Conservative management of proximal interphalangeal joint hyperextension injuries: a systematic review
J Chalmer, M Blakeway, Z Adams and S Milan
St George's Healthcare NHS Trust, London
Background. Immobilization and early motion are both used as part of non-surgical treatment of hyperextension injuries to the proximal interphalangeal (PIP) joints of the hand but there is no consensus as to the most effective regimen.
Aims/objectives. This systematic review evaluates the effects of immobilization, protected mobilization and unrestricted mobilization on outcome after PIP joint hyperextension injuries.
Methods. We searched the Cochrane, MEDLINE, EMBASE, CINAHL and PEDro databases, Zetoc, trial registers and reference lists of articles. Randomized and quasi-randomized studies were included if they compared the conservative management of acute (less than 1 month) hyperextension injuries of the PIP joint, using two or more of the following interventions: unrestricted motion, buddy strapping, immobilization or protective splinting. Two independent assessors evaluated the methodological quality of the studies using the Cochrane Collaboration Risk of Bias tool.
Results. Three trials met the inclusion criteria. Variations in the interventions meant that results could not be pooled. One trial compared immobilization to unrestricted mobility, one compared immobilization to protected motion and one compared immobilization for one week versus three weeks. Sample size varied from 40 to 181 patients and duration of follow-up ranged from six months to three years. Overall, patients who sustained a hyperextension injury to the PIP joint, managed without surgery, demonstrated similar outcomes regardless of the amount of motion allowed or when motion was initiated. All trials were more than 15 years old, of low methodological quality and lacked patient-reported functional outcome measures.
Conclusions. This systematic review demonstrates that there is a lack of evidence regarding the most effective method of rehabilitation of non-surgically managed PIP joint hyperextension injuries.
Conservative management of volar plate injuries: a randomized controlled study comparing the outcomes between neighbour strapping and dorsal blocking splint
M Donnan
Ulster Hospital, Belfast
Background. Volar plate injuries are common presentations at emergency departments and are most commonly as a consequence of a sports injury, or less often a simple fall. They are sustained fairly equally between under 16s and over 16s age groups. Treatment methods are usually simple neighbour strapping or dorsal blocking splints and this varies between emergency departments.
Aim. To establish if one particular treatment method was more effective than the other.
Method. One hundred patients presenting with volar plate injuries were randomized using a computerized system to either dorsal blocking splint or neighbour strapping for management of their injury. There were 50 patients per treatment modality with roughly equal numbers over or under 16s in each group. Exclusion criteria were a fragment>4 mm, associated collateral ligament injury, central slip or dislocation. Outcome was assessed at 0, 3 and 6 weeks and included swelling (circumferential tape measure), flexion gap (goniometer) and pain (visual analogue scale). Need for outpatient treatment after six weeks was also considered.
Results. Data were analysed using a Student's t-test for any differences in the outcome measures between the treatment methods and any differences in the age groups (although this was not an initial consideration). Both treatment methods had good clinical outcomes. The group treated with dorsal blocking splints had less pain and the over 16s in this group had less swelling at three weeks.
Conclusions. Both treatment modalities give good clinical outcomes. However, our study results suggest that dorsal blocking splints give more pain relief to under 16s and patients over 16 have less joint swelling when their volar plate injury is managed by this method than with neighbour strapping.
Sensory re-learning after surgical treatment for carpal tunnel syndrome: a pilot clinical trial
C Jerosch-Herold, L Shepstone and L Miller
University of East Anglia, Norwich
Background. Surgical treatment for carpal tunnel syndrome does not always alleviate sensory deficits especially in those patients with severe disease. Sensory re-learning is routinely used in the rehabilitation of nerve injuries; however, its effectiveness has not been evaluated in patients after carpal tunnel release.
Aims/objectives. To evaluate the feasibility, patient acceptability and obtain preliminary data on the efficacy of a sensory re-learning (SR) programme in patients who have ongoing sensory deficits after carpal tunnel decompression.
Methods. A pilot randomized controlled trial was conducted. Patients were randomized to receive either: (i) a four-week sensory re-learning home programme or (ii) no further treatment. Outcomes were assessed using touch threshold, two-point discrimination, Locognosia test, the shape–texture identification (STI) test and Moberg pick-up test. The assessor was blinded to group allocation and undertook measures at baseline, four and eight weeks after randomization.
