bluuebunny/crossref_metadata_2025 huggingface dataset:
Postoperative Treatment of Distal Radius Fractures Using Sensorimotor Therapy
Authors: Dafna Michael , Harel Hani , Wollstein Ronit
Published: September 2016

Objective/Hypothesis: Proprioception and sensorimotor modalities have been used in rehabilitation to treat neurological and joint injuries. Following distal radius fractures (DRF), there is a temporary sensorimotor loss that should be addressed during postoperative therapy. We designed an evaluation and treatment protocol aimed at sensorimotor evaluation and treatment and trialed it on a pilot series of patients following surgery for DRF. The purpose of this prospective study was to compare the outcomes of patients following surgery for DRF treated using our specific sensorimotor treatment protocol with patients treated after surgery according to postoperative standard of care. We hypothesized that patients treated using our treatment protocol will have better functional results at 3 months postsurgery. Methods: Because sensorimotor response loops are complex and it is difficult to isolate the effect of the different types of input, both the evaluation and the treatment protocols included a comprehensive sensorimotor panel. The patients were treated once a week in therapy and pursued a home therapy protocol. Thirty-four patients following surgery for DRF were randomized into a focused sensorimotor postoperative protocol and the standard of care protocol. Exclusion criteria included inability to attend therapy or comply with the home therapy protocol and patients with preceding injuries and deficits in the wrist and hand. Patients were evaluated initially in the first days after the operation, at 6 weeks, and at 4 months postsurgery. Results: All patients following surgery for DRF demonstrated similar initial significant deficits in proprioception (72%), stereognosis (36%), and the Moberg pick-up test (30 seconds vs 10.8 seconds). There was documented sensorimotor and functional improvement in both groups with treatment in range of motion (ROM), strength, and sensorimotor testing. The Disabilities of the Arm, Shoulder and Hand (DASH) score was 10.8 (14.2) in the trial group at 3 months and 29.2 (9.6) in the control group P = .05. Wrist ROM at 3 months was significantly better in the trial group ( P = .003). We had no cases of chronic regional pain syndrome (CRPS). Conclusions: (1) Patients after surgery for DRF demonstrate significant sensorimotor deficits that should be evaluated and addressed in therapy. (2) These deficits and function seem to improve more at 3 months when utilizing a comprehensive sensorimotor treatment protocol. (3) Further study is ongoing to evaluate the value of the treatment protocol and to provide sensorimotor therapeutic guidelines following surgery for DRF.
Nerve Injured Patients’ Experiences of Early Sensory Relearning Following Nerve Repair
Authors: Carlsson Pernilla Vikström Ingela , Rosén Birgitta , Björkman Anders
Published: September 2016

Objective: Early sensory relearning (phase 1) after nerve repair using the dynamic capacity of the brain can improve the outcome, especially in the area of sensory function.However, no study has been conducted on patients’ own experiences of early sensory relearning. Materials and Methods: Thirty-one consecutive adult patients with at least 50% median and/or ulnar nerve repair at wrist level, which had completed phase 1 relearning a minimum 3 months ago, were included. The individuals’ experience of phase 1 rehabilitation was assessed using the Q-methodology approach combining both qualitative and quantitative methods. In this method, the patient sorts a number of statements about a phenomenon—in this case the early sensory relearning—into a cell grid, representing their experience. Fifty-six statements within 4 topics—(1) to understand the concept, (2) the conditions for operating training (person/environment/therapist), (3) to create the illusion of sensation, and (4) to complete the sensory training—were developed after pilot interviews, expert group discussion, and pilot testing. Factor analysis was used for data processing of the 31 sorted grids. Results: Three factors emerged that refers to (1) understanding and implementation of the training concept, (2) need for support and feedback during the training, and (3) training with others as a factor for success. Conclusions: With this method, we could identify factors describing patients’ experiences from early sensory relearning, and conclude that the specific factors that were identified should be included in future development of programs for person-centered early sensory relearning.
Evaluating Scapular Dyskinesis in Lateral Epicondylitis
Authors: Degez Frédéric , Bigorre Nicolas
Published: September 2016

Objective: The scapula plays a very important role as a link between the trunk and the arm transferring the force and the stability. Some authors have reported that scapular dyskinesis represents a risk for shoulder and neck pain. But no author is interested in the relationship between scapular dyskinesis and arm or forearm pathologies. The purpose of this study was to investigate the presence of scapular dyskinesis in a population of patients with epicondylitis. Method: We performed an observational study of 37 patients with lateral epicondylitis evolving for at least 6 months and resistive to conservative treatment. We excluded patients with known pathology of the shoulder. We observed scapular kinematics according to Kibler classification. We also noted the associated signs of scapular dyskinesis: the decrease in internal rotation, pain of the pectoralis minor, and contracture of the upper portion of the trapezius. Results: Twenty-six patients (70.3%) presented scapular dyskinesis. This was 14 type 1 and 12 type 2 according to Kibler classification. The internal rotation of the pathologic side was 40.5° (0°-90°) and 65.1° (30°-90°) in the healthy side ( P = 4,04.10-7). Twenty-eight patients (75.7%) had a painful contraction of the pectoralis minor and 24 patients (64.9%) had pain of the upper portion of the trapezius. Conclusion: We thus find a correlation between scapular dyskinesis and the lateral epicondylitis confirming that dyskinesia may lead to a breakage on the kinetic chain and also decompensate pathologies of the arm and forearm due to a pronated position of the arm and the forearm.
A Pragmatic, Assessor-Blinded, Randomized Trial of the Clinical Effectiveness of a 6-Week Sensory Relearning Home Program on Tactile Function of the Hand After Carpal Tunnel Decompression
Authors: Jerosch-Herold Christina , Houghton Julie , Miller Leanne , Shepstone Lee
Published: September 2016

