Assessment from Functional Perspectives: Using Sensorimotor Control in the Hand as an Outcome Indicator in the Surgical Treatment of Carpal Tunnel Syndrome

An Evaluation of Patient-reported Outcome Measures and Minimal Clinically Important Difference Usage in Hand Surgery

Background

This study was designed to examine the current use of patient-reported outcome measures (PROMs) and minimal clinically important difference (MCID) calculations in the hand surgery literature in an effort to standardize their use for research purposes.

Methods

A systematic review of the hand surgery literature was conducted. All nonshoulder upper extremity articles utilizing PROMs were compared between different journals, different surgical indications, and differing usage. MCID values were reported, and calculation methods assessed.

Results

In total, 4677 articles were reviewed, and 410 met the inclusion criteria of containing at least one PROM. Of the 410 articles reporting PROMs, 148 also mentioned an associated MCID. Of the articles that mentioned MCIDs, 14 calculated MCID values based on their specific clinical populations, whereas the remainder referenced prior studies. An estimated 35 different PROMs were reported in the study period; 95 different MCID values were referenced from 65 unique articles.

Conclusions

There are many different PROMs currently being used in hand surgery clinical reports. The reported MCIDs from their related PROMs are from multiple different sources and calculated by different methods. The lack of standardization in the hand surgery literature makes interpretation of studies utilizing PROMs difficult. There is a need for a standardized method of calculating MCID values and applying these values to established PROMs for nonshoulder upper extremity conditions.

The effectiveness of neuromobilization exercises in carpal tunnel syndrome: Systematic review and meta-analysis

PURPOSE

To examine the effectiveness of Neuromobilization Exercises (NE) on pain, grip and pinch strength, two-point discrimination, motor and sensory distal latency, symptom severity, and functional status using the Boston Carpal Tunnel Questionnaire (BCTQ) in Carpal Tunnel Syndrome (CTS).

METHODS

Major electronic databases were searched from inception up to September 2021 for randomized trials comparing the effects of NE with or without other interventions against no treatment, surgery, or other interventions in patients with CTS. Standardized Mean Differences (SMD) and 95% confidence interval (CI) were calculated using a random-effects inverse variance model according to the outcome of interest and comparison group. Methodological quality was assessed with PEDro and quality of evidence with the GRADE approach.

RESULTS

Twenty-five articles were included and sixteen of them demonstrated high methodological quality. NE was superior to no treatment on pain (very low-quality evidence; SMD = -2.36, 95% CI -4.31 to -0.41). NE was superior to no treatment on the functional scale of the BCTQ (low-quality evidence; SMD = -1.27 95% CI -1.60 to -0.94). Most importantly, NE did not demonstrate evidence of clinical effectiveness.

CONCLUSION

Low to very low-quality evidence suggests that there are no clinical benefits of NE in patients with mild to moderate CTS.

Ultrasonography for the diagnosis of carpal tunnel syndrome: correlation of clinical symptoms, cross-sectional areas and electroneuromyography

This study evaluates the usefulness of ultrasonography in diagnosing carpal tunnel syndrome (CTS). The cross-sectional area of the median nerve was measured at the forearm and its entry into the carpal tunnel and compared with clinical symptoms and electroneuromyography. A total of 124 patients were examined, 77 patients with clinically confirmed CTS and 47 controls. A significant correlation was found between the ultrasonography cross-sectional area values at entry points into the carpal tunnel and electroneuromyography. The highest sensitivity (87%) and specificity (91%) for different cut-off values (8.5-12.5 mm²) of the cross-sectional area was for 11.5 mm². The use of ultrasonography may provide a quick and reliable differential diagnostic tool for the primary diagnosis of CTS in patients with classical symptoms.Level of evidence: II.

Sensitive nerve function measurement in facial trauma: An observational study

Background

Facial trauma is responsible for various types of health damage and may be functional or aesthetic. Depending on the degree of energy released in this type of trauma, sometimes an irreversibility degree is obtained. This study aimed to perform an objective evaluation of traumatic peripheral nerve injuries resulting from mandibular fractures and midface, using silicon monofilaments.

Material and Methods

This was an observational, cross-sectional study. All patients with maxillofacial fractures, who were hospitalized by the department of Oral and Maxillofacial Surgery of Instituto Dr. José Frota Hospital, were randomly recruited and screened for inclusion in the present study. Sixty patients, victims of automobile accidents or firearms, were evaluated using Semmes Weinstein monofilaments in the regions corresponding to the mental and infraorbital nerves, right and left.

