Doctors Demystify Journal Club for 2013-2014 self study
Driving With A Cast On. Is It Safe?
Should patients in casts or splints be driving? Is it different if it is a long arm thumb spica cast or a short arm cast? Does it make a difference whether the patient is left or right handed or which side is casted? Is it harder driving forward or backing up?
A group of investigators at Vanderbilt University recently published their results of a carefully controlled study involving 30 police officers-in-training. The closed driving course required maneuvers that officers on duty would be expected to perform safely and efficiently and included backing up, cornering, and parking.
Each student was tested twice for speed and accuracy without any cast and also tested four more times in random order, twice with a long arm thumb spica cast first on one side then the other, and twice more with a short arm cast first on one side and then the other. Each student also rated the perceived difficulty and the perceived safety under each condition.
The major finding was that the long arm thumb spica cast caused significantly more distress when it was on the left arm than when it was on the right arm regardless of handedness. Nine of the 30 recruits rated the left arm “useless” and three rated their skills as “not safe” when their left elbows were immobilized. By comparison, placement of a short arm cast had modest effects on the time/accuracy scores and on the perceived difficulty and safety.
The authors surmise that with the left elbow casted, the drivers had poor steering wheel control because of interference from the driver-side door, especially when backing up and looking over the right shoulder. Some of the maneuvers required on the course would not be encountered regularly on street driving so the results might be magnified. Conversely, the results could possibly be worse on the street where moving hazards and unexpected events occur and if the driver is in pain or in a small car, particularly if it has a stick shift.
Food for thought: the authors advise more study. I agree, and this is the type of investigation that hand therapists could and should easily involve themselves in.
Chong PY, Koehler EA, et al: Driving with an arm immobilized in a splint: a randomized higher-order crossover trial.J Bone Joint Surg Am. 2010 Oct 6;92(13):2263-9
“Should I wear the CMC brace at night?”
In a prospective, randomized trial from France involving 112 patients with osteoarthritis at the thumb base, half the subjects wore a thermoplastic long opponens splint only at night for a year. The remaining subjects were untreated. Patients self-reported their pain and disability at 1 and 12 months.
At 1 month, outcomes were no different. At 12 months, the splinted group reported significantly less pain and better function.
Study strengths: the study was rigorously designed, executed, and reported. Subject compliance and follow-up were excellent.
Study weaknesses: the study was not blinded, and measurements were not taken between 1 and 12 months.
Conclusion: night bracing in abduction for a year significantly reduces pain and dysfunction for thumb basal joint osteoarthritis. Whether night bracing for 3 or 6 months would be equally effective is unknown. It is also unknown of a short opponens brace would work as well as a long one.
Comment: Traditionally, I have asked patients with thumb basal joint OA to wear their brace as much as possible during the day. Since they are not using their hand much at night, I have told them to take it off at bedtime.
Patients do tell me that their thumb hurts when they adjust the blankets. Maybe just having the thumb rest in abduction overnight helps calm the inflammation. And then as you know, some patients cannot wear the brace continuously during the day because it interferes with activities that they cannot curtail.
So based on the results of the above-cited study, I now recommend that patients wear the brace at night and as much as they can during the day.
Rannou F, Dimet J:Splint for base-of-thumb osteoarthritis: a randomized trial. Ann Intern Med. 2009 May 19;150(10):661-9.
Diminutive Digits Discern Delicate Details fingertip size and the sex difference in tactile spatial acuity J Neuroscience 2009; 29:15756-15761
Researchers from Duquesne University in Pittsburgh tested the spatial acuity of fingertips in 100 young adults, 50 women and 50 men. Rather than using two-point discrimination that we are most familiar with, they used a computer-activated device that pressed two parallel ridges momentarily against the fingertip with a controlled force. The ridges varied in the distance separating them and were randomly presented with the ridges either first being parallel with the finger or perpendicular to the finger. The closer together the ridges were when the subject could still discern whether the ridges were oriented parallel or perpendicular to the finger indicated the degree of tactile acuity.
The investigators’ first assumption that women would have greater tactile acuity than men proved false. Instead, they found that tactile acuity was related to the size of the digit regardless of gender. Smaller fingers were more discerning than larger fingers.
Now you are probably thinking that sure, skin compliance may be greater in dainty princess digits than on the callused hand of a plumber, but the investigators tested for and controlled this variable. There was no statistically significant difference in skin compliance between men and women.