Background: Surgery for carpal tunnel syndrome (CTS) is effective in 80% to 90% of cases, but greater neurophysiological severity is more likely to result in chronic numbness and functional hand disability. Sensory relearning, which is based on the principles of learning-dependent cortical plasticity, has been shown to improve tactile sensibility after nerve trauma. Objective: The objective of this study was to investigate whether a sensory relearning intervention taught as an unsupervised 6-week home therapy program can improve tactile discrimination and self-reported hand function in patients with chronic sensory deficits after carpal tunnel decompression. Methods: This study is a multicentered, pragmatic, randomized, controlled trial. A total of 104 patients with chronic sensory impairment after surgical decompression for CTS were randomized to receive either a standardized 6-week home sensory relearning program (n = 52) or were allocated to the control group (n = 52). The primary outcome was the Shape-Texture Identification (STI) test. Secondary outcomes were touch threshold (Weinstein Enhanced Sensory Test), touch localization test, Moberg pickup test, and 3 subscales of the Michigan Hand Questionnaire (MHQ). All patients were assessed at baseline, 6 weeks, and 12 weeks. Results: Intention-to-treat analysis showed no statistically significant differences between the groups at 6 weeks on the STI test (adjusted mean, −0.47; 95% confidence interval [CI], −1.09 to 0.143; P = 0.129) or at 12 weeks (adjusted mean, −0.18; 95% CI, −0.78 to 0.42; P = 0.549). Similarly, differences between groups on secondary outcomes were not statistically significant, with the exception of the patient-reported subscales of the MHQ (overall hand function, activities of daily living—affected hand and both hands) at 6 weeks. The significant differences in the MHQ were retained in 2 subscales by 12 weeks. A secondary analysis found that adherence with the recommended exercise frequency and duration did not have a significant effect on the primary outcome. Conclusions: At present, there is no evidence to support the use of an unsupervised sensory relearning home program as an intervention for patients with tactile sensory and functional deficits after carpal tunnel decompression. Targeting of therapies to improve functional sensibility in this population may require alternative strategies.
Anatomy of the Direct Small Branches of the Proper Digital Nerve of the Fingers
Authors: Lee Young Ho , Kim Jihyeung , Lee Seung Hoo , Park Jin Woo , Kim Kahyun , Baek Goo Hyun
Published: September 2016

Background and Aim: The purpose of this study was to evaluate the anatomical constancy of the direct small branches of the proper digital nerve. Methods: A total of 208 digital nerves of the index, long, ring, and little fingers from 13 cadavers were studied. For each digital nerve, the number of direct small branches was counted at the proximal and middle phalanx levels. In addition, the diameter of these branches was measured at the level of the branch bifurcation. We also measured the diameter of the proper digital nerve at the level of the distal interphalangeal (DIP) joint. Results: The direct small branches of the proper digital nerve were anatomically constant among the index, long, and ring fingers. The average number of direct small branches was 2.7 at the proximal phalanx level and 2.3 at the middle phalanx level. At the level of the DIP joint, the average thickness of the proper digital nerve was 0.85 mm in the index finger, 0.84 mm in the long finger, 0.72 mm in the ring finger, and 0.49 mm in the little finger. Conclusion: In this study, we verified the anatomical constancy of the direct small branches of the proper digital nerve. The size of these branches at the proximal phalanx level was similar to that of the corresponding proper digital nerve at the level of the DIP joint. Therefore, these nerve branches at the proximal phalanx could be applied to the creation of various sensate flaps for the reconstruction of the fingertip injuries.
Does Upper Limb Pain Affect the Left/Right Judgment Task? A Systematic Review and Meta-analysis
Authors: Breckenridge John , Ginn Karen , Wallwork Sarah , McAuley James
Published: September 2016

