Clinical Practice Guideline: Distal Radius Fractures

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On this episode, we are joined by Sarah Mehta and Christos Kairgianopoulos, both physical therapist, who along with a team of therapist and surgeon, developed a clinical practice guideline for rehabilitation following distal radius fractures. They share with us how CPG is developed, how the evidence is synthesized, and how they came to their conclusions based on the evidence to provide recommendations for evaluation, interventions, and prognosis. Welcome to Hands in Motion, Sarah Mehta and Christos. We have two exciting guests with us this evening, and I'm just going to let them tell us a little bit about themselves. We're here tonight to discuss clinical practice guidelines on distal radius fractures. We have Christos and Sarah with us. So if Christos, you want to start off by telling us a little bit about yourself. Before to start, I teach Bulltime at the sales university. I am a core faculty and associate professor at the DPD program at the sales university. It's a small Catholic school, south to Allentown in Pennsylvania. I've been there for ten years teaching physical therapy students. I'm a certified therapist, first of all, and I'm a physical therapist. I'm a graduate from Drexel University. Back then used to be MCP Hanuman University in Philadelphia in 1999. So I have been in clinical practice for many, many years. In 2014, I finished my PhD and I decided to switch my careers from being a full-time clinician to being a full-time in academia. Then I voted a lot of time into teaching research and service. I have also been working closely with the Penelope Extramid Academy for the American Physical Therapy Association. For the last three to four years, I have been the program chair this year. I am the co-chair for the Academy. Originally I'm from Greece. I came to the United States when I was age 19 and all my training as a certified therapist and physical therapist has been achieved here in the United States. So Rob, tell us a little about yourself. I'm a physical therapist by training. Unfortunately, I do not have the Certificate of the Anthropy designation, but I've had the privilege of working with many fine CHTs. I'm a social professor in the physical therapy program at East Tennessee State University. My portfolio is mainly a director of research for College of Health Sciences and I have small teaching portfolio now. An entry level degree of in physical therapy was from India many years ago. I won't tell you when, so I don't give my age out there. But I did my master's in PhD in Canada. My PhD was at McMaster University and my thesis was focused on distal radius factor and some of the world that we did in CPG was out of pure interest and having been involved there. So I have a privilege of working with the S.H.T. President right now. She's literally her office is 50 feet away from me. So we truly enjoy that collaboration and I'm actually very, very privileged to work with her. I'm very excited to move the Anthropy research forward with her clinical expertise and her extremely wide repertoire and some of the research skills that I might bring to her work. We are very excited. So tell us what exactly is a CPG? Potentially the highest level of research you can contact as a researcher because typically you orient your CPG around a topic and truly you research and you search to find every single study or the literature that's oriented around that particular topic. He can take months and potentially years to be able to discover everything and being able to potentially appraise everything for you to start writing. He said, "Gyinormous multiple level systematic review type of research that incorporates a single topic. Primarily, your goal is to synthesize the evidence that exists out there to promote specific guidelines and recommendations that will guide the clinical practice in an evidence-based level." Yeah, so I'll actually echo everything that Chris mentioned. I'll just add a couple of more quick things. So the development process CPG tends to be very extensive at the back end. What clinicians get at the front end are evidence-based action-oriented statements about what they should be doing. What are the tools and measures they should be doing? What are some of the factors they should be considering in terms of defining the prognosis of that particular patient? And what are some of the truly when they should be doing? I'm emphasizing the word should here and that is to convey the burden of that action. When you read a statement that hand therapy should do that, it means that the evidence and the grading of evidence at the level of evidence is very strong and they should be doing it if they're not doing evidence-based practice. You might see some of the statements which actually say might physical therapists or hand therapist or occupational therapists might do that. And when you see statements like that, what we wonder hand therapists to infer from that is that the evidence is information or is not strong enough to really recommend that they should do that, but it's kind of emerging. And at that time, we want the hand therapist to think about the evidence coupled with their clinical wisdom, coupled with patient values and preferences, the true emalgamation of evidence-based practice in order to take that clinical decision. Also we're using a standardized process, which is a very robust process, utilizing grading from the actual center for evidence. So we're really actually appraising these studies based on a standardized and established system that guides evidence-based practice. There is typically five levels, level one, two, three, four, and five. So when you really decide to really come up with their accommodation, you potentially have specific grades to grade these recommendations that are based on an established scale of evidence that we use to appraise every study. The full process is very robust in terms of a standardization