Mike Szekeres

Optimizing elbow rehabilitation after instability.

Elbow instability is a common clinical problem that requires careful assessment and treatment to achieve a successful outcome. Rehabilitation is a key element in achieving a stable mobile elbow. Careful communication between the treating therapist and surgeon is essential so that an optimal rehabilitation program can be developed and implemented. By understanding the patterns of injury and the biomechanics of the elbow, a good outcome can be achieved in most patients who have elbow instability.

Clinical manual assessment of the wrist

Although hand therapists often evaluate patients with wrist pain, novice and experienced clinicians alike would benefit from a systematic assessment to efficiently identify the source of dysfunction and initiate an appropriate treatment plan. This article proposes a systematic approach for clinical evaluation of the wrist by describing the basic clinical examination (BCE) process and interpreting the findings in terms of common pathology. The BCE will enable the hand therapist to identify conditions that are contraindicated for conservative care and require further physician intervention, determine a working diagnosis for most musculoskeletal problems, and determine the appropriate extra tests to confirm the working diagnosis and/or rule out differential diagnoses. By combining findings from the patients history, BCE, and special testing, hand therapists can efficiently determine the underlying pathology and provide appropriate treatment that can optimize clinical outcomes.

The inter-rater reliability of the modified finger goniometer for measuring forearm rotation

STUDY DESIGN Prospective cohort study. PURPOSE OF THE STUDY To compare the inter-rater reliability of using a modified finger goniometer (MFG) for the measurement of isolated forearm rotation for patients with distal radius fractures to the currently accepted technique for isolated forearm measurement. INTRODUCTION The currently accepted method of forearm measurement requires the assessor to visually estimate vertical for the stationary arm and placement of the moveable arm while placing a straight edge along a curved surface. Inter-rater reliability may be limited as assessors may estimate the placement of the goniometer arms differently depending on their experience, posture, and even their positioning relative to the patient. Rather than continue to place a straight edge on a round surface, we evaluate a new technique using an MFG for measuring isolated forearm rotation. METHODS Patients with clinically healed distal radius fractures were enrolled in the study. Measurement of active forearm pronation and supination was recorded using 2 separate measurement techniques. These measurements were taken by 2 separate hand therapists with more than 10 years of clinical experience in a tertiary care setting at the beginning and end of hand therapy sessions for 3 consecutive weekly visits. Intraclass correlation coefficients (ICCs), standard error of measurement, and minimal detectable change were calculated for each technique. RESULTS The point estimates for the MFG method demonstrated a slightly higher ICC than the standard method for pronation (0.86 vs 0.82). For supination, both measurement techniques displayed equally high pooled ICCs (0.95). The standard error of measurements for the MFG were 2.1 for pronation and 1.2 for supination compared with 2.9 (pronation) and 1.2 (supination) for the standard technique. These translate into 90% minimal detectable changes of 5° and 3° for the MFG pronation/supination compared with 7° (pronation) and 3° (supination) for the standard technique, respectively. DISCUSSION Although the point estimates for the ICCs of the MFG method are equal or higher than the standard method, the confidence intervals for the ICCs overlap, indicating that the MFG is at least equivalent to the standard method in terms of inter-rater reliability. LEVEL OF EVIDENCE 2b.

A new method for measuring forearm rotation using a modified finger goniometer

In this manuscript, the authors describe the challenges with measuring forearm range of motion, and propose a new method for obtaining this measurement. Pros, cons, and future research directions are discussed.--Victoria Priganc, PhD, OTR, CHT, CLT, Practice Forum Editor.

Hand therapists report perceived differences in patient referrals from hand surgeons vs other referral sources: A survey study

Study Design: Descriptive research. Introduction/Purpose: Survey research was performed to determine if there is a perceived difference in outcomes of patients referred to hand therapy from specialized hand surgeons vs nonspecialized physicians. Methods: The survey was administered to members of the American Society of Hand Therapists through an electronic mailing. Results: A total of 744 American Society of Hand Therapists members responded to the survey. Therapists reported a difference in recovery time between patients referred by a hand surgeon vs a nonspecialized physician. Sixty‐seven percent (n = 490) of the respondents answered yes and 12% (n = 84) answered no. Discussion: It is important to consider that not all hand patients receive treatment from a specialized hand surgeon and that a specialized hand therapist may be an integral team member for patients who have not received specialized care from their referral source. Conclusion: Most hand therapists who responded to this survey believe that there is a difference in outcomes of patients referred to hand therapy from specialized hand surgeons vs nonspecialized physicians. Level of Evidence: Level 3.

The Hand Arc—A Hand-based Splint Design for Intraarticular Fractures

When a fracture of the finger is intraarticular in nature, it adds another dimension to the rehabilitation program, as the joint space is affected and subsequently gaining motion can be a challenge. Traction splinting has been reported in the literature as one way to manage intraarticular finger fractures in an attempt to provide stability while allowing motion. These authors have modified some of the original traction splints to create a hand-based version to use for the patients with an intraarticular, proximal interphalangeal joint fracture.

