This editorial introduces another of Journal of Physiotherapy‘s article collections.1, 2, 3, 4 These are collections of papers in a specific field of research, published in the Journal of Physiotherapy within the past decade and curated to alert readers to important findings and research trends in that field, while highlighing avenues for further research.
This article collection examines physiotherapy interventions for musculoskeletal disorders of the elbow, wrist and hand. Evidence in this field of research is accumulating rapidly in the Physiotherapy Evidence Database (PEDro), as shown in Figure 1.
Forearm, wrist and hand injuries represent a large challenge to functioning in everyday life and are associated with disability, low productivity, and mental health problems.5 In addition to the large impact on functional ability, hand injuries have a high incidence, representing 29% of all injuries that reach emergency departments.6 Thus, a large economic burden to society is generated, ranking hand injuries first among the most expensive injuries, specifically 32% more than lower limb fractures, 39% more than hip fractures and 108% more than skull-brain injury.5
There is great potential for rehabilitation interventions to reduce the impact of these injuries.5 Among these interventions, exercise has been one of the most frequently investigated, proving to be beneficial with few adverse effects, not only in the upper limb but also in many other musculoskeletal disorders.7 However, there is still uncertainty about the role of exercise and the best exercise combination in elbow, wrist and hand rehabilitation.8,9
Among people on the waiting list for carpal tunnel surgery, exercises combined with splinting and education reduced the conversion to carpal tunnel surgery.10 In this study with 105 participants, Lewis et al10 also demonstrated increases in perceived improvement and satisfaction in the intervention group when compared to the waitlist control group. Similarly, exercises and advice were also beneficial for people who had sustained a distal radial fracture. In the trial by Kay et al,11 exercises and advice reduced pain at 3 and 6 weeks and increased activity at 3 weeks.
More recently, new types and combinations of exercises within various rehabilitation programs have been investigated. For example, also in distal radius fracture, Reid et al12 estimated the effects of adding ‘mobilisation with movement’ exercises into supination and extension to a program of other exercises and advice. Adding these exercises produced faster and larger improvements in range of motion and functional ability at 4 and 12 weeks.
Another modification to a program of exercises and advice after distal radius fracture is the use of a dynamic splint. Jongs et al13 examined this in a trial of 40 people with contracture following their fracture. Adding the dynamic splint to the rehabilitation program did not have any therapeutic effects on active wrist extension, flexion, radial or ulnar deviation at the end of the 8-week intervention nor 4 weeks later.
Nevertheless, the therapeutic effect of exercises has also been questioned. Bruder et al14 found no benefit from adding exercise to a structured advice program in functional ability recovery at 7 and 24 weeks, during the rehabilitation phase following a distal radius fracture. In addition, a systematic review by Bruder et al9 did not identify a clear therapeutic effect of many exercise programs in reducing impairments and improving activity following an upper limb fracture, demonstrating only that early exercise combined with a shorter immobilisation is more effective than starting exercise after a longer immobilisation, after fractures of the distal radius, radial head, and proximal humerus. They concluded that many exercise programs did not clearly show an effect on activity and impairment following an upper limb fracture. They suggested that one of the possible reasons for this finding is that the exercise regimen may have a dosage that is insufficient (in intensity, duration, repetition or progression) to achieve a remodelling of the soft tissues or a truly challenging effect on the neuromuscular system. Such an effect may be achieved with an advice program, because physiotherapists encourage patients to continue with their daily life tasks, thus requiring strength and range of motion of the elbow, wrist and hand.
This notion of the need to optimise the exercises included in the exercise programs towards a more functional, high repetition and challenging perspective was shared by Blanquero et al. In comparison to conventional paper-based exercise programs, they observed greater therapeutic benefits from a new format of feedback-guided exercises by using touch-screens of Tablet devices, in two trials.15,16 In people with bone and soft tissue injuries of the wrist, hand and/or fingers, adding these feedback-guided exercises to face-to-face therapy achieved: earlier return to work, reduced healthcare usage and improved functional ability and strength at week 2, when compared to face-to-face therapy plus conventional paper-based exercise programs.15 This short-term improvement in functional ability compared to conventional exercises was also observed in people who had undergone carpal tunnel release, but using these feedback-guided exercises as single intervention (rather than in conjunction with face-to-face therapy).16 Blanquero et al suggested that the exercises may have an effect on brain plasticity, inducing a reorganisation of the sensorimotor system after it has been affected by hand, wrist and finger injury, surgery or immobilisation.
This trend to seek not only peripheral effects through interventions, but to achieve a central effect, can be partly related to the conclusions from Villafañe et al.17 They demonstrated in people with thumb carpometacarpal osteoarthritis that radial nerve gliding applied to one symptomatic hand produced hypoalgesic effects in the contralateral hand. They suggested that pain in osteoarthritis should not be ascribed only to peripheral nociception, and that peripherally directed therapies may modulate pain perception bilaterally.
This suggestion towards the central approach, more specifically towards central sensitisation, is also present in other pathologies such as lateral epicondylalgia (tennis elbow). Fortunately for readers of Journal of Physiotherapy, the invited topical review18 by Prof Leanne Bisset and Prof Bill Vicenzino expertly summarises the available evidence about the burden associated with the condition, its management (with a particular focus on physiotherapy interventions), and future directions for research and clinical practice.
In summary, this online article collection includes a range of important developments in the physiotherapy management of elbow, wrist and hand disorders, mainly related to exercises. It also highlights an important unanswered question: while exercises seem to be effective in the rehabilitation of these disorders, are the exercises that we currently use ideal or do we need to include other exercises, interventions or dosages? Future research should address two important issues. First, we need to determine which types of therapeutic exercises are the best for rehabilitation of elbow, wrist and hand disorders. Also, we need to determine what role and relevance central mechanisms and effects on the sensorimotor system have in these disorders, and how to approach these mechanisms to improve outcomes for patients.
TBI Rehabilitation 