Objective: An emerging body of evidence suggests an association between pain and altered neural representations of the body. The integrity of these neural representations can be assessed with a timed motor imagery task such as the left/right judgment task (LRJT). The purpose of this investigation was to systematically evaluate the literature and use meta-analytical methods to establish whether performance of the LRJT is impaired in people with upper limb pain. Materials and Methods: The literature was systematically searched across 8 databases for studies that reported use of the LRJT and also reported upper limb pain. Fifteen studies were found that included 6 upper limb pain conditions and 749 participants. Studies were grouped into 2 categories: (1) studies that compared response time and accuracy with healthy controls (between group comparison) and (2) studies that compared response time and accuracy for affected limb with the subject’s healthy limb (within group comparison). Data were pooled, mean effect size calculated, and forest plots produced using RevMan 5.5. Results: Response times were slower in people with upper limb pain when compared with healthy controls (effect size: 1.42; 95% CI, 0.54 to 2.30). The pain group were also slower in identifying images corresponding to their painful limb than their healthy limb (effect size: 0.71; 95% CI, 0.24 to 1.17). Accuracy was reduced in people with upper limb pain compared with healthy controls (effect size: −0.76; 95% CI, −1.17 to −0.35). The pain group were also less accurate identifying images corresponding to their painful limb compared with the healthy limb (effect size: −0.63; 95% CI, −1.21 to −0.06). Conclusions: The findings of this meta-analysis and synthesis suggest that performance of the LRJT is impaired in people with upper limb pain conditions. Response times (RTs) are slower and accuracy is worse than healthy control subjects or healthy limbs. This reflects disturbances in cortical motor imagery processing and may indicate cortical changes associated with upper limb pain.
Benefits of the Modified Graded Motor Imagery Protocol in the Treatment of Patients With Complex Regional Pain Syndrome Type I and Type II
Authors: Ortiz Jimena , Nicora Yamila , Zambon María Agustina
Published: September 2016

Introduction: The abnormal prolongation of pain, dystrophic events, autonomic dysfunction, microvascular abnormality, localized atrophy, and functional impairment constitutes complex regional pain syndrome (CRPS).It could appear after trauma or surgery. New information regarding cortical changes in patients with chronic pain has prompted a reevaluation of the type of treatment. Graded Motor Imagery (GMI) is one of the treatment techniques from the “top-down” paradigm designed to treat chronic pain. The aim of this study was to evaluate the functional results of the occupational therapy treatment in patients with CRPS type I and type II including the Modified GMI Protocol. Methods: Fifteen patients of both sexes with CRPS type I and type II as a complication of various pathologies of the upper extremity were evaluated. They were treated from November 2014 to January 2016. Patients who were diagnosed with CRPS type I or type II by the physician (hand surgeon or rheumatologist) and underwent a minimum of 10 treatment sessions were included. Patients were assessed with goniometry of the wrist and thumb opposition, distance to the distal palmar crease, visual analogue scale (VAS), and Patient-Rated Wrist/Hand Evaluation (PRWHE). GMI consisted of 3 stages: recognition of hand laterality, imagined hand movements, and mirror therapy. The execution time for these was based on the performance of the patient. Together with the Modified GMI Protocol, other activities such as global and functional range of motion of the upper extremity, sensory reeducation, and edema treatment were developed. Results: Active wrist flexion increased to 61% and the extension to 76.6% in comparison with the first evaluation. Six patients did not achieve the complete opposition of the thumb to the base of the fifth metacarpal in an average of 1.3 cm (range, 1-3 cm). Five patients were able to make the active full fist to the distal palmar crease, the remaining patients had an average deficit of 2.20 cm. Pain decreased in an average of 3/10 (range, 0-7) in the VAS. The PRWHE showed that the patients presented an average of 18.13/50 of difficulty in the Function subscale (specific activities and usual activities). Conclusions: The results obtained in this study suggest that the inclusion of the Modified GMI Protocol has significant advantages, decreasing pain, increasing the active mobility of the affected hand, as well as facilitating its performance in daily activities. We have noted that the protocol can be performed by devoting less time to the stages of laterality and imagined movements if the patient has no difficulty in performing them. Nevertheless, it is important to do the 3 steps in order to allow cortical reorganization of the body scheme and the movements of the affected limb.
The Effect of Stabilization Exercises on Playing Performance in Musicians With Joint Hyperlaxity
Authors: Akel Burcu Semin , Aran Orkun Tahir , Öksüz Çiğdem
Published: September 2016

Purpose/Hypothesis: Joint hypermobility is defined as an abnormal increase in the range of active and passive motion, which is a very common situation in musicians. However, its relation to injuries and on musical performance is not clear; it is thought that unstable joint can be harmed with repetitive playing task. Therefore, stabilization exercises can have a positive effect in hypermobile hands. This study is aimed to investigate the effect of stabilization exercises in musicians having hypermobile joints. Material and Methods: Seventy-five musicians who are playing string instruments and piano at conservatory were assessed if they have joint laxity, and it was found that 45% of this population had joint laxity. The ones who had laxity have asked if they would like to attend to an exercise program aiming stabilization. Twelve people accepted to do the exercises. These 12 people have been assessed by Disability of Arm, Shoulder and Hand (DASH). In addition, they are asked to rate their musical performance, fatigue, and pain according to visual analogue scale, and hand strength was evaluated with pinchmeter. Stabilization exercises were given for 4 weeks; once a week, students worked with the therapist, and during the whole week, they did home exercises. Ten people completed the exercise program, and they were evaluated again at the end of the month. Results: The mean DASH score (musician part) of the musicians was 25.12; this score decreased significantly ( P < .05) after exercises. Also hand strength and musical performance increased significantly( P < .05). Conclusion: When treating a musician patient, if she or he has joint hyperlaxity, adding stabilization exercises to rehabilitation program can be useful. It is also suggested that musicians with hypermobile joints can do stabilization exercises to prevent their joints from injury and to increase musical performance. Preventive programs of musicians mostly include stretching exercises, however 1 or 2 stabilization exercise can be added for especially musicians with hyperbole joints.
Grip Strength in Healthy Israeli Adults
Authors: Langer Danit , Tal-Saban Miri , Mazor-Karsenty Tal , Melchior Hanna
Published: September 2016

