Can the measure of grip strength serve as an indicator of an individual's ability to use his or her hands in activities of daily living? This is the topic explored in this brief, yet engaging article ...from the
British Journal of Hand Therapy. The authors investigate the important issues involved in measuring grip strength and examine its usefulness to us as clinicians.
Instruments used in the measurement of grip strength and the correct protocols for doing so are discussed. Adapted sphygmomanometers are still used in several departments, but this measures grip pressure, which is not as reliable a measure as force to record grip. The ASHT recommends use of the Jamar dynamometer because of its well-documented reliability and validity. This instrument may be difficult to grasp for individuals with weakness in their hands. The scale may not pick up small changes in strength as well. There are newer, more sensitive tools that measure grip in newtons. This makes it easier to record small changes between trials. The authors suggest frequent recalibration of instruments to ensure their accuracy.
The mean value from three grip strength recordings should be used as suggested by the literature. The patient's positioning is standardized with the shoulder adducted, elbow flexed to 90°, the forearm in neutral, the wrist in 0–30° of extension, and 0–15° of ulnar deviation. The authors briefly discuss the issue of submaximal (feigned) effort and conclude that the amount of variation between trials may in itself not be a good and reliable indicator of submaximal effort. We often compare our patients' grip strengths with normative data. But we need to be confident that the norms we use are applicable to our patient population. Hand function has been described as the ability to use the hand to perform daily tasks. Hand function includes range of motion, sensation, coordination, dexterity, fine motor skills, as well as grip. So what does grip strength actually tell the clinician about hand function?
The authors review the research concerning grip strength and hand function and divide the studies into three categories according to the research methods used:
1.
Studies that compare participants' grip strength with performance on a particular activity of daily living.
2.
Studies that compare grip strength with performance on a series of tasks resulting in an overall score.
3.
Studies that compare grip strength with participants' subjective evaluations of their ability to complete daily living tasks.
Comparing grip strength with performance on an activity of daily living: One study explored the relationship between grip strength and a person's ability to open six different containers. Grip strength for each individual was recorded, and his or her ability to open the containers was noted. In a study of college students, greater grip strength did not correlate with better performance at opening containers. The study was repeated with older participants, and a fair correlation was established between power grip and the ability to open two of six containers. This suggests that reduced grip strength may lead to difficulties with opening everyday containers.
Comparing grip strength with performance on a series of tasks resulting in an overall score: Several studies have been conducted on small samples comparing grip strength with overall upper extremity performance. Hand function as measured by the Jebsen Hand Function Test and the Purdue Pegboard Test was compared with Jamar dynamometer grip strength recordings. Moderate to weak correlations have been reported on a variety of patient populations. Due to small sample sizes, the information may not be generalized to other populations.
Comparing grip strength with participants' subjective evaluations of their ability to complete daily living tasks: The authors mention several studies that compared grip strength measurements with patients' subjective evaluation of their ability to perform activities of daily living. The subjective evaluations used included the self-report Health Assessment Questionnaire, the Disabilities of the Arm, Shoulder and Hand Outcome Questionnaire (DASH questionnaire), and the Michigan Hand Outcome Questionnaire. The studies varied in their use of grip strength–measuring instruments. All studies had small sample sizes and were patient-diagnosis specific. In general, a range of correlations was found between grip strength and functional outcomes as measured by patient self-report assessments.
The authors report on newer research comparing dynamic grip strength with static grip strength and raise the question of which more accurately represents the force used in hand function. But here the instrument used to measure grip strength was designed specifically for the research and has not yet appeared in the clinic.
In summary, the authors raise important questions concerning our measurements of grip strength and how we use this information. Further studies are required to provide knowledge regarding the usefulness of grip strength as an overall indicator of hand function.
The authors present modifications to a previously described skeletal traction device used to treat fracture dislocations of the proximal interphalangeal (PIP) joint. Their design improves the ...stability of the fixation and provides satisfactory functional results. Their report is based on a sample of six patients with fracture dislocations of the PIP joint.
