A descriptive study on wrist and hand sensori-motor impairment and function following distal radius fracture intervention

The reliability and applicability of the Ten Test in hand injuries: A systematic review

Introduction

The Ten Test (TT) is a touch threshold test that quantifies sensory discrimination by comparing an injured area with a contralateral uninjured area. It's quick, simple, equipment-free and repeatable. However, as a subjective measure, the TT's reliability and applicability need further investigation. This review aimed to investigate if the TT has superior inter- and intra-examiner reliability compared to the widely accepted Weinstein Enhanced Sensory Test (WEST) in a human population of all ages.

Methods

A systematic search was conducted on major databases from January 1997 to September 2023 and adhered to the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocol. Outcomes were assessed with a narrative approach. The included articles were critically appraised according to the Quality Assessment of Diagnostic Accuracy Studies two tool.

Results

This review included five articles. High inter-examiner reliability was demonstrated with intraclass correlation coefficient (ICC) values of 0.91 and 0.95, alongside a kappa statistic of 1, as reported by three distinct studies. Intra-examiner reliability displayed some variance, with one study reporting a significant ICC value in four out of six instances. Two studies corroborated that the TT results corresponded with the findings of WEST, each presenting a Spearman rank coefficient of -0.71.

Conclusion

Our findings underscore the TT's high inter-examiner reliability, though its intra-examiner reliability exhibited some inconsistencies. Interestingly, certain studies claimed its superiority over the WEST. To validate the TT's use in the clinical setting, more rigorous studies, particularly those comparing pre-operative TT outcomes with intraoperative nerve damage evaluations, are essential.

Impact of chronic wrist hypermobility on proprioception, strength, and functional performance in young adults

BACKGROUND

Chronic joint hypermobility has been attributed to repetitive ligamentous microtrauma, benign joint hypermobility syndrome (BJHS), or genetic connective tissue disorders that lead to pain and functional impairment, especially among females. Chronic wrist hypermobility (CWH) prevalence, etiology, and effects on proprioception, strength, and function have yet to be established.

PURPOSE

This pilot study aimed to determine the CWH prevalence among adults; its effects on proprioception, strength, and function; and whether these effects are gender based.

STUDY DESIGN

This was a quasi-experimental cross-sectional study.

METHODS

Ninety wrists (55 participants, mean age 27.46 years) with no wrist range of motion (ROM) restrictions or previous trauma for ≥6 months were screened for CWH based on an exploratory set of diagnostic criteria. Fifty-eight wrists (34 adults) were allocated to a CWH group, and 32 wrists (21 adults) were allocated to a healthy control group. Twenty-five CWH and 25 healthy control matched (gender, age, and handedness) participants were compared. Assessment included the active wrist joint position sense test, hand-held dynamometry for wrist extension and grip strength, and the patient-rated wrist evaluation for function. Testers were blinded to group allocation.

RESULTS

A 64.4% CWH prevalence existed among CWH participants, who were mostly asymptomatic females (74%). Frequent etiologic factors were midcarpal (96.5%) and scapholunate (39%) instabilities and BJHS (37%), which was higher among females (30%) than males (8%). Independent t-tests showed statistically significant (p < 0.05) group differences in wrist proprioception, wrist isometric extension, grip strength, and function with moderate-high (0.41-0.75) effect size. No significant gender differences existed in proprioception and function.

CONCLUSIONS

CWH is very prevalent among functional independent young adults with atraumatic midcarpal and intercarpal ligamentous laxities and BJHS. CWH prevails among women and adversely affects wrist proprioception, strength, and function. The study's specific CWH diagnostic criteria may be useful for clinicians to identify and timely manage impacted individuals by CWH.

Joint position sense testing at the wrist and its correlations with kinesiophobia and pain intensity in individuals who have sustained a distal radius fracture: A cross-sectional study

BACKGROUND

Sensorimotor impairment following distal radius fracture (DRF) has been associated with a significant decline in function. Joint position sense (JPS) testing is a meaningful and responsive way to assess sensorimotor impairment for individuals who have sustained a DRF; however, there are factors that may influence the results of JPS testing, including kinesiophobia and pain intensity.

PURPOSE

This study aimed to evaluate the influence kinesiophobia may have on wrist JPS testing and if pain intensity impacts kinesiophobia and JPS in individuals with a DRF.

STUDY DESIGN

This was a cross-sectional study.

METHODS

Participants referred from two medical centers with a diagnosis of DRF treated with at least 3 weeks of immobilization were enrolled in the study. Data were collected at 1 week and 6 weeks postimmobilization period. Demographics were summarized with descriptive statistics, and linear relationships between kinesiophobia, pain intensity, and wrist JPS were examined using Pearson correlation coefficient.

RESULTS

Forty-eight participants were included in this study (mean age 42.9 years). Significant positive correlations were found between the Tampa Scale for Kinesiophobia (TSK) and Numeric Rating Scale (NRS; r = 0.951, p < 0.001), TSK and JPS error (r = 0.942, p < 0.001), as well as NRS and JPS error (r = 0.898, p < 0.001). These correlations indicate that higher levels of kinesiophobia are associated with increased pain intensity and greater JPS error. T-tests reveal no significant difference between male and female for the TSK, NRS, or JPS scores.

CONCLUSIONS

There is an association for individuals with high levels of kinesiophobia and both greater pain and errors with JPS testing.

Wrist proprioception-An update on scientific insights and clinical implications in rehabilitation of the wrist

The field of wrist proprioception, as it relates to rehabilitation and surgery, has gone through a period of intense growth in the past decade. From being primarily focused on the function of the joint and ligaments in patients with wrist trauma or after wrist surgery, the understanding is now that of a greater complexity in treating not just the wrist but the hand and arm as a whole. Proprioception is derived from the Latin words "proprius" - belonging to (oneself) and "-ception" to sense. In other words, how to sense ourselves. To have a complete sense of self, multiple sensory afferents originating from joints, ligaments, muscles, tendons, nerves, skin, vision, and hearing work together to orchestrate a balanced integration of sensorimotor functions, with the true goal to perceive and adapt to the physical world around us. In this update on wrist proprioception, we review current developments in the understanding of proprioception, with an implication for our everyday work as hand therapists and hand surgeons. Each contributing sense-joint, ligaments, muscles, skin, and brain-will be reviewed, and the clinical relevance will be discussed. An updated wrist rehabilitation protocol is proposed where the therapist is guided to rehabilitate a patient after wrist trauma and/or surgery in 4 stages: (1) basic hand and wrist rehabilitation with a focus on reducing edema, pain, and scar formation; (2) proprioception awareness to improve the sense of joint motion and position; (3) conscious neuromuscular rehabilitation where isometric exercises of muscles that are beneficial for a particular injury are promoted, whereas others that are potentially harmful are avoided; and (4) unconscious neuromuscular rehabilitation with training of the reflex and joint protective senses.

Test-retest reliability of joint position sense in the elbow among healthy adults

BACKGROUND

Proprioception of the elbow is necessary for daily activities. Proprioception can be impaired with injury or pathology, and rehabilitation efforts seek to improve proprioception for improved upper extremity functioning. In clinical practice, joint position sense (JPS) testing is often utilized to assess conscious proprioception; however, varying methods exist with little evidence of psychometric properties, especially for the elbow.

PURPOSE

The primary aim of this study was to create a standardized elbow JPS test protocol using goniometry measurement to determine the most reliable testing position. The secondary aim was to determine if the elbow JPS test had acceptable test-retest reliability in healthy adults.

STUDY DESIGN

This was a cross-sectional study using a convenience sample of healthy adults.

METHODS

Three elbow positions (45°, 60°, and 75° of elbow flexion) were measured twice on the same day by a single rater using a universal goniometer. We calculated the absolute error in degrees between each position and reposition and the intraclass correlation coefficient (3,1) for relative reliability. We also calculated the standard error of the measurement and visually inspected Bland-Altman plots for absolute reliability.

RESULTS

Sixty-eight healthy adults (mean age 27.9 years, standard deviation 8.59) were assessed. The mean absolute error for all positions for test and retest was 5.7°. The intraclass correlation coefficients were moderate to good (0.57-0.75), and the standard error of the measurement was 2° (rounded) for all positions. The limits of agreement were moderately narrow, and the Bland-Altman plots showed a random distribution of errors for each position, indicating clinically acceptable measurement error.