Objectives: This study had 2 primary objectives. The first was to establish normative data for grip strength for the adult population in Israel. The second objective was to compare the results of this derived Israeli normative data to internationally reported measures. Two published studies were used for comparison. One study consolidated data from 12 different studies that originated from 8 different countries. The other study was limited to data from Australia. Methodology: A total of 574 healthy adult volunteers had their grip strength tested. This study was conducted over a 3-year period (2013-2015). Testing with regard to position and technique was performed in accordance with recommendations of the American Society of Hand Therapists. Grip strength was determined using the Jamar dynamometer from the average of 3 trials for each hand. Normative data were established based on age, handedness, and sex. More specifically, to allow comparison to international data, the age was subdivided in both 5- and 10-year intervals. The results from this study were then compared with international standards using a 1-sample t test. Results: Looking first at Israeli normative data, across ages and handedness, males were 45% stronger than females. Right-handed people were on average 9% stronger on their right compared with their left side. Left-handed people had the similar average strength on both side. Compared with the Australian data, Israeli men were 3% weaker and Israeli women were 15% weaker. When the data were subdivided based on age, the Israeli population was weaker but statistical significance was reached only for men below the age of 30 years and for women below the age of 60 years. When the Israeli data were compared with the consolidated norms, Israeli men were 10% weaker and women were 23% weaker. Conclusion: Normative data for grip strength were established for the Israeli population and compared with internationally published data. The lower grip strength of the Israeli population we speculate may be related to the lower demands placed on the hands for “white-collar” occupations relative to manual labor. It may also be related to lower average population size, weight, or hand girth when comparing the populations.
Comparison of the Outcomes of 2 Rehabilitation Protocols After Flexor Tendon Repair of the Hand at Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa
Authors: Wentzel Roxanne , van Velze Corrianne , Rudman Elsje
Published: September 2016

Background: Flexor tendon repair of the hand and the rehabilitation thereof are commonly discussed between hand surgeons and therapists. There are many patients in public hospitals in South Africa who require this surgery. They are regularly sent to the therapists for rehabilitation, using the early passive motion protocol. Although the early active motion protocol has yielded improved results globally, there is limited evidence on the comparison of the outcomes of these 2 protocols in the South African context. This study was implemented to compare the outcomes of these 2 protocols in a large public hospital post flexor tendon repair. Methods: Patients (n = 46) who sustained a zone II-IV flexor tendon injury were recruited for the study and equally distributed between the 2 groups (early active motion and early passive motion). Out of these participants, 11 did not return for the initial assessment at 4 weeks post surgery and were therefore excluded. There were 19 participants in the early active motion group and 16 participants in the early passive motion group. Results were collected and classified at 4, 8, and 12 weeks post surgery. The collection of data commenced in December 2014 and was completed in January 2016. Results: The results of the study included total active motion and tip to crease and tip to table measurements of the injured and uninjured fingers. At 12 weeks post surgery, the average total active motion of the injured fingers was similar between the early active and early passive motion protocols (57.46%, 61.00%, respectively). Tip to crease and tip to table measurements were also similar between the 2 groups. In terms of patient compliance, 52.17% of participants removed their splints in the initial 4-week period, and 56.52% carried out the prescribed exercises correctly. Tendon rupture occurred in 8.57% (n = 3, early active motion = 5.71%, early passive motion = 2.86%) of patients. Conclusion: There has been a global trend toward the use of an early active motion protocol post flexor tendon repair. This study found that there was no difference in outcomes between the 2 groups. Therefore, either protocol could be implemented in South African public hospitals. However, because the early active motion protocol takes less time to implement, this protocol is recommended. A larger study would be necessary to determine a significant comparison between the 2 groups; however, this is challenging due to poor patient compliance.
Anatomical Wrist Patterns on Plain Radiographs
Authors: Kramer Aviv , Wolf Alon , Lavi Idit , Kalaiman Tal , Wollstein Ronit
Published: September 2016