Results. Thirty-one patients were randomized. Mean adherence rates were high but ranged from zero to 100%. Patient acceptability of the intervention was good; however, further improvements are needed to optimize adherence. At eight weeks follow-up efficacy analysis adjusted for baseline score and age showed a potentially clinically worthwhile benefit in favour of SR in STI score (1.37, 95% confidence interval = 0.18–2.57) and the Moberg pick-up test.
Conclusions. Data on screening, eligibility and patient acceptability of the intervention confirm the feasibility of undertaking a definitive randomized controlled trial. The data on efficacy suggest that the STI test is the most appropriate primary outcome measure and should be used to calculate sample size for a definitive trial. The effect of a longer treatment programme needs also be investigated to see whether greater change over a longer treatment duration and from a more intensive programme can be observed.
Reliability study for the Nine-Hole Peg Test for dexterity in a single age group
S Mee
Chelsea and Westminster Hospital NHS Foundation Trust, London
Background. The Nine-Hole Peg Test (NHPT) is used regularly in clinical practice to assess dexterity of the hand. It is described as a single-time trial, but has been shown to have limited test–retest reliability.
Aim. To evaluate and improve test–retest reliability of the NHPT using a mean of three trials rather than a single trial, and to assess the learning effect over repeated measures.
Methods. Twenty-two asymptomatic students between 20 and 30 years of age were recruited. Each participant carried out bilateral repeated time trials over two separate sessions on the same day. The same sample was used to establish normative data.
Results. Good test–retest reliability for the average of three trials was shown (intra-class correlation coefficient (ICC) right hand 0.877, ICC left hand 0.758), in comparison to available research showing low to moderate reliability for single trials. The standard error of measurement for the mean of three trials (left 0.7 seconds, right 0.86) was smaller than the fastest of three or a single trial for men and women. There was a statistical significant difference between the first and second trial with the latter being faster in every case (P < 0.001), suggesting a strong learning effect. The normative data agreed with current evidence with women being more dextrous than men, the dominant hand being more dextrous and the subjects between 20 and 25 years of age showing the best dexterity.
Conclusion. This study suggests that the mean of three trials of the NHPT has greater test–retest reliability than a single trial. However, there may be a significant learning effect over repeated measures and this variable needs to be taken into account in clinical practice when testing or using the NHPT in treatment.
Patient acceptability and test–retest reliability of two instruments to measure pinch strength in patients with osteoarthritis of the first carpometacarpal joint
L Miller and C Jerosch-Herold
University of East Anglia, Norwich
Background. Grip and pinch strength are important components of the functional integrity of the hand and have been recommended as part of a core set of outcome measures in trials of interventions for hand osteoarthritis (OA). No previous study has investigated the reliability of a single trial of pinch strength in patients with OA of the first CMCJ, explored alternatives to the Jamar or investigated patient preferences with regards to the instrument itself.
Aim/objective. The aim of this study was to compare pain, patient preference and test–retest reliability between the Jamar Dynamometer and the MIE Myometer using a single trial of pinch strength in patients with first CMCJ osteoarthritis.
Methods. A prospective, with in patient, repeated measures design was used. The MIE and Jamar were used to measure pinch strength. Pain was assessed after each trial of pinch strength using a numeric pain rating scale (NRPS). Patients were asked which tool they preferred and why at the end of the assessment.
Results. Thirty-eight patients with a confirmed diagnosis of basal thumb joint OA referred to hand therapy took part in the study. There were no statistically significant differences between the Jamar and the MIE in pain or preference between the Jamar and MIE. The MIE recorded statistically significant higher grip strength in both trials (P = 0.001). Test–retest reliability using a single trial was high with both instruments (MIE, ICC = 0.914; Jamar ICC = 0.891)
Conclusions. The use of a single trial of pinch strength still confers high reliability when using the MIE and Jamar while minimizing discomfort to patients. Although the MIE had a slightly higher reliability coefficient, there were no statistically significant differences between the Jamar and the MIE in pain or patient preference, justifying the use of either instrument for clinical practice or research.