CONCLUSIONS

The joint position reproduction test for JPS using goniometry demonstrated moderate to good test-retest reliability and acceptable measurement error in healthy adults. The elbow joint angle of 60° flexion was the most reliable for JPS testing, providing insight for JPS assessment in clinical practice.

Test-retest reliability of joint position sense in the carpometacarpal joint among healthy adults

BACKGROUND

Accurate proprioception in the thumb carpometacarpal (CMC) joint is necessary during activities such as performing fine manipulative tasks, such as coin handling, opening doors, using keys, and pressing control buttons.

PURPOSE

The primary aim of the present study was to examine the test-retest reliability of CMC joint position sense (JPS) in healthy subjects. The secondary aim was to determine the most reliable JPS testing position for the thumb CMC joint.

STUDY DESIGN

This was a cross-sectional study of a convenience sample of healthy adults.

METHODS

Three thumb positions (20°, 30°, and 40° of thumb abduction) were measured twice on the same day by a single rater using a universal goniometer. The absolute error in degrees between each position and reposition was calculated. The intraclass correlation coefficient (2,1) was calculated for relative reliability. The standard error of the measurement was calculated.

RESULTS

Sixty-four healthy adults (mean age 27.8 years, standard deviation = 8.7) were assessed. The intraclass correlation coefficients were poor (-0.08 to 0.22), and the standard error of the measurement was 1.4° for all positions.

CONCLUSIONS

The joint position reproduction test for JPS using goniometry demonstrated poor test-retest reliability and acceptable measurement error in healthy adults.

Patients' and therapists' perspective of integrating home and family work roles into rehabilitation following distal radius fracture

PURPOSE

To explore distal radius fracture (DRF) patients' and hand therapist/occupational therapist/physiotherapists' perceptions of integrating home and family work roles (HFWR) into rehabilitation.

METHODS

Eighteen patients and eleven therapists completed a semi-structured telephone interview three months after DRF. Reflexive thematic analysis of the interviews and triangulation of patients' and therapists' themes was performed.

RESULTS

The patient interview yielded five themes: the experience of rehabilitation; predetermined expectations of rehabilitation; incorporating HFWR into therapy sessions; varying patient needs for addressing HFWR; and determination to return to valued activities drives behavioral choices. The therapists' interview yielded five themes: The challenges in integrating HFWR into rehabilitation; HFWR addressed when brought up by a patient; working context and referral sources influence the rehabilitation plan; rehabilitation is not explicitly tailored according to sex and gender; and utilizing HFWR as a rehabilitation strategy is perceived beneficial.

CONCLUSIONS

Patients have predetermined rehabilitation expectations primarily focused on mobility and strengthening exercises. Therapists and patients agree that adapting home and family work roles is beneficial but was not a major focus for either therapists' or patients' expectations during therapy. An unfavourable environment, patient budget constraints, and limited time were identified as challenges to integrating family roles.

[Effectiveness of a tablet telerehabilitation application in patients with distal radius fracture]

INTRODUCTION

To assess whether, in patients with distal radius fracture feedback-guided exercises performed on a tablet touchscreen reduce healthcare usage and improve clinical recovery, more than the conventional home exercise program prescribed on paper.

MATERIAL AND METHODS

A multicentre, parallel, two-group, pragmatic, controlled trial with assessor blinding and intention-to-treat analysis. Forty-six patients with distal radius fracture were recruited in Andalusian Public Health System. Participants in the experimental and control groups received the same in-patient physiotherapy sessions. Experimental group received a home exercise program using the ReHand tablet application and control group received an evidence-based home exercise program on paper. The primary outcome was the number of physiotherapy sessions tallied from hospitals data management system. Secondary outcomes included: the face-to-face rehabilitation consultations with a physiatrist, and clinical outcomes such as functional ability, grip strength, dexterity, pain intensity and range of motion.

RESULTS

The experimental group required fewer physiotherapy sessions (MD: -16.94; 95%CI: -32.5 to -1.38) and rehabilitation consultations (MD: -1.7; 95%CI: -3.39 to -0.02) compared to the control group.

CONCLUSIONS

In patients with distal radius fracture, prescribing feedback-guided exercises performed on a tablet touchscreen provided by ReHand reduced number of physiotherapy sessions and rehabilitation consultations.

Comparison of the validity and reliability of three different methods used for wrist proprioception measurement

BACKGROUND

ː Early detection of loss of proprioception is essential to prevent injury and maintain professional work activities. However, although many different methods are present for wrist proprioception measurement, these methods' validity and reliability studies are quite limited.

OBJECTIVE

To compare the validity and reliability of the goniometer, inclinometer, and joint position sense goniometer methods used in measuring wrist active joint position sense (AJPS).

METHODS

ː Thirty-two volunteer healthy participants (64 wrists) between the ages of 19-31 (mean age:23,34 ± 3,84) were included in the study. Wrist AJPS was assessed with an isokinetic dynamometer as a reference standard in addition to an inclinometer, goniometer, and joint position sense goniometer (JPSG). Spearman's Correlation Coefficient was used for validity analysis, and Intraclass Correlation Coefficient (ICC3,1) was used to analyze test-retest reliability.

RESULTS

ː It was found that the goniometer (p < 0.001, r = 0.529) is a moderately valid method to assess active wrist joint position sense. The JPSG (p < 0.001, r = 0.432) and inclinometer (p = 0.005, r = 0.350) have weak validity. According to the results of ICC3,1 analysis, the goniometer (p < 0.001, ICC3,1 = 0.422) and JPSG (p < 0.001, ICC3,1 = 0.369) were found to have poor reliability in assessing wrist AJPS, and the inclinometer (p = 0,183, ICC3,1 = 0,114) was not found as a reliable method.

CONCLUSIONS

ː Our results suggest that the JPSG and inclinometer should not be used in the wrist active joint position sense evaluation because of weak validity and poor reliability. The goniometer can be used in clinics and academic research to evaluate wrist joint position sense if the rater lacks a reliable and valid measurement tool.

An evaluation of wrist and forearm movement during purposeful activities and range of movement exercises after surgical repair of a distal radius fracture: A randomized crossover study

PURPOSE

Following surgical repair of distal radius fractures, range of movement (ROM) exercises are the primary approach for restoring movement during early rehabilitation. Specified purposeful activities can also be used, but the movement produced by activities is not well-understood. The study aimed to evaluate and compare movement during purposeful activity and ROM exercises METHODS: Thirty-five adults with a surgically repaired distal radius facture undertook two 10-minutes interventions: purposeful activity (PA) and active ROM exercises (AE), separated by a 60 minute washout, in random order. Data collection occurred during a single session on the same day. Electrogoniometry was used to measure time-accumulated position (TAP), a global metric of movement range and amount, maximum active end range, movement repetitions, excursions >75% of available ROM, and active time. Data were analyzed using linear mixed and generalized linear mixed regression models.

RESULTS

Purposeful activities selected were predominantly household or food preparation. TAP was significantly higher during AE than PA: -1878 [-2388, -1367], p ≤.001, for wrist extension/flexion. PA produced significantly greater movement repetitions for wrist extension/flexion and deviation, excursions beyond 75% of available ROM, and active time, than AE. During PA the wrist was extending/flexing a mean of 97% [92, 101], of the time, compared with 43% [40, 47], during AE. There were no significant differences in maximum end range for wrist extension between PA, 33.7° [29.8, 37.5] and AE, 34.5° [30.7, 38.4], or for ulnar deviation.

CONCLUSIONS

ROM exercises produced higher volumes of sustained joint position than purposeful activity but activities, selected for importance and challenge, produced significantly higher volumes of continuous, repetitious motion in equivalent ranges of movement as exercise repetitions. The study challenges therapists to consider the rehabilitative potential of movement produced by activity for restoring movement and function in the early postoperative weeks.

Proprioceptive Neuromuscular Facilitation Protocol for Thumb Osteoarthritis: A Pilot Study

BACKGROUND

Osteoarthritis (OA) of the thumb carpometacarpal (CMC) joint often presents with joint instability and proprioceptive deficits. Proprioception has been found to play an important role in the rehabilitative process. The purpose of this study was to evaluate the effectiveness of a proprioceptive training program on pain and function in individuals with early-stage thumb Carpometacarpal joint OA.

