Traumatic upper limb peripheral nerve injuries significantly impact individuals’ function and ability to return to work. Patients with peripheral nerve injury experience ongoing psychological impairments for which they are not routinely treated. The aim of this review was to investigate the psychological consequences of traumatic upper limb peripheral nerve injury.
A systematic review of MEDLINE, Embase, PsycINFO, CINAHL, AMED, BNI, the Cochrane libraries and grey literature up to October 2015 was undertaken. Two reviewers independently assessed methodological quality in accordance with Cochrane Collaboration recommendations. Eligibility criteria comprised: adults or adolescents with traumatic upper limb peripheral nerve injury using any measurement of psychological well-being.
Six studies (n = 245) met the inclusion criteria. Methodological quality varied widely. Evidence of post-traumatic stress disorder at one month, which decreased over time, was reported in three studies. Two studies found a statistically significant correlation between the early presence of post-traumatic stress disorder and reduction in function at 12 or more months. Limited information was available on anxiety, depression and mental quality of life. Combined nerve injuries (in two studies) had significantly higher levels of post-traumatic stress disorder, at one month, compared to those with an isolated nerve injury.
There is some evidence of early post-traumatic stress disorder following traumatic upper limb peripheral nerve injury, which may have an impact on functional outcome. However, high-quality studies using prospective cohorts are required to further evaluate the psychological aspects associated with this traumatic injury.
Whether baseline characteristics influence range of motion outcomes following proximal phalanx fracture remains unclear. The aim of this review was to investigate whether fixation type, time to commencement of active finger exercise, location of fracture or which finger is injured predict total active range of motion 6 weeks after surgical fixation.
A retrospective cohort of 49 patients with finger proximal phalanx fracture was analysed. Putative predictors investigated were fixation type, time to commencement of active exercise, location of fracture and injured finger. The outcome of interest was total active finger range of motion 6 weeks post-operatively.
Multiple regression analysis found that time to commencement of active exercise was the only significant independent predictor of total active range of motion 6 weeks post-operatively. The main influence on time to commencement of active exercise was fixation type, with fractures repaired using Kirschner wire fixation associated with a delay of nearly 2 weeks, compared with fractures repaired using open reduction and internal fixation.
Patients who commence active exercise early following surgical fixation of a proximal phalanx fracture may expect greater total active range of motion 6 weeks post-operatively than if exercise is delayed.
This feasibility study aimed to (i) develop a clinical protocol using a long-term potentiation-like repetitive stimulation protocol for transcutaneous electrical nerve stimulation in patients with upper limb complex regional pain syndrome and (ii) develop a research protocol for a single-blind randomised controlled trial investigating the efficacy of transcutaneous electrical nerve stimulation for complex regional pain syndrome.
This small-scale single-blind feasibility randomised-controlled trial planned to randomise 30 patients with upper limb complex regional pain syndrome to either a variant of transcutaneous electrical nerve stimulation or placebo transcutaneous electrical nerve stimulation for three weeks. Stimulation comprised 20 pulses over 1 s with a non-stimulation interval of 5 s, a so-called repetitive electrical stimulation protocol following the timing of long-term potentiation. Pain, function and body image were measured at baseline, post-treatment and at three months follow-up. At three months, participants were invited to one-to-one interviews, which were analysed thematically.
A transcutaneous electrical nerve stimulation protocol with electrodes applied proximal to the area of allodynia in the region of the upper arm was developed. Participant concordance with the protocol was high. Recruitment was below target (transcutaneous electrical nerve stimulation (n = 6), placebo (n = 2)). Mean (SD) pain intensity for the transcutaneous electrical nerve stimulation group on a 0 to 10 scale was 7.2 (2.4), 6.6 (2.8) and 7.8 (1.9), at baseline, post-treatment and at three-month follow-up, respectively. Qualitative data suggested that some patients found transcutaneous electrical nerve stimulation beneficial, easy to use and were still using it at three months.
Patients tolerated transcutaneous electrical nerve stimulation well, and important methodological information to facilitate the design of a large-scale trial was obtained (ISRCTN48768534).