Fracture dislocations of the PIP joint are common injuries. Without proper treatment, pain, stiffness, and posttraumatic arthritis often occur. Dorsal dislocations are more common than volar dislocations and are often seen in ball-handling athletes. Treatment for these fracture dislocations is either nonsurgical or surgical, depending on the severity of the comminution and the stability of the PIP joint. Surgical treatment is required when the fracture is unstable and/or when there is significant fragment displacement.
There are many surgical treatment techniques described: closed reduction and percutaneous pinning, dorsal extension block pinning, open reduction and internal fixation, and traction fixation. Early mobilization of the PIP joint along with traction and stable fixation offers the most favorable functional outcomes. Gaul and Rosenberg devised a simple frame that provided traction without rubber bands or complicated connecting pieces. The authors introduce their own modification to the frame created by Gaul and Rosenberg and describe its use in six patients with fracture dislocation of the PIP joint.
The authors treated six patients (four male, two female) who sustained fracture dislocations of the PIP joint with a dynamic external fixator. Fracture dislocation was caused by crush injury in all patients, and the fractures were all closed. The average age of the patients was 27 years (range 21–42
yr). The middle finger was involved in three patients, the little finger in two patients, and the ring finger in one patient. The average follow-up period was 24 months (7–43
mo).
Digital block anesthesia is administered, and a 1.4-mm K wire (K1) is placed transversely through the center of the head of the proximal phalanx under fluoroscopy. Another K wire (K2) is driven through the head of the middle phalanx. The K1 wire actually protrudes out on each side of the PIP joint and is bent at a 90° angle there so that the ends lay parallel and 1
cm away from the middle phalanx. The original description by Gaul and Rosenberg outlined a volar direction and longer lever arm of this K1 wire. The modifications by the author ensure a traction force parallel to the middle phalanx that will not lead to a loss of distraction force over time. The K1 wire is bent to 90° again at the level of the base of the distal phalanx where it loops into and hooks around the K2 wire. This is how the traction force is applied and maintained. The amount of distraction of the joint space is then evaluated and confirmed by x-ray. Open reduction is only necessary when articular fragments remain displaced. Fluroscopy is used to monitor flexion and extension of the PIP joint with the external fixator in place. Soft, minimally bulky dressings are applied for the first postoperative day. But immediate active PIP joint motion, supervised by a hand therapist, is initiated on the following day. The fixator provides traction and maintains joint space while allowing for active motion. It remains in place for three to four weeks.
The average range of motion of the PIP joint at the follow-up evaluation was 5–89° (range 0–100°). The average range of motion of the distal interphalangeal joint (DIP) was 2–80° (range 0–90°). At final evaluation, no instability of the PIP joint was noted.
The authors include the case report of a 21-year-old male who sustained an intra-articular fracture dislocation of the PIP joint of the right little finger. The external fixator described here was placed on his involved finger. Hand therapy was initiated, and active motion exercises were introduced immediately. The fixator was removed after three weeks, and therapy continued until full motion was achieved. The patient demonstrated 5–90° of extension–flexion at the PIP joint and 0–75° of motion at the DIP joint at follow-up evaluation.
The authors maintain that early mobilization of the PIP joint after fracture dislocation is critical to avoid stiffness and permanent ankylosis. The literature describes many techniques for this including Inanami's dynamic external fixator and the compass hinge as reported by Bain et al. and others. However, many complications (infection and breakage) have been reported with these devices. Other methods utilize rubber bands for traction, which the authors maintain, are susceptible to plastic deformation and/or deforming forces.
The authors recommend their procedure as the best method for treatment of fracture dislocation of the PIP joint because it is an easy to apply, inexpensive, and time-efficient procedure, without major complications for the patient.
As hand therapists treating difficult PIP joint injuries, we understand the benefits of early mobilization. The external device described maintains the PIP joint space and allows for early flexion and extension motion. It is held in place for a relatively short time, only three to four weeks. This is important information because the external pin protrusion makes full fist making and tendon gliding exercises difficult. No description of pin site care is offered (two patients developed pin tract infection and were treated with oral antibiotics). Information regarding protective splinting and positioning for in-between exercise sessions and at night is lacking. Despite the satisfactory functional outcomes reported, the small sample size of six patients is a limitation of this study as well.
