Regarding a human costoscapular joint by Prof. Dr. H. von Luschka (1870): A translation.

Knowledge of variant anatomy was important during the time of Dr. Hubert von Luschka (1820-1875) and continues to be of relevance in current practice to prevent medical and surgical errors and to improve patient outcomes. Dr. H. von Luschka described an anatomical variant observed in the left scapula of a 40-year-old male: a connection between the medial superior angle of the scapula, piercing through the serratus posterior muscle to connect via a synovial capsule to the articular surface of the thoracic wall. The clinical relevance of this so-called "Luschka's tubercle" of the shoulder continues to be discussed. This translation is intended to broaden access to this hallmark manuscript to a wide audience of English readers. The introduction places the manuscript in the context of historical and current discussions. Three authors, all proficient in the German and English languages and educated in the anatomy of the shoulder, conducted the translation. The skeletal process that is part of the described joint structure appears similar to what is now called Luschka's tubercle. The full structure, including its connecting parts, are not currently included in anatomical nomenclature. In conclusion, Luschka's text and named tubercle continue to contribute to the discussion of scapulothoracic joint disorders.

Translation of Runge's 1873 publication "On the etiology and treatment of writer's cramp": The first description of "tennis elbow".

This publication by Dr Ferdinand Runge is ubiquitously credited as first to describe the symptoms, pathology, and treatment of patients with lateral epicondylosis (tennis elbow). However, the main focus of his work was to provide insight into causes of writer's cramp and treatments for the condition, elegantly illustrated in four case reports. This work, recently cited as unavailable, is written in German. Given the high frequency of citations in the English literature, it was considered useful to translate it into English to widen access to a broader readership. The purpose of this project was briefly to introduce the life and clinical expertise of Dr. Ferdinand Runge and the content of his work, followed by a translation of the entire manuscript into English. The paper was translated by the three authors using a process of sequential consensus. All are proficient in German and English, with clinical expertise in both topics. A brief reflection is provided to place Dr Runge's observations, clinical reasoning, and contemporaneously available treatments in the context of current thinking about lateral epicondylalgia. Dr. Runge shares his expertise, carefully reporting pertinent examination findings for each case, sharing hypotheses about the etiology of writer's cramp, and using the effectiveness of his applied treatment as confirmation. He concludes that careful evaluation of the patient's activities that hindered writing prior to the onset of the writer's cramp is key to managing this ailment. The topics addressed in this classic work are still thought-provoking.

Lateral epicondylosis: A literature review to link pathology and tendon function to tissue-level treatment and ergonomic interventions.

BACKGROUND: Common treatments for lateral epicondylosis (LE) focus on tissue healing. Ergonomic advice is suggested broadly, but recommendations based on biomechanical motion parameters associated with functional activities are rarely made. This review analyzes the role of body functions and activities in LE and integrates the findings to suggest motion parameters applicable to education and interventions relevant to activities and life roles for patients. PURPOSE: This study examines LE pathology, tendon and muscle biomechanics, and population exposure outlining potentially hazardous activities and integrates those to provide motion parameters for ergonomic interventions to treat or prevent LE. A disease model is discussed to align treatment approaches to the stage of LE tendinopathy. STUDY DESIGN: Integrative review METHODS: We conducted in-depth searches using PubMed, Medline, and government websites. All levels of evidence were included, and the framework for behavioral research from the National Institutes of Health was used to synthesize ergonomic research. RESULTS: The review broadened the diagnosis of LE from a tendon ailment to one affecting the enthesis of the capitellum. It reinforced the continuum of severity to encompass degeneration as well as regeneration. Systematic reviews confirmed the availability of evidence for tissue-based treatments, but evidence of well-defined harm reducing occupational interventions was scattered amongst evidence levels. Integration of biomechanical studies and population information gave insight into types of potentially hazardous activities and provided a theoretical basis for limiting hazardous exposures to wrist extensor tendons by reducing force, compression, and shearing during functional activities. CONCLUSIONS: These findings may broaden the first treatment approach from a passive, watchful waiting into an active exploration and reduction of at-risk activities and motions. Including the findings into education modules may provide patients with the knowledge to lastingly reduce potentially hazardous motions during their daily activities, and researchers to define parameters of ergonomic interventions.