METHODS

A double-blind experimental trial using a 2-group pretest/posttest design was used in this pilot study. Participants had a diagnosis of grade I and II thumb CMC joint OA in their dominant hand and a pain rating of >4/10 on Visual Analogue Scale. Participants received either standard treatment (control group) or standard treatment plus a proprioceptive training program (experimental group). Outcome measures were lateral pinch strength, pain intensity during activities, and proprioceptive response via joint position sense (JPS) testing.

RESULTS

Twelve individuals (average age of 66.25 years) participated. Both groups had a statistically significant decrease in pain and increase in lateral pinch strength, all occurring with a large effect size but no statistically significant difference between groups. The experimental group experienced a large effect size for JPS testing, whereas the control group experienced a trivial effect size, and there was a statistically significant difference between groups for JPS testing.

CONCLUSIONS

Individuals who completed the proprioceptive training program in this study had an improvement in proprioceptive functioning. This program shows potential for routine inclusion in hand therapy for thumb CMC joint OA; however, additional high-level studies with larger sample sizes are required.

Effectiveness of a Telerehabilitation Evidence-Based Tablet App for Rehabilitation in Traumatic Bone and Soft Tissue Injuries of the Hand, Wrist, and Fingers

OBJECTIVE

To assess whether feedback-guided exercises performed on a tablet touchscreen improve clinical recovery and reduce health care usage more than the conventional home exercise program prescribed on paper in patients with bone and soft tissue injuries of the wrist, hand, and/or fingers treated by public health services.

DESIGN

A multicenter assessor-blinded, parallel, 2-group controlled trial.

SETTING

Trauma and rehabilitation services of 4 hospitals.

PARTICIPANTS

Six hundred sixty-three patients with limited functional ability due to bone and soft tissue injuries of the wrist, hand, and/or fingers (N=663).

INTERVENTIONS

The experimental group received a home exercise program using a tablet-based application with feedback, monitoring, and progression; the control group received an evidence-based home exercise program on paper.

MAIN OUTCOME MEASURES

The primary outcome was functional ability through Patient Rated Wrist Evaluation for wrist conditions and the short version of Disabilities of the Arm, Shoulder and Hand for all other hand pathologies. Secondary outcomes included dexterity, pain intensity, grip strength, and health care usage (number of patients referred to rehabilitation service and number of clinical appointments).

RESULTS

The experimental group showed a significant improvement on the Patient Rated Wrist Evaluation (P=.001) and the short version of Disabilities of the Arm, Shoulder and Hand (P=.001) with medium effect sizes (η²=0.066-0.067) when compared with the control group. Regarding health care usage, the experimental group presented a reduction of 41% in the rate of referrals to face-to-face rehabilitation service consultations, a reduction of rehabilitation consultations (mean difference=-1.64; 95% confidence interval, -2.64 to -0.65) and physiotherapy sessions (mean difference=-8.52, 95% confidence interval, -16.92 to -0.65) compared to the control group.

CONCLUSIONS

In patients with bone and soft tissue injuries of the wrist, hand, and/or fingers, prescribing feedback-guided exercises performed on a tablet touchscreen was more effective for improving patients' functional ability and reduced the number of patients referred to rehabilitation consultation and number of clinical appointments.

Evidence of distorted proprioception and postural control in studies of experimentally induced pain: a critical review of the literature

OBJECTIVES

Deficits in proprioception and postural control are common in patients with different musculoskeletal pain syndromes. It has been proposed that pain can negatively affect proprioception and postural control at a peripheral level, however research is limited to animal studies. Human studies have shown that it is more likely, that the link between pain and proprioceptive deficits, lies within changes in the central nervous system where noxious and non-noxious stimuli may overlap. In clinical studies, causality cannot be determined due to other factors which could confound the assessment such as pathophysiological features of the underlying musculoskeletal disorder and different psycho-social influences especially in patients with chronic pain. On the other hand, experimentally induced pain in healthy participants is able to control most of these confounding factors and perhaps offers an assessment of the effects of pain on proprioception and postural control. The aim of this paper is to critically appraise the literature related to the effect of experimentally induced pain on proprioception and postural control. Results from these studies are discussed and limitations are highlighted for future research.

METHODS

A search of databases (Medline, Scopus, PubMed) was conducted as well as reference check from relevant articles published since 2000. Fifteen studies which explored the effect of experimentally induced pain on postural control and ten studies which explored the effect of experimentally induced pain on proprioception were included.

RESULTS

We found that in the majority of the studies, postural control was negatively affected by experimentally induced pain. Results for proprioception were mixed depending on the body region and the way the painful stimuli were delivered. Kinesthesia was negatively affected in two studies, while in one study kinesthesia was enhanced. Joint position sense was not affected in four out of five studies. Finally, force sense was affected in three out of four studies.

CONCLUSIONS

From a clinical point of view, findings from the available literature suggest that experimentally induced pain impairs postural control and could potentially increases the risk for falls in patients. Interventions aiming to reduce pain in these patients could lead to preservation or improvement of their balance. On the other hand, the same conclusion cannot be drawn for the effect of experimentally induced pain on kinesthesia and joint position sense due to the limited number of studies showing such an effect.

Clinical effects of proprioceptive thumb exercise for individuals with carpometacarpal joint osteoarthritis: A randomized controlled trial

STUDY DESIGN

Randomized Control Trial.

INTRODUCTION

Thumb CMC joint OA is a common diagnosis. Currently there is no evidence available to under if proprioceptive neuromuscular training is an effective intervention for this population.

PURPOSE OF THE STUDY

To establish the effectiveness of a proprioceptive training program as a complementary therapy for patients with thumb CMC joint OA.

METHODS

Standard conservative thumb CMC joint OA treatments were received by both the control (n = 26) and experimental groups (n = 26) for a period of 12 weeks. The experimental group received a proprioceptive training program during the same intervention period. Outcome measures included severity of pain with activity according to the numerical rating scale (NRS), QuickDASH, Canadian Occupational Performance Measure (COPM), and proprioception via joint position sense (JPS).

RESULTS

Fifty-two females participated in the study. Both the experimental and control group made both clinically and statistically significant changes in the mean VAS and COPM scores over time. Only the experimental group achieved a statistically and clinically significant change in JPS error score over time.

DISCUSSION

Experimental group achieved a statistically significant change in JPS over time in concordance with previous investigations. Changes in pain scores differed from prior investigations and the between-group comparison was not statistically significant. Changes in the Quick DASH was similar to previous findings.

CONCLUSION

Proprioceptive training in addition to a traditional rehabilitation program decreased error scores on the joint position sense test.

Targeted sensorimotor retraining in the clinical setting: Improving patient outcomes following distal upper extremity injury

BACKGROUND

Existing theoretical evidence indicates sensorimotor retraining is beneficial following wrist injury. However, there are no large cohort studies applying the knowledge in a clinical setting.

PURPOSE OF THE STUDY

To Determine the clinical benefits of sensorimotor rehabilitation following distal upper extremity injury.

STUDY DESIGN

Prospective cohort study.

METHODS

A sensorimotor rehabilitation program was evaluated following distal upper extremity injury. A battery of clinical and patient-rated outcome measures (PROM) were taken before and after group completion.

RESULTS

Ninety-three patients, 49 males (53%) and 44 females (47%), completed the program. There were statistically significant improvements in 12 clinical measures. However, improvements in 11 of the clinical measures only had a small effect size (<0.5). Joint position sense had the greatest clinical change with a median improvement of 4° on the left and 3.9° on the right, and these had moderate effect sizes of 0.5 and 0.7, respectively. There were statistically significant improvements in all PROMs. PRWE had a median improvement of 21 (ES = 1.2). UEFI showed median improvements of 19.7 (ES = 1.4) and NRS (pain) median improved 2.5 (ES = 1.2). All PROM improvements had mean change greater than associated MCIDs.

DISCUSSION

These results indicate the benefits of sensorimotor group rehabilitation and supports existing literature regarding the importance of sensorimotor control for JPS accuracy and function. Group based sensorimotor programs present an efficient and low-cost opportunity to provide intervention to patients following upper extremity injury.

CONCLUSION

A sensorimotor group rehabilitation program may improve patient outcomes following distal upper extremity injury.

LEVEL OF EVIDENCE

Level 2b prospective cohort.