Obesity, a major risk factor for cardiometabolic disease, is associated with lower cognitive performance from childhood to senescence, especially on tasks of executive function. In the cardiovascular ...domain, fat stored viscerally rather than elsewhere in the body carries particularly high risk. It is unknown whether this is also true in case of obesity-cognition relationships. The aim of this study was to assess the cross-sectional relationship between visceral fat (VF) and cognitive performance in a community sample of healthy adolescents.
In a community-based sample of 983 adolescents (12-18 years old, 480 males), VF was quantified using magnetic resonance imaging, total body fat was measured using a multifrequency bioimpedance, and cognitive performance was assessed using a battery of cognitive tests measuring executive function and memory.
We found that larger volumes of VF were associated with lower performance on six measures of executive function (P=0.0001-0.02). We also found that the association of VF with executive function was moderated by sex for a subset of measures, such that relationship was present mainly in female subjects and not in male subjects (sex-by-VF interaction: P=0.001-0.04). These relationships were independent of the quantity of total body fat and a number of potential confounders, including age, puberty stage and household income.
Our results suggest that the adverse association between obesity and executive function may be attributed to fat stored viscerally and not to fat stored elsewhere in the body. They also suggest that female subjects compared with male subjects may be more sensitive to the potentially detrimental effects of VF on cognition.
Purpose: The authors of this article present a study which examines the benefits of Carpal Tunnel Release surgery in patients 65 years of age or older. A common misconception among referring ...physicians holds that elderly patients have a poorer recovery after peripheral nerve injury and repair than younger patients, and that nerve conduction velocities naturally decrease with age. Therefore, their attitude and reluctance to send patients to hand surgeons suggest the belief that CTR surgery is less effective in the older population.
Carpal Tunnel Syndrome (CTS) is a compression neuropathy of the median nerve at the wrist. Some studies suggest that CTS may be more prevalent and more severe in the elderly. The authors conducted a prospective study of patients 65 years of age or older who were seeking surgical release for treatment of CTS. These patients were evaluated before and after surgery to determine the benefits of the procedure for the older population.
Method: Seventy-five patients and a total of 105 hands were enrolled in the study. The average age of participants was 75 years of age. Patients were evaluated prior to surgery and again at six months after surgery. Thirty-one men and 35 women completed the 6-month follow up evaluation. Ninety-four percent of the patients were right handed. Fifty-nine percent of the patients had bilateral symptoms. The median duration of symptoms was 24 months (range 2–180 months). The evaluation consisted of a detailed history of hand dominance and symptoms including paresthesias, nocturnal symptoms, and subjective weakness. The physical examination included Tinel's sign, Phalen's sign, median nerve compression test, 2-pt discrimination, grip and pinch strength measurements and thenar wasting. CHTs performed quantitative sensory testing using a pressure-sensing device (Pressure Specified Sensory Device, Sensory Measurement Services, LLC, Baltimore, MD). This allowed for standardized grip and pinch strength measurements and static 2-pt discrimination testing.
The Michigan Hand Outcomes Questionnaire (MHQ) was used to assess clinical outcomes. The MHQ evaluates overall hand function, activities of daily living (ADL's), work performance, pain, aesthetics and satisfaction with hand function. It is an internally consistent and validated measurement for patients following hand surgery.
Prior to surgery, patients were asked to rate paresthesias, numbness, day pain, night pain and nocturnal weakness on a scale of 1–5 (none, mild, moderate, severe, very severe).
Results: After surgery, patient symptoms of paresthesias, numbness, day pain, night pain and nocturnal weakness were significantly decreased in severity with a p value of less than .0001. Sixty-three percent of patients had complete relief of all symptoms. Tinel's sign and Phalen's sign were significantly decreased after surgery. Grip strength increased slightly while pinch strength increased significantly from pre and post surgical measures (p < .02). Even thenar wasting, noted in 44% of the patients prior to surgery, decreased to 29% after surgery (p < .01). The 6 scales of the MHQ (overall hand function, activities of daily living, work performance, aesthetics, satisfaction with hand function and pain) all showed significant improvement after surgery with a p value of less than .0001.
