A modified-delphi study establishing consensus in the therapeutic management of posttrauamtic elbow stiffness.

STUDY DESIGN: Web-based modified Delphi study. BACKGROUND: Therapy is widely considered the first choice of treatment for posttraumatic stiffness of the elbow since loss of motion is a common sequela following traumatic elbow injuries. There is high variability in practice patterns for the management of the posttraumtic elbow. PURPOSE: The aim of this study is to identify the current therapeutic management of posttraumatic elbow stiffness using expert consensus. METHODS: This study surveyed experts using a web-based 3 round modified Delphi method. Quantitative data and comments were collected during the first round. Questions with Likert scaling were used to identify consensus (defined as 75% agreement) with each statement and comment boxes enabled open-ended responses to gather expert opinion. Lack of consensus and data from comments guided the second-round of the survey. This process was repeated after Round 2 to develop the Round 3 survey. Consensus was achieved at Round 3 and no further rounds were needed. RESULTS: Round 1 included 34 experts (response rate 20%), not all experts were able to continue through all rounds. Round 2 included 18 experts and Round 3 included 15 experts. Survey items were categorized as follows: examination procedures, therapeutic interventions, orthotic intervention considerations, contributing patient factors, and clinical decisions and rehabilitation challenges. Twenty-five percent of items achieved consensus after Round 1, 30% after Round 2 and 52% after Round 3. Although most participants agreed that orthotic intervention is critical to patient outcomes, there were conflicting thoughts about the orthotic design and wearing schedule. CONCLUSIONS: The findings of this web-based modified Delphi study helped to establish a current body of knowledge using expert consensus to guide practice and identify specific questions that can be studied in future clinical studies on posttraumatic elbow stiffness.

Therapy Considerations for Getting Athletes to Return to Play.

During the protective phase of treatment, therapy for hand and wrist injuries in athletes is similar to the plan of care provided to all patients. The nuances in the care provided to athletes become apparent during the transition to the postprotective phase of rehabilitation when the focus has shifted to return to play. Therapy following a sports injury should address the individual needs of the athletes in their everyday lives as well as the specificity of their training and sports-specific activities. The factors that influence return to play are discussed.

Tendinopathies of the elbow, wrist, and hand: histopathology and clinical considerations.

This article reviews the current opinion of the histopathological findings of common elbow, wrist, and hand tendinopathies. Implications for client management including examination, diagnosis, prognosis, intervention, and outcomes are addressed. Concepts for further research regarding common therapeutic interventions are discussed.

Exposure-dependent increases in IL-1beta, substance P, CTGF, and tendinosis in flexor digitorum tendons with upper extremity repetitive strain injury.

Upper extremity tendinopathies are associated with performance of forceful repetitive tasks. We used our rat model of repetitive strain injury to study changes induced in forelimb flexor digitorum tendons. Rats were trained to perform a high repetition high force (HRHF) handle-pulling task (12 reaches/min at 60 +/- 5% maximum pulling force [MPF]), or a low repetition negligible force (LRNF) reaching and food retrieval task (three reaches/min at 5 +/- 5% MPF), for 2 h/day in 30 min sessions, 3 days/week for 3-12 weeks. Forelimb grip strength was tested. Flexor digitorum tendons were examined at midtendon at the level of the carpal tunnel for interleukin (IL)-1beta, neutrophil, and macrophage influx, Substance P, connective tissue growth factor (CTGF), and periostin-like factor (PLF) immunoexpression, and histopathological changes. In HRHF rats, grip strength progressively decreased, while IL-1beta levels progressively increased in the flexor digitorum peritendon (para- and epitendon combined) and endotendon with task performance. Macrophage invasion was evident in week 6 and 12 HRHF peritendon but not endotendon. Also in HRHF rats, Substance P immunoexpression increased in week 12 peritendon as did CTGF- and PLF-immunopositive fibroblasts, the increased fibroblasts contributing greatly to peritendon thickening. Endotendon collagen disorganization was evident in week 12 HRHF tendons. LRNF tendons did not differ from controls, even at 12 weeks. Thus, we observed exposure-dependent changes in flexor digitorum tendons within the carpal tunnel, including increased inflammation, nociceptor-related neuropeptide immunoexpression, and fibrotic histopathology, changes associated with grip strength decline.

Tennis elbow: blending basic science with clinical practice.

Tennis elbow defines a condition of varying degrees of pain or point tenderness on or near the lateral epicondyle. It is prevalent in individuals who perform a combination of forceful and repetitive activities including athletes and wheelchair users. The most common work-related disorder at the elbow is tennis elbow. Histopathological findings indicate that tennis elbow is a degenerative condition, called tendinosis, of the common extensor tendon, with the extensor carpi radialis brevis tendon more commonly implicated as the primary location of tendinosis. Despite the absence of inflammation, patients with tennis elbow still present with pain. Neurochemicals including glutamate, substance P, and calcitonin gene-related peptide have been identified in patients with chronic tennis elbow and in animal models of tendinopathy. Their presence provides an alternative mechanism for pain mediation. Based on what is known about tissue changes within chronic tendinopathies, implications for therapy including examination and interventions are discussed.