Swedish investigators recently ... - Doctors Demystify



Doctors DemystifyJournal Club 201812 recent journal articles relevant to hand therapists from journals other than JHTRead the synopses and Dr. Meals’ comments hereLink to the PubMed abstracts to access the full-length article if you wishTake the on-line multiple-choice quiz at Earn 2.5 hours of continuing education creditJanuary, 2018: How does long-standing, type I diabetes affect upper limb function? HYPERLINK "" \o "Disability and rehabilitation." Gutefeldt, K et al: Upper extremity impairments in type 1 diabetes with long duration; common problems with great impact on daily life. Disabil Rehabil.?2017 Nov 5 [Epub ahead of print]Swedish investigators recently published a population study comparing 703 patients with insulin-dependent (type 1) diabetes of at least 20 years duration with a similarly sized group of age-matched control individuals selected from a national population register. All participants filled out a self-administered questionnaire. This covered demographic data, smoking history, occupation, current sick leave, physical activity, and any complications in the diabetic patient group. The survey also inquired about 5 common upper extremity impairments and any previous surgery for carpal tunnel syndrome or trigger finger. The participants then filled out the standardized Health Assessment Questionnaire (HAQ), which includes 20 questions in 8 categories inquiring about their degree of activity limitation in the past week. The researchers asked all participants to have their blood tested and 78% of patients and 75% of controls did so. All of the diabetic patients were either taking multiple insulin injections or were using an insulin pump. RESULTS: Ten percent of both groups smoked. Women were slightly over represented in the control group (61%) compared to the diabetic patients (55%), and the control group was slightly older (average 54 years vs 50 years). Body mass index (BMI) scores were 26 for both groups. Statistically significant differences were noted in the following areas. Night waking with numbness and tingling: patients 48%, controls 28%Shoulder pain and stiffness: 38% patients, 18% controlsHand stiffness: 34% patients, 15% controlsTriggering: patients 31%, controls 12%Dupuytren contracture: 28% patients, 7% controlsAbsence of all five upper extremity impairments and any history of either trigger or carpal tunnel release: 21% patients, 56% controlsPresence of all 5 impairments: 6% patients, 1% controlsPrevious trigger release: 22% patients, .1% controlsPersistent symptoms following trigger finger release: 9% patients, .1% controlsPrevious carpal tunnel release: 26% patients, 5% controlsPersistent paresthesias following carpal tunnel release: 11% patients, 2% controlWomen were at higher risk for having any of the impairments, as were those diabetic patients with longer duration of disease, higher BMI scores, and increased glycemic index (HbA1c) scores. Smoking did not show any significant association with any of the 5 studied upper extremity impairments among patients, but smoking was correlated with increased incidence of shoulder stiffness, hand stiffness, and Dupuytren disease in the control group. In absence of any upper limb impairments, diabetic patients did not show any activity limitation compared to controls; but for each impairment, the diabetic patients showed more activity limitation compared to controls. The authors note that their study is limited by the fact that their data were based on a self-reported questionnaire and not a clinical examination. Conversely, a strength of their study is the large number of diabetic patients combined with a matched control MENT: This study confirms my general impression that, in addition to well-known retinal and wound healing issues, diabetic patients are more prone to soft tissue upper extremity conditions and that they do not respond as well to trigger and carpal tunnel releases. All diabetic patients with soft tissue conditions should be cautioned about their guarded prognosis and should be encouraged to control their glycemic index and BMI to the extent possible. The extreme case would be a woman with insulin-dependent diabetes for over 35 years with an increased glycemic index and a high BMI. She may need a lot of therapy following trigger or carpal tunnel release. February 2018 Dealing with a racist patientPaul-Emile, K et al: Perspective: Dealing with Racist Patients. N Engl J Med 2016; 374:708-711 full text of article Since the full text of this easy-to-read editorial is available on line, I will not summarize it here. The situation may never come up, but it is worth while to play out the options and implications ahead of time. March, 2018: How a patient’s life situation or character affects their perception of care HYPERLINK "" \o "Disability and rehabilitation." Turesson, C: et al: Patients’ needs during a surgical intervention process for Dupuytren’s disease. Disability and Rehabilitation, 2017; Nov, 21:1-8 Investigators from Sweden interviewed 21 men (age average 66, range 46-83 years) with Dupuytren disease several weeks before surgery and again six to eight months later. The average number of previous treatments was one (range 0-15). Each phone interview was structured and lasted 20-45 minutes. The questions were asked in such a way as to stimulate a dialog. Information sought includedPrevious experiences and significance of illness and careExpectations regarding illness and health careNeeds, both general human and specific medicalResults of health outcome and quality of careExpectations regarding health and lifeBased on previous work and each interviewee’s responses, the