Discussion: In recognition of the fact that CTS is common among the elderly, and that their symptoms are often more severe than in the general public, CTR should be considered a viable course of treatment for this population. This study demonstrates the benefits of surgical interventions in terms of improved physical findings and most importantly, improved clinical outcomes. Despite long duration of symptoms in this elderly population, pre-operative symptoms decreased significantly. Overall, 83% of the patients were either completely satisfied or very satisfied with their surgical outcome.
Abstract
Disclosure: S. Yuksel: None. R. Lopez Fanas: None. D. Schwartz: None. V. Tabatabaie: None. S. Sachdev: None.
Introduction: Adult T-cell leukemia/lymphoma (ATLL) is a rare, aggressive ...lymphoproliferative disorder associated with human T-cell leukemia virus type 1 (HTLV-1), often presenting with severe refractory hypercalcemia. Here, we present a rare case of bisphosphonate-resistant ATLL-associated hypercalcemia successfully treated with denosumab (Dmab). Clinical Case: A 47-year-old woman from Jamaica presented with pruritic rash of left forearm and bilateral lower extremity (LE) pain for 6 weeks. Laboratory evaluation noted serum Ca of 16.2 mg/dL (n 9-11), PTH 12.5 pg/mL (n 16-65), PTHrP 24 pg/mL (n 11-20) and 25(OH)D 16 ng/mL (n 30-60). 1,25(OH)2D level was normal. Cr was 1.5 mg/dL (n 0.7-1.2). X-rays demonstrated punctate lytic lesions throughout LEs. The patient received IV fluids, calcitonin, pamidronate 60 mg IV, and ergocalciferol 50,000 IU. Corrected Ca (cCa) improved to 9.3 mg/dL. However, hypercalcemia recurred after 2 days. HTLV-1 serology was positive. Flow cytometry and bone marrow biopsy were consistent with ATLL. When Ca rose to 14.3 mg/dL, Dmab 60 mg SC was administered. Within 1 week, she developed asymptomatic hypocalcemia with cCa of 7.1 mg/dL requiring oral calcium citrate and calcitriol. Stable normocalcemia was achieved after 10 days. Hospital course was complicated by pathologic right wrist fracture. Palliative radiation to LE was initiated. She was discharged on calcium citrate 2850 mg TID, calcitriol 0.25 mcg BID and ergocalciferol 50,000 IU weekly. The patient was treated with 6 cycles of etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin, and rituximab, as well as intrathecal methotrexate for CNS prophylaxis. She received 120 mg of Dmab 6 months after the first dose. Ca remained stable. Conclusion: ATLL-associated hypercalcemia is mediated by increased secretion of PTHrP, and RANK ligand and proinflammatory cytokines that promote RANK expression. Dmab is an effective treatment for ATLL-associated hypercalcemia as it specifically targets RANK ligand. A dose of 120 mg Dmab is recommended for patients with bisphosphonate-resistant hypercalcemia of malignancy and GFR greater than 30 mL/min. In another published case report on the use of Dmab in ATLL-associated hypercalcemia, treatment with Dmab 120 mg SC resulted in protracted hypocalcemia lasting 5 months despite calcium carbonate and Vitamin D supplements (1). Our patient had a significantly shorter hypocalcemia course likely due to reduced Dmab dose and more aggressive proactive treatment with ergocalciferol, calcium citrate and calcitriol. This case supports the successful use of Dmab in bisphosphonate-resistant ATLL-associated hypercalcemia. Protracted Dmab-induced hypocalcemia may be mitigated by Dmab dose reduction even in the presence of normal GFR and early aggressive treatment with calcium citrate and calcitriol. Reference: (1) Japp et al. AACE Clin Case Rep.2019;5:e210-213
Presentation: Saturday, June 17, 2023
Abstract In the normal course of practice, rehabilitation professionals are not typically provided with x-rays or radiology reports. Hand therapists who obtain x-rays or reports will glean valuable ...information about the patient that might otherwise go unidentified. Unique details discovered from an x-ray can contribute to improved clinical treatment plans and functional outcomes. Radiography is the general term used to describe the commonly known imaging procedures of x-ray and fluoroscopy. The purposes of this article are to provide the reader with an overview of basic radiography terminology and provide information to help better understand the typical positions and views used in upper extremity radiography. With this knowledge, guidelines for reviewing x-rays will be presented and several examples of bony pathology revealed by x-rays will be presented along with several case studies.
