsal radial sensory nerve in the subjects who underwent denervation. The study states the denervation procedure may be a favorable alternative treatment for CMC pain, but did imply that this procedure was superior to arthroplasty. One downfall of the study was the short-term follow up and the authors did reference to further studies with longer term follow-ups. In addition to the short term follow up, the authors also expressed a concern with using patient-reported outcome measures and the possibility of bias and having a preconceived perception of expected outcomes.
In conclusion, the authors supported the findings of the study despite the limitations. These results, with other studies, do offer support of denervation for pain control, improved quality of life and quicker recovery times.
Citation: J.W. Hustedt, S.T. Deeyor, C.H. Hui, A.Vohra, A.C. Llaes, & B.L. Silvestri. A prospective clinical trial comparing denervation with suspension arthroplasty for treatment of carpometacarpal arthritis of the thumb. American Journal of Hand Surgery 2023: 48(4); 348-353.
Journal Source: American Journal of Hand Surgery
Access the Journal Article Here
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.
May Research Update
Open and Arthroscopic Triangular Fibrocartilage Complex (TFCC) Repair
Summary Provided by Melanie Hubbuck, MS, OTD, OTR/L
TFCC injury is a frequent cause of ulnar-sided wrist pain with the need for surgical repair in both acute and chronic or degenerative cases. There is ongoing debate over optimal surgical technique for repair, specifically arthroscopic versus open. This article reviewed the literature to date surrounding TFCC injury.
Surgical intervention is considered for acute injuries in high demand patients, patients who have failed conservative management with persistent ulnar sided wrist pain (typically at least 3-6 months), chronic degenerative tears with ulnar impaction, and persistent DRUJ instability. Surgical options are divided into open or arthroscopic treatments. Peripheral TFCC tear with DRUJ instability can be treated with either open or arthroscopic foveal repair. Due to the proximity to the rotational axis of the forearm, foveal detachment often results in DRUJ instability. Alternatively, peripheral tears without DRUJ instability can be repaired by directly repairing the torn TFCC to the wrist capsule. If ulnar positive, the authors encourage consideration of ulnar shortening osteotomy (USO) rather than TFCC debridement or repair alone with high fail rate/return for USO. There are many fixation techniques described for both open and arthroscopic repair. From a biomechanical standpoint, the suture anchor technique performs the best in terms of load to failure rate and load to gap formation. Johnson et al demonstrated foveal repair with knotless suture anchor resulted in DRUJ stiffness and ulnar translation similar to native forearm rotation. Thus, from a biomechanical standpoint, direct foveal repair (either open or arthroscopic) with suture anchor may be best, especially if pre-operative DRUJ instability was noted. Central and radial portions of the TFCC are poor in blood supply, so typically best treated with debridement over repair.
Postoperative rehabilitation is dependent on surgical technique and intraoperative findings. Generally, progression is dependent on capsular repair of peripheral TFCC tears with deep fibers intact versus patients with concurrent DRUJ instability treated with foveal repair. For patients who undergo capsular repair with deep fibers still intact, recommended original immobilization includes Muenster orthosis in full supination for three weeks. At that time, patients can be transitioned to short removable orthosis with start of pronation. Comparatively, patients who have concurrent DRUJ instability with foveal repair, forearm rotation may be restricted for up to six weeks post op. At that time, splinting can be discontinued with initiation of wrist/forearm range of motion. Gradual light strengthening can be resumed at 10 weeks post op. For both types of repairs, sports are typically not resumed until at least 12 weeks post op.
There is limited evidence comparing open versus arthroscopic TFCC repair. Both open and arthroscopic repair to the capsule or fovea have demonstrated improved pain scores, and functional outcomes with comparable post-operative residual DRUJ instability, range of motion, grip strength, and DASH score (Andersson et al., 2018). Future research with adequately powered trials is needed to compare clinical and functional outcomes of open versus arthroscopic repair.
Andersson, J. K., Åhlén, M., & Andernord, D. (2018). Open versus arthroscopic repair of the triangular fibrocartilage complex: A systematic review. Journal of Experimental Orthopaedics, 5(1), 6. https://doi.org/10.1186/s40634-018-0120-1
Johnson, J. C., Pfeiffer, F. M., Jouret, J. E., & Brogan, D. M. (2019). Biomechanical analysis of capsular repair versus arthrex TFCC ulnar tunnel repair for Triangular Fibrocartilage Complex tears. Hand, 14(4), 547-553. https://doi.org/10.1177/1558944717750920
Citation: Srinivasan, R. C., Shrouder-Henry, J. J., Richard, M. J., & Ruch, D. S. (2021). Open and arthroscopic triangular fibrocartilage complex (TFCC) repair. Journal of the American Academy of Orthopaedic Surgeons, 29(12), 518-525.
