- Email: [email protected]
Clinical Usefulness of Provocative Tests for the Hand, Wrist, and Elbow: A Systematic Review
Barriers to EBP in respondents’ clinical setting Reason
N¼(%)
Time Lack of high-level evidence for specific diagnoses Lack of access to full-text articles Unsure how to critically appraise literature & decreased understanding of EBP process Difficulty understanding statistical information presented in literature Lack of colleague support Difficulty changing established practice patterns Lack of reimbursement for specific treatments (i.e.: orthotics) Lack of time to initiate research Lack of IRB access to initiate research Referring surgeons protocols will not allow deviation of information. Most of the respondents felt comfortable or very comfortable in their ability to form a clear question based on a specific patient population, 262 (84%), performing a literature search, 226 (72%), and extrapolating the evidence to a patient, 241 (77%). Over 50% of the respondents (166) felt comfortable critically appraising the literature. 37% (115) of respondents felt comfortable identifying valid and reliable outcome measures, but only 18% (55) of respondents are comfortable designing a research study. 31% (96) of the therapist respondents are comfortable understanding statistical analysis that is presented in the literature, and 8% (26) are comfortable performing statistical analysis of data. The majority of therapist respondents (297) believe that EBP plays a positive role in clinical practice. 65% (202) of therapists believe that EBP is not a new concept. Most of the respondents, 92% (287), believe therapists should be able to distinguish methodologically sound research from poor research, EBP helps clinical decision making, 88% (276) and that EBP improves patient outcomes, 74% (231). 53% (166) of the respondents believe that clinical decisions should be based on numerical estimates of risks and benefits. Approximately 30% of the respondents believe that the proponents of evidence based medicine are academics rather than clinicians (89) and that there is little evidence available to guide practice (100). Less than 13% of the respondents believe that EBP is impractical for every day clinical practice (42), that it devalues clinical experience and intuition (37), and that it removes the ‘‘art’’ from practice (38).
e8
Journal of Hand Therapy
63 29 29 21
(20%) (9%) (9%) (7%)
10 (3%) 8 7 5 5 2 2
(3%) (2%) (2%) (2%) (1%) (1%)
Conclusion: The attitudes and opinions of EBP are extremely favorable among respondents, and most believe that evidence-based clinical practice improves patient care. Further educational initiatives should be undertaken to address methods in which EBP skills are taught and reinforced among hand therapy practitioners.
CLINICAL USEFULNESS OF PROVOCATIVE TESTS FOR THE HAND, WRIST, AND ELBOW: A SYSTEMATIC REVIEW Kristin Valdes1, Paul LaStayo2, 1 Hand Works Therapy, Sarasota, FL, USA; 2Physical Therapy, University of Utah, Salt Lake City, UT, USA Purpose: To provide the clinician with the most current information regarding the likelihood ratios (LR) of common provocative tests for the hand, wrist, and elbow to enable the hand therapist to choose the test that provides the most clinically useful and diagnostically accurate test. Background: The use of provocative tests to predict the presence of upper extremity conditions has been studied previously in systematic reviews. However, these reviews did not provide the likelihood ratios of diagnostic tests. The sensitivity and specificity of the tests were provided, but these values are not as clinically useful as the LRs. The diagnostic accuracy of any maneuver is considered useful if the positive LR is 2.0 or greater (to rule in the disease) or if the negative LR is 0.5 or less (to rule out the disease).
Methods: A systematic review was performed on the articles that studied upper extremity provocative testing. Literature searches included search terms of common upper extremity conditions and hand, wrist, and elbow. The articles were rated using the MacDermid scale for critically appraising the diagnostic testing literature. The LR ratios were also calculated if the authors did not provide the values, but could be determined from the sensitivity and specificity values. Rules were established regarding the clinical usefulness of the diagnostic tests. A top test included data from 2 or more studies that provided diagnostic/prognostic data if the study scored .8/12 on the MacDermid scale and the average +LR was 2.0 or greater or the -LR was 0.5 or less. Reasonable tests included data if the +LR ratio was .5 2.0 or the -LR was,5 0.5 or less, from one study that scored 5.7 on the MacDermid scale. Results: The top provocative diagnostic/prognostic tests for determining the presence or absence of carpal tunnel were the Phalen’s test and Tinel’s test. The scaphoid shift test was the top provocative test maneuver for the wrist. The Tinel’s test and the Elbow Flexion test were determined to be the most clinically useful tests to determine the presence or absence of cubital tunnel syndrome. Reasonable tests to determine the presence of carpal tunnel syndrome include the: modified compression test, carpal tunnel relief maneuver, flick test, and the ratio of thumb abduction strength to the index finger. The ulnar fovea, press test, CMC grind, ECU synergy, midcarpal, and the DRUJ tests were found to be reasonable for determining the presence or absence of wrist conditions. To determine the presence or absence of elbow conditions the moving valgus stress test, crossed fingers, shoulder IR, and scratch collapse test were found to be reasonable. Other commonly used upper extremity provocative test maneuvers were found to have limited clinical usefulness in terms of diagnostic accuracy. Conclusion: The clinician needs to perform diagnostic test maneuvers that provide clinically useful information regarding the absence or presence of hand, wrist, and elbow conditions. The top provocative tests
for hand, wrist, and elbow conditions were found to be the Phalen’s, Tinel’s, scaphoid shift test, elbow flexion test.