level. So I know that this particular topic was a collaboration with the orthopedic academy as well as hand and upper extremity. I know that there are some others, and I know that there are several across APTs put out. How did you all decide we want to look at distal radius fractures? But we think that this is important and we want to establish this. How did you all choose that topic? First of all, this is the very first CPG on this standardized practice. There wasn't any other CPG before. And if you look at the distal radius fractures, this standardized fractures is actually the most common fracture we have for extremity that is seen in the main series. So really, truly therapists have been treating distal radius fractures out there in the clinics for years without having a CPG available in terms of their rehabilitation aspect. So really, it was not just us selecting this topic. It was an imperative movement for the APTA to suggest if someone able to retake this initiative and we take this topic. So it was really not us, it was really actually the necessity driven by the need to have a topic like this established in the literature. The whole idea really started back in around like 2015 or so, when the original idea was proposed to a group of us and the group that really actually finished this particular CPU, it wasn't just the original group that we started from. So it was an evolution of work from several people who actually had the initiative to really collaborate with the APTA and start initiating this particular CPG from the ground up. Yeah, I very much I put what Chris mentioned, I think Fred it should be given to Sue Michaelvitz who was the pioneer. She is the one who offered this project to APTA. She saw the needs and I think everything that Trish mentioned why this topic, just the prevalence of this fracture and I think we're going to talk a little bit about it, but when super post CPG and our initial talk, we wanted the distal radius fracture, TPG to come out not as a somebody which comes with us. Somebody which comes with a fracture and you treat their impairments, we want hand therapist to got thinking about this person has fallen and fractured the wrist and their impairments related to that. The person might have some other chronic diseases, some person might have different things, there is this evidence is all moving about the intervention. Is it home intervention is enough or supervised therapy is needed so there were a lot of these issues that necessitated that okay well, I think there is a lot of controversy and we are all looking at distal radius factors one entity without thinking about all these factors that might be affecting the outcomes as well as the falsies coming what are we doing with that. So I think that just gave the impetus to propose this topic, I'm sure we're going to talk a little bit more about all these factors that I mentioned, but that was a driving force behind the proposal to APTA. Yeah, pretty much it was really nothing out there to drive practice in an evidence based level. It was really a highly needed topic to be established for not just future research, but also for the clinical aspect for the clinicians to really have an evidence based source to the base their potentially work they do every day in the clinic. So I alluded to a little bit about how this came to be and what is the PGS when you all sat down and sounds like this was quite an extensive process where do you start and how do you go about those initial research initial facts finding to start working toward this. One of the good things that APTA has done is they've actually trained all of us and they have two days intensive training that they provide. So I think I'm just doing the starting part where did it all start? Well, they we propose a topic they thought it's a great topic let's do it. And then they actually train the team about all the steps involved in the process some of the resources that they provide for example the online software to manage the citations online software to synthesize the evidence online software to write the guidelines and all that. Following that Chris and I wrote a grant and we were successful in obtaining the grant offered by APTA to write the CPG that actually was very helpful. So again using all these resources and training we were actually well prepared and set up for success. Chris can mention about how we synthesize the evidence and how we took all that training and software and what did we do with them. I just want to add couple of key points here. The really actually the process starts with a very well versed team. A team that is comprised by researchers clinicians with multiple experiences and specialties people who we have done research before have published before have we done work in terms of literature or searches and understanding the evidence that they read. It starts with a very nice collection of members or a versatile team that is able to respond to the needs of the CPG and I thought that our team was extremely well-gurged in that regards. And then you really utilize the resources that that's available. The resources have been extremely helpful for us from the APTA and from both the academies. Specifically answered the question of how you find the evidence. We also utilize a librarian that it was very helpful in terms of establishing a very well designed searches. In terms of the specific physical topics that we're looking in the CPG relating to potential examination piece, the prognosis piece and the intervention piece. We really took multiple different searches from a librarian for multiple times to make sure that we Chris cross all the ins and outs in terms of covering every single potential topic that we should be including in the CPG in a very detailed manner. Then a librarian really comes up with the assortment of studies and citations and he goes through a very kind of intricate process of reviewing every single study based on specific criteria that we had established. And potentially