Journal Source: Journal of the American Academy of Orthopaedic Surgeons
Access the Journal Article Here
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.
April Research Update
Non-surgical management of displaced bony mallet injuries using dorsal hyperextension splint: An early-term outcome analysis
Summary Provided by Renee McDade, MOT, OTR/L, CHT
Bony mallet injuries are commonly seen as a result of sports injuries, daily activities or work related injury. These occur as a result of forced flexion on and extended DIP joint which causes an avulsion fraction and disruption of the terminal extensor tendon. The management of these injuries varies based on both the fracture pattern and surgeon preference.
For this study, the authors completed a retrospective review of the medical records and radiographs of patients with a diagnosis of a bony mallet who underwent conservative treatment with a dorsal hyperextension splint from a single institution from March 2019-March 2020. The selection criteria included acute (up to three weeks) displaced and closed bony mallet injuries, and no volar subluxation of the DIP joint after splint application. Exclusion criteria included any lacerations, comminuted fractures, persistent volar subluxation after splint application and non-compliance with the treatment protocol.
Aluminum finger splints padded with cell foam were used. The splint was cut to the length form the PIP dorsal crease to the tip of the nail and bent to 10-15 degrees of hyperextension at the level of the DIP joint. It was held in place by porous medical tape in two layers. Patient were asked to keep the splint away from water, not to change it at home by themselves, and to strap the same type of tape over the existing splint if it loosened. Patients were encouraged to move their PIP and were monitored every 2-3 weeks for up to six weeks for cleaning, reapplication and assessment of the fracture. After an appropriate union was achieved, the splint was worn an additional two weeks at night time and weaned into motion thereafter.
Seventeen patients were enrolled with mean treatment delay of seven days. Healing was achieved in all patients with mean duration between 4-6 weeks. Early complications included skin maceration in two patients, a wound in one patient and long term complications included two slight swan neck deformities and one patient developed complex regional pain syndrome.
Using a dorsal hyperextension splint does provide overall good results in terms of bony mallet injuries. Overall, there is a consensus that conservative treatment of mallet fractures is an acceptable level of treatment. Splint material whether aluminum based or thermoplastic, if placed in slight hyperextension is preferred versus a stack splint which is not customizable. Frequent outpatient assessment and solving any splint related discomfort are essential components of successful nonsurgical treatment.
BO, Arık A. Non-surgical management of displaced bony mallet injuries using dorsal hyperextension splint: an early-term outcome analysis. Hand and Microsurgery 2022: 11(3): 127-134.
Journal Source: Hand and Microsurgery
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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.
March Research Update
Shared decision making in youth with brachial plexus birth injuries and their families: A qualitative study
Summary Provided by Jenny M. Dorich, PhD, MBA, OTR/L, CHT
Recurrent elbow flexion contractures are common sequelae among children who sustain a brachial plexus birth injury (BPBI). As such, children with BPBI and their families are commonly faced with weighing the rehabilitative and surgical options to address elbow flexion contractures. This interpretivist qualitative study sought to explore the lived experience of youth with respect to shared decision-making when seeking care for elbow flexion contracture management.
This study involved individual semi structured interviews with six youth/young adults and 13 youth and parent dyads or triads (mom only n=9; parents n=4). Data analysis included deductive and inductive coding to elucidate youth’s and parent’s experiences with the child having an elbow flexion contracture, deciding between intervention options, and undergoing treatment. Additionally, researcher-created drawings were analyzed along with coding for thematic analysis.
Four themes respective to shared decisioning making evolved from the data. The first theme, Trust in the expertise of the clinician, was characterized by trust being discovered as both a facilitator and a barrier in the shared decision-making experience. For some participants the trust in the clinician facilitated an ease of open discussion about treatment options and the child’s preferences and concerns. At the same time, youth were found to have developed a trust that led them to accept the clinicians’ recommendations based upon their trust in the provider more than weighing all options and their associated pros and cons. The second theme was Youth’s role in the shared decision. The extent to which parents considered the youth’s perspectives in the decision was dependent on the child’s developmental stage, with increasing autonomy being extended in the teenage years and the preteen years being most characterized by conflict between the child’s desire to have a say in the decision and the parents’ unwillingness to defer to the child’s preferences. A third theme, Parental perceived responsibility, illustrates how parents feel a need to try anything possible that may achieve improvements in their child’s arm even if maintaining range of motion is to keep the mobility with the hope of medical future medical advancements. Youth-parent decision discord was the fourth theme. The experience of parents choosing treatment, especially trying rehabilitative treatment, over the child’s preference to forego treatment was observed. Furthermore, some young adults shared that they chose not to vocalize their dissent with their parents’ desire for treatment in the context of the medical consultation. Additionally, it was discovered that youth can experience undergoing rehabilitative care negatively because the treatment intervention drew more attention from their peers to their arm.