researchers classified each patient’s character as either tolerant or eager. A tolerant patient was one who would watch and wait to see events unfold and put his trust in the treatment team. Eager patients were ones who were interested in being involved in their care in some way. Results: The investigators identified four categories of needs: for improved hand function, for knowledge, for support during treatment, need for participation in evaluation and improving care. The authors recognized that a patient’s life situation could contribute to the occurrence of needs but also be a resource for managing them. Most relevant to hand therapists were the responses regarding need for support after surgery. The patients noted that the many issues of concern included splints, dressings, advancement of activities, and home exercise programs. The eager patients typically prepared list of questions and contacted the surgeon or therapist if they needed further information. They also described themselves as being highly involved in shared decision-making. The tolerant patients thought that they should ask questions but waited for the provider to offer information. They did not actively take part in decision making but rather expected the care givers to make the right decisions. Perhaps most importantly, both the tolerant and the eager character types said that they only followed instructions to a certain degree. They made their own decisions about medications, return to driving, wound care, and exercises based on whether the information provided to them made sense and was congruent with their own perceptions. Discussion: The investigators noted that previous studies have indicated that a lack of information and a wish for more extensive follow-up are possible reasons for a negative view of outcome after surgery and therapy. They stress that communication between patients and medical professionals is as important as meeting their needs and that there is great value provided by support and follow-up by surgeon and/or therapist. The researchers acknowledged that their study included only men. Comment: I like this article. Sure, a patient can have a great result from Dupuytren fascia excision when one of us examines their skin scars and joint motion, but the patient may not perceive the result as good if they felt abandoned during the healing process and had questions that went unanswered. We intuitively know about the eager vs. tolerant patients, but we need to consciously provide a stream of information to both. Since many studies have shown that patients retain less than half of what we tell them, repetition is good, having a family member or friend present is good, and providing written information is good. This includes stressing information that we think is most important, which can be easily done by underlining or highlighting critical information in printed handouts. Furthermore, recognize that the patients in this study indicated that they did not always follow instructions even when they were provided. So maybe we should ask patients to do their home exercises four times daily if we secretly hope that they will do them twice. And perhaps most importantly, be credible and thorough with the education process. Either the instructions have to conform to their intuition or we have to explain why the information we are providing may seem counterintuitive. Then the patients, according to this study, will have a positive attitude toward their encounter and sing our praises.April, 2018: Does dry needling work? HYPERLINK "" \o "Physiotherapy." Hall ML et al: Effects of dry needling trigger point therapy in the shoulder region on patients with upper extremity pain and dysfunction: a systematic review with meta-analysis. Physiotherapy.?2017 Aug 7. pii: S0031-9406(17)30079-2. doi: 10.1016/j.physio.2017.08.001. [Epub ahead of print] HYPERLINK "" Gattie E et al: The Effectiveness of Trigger Point Dry Needling for Musculoskeletal Conditions by Physical Therapists: A Systematic Review and Meta-analysis.J Orthop Sports Phys Ther. 2017; 47(3):133-149.?Espejo-Antunez L et al: Dry needling in the management of myofascial trigger points: A systematic review of randomized controlled trials. Complement Ther Med 2017; 33:46-57Within the past year, three groups of investigators from Spain/Portugal, New Zealand, and New Hampshire have published systematic reviews, and in two instances meta-analyses, of the current literature on the effects of dry needling. The investigators restricted their reviews solely to randomized controlled trials. The three reviews complement one another and do not have significant overlap. One investigated trigger point dry needling (TDN) on “upper extremity pain and dysfunction.” 1 One investigated “musculoskeletal conditions.”2 And the other studied “myofascial trigger points.”3 Their analyses included 11, 15, and 13 original studies, respectively. One original study was included in all three of the reviews, and four original studies were included in two of the reviews. Hence the three reviews analyzed 33 separate studies. Six of the original papers studied neck pain; and one each studied temporomandibular, knee, ankle, low back, and lateral elbow pain. So 22 of the 33 of the papers under analysis looked at shoulder pain in over 900 patients. The original randomized controlled trials used a wide variety of controls for comparison. These included no treatment, sham needling (only touching the skin with a blunt needle or needling near but not on the trigger point), routine physiotherapy (US, TENS, hot pack, exercise, stretching), acupuncture, electroacupuncture, trigger point compression, botulinum toxin injection, lidocaine