Objective/Hypothesis: It is recognized that in many joints, structure dictates function and later pathology. Interpreting the structure is complicated by the existence of multiple joints as well as variability in bone shapes and anatomical patterns in the wrist. Previous studies have evaluated lunate and capitate shape in an attempt to understand functional anatomical patterns. The purpose of this study was to describe anatomical shapes and wrist patterns in normal wrist radiographs using bone shape and measurements of joint contact and position. We hypothesized that we will find significant relationships between measurements enabling us to identify one or more patterns of wrist anatomy. Materials and Methods: Seventy plain posteroanterior and lateral wrist radiographs were evaluated. These radiographs were part of a previously established normal database, had all been read by a radiologist as normal, and had undergone further examination by 2 hand surgeons for quality. Measurements included lunate and capitate shape, ulnar variance, radial inclination and height, volar tilt, distance and angle between 2 lines of reference and percentage of the lunate and capitate radial to these lines as well as the percentage of capitate circumference on PA radiographs that articulate with the lunate, scaphoid, and trapezoid. Results: We found a significant association between lunate and capitate shape using a dichotomal classification system for both lunate and capitate types ( P = .003). Type 1 wrists had a lunate with no contact on the PA radiograph with the hamate bone (as described) and a spherical distal capitate. Type 2 wrists had a lunate with a facet for the hamate bone and a flat distal capitate. When using this distinction between type 1 and 2 wrists, we found that type 1 wrists were associated with a greater amount of contact between the scaphoid and capitate ( P = .04) and a smaller amount of contact area with the hamate bone ( P = .05). There was an inverse relationship between measured contact between the capitate and lunate and the amount of contact between the capitate and hamate ( P = .004). Conclusions: We were able to identify significant relationships within the joints of the wrist, especially in midcarpal joint. Further study needs to be done to better describe the 2 types of wrist patterns more precisely, to describe other joints/parameters in the wrist and their association with these anatomical variants, and then to understand their influence on wrist biomechanics and pathology.
Restricting Scaphoid and Lunate Motion With a Dart Throwers’ Orthosis
Authors: Anderson Hamish , Hoy Greg , Ek Eugene
Published: September 2016

Objective/Hypothesis: The dart throwers’ motion and its influence on restricting movement at the scapholunate joint have been well discussed over the past 12 years. Its potential for use in rehabilitation of persons with scapholunate interosseous ligament tears has been encouraged; however, evidence of its value to conservative management of this injury remains limited. There is also limited evidence that dart throwers’ orthoses (DTO) actually restrict movement to the plane they are designed to restrict it to. The authors will report on the ability of 1 particular type of DTO to control motion to the dart throwers’ plane and then will discuss the results of the integration of this same DTO into a neuromuscular rehabilitative program for conservative management of scapholunate injury. Materials and Methods: We present an orthosis that restricts motion to the dart throwers’ motion plane and discuss its role as part of a hand therapy program. A video fluoroscopy study was completed to assess the orthosis’s restrictive influence on scapholunate motion within the dart throwers’ plane of radial extension to ulnar flexion. The fluoroscopy was completed on a patient with a deficient scapholunate ligament in one wrist, and an intact scapholunate ligament in the other. The orthosis had previously been fitted to a series of 5 patients over a period of 6 years. All patients had a demonstrated scapholunate interosseous ligament injury. Follow-up was from 7 months to 5 years with a median value of 4 years. After a prescribed period of DTO use, the patients began a neuromuscular rehabilitation program designed to enhance the proprioceptive capacities of the joint and to reinforce the role of secondary stabilizers in the wrist. Results: Video fluoroscopy testing indicated that the DTO used was able to restrict scapholunate motion in both scapholunate interosseous ligament (SLIL) intact and deficient wrists as it moved through the dart throwers’ plane. All patients returned to their preinjury level of activity and all reported improved functional hand use in subjective testing following intervention. Visual analogue pain scores were reduced from a mean of 6.5 pre treatment to 0 at the end of treatment. Grip strength and range of motion had returned to be within normal limits in all patients post treatment. Conclusions: The use of video fluoroscopy with an innovative orthosis demonstrated the ability of the orthosis to restrict scapholunate motion following damage to the scapholunate interosseous ligament. Promising results that followed the use of this DTO in combination with a neuromuscular re-education program indicate potential for these guidelines in the conservative management of this injury.
Early Active Mobilization Rehabilitation Protocol After Flexor Tendon Repair in Zone II of the Hand
Authors: Liying Pang , Lian Tong Duan
Published: September 2016

