Evidence based practice

Definition: A process of lifelong learning where the practitioner systematically finds, appraises, and uses the most current and valid research findings as the basis for clinical decisions and treatment planning.

Our therapists continually evaluate past and emerging research to consistently provide the most up to date and proven treatment. It is our belief that utilizing techniques proven by research is better than basing decisions on “that is the way it has always been done.”

Below are reviews of research related to conditions and treatments common in hand therapy:

Tennis Elbow/Lateral Epicondylitis

Tennis Elbow/Lateral Epicondylitis

Evidence Based Practice Summary

Evidence of effectiveness:

Therapy patients experienced decreased pain, increased grip strength, and improved tendon health compared to a “wait and see“ approach, splinting only, or corticosteroid injections.1-8 Patients receiving therapy also had less recurrence of symptoms compared to injection.3,5 Patients who received injection had better results if combined with therapy. 10

Which interventions work?

Forearm braces decrease symptoms and forces at ECRB origin10-15 and are more effective than wrist splints.16

Strengthening, specifically eccentric, is shown to decrease pain, increase grip strength, and improve tendon health.1,6,9

Low level laser has proven to be an effective adjunct to other treatment modalities such as ultrasound, bracing, and exercise with a decrease in pain, increased grip strength, and increased function.2,17-20

Iontophoresis applied at least 3x/wk and Phonophoresis helped decrease pain.21-22

Joint mobilization has been shown to increase pain free grip and maximal grip as well as improve shoulder ROM.3,7,8 In order to be effective treatment must not simply focus on the elbow but the whole upper extremity.23

Returning to work has been shown to increase risk of relapse and hinder recovery.24,25 Repetitive keyboard tasks are the key factor associated with pain and disability.26 Therefore, therapy should include progressively increasing work load and address ergonomics to successfully transition back to work.