Israel is a vastly multi-cultural society with various religious affiliations, secularism, ethnicities, cultures, and social-economic groups. The task of developing and implementing a nationalized ...education curriculum for these various sectors and cultures is a complex task which incorporates many protocols and involves various stakeholders who motivate and influence the whole process. As English is an international language, it is a compulsory subject in Israeli schools from 3rd-12th grades, and a great deal of emphasis is placed on the Israel English curriculum in schools; however, each school may have different methods of implementing the national English curriculum and will therefore lead to different outcomes. The English Matriculation Exam (Bagrut), is a national standardized exam for high school students which has the goal of determining the achievements of students in their English language skills. Data on the success of the Arab and the Jewish population (success in matriculation exams and tests of Indicators of Efficiency and School Growth- IESG) that are published annually by the Ministry of Education reveal a significant gap between the scores in English among the Arab population and the Jewish population. School principals are responsible for ensuring the management of the school and the success of their students' educational achievements. Their management style highly impacts the pedagogical methods and activities which are integral to leading their students to achieving higher scores on standardized tests and superior school rankings according to the Ministry of Education. There are various styles of school managerial leadership which may be linked to cultural norms and lead to various outcomes in achievement. How do cultural differences and methods of management in schools affect the results of Israeli high school English matriculation exams and students' general English skills?
Small renal masses (SRMs) are often incidentally diagnosed, and a large proportion are malignant. However, there is a paucity of data describing predictors of malignancy in minority patients with ...SRMs. Thus, our goal was to examine clinical risk factors associated with SRM malignant histology in patients undergoing partial nephrectomy (PN) a diverse, urban academic center.
Patients with a SRM undergoing PN at a single institution between 2010 to 2018 were reviewed. Demographic, clinical, and imaging characteristics were compared to pathology results. Logistic regression was used to examine associations between demographic/clinical variables for malignant and high-grade histology.
In total, 331 patients who underwent PN for SRM were included. Of those, 264 (79.8%) had malignant histology while 67 (20.2%) had benign histology. The proportions of men and of current smokers were significantly higher among patients with malignant histology. In multivariate models, non-Hispanic Black (NHB) patients had increased odds of having malignant histology (OR 2.46, 95% CI: 1.01-5.99, P = .048) and current smokers (OR = 4.02; 95% CI 1.14-14.18, P = .031). Hispanic patients had a 3-fold increased risk of high-grade RCC (OR 3.06, 95% CI: 1.19-7.87, P = 0.02) compared to Non-Hispanic White patients.
In our population, male sex, smoking, and NHB race/ethnicity was associated with an increased risk of malignancy in patients undergoing partial nephrectomy for SRM. Older age and Hispanic race/ethnicity were associated with high grade RCC. Our results suggest that urologists should exercise a higher level of vigilance in managing and treating SRM among NHB and Hispanic patients.
Incidentally diagnosed small renal masses (SRM) may or may not represent kidney malignancy. Therefore, risk factors for likelihood of malignancy are needed. We reviewed 331 patients who underwent partial nephrectomy for SRM. We found that non-Hispanic Black (NHB) patients had an increased odds of having malignant SRM compared to non-Hispanic White patients. Therefore, Urologists should exercise increased caution in managing SRM among NHB patients.
Frequently when one sustains an injury to a digit, multiple soft tissue structures can be involved. As a result, the MCP, PIP, and DIP joints can be affected, thus limiting the ability to fully flex ...the finger. As hand therapists, one of our primary goals is to improve functional grasp/grip. These authors have designed a single-digit, composite flexion splint to help achieve this goal.—
P
eggy F
illion, OTR, CHT,
Practice Forum Editor
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