injection, oral drugs, and laser. Outcomes measured by the three reviews all included pain, and one or two included range of motion, disability/functional outcome, depression, quality of life, pressure pain threshold, and strength. RESULTS The best way to summarize the results is to quote from from the systematic reviews/meta-analyses: Hall et al: “As a result of the high risk of bias within the included studies and the low strength and quality of the evidence, there is very low evidence to support the use of TDN in the shoulder region for treating patients with upper extremity pain or dysfunction.”Gattie et al: “Very low-quality to moderate-quality evidence suggests that dry needling performed by physical therapists is more effective than no treatment, sham dry needling and other treatments for reducing pain and improving pressure pain threshold in patients presenting with musculoskeletal pain in the immediate to 12-week follow-up period.” “No difference in functional outcomes exists when compared to other physical therapy treatments. Evidence of long-term benefit of dry needling is currently lacking.”Espejo-Antunez et al: “The results suggest that dry needling is effective in the short term for pain relief, increased range of motion and improved quality of life when compared to no intervention/sham/placebo. There is insufficient evidence on its effect on disability, analgesic medication intake and sleep quality. Despite some evidence for a positive effect in the short term, further randomized clinical trials of high methodological quality, using standardized procedures for the application of dry needling are needed.”COMMENT Dry needling is clearly a topic of current interest, testified by 33 randomized controlled trials to show up in the past 10-14 years and for three systematic reviews/meta-analyses from far reaching areas of the world to be published in the past year. Each of the reviews seem to be solidly designed and executed, and as one review noted, the underlying investigations are likely to contain some selection bias. In other words, some studies not showing desired results were likely left incomplete, or if completed, never got published. Proponents of TDN can pick portions of the three reviews to bolster support for its efficacy: “moderate quality evidence”“effective in the short term”Skeptics can cite the same reviews and claim: “very low-quality evidence” “very low quality” “no difference … when compared to other … treatments” As with most things in health care, maybe in life, “Better studies are needed.” May, 2018: Low-Level Laser Therapy and Muscle StrengthBarbosa R et al: Effect of Low-Level Laser Therapy and Strength Training Protocol on Hand Grip by Dynamometry. J Lasers Med Sci. 2017 Summer;8(3):112-117 Free Full TextLow-level laser therapy (LLLT) has previously been shown to improve muscle performance, delay fatigue, and prevent muscle injuries. The effect is known as photobiomodulation. Various tests, including testing strength and monitoring biomarkers such as lactate, creatine kinase and C-reactive protein, have verified the results. Most studies have looked at large muscle groups including biceps and quadriceps. Recently, investigators in Brazil studied the effect of LLLT on grip strength and limited the treatment and measurements to the long digital flexor forearm muscles. They divided 45 healthy women (average age 23 years, narrow standard deviation) into three groups. The control group received sham LLLT with the probe applied to the forearm but the machine turned off. One study group received a 660 nanometer laser treatment of 1.2 Joules of issued energy to 10 points on the middle and proximal forearm to stimulate the deep and superficial digital flexor muscles. The other study group received 904 nanometer laser treatment at the same sites and at the same total energy application. Each subject received twice weekly LLLT (or sham) sessions for two weeks before beginning the strengthening regimen, which was identical for each group.Dominant hand strength training consisted of using a finger exerciser that calculated the maximum resistance (MR) of the finger flexors. Then the Oxford protocol was performed: 10 repetitions at 100% of MR, 10 reps at 75% of MR, and 10 reps at 50% of MR. The subjects performed the exercises twice weekly for four weeks. The researchers measured grip strength in each subject’s dominant hand using a standard protocol and body/arm position at the beginning and end of the study. RESULTS: None of the 45 subjects experienced any adverse events, and 43 completed the study. Grip strength was statistically equal among the groups at the beginning of the study. In the control group and in the 660 nm group, grip strength increased slightly but not to a statistically significant degree. In the 904 nm group, grip strength increased from about 24 kg to about 29 kg, which proved to be a statistically significant difference. DISCUSSION: The authors compare their results to previous studies that focused on other muscle groups and different protocols for strengthening, LLLT application, and measurements recorded. They also cite other papers that studied light emitting diode therapy as an alternate form of photobiomodulation. The researchers note that although previous studies also show benefits of LLLT on muscle strength and endurance, lack of a standardized protocol makes comparisons difficult. They do not offer any explanation why LLLT works or how it could be applied MENT: When I first heard about LLLT I was entirely skeptical, and I generally remain so. Its clinical application, in wound healing for instance, has raced far ahead of the basic science that might elucidate