References
  1. Crosier JL, Foidart-Dessalle M, Tinant F, Crielaard JM, Forthomme B. An isokinetic eccentric programme for the management of chronic lateral epicondylar tendinopathy. Br J Sports Med. 2007 Apr; 41(4):269-75.
  2. Oken O, Kahraman Y, Ayhan F, Canpolat S, Yorgancioglu AR, Oken OF. The short-term efficacy of laser, brace, and ultrasound treatment in lateral epicondylitis: a prospective, randomized, controlled trial. J Hand Ther. 2008 Jan-Mar;21(1):63-7
  3. Bisset L, Beller E, Jull G, Brooks P, Darnell R, Vicenzino B. Mobilization with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomized trial BMJ. 2006 Nov 4;333(7575):939. Epub 2006 Sep 29.
  4. Struijs PA, Kerkhoffs GM, Assendelft WJ, Wan Dijk CN. Conservative treatment of lateral epicondylitis: barce versus physical therapy or a combination of both – a randomized clinical trial. Am J Sports Med. 2004 Mar:32(2):462-9.
  5. Smidt N, van der Windt DA, Assendelft WJ, Devillé WL, Korthals-de Bos IB, Bouter LM. Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: a randomised controlled trial. Lancet. 2002 Feb 23;359(9307):657-62.
  6. Svernlöv B, Adolfsson L. Non-operative treatment regime including eccentric training for lateral humeral epicondylalgia. Scand J Med Sci Sports. 2001 Dec;11(6):328-34.
  7. Abbott JH. Mobilization with movement applied to the elbow affects shoulder range of movement in subjects with lateral epicondylalgia. An Ther. 2001 Aug;6(3):170-7.
  8. Abbott JH, Patla CE, Jensen RH. The initial effects of an elbow mobilization with movement technique on grip strength in subjects with lateral epicondylalgia. Man Ther. 2001 Aug;6(3):163-9.
  9. Pienimaki T, Karinen P, Kemila T, Koivukangas P, Vanharanta H. Long-term follow-up of conservatively treated chronic tennis elbow patients. A prospective and retrospective analysis. Scand J Rehabil Med. 1998 Sep;30(3):159-66.
  10. Zehtab MJ, Mirghasemi A, Majlesara A, Tajik P, Siavashi B. The predictive value of extensor grip test for the effectiveness of treatment for tennis elbow. Saudi Med J. 2008 Sep;29(9):1270-5.
  11. Jafarian FS, Demneh ES, Tyson SF. The immediate effect of orthotic management on grip strength of patients with lateral epicondylosis. J Orthop Sports Phys Ther. 2009 Jun;39(6):484-9.
  12. Borkholder CD, Hill VA, Fess EE. The efficacy of splinting for lateral epicondylitis: a systematic review. Hand Ther. 2004 Apr-Jun;17(2):181-99.
  13. Meyer NJ, Walter F, Haines B, Orton D, Daley RA. Modeled evidence of force reduction at the extensor carpi radialis brevis origin with the forearm support band. J Hand Surg Am. 2003 Mar;28(2):279-87.
  14. Meyer NJ, Pennington W, Haines B, Daley R. The effect of forearm support band on forces a the origin of the extensor carpi radialis brevis: a cadaveric study and review of literature. J Hand Ther 2002 Apr-Jun;15(2):179-84.
  15. Walther W, Kirschner S, Koenig A, Barthel T, Gohlke F. Biomechanical evaluation of braces used for the treatment of epicondylitis. J J Shoulder Elbow Surg. 2002 May-Jun;11(3):265-70.
  16. Jansen CW, Olson SL, Hasson SM. The effect of use of a wrist orthosis during functional activities on surface electromyography of the wrist extensors in normal subjects. J Hand Ther. 1997 Oct-Dec;10(4):283-9.
  17. Bjordal JM, Lopes-Martins RA, Jeoensen J, Couppe C, Ljunggren AE, Stergioulas A, Johnson MI. A systematic review with procedural assessments and meta-analysis of low level laser therapy in lateral elbow tendinopathy (tennis elbow.) BMC Musculoskelet Disorders. 2008 May 29;9:75.
  18. Stergioulas A. Effects of low-level laser and plyometric exercises in the treatment of lateral epicondylitis. Photmed Laser Surg. 2007 Jun;25(3):205-13.
  19. Lam LK, Cheing GL. Effects of 904-nm low-level laser therapy in the management of lateral epicondylitis: a randomized controlled trial. Photomed Laser Surg. 2007 Apr;25(2):65-71.
  20. Simunovic Z, Trobonjaca T, Trobonjaca Z. Treatment of medial and lateral epicondylitis-tennis and golfers elbow- with low level laser therapy: a multicenter double blind, placebo-controlled clinical study on 324 patients. J Clin Laser Med Surg. 1998 Jun;16(3):145-51.
  21. Nirschl RP, Rodin DM, Ochiai DH, Maartmann-Moe C, DEX-AHE-01-99 Study Group. Iontophoretic administration of dexamethasone sodium phosphate for acute epicondylitis. A randomized, double-blinded, placebo –controlled study. Am J Sports Med. 2003 Mar-Apr;31(2):189-95.
  22. Baskurt F, Ozcan A, Algun C. Comparison of effects of phonophoresis and iontophoresis of naproxen in the treatment of lateral epicondylitis. Clin Rehabil. 2003 Feb;17(1):96-100.
  23. Struija PA, Damen PJ, Bakker WE, Blankevoort L, Assendelft WJ, van Dijk CH. Manipulation of the wrist for management of lateral epicondylitis: a randomized pilot study. Phys Ther. 2003 Jul;83(7):608-16.
  24. Lewis M, Hay EM, Paterson SM, Croft P. Effects of manual work on recovery from lateral epicondylitis. Scand J Work Environ Health. 2002 Apr;28(2):109-16.
  25. Waugh EJ, Jaglal SB, Davis AM, Tomlinson G, Verrier MC. Factors associated with prognosis of lateral epicondylitis after 8 weeks of physical therapy. Arch Phys Med Rehabil. 2004 Feb;85(2):308-18.
  26. Waugh EJ, Jaglal SB, Davis AM. Computer use associated with poor long-term prognosis of conservatively managed lateral epicondylalgia. J Orhtop Sports Phys Ther. 2004 Dec;34(12)770-80.
Carpal Tunnel Syndrome