What accounts for the finding that tactile acuity increases as finger size diminishes? The researchers postulate that static tactile acuity is conveyed to the brain via the Merkel receptors, which are closely associated with the sweat pores in the deep dermis. Short of biopsying their subjects’ fingers and determining the density of their Merkel receptors, they measured the density of the sweat pores and showed that smaller fingers had more densely packed sweat pores.
In other words, it appears that everybody has roughly the same number of Merkel receptors and that they are just distributed more widely in larger fingertips regardless of gender. If this is true through life, then children, with the smallest fingertips, should have the highest tactile spatial acuity. These differences may be too subtle to ascertain with two-point discrimination, but don’t be surprised if two-point discrimination is closer in a petite plumber than in her hulking househusband.
Peters RM et al: Diminutive digits discern delicate details: fingertipsize and the sex difference in tactile spatial acuity. J Neurosci. 2009 Dec 16;29(50):15756-61.
Does early return to ADLs after volar plating of distal radius fractures reduce depressive symptoms?
Investigators in Korea studied 26 patients undergoing volar plating (VP) and 24 age- and gender-matched patients undergoing cast immobilization (CI) for unstable distal radius fractures. Their hypothesis was that early return to daily activities in the VP group would reduce depressive symptoms.
Patients in the VP group wore a short arm plaster splint for the first week and then a removable splint. They started hand therapy 2 weeks after injury. Patients in the CI group wore a sugar-tong splint or short arm cast for 6 weeks and then switched to a removable splint and started hand therapy.
All patients answered questionnaires at 0, 2, 6, 12, and 24 weeks. These included the DASH, an assessment of depressive symptoms, and a pain numerical rating scale.
Over all, 76% of the patients at time of injury and 48% at 2 weeks had scores indicating a major depressive disorder. These percentages dropped progressively as time went on. At no point, however, were the depression scores significantly different between VP and CI groups.
The VP group had significantly better pain scores at 12 and 24 weeks and significantly better DASH scores at 24 weeks, otherwise the CI and VP groups fared similarly at all other time points for functional ability and comfort.
The presence of pain proved to a significant predictor of depression at 0 and 24 weeks. A high DASH score (higher is worse) was a significant predictor of depression at 6 weeks.
Study weaknesses included that there were no pre-fracture depression scores, that the 2 groups started hand therapy at different times, and that other predictors of depressive symptoms such as social support, level of education, and socioeconomic status were not studied.
The take home message for me is that patients with distal radius fractures are likely depressed. Volar plating with early return to daily activities may reduce pain and improve functional scores but will not alleviate their depression. Recognizing this likelihood, we should let the patients know that depression in this situation is common and encourage them to seek professional help.
Gong et al: Comparison of depressive symptoms during the early recovery period in patients with a distal radius fracture treated by volar plating and cast immobilization.
Gong HS, Lee JO: Comparison of depressive symptoms during the early recovery period in patients with a distal radius fracture treated by volar plating and cast immobilisation. Injury 2011 Nov;42(11):1266-70
Surgeons Underestimate Domestic Violence
Not yet published but too important to wait is a paper that was presented at the recent annual meeting of the American Academy of Orthopedic Surgeons. Della Rocca surveyed 153 (90% male) members of the Orthopedic Trauma Association about their perception and attitude toward domestic violence.
Although various studies report that 40% of North American women have experienced some form of violence and 35% have experienced intimate partner (domestic) violence, the survey respondents estimated the incidence of domestic violence in their practices to be approximately 1%. Well over half said they did not know how to ask and did not know what to do if a patient said yes. Seventy-four percent, however, said that identifying victims of domestic violence was relevant to their practices.
How about hand therapists? You spend far more time talking with patients than surgeons do, and your people skills are generally better. Do you identify domestic violence? If therapists have picked this up on my patients, they have never told me.
I cite this paper for two reasons. 1) Keep your antennae up. 2) One of you should mastermind and publish a similar survey among therapists.
Here are more details about the AAOS paper including links to helpful resources.
Is Knuckle Cracking Dangerous?
Does cracking knuckles cause osteoarthritis? A group of investigators surveyed 215 patients aged 50-89 regarding their knuckle cracking habits. All of the patients had an x-ray of their right hand taken within the past 5 years, and 63% showed radiographic evidence of osteoarthritis. Twenty percent of the patients cracked their knuckles. The knuckle crackers indicated which joints they cracked, how often, and for how many years. Was there a correlation?
The results showed that men crack their knuckles more often than women. The PIP joint is the most commonly cracked joint followed by the MP joint and then the DIP joint. A clear correlation was present between radiographic presence of osteoarthtic changes and both advancing age and a family history of osteoarthritis. There was no relationship between the presence of arthritis and gender, occupation, or duration/frequency of knuckle cracking. Even those who cracked their knuckles up to 20 times daily for decades did not have more arthritis than those who did not indulge.
