Joint Mobilization in the Distal Upper Extremity - Putting Evidence into Practice

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  • Table 1Work Status and Mean Outcomes

    Work Status CR12 Eval CR12 Re-eval DASH Eval DASH Re-eval

    Full Duty 3.48 1.58** 40.21 14.25**Modified Duty 3.68 2.46 48.95 25.71Off Duty 4.45 2.94 50.55 31.71

    ** p .000

    Abstracts / Journal of Hand Therapy 27 (2014) e1ee9 e5impact of demographic factors and comorbidities on pain,perceived disability, and functional outcomes.Background: Diabetes, hypertension, and depression have beenlinked to a reduction in bone mineral density, which leads to anincrease risk for falls and fractures (Vestergaard et al., 2009;Botushanov & Orbetzova, 2009). Cigarette smoking can also influ-ence the healing of fractures, as cigarettes contain multiplecomponents such as nicotine and carbon monoxide that aredetrimental to bone health (Sloan et al., 2010). There is limitedresearch that analyzes the effects of these comorbidities and/ordemographic factors as they relate to outcomes following DRF.Methods: Data from 182 patients who sustained distal radiusfractures were extracted from an established clinical outcomesdatabase at a private, outpatient hand therapy clinic. Demographicinformation, comorbidities, pain, perceived disability, and func-tional outcomes were collected; the latter categories measured bya criterion-based numeric pain scale (CR12), the Disabilities of theArm, Shoulder, and Hand (DASH) questionnaire, and a global rate ofchange (GROC) scale.Results: The sample in this study included 182 subjects, ranging inage between 18-76 years with a mean age of 50 years. There were63 male (34.6%) and 119 female (65.4%) subjects. Mean length oftime from injury to initial evaluationwas 54 days; initial evaluationto re-evaluation 44 days. Eighty subjects injured their dominanthand, 95 injured their non-dominant hand, and 7 had bilateralDRFs. Ninety-seven patients reported being a non-smoker, 49 wereprior smokers, and 36 reported smoking during their recovery fromDRF. Fifteen patients reported having diabetes while 167 reportedno history of diabetes. Forty-two patients reported high bloodpressure and 140 reported no history of such. Forty subjects re-ported a history of or current depressive symptoms. Averagechange scores from initial to re-evaluation were 1.79 for the CR12and 24.52 for the DASH. Upon re-evaluation, subjects reported anaverage perceived recovery of 3.03 on the GROC scale (range -4 to5). Moderately strong and statistically significant inverse correla-tions were noted between the number of days between injury andinitial evaluation and change in CR12 and DASH scores. Moderatelystrong and statistically significant correlations were also notedbetween work status and average CR12 and DASH scores at re-evaluation. No significant relationships were noted betweencomorbidities and pain, perceived disability, or function.Conclusion: While all individuals were observed to have madeprogress by re-evaluation, those who did not report having one ofthe comorbidities investigated in this study scored lower overallduring both initial evaluation and re-evaluation. Subjects who re-ported full duty work status in this study were noted to havesignificantly lower CR12 andDASH scores as compared to thosewithmodified and off dutywork status (Table 1). Subjectswhowere seenfor an initial therapy evaluation sooner had significantly greaterchanges in pain and perceived disability over time.

    Joint Mobilization in the Distal Upper Extremity - PuttingEvidence into PracticeRICK D. HEISER 1, VIRGINIA OBRIEN 2, DEBORAH A. SCHWARTZ 31 CoxHealth, Springfield, MO, USA2 Fairview Hand Center, University of Minnesota Medical Center -Fairview, Minneapolis, MN, USA3Orfit Industries America, Leonia, NJ, USA

    Purpose: Examine the current evidence describing joint mobili-zations for treatment of conditions of the elbow, wrist and hand,and offer an informative practical review of the evidence to guideclinical treatment.Background: Joint mobilizations are used as an intervention forimproving range of motion, decreasing pain and ultimatelyimproving function in patients with a wide variety of upperextremity diagnoses. However, there are only a limited number ofstudies describing this treatment for conditions affecting the elbow,wrist, and hand. Furthermore, it is unclear as to the most effectivejoint mobilization technique utilized and the most beneficialfunctional outcomes gained.Methods: A comprehensive literature search was performedusing the following computerized databases: Medline, CINAHL,EMB Cochrane Database of Systematic Reviews, PubMed, OTSeeker, PEDro, and Google Scholar for the years 1980-2011. Searchterminology included the words joint mobilizations, passivemobilizations, elbow, wrist, hand, fingers, stiffness and contrac-tures, physical therapy, occupational therapy, Maitland, Kalten-born, Mulligan, mobilization with movement, and variouscombinations of the above terms. In addition to searches of thecomputerized databases, hand searches were performed fromeach of the reference lists of the pulled articles themselves. Severalrelevant systematic reviews describe joint mobilizations and thespecific studies mentioned in these were also included for review.Only English language studies and studies on adults wereconsidered. All abstracts were reviewed for relevance to thetherapeutic management of conditions of the upper extremityincluding the elbow, wrist and hand utilizing joint mobilizationsas an intervention. Studies including pre and post -surgicalconditions and all possible outcomes measures were included.Studies on joint mobilizations of the shoulder, back, neck or lowerextremity were excluded. A total of 103 studies were selected forfurther review. These studies were further examined for Level ofEvidence according to Sacketts hierarchy using the Oxford 2011Levels of Evidence table. Only studies that were Level 3 or higherwere included for further review. Twenty-two studies datedbetween 1980 and 2011 were included in the systematic reviewfor analysis.Results: Sixteen studies were found to include joint mobilizationof the elbow, all of which considered the diagnosis of lateral epi-condylalgia. The current evidence provides moderate support forthe inclusion of joint mobilizations in the treatment of lateralepicondylalgia. In particular, mobilization with movement asdescribed by Mulligan is supported with evidence from nine of thesixteen randomized clinical trials as an effective technique for thetreatment of pain. Other described techniques include those knownas Kaltenborn, Cyriax Physical Therapy, and Maitland, but theevidence for these techniques is limited. There is a paucity ofevidence for joint mobilizations in the treatment of wrist and handconditions. Only four studies were found to consider joint mobili-zation of the wrist and two studies were found for the hand.Conclusion: The current literature offers limited support for jointmobilizations of the wrist and hand. There is moderate support forMulligans mobilization with movement technique for reducinglateral epicondylalgia pain.Peripheral Nerve

    Outcomes Following the Conservative Management of PatientsWith Non-Radicular Peripheral Neuropathic PainJOSEPH M. DAY 1,2, TIMOTHY L. UHL 1,2, DONALD G. PITTS 1,2,JASON WILLOUGHBY 2, MICHELLE MCCALLUM2, RYAN FOISTER 21Rehabilitation Sciences, University of Kentucky, Lexington, KY, USA2Kentucky Hand and Physical Therapy, Lexington, KY, USA

    Purpose: To investigate the efficacy of a comprehensive treatmentapproach on pain and disability in patients with non -radicular PNPand to determine if improvements are maintained following thediscontinuation of therapy.

    Outline placeholderJoint Mobilization in the Distal Upper Extremity - Putting Evidence into PracticeOutcomes Following the Conservative Management of Patients With Non-Radicular Peripheral Neuropathic Pain


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