Carpal Tunnel Syndrome

Evidence Based Practice Summary

Evidence of effectiveness:

Patients receiving hand therapy interventions had significant benefit including decreased pain13,17-19, and parasthesias20, improved function13,18,19 ,increased grip strength13,18,20-22, improved nerve velocities20,21,23, improved dexterity29, higher patient satisfaction14,17, less progression to surgery16, and quicker return to work.29

Which interventions work?

Splinting has been widely shown to alleviate symptoms1-3 and is recommended by the American Academy of Orthopedic Surgeons before surgery is considered.4 This is an effective strategy for carpal tunnel syndrome related to pregnancy.5-6 Splinting after carpal tunnel release surgery has not proven beneficial7-8 and ROM for the wrist and fingers should be done separately.28 Splinting immediately after symptoms begin yields better results.9-10 While night splinting is typical, there is some evidence that full time splinting is more effective,11 so the treatment plan must be tailored to the individual. The type of splint must also be considered in each case as a splint that also maintains the MCP joints in neutral may be more beneficial than a simple wrist cock-up.12

Tendon and Nerve gliding have been shown to increase speed of pain reduction, improve function, and increase grip strength, and decrease the need for surgery.13-16

Low Level Laser can decrease pain17-19, numbness, and parasthesias20, while increasing function18,19, grip strength18,20-22, patient satisfaction17, and results on electrodiagnostic tests (EMG).20,21,23 A review of seven studies concluded that higher levels of laser (at least 9 J) produced greater results. 24 Further quality research is needed in this area.

Ultrasound is supported in the research to have short to medium term benefits in mild to moderate carpal tunnel syndrome.3,15,17,25-27 Recommended as a treatment option by the American Academy of Orthopedic Surgeons.4