Results

The highest frequencies mandibular nerve changes were those that there was a loss protective sensation, but in which, the patient can feel deep pressure and pain; In which the worst sensory alterations occurred in patients’ victims of firearm. In the middle third of the face, the worst alterations were those that there was a loss of the protective and discriminating sensation for hot and cold.

Conclusions

The use of monofilaments is a support tool in oral and maxillofacial traumatology for the diagnosis and monitoring of peripheral sensory alterations.

Key words:Peripheral nerve injuries, facial trauma, wounds and injuries, accidents, traffic, violence.

Disturbance of somatotopic spatial cognition and extra-territorial pain in carpal tunnel syndrome

BACKGROUND

Several studies on carpal tunnel syndrome have reported pain that exists beyond the median nerve territory of the affected hand. However, the mechanism is unknown.

PURPOSE

We investigated the cause of extra-territorial pain by the analysis of clinical assessments and cortical activity using magnetoencephalography.

METHODS

To compare patients with and without extra-territorial pain, fourteen patients with carpal tunnel syndrome were assessed using clinical examination, such as patients' profile, paresthesia, physical tests, and psychological tests. The physical assessment included tactile threshold and static and moving two-point discrimination sensations on digital pulp. Neural activation in the cerebral cortex was also measured using z-scores calculated by magnetoencephalography.

RESULTS

Among fourteen patients, ten patients had pain in the affected median nerve territory only and four patients had extra-territorial pain. When comparing the groups, the static and moving two-point discrimination sensation values in patients with extra-territorial pain were larger than those of patients without the pain (p < 0.05). The supra-marginal gyrus, mid-part of the precentral sulcus, angular gyrus in the left hemisphere, bilateral sensorimotor areas for legs, and bilateral isthmus-cingulate areas showed larger z-scores in patients with extra-territorial pain than in patients without the pain (p < 0.05).

CONCLUSIONS

The static and moving two-point discrimination sensations signify the ability of tactile spatial acuity. Bilateral sensorimotor areas were activated in sites that were not the hand. Furthermore, the inferior parietal lobule in the left hemisphere, which synthesizes and integrates multiple sensations showed high activation. Our findings suggested that the mechanism of extra-territorial pain was associated with dysfunction of spatial cognition.

Tamai Zone 1 Fingertip Amputation: Reconstruction Using a Digital Artery Flap Compared With Microsurgical Replantation

PURPOSE

The surgical treatment of fingertip amputations is controversial. This study was designed to compare the clinical results of 2 surgical procedures for fingertip amputation: reconstruction with a digital artery flap and microsurgical replantation.

METHODS

Between 2003 and 2015, 37 patients with Tamai zone 1 fingertip amputation of the index or middle finger were treated by reconstruction with a digital artery flap (n = 23) or microsurgical replantation (n = 14). Data for these patients were evaluated retrospectively. Nerve suture was not conducted in microsurgical replantation because spontaneous sensory recovery is expected in zone 1 replantation. Primary outcomes included hand dexterity (Purdue Pegboard Test), and disability of the upper extremity (Disabilities of the Arm, Shoulder, and Hand score). Secondary outcomes included strength (key pinch), digital sensitivity (Semmes-Weinstein test), and finger mobility (% total active motion).

RESULTS

The average follow-up period was 34 months. There was no significant difference in the primary outcomes between the 2 groups. The reconstruction group showed significantly better results for the secondary outcomes.

CONCLUSIONS

This study suggests that the 2 procedures were comparable regarding postoperative activities of daily living and hand performance, but reconstruction using a digital artery flap gave better objective functional outcomes than microsurgical replantation.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Upper extremity disability is associated with pain intensity and grip strength in women with bilateral idiopathic carpal tunnel syndrome

BACKGROUND

The upper extremity disability in patients with carpal tunnel syndrome (CTS) is related to dysfunction due to the median nerve damage. However, there is no report on which dysfunctions affect the upper extremity disability.

PURPOSE

This study aimed to investigate which clinical factors influence upper extremity disability in women with CTS.