its biologic effects. We should demand better explanations than, “It just works, that’s all I know.”Now having read this paper, however, and seeing that it basically repeats the results of other LLLT protocols in other muscle groups using various methods of measurement, there seems to be something to LLLT. The question I have been unable to find an answer to is how it works. Light makes muscle strong? Sounds weird. Yet, consider photosynthesis—light modulates a chemical reaction that converts carbon dioxide into water. Or in animals, sunshine stimulates production of vitamin D, melanin production, and skin cancers. So photobiomodulation certainly does exist. Has anybody heard of LLLT being used clinically for muscle strengthening? If so, please let me know and I will let this newsletter’s readership know. Also, high performance athletes typically have their ears to the ground regarding most anything that might give them a competitive advantage, even without a scientific basis for it. Cupping comes to mind. Has anybody heard of athletes getting their quads zapped with LLLT? If so, let’s get a discussion going. My quads could use a boost.June, 2018: “I’m now feeling much better after my wrist fracture, but am I eventually going get arthritis?” HYPERLINK "" Lalone E et al: Patient Reported Pain and Disability Following a Distal Radius Fracture: A Prospective Study. Open Orthop J. 2017 Jul 31;11:589-599. ?Free PMC ArticleYou may have had patients express gratitude and concern as you discharged them from therapy after helping them recover motion and strength following a distal radius fracture. Here is some science to inform your answer. Investigators from Canada prospectively followed 65 patients (17 men, 48 women, average age at injury 57 years) for an average of 11 years (range 2-20 years) after they had sustained a distal radius fracture. The participants were among 262 patients who had previously reported their results in a one-year follow-up study. Reasons for those choosing not to be part of the long-term study included time commitment, not recalling the injury, and doing well so not seeing any need for further analysis. Participants and non-participants in the long-term follow-up study did not differ significantly with respect to sex, age, or Patient Rated Wrist Evaluation (PRWE) scores at one year. Original X-rays were available on 38 of the 65 long-term participants, so radiographic parameters of fracture pattern and bone alignment at healing could be analyzed. The long-term analysis consisted of each participant completing the 15-item PRWE outcome measure for the third time. The PRWE allows rating of wrist pain and disability during various daily living activities. A lower score indicates a better outcome. The investigators compared the recently obtained scores to those obtained at base-line and again 6-12 months after injury. On average, PRWE scores were 70 at baseline and dropped to 17 at one year and to 12 at 2-20 years. Overall, 55/65 (85%) of participants reported having no change or less pain and disability at long-term follow-up, and this held steady from 2 and 10 years (84%) and from 10 and 20 years (85%). The investigators were unable to identify any factors (sex, age, mechanism of injury, fracture pattern) that were predictive of outcome as long as 20 years after injury. The authors noted that, considering the common nature of distal radius fractures, 15% of those injured constitutes a large population burden of long-term pain and disability. The investigators also addressed the possibility of selection bias because of the large number of participants in the one-year follow-up study who chose not to participate in the presently reported study. They also acknowledge that a much larger study would be required to identify specific patient and fracture characteristics that would be predictive of long-term outcome. COMMENT: So according to the results of this study, we can tell patients that they will likely be doing well at a year after injury, and if so, they have an 85% chance of remaining the same or becoming even better over the ensuing years. My experience suggests that we can be even more optimistic regarding long-term prognosis. An unknown percentage of people with scapho-lunate dissociations develop scapho-lunate advanced collapse pattern of osteoarthritis over decades following injury. This is well-known. It is certainly not common experience among hand surgeons nor is it reported in our literature, however, that patients initially doing well after distal radius fractures, even if the fracture is intra-articular and incompletely reduced, later become symptomatic. Consider that the current investigators analyzed long-term results in 65/262 patients who were studied at one year. That means that 197 were not taken into consideration for the long-term follow-up. I suspect that 95-99% of those 197 were asymptomatic or only minimally symptomatics. So 95% of 197 plus 85% of 65 equals 92%. And 99% of 197 plus 85% of 65 equals 95%.My bottom-line response to the title question combines the results of this study with the literature and my experience: “You can expect to improve in comfort, motion, and strength for at least two years after injury and likely not give it another thought thereafter. Nothing is guaranteed, however, so save my phone number.” July, 2018: Carpometacarpal joint arthritis: does non-operative intervention prevent surgery? HYPERLINK "" Tsehaie J et al: Outcome of a Hand Orthosis and Hand Therapy for Carpometacarpal Osteoarthritis in Daily Practice: A Prospective Cohort Study. J Hand Surg Am.2018 May 15. [Epub ahead of print] abstractRocchi L et al: Trapeziometacarpal joint arthritis: a prospective trial on two widespread conservative therapies. Muscles, Ligaments and Tendons Journal, 2017; 7:603-610 free full textTwo recent articles address the issue of non-operative management of osteoarthritis at the trapeziometacarpal joint. Reviewing the articles together adds perspective. The first article by Tsehaie et al comes from the Netherlands. The investigators prospectively followed 809 patients for at least a year and measured visual analog pain scale scores and the Michigan Hand Questionnaire at 2, 4, 6, and 12 months. On entry into the study, each subject received a custom or prefabricated orthosis and was advised to wear it full time for 6 weeks. Some patients also received hand therapy twice weekly depending on patients’ insurance and work schedules. Therapy, when administered, consisted of position training and strengthening and was personalized by therapist and patient. Both the orthosis and the training were phased out between weeks 7 and 12. After a mean follow-up of 2.2 +/- .9 years, 15% of all patients had received surgery. Those patients undergoing surgery had higher pain scale scores to begin with and the scores did not change significantly over 3 months. Surgery was performed at an average of 5 months after enrollment in the trial. For the 85% of patients not requiring surgery, their pain diminished significantly during the first 6 weeks and then remained stable over a year. The second article by Rocchi et al comes from Italy. These researchers identified patients with stage 1 or 2 (early) osteoarthritis and invited them to participate in the study and to choose if they preferred one cortisone injection or 10 sessions of hand therapy. Both groups of 25 subjects received an orthosis. Both groups were assessed for pain, function and strength at 2, 6, and 12 months. The measured parameters improved more quickly in the group receiving the injection, whereas the subjects receiving hand therapy showed a longer remission of pain. Functional evaluation scores at one year were were similar to the pre-treatment scores. COMMENT: Both articles offer food for thought. The first study was poorly controlled by type of orthosis used and the type and extent of hand therapy applied. The authors note that in the future it would be helpful to study the effect of orthosis alone, therapy alone, or combined therapy and orthosis. The bottom line of the study is that 85% of patients were successfully treated without surgery. In my experience, I think the success for non-operative treatment is closer to 95%, and that the benefit results from wearing a custom-orthosis for 6-8 weeks and just at night. I do not put much stock in the prefabricated orthoses. An article from 2009 indicates that night-splinting alone is not effective at one month but is effective at one year. I wish they had studied their patients at 3 and 6 months. Based on the experience of my own aching thumb, I know that it took me more than a year to break my lifelong pinch-posture habits, and once I did, my thumb osteoarthritic symptoms stabilized to an entirely tolerable level.Can we identify the 15% who are going to need surgery? Are they more pain sensitive? Less patient? More aggressive pinchers? Unwilling to slow down? Intolerant of the concept of middle age and its attendant aches? Anatomically or physiologically different? Perhaps with more guidance and counseling, the size of this group could be diminished. Thoughts?The second study parallels my experience and supports my reasoning for not giving patients a cortisone injection early on. It does make them feel good--so good that they go right on subconsciously with their abusive pinch habits. Also, it is my experience that the first injection works for many months, the second one for many weeks, and after that, not much at all. So I would rather start off by having them use a night brace, to become aware of how they use and abuse their thumb, and to modify their habits to avoid pinch postures that hurt. For most of my patients, that is all they need. For those who fail the orthosis, the injection may last longer or even be life-durable since they have also retrained themselves to some extent on pinch habits. Let me know your thoughts. I am happy to share them with the readership., 2018: The best way to rehab a thumb after ligament reconstruction and tendon interposition (LRTI) for basal joint osteoarthritis.Hutchinson DT et al: A Prospective, Randomized Trial of Mobilization Protocols Following Ligament Reconstruction and Tendon Interposition. J Bone Joint Surg 2018 Aug 1;100(15):1275-1280Investigators at the University of Utah last week published a randomized, prospective trial comparing two methods of postoperative rehabilitation for patients undergoing ligament reconstruction and tendon interposition (LRTI) for osteoarthritis (OA) at the thumb carpometacarpal (CMC) joint. LRTI is the most commonly performed procedure for CMC OA, yet prior evidence has been weak in ascertaining the postoperative rehabilitation protocol. Recommendations have varied from 8 to 13 weeks of immobilization, a considerable difference when patients need to plan their return to vocational and avocational activities. The investigators hypothesized that the immobilization protocol would yield better results. At 2 institutions, the investigators recruited 223 patients (238 thumbs) undergoing LRTI to receive 1 of 2 postoperative rehab protocols. The thumbs were prospectively randomized. Patients under 40, and those with either rheumatoid arthritis or previous CMC joint surgery were excluded. Patients that had concomitant thumb MP joint stabilization or carpal tunnel or trigger finger release were included. The