The Effect of Proprioception Training on Pain Intensity in Thumb Basal Joint Osteoarthritis: A Randomized Controlled Trial

A randomized controlled trial of forty-five females over 18 years of age with diagnosis of thumb basal osteoarthritis in their dominant hand and with a minimum pain rating of 4/10 on the Visual Analogue Scale (VAS) during activities of daily living (ADLs) were recruited from March to June 2021. The group receiving proprioception training was compared to routine conservative physiotherapy treatment. The main purpose of this clinical trial is to test the effect of proprioception training on pain intensity in subjects with thumb osteoarthritis. Primary outcome was joint position sense (JPS) for the assessment of CMC proprioception and secondary outcomes were Visual Analogue Scale (VAS) and Canadian Occupational Performance Measure (COPM) for the assessment of patient satisfaction and the Quick-DASH which assessed upper limb function. A block randomization was carried out for the control group (n = 22) and experimental group (n = 23). Participants and evaluator were blinded to the group assignment. Proprioception training produced a statistically significant reduction in pain post intervention, but this reduction was small (d = 0.1) at the 3-month follow-up. JPS accuracy demonstrated statistically significant differences between the groups (p = 0.001) post-intervention and at the 3-month follow-up (p < 0.003). Statistically significant differences between means were found in both the Quick-Dash and COPM post intervention (both, p < 0.001), as well as at the 3-month follow-up (both, p < 0.001). There was a significant time factor for the reduction of pain intensity over time but effect sizes between groups was small at the 3-month follow-up period. Proprioceptive training improves thumb JPS accuracy; however, it does not contribute to a reduction in pain intensity in the long term. The inclusion of a proprioceptive program may be beneficial for improving individuals with thumb CMC OA sensorimotor performance. The study was registered at ClinicalTrials.gov NCT04738201. No funding was provided for this study.

A long-term effect of distal radius fracture on the sensorimotor control of the wrist joint in older adults

INTRODUCTION

Sensorimotor control can be disturbed because of pain and trauma. There is scarce comprehension about which component of the sensorimotor system would benefit the most from treatment in distal radius fracture (DRF).

PURPOSE OF THE STUDY

The purpose of this study was to determine whether the sensorimotor control of subjects with a history of DRF impaired compared with healthy subjects. If so, which component of the sensorimotor system is most affected.

METHODS

Nine healthy participants and 11 participants with a DRF history executed posture and reproduction tasks in interaction with a robotic wrist manipulator. A posture task with force perturbations assess sensorimotor control. Position and force reproduction tasks assessed sensory feedback. Electromyography recorded the muscle activity to study the motor part of the sensorimotor system.

STUDY DESIGN

Cross-sectional case-control.

RESULTS

The results showed that the motor responses to the perturbations during the posture task did not differ significantly, whereas the position reproduction did significantly differ between the 2 groups. Moreover, participants with a DRF history did not adapt to the changed dynamics of the environment during the posture task, whereas the controls did.

DISCUSSION

The results of this study imply that processing of sensory position feedback is impaired in people with a DRF history while sensorimotor control during a posture task is unaffected. A possible explanation for these results is that different neural networks are involved during reproduction and posture tasks.

CONCLUSIONS

A history of DRF is related to disturbed processing of sensory feedback of the sensorimotor system, especially the Joint Position Sense, which leads to an impairment in detecting a changed environment and adapting to it. Impaired Joint Position Sense and thereby the inability to adapt adequately to a changing environment should be taken into account during the rehabilitation of patients with DRF.

Clinical evaluation of a wrist sensorimotor rehabilitation program for triangular fibrocartilage complex injuries

Introduction

Triangular fibrocartilage complex (TFCC) injuries are associated with distal radioulnar joint (DRUJ) instability and impaired wrist proprioception. Sensorimotor training of extensor carpi ulnaris (ECU) and pronator quadratus (PQ) can enhance DRUJ stability. With limited evidence on effectiveness of TFCC sensorimotor rehabilitation, this study aimed to evaluate the effects and feasibility of a novel wrist sensorimotor rehabilitation program (WSRP) for TFCC injuries.

Methods

Patients diagnosed with TFCC injuries were recruited from May 2018 to January 2020 at an outpatient hand clinic in Singapore General Hospital. There are four stages in WSRP: (1) pain control, (2) muscle re-education and joint awareness, (3) neuromuscular rehabilitation, and (4) movement normalization and function. WSRP also incorporated dart throwing motion and proprioceptive neuromuscular facilitation. Outcome measures included grip strength measured with grip dynamometer, numerical pain rating scale, joint position sense (JPS) measurement, weight bearing measured with the 'push-off' test, and wrist function reported on the Patient Rated Wrist Hand Evaluation.

Results

Ten patients completed the WSRP. Mean changes were compared with minimal clinically important differences (MCID) for outcomes. All patients achieved MCID on pain, 70% of patients achieved MCID on grip strength, weight bearing and wrist function. Paired t-tests and Cohen's D for outcome measures were calculated. There were large effect sizes of 2.47, 1.35, and 2.81 for function, grip strength and pain respectively, and moderate effect sizes of 0.72 and 0.39 for axial loading and JPS respectively.

Discussion

WSRP presents a potential treatment approach in TFCC rehabilitation. There is a need for future prospective clinical trials with control groups.

The Influence of Hand Dominance in Wrist Fracture Post-Operative Functional Evaluation

Sensorimotor testing is used to measure outcomes in surgery, to document results of treatment and rehabilitation, and to compare results between surgeons, therapists, and institutions. When performing sensorimotor testing, failure to address dominant side differences may cause a bias in evaluation of outcomes. This study evaluated the effect of hand dominance on outcomes testing performed on patients following surgery for distal radius fractures (DRF). We hypothesized that the injured dominant hand will perform differently than the injured non-dominant hand. This is a retrospective study of patients following DRF treated surgically and evaluated in therapy. The patients were evaluated at fixed intervals: initially, at 6 weeks, and at 3 months post-surgery. Testing included grip strength, monofilaments, static and moving 2-point discrimination, Moberg testing, and stereognosis. Sixty patients included 46 (76.6%) females. Age averaged 62.1 (standard deviation: 16.9) years, and 54 were right-handed (90%). There were differences between dominant and non-dominant hand injury in 2 of 9 tests of sensibility for each time period, including little finger monofilament and Moberg testing initially, and moving 2-point discrimination in the little finger, monofilament testing of the thumb at 3 months. Both groups improved between initial and 3-month evaluation without differences in amount of improvement. Despite some significant differences in the applied tests between dominant and non-dominant injured hands, our results do not support correction for hand-dominance when using the described examinations in evaluating outcomes following DRF surgery.

The effect of muscle fatigue on wrist joint position sense in healthy adults

STUDY DESIGN

Pretest and posttest experimental study.

INTRODUCTION

The effect of muscle fatigue on wrist joint position sense (JPS) has yet to be determined.

PURPOSE OF THE STUDY

The primary aim was to determine whether muscle fatigue affects wrist JPS in healthy adults. The secondary aims were to compare the effect of muscle fatigue on younger and older adults JPS and determine the association between JPS rate of change and total muscle fatigue (TMF) rates postexercise.

METHODS

Forty male and female healthy adults were assigned into younger (18-40 years) and older (41-65 years) groups. Preexercise and postexercise testing consisted of active wrist JPS, handgrip, and wrist extensor strength assessments. Muscle fatigue was induced via a calibrated gripper and wrist extension dumbbell exercises. Dependent variables were the JPS rate of change (ie, preexercise and postexercise), TMF rate (ie, grip and wrist extension average strength decline), and Borg Rating of Perceived Exertion scale scores.

RESULTS

Postexercise wrist JPS test scores were significantly higher than preexercise. Exercises induced statistically significant TMF rates and Borg Rating of Perceived Exertion scores among all participants. No statistically significant age-group differences on JPS rate of change, and TMF rate was found. A statistically significant mild correlation (r = 0.425) existed between JPS rate of change and TMF rates.

DISCUSSION

Postexercise fatigue significantly impairs wrist JPS in both younger and older adults. On average, an 18% muscle strength decline led to 215% wrist JPS deficit.

CONCLUSIONS

Significant wrist proprioception deficits persist for ≤5 min following exertional exercises, regardless of age level.