selecting the studies that will be placed in the CPG or be considered for the CPG versus the ones that we should not be considering. So it's really a stepwise process that really starts from the team that resources the librarian and a collaboration more at multiple levels. So how long did that collection process take? You know, I'm sure it's not something that's done in two or three months, like how many years have you been trying to gather the most recent evidence to begin to look at this CPG? We started around 2015. At CSM in 2016, I believe we presented our first proposal at CSM, I believe in unhigh California. We were trained. We added potentially a couple of different members in the process as we were expanding our research and capacities and efforts. We were in San Diego in 2017 being trained by the APTA for the latest ways of researching conducted CPGs. Really, you can do the math since 2015 to 16, assorting that the team members and learning the process, potentially training by the APTA a couple of different times. And we published in 2024. So it took an innocent years for this whole process to come to fruition. I would add to that one to emphasize that it did take us a very long time for multiple reasons, but usually it shouldn't take that long. And the reason it took that long is because APTA was starting on this journey of developing multiple CPGs across different academies. And as they were doing that, they were refining the process of what is the best method for developing CPG? And they were trying to make it more efficient. And as we did our work, we were told that, okay, well, now you have to do it this way. We did several course correction along the way. And at some point, they were more settled into accepting, okay, there could be a couple of template will accept what you're doing. However, we have kind of moved to new template, but will grandfather you in? And that's how we were able to finish that towards the end. You mentioned step that how recent is the evidence? Well, evidence, as you know, it cannot be any older than 12 months. If you are into this loop where you have compiled the study, you've kind of written few things, but then they came up with new way of doing things, then you had a little bit of pause and that 12 months have passed. You have to start this search all over again. So it's just the way it is. And that just took us a little bit longer. However, I think collectively we feel more confident. We feel more confident in the robustness and the solid methodology and strong CPG that we have created because to be honest, I was telling Chris this morning, we were just talking about this evening that actually I maybe some of the hand therapists might know a great tool. A great tool is actually used for appraising the quality of CPG's and we used a great tool to appraise our CPG and actually we scored pretty high and it was blinded not that I appraised my own CPG. I had somebody else do it took long, but finally when we arrived, we came with the product. Just to add to the fact that this CPG was one of the first CPG that was accepted by the APTA. So when we started, we kind of lived the first wave of CPG that the APTA had been processing and producing. I think that we have learned from this process as much as the APTA has learned from this process in terms of not only designing and conducting CPG's but also finishing and publishing the CPG's at the very end. So I think it was really reciprocal learning that helped both us and the APTA to become better in terms of the timing of completion for the CPG's. Well, let's get into the meat of it. Tell us what you found or what you've included in my blog. to also get into just how we as clinicians use this. Tell us what's in it. Yeah, how many pages is this? Like a lot. A lot. Yeah. Well, even to know that you have 327 references or something. It's a lot. It is a lot. It's really multiple CPDs within a CPD. The CPD thing about it is not just a single topic. It's a multiple topics of the topic. We were talking about examination, prognosis, intervention. So there's three multiple chapters, multiple levels. We have different members really specializing and focusing more on the different topics of the CPD. I was assigned mostly to work closely with the intervention piece. So I'm going to let Sarah really talk more about the prognosis first. We can start with intervention and then Sarah can we talk about the prognosis. For the intervention aspect, which is actually a very important aspect because people ask what do we do for these different structures? We use multiple topics based on the research we did and just by dissecting the evidence that we have. We came up with the topics that we were potentially interested to explore and figure out what the evidence and water accommodation we can come up with were potentially eight topics. So the very first topic was therapy initiation timing after surgery. Whether supervised therapy is effective versus a home exercise program. That was a really very hot topic in the literature on many different studies and different levels. Believe it or not, many studies came out and really claiming that supervised therapy, that a therapist, OT or PTU, whoever, provides, it doesn't add more than just people having only a home exercise program. And that was very frustrating to see that we spend so much time in the clinic and studies coming out to really completely contradict what we do and how beneficial is that for our patients. For me, that was a really very emotional topic for me particularly as I said by her therapist. We looked also the evidence for sensory motor control training therapeutic modalities, therapeutic exercises, manual therapy, interventions for eagema control and potentially the orthosis management that a lot of times you see out there and you really truly don't know how much everything is going to happen. So all these were like eight particular topics that we addressed in the CPG in terms of the intervention aspect. I mean, I'm not going to