Background: Achieving best outcomes for flexor tendon injuries in zone II of the hand remains a challenge to hand therapists and surgeons. With advances in the understanding of flexor tendon biomechanics and the development of multistrand core suture repair techniques, there has been a trend toward early active mobilization protocols post flexor tendon repair in zone II of the hand. Early active mobilization has been shown to minimize adhesion formation and increase repair strength. Many publications have also reported good outcomes when repaired flexor tendons in zone II were actively mobilized at an earlier stage. Objective: This systematic review seeks to identify an optimal early active mobilization protocol that brings about the best outcomes post flexor tendon zone II repair. Materials and Methods: PubMed, ScienceDirect, and Cochrane Library databases were searched to locate articles published from 1980 to February 2016. English studies that were included involved adult participants who (1) sustained flexor tendon injury to zone II of the hand, (2) had surgical repair done, and (3) underwent early active mobilization rehabilitation which was defined as any form of active digital flexion exercises within the first 4 weeks post repair, including place and hold. Studies that involved the thumb or lack details on the repair technique, rehabilitation protocol, and clinical outcomes were excluded. The primary outcomes were rupture rates and range of motion. In addition, surgical techniques, splint designs, therapy exercises, and regimes were also examined to identify the optimal early active mobilization rehabilitation protocol. Results: One hundred twelve articles were identified. Twelve studies met the inclusion criteria, with evidence ranging from level I to level IV. The rupture rates compared with number of core strand sutures were lowest with 6-strand repair (1.0%) compared with 4 (2.5%) and 2 (9.6%) strand repair. With a postoperative orthosis placing the wrist in neutral position, the rupture rate was low (2.7%) and had the highest excellent to good range of motion (90.6%) according to the original Strickland criteria. During the first 4 weeks of postoperative rehabilitation, a combination of high therapy frequency (daily to once a week) and low daily repetitions of active finger flexion exercises (not more than 2 repetitions per hour) involving active fisting, place and hold and synergistic wrist motion were shown to contribute to low rupture rates (<5%) and excellent range of motion (>85%) according to the original Strickland criteria. Conclusions: The optimal early active mobilization protocol is one that is used on flexor repairs with 4-strand core sutures and above, and a postrepair orthosis that puts the wrist in neutral position. With the integration of intensive therapist supervision and hourly low frequency active mobilization exercise program, this protocol can potentially improve the outcomes of flexor tendon repair in zone II.
Static Progressive and Dynamic Splinting for Wrist and Elbow
Authors: Thomas Dominique , Zanin Davide
Published: September 2016

Objective: As the number of recent publications show, mobilization splinting of wrist and elbow throws a challenge to hand therapists. The number of existing designs is confusing. The purpose of this study is to present a simple and efficient solution to improve ROM based on revisited metal frame, easy to custom make, “lively splint” technology. Biomechanics: All movements are diagonal and spiral in character due to joint anatomy and diagonal orientation. For instance, dart throwing motion starting from wrist extension, radial deviation, and supination leads the wrist into flexion, ulnar deviation, and pronation. Elbow extension brings the forearm from a flexed and varus position to extension and valgus. During flexion and extension, physiological joint axis move. Full finger, wrist, and elbow flexion shortens the anterior anatomical structures while lengthening the posterior one and reciprocally for extension. Fixed axis hinged splints cannot follow the physiological joint axis displacement nor can shorten or lengthen to accommodate anatomical modifications. Fixed axis hinged splint cannot allow full flexion and extension and actually prevent it. Joints and soft tissues have to adapt to the 1-plane movement allowed by fixed axis splints, because these splints do not adapt to physiological movement. Materials and Methods: After the work of Capener and Whynn Parry, metal frame splints also known as “lively splints” were very popular in the 1950s and 1960s. With the advent of thermoplastic, they fell somehow in disgrace. However, modernized by adding proximal and distal cuffs swiveling on the frame, counter pressure cuff made of conforming material like leather to exert a perpendicular force whatever the limb position, the concept of metal frame acting as a “chassis” as well as a “motor” located on either side of the anatomical segment represent the ultimate low profile and are user’s friendly. They allow diagonal movements and some rotation and can follow the shortening or lengthening of anatomical structures during flexion and extension. They act as a 3-point splint, as a double lever of the second order, the most efficient mode of improving ROM. According to Paul Brand’s work, serial static splinting is the most efficient technique followed by progressive static splinting. However, serial static splinting using plaster of Paris or thermoplastic is time consuming since it requires at each increase in range of motion making a new cast or reheating and remodeling the thermoplastic splint. Conclusions: Metal frame splinting can act either on the progressive static or dynamic mode if coils are built into the frame. They are made once for all and are easy and fast to adjust. Thanks to adapted tools they are also easy to make and inexpensive.
Physiological Interphalangeal Stiffness in High-level Climbers
Authors: Punsola-Izard Vicenç , Ozaes-Lara Elena , Peris-Fonte Claudia , Pallejà-DeMingo Laia , Valero Carmen
Published: September 2016

Objective/Hypothesis: Sport climbing involves high demands on the load undergone by the structure of the hand. It is known that the structure of the hand in climbers tends over time to become reinforced and increase in resistance. This resistance increase has a direct impact on the mobility of climbers’ fingers, which is gradually reduced. This loss of mobility especially affects interphalangeal extension. This clinically evident concept has never been scientifically verified. The purpose of this study is to demonstrate that this reduction of mobility is quantifiable and follows a certain pattern. Materials and Methods: Four groups of individuals, both men and women, climbers and nonclimbers, were evaluated. The group of climbers was evaluated in the Climbing World Championship; thus, it consisted of a group of experienced climbers with a high load of daily and weekly sports hours. The control group was a group of people having the same age and sex distribution as that of the study group but who had never done any climbing-related sports activity. The mobility toward extension of the proximal interphalangeal (PIP) and distal interphalangeal (DIP) of the second, third, and fourth fingers was measured in all the participants. Results: In the group of both men and women, a statistically significant difference was obtained in terms of both PIP and DIP extension, with average differences reaching 20°. Conclusions: Stiffness in PIP or DIP extension in climbers is a physiological constraint that cannot be interpreted as a deformity associated with an injury, but part of an adaptation of tissues to the sport.
Pyrocarbon Interposition Arthroplasty of the Trapeziometacarpal Joint With the PyroDisk
Authors: Abramo Antonio , Risto Anton , Tagil Magnus , Kopylov Philippe
Published: September 2016