Change to splinting practice in controlled active motion regimens following Zone 2 flexor tendon repairs in the hand
A Roe, E Berkin, S Turner and P Feck
Wythenshawe Hospital, Manchester
Background. A significant amount of research in the field of flexor tendon injury has contributed to advances in surgical and rehabilitation techniques. Overwhelming evidence demonstrates early active motion rehabilitation programmes are critical to achieving favourable outcomes following primary digital flexor tendon repair, but there is no definitive regimen guaranteed to restore full active digital motion. Early loss of interphalangeal joint extension impacts tendon glide and remains a typical complication.
Aims. The aim of this study was to improve early outcomes in Zone 2 repairs by changing current postoperative splinting regimens.
Patients and method. There were 22 patients with complete divisions of flexor digitorum profundus (FDP) and 17 flexor digitorum superficialis divisions in 24 digits. All FDP tendons were repaired using varied multistrand techniques. In all patients a short dorsal thermoplastic splint was applied postoperatively.
Controlled active motion exercises were initiated from the distal interphalangeal joint with the wrist extended to 45°. Active extension exercises of the interphalangeal joints were performed with the wrist in flexion.
The results were compared with previous audits using the traditional forearm-based splints.
Results. The rupture rate for this ongoing study was 4%. The mean loss of proximal interphalangeal joint extension at six weeks postoperatively was 17.8° (range 0–50°) compared with 29.4° (range 0–66°) in our previous audit. Using the Modified Strickland Outcome Measure 50% achieved an excellent/good outcome and 50% a fair/ good outcome with the short splint. The traditional splint group had 26% in the excellent/good category and 74% in the fair/poor outcome category.
Conclusions. The loss of extension at the interphalangeal joints is reduced using a short splint, demonstrating improved early outcomes. In an ever challenging resource environment this may have implications for the amount of rehabilitation required for this patient group.
Evaluating service efficacy and efficiency: the evolution of a hand therapy service for patients post-Dupuytrens fasciectomy
S Bradley, B Ellis, C Cheng, K Bancroft and P Reynolds
Poole Hospital NHS Foundation Trust, Poole
Introduction. Historically hand therapy at Poole Hospital was delivered by both occupational therapists and physiotherapists undertaking complementary roles. Implementation of a generic, single therapist approach for patients post Dupuytren's fasciectomy resulted in a £48.3 (51%) saving per patient and maintained outcomes. Postoperative treatment included night extension splinting in all cases.
Aims. New research evidence (Jerosch-Herold et al.1) supporting the implementation of a ‘no splint’ approach was trialled and audited with the aim of identifying any further efficiency savings while ensuring quality was not compromised.
Methods. All patients following Dupuytren's fasciectomy or dermofasciectomy were treated according to a no splint principle. Loss of extension only was an indication for splinting. Range of movement and Quick DASH outcomes were used. Treatment attendances and cost of treatment was calculated. These data were compared with generic practice data to ascertain if there were any additional efficiency savings achieved.
Results. Twenty-eight patients were referred over six months. Subsequent to commencing treatment extension was lost in six cases and splinting was implemented. Mean treatment time in the no splint group was 110 minutes compared with 117 minutes in the generic practice group with splint. Mean treatment cost using the hourly rate of the relevant staff was £42.90 compared with £55.70 per patient in the generic practice group representing £12.80 (21%) saving per patient. The average Quick DASH score in the no splint group was 12.7, and 10.73 in the generic practice group.
Conclusion. A staged, evidence-based evaluative approach to the postoperative management of Dupuytren's patients has demonstrated significant efficiency savings which satisfied Trust objectives. Additionally, the changes have benefitted patients who required fewer attendances and no splint in the majority of cases without any compromise to outcomes.
Reference
1 Jerosch-Herold C, Shepstone L, Chojnowski AJ, Larson D, Barrett E, Vaughan S. Night-time splinting after fasciectomy or dermo-fasciectomy for Dupuytren's contracture: a pragmatic, multicentre, randomised controlled trial. BMC Musculoskeletal 2011;12(136):1–9
Investigation of factors influencing the resumption of driving following immobilization in a below-elbow cast
M J Calcraft, S Young, R Fox, C Musselwhite, P Turton and A Swinkels
North Bristol NHS Trust, Bristol
Background. Driving in a cast while not illegal is at best bad driving and at worst dangerous driving. Research tells us that 9–50% of patients drive in their cast, and that advice from healthcare personnel can be ambiguous and contradictory.
Aims/objectives. The purpose of our study was to explore what factors influence a patient to resume driving while immobilized in a below-elbow cast following a distal radial fracture?’