Efficacy of wrist robot-aided orthopedic rehabilitation: a randomized controlled trial

Background

In recent years, many studies focused on the use of robotic devices for both the assessment and the neuro-motor reeducation of upper limb in subjects after stroke, spinal cord injuries or affected by neurological disorders. Contrarily, it is still hard to find examples of robot-aided assessment and rehabilitation after traumatic injuries in the orthopedic field. However, those benefits related to the use of robotic devices are expected also in orthopedic functional reeducation.

Methods

After a wrist injury occurred at their workplace, wrist functionality of twenty-three subjects was evaluated through a robot-based assessment and clinical measures (Patient Rated Wrist Evaluation, Jebsen-Taylor and Jamar Test), before and after a 3-week long rehabilitative treatment. Subjects were randomized in two groups: while the control group (n = 13) underwent a traditional rehabilitative protocol, the experimental group (n = 10) was treated replacing traditional exercises with robot-aided ones.

Results

Functionality, assessed through the function subscale of PRWE scale, improved in both groups (experimental p = 0.016; control p < 0.001) and was comparable between groups, both pre (U = 45.5, p = 0.355) and post (U = 47, p = 0.597) treatment. Additionally, even though groups’ performance during the robotic assessment was comparable before the treatment (U = 36, p = 0.077), after rehabilitation the experimental group presented better results than the control one (U = 26, p = 0.015).

Conclusions

This work can be considered a starting point for introducing the use of robotic devices in the orthopedic field. The robot-aided rehabilitative treatment was effective and comparable to the traditional one. Preserving efficacy and safety conditions, a systematic use of these devices could lead to decrease human therapists’ effort, increase repeatability and accuracy of assessments, and promote subject’s engagement and voluntary participation. Trial Registration ClinicalTrial.gov ID: NCT04739644. Registered on February 4, 2021—Retrospectively registered, https://www.clinicaltrials.gov/ct2/show/study/NCT04739644.

Joint position sense impairments in older adults with carpometacarpal osteoarthritis: A descriptive comparative study

STUDY DESIGN

This study has a descriptive-comparative, cross-sectional design.

INTRODUCTION

Sensorimotor (SM) impairments have been observed after common wrist and hand injuries such as distal radius fractures. However, there is a lack of research regarding SM impairments in patients with carpometacarpal (CMC) osteoarthritis (OA).

PURPOSE OF THE STUDY

This study sought to quantify proprioception deficits in older adults with CMC OA as compared with healthy adults using the joint position sense (JPS) test.

METHODS

The active JPS test was used to measure proprioception function in 29 thumbs with CMC OA and their 29 matched-control healthy counterparts. For comparison, participants with unilateral CMC OA were matched against themselves, whereas those with lateral CMC OA were age matched with a healthy participant. Data analysis was performed to compute the mean error of JPS; an unpaired t test was used to compare the mean error of the non-CMC OA group with the healthy control group.

RESULTS

The mean positional error measured from subjects with CMC OA was 9.53° compared with 1.32° for the age-matched healthy subjects. The effect size for the difference in means was D = 1.96.

CONCLUSIONS

Thumb SM impairments were found to be greater in subjects with CMC OA than in their healthy counterparts when using the JPS test to assess proprioception.

"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

PURPOSE

The study aimed to explore perceptions and experiences about how engaging in daily activities and occupations influenced recovery in the first eight weeks after surgical treatment of a distal radius fracture.

METHODS

Twenty-one adults completed an online activity and exercise log then participated in a semi-structured interview between weeks 6 and 8 postoperatively. Interviews were transcribed and analysed using reflexive thematic analysis.

RESULTS

Daily activities and occupations were highly influential in facilitating recovery of movement and function of the operated limb. Five themes provided an understanding of how occupation operated to promote recovery. Occupation was (i) a primary driver of the rehabilitative process, providing an impetus for recovery, (ii) offered ready-to-hand challenges for opportunistic, automatic movement, (iii) invited intentional use of the affected wrist, (iv) habituated the wrist to movement through repetition and confidence-building, and (iv) drew on psychosocial resources to enable reengagement with life activities and roles.

CONCLUSIONS

Incorporating the performance of graded, modified activities during the early weeks of rehabilitation creates opportunities for wrist movement, enhances wellbeing, and assists in the habituation of wrist movement. Activities and occupations can be used as a therapeutic strategy to promote recovery from surgical treatment of a distal radius fracture.Implications for rehabilitationRehabilitation after surgical repair of distal radius fractures has traditionally focused on exercise routines.Daily activities and occupations can also be used to promote wrist movement and function during the early weeks of rehabilitation.Occupation is a naturally occurring source of wrist movement, motivation, and wellbeing that can be harnessed for therapeutic advantage after surgical repair of distal radius fractures.Therapists can collaborate with patients to select and modify daily activities and occupations to incorporate into early postoperative therapy programmes.

Measurement Properties of Outcome Measures Used to Assess Physical Impairments in Patients After Distal Radius Fracture: A Systematic Review

OBJECTIVES

Individuals with distal radius fractures (DRF) may experience difficulty with gripping an object, painful wrist movements, sensorimotor difficulties, and swelling around the wrist and hand. A comprehensive review of the existing evidence concerning the measurement properties of common physical impairment measures can provide a valuable resource to guide hand therapy practice while managing DRF. The primary objective was to locate and assess the quality of literature on the measurement properties for the measures of physical impairment used in individuals with DRF.

METHODS

Two reviewers searched PubMed, CINAHL, and EMBASE. A combination of DRF, measurement properties, and physical impairments were used as keywords, and articles were independently assessed using the Consensus-Based Standards for the Selection of Health Measurement Instruments critical appraisal tool. Primary studies were included if they examined at least 1 of the following: reliability, validity, responsiveness, or indices of true and meaningful changes for measures of physical impairment in the DRF sample. A total of 19 articles were included in this review. The quality of the studies ranged from 46% to 92%. This review suggests that measures such as assessment of grip strength and supination and pronation range of motion (ROM), using various goniometric devices, showed good intrarater and interrater reliability, construct validity, and responsiveness in individuals with DRF.

CONCLUSION

Acceptable reliability and responsiveness were reported in grip and wrist ROM assessments for measuring changes in wrist and hand function after DRF; however, wrist ROM assessed using traditional goniometric techniques were less reliable in individuals with DRF.

IMPACT

This study provides insight into which objective tools might be better suited for measuring outcomes related to DRF.

Similar effects of two different external supports on wrist joint position sense in healthy subjects: A randomized clinical trial

The hand is one of the most injured organs. Proprioceptive rehabilitation decreases the incidence of injury while using external supports can increase proprioception. The aim of this study was to investigate the effects of taping and elastic bandaging on wrist joint position sense (proprioception) in healthy individuals. Sixty-eight healthy students were included in our study and randomized into two groups. External supports were to apply to the dominant hand for 24hours in both groups. Joint position sense was evaluated with an angle reproduction test before applying the external support and 20 minutes after and then 24hours later with the external support and after removing it. There were significant improvements in joint position sense 20 minutes after applying the external support and 24hours later (P<0.05). Although a significant decrease in joint position sense was observed after removing the external support compared to while wearing it (P<0.05), there was a significant improvement in the joint position sense relative to the pre-study assessment (P<0.05). In between group comparisons, the only significant difference was observed 20 minutes after the external support was applied: the taping group had better results in joint flexion position sense than the bandaging group (P<0.05), but in the other assessments there were no significant differences between two groups (P>0.05). It was found that two different types of external support can improve the wrist joint's position sense in healthy subjects. These procedures can be used as a supplemental treatment in wrist rehabilitation.

A novel staged wrist sensorimotor rehabilitation program for a patient with triangular fibrocartilage complex injury: A case report

STUDY DESIGN

Case report.

INTRODUCTION

Studies have highlighted the sensory innervations and stabilizing role of forearm muscles on wrist joint and implications to wrist sensorimotor rehabilitation. This case explored the novel incorporation of dart-throwing motion and proprioceptive neuromuscular facilitation in wrist sensorimotor rehabilitation.

PURPOSE OF THE STUDY

To describe and evaluate a staged wrist sensorimotor rehabilitation program for a patient with triangular fibrocartilage complex (TFCC) injury.

METHODS

The patient participated in the staged program for 9 sessions over a 3-month period. Treatment involved neuromuscular strengthening at the wrist and movement normalization of the upper extremity. Outcome measures were grip strength, visual analog scale, joint position sense, Quick Disabilities of the Arm, Shoulder and Hand, and patient-rated wrist evaluation.