Study findings uncover that among youth with a BPBI the shared decision-making experience for elbow flexion contracture management is complex and can be characterized by discord between the youth and the parents, yet not realized in the medical consultation. Furthermore, variables such as trust the medical professionals, parental perceived responsibility to maximize their child’s arm abilities, and the parents’ perceptions of their child’s developmental readiness for making care decisions all contribute to the dynamics of the shared decision-making experience. As such, decision making supports may be valuable to facilitate empowering youth to fully participate in their care decisions.
Ho, E. S., Parsons, J. A., Davidge, K. M., Clarke, H. M., & Wright, F. V. (2021). Shared decision making in youth with brachial plexus birth injuries and their families: A qualitative study. Patient Education and Counseling, 104(10), 2586-2591.
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 Jenny M. Dorich, PhD, MBA, OTR/L, CHT, ASHT Research Division Director at jenny.dorich@cchmc.org.
February Research Update
Prospective Randomized Clinical Trial Comparing 3-point Prefabricated Orthosis and Elastic Tape Versus Cast Immobilization for the Nonsurgical Management of Mallet Finger
Summary Provided by Lori Algar, OTD, OTR/L, CHT
Does the use of elastic tape and a 3-point prefabricated orthosis for non-surgical mallet finger have improved outcomes over other forms of immobilization that do not allow the orthosis to get wet?
A randomized clinical trial compared the outcomes of using a 3-point prefabricated orthosis (Oval 8) with elastic tape (Kinesiotape), which may get wet during immobilization versus casting for the management of nonsurgical mallet finger. A total of 70 participants were randomized to the treatment groups. Outcomes were assessed at 12 weeks and 6 months post initiation of immobilization for the mallet injury. There were no statistically or clinically significant differences between groups for extensor lag, DIP joint flexion deficit, function according to the Brief MHQ, and pain on the NPRS. The researchers suggest that both methods of immobilization are appropriate options for mallet injury immobilization each with clinical advantages (i.e. being able to get wet versus providing circumference pressure for edema).
Algar L, Backe H, Richer R, Andruskiwec S, Zalenski P, Lengyel A, Svogun C. Prospective randomized clinical trial comparing 3-point prefabricated orthosis and elastic tape versus cast immobilization for the nonsurgical management of mallet finger. J Hand Surg. 2022; epub ahead of print.
Journal Source: Journal of Hand Surgery
Access the Journal Article Here
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.
January Research Update
Task-oriented exercises improve disability of working patients with surgically-treated proximal humeral fractures. A randomized controlled trial with one-year follow-up
Summary provided by Nancy Naughton, OTD, OTR/L, CHT
A randomized controlled trial n=70, studied individuals with a diagnosis of proximal humeral fracture and were s/p an open reduction and internal fixation. The participants’ mean age was 49 years. The participants were randomized into two groups.
The experimental group (n=35) included early motion beginning a 1-week post op which included a rehab program of task-oriented exercises tailored to their specific occupational demands and received O.T. along with physiotherapy. The control group (n=35) included traditional physiotherapy initiated at 1-week post-op. Both groups had 4 reassessments time points; Pre-surgery and pre- therapy, at the end of therapy and at 1 year follow up.
The primary outcome (DASH) had a clinically meaningful difference between groups. Although the primary or secondary outcomes did not achieve statistical significance and effect size was not assessed, the authors found that the experimental group achieved significantly larger improvements over time with respect to the control group.
The authors conclude that task-oriented exercises and occupational therapy (experimental group) was superior to general physiotherapy (control group) in improving disability, pain, and the quality of life of working patients with surgically treated PHFs.
Monticone, M., Portoghese, I., Cazzaniga, D. et al. Task-oriented exercises improve disability of working patients with surgically-treated proximal humeral fractures. A randomized controlled trial with one-year follow-up. BMC Musculoskelet Disorder 22, 293 (2021).
Journal Source: BMC Musculoskeletal Disorders
Access the Journal Article Here
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.
2022 Research Updates
2021 Research Updates
2020 Research Updates
2019 Research Updates
2018 Research Updates
2017 Research Updates