early rehab protocol consisted of a forearm (FA) based thumb spica splint (TSS) for a week followed by a FA based thermoplastic TSS for 3 weeks, then a hand-based TSS for 4 weeks. Active range of motion exercises were started 4 weeks post-op.The immobilization protocol consisted of the same splint for the first week followed by a FA based TSS for 11 weeks. Active ROM exercises were started 6 weeks post-op.Outcome measures included DASH score, pinch and grip measurements, 9-hole peg test, visual analog scale (VAS) scores for pain and patient satisfaction, and wrist/thumb ranges of motion. All measures were obtained preoperatively and at 6, 12, 26, 52, and 104 weeks postoperatively.Follow-up was at least 1 year (average 1.7 years) for 74 patients (80 thumbs) treated with the immobilization protocol and for 83 patients (89 thumbs) with the early rehab protocol. RESULTS: DASH scores, grip and pinch strengths, and VAS scores for pain and satisfaction improved in both groups and without any significant between-group differences at any time point. Wrist and thumb movements and peg tests were better at 6 weeks for the early rehab group, but thereafter both groups showed only statistically insignificant differences. Concomitant surgery did not affect outcome. For the early rehab group, DASH scores and patient satisfaction VAS scores maximized at 12 weeks and at 6 weeks, respectively. These scores maximized at 26 and 12 weeks for the immobilization group. COMMENT: I love to read and review prospective, randomized trials—high level evidence! Blinding of the patients was impossible, as it was for the examiner during the early postoperative visits when an orthosis was still in place. Whether or not the examiner remembered at the late follow-up visits which group the patient was in is not known. Although this could be a source of observer bias, is would likely be negligible. The authors also caution that the conclusions here may not apply to other rehab protocols for LRTI or for other surgical procedures, such as simple trapezial excision. The immobilization protocol did not produce better results for the measures tested; and although the study did not assess the overall patient experience with the two protocols, I have my guess which group was happier. I am going with early rehab. September, 2018: Video gaming and arm pain in young baseball players HYPERLINK "" \o "Journal of shoulder and elbow surgery." Sekiguchi T et al: Playing video games for more than 3 hours a day is associated with shoulder and elbow pain in elite young male baseball players. J Shoulder Elbow Surg.?2018 Sep;27(9):1629-1635.This month, investigators from Japan are publishing the results of a simple survey that provides food for thought regarding the perils of prolonged video game playing. They sent a self-reporting questionnaire to 210 elite male baseball players age 9-12 who were playing in a national tournament. The survey asked how many hours they played video games per day and the same for television and for baseball practice. It also asked them if in the past year they had elbow pain or shoulder pain in their throwing arm. Two hundred six responded. Six were girls, who were excluded based on their small number, which left 200 surveys for analysis. Over half of respondents practiced more than two hours a day during the week, and 80% of respondents practiced for more than six hours a day on the weekends. Thirty percent of respondents had experienced shoulder or elbow pain within the last year. Sixty three percent of those who played video games more than 3 hours of day experienced pain, whereas only 24-32% of those playing less time experienced pain. This difference was statistically significant. There was no statistically significant difference in the occurrence of pain with respect to number of hours of television watched daily. The authors conclude that prolonged video game playing is associated in a statistically significant manner with pain in the throwing shoulder and elbow in young, elite baseball players, whereas prolonged television watching had no effect. Since both activities are sedentary, the investigators speculate that the difference is related to the constant, rapid movements and upper limb stabilization needed to play video games, perhaps most importantly the trapezius. Also, looking down rather than forward tightens up the spine and shoulders. Once the scapula is not moving properly on the thorax, altered throwing mechanics runs the risk of developing medial collateral ligament injuries, osteonecrosis of the capitellum, and shoulder soft tissue injuries. COMMENT: This is a simple study. It makes sense intuitively. Do the results translate to older amateurs and to professionals? Does it translate to females? The study did not ascertain how many months a year these boys played baseball and if their symptoms subsided off-season, which is likely short for these aspiring stars. Video gaming does not at first glance seem to be strenuous, but when continued for hours after the throwing arm has already had a stressful day, problems may ensue. , 2018: Blood Flow Restriction Therapy, Part I: The Basics and Use in Normal Individuals HYPERLINK "" Day B: Personalized?Blood?Flow?Restriction?Therapy: How, When and Where Can It Accelerate Rehabilitation After Surgery? Arthroscopy. 2018 Aug;34(8):2511-2513. HYPERLINK "." \o "The Journal of sports medicine and physical fitness." Heitkamp HC: Training?with?blood?flow?restriction. Mechanisms, gain in strength and safety. J Sports Med Phys Fitness.?2015 May;55(5):446-56. HYPERLINK "" \o "Journal of strength and conditioning research." Hwang P, Willoughby DS: Mechanisms?Behind?Blood?Flow?Restricted?Training?and its?Effect?Towards?Muscle Growth. J Strength Cond Res.2017 Dec 4. HYPERLINK "" \o "Sports medicine (Auckland, N.Z.)