RESULTS

The patient showed improvement in all outcome measures. Most outcomes exceeded the established minimal clinically important difference values.

DISCUSSION

The results suggest that dart-throwing motion and proprioceptive neuromuscular facilitation are beneficial in rehabilitation of TFCC injury.

CONCLUSIONS

This is the first study that incorporated dart-throwing motion and proprioceptive neuromuscular facilitation in the sensorimotor rehabilitation of TFCC injury and yielded promising results. There is a need to further evaluate the program in prospective randomized controlled trial recruiting a larger group of patients with TFCC injury.

Assessment of human wrist rigidity and pain in post-traumatic patients

The aim of this work is to present a novel robot-based method to assess the sources of a lack of functionality in patients with recent traumatic wrist injuries. Post-traumatic patients experience limited range of motion as well as strength and proprioceptive deficits. These dysfunctions are related to different complications that usually follow the injuries: pain, increased rigidity, lack of movement fluency and loss of stability could arise differently, according to the severity, site and kind of lesion. Their quantitative evaluation could be essential to target rehabilitation treatments to the specific problem and to optimize and speed up the functional recovery. The use of robotic devices for assessment not only ensures objectivity and repeatability, but could also help to estimate the goodness of the evaluation itself, in terms of reliability and patient's engagement. Ten subjects with different types of wrist injuries were enrolled in this study and required to perform passive robot-guided reaching movements. Forces and angular positions were used to evaluate subject's range of motion, rigidity and pain that, considered together, allowed a comprehensive characterization of the level of healing and functionality achieved by each subject.

Graded motor imagery for women at risk for developing type I CRPS following closed treatment of distal radius fractures: a randomized comparative effectiveness trial protocol

BACKGROUND

Distal radius fractures (DRF) account for nearly one-fifth of all fractures in older adults, and women experience them 5× as often as men. Most DRF occur with low impact injuries to the wrist with an outstretched hand, and are often managed via closed treatment and cast immobilization. Women sustaining a DRF are at risk for upper limb immobility, sensorimotor changes, edema and type I complex regional pain syndrome (CRPS). Since CRPS onset is likely influenced by alterations in the brain's somatosensory region, a rehabilitation intervention, Graded Motor Imagery (GMI), aims to restore cortical representation, including sensory and motor function, of the affected limb. To date, there are no studies on the use of GMI in reducing risk of or preventing the onset of type I CRPS in women with DRF treated with cast immobilization. Due to a higher likelihood of women with this injury developing type I CRPS, it is important to early intervention is needed.

METHODS/DESIGN

This article describes a six-week randomized comparative effectiveness trial, where the outcomes of a modified GMI program (mGMI) + standard of care (SOC) group (n = 33) are compared to a SOC only control group (n = 33). Immediately following cast immobilization, both groups participate in four 1-h clinic-based sessions, and a home program for 10 min three times daily until cast removal. Blinded assessments occur within 1 week of cast immobilization (baseline), at three weeks post cast immbolization, cast removal, and at three months post cast removal. The primary outcomes are patient reported wrist/hand function and symptomology on the Patient Rated Wristand Hand Evaluation, McGill Pain Questionnaire, and Budapest CRPS Criteria. The secondary outcomes are grip strength, active range of motion as per goniometry, circumferential edema measurements, and joint position sense.

DISCUSSION

This study will investigate the early effects of mGMI + SOC hand therapy compared to SOC alone. We intend to investigate whether an intervention, specifically mGMI, used to treat preexisiting pain and motor dysfunction might also be used to mitigate these problems prior to their onset. If positive effects are observed, mGMI + SOC may be considered for incorporation into early rehabilitation program.

TRIAL REGISTRATION

This trial is registered at ClinicalTrials.gov with identifier NCT02957240 (Approval date: April 20, 2017).

Test–retest reliability of wrist joint position sense in healthy adults in a clinical setting

Introduction

Proprioceptive assessments of the wrist inform clinical decision making. In wrist rehabilitation, joint position sense has emerged as one way of assessing conscious proprioception with varying methods and minimal psychometric analysis reported. The purpose of this study was to standardise the wrist joint position sense test method for clinical use and to determine its test–retest reliability in a healthy population.

Methods

Four wrist positions (20° and 45° flexion, 20° and 45° extension) were measured twice in a random order, by a single rater, using a universal goniometer on the same day. The absolute error in degrees between each position and reposition was calculated. For relative reliability analysis, the intraclass correlation coefficient (3,1) was calculated. For absolute reliability the standard error of the measurement was calculated and Bland–Altman plots visually inspected.

Results

Fifty-five healthy volunteers (mean age 31.1 SD±10.25 years) were assessed. The mean absolute error, summarised for all positions for test and retest, was 3.98°. The intraclass correlation coefficients were poor to fair (0.07–0.47), and standard error of the measurement was 2° (rounded) for all positions. The limits of agreement were fairly narrow, and the Bland–Altman plots showed random distribution of errors for each position, therefore the measurement error was clinically acceptable.

Conclusions

The active wrist joint position sense test using goniometry demonstrated poor to fair test–retest reliability and acceptable measurement error in healthy volunteers. The wrist joint position sense angle of 20° flexion was the most reliable.

Responsiveness of the active wrist joint position sense test after distal radius fracture intervention

STUDY DESIGN

Prospective cohort study.

INTRODUCTION

The active wrist joint position sense (JPS) test has been determined to be a clinically useful test for assessing wrist sensorimotor (SM) status after distal radius fracture (DRF). Its responsiveness is yet to be determined.

PURPOSE OF THE STUDY

Primary study aim was to determine the active wrist JPS test responsiveness to detect change in wrist SM status at 8 and 12 weeks after DRF treatment intervention. Secondary aims were to compare group (nonsurgical, surgical, high, and low pain) test responsiveness; compare pain-level group participants test scores; determine the relationship between test minimal clinically important difference (MCID) value and function; compare functional outcomes across assessment times; and determine the Patient Global Impression of Change Scale intrarater reliability.

METHODS

A total of 33 male and female participants were tested at baseline, 8, and 12 weeks after nonsurgical (n = 13) and surgical (n = 20) DRF treatment interventions. Distribution-based analysis encompassed both group- (ie, effect size, standardized response mean) and individual-based (ie, minimum detectable change) statistical indices. Anchor-based analysis determined the MCID value by linking test scores to the Patient Global Impression of Change Scale.

RESULTS

The active wrist JPS test is highly responsive based on effect size (8 weeks = 1.53 and 12 weeks = 2.36) and standardized response mean (8 weeks = 1.57 and 12 weeks = 2.14). Statistically significant minimum detectable change values were 4.28° and 4.94° at 8 and 12 weeks, respectively. Clinically meaningful MCID values were 5.00° and 7.09° at 8 and 12 weeks, respectively. Between treatment type and pain-level group responsiveness levels were not significantly different. High-pain participants demonstrated significantly greater JPS deficit. Test MCID values and function were significantly associated.

DISCUSSION

This is the first study to determine the active wrist JPS test responsiveness as reflected by its group- and individual-based statistical indices following DRF surgical and non-surgical interventions among low- and high-pain level participants. The statistical analysis approach, which was used to determine the aforementioned variables of the active wrist JPS test, is consistent with current research. This study's strengths included its design, methodology, and statistical approach. The study findings must be interpreted, however, within the content of several methodological limitations.

CONCLUSIONS

The active wrist JPS test was determined to be highly responsive to detect wrist SM status change at 8 and 12 weeks regardless of treatment type or pain level. Clinicians can use this test with confidence to measure clinically meaningful SM impairment after DRF treatment.

LEVEL OF EVIDENCE

2b.

A new clinical test for sensorimotor function of the hand - development and preliminary validation

BACKGROUND

Sensorimotor disturbances of the hand such as altered neuromuscular control and reduced proprioception have been reported for various musculoskeletal disorders. This can have major impact on daily activities such as dressing, cooking and manual work, especially when involving high demands on precision and therefore needs to be considered in the assessment and rehabilitation of hand disorders. There is however a lack of feasible and accurate objective methods for the assessment of movement behavior, including proprioception tests, of the hand in the clinic today. The objective of this observational cross- sectional study was to develop and conduct preliminary validation testing of a new method for clinical assessment of movement sense of the wrist using a laser pointer and an automatic scoring system of test results.