Healthcare professionals, including hand therapists, are frequently called upon to identify barriers to return-to-work for workers with upper extremity injuries. However, the methods and tools used to assess barriers to return-to-work remain unknown. Results from these assessments can be used to direct appropriate interventions for those who may be at risk of a prolonged work absence.
The purpose of this study was to identify the tools and methods used by healthcare professionals to assess barriers to return-to-work for workers with upper extremity conditions. A total of 596 Australian healthcare professionals responded to an open-ended question regarding the tools/methods they use to identify barriers to return-to-work. All responses were coded and analysed descriptively. Differences between professional disciplines were recorded.
Healthcare professionals nominated 59 types of tools and methods that they use to identify barriers to return-to-work for workers with upper extremity conditions in their clinical practice. The most favoured method was clinical interviewing. Other commonly used tools were clinical measures, e.g., strength, and a return-to-work risk-factor screening tool validated on musculoskeletal diagnoses, the Orebro Musculoskeletal Screening Questionnaire.
Healthcare professionals use a variety of methods and tools to identify barriers to return-to-work for workers with upper extremity conditions. Generally, they favoured subjective methods. Future research is needed to develop or validate assessment tools designed to identify barriers to return-to-work for workers with upper extremity conditions. In the absence of upper extremity specific screening tools, hand therapists should consider the biopsychosocial framework when evaluating barriers to return-to-work.
The aim of this study was to compare hand impairment and function in a cohort of patients with rheumatoid arthritis and matched healthy participants.
A matched case comparison research design comparing hand impairment and functional ability between patients with rheumatoid arthritis and healthy participants (males or females, aged ≥ 50 years). Functional ability was assessed using the Michigan Hand Questionnaire, power and pinch grip strength and the nine-hole peg test.
A total of 100 participants (50 patients with rheumatoid arthritis and 50 matched healthy participants) were recruited. Patients with rheumatoid arthritis reported significantly lower overall hand function, activities of daily living, work, aesthetics, satisfaction (p < 0.001) and significantly higher pain scores when compared with healthy controls. The patients with rheumatoid arthritis had significantly lower maximum power and pinch grip strength in both left and right hands (p < 0.001) when compared with healthy controls. The rheumatoid arthritis group took significantly longer to complete the nine-hole peg test using both right and left hands compared with healthy controls (p < 0.001, respectively). Additionally, in rheumatoid arthritis patients, a significant moderate, positive correlation between power grip strength and activities of daily living (r = 0.584, n = 50, p < 0.01) and a weak-to-moderate, significant negative correlation between power grip strength and pain (r = –0.314, n = 50, p < 0.05) were reported.
Despite the recent substantial improvement of drug therapy and disease control, the functional impact of rheumatoid arthritis on hand pain and function remains significant.
Previous research concerning the conservative management of mallet finger has focused on splint application, with limited representation of supplementary rehabilitation and best practice. This research sought to investigate the practice and opinions of members of the British Association of Hand Therapists regarding their current treatment and to determine whether any specific exercise prescription or rehabilitation protocols are followed.
British Association of Hand Therapists members were contacted via e-mail and requested to complete an online survey. Thirty-five responses (5.7% response rate), 30 (4.8% response rate) of which were fully completed were obtained over the eight-week data collection period. The questionnaire consisted of 30 questions (20 quantitative and 10 qualitative) concerning therapists’ roles and condition management. Responses were analysed in terms of response frequencies, percentages and thematic text analysis.
The results demonstrated current clinical practices in line with available best-evidenced practice. Conservative therapeutic management is diverse and varied. Therapists believe their role to be significant in optimising outcome success.
Exercises and other interventions supplementary to splinting are commonly utilised in the therapeutic management of acute, closed mallet finger. This research found hand therapists implement a diverse range of clinical skills in order to optimise outcome success. Recommendations for best practice and further research are presented.
The Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire is a widely used upper extremity outcome measure. However, it is yet to be translated into any of the major languages in Nigeria, thus limiting its utility in the Nigerian clinical setting. The aim of this study was to cross-culturally adapt the DASH questionnaire into Yoruba, a major Nigerian language and investigate its initial validation.