Psychosocial influences in the development of cumulative trauma disorders.

STUDY DESIGN: This study is a single-phase, qualitative study using grounded theory methodology. INTRODUCTION: Cumulative trauma disorders (CTDs) are musculoskeletal disorders that impact health and productivity. CTD risk factors are present in the workplace, home, and community. Occupational and physical therapists specializing in hand and upper extremity rehabilitation (hand therapists) are widely involved with this population. Hand therapists often employ a medical model in the assessment and treatment of these conditions; however, the medical model has not proven to be consistently effective in relieving symptoms or producing a durable return to daily living activities. PURPOSE OF THE STUDY: The purpose of this study was to explore the lived experiences of individuals diagnosed with CTD, and investigate the psychosocial phenomena influencing CTD development as an impediment to occupational performance. METHODS: The principal investigator recruited 11 participants who met specific inclusion criteria, then used semi-structured interviews aimed at exploring the lived experiences of the participants while investigating the psychosocial phenomenon influencing CTD development. Interviews were transcribed and analyzed using a process of constant comparison, up until saturation occurred. Trustworthiness techniques were used in the data analysis phase and included peer reviews and member checking. FINDINGS: The findings suggest that many psychosocial factors contribute to the development and impact of CTDs, at both onset of symptoms and throughout the duration of the condition. A significant number of contextual factors influence participants' function, behavior, relationships, and the course of medical care. Themes derived from the participants' expressions, included the following: 1) an initial strategy of "work through the pain," can be detrimental to symptom resolution and leads to progressive failure to meet role expectations, 2) a pervasive notion of CTDs as "an invisible disability," leaving participants feeling isolated and frustrated when significant others fail to offer support or reject them, 3) participants often delayed reporting symptom development to employers, family members, and medical personnel, risking permanent injury and disability, 4) a "stigma" is attached to CTDs that encourages isolation; however, the social support of even one significant other in a person's life can facilitate adaptation. DISCUSSION AND CONCLUSION: All participants experienced hardship because of their conditions; however, two of the eleven participants capably navigated the process, using past experience and support from family and employer to successfully adapt. These findings offer support that CTDs are adaptive disorders. The study's conclusion suggests a new model to describe CTD dysfunction and presents new ways of thinking for clinicians who treat the CTD population.

Minimally Invasive SPML Surgery for Children with Cerebral Palsy: Program Development.

Improvements in surgical and rehabilitation care are critical to lessen the burden of cerebral palsy (CP), the most common cause of severe physical disability in childhood. The selective percutaneous myofascial lengthening (SPML) surgical procedure is a minimally invasive method designed to improve ambulation by lengthening contracted musculoskeletal tissues. Information on surgical procedures, efficacy, and safety of SPML for children with CP is lacking. Phase 1 of our research is a "proof-of-principle" study for multisite SPML to improve functional mobility of children with CP, and Phase 2 assesses safety, reoperation rates, and efficacy over time in subsequent patient series. Phase 1 was a repeated measurement case series study of 17 children (mean age 7.6 years). One physical therapist, blinded to the surgeon's measurements, measured bilateral knee and ankle motion before and after SPML procedures, using video recordings of a standardized gait path. Functional Mobility Scale (FMS) 5, 50, and 500 outcomes were taken pre- and postoperatively and via telephone follow-up. In Phase 2, multisite SPLM surgeries were implemented in larger successive cohorts from 2006 to 2017. Complications, reoperation rates, and efficacy were retrospectively analyzed. Phase 1 results showed improvement in the children's knee and ankle motion while ambulating and improved FMS 5, 50, and 500 outcomes postoperatively (mean, 6.3 months). At second follow-up (mean 33.3 months), FMS 500 scores continued improvement, while FMS 5 and FMS 50 scores maintained. During Phase 2, the complication rate was 2.4%, and reoperation rates (including reoperations due to maturation) were between 8% and 13%. Improvements to correct ankle equinus were recorded in 498 cases. In conclusion, in a specialized center, single-event, multilevel SPML surgeries of children with CP safely improved ambulatory knee and ankle angle motion and daily mobility outcomes. Future educational studies of training needs for surgeons new to the approach are needed.