Carpal Mobilization has been shown to improve symptoms.15

References
  1. Premoselli S, Sioli P, Grossi A, Cerri C. Neutral wrist splinting in carpal tunnel syndrome: a 3- and 6-months clinical and neurophysiologic follow-up evaluation of night-only splint therapy. Eura Medicphys. 2006 Jun;42(2):121-6.
  2. Werner RA, Fanzblau A, Gell N. Randomized controlled trial of nocturnal splinting for active workers with symptoms of carpal tunnel syndrome. Arch Phys Med Rehabil. 2005 Jan;86(1)1-7.
  3. O’Connor D, Marshall S, Massy-Westropp N. Non-surgical treatment (other than steroid injection) for carpal tunnel syndrome. Cochrane Database Syst Rev 2003;(1):CDC003219. Review.
  4. Keith MW, Masear V, Amadio PC, Andary M, Barth RW, Graham B, Chung K, Maupin K, Watters WC 3rd, Haralson RH 3rd, Turkelson CM, Wies JL, McGowan R. Treatment of carpal tunnel syndrome. J Am Acad Orthop Surg. 2009 Jun;17(6):397-405.
  5. Courts RB. Splinting for symptoms of carpal tunnel syndrome during pregnancy. J Hand Ther. 1995 Jan-Mar;8(1):31-4.
  6. Ekman-Ordeberg G, Salgeback S, Ordeberg G. Carpal tunnel syndrome in pregnancy. A prospective study. Acta Obstet Gynecol Scand. 1987;66(3):233-5.
  7. Henry SL, Hubbard BA, Concannon MJ. Splinting after carpal tunnel release: current practice, scientific evidence, and trends. Plast Reconstr Surg. 2008 Oct;122(4):1095-9.
  8. Huemer GM, Koller M, Pachinger T, Dunst KM, Schwartz B, Hintringer T. Postoperative splinting after open carpal tunnel release does not improve functional and neurological outcome. Muscle Nerve. 2007 Oct;36(4):528-31.
  9. Gerritsen AA, Korthals-de Bos IB, Laboyrie PM, de Vet HK, Scholten RJ, Bouter LM. Splinting for carpal tunnel syndrome: prognostic indicators for success. J Neurol Neurosurg Psychiatry. 2003 Sep;74(9):1342-4.
  10. Kruger VL, Kraft GH, Deitz JC, Ameis A, Polissar L. Carpal tunnel syndrome: objective measures and splint use. Arch Phys Med Rehabil. 1991 Jun;72(7):517-20.
  11. Walker WC, Metzler M, Cifu DX, Swartz Z. Neutral wrist splinting in carpal tunnel syndrome: a comparison of night-only versus full-time wear instructions. Arch Phys Med Rehabil. 2000 Apr;81(4):424-9.
  12. Brininger TL, Rogers JC, Holm MB, Baker NA, Li ZM, Goitz RJ. Eficacy of a fabricated customized splint and tendon and nerve gliding exercises for the treatment of carpal tunnel syndrome: a randomized controlled trial. Arch Phys Med Rehabil. 2007 Nov;88(11):1429-35.
  13. Pinar L, Enhos A, Ada S, Gungor N. Can we use nerve gliding exercises in women with carpal tunnel syndrome? Adv Ther. 2005 Sep-Oct;22(5):467-75.
  14. Baysal O, Altay Z, Ozcan C, Ertem K, Yologlu S, Kayhan A. Comparison of three conservative treatment protocols in carpal tunnel syndrome. Int J Clin Pract. 2006 Jul;60(7):820-8.
