Early post-immobilization pain at rest, movement evoked pain, and their ratio as potential predictors of pain and disability at six- and 12-months after distal radius fracture

Background: Removal of immobilization is a critical phase of distal radius fracture (DRF) rehabilitation, typically occurring by 2 months post injury. This study examined the extent to which pain at rest (PAR), movement evoked pain (MEP), or the ratio between those (MEPR) assessed at 2-months after DRF predicts the occurrence of chronic pain or disability at 6- and 12-months after the injury. Methods: This secondary analysis of a prospective cohort study was done at the Hand and Upper Limb Centre (HULC), London, Ontario, Canada. A total of 229 patients with DRF (159 (69.4%) women) were included. Scores for the pain and function subscales of the Patient-Rated Wrist Evaluation (PRWE) were extracted for 2, 6 and 12 months after DRF. Logistic as well as nonlinear quartile regression examined whether PAR and MEP predicted the severity of chronic pain and disability at 6- and 12-months after DRF. Receiver Operating Characteristics Curve were plotted, where area under the curve (AUC) examined the accuracy of the PAR and MEP scores in classifying those who experienced chronic pain and disability. Results: Scores of ≥3 (AUC of 0.77) for PAR or ≥ 6 (AUC of 0.78) for MEP at 2 months after DRF predicted moderate to severe wrist pain at 6-months, whereas scores of ≥7 (AUC of 0.79) for MEP at 2-months predicted ongoing wrist disability at 6-months after the injury. The MEPR of 2 ≤ or ≥ 8 at 2-months was associated with adverse pain at 6-months and functional outcomes at 6- and 12-months (R-square = 0.7 and 0.04 respectively), but prediction accuracy was very poor (AUC ≤ 0.50). Conclusion: Chronic wrist-related pain at 6-months can be predicted by either elevated PAR ≥ 3/10) or MEP (≥ 6/10) reported at 2-months after the injury, while disability experienced at 6-months after DRF is best predicted by MEP (≥7/10) reported at 2-months. The ratio of these two pain indicators increases assessment complexity and reduces classification accuracy

Rasch analysis of the Patient Rated Elbow Evaluation questionnaire

© 2015 Vincent et al. Background: The Patient Rated Elbow Evaluation (PREE) was developed as an elbow joint specific measure of pain and disability and validated with classical psychometric methods. More recently, Rasch analysis has contributed new methods for analyzing the clinical measurement properties of self-report outcome measures. The objective of the study was to determine aspects of validity of the PREE using the Rasch model to assess the overall fit of the PREE data, the response scaling, individual item fit, differential item functioning (DIF), local dependency, unidimensionality and person separation index (PSI). Methods: A convenience sample of 236 patients (Age range 21-79 years; M: F- 97:139) with elbow disorders were recruited from the Roth|McFarlane Hand and Upper Limb Centre, London, Ontario, Canada. The baseline scores of the PREE were used. Rasch analysis was conducted using RUMM 2030 software on the 3 sub scales of the PREE separately. Results: The 3 sub scales showed misfit initially with disordered thresholds on17 out of 20 items), uniform DIF was observed for two items ( Carrying a 10lbs object from specific activities subscale for age group; and household work from the usual activities subscale for gender); multidimensionality and local dependency. The Pain subscale satisfied Rasch expectations when item 2 Pain - At rest was split for age group, while the usual activities subscale readily stood up to Rasch requirements when the item 2 household work was split for gender. The specific activities subscale demonstrated fit to the Rasch model when sub test analysis accounted for local dependency. All three subscales of the PREE were well targeted and had high reliability (PSI \u3e0.80). Conclusion: The three subscales of the PREE appear to be robust when tested against the Rasch model when subject to a few alterations. The value of changing the 0-10 format is questionable given its widespread use; further Rasch-based analysis of whether these findings are stable in other samples is warranted

Short-term sensory and cutaneous vascular responses to therapeutic ultrasound in the forearms of healthy volunteers