METHODS

Fifty physiotherapists performed a tracking task with a hand-held laser pointer by following a zig-zag pattern as accurately as possible. The task was performed with left and right hand in both left and right directions, with three trials for each hand movement. Each trial was video recorded and analysed with a specifically tailored image processing pipeline for automatic quantification of the test. The main outcome variable was Acuity, calculated as the percent of the time the laser dot was on the target line during the trial.

RESULTS

The results showed a significantly better Acuity for the dominant compared to non-dominant hand. Participants with right hand pain within the last 12 months had a significantly reduced acuity (p < 0.05), and although not significant there was also a similar trend for reduced Acuity also for participants with left hand pain. Furthermore, there was a clear negative correlation between Acuity and Speed indicating a speed-accuracy trade off commonly found in manual tasks. The repeatability of the test showed acceptable intra class correlation (ICC_2.1) values (0.68-0.81) and standard error of measurement values ranging between 5.0-6.3 for Acuity.

CONCLUSIONS

The initial results suggest that the test may be a valid and feasible test for assessment of the movement sense of the hand. Future research should include assessments on different patient groups and reliability evaluations over time and between testers.

Effect of Low-Level Laser Therapy and Strength Training Protocol on Hand Grip by Dynamometry

Introduction: The purpose of this study was to investigate the effect of low-level laser therapy (LLLT) - 660 nm and 904 nm - before grip strength protocol in healthy subjects. Methods: The study included 45 healthy volunteers with an average age of 22.7 (±1.4) years, subdivided into the following groups, control group: grip strength training associated with placebo LLLT; 660 nm group: LLLT (660 nm, 20 J/cm², power of 30 mW, and beam area of 0.06 cm², continuous, energy 1.2 J, and exposure time 40 seconds per point) before grip strength training and 904 nm group: LLLT (904 nm, 10 J/cm², peak power of 70 W and 0.13 cm² beam area, with pulsed beam 9.500 Hz and 30 seconds of exposure time per point and emitted energy 1.2 J) before grip strength training. The LLLT was timed to contact 10 points located in the region of the superficial and deep flexor muscles of the fingers, with a total energy of 12.0 J per session. For the strength training protocol, the volunteer exercised their fingers with the dominant hand on a small table, elbow flexed at 90°, forearm in neutral, using a light extension handle. The Oxford protocol was performed during four weeks. The grip strength was assessed using a dynamometer (Jamar™). The data were evaluated by the analysis of variance (ANOVA) statistical method. Results: In the comparison of intragroup evaluation, only the 904 nm group showed a difference compared to the baseline assessment after 4 weeks (P < 0.05), in the final intergroup evaluation, a difference was observed in the comparison between the control and 904 nm groups Conclusion: In conclusion, LLLT (904 nm) applied before resistance training was effective in gaining grip strength when compared to LLLT (660 nm) and isolated strength training after 4 weeks.

A Protocol for Evaluation and Rehabilitation of Distal Radius Fractures Using Sensorimotor Input: A Case Series

BACKGROUND

Proprioception and sensorimotor input are used to treat neurological and joint injuries. Following distal radius fractures (DRF) there is a temporary loss of proprioception that should be addressed. We created a protocol for evaluation, and a treatment plan following wrist surgery that is based on proprioceptive and sensorimotor input. We describe a series of patients undergoing surgery for DRF that were evaluated and treated with these protocols.

METHODS

Both evaluation and treatment protocols included comprehensive sensorimotor procedures performed with eyes open and closed. These included Semmes- Weinstein, static and moving 2-point discrimination, vibration, temperature testing, Moberg pick-up- test, stereognosis and proprioception.

RESULTS

A series of twelve patients was evaluated and treated with the protocol following surgical treatment for DRF. Patients demonstrated significant sensorimotor deficits, which improved utilizing the comprehensive sensorimotor treatment protocol.

CONCLUSIONS

Further study is necessary to validate the results of this pilot series. Use of proprioception and sensorimotor input may improve outcomes of rehabilitation following DRF.

Supervised physical therapy vs home exercise program for patients with distal radius fracture: A single-blind randomized clinical study

STUDY DESIGN

Randomized clinical study.

INTRODUCTION

Supervised physical therapy (PT) and home exercise programs (HEPs) are frequently used in the rehabilitation of patients with distal radius fracture (DRF). However, there is no consensus as to whether unsupervised HEP provides comparable benefits to those achieved by supervised PT.

PURPOSE OF THE STUDY

To compare the improvements in pain and functional status between a supervised PT program and unsupervised HEP in DRF patients older than 60 years.

METHODS

A total of 74 patients were randomized into 2 groups. One group received 12 sessions of supervised PT (n = 37), and the other group followed an exercise program at home (n = 37). Three evaluations were performed, before the initiation of treatment, at 6-week, and 6-month follow-up. The study conducted a statistical power analysis to detect an intergroup difference score of 15 points on the Patient-Rated Wrist Evaluation (PRWE). The t-test or Mann-Whitney test was used, and it was set with a significance level of .05.

RESULTS

The supervised PT group showed clinically significant differences in the total PRWE score at 6 weeks (17.67 points, P = .000) in the PRWE function score (15.2 points, P = .000) and in the PRWE pain score (5.6 points, P = .039). There was also a significant difference in the total PRWE score at 6-month follow-up (17.05 points, P = .000) in the PRWE function score (14.5 points, P = .000) and in the PRWE pain score (2.5 points, P = .35).

CONCLUSIONS

A supervised PT program is more effective for improving function in the short- and medium-term when compared with HEP in patients older than 60 years with DRF extraarticular without immediate complications.

LEVEL OF EVIDENCE

1b.

Rehabilitation for scapholunate injury: Application of scientific and clinical evidence to practice

In this article, the development of a rehabilitation approach is describe using scapholunate injury as a model. We demonstrate how scientific and clinical evidence is applied to a treatment paradigm and modified based on emerging evidence. Role of the scapholunate interosseous ligament within the pathomechanics of the carpus, along with the progression of pathology, and specific rehabilitation algorithms tailored to the stage of injury. We review the recent and current evidence on the kinematics of wrist motion during functional activity, role of the muscles in providing dynamic stability of the carpus, and basic science of proprioception. Key relevant findings in each of these inter-related areas are highlighted to demonstrate how together they form the basis for current wrist rehabilitation. Finally, we make recommendations for future research to further test the efficacy of these approaches in improving functional outcomes.

Proprioception retraining for a patient with chronic wrist pain secondary to ligament injury with no structural instability

STUDY DESIGN

Case report.

INTRODUCTION

Previously published studies demonstrate the importance of the sensory innervation of the carpal ligaments and the implication for the sensorimotor control of the wrist. In addition, this case considers key rehabilitation concepts to include the dart-throwing motion and the stabilizing effect of the forearm muscles.

PURPOSE OF THE STUDY

To describe the rehabilitation program for a patient with chronic wrist pain, diagnosed with a partial tear of the dorsal intercarpal ligament and a sprain of the scapholunate ligament of the right wrist.

METHODS

The patient participated in a staged treatment plan over a 3-month period (20 sessions), which began with a focus on proprioceptive awareness and joint position sense retraining. The treatment progressed to strengthening of specific muscles to enhance stability of the wrist joint. The patient completed the Quick Disabilities of the Arm, Shoulder and Hand and the patient-rated wrist evaluation on initial evaluation, re-evaluation at ninth session, and discharge at 20th session.

RESULTS

Raw scores in the Quick Disabilities of the Arm, Shoulder and Hand and the patient-rated wrist evaluation improved from 33 and 61.5 on initial evaluation to 18 and 17.5 on discharge, respectively.

CONCLUSIONS

Sensorimotor techniques including proprioceptive retraining may improve pain, neuromuscular control, and functional outcomes in patients with chronic wrist pain due to ligament injury. The effectiveness of proprioceptive retraining needs to be evaluated in a well-designed randomized controlled trial recruiting this patient population.

LEVEL OF EVIDENCE

5.