Rater Variation in Ultrasound Detection of Dorsal Cortex Screw Protrusion in Fixed-Angle Volar Plating of the Distal Radius.

This study evaluates rater accuracy and variation for the purpose of using intraoperative ultrasound (US) imaging to detect dorsal screw protrusion during fixed-angle volar plating of distal radius fractures. Stabilizing volar plates and screws with varying lengths of dorsal protrusion were applied to 10 cadaver wrist pairs. After a brief training session, seven surgeons without prior ultrasound experience assessed screw protrusion on two separate occasions using a diagnostic ultrasound machine. Screw protrusions were visually confirmed after data collection was completed. Statistical analyses included percent agreement and Cohen's kappa for accuracy and intra- and inter-rater reliability, sensitivity, specificity, and positive and negative predictive values. Only two out of seven raters met acceptable levels of accuracy and consistency. Our findings inform us that accuracy and consistency of ultrasound-guided detection of dorsal screw protrusion are negatively impacted by rater variation. Further investigations are needed to improve rater effectiveness. (Journal of Surgical Orthopaedic Advances 28(4):260-267, 2019).

A geographical workforce analysis of hand therapy services in relation to US population characteristics.

INTRODUCTION: A paucity of work force planning literature exists for hand therapy services. PURPOSE: This descriptive study aimed to map the geographical distribution of US Certified Hand Therapists (CHTs) and describe characteristics of US populations living in respective CHT workplace Zip Code Tabulation Areas (ZCTAs). METHODS: A de-identified Zip Code list of all active CHTs through April 2016 from the Hand Therapy Certification Commission, included 5572 CHTs with US ZCTAs. The CHT ZCTAs were matched with population parameters "rurality", "poverty" and "race and ethnicity" from the 2010 US Census and 2014 American Community Survey. RESULTS: The 5,572 CHTs practice ZCTAs mostly overlapped with high density US population areas, covering just 9% of the total number of 33,120 US ZCTAs. The population in CHT ZCTAs was 1) urban in nature, 2) with lower poverty rates than ZCTAs without CHTs, and 3) mostly reflecting US race and ethnicity population distribution. Only 3.7% of CHTs worked in large concentrations of 11 to 26 CHTs per ZCTA near or in urban centers. Most CHTs, 67%, worked in one to three CHTs per ZCTA concentrations, contributing to a larger geographic spread of CHT locations than expected. DISCUSSION AND CONCLUSION: This study provides a foundational snap shot of the distribution, the potential availability, of the 2016 CHT workforce in the context of US population characteristics. It may serve as baseline for supply and demand studies and interventions to grow the CHT profession and optimize the distribution of CHTs to better meet population needs.

Validity and reliability of the Functional Dexterity Test in children.

STUDY DESIGN: Clinical measurement study. INTRODUCTION: The Functional Dexterity Test (FDT) has not been validated in children. PURPOSE OF THE STUDY: To determine reliability and validity of the FDT in a pediatric population. METHODS: Intraclass Correlation Coefficients (ICCs) were used to calculate interrater and test-retest reliability in typically developing children. Pearson correlation coefficients were used to compare FDT speed with the Jebsen-Taylor Hand Function Test (JHFT) and with 2 activities of daily living tasks to establish validity in children with congenital hand differences. RESULTS: The FDT demonstrated excellent interrater (ICC, 0.99) and test-retest (ICC, 0.90) reliability. Pearson correlation coefficients exceeded 0.67 for JHFT subsets of fine dexterity and were all less than 0.66 for JHFT subsets of gross grasp. Correlations with the activities of daily living tasks were good to excellent. FDT speeds in TD children exceeded those of children with congenital hand differences (P < .001), demonstrating discriminant validity. DISCUSSION: Children with congenital hand differences are often treated early in life, making it important to reliably assess hand function of these young children to distinguish developmental change from changes due to interventions. The FDT can reliably measure functional progress over time, help clinicians monitor the efficacy of treatment, and provide families realistic feedback on their child's progress. CONCLUSION: The FDT is a valid and reliable instrument for the measurement of fine motor dexterity in children.