  15. Muller M, Tsui D, Schnurr R, Biddulph-Deisroth L, Hard J, MacDermid JC. Effectiveness of hand therapy interventions in primary management of carpal tunnel syndrome: a systematic review. J Hand Ther. 2004 Apr-Jun;17(2):210-28.
  16. Rozmaryn LM, Dovelle S, Rothman ER, Gorman K, Olvey KM, Bartko JJ. Nerve and tendon gliding exercises and the conservative management of carpal tunnel syndrome. J Hand Ther. 1998 Jul-Sep;11(3):171-9.
  17. Dincer U, Cakar E, Kiralp MZ, Kilac C, Durson H. The Effectiveness of Conservative Treatments of Carpal Tunnel Syndrome: Splinting, Ultrasound, and Low-Level Laser Therapies. Photomed Laser Surg. 2009 Jan 26
  18. Chang WD, Wu JH, Jiang JA, Ueh CY, Tsai CT. Carpal tunnel syndrome treated with a diode laser: a controlled treatment of the transverse carpal ligament. Photomed Laser Surg. 2008 Dec;26(6):551-7
  19. Ekim A, Armagon O, Tascioglu F, Oner C, Colak M. Effect of low level laser therapy in rheumatoid arthritis patients with carpal tunnel syndrome. Swiss Med Wkly. 2007 Jun 16:137(23-24):347-52.
  20. Shooshtari SM, Badiee W, Taghizadeh SH, Nematollahi AH, Amanollahi AH, Grami MT. The effects of low level laser in clinical outcome and neurophysiological results of carpal tunnel syndrome. Electromyogr Clin Neurophysiol. 2008 Jun-Jul;48(5):229-31
  21. Yagci I, Elmas O, Akcan E, Ustun I, Gunduz OH, Guven Z. Comparison of splinting and splinting plus low-level laser therapy in idiopathic carpal tunnel syndrome. Clin Rheumatol. 2009 Sep:28(9):1059-65.
  22. Evcik D, Kavuncu W, Cakir T, Subasi V, Yaman M. Laser therapy in the treatment of carpal tunnel syndrome: a randomized controlled trial. Photomed Laser Surg. 2007 Feb;25(1):34-9.
  23. Naeser MA, Hahn KA, Leiberman BE, Branco KF. Carpal tunnel syndrome pain treated with low-level laser and microamperes transcutaneous electric nerve stimulation: A controlled study. Arch Phys Med Rehabil. 2002 Jul;83(7):978-88.
  24. Naeser MA. Photobiomodulation of pain in the carpal tunnel syndrome: a review of seven laser therapy studies. Photomed Laser Surg. 2006 APR;24(2):101-10. Review.
  25. Bakhtiary AH, Rashidy-Piur A. Ultrasound and laser therapy in the treatment of carpal tunnel syndrome. Aust J Physiother. 2004;50(3):147-51.
  26. Ebenbichler GR, Resch KL, Nicolakis P, Wiesinger GF, Uhl F, Ghanem AH, Fialka V. Ultrasound treatment for treating the carpal tunnel syndrome: a randomized “sham“ controlled trial. BMJ 1998 Mar 7;316(7133):731-5.
  27. Piravej K, Boonhong J. Effects of ultrasound thermotherapy in mild to moderate carpal tunnel syndrome. J Med Assoc Thai 2004 Sep;87 Suppl 2:S100-6.
  28. Cook AC, Szabo RM, Birkholz SW, King EF. Early mobilization following carpal tunnel release. A prospective randomized study. J Hand Surg Br. 1995 Apr;20(2):228-30.
  29. Keilani MY, Crevenna R, Fialka-Moser W. Postoperative rehabilitation of patients with carpal tunnel syndrome. Wien Med Wochenschr. 2002;152(17-18):479-80. Review. German.
Ergonomics