." Pearson SJ, Hussain SR: A?review?on the?mechanisms?of?blood-flow restriction resistance training-induced muscle hypertrophy. Sports Med.?2015 Feb;45(2):187-200. Spranger MD et al: Blood?flow?restriction?training?and the?exercise?pressor?reflex: a call for concern. Am J Physiol Heart Circ Physiol.?2015 Nov;309(9):H1440-52 FREE FULL TEXTRather than discuss one article as usual, for this month and next, I will discuss one topic with information drawn from the above five journal articles. Blood flow restriction (BFR) (also known as Kaatsu) training originated in the 1990s in Japan. After kneeling in front of a Buddha statue, the originator noted a tingling sensation in his leg that was similar to the sensation he experienced after weight training. The widespread acceptance and use among weightlifters and athletes, however, is a relatively recent occurrence. Conventional strengthening techniques require the trainee to load a muscle group to at least 70% of its one-repetition maximum to achieve noticeable improvements in muscle strength and mass over time. In multiple studies, investigators have shown that by placing a venous tourniquet as proximally as possible on either the upper or lower limb, blood accumulates distal to the tourniquet while arterial inflow is unaffected. Low-load exercise at 20-30% of the individual’s one-repetition maximum then has similar muscle building effects as conventional strengthening techniques. During high-intensity exercise, skeletal muscle’s demand for oxygen outstrips the supply. This results in accumulation of lactic acid and other metabolites, which stimulates the production of growth hormone and opens up intracellular signaling pathways, satellite cell (muscle cell precursor) activity, and fiber type recruitment patterns. Muscle hypertrophy and hyperplasia ensue. BFR training takes advantage of this normal physiological response to exercise; but with BFR, the effects of high-intensity training are only simulated. The tourniquet mechanically restricts outflow of blood and thereby causes pooling of low-oxygen-tension blood in the capillaries. The same physiological response of muscle hypertrophy and hyperplasia occurs. One reason that BFR training was slow to catch on is that the original method required the use of a proprietary inflatable cuff. Ensuing studies have shown that a blood pressure cuff inflated anywhere between 50 and 150 mmHg or an elastic band applied with “moderate” tightness provides a similar effect. BFR training not only affects the muscles that are located entirely distal to the cuff, it also affects those muscles under the cuff and even at least some muscles that are entirely proximal to the cuff. For instance, a cuff placed on the upper arm affects forearm muscles, biceps and triceps, and pectorals. Gluteal muscles are similarly enhanced by use of BFR on the thigh. Furthermore, BFR has been shown to prevent muscle atrophy even when applied without exercise. The possible importance of applying BFR in rehabilitation settings is profound, and I will discuss some recent avenues of investigation, the unknowns of BFR optimal dosing, and possible deleterious side effects next month. November, 2018: Blood Flow Restriction Therapy, Part II: Implications for Rehabilitation and Caveats HYPERLINK "" Day B: Personalized?Blood?Flow?Restriction?Therapy: How, When and Where Can It Accelerate Rehabilitation After Surgery? Arthroscopy. 2018 Aug;34(8):2511-2513. HYPERLINK "." \o "The Journal of sports medicine and physical fitness." Heitkamp HC: Training?with?blood?flow?restriction. Mechanisms, gain in strength and safety. J Sports Med Phys Fitness.?2015 May;55(5):446-56. HYPERLINK "" \o "Journal of strength and conditioning research." Hwang P, Willoughby DS: Mechanisms?Behind?Blood?Flow?Restricted?Training?and its?Effect?Towards?Muscle Growth. J Strength Cond Res.2017 Dec 4. HYPERLINK "" \o "Sports medicine (Auckland, N.Z.)." Pearson SJ, Hussain SR: A?review?on the?mechanisms?of?blood-flow restriction resistance training-induced muscle hypertrophy. Sports Med.?2015 Feb;45(2):187-200. Spranger MD et al: Blood?flow?restriction?training?and the?exercise?pressor?reflex: a call for concern. Am J Physiol Heart Circ Physiol.?2015 Nov;309(9):H1440-52 FREE FULL TEXTIn last month’s Report on Hands, I discussed blood flow restriction (BFR) therapy as a proven means of stimulating muscle hypertrophy and hyperplasia by creating a low-oxygen environment. A venous tourniquet around the proximal portion of the limb restricts outflow of metabolites during low-intensity exercises and stimulates muscle growth. The technique has proven to have the desired effects on normal people who are interested in bulking up. Since the posting of BFR Part I, I have reviewed several 2018 articles and have incorporated information from them in the Part II. Two of these references are included at the end of this post. Much remains unknown about the best way to apply BFR. Cuffs that differ in width and composition will apply different degrees of pressure, and limbs with varying degrees of fat will respond individually. Cuff pressures ranging from 50-150 mmHg have proved effective, and some investigators have merely qualified cuff tightness as “loose, moderate, tight.” As evidence accumulates, cuff tightness is probably best personalized to the individual’s blood pressure because the idea is to restrict venous outflow, far greater than arterial inflow.Then questions arise regarding the frequency of exercises, the number of repetitions, and the degree of resistance. Various protocols have achieved