You are on page 1of 24

Journal of Hand Therapy

Read for Credit Presentation

(Day et al., 2014)

PNP: nociceptive symptoms that are a result


of a lesion or disease affecting the
somatosensory nervous system distal to the
cervical nerve roots (Treede et al., 2008)
Symptoms: burning, numbness, pain, tingling
Etiology: repetitive motion, micro-trauma, &
poor posture
(Day et al., 2014)

Evidence suggests that the proximal region of


the upper quarter needs to be included to
treat patients with non-radicular PNP
Proximal posture corrections and peri-scapular
strengthening were effective at reducing pain,
improving function, and facilitating return to work
in patients with thoracic outlet syndrome (Vanti et
al., 2007)
(Day et al., 2014)

Distal mobility has been shown to decrease when


the scapula is placed in a protracted position (Julius
et al., 2004)
Patients with mild to moderate CTS exhibit an
increase in forward head posture (De-La-LlaveRincn et al., 2009)

(Day et al., 2014)

To investigate the effectiveness of a


comprehensive treatment approach in
patients with non-radicular PNP

(Day et al., 2014)

Consecutive patients presenting to outpatient


clinic with non-surgical neurological
complaints in UE

36 enrolled (2 dropped out; 2 excluded)


21-71 yrs old (mean age 44+/- 11 years)
Symptom duration 2 wks to 2 yrs
Bilateral involvement (47% of patients; only right
side measurements were used for these patients)

(Day et al., 2014)

Primary compliant of unilateral/bilateral


neurological symptoms in UE
Between ages of 18-75

Presented with any positive upper-limb


neurodynamic test (ULNT) that was exacerbated
with a proximal maneuver
Median, ulnar, and radial
Performed in seated position
Positive if reproduced neurological symptoms

(Day et al., 2014)

Demonstrating at least 2 signs consistent with


cervical radiculopathy
Spurling A
Cervical distraction
Cervical AROM in sitting

Patient reported history of:

Diabetes
Peripheral neuropathy
Progressive neurological disorders
Cancer
Upper motor neurologic disorder
Surgery in last 6 months
Significant hand deformation due to nerve damage

(Day et al., 2014)

Numeric Pain Rating Scale (NPRS)

QuickDASH

Secondary Outcomes

Based on worst, current, and best


Mean was used for statistical analysis
Minimal detectable change 2 points
Minimal difference: decrease of 11 points
Grip Strength

Elbow flexed at 90 degrees


3 trials

Collected at IE, 4th visit, and Discharge


Primary outcomes attempted at 3 and 6 months
post-discharge by phone

(Day et al., 2014)

Approach addressed 5 components


Postural education

Verbal & written

Scapular stabilization
Neural gliding
Proximal manual therapy
Distal stretching

(Day et al., 2014)

Sleeping Posture

Sitting Posture

Verbally Position to avoid

Patients with signs and symptoms of

Supported side-lying position with pillows or towel rolls


Elbows bent at 90 degrees by side, wrists in neutral
position, feet rested on floor

Elbow flexion > 90 degrees, non-neutral wrist


Carpal Tunnel Syndrome issued a custom wrist orthosis
fitted in neutral wrist position
Cubital Tunnel Syndrome issued Helbo Elbow Protector
Frequency and duration schedule determined by treating
therapist.

(Day et al., 2014)

Patient given at least one clinic AND one


home exercise to address:
Anterior musculature (serratus anterior)
Posterior musculature (rhomboids and trapezius)

3 phase progression
Progressing from low to high electromyograhical
activity
Short to long lever arm to challenge patients
(Day et al., 2014)

Phase One: Neuromuscular Education

Facilitate scapular motor control for all patients

Phase Two: Short Lever Arm Resistance

Demonstrate ability to isolate scapular retraction


and sternal lift with correct head posture 20 times,
held for 5 seconds each
Progress when able to perform a single arm row for
20 repetitions with a set load of 10 lbs
without substitution, support and without aggravating
symptoms

(Day et al., 2014)

Phase 3: Long Level Arm Resistance


Patient performs each exercise for 3 sets of 10
Resistance was added when patient no longer
reported 24 hr post onset muscle soreness OR
Pain did not go up more than 1 level on NPRS