Ergonomics

Evidence Based Practice Summary

Evidence of effectiveness:

When done correctly, ergonomic training has been shown to decrease number of workers compensation cases1 while decreasing frequency and severity of pain and other symptoms2,3. There is strong research showing a causal relationship between musculoskeletal disorders (tendonitis, shoulder injuries, carpal tunnel syndrome and other nerve entrapments, etc. ) and work related risks such as repetitive movements, forceful work, extreme or awkward positions, direct load bearing, lack of rests, and poor ergonomic design4-9. Some research suggests that up to 1 in 3 neck and upper extremity injuries may be avoided with such programs10. The benefits are both immediate and long term11. For treatment to be effective it must address physical factors12, work, and non-work related risks (activities of daily living.)13

What interventions work?

Ergonomic Training to risk factors, work design, proper equipment and adjustment, organizational factors and how to alleviate these risks is shown to reduce injuries and pain.2,3,11

Ergonomic products such as alternative keyboards11,14,15, ergonomic mouses16, and keyboard trays17 have been shown to decrease discomfort. These improvements were enhanced further with training.14

Physician recommendation of the need for ergonomic changes is strongly associated with the willingness of employers to implement ergonomic risk reductions.18

References
  1. May DC. Results of an OSHA ergonomic intervention program in New Hampshire. Appl Occup Environ Hyg. 2002 Nov;17(11):768-73.
  2. Cole DC, Hogg-Johnson S, Manno M, Ibrahim S, Wells RP, Ferrier SE, Worksite Upper Extremity Research Group. Reducing musculoskeletal burden through ergonomic program implementation in a large newspaper. Int Arch Occup Environ Health. 2006 Nov; 80(2):98-108. Epub 2006 May 31.
  3. Ketola R, Toivonen R, Kakkanen M, Luukkonen R, Takala EP, Vikari-Juntura E, Expert Group in Ergonomics. Effects of ergonomic intervention in work with video display units. Scand J Work Environ Health. 2002 Feb:28(1):18-24.
  4. Hagberg M, Morgenstern H, Kelsh M. Impact of occupations and job tasks on the prevalence of carpal tunnel syndrome. Scand J Work Environ Health. 1992 Dec; 18(6):337-45. Review.
  5. Stock SR. Workplace ergonomic factors and the development of musculoskeletal disorders of the neck and upper limb: a meta-analysis. Am J Ind Med. 1991; 19(1):87-107
  6. Grieco A, Molteni O, De Vito G, Sias N. Epidemiology of musculoskeletal disorders due to biomechanical overload. Ergonomics. 1998 Sep;41(9):1322-39.
  7. Turhan N, Akat C, Akyuz M, Cakci A. Ergonomic risk factors for cumulative trauma disorders in VDU operators. Int J Occup Saf Ergon. 2008; 14(4):417-22.
  8. Latko WA, Armstrong TJ, Franzblau A, Ulin SS, Werner RA, Albers JW. Cross-sectional study of the relationaship between repetitive work and the prevalence of upper limb musculoskeletal disorders. Am J Ind Med. 1999 Jun;35(6):647-61.
  9. Juul-Kristensen B, Jensen C. Self-reported workplace related ergonomic conditions as prognostic factors for musculoskeletal symptoms: the “BIT“ follows up study on office workers. Occup Environ Med. 2005 Mar;62(3):188-94.
  10. Sim J, Lacey RJ, Lewis M. The impact of workplace risk factors on the occurrence of neck and upper limb pain: a general population study. BMC Public Health. 2006 Sep 19; 6:234.
  11. Aaras A, Horgen G, Bjorset HH, Ro O, Walsoe H. Musculoskeletal, visual, and psychosocial stress in VDU operators before and after multidisciplinary ergonomic interventions. A 6years prospective study –Part II. Appl Ergon. 2001 Dec;32(6):559-71.
  12. Herbert R, Gerr F, Dropkin J. Clinical evaluation and management of work related carpal tunnel syndrome. Am J Ind Med. 2000 Jan;37(1):75-93. Review.
  13. Werner PA, Franzblau A, Gell N, Ulin SS, Armstrong TJ. A longitudinal study of industrial and clerical workers: predictors of upper extremity tendonitis. J Occup Rehabil 2005. Mar;15(1):37-46.
  14. Tittiranonda P, Rempel D, Armstrong T, Burastero S. Effect of four computer keyboards in computer users with upper extremity musculoskeletal disorders. Am J Ind Med. 1999 Aug;36(2):248-59.
  15. Ripat J, Scatliff T, Giesbrecht E, Quanbury A, Friesen M, Kelso S. The effect of alternate style keyboards on severity of symptoms and functional status of individuals with work related upper extremity disorders. J Occup Rehabil. 2006 Dec;16(4):707-18.
  16. Houwink A, Oude Hengel KM, Odell D, Dennerlein JT. Providing training enhances the biomechanical improvements of an alternative computer mouse design. Hum Factors 2009 Feb;51(1):46-55.
  17. Hedge A, Morimoto S, McCrobie D. Effects of keyboard tray geometry on upper body posture and comfort. Ergonomics 1999 Oct;42(10):1333-49.
  18. Keough JP, GUcer PW, Gordon JL, Nuwayhid I. Patterns and predictors of employer risk-reduction activities (ERRAs) in response to a work-related upper extremity cumulative trauma disorder (UECTD): reports from workers’ compensation claimants. AM J Ind Med. 2000 Nov;38(5):489-97.
Arthritis/Joint Protection

Arthritis/Joint Protection

Evidence Based Practice Summary

Evidence of effectiveness:

Hand therapy is effective for OA and RA in improving pain, stiffness, grip force, daily activities, 1-28 and reducing the need for surgery by 70%.2 Patients at all stages of RA benefit from regular contact with an Occupational Therapist.3

What interventions work?