Astym treatment vs. eccentric exercise for lateral elbow tendinopathy: a randomized controlled clinical trial.

UNLABELLED: Introduction. Patients with chronic lateral elbow (LE) tendinopathy, commonly known as tennis elbow, often experience prolonged symptoms and frequent relapses. Astym treatment, evidenced in animal studies to promote the healing and regeneration of soft tissues, is hypothesized to improve outcomes in LE tendinopathy patients. This study had two objectives: (1) to compare the efficacy of Astym treatment to an evidence-based eccentric exercise program (EE) for patients with chronic LE tendinopathy, and (2) to quantify outcomes of subjects non-responsive to EE who were subsequently treated with Astym treatment. Study Design. Prospective, two group, parallel, randomized controlled trial completed at a large orthopedic center in Indiana. INCLUSION CRITERIA: age range of 18-65 years old, with clinical indications of LE tendinopathy greater than 12 weeks, with no recent corticosteriod injection or disease altering comorbidities. Methods. Subjects with chronic LE tendinopathy (107 subjects with 113 affected elbows) were randomly assigned using computer-generated random number tables to 4 weeks of Astym treatment (57 elbows) or EE treatment (56 elbows). Data collected at baseline, 4, 8, 12 weeks, 6 and 12 months. PRIMARY OUTCOME MEASURE: DASH; secondary outcome measures: pain with activity, maximum grip strength and function. The treating physicians and the rater were blinded; subjects and treating clinicians could not be blinded due to the nature of the treatments. Results. Resolution response rates were 78.3% for the Astym group and 40.9% for the EE group. Astym subjects showed greater gains in DASH scores (p = 0.047) and in maximum grip strength (p = 0.008) than EE subjects. Astym therapy also resolved 20/21 (95.7%) of the EE non-responders, who showed improvements in DASH scores (p < 0.005), pain with activity (p = 0.002), and function (p = 0.004) following Astym treatment. Gains continued at 6 and 12 months. No adverse effects were reported. Conclusion. This study suggests Astym therapy is an effective treatment option for patients with LE tendinopathy, as an initial treatment, and after an eccentric exercise program has failed. Registration/Funding. Ball Memorial Hospital provided limited funding. Trial registration was not required by FDAAA 801. Known about the Subject. Under the new paradigm of degenerative tendinopathy, eccentric exercise (EE) is emerging as a first line conservative treatment for LE tendinopathy. EE and Astym treatment are among the few treatment options aiming to improve the degenerative pathophysiology of the tendon. In this trial, Astym therapy, which has shown success in the treatment of tendinopathy, is compared to EE, which has also shown success in the treatment of tendinopathy. Clinical Relevance. There is a need for more effective, conservative treatment options. Based on the current efficacy study, Astym therapy appears to be a promising, non-invasive treatment option.

Rehabilitation of hand burn injuries: current updates.

The improved short and long term survival rate of individuals with large burn injuries has made rehabilitation for optimal recovery of the patient increasingly important. Burn injury to the hands worsens the prospect of functional recovery and good quality of life in single events, especially when included in larger burns. The purpose of this paper is to present a narrative review of examination strategies used for children with burn injuries to the hands in the acute, intermediate and long term stages of rehabilitation, and apply these concepts to selected treatments, using a case that is representative of this complex patient population. The model of health described by the World Health Organisation provided the framework for the review, to structure the review in the domains of body structures and body functions, functional activities and participation in life roles. The lack of consensus in the burn literature regarding the most appropriate outcome measures and interventions necessitates futures research and long term outcome studies to identify, predict and prevent the difficulties patients may face over their lifespan.

Computer simulation of pectoralis major muscle strain to guide exercise protocols for patients after breast cancer surgery.