© 2014 Shaik et al. Background: Therapeutic ultrasound (US) is used for a variety of clinical pathologies and is thought to accelerate tissue repair and help with pain reduction via its thermal and nonthermal effects. The evidence on physiological effects of US on both sensory and vascular functions in humans is incomplete. Hence, the purpose of this study was to determine the short-term impact of two doses of US (3 MHz, 1:4, 0.25 W/cm2, 5 min; 1 MHz, continuous, 0.8 W/cm2, 3 min), on sensory and vascular responses in the healthy forearms. Methods: Twenty healthy subjects were recruited (mean age, 29.6 ± 8.8 years) for the study. Superficial blood flow (SBF) in the distal forearms was determined using the tissue viability imaging system. Sensory perception thresholds (SPT) were determined from ring finger (C7, C8) to assess A-beta (at 2,000 Hz) and C fiber function (at 5 Hz), using a Neurometer CPT/C device. Subject\u27s two hands were randomly allocated to group order (AB/BA). Scores were obtained before and immediately after the application of US and control. Differences in these were analyzed using repeated measures. Results: Both 3 MHz pulsed US and 1 MHz continuous US showed small to moderate (effect size = 0.12 to 0.68), statistically significant reductions in SBF (3 MHz, mean change = 2.8 AU and 1 MHz, mean change = 3.9 AU, p \u3c 0.05 respectively), skin temperature (2.5°C and 1.1°C, p \u3c 0.05), and SPT at 5 Hz (1.3 and 1 mA, p \u3c 0.05) across time. SPT at 2,000 Hz remained unaltered by all three conditions (p \u3e 0.05). Age and gender also had no effect on all outcome measures (p \u3e 0.05). Conclusion: This study demonstrated minor reductions in skin blood flow, skin temperatures, and C fiber perception thresholds immediately after 3 MHz, and 1 MHz US. The responses observed may have been due to a thermo-cooling effect of the gel or due to the direct effect of US on C fibers ofmedian and ulnar nerves. US had a negligible effect on A-beta fibres. This would suggest that future studies looking at physiological effects of US should move towards investigating larger dosages and study the effects in patient populations

A comparison of two headless compression screws for operative treatment of scaphoid fractures

<p>Abstract</p> <p>Purpose</p> <p>The purpose of this study was to compare the interfragmentary compression force across a simulated scaphoid fracture by two commonly used compression screw systems; the Acutrak 2 Standard and the 3.0 mm Synthes headless compression screw.</p> <p>Methods</p> <p>Sixteen (8 pairs; 6 female, 2 male) cadaver scaphoids were randomly assigned to receive either the Acutrak 2 or Synthes screw with the contralateral scaphoid designated to receive the opposite. Guide wires were inserted under fluoroscopic control. Following transverse osteotomy, the distal and proximal fragments were placed on either side of a custom load cell, to measure interfragmentary compression. Screws were placed under fluoroscopic control using the manufacturer's recommended surgical technique. Compressive forces were measured during screw insertion. Recording continued for an additional 60s in order to measure any loss of compression after installation was complete. The peak and final interfragmentary compression were recorded and paired t-tests performed.</p> <p>Results</p> <p>The mean peak compression generated by the Acutrak 2 Standard was greater than that produced by the Synthes compression screw (103.9 ± 33.2 N vs. 88.7 ± 38.6 N respectively, p = 0.13). The mean final interfragmentary compression generated by the Acutrak 2 screw (68.6 ± 36.4 N) was significantly greater (p = 0.04) than the Synthes screw (37.2 ± 26.8 N). Specimens typically reached a steady state of compression by 120-150s after final tightening.</p> <p>Conclusion</p> <p>Peak interfragmentary compression observed during screw installation was similar for both screw systems. However, the mean interfragmentary compression generated by the Acutrak 2 Standard was significantly greater. Our study demonstrates that the Synthes headless compression screw experienced a greater loss of interfragmentary compressive force from the time of installation to the final steady state compression level. The higher post-installation compression of the Acutrak 2 Standard may be attributable to the greater number of threads throughout the entire length of the screw. The clinical significance of these results, are, at this point uncertain. We do demonstrate that a fully threaded design offers a more reliable compression that may translate to more predictable bony union.</p