kind of read the recommendations, but anybody is available. This CPG is available online actually. It's a free access by the general sports physical, the JOSPT. So anybody can just go online and find this particular CPG, which is a really a good thing. From the initiation of therapy, highlight there was that we actually found out that the majority of the evidence suggests that after surgery, therapy should really be starting within the first three weeks. It has been really actually being divided between two school of thoughts. One is the traditional school thought that let's wait for four to six weeks until we do any therapy to protect the side of the surgery. The other, it was the accelerated thought that has been proposed for the last potentially 10 to 15 years. We found that the evidence was already very supporting of that after surgery. Potentially most of the recover days came out that if you start earlier within the first three weeks, you have a better outcomes in terms of pain range motion functionality and return back to activities for the early day quicker. Really very interesting finding is when do you start strengthening? And we usually hold up to strengthening for several weeks, potentially up to eight weeks because we think that, but that's what we need to be protective of the fracture. And that's fine. And most of the research have shown that this is correct, but for some cases where the fracture is not as complicated, more stable in fractures that are associated with persons with no complications or comorbidities, especially younger population. Those cases, we found out that potentially strengthening can start within two to three weeks after surgery or even doing the cast demobilization at about two to three weeks after the initiation of casting. But that's how you can start doing some really gentleized somatrix to really kind of allow someone to really provide this neuromuscular education where we need it and promote really functionalally later after the casting was completed. So those are really the two really highlights on the CPG from the initiation therapy and strengthening aspect. You mentioned just now with the initiation of therapy after surgery, but then also initiating strengthening with cast mobilization, what not. Did most of the CPG focus on post operative management or was it also potentially non-surgical interventions? Where did y'all focus that or was it a combination? It was a combination. We did not exclude one or the other and we didn't really not divide the entire CPG into these two different levels. We looked in a composite way all the studies and really a lot of studies, it was very hard to divide the CPG in that way because a lot of studies that we found included both surgical and non-surgical interventions for their physical therapy outcomes. Some studies were exclusively focusing on post-op cases. Few studies focus on the non-ops, but however, most of the studies really were recruiting patients from surgical and non-surgical kind of status. We included both. Now if you look at the other topics, that was the very first topic to be honest with you. The next topic was really the topic of comparing outcomes in terms of supervised therapy versus home exercise program. I was really very surprised to see that several studies that was actually mostly driven or actually completed by surgeons came up to really advocate the fact that whether you do supervised therapy or you do a home exercise program, the outcome is very similar. Therefore, let's save money, let's save healthcare resources and let's promote the home exercise program more because the outcomes are very similar. So then we decided to really look very closely and analyze and honestly, I praised the studies in a way that to find out what kind of methodological approaches the studies utilized. Some of the studies were actually putting methodology. Some of the studies had a lot of limitations. One of the limitations was that yes, they came up with a conclusion that home exercise program has equal or similar outcomes with the supervised therapy. But we found out that most of the studies really utilized a non-complicated type of fractures, non-complicated patients without significant capabilities and complications, which they will have otherwise done well anyway, even without supervised physical therapy. So it was really kind of a big bias. The other thing that I really actually discovered by looking at all these studies, I discovered that was really a dichotomous approach in supervised therapy. Some studies really claimed that they really actually apply supervised therapy, but the frequency was so rare in terms of the dose of therapy. So if I tell you that the study claims that they're really comparing supervised therapy to home exercise program, but the supervised therapy is done once every two or three weeks in the clinic, that's really not supervised therapy for me, right? So the typical supervised therapy is potentially one to three times a week if you really want to see in real terms supervised therapy level. So what I did, I really divided the studies between two levels, the level that they use kind of infrequent therapy to the studies they use, typical or frequent therapy. And when I compared the studies, I found that the outcomes really actually supported the supervised therapy when the frequency was proper and then when the frequency was really actually very infrequent or very rare, the outcomes were really actually very close similar to home exercise program. So that was just from my perspective, really, did you need to these studies to come up with their accommodation? So we came up with their accommodation that was really stating that if you are 60 years old or older with at least one or more complications and commemorabilities, you should have supervised therapy by a hand therapist in a frequent manner, at least once a week, compared to a home exercise program. Unfortunately, we didn't have really very strong sample of studies to come up with a