title: Multimodal care for the management of musculoskeletal disorders of the elbow, forearm, wrist and hand: a systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration.
abstract: BACKGROUND
  Musculoskeletal disorders of the elbow, forearm, wrist and hand are associated with pain, functional impairment and decreased productivity in the general population. Combining several interventions in a multimodal program of care is reflective of current clinical practice; however there is limited evidence to support its effectiveness. The purpose of our review was to investigate the effectiveness of multimodal care for the management of musculoskeletal disorders of the elbow, forearm, wrist and hand on self-rated recovery, functional recovery, or clinical outcomes in adults or children.
  
  
  METHODS
  We conducted a systematic review of the literature and best evidence synthesis. We searched MEDLINE, EMBASE, CINAHL, PsycINFO, and the Cochrane Central Register of Controlled Trials from January 1990 to March 2015. Randomized controlled trials, cohort studies, and case-control studies were eligible. Random pairs of independent reviewers screened studies for relevance and critically appraised relevant studies using the Scottish Intercollegiate Guidelines Network criteria. Studies with a low risk of bias were synthesized following best evidence synthesis principles.
  
  
  RESULTS
  We screened 5989 articles, and critically appraised eleven articles. Of those, seven had a low risk of bias; one addressed carpal tunnel syndrome and six addressed lateral epicondylitis. Our search did not identify any low risk of bias studies examining the effectiveness of multimodal care for the management of other musculoskeletal disorders of the elbow, forearm, wrist or hand. The evidence suggests that multimodal care for the management of lateral epicondylitis may include education, exercise (strengthening, stretching, occupational exercise), manual therapy (manipulation) and soft tissue therapy (massage). The evidence does not support the use of multimodal care for the management of carpal tunnel syndrome.
  
  
  CONCLUSIONS
  The current evidence on the effectiveness of multimodal care for musculoskeletal disorders of the elbow, forearm, wrist and hand is limited. The available evidence suggests that there may be a role for multimodal care in the management of patients with persistent lateral epicondylitis. Future research is needed to examine the effectiveness of multimodal care and guide clinical practice.
  CRD42014009093.
authors.affiliation: UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie Street, Toronto, Ontario Canada M2H 3J1 ; Division of Graduate Education and Research, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie Street, Toronto, Ontario Canada M2H 3J1.
authors.forename: Deborah
authors.initials: D
authors.lastname: Sutton
authors.affiliation: Faculty of Rehabilitation Medicine, Department of Physical Therapy, University of Alberta, 8205 114 St, 3-28 Corbett Hall, Edmonton, AB Canada T6G 2G4 ; Rehabilitation Research Centre, University of Alberta, 8205 114 St, 3-48 Corbett Hall, Edmonton, AB Canada T6G 2G4.
authors.forename: Douglas P
authors.initials: DP
authors.lastname: Gross
authors.affiliation: UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie Street, Toronto, Ontario Canada M2H 3J1 ; Canada Research Chair in Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT), 2000 Simcoe Street North, Oshawa, Ontario Canada L1H 7L7 ; Faculty of Health Sciences, University of Ontario Institute of Technology (UOIT), 2000 Simcoe Street North, Oshawa, Ontario Canada L1H 7L7.
authors.forename: Pierre
authors.initials: P
authors.lastname: Côté
authors.affiliation: UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie Street, Toronto, Ontario Canada M2H 3J1 ; Division of Graduate Education and Research, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie Street, Toronto, Ontario Canada M2H 3J1 ; Division of Undergraduate Education, Canadian Memorial Chiropractic College, 6100 Leslie Street, Toronto, Ontario Canada M2H 3J1.
authors.forename: Kristi
authors.initials: K
authors.lastname: Randhawa
authors.affiliation: UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie Street, Toronto, Ontario Canada M2H 3J1 ; Division of Graduate Education and Research, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie Street, Toronto, Ontario Canada M2H 3J1.
authors.forename: Hainan
authors.initials: H
authors.lastname: Yu
authors.affiliation: UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie Street, Toronto, Ontario Canada M2H 3J1 ; Division of Undergraduate Education, Canadian Memorial Chiropractic College, 6100 Leslie Street, Toronto, Ontario Canada M2H 3J1.
authors.forename: Jessica J
authors.initials: JJ
authors.lastname: Wong
authors.affiliation: Division of Graduate Education and Research, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie Street, Toronto, Ontario Canada M2H 3J1 ; Graduate Education Program, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie Street, Toronto, Ontario Canada M2H 3J1.
authors.forename: Paula
authors.initials: P
authors.lastname: Stern
authors.affiliation: UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie Street, Toronto, Ontario Canada M2H 3J1 ; Division of Graduate Education and Research, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie Street, Toronto, Ontario Canada M2H 3J1 ; Division of Undergraduate Education, Canadian Memorial Chiropractic College, 6100 Leslie Street, Toronto, Ontario Canada M2H 3J1.
authors.forename: Sharanya
authors.initials: S
authors.lastname: Varatharajan
authors.affiliation: UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie Street, Toronto, Ontario Canada M2H 3J1 ; Rebecca MacDonald Centre for Arthritis and Autoimmune Disease, Mount Sinai Hospital, Joseph and Wolf Lebovic Health Complex, 60 Murray Street, 2nd Floor (Main), Toronto, Ontario Canada M5T 3L9.
authors.forename: Danielle
authors.initials: D
authors.lastname: Southerst
authors.affiliation: UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie Street, Toronto, Ontario Canada M2H 3J1 ; Division of Graduate Education and Research, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie Street, Toronto, Ontario Canada M2H 3J1.
authors.forename: Heather M
authors.initials: HM
authors.lastname: Shearer
authors.affiliation: UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie Street, Toronto, Ontario Canada M2H 3J1.
authors.forename: Maja
authors.initials: M
authors.lastname: Stupar
authors.affiliation: Graduate Student, Faculty of Health Sciences, University of Ontario Institute of Technology (UOIT), 2000 Simcoe Street North, Oshawa, L1H 7L7 Ontario Canada.
authors.forename: Rachel
authors.initials: R
authors.lastname: Goldgrub
authors.affiliation: Toronto Health Economics and Technology Assessment (THETA) Collaborative, 6th Floor, Room 658, 144 College Street, Toronto, Ontario Canada M5S 3M2 ; Faculty of Pharmacy, University of Toronto, 144 College Street, Toronto, Ontario Canada M5S 3M2 ; Institute for Work and Health, 481 University Avenue, Toronto, Ontario Canada M5G 2E9.
authors.forename: Gabrielle
authors.initials: G
authors.lastname: van der Velde
authors.affiliation: Departments of Orthopedic Surgery and Environmental Medicine, Occupational and Industrial Orthopedic Center, NYU School of Medicine, New York University, 550 1st Avenue, New York, NY 10016 USA.
authors.forename: Margareta
authors.initials: M
authors.lastname: Nordin
authors.affiliation: School of Public Health and Injury Prevention Centre, University of Alberta, 3-300 Edmonton Clinic Health Academy 11405 - 87 Ave, Edmonton, Alberta Canada T6G 1C9.
authors.forename: Linda J
authors.initials: LJ
authors.lastname: Carroll
authors.affiliation: UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie Street, Toronto, Ontario Canada M2H 3J1.
authors.forename: Anne
authors.initials: A
authors.lastname: Taylor-Vaisey
keywords: Carpal tunnel syndrome; Epicondylitis; Hand injuries; Multimodal treatment; Review literature as topic; Tennis elbow; Wrist injuries