These results confirm those from two previous, smaller studies. So dangerous? No. Annoying? You decide. Read the article in the Journal of the American Board of Family Medicine, April, 2011.
deWeber K, Olszewski M, Ortolano R: Knuckle Cracking and Hand Osteoarthritis J Am Board Fam Med 2011;24:169 –174.
Forearm strap or wrist brace for lateral epicondylitis?
Forty-two patients (44 elbows) with lateral epicondylitis untreated in the previous 6 months wore either a standardized tennis-elbow strap or a standardized wrist extension splint for 6 weeks. The groups were similar for age, gender, and handedness. All patients were advised to use ice and home stretching exercises, and the strap or brace was only to be removed for bathing, sleeping, and performing the prescribed stretches. Occasional use of an over-the-counter non-steriodal anti-inflammatory analgesic was permitted.
At the start of the study and after 6 weeks, all patients filled out 2 assessment surveys, which investigated pain and ease of carrying heavy objects and performing heavy chores.
And the winner was… The patients wearing the wrist extension brace had a significantly greater reduction in pain than did the patients wearing the tennis-elbow strap. The two groups showed no difference in pain with heavy lifting or strenuous activity.
The study would have been stronger had it included a control group that received no treatment, had it prohibited or at least recorded and studied NSAID use, and had it reassessed the patients at 3-6 months.
The authors surmise that the brace was more effective than the strap because the brace allowed the wrist extensors to rest in a relaxed position and prevented passive stretching. The wrist brace was bulky, cumbersome, and it may have served as a visible reminder to ease up on activities.
Garg R, Adamson GJ et al: A prospective randomized study comparing a forearm strap brace versus a wrist splint for the treatment of lateral epicondylitis. J Shoulder Elbow Surg2010 Jun;19(4):508-12
Does Assistive Technology Help for Hand Osteoarthritis?
A group in Norway recently published their results from a randomized, prospective, controlled trial in Annuals of Rheumatic Diseases.
The authors divided sixty-six subjects with hand osteoarthritis into two well-matched groups and gave all of them a leaflet explaining three hand exercises and five methods for alternative means of performing daily activities. One group served as the control. The other group received assistive technology (AT), which was subject-specific and took the person, the activity, and the particular aid or brace into consideration. The ATs included modified knives, bottle grippers, electric can openers, self-opening scissors, and thumb splints. The AT group could also receive instruction in energy conservation and alternative work methods.
Initially and after three months, all subjects completed an occupational performance measure that reported activity performance and satisfaction with performance. The participants used a visual analog scale to indicate pain, fatigue, and disease activity.
At three months, the improvements in performance and satisfaction scores in the AT group were different to a highly significant degree (p = .001) compared to the control group. The AT group also had significantly higher function scores, but pain, fatigue, and disease activity as recorded on the visual analog scales were no different.
Blinding was not possible, men were under-represented, and all subjects came from a university hospital clinic, so some selection bias may have occurred.
Intuitively, we could have predicted the results of this trial, but now we have Level II evidence to support our impressions. It is to our patients’ and our advantage to have objective data available as payers further scrutinize allocation of payment for treatment.
Kjeken I, Darre S, et al: Effect of assistive technology in hand osteoarthritis: a randomised controlled trial. Ann Rheum Dis 2011 Aug;70(8):1447-52
Massage Therapy for CTS?
A study just published from Turkey looked at the effect of a specific self-massage technique and night bracing vs. night bracing alone for the treatment of carpal tunnel syndrome. In a prospective randomized study, the investigators carefully evaluated 80 patients equally divided into two groups both pre-treatment and again 6 weeks later.
The subjects clearly had carpal tunnel syndrome by history, physical, and electro diagnostic studies; and patients with thenar muscle wasting, recent treatment for CTS, or predisposing factors such as diabetes or cervical radiculopathy were excluded. Measures included patient global assessment, physician global assessment, Boston symptom severity and functional capacity scales, grip strength, and electrical studies.
All subjects wore conventional canvas wrist braces at night and performed tendon and nerve gliding exercises. The investigators demonstrated the massage technique to one group, gave them a CD showing the technique to review at home, and asked the subjects to demonstrate the technique at weekly follow up visits. The subjects not attending weekly received regular phone calls reinforcing the technique and its daily application.
The massage routine consisted of five stages:
30 seconds effleurage (lightly touching the distal forearm skin with opposite fingertips or palm without dragging the skin)