Rehabilitation strategies for wrist sensorimotor control impairment: From theory to practice

This clinical review discusses the organization, neuroanatomy, assessment, clinical relevance, and rehabilitation of sensorimotor (SM) control impairment after wrist trauma. The wrist SM control system encompasses complex SM pathways that control normal wrist active range of motion and mediate wrist joint neuromuscular stability for maintaining joint function. Among various known assessment methods of wrist SM control impairment, the active wrist joint position sense test is determined to be a clinically meaningful and responsive measure for wrist SM control impairment after wrist fracture. Wrist trauma may involve significant soft tissue injury (ie, skin, ligament, muscle), which could disrupt the generation and transmission of adequate proprioceptive input from wrist mechanoreceptors, thus leading to significant joint SM impairment. Various clinical examples of wrist trauma (eg, distal radius fracture, scapholunate joint injury) along with known prognostic factors (eg, pain) that may influence wrist SM control impairment recovery are discussed to illustrate this point. This article proposes promising rehabilitation strategies toward restoring wrist joint conscious and unconscious SM control impairments, integrating current research evidence with clinical practice. These strategies require more rigorous evaluation in clinical trials.

LEVEL OF EVIDENCE

5.

Volar locking plate vs epibloc system for distal radius fractures in the elderly

PURPOSE

To compare clinical outcomes of ORIF with volar locking plates and the Epibloc system (ES) in the treatment of distal radius fractures (DRFs) in patients aged over 65 years.

METHODS

We retrospectively examined a consecutive series of 100 patients with intra-articular or extra-articular DRF who were admitted to our Department of Orthopaedics and Traumatology between January 2007 and January 2013. Fifty patients were treated using the Epibloc System; and the other 50 patients using ORIF with volar locking plates. In all patients, functional evaluation (wrist range of motion [ROM], grip strength and Disability of the Arm, Shoulder and Hand [DASH] Score) and radiographic assessment (radial inclination, volar tilt, ulnar variance and articular congruity) were performed at 2 and 6 weeks, and 3, 6 and 12 months postoperatively; then every 12 months thereafter.

RESULTS

ORIF with volar locking plates was associated with better outcome than ES in the intra-articular and extra-articular DRF groups, generating higher average ROM, DASH and visual analogue scale (VAS) scores. Grip strength mean values, however, were quantified over the minimum level for a functional wrist (>60%) in both groups. There were no differences between the two techniques in X-ray parameters, and no further correlation was found with functional outcome and ROM.

CONCLUSIONS

In a low-functioning patient with multiple medical comorbidities, minimally-invasive surgery with the ES is a safe option, enables early mobilisation of the wrist and is likely to produce acceptable clinical outcomes.

Clinical DRUJ instability does not influence the long-term functional outcome of conservatively treated distal radius fractures

OBJECTIVE

The presence of distal radioulnar joint (DRUJ) instability remains often unnoticed initially, but may worsen functional outcome of distal radius fractures (DRF). The aim of this study was to evaluate the influence of concurring clinical DRUJ instability on the outcome of conservatively treated DRF.

METHODS

In a retrospective cohort study, all unilateral, conservatively treated DRF patients were invited for physical examination, CT scan of both wrists and filling out questionnaires. Static and dynamic DRUJ instability were clinically tested.

RESULTS

Forty-nine DRF patients with a mean follow-up of 4.2 years (SD 0.5) were assessed. Seventeen patients tested positive for DRUJ instability. No differences were found in baseline characteristics between the DRUJ stable and unstable group. Apart from wrist flexion, no statistical significant differences in outcome was found between patients with and without DRUJ instability.

CONCLUSION

The presence of clinical DRUJ instability does not seem to affect functional outcome of conservatively treated distal radius fractures at long-term follow-up.

Bridging external fixation versus non-bridging external fixation for unstable distal radius fractures: A systematic review and meta-analysis

OBJECTIVE

A systematic review and meta-analysis was conducted to compare the relative effectiveness of bridging external fixation and non-bridging external fixation for distal radius fractures treatment.

METHOD

Relevant literature were comprehensively searched using the PubMed, Springer Link, Karger Medical and Scientific Publishers, Chinese Biomedical Database (CBM) and Chinese National Knowledge Infrastructure (CNKI) databases without any language restrictions. STATA Version 12.0 software and Comprehensive Meta-analysis 2.0 were applied.

RESULTS

A total of 905 patients with distal radius fracture from six eligible cohort studies were selected for statistical analysis. Our meta-analysis results indicate that the non-bridging cases had a higher risk of pin track infection, rupture of the extensor pollicis longus and nerve injury than the bridging cases. Subgroup analysis stratified by country indicated non-bridging patients showed evidence of an increased risk of pin track infection and higher risk of rupture of the extensor pollicis longus compared with the patients treated with bridging external fixation in the UK population. The follow-up results showed flexion degree of patients treated with non-bridging external fixation was slightly better than that of patients treated with bridging external fixation (P < 0.05).

CONCLUSION

There is evidence in our systematic review and meta-analysis to support that bridging external fixation can reduce the incidence of pin tract infections and nerve injury compared to non-bridging external fixation, but have no significant difference in other complications and the recovery of wrist joint function. Bridging external fixation could therefore be a better choice in patients with distal radius fractures.

Comparison of Risk of Carpal Tunnel Syndrome in Patients with Distal Radius Fractures After 7 Treatments

Background

To compare risk of carpal tunnel syndrome (CTS) in distal radius fracture (DRF) patients after 7 treatments using bridging external fixation (BrEF), non-bridging external fixation (non-BrEF), plaster fixation, K-wire fixation, dorsal plating fixation, volar plating fixation, and dorsal and volar plating by performing a network meta-analysis.

Material/Methods

An exhaustive search of electronic databases identified randomized controlled trails (RCTs) closely related to our study topic. The published articles were screened, based on predefined inclusion and exclusion criteria, to select high-quality studies for the present network meta-analysis. Data extracted from the selected studies were analyzed using STATA version 12.0 software.

Results

The literature search and selection process identified 12 eligible RCTs that contained a total of 1370 DRF patients (394 patients with BrEF, 377 patients with non-BrEF, 89 patients with K-wire fixation, 192 patients with plaster fixation, 42 patients with dorsal plating fixation, 152 patients with volar plating fixation, and 124 patients with dorsal and volar plating fixation). Our network meta-analysis results demonstrated no significant differences in CTS risk among the 7 treatments (P>0.05). The value of surface under the cumulative ranking curve (SUCRA), however, suggested that dorsal plating fixation is the optimal treatment, with the lowest risk of CTS in DRF patients (dorsal plating fixation: 89.2%; dorsal and volar plating: 57.8%; plaster fixation: 50.9%; non-BrEF: 50.6%; volar plating fixation: 39.6%; BrEF: 38.4%; K-wire fixation: 23.6%).

Conclusions

Our network meta-analysis provides evidence that dorsal plating fixation significantly decreases the risk of CTS and could be the method of choice in DRF patients.

Sensorimotor interventions and assessments for the hand and wrist: a scoping review

STUDY DESIGN

Scoping review.

INTRODUCTION

Sensorimotor deficits can impair function and may be present in individuals with common upper extremity conditions.

PURPOSE OF THE STUDY

To provide clinicians with an understanding of the usefulness of the assessments to evaluate sensorimotor function and the interventions reported in the literature to effect positive change in our patients with sensorimotor deficits affecting the hand and wrist.

METHODS

A systematic search produced seventeen studies involving sensorimotor retraining and assessment of sensorimotor performance for the upper extremity.

RESULTS

Sensorimotor interventions and assessments found in the literature vary in regards to their effectiveness in restoring sensorimotor function in subjects with a number of conditions that affect hand and wrist function.

CONCLUSIONS

There is a potential value of sensorimotor interventions for individuals with specific upper extremity conditions. There is a need for further studies to improve treatment of sensorimotor deficits and understanding of sensorimotor interventions.

Using smartphone applications as hand therapy interventions

In the hand therapy clinic, smartphones can be used as an educational resource, to view a photo or video of a home exercise program, or as a method of electronically documenting progress related to healing from an injury. Smartphone applications may also serve as appropriate therapy interventions to address deficits often presenting with common hand injuries. For individuals with trapeziometacarpal arthrosis, gaming can encourage radial abduction range of motion and neuromuscular control required for joint stability. People with distal radius fractures may benefit from smartphone applications for range of motion and proprioceptive training. These treatments may assist with addressing client-centered goals and be motivating in the current technology driven times.