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Diagnostic values of tests for acromioclavicular joint pain: A case report
ABSTRACTS FROM THE LITERATURE Abstracts from the Literature editor is Greg Hritzo, MPT, CHT [email protected] Management of Postsurgical Hyperhidrosis with Direct Current and Tap Water: A Case Report. Gillick BT et al. Phys Ther. 2004;84:262–7 Purpose. This case study explores the treatment of excessive sweating, known as hyperhidrosis, using tap water galvanism, the process of using direct current submerged in tap water to treat the body part. In this case, the authors studied the effects of tap water galvanism on a 36-year-old male electrician with postsurgical hyperhidrosis of the left hand. Literature Search. Hyperhidrosis is a common disorder normally idiopathic involving the eccrine sweat glands resulting from neurogenic overactivity of the sweat glands. The use of electric stimulation to reduce or eliminate excessive sweating has been described in the literature since 1952. Before 1952, investigators claimed success with iontophoresis and chemicals such as aluminum chloride, potassium permanganate, and formaldehyde. Researchers in 1952 reasoned that because formaldehyde is not ionizable, positive outcomes for the treatment of hyperhidrosis with direct current depended simply on the passage of unidirectional current through the tissues without medicinal ions. The authors were unable to find any reference to treat hyperhidrosis after a traumatic incident. Case Description. The left hand of a 36-year-old male electrician was caught in a cable puller machine resulting in partial traumatic amputations of digits II to V and fracture of the distal radius and ulna. Thirtyfour days after surgery, the patient began to notice excessive wetness of his hand that prevented him from maintaining grasp on tools and the steering wheel of his car. He was forced to carry a towel in his hand, and wore six pairs of cotton gloves daily, which decreased his dexterity. Tap water galvanism was administered two or three times per week for
ten treatments using a direct-current generator. Both hands of the patient were submerged in separate trays of room-temperature tap water with one electrode immersed in each tray. Treatments were 30 minutes of tap water galvanism at 12 mA and the polarity was reversed after the first 15 minutes of treatment. After treatment, the hands were dried with a towel, and then measured by taking a 5-second imprint of the left hand on a dry paper towel. The area of hyperhidrosis was determined by tracing the borders of saturation and recorded to the nearest millimeter. Outcomes. The area of hyperhidrosis was reduced from a 10.3 3 12.0-cm area to a 2.2- 3 2.7-cm area. The patient returned to full-time work two weeks after starting tap water galvanism. He wore two pairs of absorbent gloves compared with the six pairs that he wore before intervention. After ten treatments, he did not need to wear absorbent gloves at work. Treatment was concluded. Side effects included temporary erythema and a slight burning during the treatment session. A two-year telephone followup call with the patient revealed no long-term sweating patterns. Discussion. The choice of current and intervention used by the authors was based on reports in the literature that indicated that DC current minimized or abated hyperhidrosis, whereas AC current alone had no demonstrated intervention effect. The patient in this study had a significant decrease in sweating, and was a able to return to full time work as an electrician. Limitations of the study include accuracy of measurements, and uncertainty of not knowing the treatment effects of positive or negative polarity alone.
GREG HRITZO, MPT, CHT Diagnostic Values of Tests for Acromioclavicular Joint Pain: A Case Report. Walton J et al. J Bone Joint Surg Am. 2004;86A(4):807–12.