SWAN NECK DEFORMITY ORTHOSIS DEVELOPMENT: AOA (ARTICULATED RING ORTHOSIS) Valeria M. Elui1, Maysa C. Rodrigues2, Benedito M. Purquerio3, Carlos A. Fortulan3, Marisa R. Fonseca4, 1 Neurosciences, Medicine Faculty of Ribeirao Preto University of Sao Paulo,
Ribeirao Preto, Brazil; 2InterBioengineering Post graduate program Inter-Bioengineering EESC/FMRP/ IQSC-USP, University of Sao Paulo, Sao Carlos, Brazil; 3Department of Mechanical Engineering - EESC, University of Sao Paulo, Sao Carlos, Brazil; 4Biomechanics Medicine and Locomotor Rehabilitation Department FMRP, University of Sao Paulo, Riberiao Preto, Brazil Purpose: Aims to present the development of a splint with the original concept for blocking hyperextension of the proximal
Fig. 1. AOA virtual version.
interphalangeal joint (PIP), in order to increase the functionality of the hand in carrying out daily activities (KURAN et al, 2008) and better comfort with pleasing aesthetics. Background: Orthotic rings are one of the therapeutic resources for the treatment of rheumatoid arthritis (RA). RA is an autoimmune inflammatory disease, which leads to deformity and joint destruction (BERTOLO, 2007). One of the characteristic deformity in the fingers is the swan-neck deformity consisting of hyperextension of the PIP being one of the most disabling deformities (MELVIN; JENSEN, 1998) that can lead to loss of PIP flexion, making the pinch grip and the ability to grasp objects difficult what have a negative impact, even in functional and aesthetic aspects. Methods: Anthropometric measurements of the finger were evaluated and from them developed a ring splint design with the use of CAD software Solid Edge ST2 and experienced it virtually. The design was prepared in two separate parts which are joined by a concentric axis of rotation (two pins) with faces perpendicularly to the rotational movement. Also has a built locking mechanism of the AOA at 20 degree of flexion to limit hyperextension of the finger (Fig. 1). The virtual model was materialized through the use of
Fig. 2. Finger flexion and extension with the AOA and deformity correction. OctobereDecember 2012
e9
N¼(%)
Time Lack of high-level evidence for specific diagnoses Lack of access to full-text articles Unsure how to critically appraise literature & decreased understanding of EBP process Difficulty understanding statistical information presented in literature Lack of colleague support Difficulty changing established practice patterns Lack of reimbursement for specific treatments (i.e.: orthotics) Lack of time to initiate research Lack of IRB access to initiate research Referring surgeons protocols will not allow deviation of information. Most of the respondents felt comfortable or very comfortable in their ability to form a clear question based on a specific patient population, 262 (84%), performing a literature search, 226 (72%), and extrapolating the evidence to a patient, 241 (77%). Over 50% of the respondents (166) felt comfortable critically appraising the literature. 37% (115) of respondents felt comfortable identifying valid and reliable outcome measures, but only 18% (55) of respondents are comfortable designing a research study. 31% (96) of the therapist respondents are comfortable understanding statistical analysis that is presented in the literature, and 8% (26) are comfortable performing statistical analysis of data. The majority of therapist respondents (297) believe that EBP plays a positive role in clinical practice. 65% (202) of therapists believe that EBP is not a new concept. Most of the respondents, 92% (287), believe therapists should be able to distinguish methodologically sound research from poor research, EBP helps clinical decision making, 88% (276) and that EBP improves patient outcomes, 74% (231). 53% (166) of the respondents believe that clinical decisions should be based on numerical estimates of risks and benefits. Approximately 30% of the respondents believe that the proponents of evidence based medicine are academics rather than clinicians (89) and that there is little evidence available to guide practice (100). Less than 13% of the respondents believe that EBP is impractical for every day clinical practice (42), that it devalues clinical experience and intuition (37), and that it removes the ‘‘art’’ from practice (38).
e8
Journal of Hand Therapy
63 29 29 21
(20%) (9%) (9%) (7%)
10 (3%) 8 7 5 5 2 2
(3%) (2%) (2%) (2%) (1%) (1%)
Conclusion: The attitudes and opinions of EBP are extremely favorable among respondents, and most believe that evidence-based clinical practice improves patient care. Further educational initiatives should be undertaken to address methods in which EBP skills are taught and reinforced among hand therapy practitioners.