stronger accommodation for the younger population, something to consider for the future updates of the CBD. But potentially, at least we came up with a very strong statement with a good evidence that say that the older folks with complications to come up with this, they need to really see supervised therapy. And potentially, if they have a home exercise program designed, that program should be dedicated and designed and allocated by a clinician, not a surgeon. So that was part of the second topic. Potentially all the other topics were based on exercises, myotherapy, modalities, and edema control. The evidence was very variable. And the challenge in this EPG was that we did not see a lot of available studies, the sample of the available of the studies that we consider to include in this EPG or not even wasn't that large. That is actually one of the limitations of the sympathy. That we came up with recommendations that would potentially could be stronger recommendations if we had more available studies to rely on. Most of these topics, the topic of myotherapy, was supported with potentially a accommodation grade level B. Most of the modalities were supported, thermal modalities were supported, mechanical modalities which was actually not very well supported by the evidence. Our thoughts was really actually very tough. We only had two or three studies and we clearly not find strong studies to really support a stronger accommodation for our thoughts. Manual therapy was actually supported by a studies on the third accommodation B. And edema control also was supported by the studies that we found. Particularly if you look over the intervention topics that we had concluded on some recommendations. Most of the recommendations support what the physical therapist and the occupational therapist doing in the clinic today. And potentially they can only read the CPG and they can actually short out the small details that they can navigate through in the clinical practice and how to apply these clinical guidelines in edelina. Even to what Sraub said earlier about the statements you see with those interventions should use this, should use this, I mean in several of those with the manual therapy, should use manual therapy, should use their pediatric exercise, this should use. So there's lots of those strong statements that we have for those interventions. - Correct, the sample of the studies was really not very large. A good conclusion after this long effort is that more research needs to be done. And more research with stronger studies will be better quality studies. But certainly based on what we had, we concluded the recommendations that will be very useful for clinical practice. And also just remember this is the very first CPG on the studies for actions. We took a huge initiative and we spent a lot of time on it, we've indicated about 10 years of parallel haves to the finish this up. We very proud about the results in terms of the usefulness of the accommodation and the one can actually, that's kind of really what I feel about this. - So Rob, tell us about the work on the prognosis for these patients. - Before I start discussing about prognosis, I'm gonna tie what I'm about to say with some of the evidence that we may have on the interventions I don't think, you know, as Chris was alluding to that. There's some studies that might have been done by surgeons or some other groups that say that, well, you don't need not a pair of people for this. And that's where the prognosis kicks in, we should not take a patient with distilled radiants fracture and one entity, rather than we should add, we should think about the clinical profile. And clinical profile could mean a lot of things. It could mean the present take symptoms and impairment or where are they scoring on some of these outcome measures at the initial assessment or they scoring towards the very high on the impairment score. So that's one domain, purely looking at the presenting symptoms and what we've seen in terms of the pain and physical dysfunction and all that. Second cluster that I wish am therapists will start looking at in general based on what we have seen in their literature is the comorbid burden profile. And that could be mental health comorbidity, physical health comorbidity, when people are struggling with different things. You know, when we think of distilled radiants fracture, I'm sure it's prevalent in different age groups, but I'm thinking about a profile that is over the age of 60 by tends to be more female, higher proportion of females than males, mental health concerns, you know, that's very common in aging in general, not just distilled radiants fracture, you know, depression is very common in older adults. And my board certification is geriatric, so I have a little corner in my heart for older adults, so I think that's all coming out right now. Then you look at the fall risk. The fall risk guidelines suggest that if they're fallen and come to you, you should assess fall risk and do what's needed. In most individuals, specially older adults are falling from standing height or what we call it ground level fall, which should not have broken a bone. So they're coming to us with that fracture. We're working on the risk, we're not doing anything about fall. So again, with all that background and contextual information, let me say what we found in the CPG in terms of brokenosis, we found that the evidence for being older, being of female sex, having certain number of comorbidities, mental health concerns were associated with poor outcome. We would tell you that based on the prevalent literature, evidence for these association is not very robust. It's not weak, but it's not like hit the ball out of the park kind of strong. It is somewhere in between. My hypothesis is for that, and it's based on science, is that most of the studies tend to focus on one particular comorbidity and they ignore everything else. And then they see that, okay, people who have mental health issues had some problems