Method. A mixed methods design was used involving a quantitative component (questionnaires) for demographics, background driving information and cast driving behaviour; and a qualitative component (semistructured interviews) to elicit information of driving influences and behaviour.
Results. Eleven percent of participants drove in their cast citing necessity – work, caring or domestic reasons. These participants were more likely to have a left arm injury, be right handed and have little physical symptoms from their fracture. Non-drivers cited a belief that driving in a cast was not allowed by their insurance, or that they had been advised not to drive by a healthcare professional. Non-drivers also complained of more physical symptoms such as pain and stiffness than drivers. No participants thought driving in a cast was illegal.
Conclusion. Patients do drive in their cast often without understanding the complexity of their decision. While driving in a cast may not be wise, it is not illegal and patients need to be provided with information that allows them to make an informed decision. Practically, healthcare professionals can facilitate this via verbal advice, leaflets or posters.
Qualitative exploration of patients’ expectations, experiences and the determinants of satisfaction related to metacarpophalangeal arthroplasty
C Sharrock and S Spencer
Imperial NHS trust
Background. Most previous research has used quantitative measures to identify the effectiveness of metacarpopha-langeal (MCP) arthroplasty. However, little is known about the lived experience of MCP arthroplasty and postoperative treatment, how this compares with expectations and the meaning of satisfaction, from the patients’ perspective.
Aim/objective. The aim of this study was to gain an in-depth understanding of patients’ expectations, experiences and the determinants of satisfaction related to MCP arthroplasty and postoperative rehabilitation.
Methods. A descriptive phenomenological approach was adopted. Semistructured interviews were conducted with a criterion sample of five participants from two London hospitals at four months to three years postsurgery. Interviews were transcribed verbatim and analysed according to Colaizzi's phenomenological analysis method.
Results. Four common themes emerged. Factors influencing decision-making describes the range of individual reasons for surgery and expectations which informed the decision-making process. The ‘highs and lows’ of postoperative care illuminates participants’ perceptions of various aspects of hand therapy intervention and the value of reassurance and understanding by the healthcare team. Impact on self highlights the ways in which participants’ personal lives were affected, including the experience of coping with loss of independence and control. Factors influencing satisfaction describes the determinants of satisfaction for participants in this study, which included the evaluation of life changes, the extent to which goals were met and the level of congruence between expectations and experiences.
Conclusions. Participants’ expectations and experiences varied greatly and were influenced by factors extraneous to MCP arthroplasty, including personal situation and level of disease activity. Findings highlight the importance of identifying and monitoring individual patients’ expectations, and providing education on factors influencing longterm outcome, in order to facilitate decision-making and psychological preparation.
Field study using mixed methods to investigate the effect of wrist posture on user comfort when using a computer mouse
E Juzl
Private Practice, London
Aims. Taking a pragmatic approach based on studying individuals in the workplace, the variability of individuals, and the often subjective nature of symptoms, the aim of this study was to investigate subjective comfort in the workplace with a product designed to improve user comfort when using a computer mouse. The study also aimed to relate user experience (time spent on a computer and ‘pressure felt to achieve’) to reported comfort.
Design. This longitudinal field study used mixed methods. Comfort was investigated using visual analogue scales, wrist extension with goniometry and the perspectives of those being studied through semistructure interviews. Within group differences, between group differences and correlations were investigated.
Subjects. The study population consisted of 14 individuals, five men and nine women with ages ranging from 27 to 53 (mean 39). This was a convenience sample of employees in the administrative headquarters of a large private health provider.
Results. The results of this study showed a significant change in shoulder comfort scores with the donut, a change in wrist position when wearing the donut. A correlation was observed between comfort in different body areas; between pain and comfort scores; and between disability and comfort scores
Conclusions. This study was able to show that wearing the wrist donut affected reported comfort in the shoulder but no other body area, this intervention is therefore not region specific.
It was able to show that reporting pain when using a computer in the pre trial questionnaire correlated to comfort ratings as did quick DASH scores; therefore, pain and disability affect reported comfort. A correlation between comfort ratings in different body areas was shown, so that if an individual experiences comfort in their hand there is a strong likelihood that they will also be comfortable in their wrist, forearm and shoulder. Initial participant reports appeared to be positive and in contradiction to the quantitative data; however, these reports changed following a longer exposure.