STUDY DESIGN: Descriptive study. OBJECTIVES: To quantify and rank the order of strain (length change in proportion to the resting length) of 3 portions of the pectoralis major (PM) muscle during various exercises. BACKGROUND: A biomechanical foundation on which to base exercise prescriptions for patients after breast cancer surgery is lacking. METHODS: An interactive, 3-D, computer graphic simulation system, developed to study biomechanical properties of the musculoskeletal system, was used to simulate movements of the glenohumeral, scapulothoracic, and scapuloclavicular joints of the shoulder, and to estimate strain in 3 portions of the pectoralis major (PM) muscle throughout the motions. The computed tomography scans of 2 male cadavers and literature review formed the basis for the estimations used in the model. Strains in the clavicular, midsternum, and abdominal regions of the PM were expressed as percent strain: [(change in muscle length/resting length) × 100]. Exercise motions were based on PM muscle anatomy and published breast cancer rehabilitation protocols. RESULTS: Strains of the PM regions ranged from -21% shortening of the clavicular region during flexion to 55% lengthening of the abdominal region during the overhead stretch. Strain between adjacent regions was most uniform for the movement of abduction with external rotation, and least uniform with flexion. CONCLUSION: PM muscle lengthening estimates were not linearly proportioned to shoulder joint motions, and varied for 3 portions of the PM. This information may help clinicians and researchers to estimate lengthening of PM portions throughout measurable shoulder motions.

Does hand therapy literature incorporate the holistic view of health and function promoted by the World Health Organization?

The International Classification of Function (ICF), as formulated by the World Health Organization (WHO), is an accepted international standard for categorizing health and disability. We examined the frequency that ICF domains have been included in 788 Journal of Hand Therapy articles and 78 hand therapy articles from other sources using a scoring system based on the WHO ICF definitions. We found emphasis on body functions and body structures, with less emphasis placed on activities, participation, and environmental factors. This trend has remained stable over time despite the emergence of patient-centered disability measures. We recommend that scientists increasingly incorporate all of the WHO ICF domains in their scientific investigations to demonstrate the societal and personal impact of the profession in a language that is understood and appreciated by a wide array of health care users, policy makers, and third-party payers.

Measurement of maximum voluntary pinch strength: effects of forearm position and outcome score.

The purpose of this study was to determine the effects of forearm position and outcome score on key, fingertip, and three-jaw chuck pinch strength. Maximum voluntary key, fingertip, and three-jaw chuck pinches were performed by 135 healthy adults (20-88 years old) three times in a pronated, supinated, and neutral forearm position with the right and left hand using a B&L (B&L Engineering, Tustin, CA) pinch gauge. The highest, first, and mean scores of three pinch forces were recorded. Three 3 x 3 factorial repeated-measures analyses tested each type of pinch strength. Forearm position affected key and fingertip pinches (p<0.017; effect sizes <0.14) but not three-jaw chuck pinch. The highest score ranked highest followed by the first and then the mean of the three scores (p<0.017; effect sizes >0.53). Although the effects of type of outcome score were consistent, the statistically significant effects of forearm position and outcome score may be too small (<1 lb) to be clinically relevant. Standardized positioning during pinch strength measurement is still recommended despite these findings.

Multidimensional EMG-based assessment of walking dynamics.

The electromyogram (EMG) provides a measure of a muscle's involvement in the execution of a motor task. Successful completion of an activity, such as walking, depends on the efficient motor control of a group of muscles. In this paper, we present a method to quantify the intricate phasing and activation levels of a group of muscles during gait. At the core of our method is a multidimensional representation of the EMG activity observed during a single stride. This representation is referred to as a "trajectory." A hierarchical clustering procedure is used to identify representative classes of muscle activity patterns. The relative frequencies with which these motor patterns occur during a session (i.e., a series of consecutive strides) are expressed as histograms. Changes in walking strategy will be reflected as changes in the relative frequency with which specific gait patterns occur. This method was evaluated using EMG data obtained during walking on a level and a moderately-inclined treadmill. It was found that the histogram changes due to artificially altered gait are significantly larger than the changes due to normal day-to-day variability.