The English version of DASH was adapted into Yoruba through forward–back translations, experts’ committee meetings, pretesting and cognitive debriefing interview in accordance with the guidelines recommended by the developers of DASH. Fifty-two purposively selected patients with upper extremity musculoskeletal disorders participated in a cross-sectional survey. Factor analysis was performed to ensure structural validity of Yoruba version, and construct validity was investigated with Spearman rank correlation coefficient.
The Yoruba version of DASH has semantic, idiomatic, linguistic and conceptual equivalence with the English DASH. Thirty linear components were identified within the data set. Principal factor analysis of the Yoruba DASH revealed a seven factor scale, having fulfilled all the necessary conditions. The Kaiser-Meyer-Olkin measure of sampling adequacy was 0.61, and Barlett’s test of Sphericity was adequate and significant (2 (1066) = 435, p = 0.001). Significant correlation (r = 0.994, p = 0.001) exists between scores obtained on English and Yoruba versions of DASH.
A cross-culturally adapted, valid Yoruba version of DASH is available for use in in south western Nigeria and other similar populations.
Complex regional pain syndrome is a multifaceted condition, which is relatively common after distal radius fracture.
A series of audits and service evaluations were conducted from 2004 to 2013 to investigate the incidence of complex regional pain syndrome type I and any correlation to tight, restrictive, over-flexed casts. Simple subsequent clinical and patient management changes were implemented and impact re-evaluated.
These audits have contributed to organisational learning and a subsequent reduction in the incidence of complex regional pain syndrome type I in non-operatively managed distal radius fracture from 25%, in keeping with expected incidence in the relevant literature, to a rare event (<1%).
The authors suggest that careful attention to the prevention of complex regional pain syndrome through staff and patient awareness, vigilance for warning signs and minor modifications to the traditional management of distal radius fractures can significantly reduce the incidence of complex regional pain syndrome type I after distal radius fracture.
Lateral elbow tendinosis is a condition that is well known to cause difficult challenges for hand therapists due to its long-term recovery and morbidity. Elastic therapeutic tape is commonly used as a treatment modality, despite limited evidence.
A randomized controlled trial was conducted to evaluate the effectiveness of elastic therapeutic tape, in conjunction with eccentric exercises, in the treatment of lateral elbow tendinosis. Forty participants with this condition (12 men, 28 women) were randomly allocated to three groups: (i) elastic therapeutic tape and eccentric exercises, (ii) sham tape and eccentric exercises, and (iii) eccentric exercises alone. All groups received education on activity modification techniques. Interventions were undertaken over a 12-week period (four weekly sessions and four fortnightly sessions) and outcome measures were recorded at baseline, three months and six months post randomisation.
At three and six months, improvements were made in all three groups as assessed with the Patient-Rated Tennis Elbow Evaluation, the Short Form 36, pain-free grip strength, and the Occupational Self Assessment. However, there were no statistically significant differences between groups in any of these measures. There were no significant side effects or symptom exacerbation with using the elastic therapeutic tape.
Whilst all groups improved on key outcomes, it is possible that exercise alone and/or natural recovery were responsible for improvements. It is positive to note that the use of elastic therapeutic tape was well tolerated by participants and not associated with any significant side effects or symptom exacerbation.
Facilitating function through occupation and purposeful activity is the basic tenet of occupational therapy. However, the majority of research in hand rehabilitation clinics continues to focus on biomechanical interventions. The purpose of this research was to study practice patterns and personal opinions of occupational therapy practitioners before and after providing purposeful activity kits to an outpatient occupational therapy hand clinic.
Mixed-method design to evaluate an 8-week intervention of providing purposeful activity kits to a busy, military outpatient hand clinic. A paper survey was administered to nine occupational therapy practitioners before and after the intervention. Qualitative data were gathered through semi-structured interviews.
A descriptive analysis indicated an increase in the use of activities, crafts, and occupation after the introduction of the purposeful activity kits. Practitioners consistently reported time as the top factor in their inability to incorporate more purposeful activities. Qualitative results support use of the new activities during both intervention and evaluation due to the focus on function and ease of use of the kits.
Purposeful activities can enhance any rehabilitation clinic in an organized, cost-effective manner. Practitioners responded positively toward the added equipment; however, it will take time and effort to adjust the theoretical decision making of practitioners. Additional participants and length of intervention is needed.