or did not have worse outcome or had worse outcome. When I think of it, I think of a patient as a human being who may have more than one of these risk factors. So we do not find any study in the literature where there is a cluster approach. Okay, if people have a cluster of risk factor, what is the overall prognosis? And that is something that Chris, I, and actually Kim Masper and everybody, we are actually planning that study right now. We are hoping to submit a grant in few months. Once we know what is the grant, let's get to settle it. That is hopefully going to be available when we revise this CPG. So those are some of the prognostic indicators we found. The evidence for fall is as it directly relates to distal rate is factor isn't much there. So I guess if I have to ask the question, what are the studies where fallist measures were validated or tested for the reliability in distal rate is factor population not much. But there is significant number of studies that say that people who have distal rate is factor will fall and break their hip. 20% of the people over the age of 65 will fall and break their hip in next five years. A large proportion of patients distributed factor is a life-changing event where their level of mobility does not go back to the green injury level. So we have all these tell tell signs that say that at certain age, specifically over the age of 70, distal rate is factor is a life-changing event that can perpetuate the cycle of other falls and feature factors that can perpetuate the functional impairment in disability and institutionalization, dependence, and ADLs. So the message that I'm hoping to drive here is that we look at a patient as a whole. We focus on their wrist and hand. They came to us for that. We make sure that we work our best and outlining these intervention strategies that Chris suggested a little earlier. But we also look at their fall risk risk for function decline and these factors that can perpetuate their impairment for longer time, even the risk-specific impairment. These are the people, and again, time back to intervention. These are the people who need supervised therapy. I cannot justify in my mind how you can just teach them exercise and tell them, okay, come and see me in four weeks and we'll see how you do it. It is not something that we should do with every patient. We should look at their clinical profile, use our clinical judgment, take help of some of these recommendations. As I mentioned to you, the evidence is not very weak, but not very strong either. And the initial part of this are talk. We mentioned that when that happens, you mix your clinical wisdom. And this is the perfect opportunity to mix your clinical wisdom with the guidelines and do what's best for that individual patient rather than just having a prescriptive approach or do home exercises. To wrap up the conversation with examination, I mean, there are no surprises. I mean, that's another chapter that Chris mentioned that I was involved more in examination and prognosis. So again, I'm not going to spend a lot of time there. As I mentioned, there are no surprises. Very high level of evidence for using impairment-based measures of dash, patient-rated distribution evaluation and Michigan hand questionnaire. Very high evidence for using physical function tests like group strength, dexterity test things, one of the tests that Chris had worked a lot on in the last few years, which is the joint position sense. So there is very high quality evidence for that. So again, no surprises there. I'm sure reflects the contemporary practice. So again, the change may not be needed much there, but we just hope that this CPG will help in identifying that patient profiles who might get risk of poor outcome, matching that with a proper intervention that Chris alluded to and promoting the best practice by kind of linking their prognosis with the profit. interventions? Yeah, that was very well said. Just a lot of that sorabs points that if we do more research and we get more research, we will be able to supply the persons we have in the different categories based on their cognistic factors. So the intervention recommendations that we have now in the CPG potentially contains and we can actually allocate certain categories of persons to need to have therapy versus maybe should have therapy or maybe some of these other persons that maybe should go ahead and have just a home exercise program or maybe few visits because of their cognistic factors and now that intense. I think that what we're looking for the future is to be able to see that more research will be published and more research will be published to really support subcategories of recommendations based on the prognostic factors and profile. That's very important point that the current literature does not say so if the evidence could be contrary that don't do this, we now know that you shouldn't do this or we now know that age is not the prognostic factor. We strongly feel about that that's not what the evidence is but I'm just saying the evidence is also not like we are pounding on the table that age is the prognostic factor. We are somewhere in between and as we said more research is generated the needle will move towards we now know the age is in it is a prognostic factor. I don't think we're going to go backwards. All those studies are suggesting that age is a prognostic factor. It's just the methodological quality of those studies are not very strong and therefore we are again not pounding the table just kind of silently whispering right now. We have a lot of good studies that we have shown the or proven the prognostic factors affect in these studies factors but we don't really have enough studies that we have connected this with interventionities. I mean for example my dissertation work and my PhD was dedicated on the proprioception aspect on these studies factors and we have found out that the risk proprioception after this strategy structure is significantly reduced. Also we found that