Purpose. Disorders that produce shoulder pain often have similar clinical symptoms, thus challenging the differential diagnosis. This prospective study was conducted to determine which clinical tests and imaging studies were most helpful for diagnosing acromioclavicular joint (ACJ) pain. Methods. Of 1,037 patients with shoulder pain, 113 who mapped pain about the ACJ (within an area bounded by the midpart of the clavicle and the deltoid insertion) were eligible for inclusion in the study. This area was chosen because it represents the site map for pain after provocative injection into the ACJ. Of 113 subjects, 38 agreed to participate in and completed the study. Twenty clinical tests, three imaging modalities, and ACJ diagnostic injection tests were performed on all subjects. The physical examination included inspection of the supraspinatus, infraspinatus and deltoid muscles for atrophy; tenderness at the sternoclavicular, acromioclavicular, subacromial and biceps regions; passive range of motion of the neck; passive range of motion of the shoulder in flexion, abduction, internal and external rotation; the Paxinos sign; the O’Brien sign; testing for impingement in internal and external rotation; strength testing in external rotation (supraspinatus resisted external rotation); and strength testing of internal rotation (lift off test for subscapularis). The Paxinos sign was performed with the patient seated and the affected arm dependent. The examiner placed his hand over the affected shoulder with his thumb under the posterolateral aspect of the acromion and the index and long fingers of the same or contralateral hand superior to the midpart of the ipsilateral clavicle. The examiner then applied pressure to the acromion with the thumb, in an anterosuperior direction, and inferiorly to the midpart of the clavicular shaft with the index
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and long fingers. The response was considered positive if pain was felt or increased in the region of the acromioclavicular joint and negative if there was no change in the pain level. The test for the O’Brien sign was designed primarily to detect labral tears, but it can also reproduce ACJ pain. The patient is asked to forward flex the affected arm 90 degrees with the elbow in full extension. The arm is then adducted 10 to 15 degrees medial to the sagittal plane and internally rotated so that the thumb points downward. The examiner applies uniform downward force to the arm. The maneuver is repeated in external rotation (palm up). The test result is positive if the first maneuver causes pain on top of the shoulder or at the ACJ, and the pain is less intense or is absent with the second maneuver. The reference test standard was the patient’s response to the ACJ injection, which consisted of lidocaine and methylprednisolone. The injection was performed under imaging control, by an experienced musculoskeletal radiologist who was masked to the patients’ clinical data. The initial examiner then evaluated patients. The test result was considered positive if the patient reported alleviation of the superior shoulder pain by at least 50% within 10 minutes after the injection (i.e., they were considered to have pain at the ACJ). Results of imaging studies (radiographs, magnetic resonance, and bone scans) of the ACJ were classified as abnormal or normal by an experienced musculoskeletal radiologist who examined them for joint space narrowing, osteophytes, or subchondral cysts. Results and Discussion. Of the 48 patients who indicated pain about the ACJ on the body diagram, 38 (74%) were confirmed to have ACJ pathology based on their positive response to the injection. This suggests that the patient’s pain diagram is a good screening tool for ACJ pain. The clinical tests and imaging modalities were highly sensitive or highly specific, but not both. Each test was, by itself, relatively poor at predicting the ACJ as the cause of shoulder pain. The most sensitive tests were examination for acromioclavicular tenderness (96% sensitivity), the Paxinos test (79%), magnetic resonance imaging (85%), and bone
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scanning (82%), but these studies had low specificity. The tests that best identified patients without an ACJ abnormality as such were the O’Brien test and radiographs; each had a specificity of 90%. However, the Paxinos test and bone scan in combination was highly predictive for ACJ abnormality (likelihood ratio 55:1; p , 0.001). Thus, if a new patient who had mapped pain at the ACJ and radiating to the marked area had both a positive Paxinos test result and a positive bone scan result, the odds that that patient had ACJ pain as opposed to another type of shoulder pain would be 55:1. Similarly, if the patient had a negative result on both the Paxinos test and the bone scan, ACJ joint damage could be ruled out as the source of the pain. Other investigators have reported that radiographs and magnetic resonance imaging have poor specificity (i.e., degenerative changes of the ACJ do not correlate well with ACJ pain). These authors found that bone scans had relatively high sensitivity and specificity and therefore were more accurate in the diagnosis of ACJ pain. The O’Brien sign and the cross-arm adduction test may compress the ACJ indirectly and elicit pain by horizontal adduction of the arm or internal rotation of the shoulder. However, these test results can be positive in other shoulder disorders, such as posterior capsular tightness, or rotator cuff pathology. In contrast, the Paxinos test involves direct manual compression of the ACJ. It was found to be more sensitive than the O’Brien test for ACJ pain. The authors conclude that ‘‘direct compression of the ACJ (the Paxinos test) is a good clinical diagnostic tool, and bone-scanning is the best imaging modality for the diagnosis of ACJ pain. When both of these tests are positive in a patient with shoulder pain, the diagnosis of ACJ pain is virtually certain.’’