Distal radius fractures are common in women aged over 50. Common complications are pain, oedema, and finger stiffness, which can impact the ability to perform many daily activities. An exercise program for mobility and strength is a traditional early treatment. Little is known about the influence of occupational performance intervention in the early stage. The aim was to evaluate the effect of early intervention at the emergency department focusing on occupational performance in women over 50 years with distal radius fracture.
A nonrandomized controlled trial, with an intervention group (n = 24) and a control group (n = 24). The intervention group had a dialogue with an occupational therapist highlighting activity issues in the present situation. The control group got treatment as usual. Patient reported outcome measures were used as assessment at an estimated baseline, 1 week, 4 to 5 weeks, and 7 to 8 weeks after injury with COPM, DASH, and a single question about perceived independence of occupational performance. Change over time and differences between groups were calculated.
Both groups improved their occupational performance significantly during the 2 months follow up, but the intervention group valued their improved ability and independence significantly higher than the control group. Some of the participants in the intervention group scored within normative values for women with DASH, already at 4 to 5 weeks and 7 to 8 weeks after the injury.
The results indicate potential importance of very early occupational performance intervention at the emergency department, as a valuable complement to traditional treatment of distal radius fracture.
Children with Down syndrome present with joint laxity, hypotonia and shortened hands resulting in reduced grip and pinch strength. Limited information on grip and pinch strength in children with Down syndrome motivated this study.
A convenience sample of 30 children with Down syndrome (9–16 years) from special schools and 30 age- and gender-matched healthy school children was studied. Grip and pinch strength were measured according to ASHT standard procedure using JAMAR® dynamometer and B&L pinch gauge. Anthropometric data of upper limb and subject characteristics were recorded.
Children with Down syndrome had significantly lower values for grip, palmar and key pinch strength (p < 0.001) (6.3 kg, 1.91 kg, 2.75 kg) compared to healthy children (15.9 kg, 2.86 kg, 3.52 kg), respectively. A positive moderate correlation was observed between right hand grip strength and body height (r = 0.67), bodyweight (r = 0.69), total arm length (r = 0.68), upper arm length (r = 0.68), forearm length (r = 0.63), hand length (r = 0.68) and hand breadth (r = 0.66) in children with Down syndrome.
Children with Down syndrome presented with 60% less grip strength, 33% less palmar pinch strength and 22% less key pinch strength when compared to children without Down syndrome. Positive moderate correlation was observed between grip strength, body height, body weight and upper limb anthropometric variables in children with Down syndrome.
Extension orthoses are frequently prescribed by hand therapists to treat fixed flexion deformity of the proximal interphalangeal joint. A wide variety of proximal interphalangeal joint extension orthoses exist, but there is limited research evidence to guide implementation in clinical practice. Consequently, effective management of fixed flexion deformity of the PIP joint remains a challenge.
An electronic survey was distributed to members of the Australian Hand Therapy Association. The survey included two case scenarios, (including a fixed flexion deformity of 30° and 55°) and participants were asked to identify their preferred orthosis for each case. Responses to closed questions were analyzed descriptively. Thematic analysis for open-ended questions was completed by two experienced hand therapists.
One hundred ninety-five therapists completed the electronic survey. Handmade capener (21.7%), pre-fabricated capener (22.2%), and static finger troughs (21.1%) were the preferred orthoses for treatment of contractures of 30°. Serial casts (60.9%) were the preferred choice for a contracture of 55°. Key themes influencing choice of orthosis reflected an evidence-based practice approach to clinical reasoning that combined use of available evidence with therapists’ experience and the needs of the patient. Therapists’ interpretation and application of research differed according to their unique situation.
Orthotic prescription is a multifaceted process that combines therapists’ interpretation of evidence with their experience and the needs of the patient. Further research is needed to evaluate and clarify current theories that are used to guide intervention.
The cold intolerance symptom severity (CISS) questionnaire is frequently used for the assessment of cold intolerance (CI) in patients following hand trauma. Its practical and conceptual limitations prompted the development of a new cold intolerance questionnaire (CIQ). The CIQ assesses and gives equal weighting to five components of CI, severity, frequency, extent, duration and prevention. An optional impact score can be included as the CIQ+.