positive results, yet they are hard to compare to one another because of differences in subject ages, body habitus, and the type and width of the constricting band used. For healthy individuals, BFR appears safe. Venous thrombosis would be a theoretical concern but occurred in 6 of about 12,600 individuals (.005%). In the same study, subcutaneous bleeding occurred in 13% and temporary numbness in 1.3%.Does BFR work on people for whom it is unsafe or too painful to perform a conventional weight lifting routine? This might include patients requiring rehab for arthritic joints, healing tendons, and fragile bones both before and after surgery or instead of surgery. The concept is appealing: strengthen a biceps muscle following distal tendon attachment without risking a detachment, strengthen a digital flexor before a tendon repair mature, strengthen wrist and finger motors while the patient is still casted for a distal radius fracture, strengthen patients with limited cardiac and pulmonary reserves who cannot tolerate a heart-pounding workout? All these scenarios seem possible with a caveat.It has been known since the 1930s that restricting blood flow to exercising muscle engages the so-called exercise pressor reflex (EPR), which contributes to the autonomic cardiovascular response to exercise. BFR exercise regimens also trigger the EPR, which could have adverse sympathetically mediated consequences for individuals with hypertension, heart failure, and peripheral artery disease. These dire consequences include stroke, myocardial infarction, and sudden death. Those individuals at risk even include “healthy” individuals who are using BFR for body building. Their baseline blood pressures may be unknowingly high related to use of cardio accelerants such as caffeine, sympathomimetics such as pseudoephedrine, and performance-enhancing drugs. In 2015, Spranger et al, cited above, concluded their abstract by saying, “A more complete understanding of the consequences of BFR training is needed before this technique is passively explored by the layman athlete or prescribed by a health care professional.”Since then, more studies have been published, especially related to rehabilitation following knee surgery. With regard to hypertension, Wong et al recently published a meta-analysis of 86 patients taken from six studies. They concluded that the cardiovascular response to exercise depended on the muscle group being exercised and on the parameters of BFR applied. In general, these responses were greater in the BFR group than in the non-BFR group. BFR training certainly has potential for hastening rehabilitation in normal individuals and for allowing rehabilitation in individuals with comorbidities. It is certainly a topic that bears following as experimental results accumulate. Carefully controlled, prospective studies will help.Day B: Personalized Blood Flow Restriction Therapy: How, When and Where Can It Accelerate Rehabilitation After Surgery? Arthroscopy,?2018 Aug;34(8):2511-2513.?Wong M et al: Safety of Blood Flow Restricted Exercise in Hypertension: A Meta-Analysis and Systematic Review With Potential Applications in Orthopedic Care. Techniques in Orthopaedics, 2018: 33:80-88. December 2018: Does post-traumatic cold intolerance last forever? HYPERLINK "" Valsyik T et al: Cold hypersensitivity?after?hand?injuries. A prospective 7-year follow-up.J Plast Surg?Hand?Surg. 2018 Oct 5:1-4. doi: 10.1080/2000656X.2018.1520124. [Epub ahead of print]Norwegian investigators queried 71 patients who seven years previously had sustained avulsing/crushing/lacerating upper extremity injuries involving nerves. The investigators had previously queried these same patients three years after injury and were interested in knowing if this group had experienced changes over longer follow-up, information previously unavailable. The researchers contacted the patients by mail and asked them to fill out the McCabe Cold Sensitivity Severity (CSS) questionnaire, which asks about five specific indoor activities such as holding a glass of ice water, washing hands in cold water, and holding a package of frozen food. In addition, participants scored a visual analog scale (VAS) that had five underlying descriptors ranging from “no discomfort” to “extreme discomfort” for the same activities that the CSS asked only “yes” or “no.” RESULTS: Seven years after injury, 90% of the patients were still cold intolerant, and their three- and seven-year scores on the CSS were statistically equivalent. On the self-reported severity level, however, 28% had one or two-level reduction in cold hypersensitivity that occurred between three- and seven-year follow-up. Fourteen percent had an increase in symptoms of one level, and 58% had no change. Using this same group of patients, the same investigators had previously reported a worsening in CSS scores for the first six months after injury, no change from six months to one year, and an improvement both from one to two years and from two to three years. Although the current study indicates that CSS scores do not change between three and seven years, the patients had apparently adapted by wearing gloves and avoiding grasp of cold objects in the injured hand, which likely accounts for the improvement in the VAS scores in 28% of subjects. COMMENT: Sadly, the answer to the opening question is “probably yes.” The good news you can tell patients, however, is that there is a fair chance that the severity of the cold intolerance will continue to diminish over at least seven years. Activity modification, more than neural adaptation, likely accounts for the improvement. ................
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