The assessment of psychological factors on upper extremity disability: A scoping review

Introduction: The primary purpose of this scoping review was to describe the nature and extent of the published research that assesses the relationship between psychological features and patient‐reported outcome following surgery or rehabilitation of upper extremity disease or injury. Methods: Twenty‐two included studies were examined for quantitative study design, outcome measure, inclusion/exclusion criteria, follow‐up and recruitment strategy. Patient population and psychological assessment tools were examined for validity. Results: Twenty‐two studies met the inclusion criteria for this study. Only 7 of the 22 studies were longitudinal and the rest were cross sectional studies. Depression was the most common psychological status of interest and was included in 17 studies. Pain catastrophizing was the psychological status of interest in 5 of the studies. Four studies considered anxiety, 3 considered pain anxiety, 3 considered distress, 2 considered coping, 2 considered catastrophic thinking, and 2 considered fear avoidance beliefs. Discussion: The majority of studies in this review were cross‐sectional studies. Cross‐sectional studies may not provide conclusive information about cause‐and‐effect relationships. This review encourages clinicians to be mindful of the psychological implications found in rehabilitation of individuals with upper extremity disease or injury along with being cognizant of choosing appropriate measurement tools that best represent each patients characteristics and diagnoses. Conclusions: The nature of the research addressing psychological factors affecting outcomes after hand injury focus on negative traits and have limited strength to suggest causation as most have used cross‐sectional designs. Stronger longitudinal designs and consideration of positive traits are needed in future studies.

The Effect of Therapeutic Whirlpool and Hot Packs on Hand Volume During Rehabilitation After Distal Radius Fracture A Blinded Randomized Controlled Trial

Background: Edema is a possibility with all heating modalities due to the increase in local blood flow caused by vasodilation. Despite the frequent application of superficial heat modalities, their relative effect on hand volume has not been determined for the upper extremity. The objective of this study was to compare the immediate effects of hot packs and whirlpool on hand volume for patients with distal radius fracture (DRF) and to determine whether any changes in volume between these modalities were still present 30 minutes after heat application. Finally, to determine whether there were any differences in volume change between groups after 3 repeated therapy visits. Methods: Sixty patients with clinically healed DRFs were divided into 2 groups. Half received therapeutic whirlpool at each therapy visit, and the other half received a moist hot pack treatment for 3 consecutive visits. Hand volume was measured before heat, after heat, and at the end of each 30-minute therapy session. Results: There was a significant difference between groups immediately after heat application, as patients in the whirlpool group experienced an initial volume increase greater than those who received a hot pack. When remeasured after a hand therapy session approximately 30 minutes later, this group difference in volume change was no longer significant. The overall change in volume from enrollment in the study to completion of the study 3 weeks later was not statistically different between groups. Conclusion: Whirlpool is a potential consideration when selecting a heat modality for patients with DRF.

Static progressive wrist extension splint

: The authors have found that for best results, a wearing time of 1 hour 3 to 4 times a day is desired. Similar to many splints designed to increase range of motion, there is some functional loss during wearing time. Application of the splint should be scheduled appropriately around functional activities. Based on clinical experience, the authors have found this splint is easy to fabricate, cost-effective, and relatively comfortable.

The short-term effects of hot packs vs therapeutic whirlpool on active wrist range of motion for patients with distal radius fracture: A randomized controlled trial

Study Design: Blinded randomized controlled trial. Introduction: It is generally accepted that heat is beneficial for improving range of motion (ROM). However, the mechanism of action is not clearly understood, and the optimal method of heat application has not been established. Purpose of the Study: To investigate the immediate effects of using a moist hot pack (MHP) vs therapeutic whirlpool bath (WB) for improving wrist ROM during a therapy session for patients with distal radius fracture. Methods: About 60 adult patients, with a mean age of 54 years in the MHP group and 53 years in the WB group, with healed distal radius fracture were randomized into 2 groups of 30. Patients in group 1 were placed in an MHP for 15 minutes during therapy. Patients in group 2 had their arm placed in a WB and were asked to perform active wrist ROM exercises for the same period. This occurred for 3 consecutive therapy visits, with wrist and forearm ROM being measured before and after heat during each visit. Results: The multivariate analysis of variance demonstrated that the canonical variate for ROM was significantly different between groups (F[6,53] = 6.01; P < .05), indicating that patients in the WB group had a significantly larger increase in ROM than patients receiving MHP application. Discussion: Both WB and MHP improved wrist ROM during therapy sessions in this study, making both these acceptable options for clinical use when the goal is to precondition a patient for other treatments. Conclusions: Individuals who received WB showed a statistically greater increase in wrist ROM than those receiving MHP during a therapy session, although the difference between groups may or may not be clinically important considering the small changes in ROM observed in this study. Level of Evidence: Level II.