Data were collected over a five-month period from adult hand trauma patients. Each patient completed the CISS, CIQ and the Quick DASH questionnaires during their assessment. A total of 51 patients (34 men and 17 women) were examined at a median interval of 14 months (3–48) after injury. Their mean age was 42 years (SE = 2, range 18–81).
The median (range) scores were CIQ = 16 (0–27), CIQ + = 18 (0–33), CISS = 56 (0–89) and Quick DASH = 44 (2–86). The scores were significantly correlated. The majority of patients had symptoms localised to the digit or point of injury. All but one of the five selected components of the CIQ and the separate impact score were significantly correlated.
The authors found the CIQ to be a simple scoring system that is suited to clinical use. The CIQ has value as a research tool as it provides a method of categorising patients and of identifying patients suited to certain treatment methods. Furthermore, it may be a more informative tool in monitoring treatment as it is able to assess changes in pattern as well as overall score.
Fractures of the distal radius are common in the elderly population. Elderly patients have been considered to be functionally low-demand, but as the population becomes more active, expectations of outcomes may be increasing. The aim of this review was to determine whether there is any correlation between radiographic and functional outcome for elderly patients following fracture of the distal radius.
Medline, PubMed, CINAHL, Embase and AMED were searched for studies including elderly patients managed conservatively or surgically following distal radius fracture, either alone or in combination with younger patients.
Eleven studies were selected for review. A wide variety of outcome measures and radiological parameters were found to be used. Of the 11 studies, 6 found no correlation between functional outcome and radiological outcome.
The literature reviewed suggests functional outcome for elderly patients following distal radius fracture is not dependant on radiological outcome. This may give therapists better insight into potential outcomes for their patients, however further studies may be required to determine the most effective therapeutic management of these patients.
Though there is a general perception that Asian hands have an increased range of movements in all their joints, there is very little written in the literature on this topic. Our unit caters to a multiethnic population and it has been our experience that the outcomes after hand surgery are generally better in Asian hands. This study was aimed at comparing the range of movements between two cohorts of volunteers: Asians and Caucasians.
Data were collected on their ethnicity, gender, age, handedness and any medical conditions. The Beighton score was measured for all subjects and range of movements was measured using a standard goniometer. Totally, 114 subjects were enrolled into the study, which included 53 men (46%).
There were 59 Caucasians and 55 Asians. The range of movements of wrist and hand was greater in Asians and the difference was statistically significant (p < 0.05). Men in general had greater range of movement of the fingers whereas women had greater range of movement of the thumb. There was no difference between Asian men and women with regard to wrist movements. However, Caucasian women had greater wrists movements than Caucasian males. The average Beighton score was the highest in Asian women (7), followed by Asian men (6). Caucasian men and women had an average Beighton Score of 2.
Normative data for different ethnic groups are important for hand therapy as they can guide rehabilitation protocols. Our study demonstrates that a difference in hand flexibility between British Asians and their Caucasian counterparts exists.
The use of a placebo thumb base splint in an osteoarthritis trial is novel and may help identify specific and non-specific effects of hand splinting. This study aimed to explore the thoughts and feelings of trial clinicians who would be delivering a placebo splint to understand their perspective and to identify how these feelings may affect them personally, professionally and practically.
Three senior Occupational Therapists selected from a purposive sample of trial collaborators participated in a focus group interview. Structured questions were used to elicit debate and discussion and three designs of placebo splint developed for this trial were available for consideration. The 60-min audio recorded focus group was transcribed verbatim, validated and underwent thematic analysis.
Four main themes were identified; justification of placebo thumb splint use in this research, anxiety about causing of harm, preconceptions about thumb splint activity, and the practicalities of convincing placebo thumb splint delivery. This last theme was broken down into three sub-themes: anxiety about ‘selling’ the splint, the therapeutic relationship in splint delivery, and training requirements for splint delivery.
Clinicians have anxieties and practical concerns regarding delivering placebo splints in a clinical effectiveness trial for rehabilitation for thumb base osteoarthritis. Tailored support and training throughout all stages of trial delivery is required to ensure their ability to deliver the intervention in a rigorous, unbiased manner.