(Day et al., 2014)

Prescribed at least 1 glide according to


identified deficits
Purpose: to mobilize the peripheral nervous
system
Goals: to reduce symptoms and improve function

3 Phases

Supine
Sitting
Standing
Progressed when able to demonstrate 30 nerve
glides w/o reproducing symptoms
(Day et al., 2014)

Stretching included patient flexibility and


manual therapy
Held for 30 seconds, 3-5 repetitions

Manual therapy techniques included:

proximal and distal STM


cervical mobilizations (grades 1-4)
Thrust and non-trust thoracic mobilizations

(Day et al., 2014)

Mean number of visits until discharge


9.5 +/- 5 visits

Mean follow-up period


5 +/- 2 months

QuickDASH improvement

Baseline to visit 4: mean change of 11 pts


Visit 4 to discharge: mean change of 11

Mean Pain

Baseline to visit 4: significant improvement

Grip Strength: no change when controlled for


gender and hand dominance
(Day et al., 2014)

Comprehensive treatment appears to have


lasting benefits for patients

No significant differences in pain and disability


scores from discharge to follow-up (ave: 5 months)

A similar patient may expect an average of 10


PT/OT visits at 2x/wk for one month
Lack of significant change in grip strength
May not have been severely impaired at baseline
Not adequately powered for grip strength analysis

3 patients did worsened or did not report


change

(Day et al., 2014)

Bias

therapist that enrolled patients also treated


Follow-up data collected on 20/32 available,
possible selection bias
Of those, 4/20 were potentially confounded by
follow-up treatment

CTR (2), cortisone injection (1), massage therapy (1)

Reliability of the neurodynamic test for UE


has only been established for supine position
No cause and effect; no control group or
alternative treatment group
(Day et al., 2014)

Compare a comprehensive treatment


proposed with control group and/or
traditional treatment
Perform specific studies with specific PNP
CTS, TOS, CUTS

(Day et al., 2014)

1.

Patients with cervical radiculopathy


a)
b)
c)
d)

2.

Comprised 50% of the subject population


Were not included in the subject population
Were blended in with the carpal tunnel subjects
Were blended in with the cubital tunnel subjects

Outcome measures included


a)
b)
c)
d)

Grip and the Purdue Peg Board


The DASH and the Sollerman functional scale
Endurance and comfort levels
A modified DASH and pain
(Day et al., 2014)

3.

a)
b)
c)
d)
4.

The primary inclusionary criterion was a


positive
Phalens
Cubital tension test
ULNT
Tinels

Five interventions were utilized. Of the five

a) All were equally effective


b) No one intervention can be said to be the most
effective
c) Neural gliding was the most effective
d) Neural gliding was the least effective

(Day et al., 2014)

5.

One strength of the study was the inclusion


of a control group
a) False
b) True

jhtreadforcreadit.com
Article # 311

(Day et al., 2014)

Day, J. M., Willoughby, J., Pitts, D. G., McCallum, M., Foister, R., &
Uhl, T. L. (2014). Outcomes following the conservative
management of patients with non-radicular peripheral
neuropathic pain. Journal of Hand Therapy.
De-La-Llave-Rincn, A. I., Fernndez-De-Las-Peas, C., PalaciosCea, D., & Cleland, J. A. (2009). Increased forward head
posture and restricted cervical range of motion in patients
with carpal tunnel syndrome. Journal of Orthopedic &
Sports Physical Therapy, 39(9), 658-664.
Julius, A., Lees, R., Dilley, A., & Lynn, B. (2004). Shoulder posture
median nerve sliding. BMC Musculoskeletal Disorders, 5(1),
23.
Treede, R. D., Jensen, T. S., Campbell, J. N., Cruccu, G., Dostrovsky,
J. O., Griffin, J. W., & Serra, J. (2008). Neuropathic pain
redefinition and a grading system for clinical and research
purposes. Neurology, 70(18), 1630-1635.
Vanti, C., Natalini, L., Romeo, A., Tosarelli, D., & Pillastrini, P.
(2006). Conservative treatment of thoracic outlet
syndrome. Europa Medicophysica,42

You might also like