Joint Protection has been shown to be effective in reducing pain, disability3 and improving self-management over a year after training.4,5,6,7

Splinting is beneficial in both osteoarthritis and rheumatoid arthritis.

  • Resting wrist splints reduce pain 8, 9, 10:, increase strength, and do not negatively affect dexterity. Improvement may not be noted until after 4 wks.8 Resting splints may be better in later stages of RA.11
  • Work splints reduce pain 12 and increase fxn 13 but to be effective they must consider demands of everyday life14 and be designed with client input and carefully constructed15
  • Silver ring splints can reduce mobile swan neck deformities and improve dexterity.16
  • After MCP joint replacement splinting is important for optimal results.17, 18
  • Deformities such as ulnar deviation and MCP subluxation can be reduced with splinting with minimal interference with ADLs 19
  • Thumb OA pain is relieved with splinting20-23 but benefits may not be evident for several months.24

Strengthening has been shown to safely increase hand strength and function in arthritic patients.25-27

Modalities such as low-level laser and thermal modalities (paraffin, hot packs) are beneficial.7,10

References
  1. Boustedt C, Nordenskiöld U, Lundgren Nilsson A. Effects of a hand-joint protection programme with an addition of splinting and exercise: one year follow-up. Clin Rheumatol. 2009 Jul;28(7):793-9. Epub 2009 Mar 18.
  2. Berggren M, Joost-Davidsson A, Lindstrand J, Nylander G, Povlsen B. Reduction in the need for operation after conservative treatment of osteoarthritis of the first carpometacarpal joint: a seven year prospective study. Scand J Plast Reconstr Surg Hand Surg. 2001 Dec;35(4):415-7.
  3. Malcus-Johnson P, Carlqvist C, Sturesson AL, Eberhardt K. Occupational therapy during the first 10 years of rheumatoid arthritis. Scand J Occup Ther. 2005;12(3):128-35.
  4. Masiero S, Boniolo A, Wassermann L, Machiedo H, Volante D, Punzi L. Effects of an educational-behavioral joint protection program on people with moderate to severe rheumatoid arthritis: a randomized controlled trial. Clin Rheumatol. 2007 Dec;26(12):2043-50. Epub 2007 Apr 3.
  5. Vliet Vlieland TP, Pattison D. Non-drug therapies in early rheumatoid arthritis. Best Pract Res Clin Rheumatol. 2009 Feb;23(1):103-16.
  6. Hammond A, Bryan J, Hardy A. Effects of a modular behavioural arthritis education programme: a pragmatic parallel-group randomized controlled trial. Rheumatology (Oxford). 2008 Nov;47(11):1712-8. Epub 2008 Sep 24.
  7. Christie A, Jamtvedt G, Dahm KT, Moe RH, Haavardsholm EA, Hagen KB. Effectiveness of nonpharmacological and nonsurgical interventions for patients with rheumatoid arthritis: an overview of systematic reviews. Phys Ther. 2007 Dec;87(12):1697-715. Epub 2007 Sep 25.
  8. Haskett S, Backman C, Porter B, Goyert J, Palejko G. A crossover trial of custom-made and commercially available wrist splints in adults with inflammatory arthritis. Arthritis Rheum. 2004 Oct 15;51(5):792-9.
  9. Kjeken I, Møller G, Kvien TK. Use of commercially produced elastic wrist orthoses in chronic arthritis: a controlled study. Arthritis Care Res. 1995 Jun;8(2):108-13.
  10. Hammond A. Rehabilitation in rheumatoid arthritis: a critical review. Musculoskeletal Care. 2004;2(3):135-51.