Introduction: Pyrocarbon is a high-strength, low-friction carbon material. It is isoelastic to bone and therefore considered ideal for a hemiarthroplasty. Pyrocarbon interposition arthroplasty is an alternative to the traditional tendon interposition arthroplasty in the trapeziometacarpal joint, but follow-up series are rare. Objectives: We aimed to evaluate the short-term results and safety of pyrocarbon prosthesis in a younger population. Methods: Between February 2006 and April 2009, 25 patients (29 arthroplasties) were operated with a PyroDisk interposition arthroplasty (Ascension Orthopedics/Integra, Austin, Texas). The mean age was 61 years (range, 52-71 years). Four patients were males and 21 females. The mean follow-up time was 28 months (range, 10-44 months). The patients were evaluated subjectively using the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score as well as a visual analogue scale (VAS 0-10 cm) regarding pain at rest and at activity, and the cosmetic. Grip strength was recorded with a JAMAR dynamometer and the pinch grip strength as well as volar and radial thumb abduction noted. Results: Six prostheses were revised: 4 due to prostheses dislocation, 1 due to scapho-trapezium-trapezoid (STT) arthritis and persistent, and 1 due to persistent pain without any cause. All 6 patients were converted into abductor pollicis longus (APL) tendon interposition arthroplasty. The average pinch grip strength was 5.0 kg force (range, 1.2-9.5 kg) in the operated hands. In patients with unilateral surgery (n = 21), the pinch grip strength was 86 % of the untreated hands. The mean VAS pain at rest was 1.1 cm (SD = 2.0 cm), and 17 of 25 patients were pain free at rest. Six patients reported mild pain (VAS 1-3), and 2 patients reported VAS 7 at rest. VAS pain at activity was 4.2 cm (SD = 2.5 cm). The average DASH score was 32 (range, 0-93). Conclusion: The use of PyroDisk arthroplasty gives good range of motion and pain relief at rest, and the pinch grip after mean 28 months was close to the nonaffected side but not completely normalized. However, a large number (6/29) of the prostheses were revised, which is a major concern.
Dissecting the Development of Dupuytren Disease Through Human Genetics
Authors: Ng Michael , Zeggini Eleftheria , Hennies Hans C. , Werker Paul M. , Furniss Dominic
Published: September 2016

Objective: Dupuytren disease (DD) is a polygenic fibroproliferative disorder of the palmar fascia of the hand. Building on our previous work, we aimed to further characterize the genetic predisposition to DD by performing a genome-wide association study (GWAS) on a total of 7934 DD cases and 12°861 controls from the United Kingdom, Holland, and Germany. We then aimed to dissect the functional effects of the statistically associated variant within DD-derived myofibroblasts. Materials and Methods: We extracted DNA from saliva or blood of DD patients who had undergone fasciectomy or dermofasciectomy. The genotypes of each sample were investigated using Illumina HumanExomeCore microarray chips in the discovery phase, and other platforms for replication phase. For our functional analysis, we used single-gene TaqMan assays to measure messenger RNA (mRNA) expression of myofibroblast cells that were disaggregated from DD nodules. Primary myofibroblasts were stimulated with a combination of recombinant WNT3A, SFRP4, and DKK1 proteins for 48 hours, and mRNA expression was measured. Results: Our GWAS meta-analysis revealed a total of 24 DD-associated regions, 15 of which were novel ( P < 5 × 10−8). We observed a 4-fold difference in SFRP4 mRNA expression between the 2 homozygous genotypes of our most associated single-nucleotide polymorphism rs1687975. Interestingly, an inverse correlation was observed in extracellular SFRP4 protein secretion. Our WNT signaling pathway stimulation experiments demonstrated that SFRP4 attenuates WNT3A-induced connective tissue growth factor (CTGF) expression, showing a 20% decrease ( P < .05). SFRP4 alone has no effect on alpha-smooth muscle actin, COL1A1, and COL3A1 mRNA expression. Conclusions: We have performed a large 3-stage GWAS and have discovered 15 novel Dupuytren-associated regions. We have identified that our most significantly associated variant, rs16879765, has an effect on the mRNA expression of a WNT antagonist gene SFRP4. Further functional analysis on SFRP4 has revealed that it affects the expression of CTGF. This implies its anti-fibrotic effect is mediated by the non-canonical WNT signaling pathway, potentially via the YAP/TAZ pathway that is known to interact with transforming growth factor β (TGF BETA) pathway, and this plays a critical role in the development of DD. Our GWAS has also revealed multiple potential new therapeutic targets for DD. Genes within the associated regions include MMP14 and WNT4 and have effects on diverse functions such as inflammation, extracellular matrix remodeling, cellular differentiation, and proliferation, which are likely to be important processes in the development of DD and fibrotic diseases in general.
Comparative Study of Phrenic and Intercostal Nerve Transfers for Elbow Flexion After Global Brachial Plexus Injury
Authors: Liu Yuzhou , Lao Jie , Zhao Xin , Gao Kaiming
Published: September 2016