METHODS

We analyzed 60 hands of women with bilateral idiopathic CTS. Upper extremity disability was assessed using Hand10, a validated and self-administered tool. Pain intensity was measured using the Japanese version of the Short-Form McGill Pain Questionnaire (SF-MPQ-J). We performed nerve conduction studies, assessed physical and psychological parameters, and collected demographic data. Physical parameters comprised grip strength, pinch strength, tactile threshold, static 2-point discrimination sensation, and severity of numbness. Psychological parameters include depression, pain anxiety, and distress.

RESULTS

The bivariate analysis revealed that Hand10 was significantly correlated with age, symptom duration, SF-MPQ-J, grip strength, pain anxiety, and distress. Multiple regression analysis demonstrated that SF-MPQ-J and grip strength were related to Hand10 score.

CONCLUSIONS

Pain intensity and grip strength were dysfunctions affecting the upper extremity disability in women with bilateral idiopathic CTS. Rehabilitation approaches for CTS should be considered based on the adaptive activities of the neural networks.

Hand Pain and Sensory Deficits: Carpal Tunnel Syndrome

The Academy of Orthopaedic Physical Therapy and the Academy of Hand and Upper Extremity Physical Therapy have an ongoing effort to create evidence-based clinical practice guidelines (CPGs) for orthopaedic and sports physical therapy management and prevention of musculoskeletal impairments described in the World Health Organization's International Classification of Functioning, Disability and Health (ICF). This particular guideline focuses on hand pain and sensory deficits in carpal tunnel syndrome. J Orthop Sports Phys Ther 2019;49(5):CPG1-CPG85. doi:10.2519/jospt.2019.0301.

Assessing the effects of biomechanical overload on dairy parlor workers' wrist: Definition of a study approach and preliminary results

BACKGROUND

Dairy milking is a demanding work task that has been associated with hand and wrist musculoskeletal disorders. Clinical approaches to identify the early effects of musculoskeletal disorders among dairy parlor workers' wrist have not been well defined.

OBJECTIVES

The purpose of this pilot study was to develop a study protocol that would assist in the identification and quantification of hand and wrist disorders among dairy workers that perform tasks in the dairy parlor. Additionally, such a study protocol was needed to perform relatively rapid assessments of the wrist/hand on large samples of dairy workers.

METHODS

Fourteen dairy parlor workers were assessed for i) upper limb symptoms and work history through questionnaire, ii) a physical examination of the upper limb and in particular wrists and iii) wrist ultrasonography. An additional 21 unexposed paired participants (the control group) also participated in the data collection.

RESULTS

The study results identified two ultrasound acoustic windows characterized by the highest predictive value for alteration of the wrist's structure. Study results indicated an impairment of the distal median nerve in structure and mobility and impairment of the distal tendon of the muscle extensor carpi ulnaris that included dislocation and frank damage.

CONCLUSIONS

This study identified at least two acoustic windows that should be assessed with ultrasound studies on larger groups and in prospective periodical health surveillance of dairy workers. The study confirmed the wrist was at risk for biomechanical stress among workers conducting milking tasks in the dairy parlors.

A structured literature synthesis of wrist outcome measures: An evidence-based approach to determine use among common wrist diagnoses

STUDY DESIGN

Structured literature synthesis.

INTRODUCTION

Hand therapists and researchers have numerous options when selecting outcome measures for patients with wrist pathologies. An evidence-based approach to determining which measures are used most often can inform choices.

PURPOSE OF THE STUDY

To describe how frequently outcome measures are used in recent randomized controlled trials of patients with wrist diagnoses. Identifying assessment design and related International Classification of Functioning, Disability and Health (ICF) domains provides additional consideration for selection.

METHODS

Systematic PubMed and Cumulative Index to Nursing and Allied Health Literature searches for the time frame between January 2005 and March 2015 captured measures used in randomized controlled trials researching wrist-specific fractures, ligament injuries, nerve injuries, arthritis/arthroplasty, or stress injuries/wrist pain.

RESULTS

Three most frequent measures used within each diagnostic category are detailed with assessment design described and ICF domain identified. Across diagnoses, grip/pinch strength and Disabilities of Arm, Shoulder and Hand were the most frequently used physical and patient-reported outcome measures, respectively. The Jebsen-Taylor Hand Function Test was the most frequently used performance measure.

DISCUSSION AND CONCLUSIONS

Consideration of the evidence, ICF domains, wrist diagnoses, and assessment design can help hand therapists select the measure most appropriate for use.

LEVEL OF EVIDENCE

2a.