  11. Adams J, Burridge J, Mullee M, Hammond A, Cooper C. The clinical effectiveness of static resting splints in early rheumatoid arthritis: a randomized controlled trial. Rheumatology (Oxford). 2008 Oct;47(10):1548-53. Epub 2008 Aug 13.
  12. Veehof MM, Taal E, Heijnsdijk-Rouwenhorst LM, van de Laar MA. Efficacy of wrist working splints in patients with rheumatoid arthritis: a randomized controlled study. Arthritis Rheum. 2008 Dec 15;59(12):1698-704.
  13. Kjeken I, Møller G, Kvien TK. Use of commercially produced elastic wrist orthoses in chronic arthritis: a controlled study. Arthritis Care Res. 1995 Jun;8(2):108-13.
  14. Pagnotta A, Baron M, Korner-Bitensky N. The effect of a static wrist orthosis on hand function in individuals with rheumatoid arthritis. J Rheumatol. 1998 May;25(5):879-85.
  15. McKee P, Rivard A. Orthoses as enablers of occupation: client-centred splinting for better outcomes. Can J Occup Ther. 2004 Dec;71(5):306-14.
  16. Zijlstra TR, Heijnsdijk-Rouwenhorst L, Rasker JJ. Silver ring splints improve dexterity in patients with rheumatoid arthritis. Arthritis Rheum. 2004 Dec 15;51(6):947-51.
  17. Burr N, Pratt AL, Smith PJ. An alternative splinting and rehabilitation protocol for metacarpophalangeal joint arthroplasty in patients with rheumatoid arthritis. J Hand Ther. 2002 Jan-Mar;15(1):41-7.
  18. Massy-Westropp N, Johnston RV, Hill C. Post-operative therapy for metacarpophalangeal arthroplasty. Cochrane Database Syst Rev. 2008;(1):CD003522.
  19. Rennie HJ. Evaluation of the effectiveness of a metacarpophalangeal ulnar deviation orthosis. J Hand Ther. 1996 Oct-Dec;9(4):371-7.
  20. Rannou F, Dimet J, Boutron I, Baron G, Fayad F, Macé Y, Beaudreuil J, Richette P, Ravaud P, Revel M, Poiraudeau S. Splint for base-of-thumb osteoarthritis: a randomized trial. Ann Intern Med. 2009 May 19;150(10):661-9.
  21. Silva PG, Lombardi I Jr, Breitschwerdt C, Poli Araújo PM, Natour J. Functional thumb orthosis for type I and II boutonniere deformity on the dominant hand in patients with rheumatoid arthritis: a randomized controlled study. Clin Rehabil. 2008 Aug;22(8):684-9.
  22. Weiss S, Lastayo P, Mills A, Bramlet D. Splinting the degenerative basal joint: custom-made or prefabricated neoprene? J Hand Ther. 2004 Oct-Dec;17(4):401-6.
  23. Swigart CR, Eaton RG, Glickel SZ, Johnson C. Splinting in the treatment of arthritis of the first carpometacarpal joint. J Hand Surg Am. 1999 Jan;24(1):86-91.
  24. Rannou F, Dimet J, Boutron I, Baron G, Fayad F, Macé Y, Beaudreuil J, Richette P, Ravaud P, Revel M, Poiraudeau S. Splint for base-of-thumb osteoarthritis: a randomized trial. Ann Intern Med. 2009 May 19;150(10):661-9.
  25. Rønningen A, Kjeken I. Effect of an intensive hand exercise programme in patients with rheumatoid arthritis. Scand J Occup Ther. 2008 Sep;15(3):173-83.
  26. Brorsson S, Hilliges M, Sollerman C, Nilsdotter A. A six-week hand exercise programme improves strength and hand function in patients with rheumatoid arthritis. J Rehabil Med. 2009 Apr;41(5):338-42.
  27. de Jong Z, Munneke M, Zwinderman AH, Kroon HM, Ronday KH, Lems WF, Dijkmans BA, Breedveld FC, Vliet Vlieland TP, Hazes JM, Huizinga TW. Long term high intensity exercise and damage of small joints in rheumatoid arthritis. Ann Rheum Dis. 2004 Nov;63(11):1399-405.