Objective: The aim of this study was to compare phrenic and intercostal nerve transfers for elbow flexion after global brachial plexus injury. Methods: A retrospective review of 33 patients treated with phrenic and intercostal nerve transfer for elbow flexion in posttraumatic global root avulsion brachial plexus injury was carried out. Phrenic nerve transfer group: phrenic nerve was transferred to anterolateral bundle of anterior division of upper trunk (23 patients); intercostal nerve transfer group: three intercostal nerves were coapted to the anterolateral bundles of musculocutaneous nerve. The British Medical Research Council (MRC) grading system, angle of elbow flexion, and electromyography (EMG) were used to evaluate the recovery of elbow flexion at least 3 years after surgery. Results: The efficiency of motor function in phrenic nerve transfer group was 83%, while it was 70% in intercostal nerve transfer group. The 2 groups were not statistically different in terms of MRC grade ( P = .646) and EMG results ( P = .646). The outstanding rates of angle of elbow flexion were 48% and 40% in phrenic and intercostal nerve transfer groups, respectively. There was no significant difference of outstanding rates in angle of elbow flexion between the 2 groups. Conclusion: Phrenic nerve transfer had a higher proportion of good prognosis for elbow flexion than intercostal nerve transfer, but the effective and outstanding rate had no significant difference for biceps reinnervation between the 2 groups according to MRC grading, angle of elbow flexion, and EMG.
Functional Outcome of Nerve Transfers for Traumatic Global Brachial Plexus Avulsion
Authors: Liu Yuzhou , Lao Jie , Gao Kaiming , Gu Yudong , Zhao Xin
Published: September 2016

Objective: We sought to combine Medical Research Council (MRC) grading with the Disability of the Arm, Shoulder and Hand (DASH) questionnaires and Numerical Rating Scale (NRS) for pain to evaluate the functional outcome of patients who suffered complete brachial plexus avulsion before and after nerve transfers. Methods: The author carried out a retrospective review of 37 patients with global avulsion of the brachial plexus from 2010 to 2012. All of them underwent nerve transfers in Hua Shan Hospital in Shanghai. They were followed up for over 3 years for physical examination and responding to the questionnaires of DASH, NRS, as well as the satisfaction with the surgery. Results: The mean time to surgery was less than 6 months and the mean follow-up period was 4.59 years. The effective motor recovery rate was 54%, 86%, 46%, and 43%, respectively, in supraspinatus, biceps, triceps, and finger flexor. Patients who underwent nerve transfers scored consistently better on the DASH score and NRS score than those before surgery. There was also a significant correlation between the change in NRS scores and patient satisfaction. Conclusion: This study validated the effect of nerve transfers for global brachial plexus avulsions from objective MRC grading combining with patients’ self-assessments. Neurolysis after neurotizations correlated positively with functional outcomes.
The Antiadhesive Mechanism of the Lactoferrin Peptide rabPXL01 in Sodium Hyaluronate May Involve Proteoglycan 4
Authors: Edsfeldt Sara , Holm Björn , Mahlapuu Margit , Reno Carol , Hart David A. , Wiig Monica
Published: September 2016

Objective/Hypothesis: A recent clinical study of the human lactoferrin peptide PXL01 in sodium hyaluronate (HA) administrated around repaired tendons in the hand showed significantly improved digit mobility compared with placebo. To investigate the antiadhesive mechanisms of PXL01 in HA, we have used the rabbit lactoferrin peptide, rabPXL01 in HA, in a rabbit model of healing tendons and tendon sheaths. Materials and Methods: On days 1, 3, and 6 after tendon injury and surgical repair, reverse transcription-quantitative PCR (RT-qPCR) was used to assess messenger RNA (mRNA) expression levels for genes encoding the mucinous glycoprotein PRG4 (also called lubricin), and a subset of matrix proteins, cytokines, and growth factors involved in flexor tendon repair. RabPXL01 in HA was administrated locally around the repaired tendons, and the mRNA expression was compared with untreated repaired tendons and tendon sheaths using analysis of variance. Results: We observed, at all time points, significantly increased expression of PRG4 mRNA in tendons treated with rabPXL01 in HA, but not in tendon sheaths. In addition, treatment with rabPXL01 in HA lead to repression of the mRNA levels for the proinflammatory mediators interleukin IL-1β, IL-6, and IL-8 in tendon sheaths. Conclusions: These findings suggest that rabPXL01 in HA increases lubricin production while diminishing inflammation, which correspondingly reduces the gliding resistance and inhibits adhesion formation after flexor tendon repair.