MARILYN P. LEE, MS, OTR/L, CHT Trowels Labeled Ergonomic versus Standard Design Preferences and Effects on Wrist Range of Motion during a Gardening Occupation. Tebben AB, Thomas
JJ. Am J Occup Ther. 2004;58:317– 23. Purpose. To test the hypothesis that extremes of deviation and palmar and dorsiflexion would be less with the use of a trowel labeled ‘‘ergonomic’’ than with a standard-design trowel. The hypothesis that participants would rate the trowel labeled ‘‘ergonomic’’ as more comfortable and easier to use was also tested. Background. Eighty-four percent of American households are involved in some form of gardening. Tools labeled ‘‘ergonomic’’ are readily available in the consumer market. A comprehensive definition of ergonomics, also known as human factors, exists, but there are no industry standards for use of the term. Human anatomy and biomechanics literature emphasizes the wrist-neutral posture when using the hands and hand tools. Tool should be designed to maintain a straight wrist. Only one study was found involving the ergonomic design of gardening tools. That study concerned hand-pruner use and preference in the older adult. Methods and Materials. Sixty-four right-dominant, female participants, aged 20–50 years, who reported no disease or disability in their preferred extremity, used both trowels to fill a flower pot with soil. This method eliminated variables due to aging, sex, and hand preference. The study used a repeated-measures counterbalance design. The ‘‘ergonomically-designed cushion grip handle’’ trowel by Hi-Point purchased at a local home improvement store was 35.5 cm long and weighed 333 g. The standard-design trowel manufactured by Ames Lawn and Garden Tools and purchased at a local garden center was 28 cm long and weighed 155 g. Participants were assigned through a computerized random number algorithm to one of two orders of trowel use and they were compared with themselves. A Penny & Giles Limited Goniometer XM65 (Elgon) was applied on the dorsum of each participant’s right wrist to measure wrist movement. The Elgon was calibrated with the elbow in 90 degrees of flexion and forearm and wrist in neutral. Participants stood at an adjustable height table that was adjusted to 15
ten treatments using a direct-current generator. Both hands of the patient were submerged in separate trays of room-temperature tap water with one electrode immersed in each tray. Treatments were 30 minutes of tap water galvanism at 12 mA and the polarity was reversed after the first 15 minutes of treatment. After treatment, the hands were dried with a towel, and then measured by taking a 5-second imprint of the left hand on a dry paper towel. The area of hyperhidrosis was determined by tracing the borders of saturation and recorded to the nearest millimeter. Outcomes. The area of hyperhidrosis was reduced from a 10.3 3 12.0-cm area to a 2.2- 3 2.7-cm area. The patient returned to full-time work two weeks after starting tap water galvanism. He wore two pairs of absorbent gloves compared with the six pairs that he wore before intervention. After ten treatments, he did not need to wear absorbent gloves at work. Treatment was concluded. Side effects included temporary erythema and a slight burning during the treatment session. A two-year telephone followup call with the patient revealed no long-term sweating patterns. Discussion. The choice of current and intervention used by the authors was based on reports in the literature that indicated that DC current minimized or abated hyperhidrosis, whereas AC current alone had no demonstrated intervention effect. The patient in this study had a significant decrease in sweating, and was a able to return to full time work as an electrician. Limitations of the study include accuracy of measurements, and uncertainty of not knowing the treatment effects of positive or negative polarity alone.
GREG HRITZO, MPT, CHT Diagnostic Values of Tests for Acromioclavicular Joint Pain: A Case Report. Walton J et al. J Bone Joint Surg Am. 2004;86A(4):807–12.
Purpose. Disorders that produce shoulder pain often have similar clinical symptoms, thus challenging the differential diagnosis. This prospective study was conducted to determine which clinical tests and imaging studies were most helpful for diagnosing acromioclavicular joint (ACJ) pain. Methods. Of 1,037 patients with shoulder pain, 113 who mapped pain about the ACJ (within an area bounded by the midpart of the clavicle and the deltoid insertion) were eligible for inclusion in the study. This area was chosen because it represents the site map for pain after provocative injection into the ACJ. Of 113 subjects, 38 agreed to participate in and completed the study. Twenty clinical tests, three imaging modalities, and ACJ diagnostic injection tests were performed on all subjects. The physical examination included inspection of the supraspinatus, infraspinatus and deltoid muscles for atrophy; tenderness at the sternoclavicular, acromioclavicular, subacromial and biceps regions; passive range of motion of the neck; passive range of motion of the shoulder in flexion, abduction, internal and external rotation; the Paxinos sign; the O’Brien sign; testing for impingement in internal and external rotation; strength testing in external rotation (supraspinatus resisted external rotation); and strength testing of internal rotation (lift off test for subscapularis). The Paxinos sign was performed with the patient seated and the affected arm dependent. The examiner placed his hand over the affected shoulder with his thumb under the posterolateral aspect of the acromion and the index and long fingers of the same or contralateral hand superior to the midpart of the ipsilateral clavicle. The examiner then applied pressure to the acromion with the thumb, in an anterosuperior direction, and inferiorly to the midpart of the clavicular shaft with the index
October–December 2004 427