pain is a very strong prognostic factor in terms of reducing or affecting proprioception and also we found out that prognostically pain overall is a poor prognostic factor especially if it is at the final level for this strategy structure. So you really look at the visual studies and use scientific thinking and you connect the dots you can actually make sense to say that if you really have xyz you will have prognosis or potentially you need to do this interventions to improve these particular outcomes but we really like studies that have connected the two or the three levels of thinking here. So I think that as we produce more research, more meaningful research we'll have future CPG to grow stronger accommodation more meaningful accommodations for the clinicians. So for our super busy clinician listeners, his podcast, who might not have time to read all 78 pages of this, is it safe to go straight to that summary of recommendations where you have those grades on the prognosis, you have those grades on the examination, the interventions, is that an okay place to start with this CPG and then with more time sit down and look at some of the evidence that you all pulled that from. I would say yes but I will also say that if you really read these quick statements, it's actually provide the food for thought to instigate a little further investigation through the CPG. I will also say if you're going to only be one of those people who really want to take a quick taste of the CPG, I will also go and really read the synch-piavidensynthesis paragraphs that really follow through every topic within the CPG because there's some really busy sections where we analyze every single study and we classify the studies and we say this study found this and this study found that and therefore that's the recommendation but then we also have like a small sections for each topic that they call synthesis of the evidence so I think that this is a very important piece of information because that really provides the analytic aspect that leads and supports the recommendations that you've read. And I think I will just add one more thing, I'll probably take this moment to advertise the next step that we are going to do, press and I end came in everybody else. We are actually developing an app to push the CPGs, not just this one but the other two opportunities CPGs. So clinicians who are really interested in changing the practice or making the practice more evidence based look for the email that might come through Htt, I guess in next little while we'll hope that clinicians who are busy as you mentioned, you know busy clinicians they may not have the time and resources to read that document and we hope to drive some easier ways to implement the CPG because again to create CPGs one thing we just as Chris mentioned a lot of sleepless nights and a lot of this content at the family level and we put all these work for eight, ten years and we finally are here we don't want this to not be read and that's where our next step is to acknowledge implementation. That's really exciting that would put it literally at people's fingertips. I have one more question because you both alluded to this, you've both talked about revisions, you've also alluded to the fact this took a lot of time but will that happen and when would that happen or like I know we've mentioned many times like research it does get outdated but what sort of the expectation of revisions of this or additions to it. With and I've decided that we'll do this in our retirement. Yeah, or you'll pass it along to the next person. The short answer to this is that typically CPGs usually they get an update or they get revised or updated after five years. This is really the typical timeframe in the market if you will for CPGs. So we are following that pattern and I'm pretty sure the APTA is going to be during our doorbells in five years from now and say, "Sarab, investors, you've done all this work, now you up again for taking the next step and doing the updating of this." So we are preparing for that. Alluding to the exciting news that Sarab just mentioned about the new steps, we are very proactive about it and I have been developing some research in my academic agenda towards studies that will potentially support the help the update and potentially we're collaborating with very well versed individuals in the industry to potentially produce quality of studies that will support the next step. I'm going to thank you both for all the hard work and years of dedication. I truly am thankful for that as well as I'm sure every other clinician is. I know it takes a lot of work and time and blood sweat and tear so we appreciate everything that you've contributed to this CPG. Before we end, I just want to thank the entire team without Sarab's leadership and potentially everybody else, the members of this team was fantastic and most particularly I would like to really thank Sue Michaelvitz for being the mother of this particular initiative. Sue has been a very important person in my whole academic career but besides that this initiative was first similar to that idea with the FPTA and it's collected a number of individuals that we're here today to be very proud about this ending on the CPG effort. I agree. I think so. There's probably the biggest compliment and appreciation. I don't think that we can carry 10% of our energy and bigger and knowledge that she has. Even if we can do that, we probably would have done the CPG in two years. Yeah, again to echo what Steph said. We appreciate the work that you and your team have put into this and we appreciate you both discussing this with us and hope that our listeners, I know they will find this valuable not only this conversation but also this masterpiece that you put together to help guide our clinical practice. Thank you. Thank you. Thank you for joining us for another episode of Hands Emotion brought to you by the American Society of Hand Therapists. 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