Social Support Contributes to Outcomes following Distal Radius Fractures

Background. Distal radius fractures are the most common fracture of the upper extremity and cause variable disability. This study examined the role of social support in patient-reported pain and disability at one year following distal radius fracture. Methods. The Medical Outcomes Study Social Support Survey was administered to a prospective cohort of 291 subjects with distal radius fractures at their baseline visit. Pearson correlations and stepwise linear regression models (F-to-remove 0.10) were used to identify whether social support contributes to wrist fracture outcomes. The primary outcome of pain and disability at one year was measured using the Patient Rated Wrist Evaluation. Results. Most injuries were low energy (67.5%) and were treated nonoperatively (71.9%). Pearson correlation analysis revealed that higher reported social support correlated with improved Patient Rated Wrist Evaluation scores at 1 year, r(n = 181) = −0.22, P < 0.05. Of the subscales within the Social Support Survey, emotional/informational support explained a significant proportion of the variance in 1-year Patient Rated Wrist Evaluation scores, R (2) = 4.7%, F (1, 181) = 9.98, P < 0.05. Conclusion. Lower emotional/informational social support at the time of distal radius fracture contributes a small but significant percentage to patient-reported pain and disability outcomes

Evaluation of the content validity index of the Australian/Canadian osteoarthritis hand index, the patient-rated wrist/hand evaluation and the thumb disability exam in people with hand arthritis

© 2020 The Author(s). Background: The Australian/Canadian Osteoarthritis Hand Index (AUSCAN), the Patient-Rated Wrist/Hand Evaluation (PRWHE) and the Thumb Disability Exam (TDX) are patient-reported outcome measures (PROM) designed to assess pain and hand function in patients with hand arthritis, hand pain and disability, or thumb pathology respectively. This study evaluated the content validity of AUSCAN, PRWHE and TDX in people with hand arthritis. Methods: This study enrolled participants with hand arthritis to rate the items of all 3 PROM in terms of relevance and clarity. The Content Validity Index (CVI) was computed for each item in each scale (I-CVI) as well as for the overall scale (S-CVI). Kappa was used to determine the inter-rater agreement among the raters. Results: Overall, 64 individuals with hand arthritis (27% with OA, 67% with rheumatoid arthritis and 6% with psoriatic arthritis) participated in the study. The I-CVI for all items and all scales were very high (I-CVI \u3e 0.76) and the modified Kappa agreement among the raters demonstrated excellent agreement (k \u3e 0.76). The S-CVI for all PROMs was very high for relevance (AUSCAN = 0.92, 95% CI 0.90 to 0.94; PRWHE = 0.85, 95% CI 0.82 to 0.88 and TDX = 0.87, 95% CI 0.85 to 0.89) and for clarity (AUSCAN = 0.99, 95% CI 0.98 to 1.00; PRWHE = 0.95, 95% CI 0.93 to 0.97 and TDX = 0.91, 95% CI 0.89 to 0.94), respectively. Conclusions: This study demonstrated very high content validity indices for the AUSCAN, PRWHE and TDX; with strong consensus across raters. This augments prior studies demonstrating appropriate statistical measurement properties, to provide confidence that all three measures assess important patient concepts of pain and disability

A quantitative definition of scaphoid union: determining the inter-rater reliability of two techniques

BACKGROUND: Despite extensive literature supporting the use of computerized tomography (CT) scans in evaluating scaphoid fractures, there has not been a consensus on the methodology for defining and quantifying union. The purpose of this study was to test the inter-observer reliability of two methods of quantifying scaphoid union. METHODS: The CT scans of 50 non-operatively treated scaphoid fractures were reviewed by four blinded observers. Each was asked to classify union into one of three categories, united, partially united, or tenuously united, based on their general impression. Each reviewer then carefully analyzed each CT slice and quantified union based on two methods, the mean percentage union and the weighted mean percentage union. The estimated percentage of scaphoid union for each scan was recorded, and inter-observer reliability for both methods was assessed using a Bland-Altman plot to calculate the 95% limits of agreement. Kappa statistic was used to measure the degree of agreement for the categorical assessment of union. RESULTS: There was very little difference in the percentage of union calculated between the two methods (mean difference between the two methods was 1.2 ± 4.1%), with each reviewer demonstrating excellent agreement between the two methods based on the Bland-Altman plot. The kappa score indicated very good agreement (Ƙ = 0.80) between the consultant hand surgeon and the musculoskeletal radiologist, and good agreement (Ƙ = 0.62) between the consultant hand surgeon and the hand fellow for the categorical assessment of union. CONCLUSIONS: This study describes two methods of quantifying and defining scaphoid union, both with a high inter-rater reliability. This indicates that either method can be reliably used, making it an important tool for both for clinical use and research purposes in future studies of scaphoid fractures, particularly those which are using union or time to union as their endpoint. LEVEL OF EVIDENCE: Diagnostic, level II