and long fingers. The response was considered positive if pain was felt or increased in the region of the acromioclavicular joint and negative if there was no change in the pain level. The test for the O’Brien sign was designed primarily to detect labral tears, but it can also reproduce ACJ pain. The patient is asked to forward flex the affected arm 90 degrees with the elbow in full extension. The arm is then adducted 10 to 15 degrees medial to the sagittal plane and internally rotated so that the thumb points downward. The examiner applies uniform downward force to the arm. The maneuver is repeated in external rotation (palm up). The test result is positive if the first maneuver causes pain on top of the shoulder or at the ACJ, and the pain is less intense or is absent with the second maneuver. The reference test standard was the patient’s response to the ACJ injection, which consisted of lidocaine and methylprednisolone. The injection was performed under imaging control, by an experienced musculoskeletal radiologist who was masked to the patients’ clinical data. The initial examiner then evaluated patients. The test result was considered positive if the patient reported alleviation of the superior shoulder pain by at least 50% within 10 minutes after the injection (i.e., they were considered to have pain at the ACJ). Results of imaging studies (radiographs, magnetic resonance, and bone scans) of the ACJ were classified as abnormal or normal by an experienced musculoskeletal radiologist who examined them for joint space narrowing, osteophytes, or subchondral cysts. Results and Discussion. Of the 48 patients who indicated pain about the ACJ on the body diagram, 38 (74%) were confirmed to have ACJ pathology based on their positive response to the injection. This suggests that the patient’s pain diagram is a good screening tool for ACJ pain. The clinical tests and imaging modalities were highly sensitive or highly specific, but not both. Each test was, by itself, relatively poor at predicting the ACJ as the cause of shoulder pain. The most sensitive tests were examination for acromioclavicular tenderness (96% sensitivity), the Paxinos test (79%), magnetic resonance imaging (85%), and bone
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scanning (82%), but these studies had low specificity. The tests that best identified patients without an ACJ abnormality as such were the O’Brien test and radiographs; each had a specificity of 90%. However, the Paxinos test and bone scan in combination was highly predictive for ACJ abnormality (likelihood ratio 55:1; p , 0.001). Thus, if a new patient who had mapped pain at the ACJ and radiating to the marked area had both a positive Paxinos test result and a positive bone scan result, the odds that that patient had ACJ pain as opposed to another type of shoulder pain would be 55:1. Similarly, if the patient had a negative result on both the Paxinos test and the bone scan, ACJ joint damage could be ruled out as the source of the pain. Other investigators have reported that radiographs and magnetic resonance imaging have poor specificity (i.e., degenerative changes of the ACJ do not correlate well with ACJ pain). These authors found that bone scans had relatively high sensitivity and specificity and therefore were more accurate in the diagnosis of ACJ pain. The O’Brien sign and the cross-arm adduction test may compress the ACJ indirectly and elicit pain by horizontal adduction of the arm or internal rotation of the shoulder. However, these test results can be positive in other shoulder disorders, such as posterior capsular tightness, or rotator cuff pathology. In contrast, the Paxinos test involves direct manual compression of the ACJ. It was found to be more sensitive than the O’Brien test for ACJ pain. The authors conclude that ‘‘direct compression of the ACJ (the Paxinos test) is a good clinical diagnostic tool, and bone-scanning is the best imaging modality for the diagnosis of ACJ pain. When both of these tests are positive in a patient with shoulder pain, the diagnosis of ACJ pain is virtually certain.’’
MARILYN P. LEE, MS, OTR/L, CHT Trowels Labeled Ergonomic versus Standard Design Preferences and Effects on Wrist Range of Motion during a Gardening Occupation. Tebben AB, Thomas
JJ. Am J Occup Ther. 2004;58:317– 23. Purpose. To test the hypothesis that extremes of deviation and palmar and dorsiflexion would be less with the use of a trowel labeled ‘‘ergonomic’’ than with a standard-design trowel. The hypothesis that participants would rate the trowel labeled ‘‘ergonomic’’ as more comfortable and easier to use was also tested. Background. Eighty-four percent of American households are involved in some form of gardening. Tools labeled ‘‘ergonomic’’ are readily available in the consumer market. A comprehensive definition of ergonomics, also known as human factors, exists, but there are no industry standards for use of the term. Human anatomy and biomechanics literature emphasizes the wrist-neutral posture when using the hands and hand tools. Tool should be designed to maintain a straight wrist. Only one study was found involving the ergonomic design of gardening tools. That study concerned hand-pruner use and preference in the older adult. Methods and Materials. Sixty-four right-dominant, female participants, aged 20–50 years, who reported no disease or disability in their preferred extremity, used both trowels to fill a flower pot with soil. This method eliminated variables due to aging, sex, and hand preference. The study used a repeated-measures counterbalance design. The ‘‘ergonomically-designed cushion grip handle’’ trowel by Hi-Point purchased at a local home improvement store was 35.5 cm long and weighed 333 g. The standard-design trowel manufactured by Ames Lawn and Garden Tools and purchased at a local garden center was 28 cm long and weighed 155 g. Participants were assigned through a computerized random number algorithm to one of two orders of trowel use and they were compared with themselves. A Penny & Giles Limited Goniometer XM65 (Elgon) was applied on the dorsum of each participant’s right wrist to measure wrist movement. The Elgon was calibrated with the elbow in 90 degrees of flexion and forearm and wrist in neutral. Participants stood at an adjustable height table that was adjusted to 15