CLINICAL USEFULNESS OF PROVOCATIVE TESTS FOR THE HAND, WRIST, AND ELBOW: A SYSTEMATIC REVIEW Kristin Valdes1, Paul LaStayo2, 1 Hand Works Therapy, Sarasota, FL, USA; 2Physical Therapy, University of Utah, Salt Lake City, UT, USA Purpose: To provide the clinician with the most current information regarding the likelihood ratios (LR) of common provocative tests for the hand, wrist, and elbow to enable the hand therapist to choose the test that provides the most clinically useful and diagnostically accurate test. Background: The use of provocative tests to predict the presence of upper extremity conditions has been studied previously in systematic reviews. However, these reviews did not provide the likelihood ratios of diagnostic tests. The sensitivity and specificity of the tests were provided, but these values are not as clinically useful as the LRs. The diagnostic accuracy of any maneuver is considered useful if the positive LR is 2.0 or greater (to rule in the disease) or if the negative LR is 0.5 or less (to rule out the disease).
Methods: A systematic review was performed on the articles that studied upper extremity provocative testing. Literature searches included search terms of common upper extremity conditions and hand, wrist, and elbow. The articles were rated using the MacDermid scale for critically appraising the diagnostic testing literature. The LR ratios were also calculated if the authors did not provide the values, but could be determined from the sensitivity and specificity values. Rules were established regarding the clinical usefulness of the diagnostic tests. A top test included data from 2 or more studies that provided diagnostic/prognostic data if the study scored .8/12 on the MacDermid scale and the average +LR was 2.0 or greater or the -LR was 0.5 or less. Reasonable tests included data if the +LR ratio was .5 2.0 or the -LR was,5 0.5 or less, from one study that scored 5.7 on the MacDermid scale. Results: The top provocative diagnostic/prognostic tests for determining the presence or absence of carpal tunnel were the Phalen’s test and Tinel’s test. The scaphoid shift test was the top provocative test maneuver for the wrist. The Tinel’s test and the Elbow Flexion test were determined to be the most clinically useful tests to determine the presence or absence of cubital tunnel syndrome. Reasonable tests to determine the presence of carpal tunnel syndrome include the: modified compression test, carpal tunnel relief maneuver, flick test, and the ratio of thumb abduction strength to the index finger. The ulnar fovea, press test, CMC grind, ECU synergy, midcarpal, and the DRUJ tests were found to be reasonable for determining the presence or absence of wrist conditions. To determine the presence or absence of elbow conditions the moving valgus stress test, crossed fingers, shoulder IR, and scratch collapse test were found to be reasonable. Other commonly used upper extremity provocative test maneuvers were found to have limited clinical usefulness in terms of diagnostic accuracy. Conclusion: The clinician needs to perform diagnostic test maneuvers that provide clinically useful information regarding the absence or presence of hand, wrist, and elbow conditions. The top provocative tests
for hand, wrist, and elbow conditions were found to be the Phalen’s, Tinel’s, scaphoid shift test, elbow flexion test.
SWAN NECK DEFORMITY ORTHOSIS DEVELOPMENT: AOA (ARTICULATED RING ORTHOSIS) Valeria M. Elui1, Maysa C. Rodrigues2, Benedito M. Purquerio3, Carlos A. Fortulan3, Marisa R. Fonseca4, 1 Neurosciences, Medicine Faculty of Ribeirao Preto University of Sao Paulo,
Ribeirao Preto, Brazil; 2InterBioengineering Post graduate program Inter-Bioengineering EESC/FMRP/ IQSC-USP, University of Sao Paulo, Sao Carlos, Brazil; 3Department of Mechanical Engineering - EESC, University of Sao Paulo, Sao Carlos, Brazil; 4Biomechanics Medicine and Locomotor Rehabilitation Department FMRP, University of Sao Paulo, Riberiao Preto, Brazil Purpose: Aims to present the development of a splint with the original concept for blocking hyperextension of the proximal
Fig. 1. AOA virtual version.
interphalangeal joint (PIP), in order to increase the functionality of the hand in carrying out daily activities (KURAN et al, 2008) and better comfort with pleasing aesthetics. Background: Orthotic rings are one of the therapeutic resources for the treatment of rheumatoid arthritis (RA). RA is an autoimmune inflammatory disease, which leads to deformity and joint destruction (BERTOLO, 2007). One of the characteristic deformity in the fingers is the swan-neck deformity consisting of hyperextension of the PIP being one of the most disabling deformities (MELVIN; JENSEN, 1998) that can lead to loss of PIP flexion, making the pinch grip and the ability to grasp objects difficult what have a negative impact, even in functional and aesthetic aspects. Methods: Anthropometric measurements of the finger were evaluated and from them developed a ring splint design with the use of CAD software Solid Edge ST2 and experienced it virtually. The design was prepared in two separate parts which are joined by a concentric axis of rotation (two pins) with faces perpendicularly to the rotational movement. Also has a built locking mechanism of the AOA at 20 degree of flexion to limit hyperextension of the finger (Fig. 1). The virtual model was materialized through the use of
Fig. 2. Finger flexion and extension with the AOA and deformity correction. OctobereDecember 2012
e9