Author Names
Smedes F, Salm A, Koel G, Oosterveld F
Reviewer Name
Katharina Nevsimal SPT
Reviewer Affiliation(s)
Duke University School of Medicine, Doctor of Physical Therapy Division
Paper Abstract
Study design: Prospective pilot cohort study, quasi-experimental design. Introduction: Restricted hand mobility, limitation in activities and participation, due to relative immobilization of the hemiplegic hand are frequently reported after stroke. Purpose of the study: To establish whether manual mobilization of the wrist has an additional value in the treatment of the hemiplegic hand. Methods: Eighteen patients received treatment twice a week for a period of 6 weeks. Both treatment groups received therapy based upon the Dutch guidelines for stroke. In the intervention group, a 10-min manual mobilization of the wrist was integrated. The primary outcomes were active and passive wrist mobility and activity limitation. The secondary outcomes were spasticity, grip strength, and pain. Data were collected at 0, 6 and 10 weeks. Statistical analysis was performed using the Friedman’s test, related t-test, Wilcoxon test, independent t-test, and ManneWhitney U-test. Results: Statistically significant differences were found in the intervention group; between T0 and T2 measurements in active wrist extension (þ18; p < 0.001), in passive wrist extension (þ15; p < 0.001), and in the Frenchay Arm Test (þ2 points, 18%; p 1⁄4 0.038). This significant improvement was not found in the control group. Statistically significant differences were found between the two groups in active and passive wrist extension (p < 0.001; p 1⁄4 0.002), as well as a change in Frenchay Arm Test (p 1⁄4 0.01). Conclusion: This study suggests that manual mobilization of the wrist has a positive influence on the recovery of the hemiplegic hand. Replication of the results is needed in a large scale randomized controlled trial. Level of evidence: 4.
NIH Risk of Bias Tool
Quality Assessment of Controlled Intervention Studies
- Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT
- No
- Was the method of randomization adequate (i.e., use of randomly generated assignment)?
- No
- Was the treatment allocation concealed (so that assignments could not be predicted)?
- Cannot Determine, Not Reported, or Not Applicable
- Were study participants and providers blinded to treatment group assignment?
- Cannot Determine, Not Reported, or Not Applicable
- Were the people assessing the outcomes blinded to the participants’ group assignments?
- No
- Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?
- Yes
- Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?
- Yes
- Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?
- Yes
- Was there high adherence to the intervention protocols for each treatment group?
- Yes
- Were other interventions avoided or similar in the groups (e.g., similar background treatments)?
- Cannot Determine, Not Reported, or Not Applicable
- Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?
- Yes
- Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?
- Cannot Determine, Not Reported, or Not Applicable
- Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?
- Yes
- Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?
- Yes
Key Finding #1
The treatment plan that involved manual therapy of the wrist as well as the standardized treatment for patients with a chronic hemiplegic hand post-stroke demonstrated an increase in active and passive range of motion.
Key Finding #2
The secondary measurements of grip strength, spasticity, and pain showed improvements as well when manual therapy was integrating into the treatment plan.
Key Finding #3
This was a pilot study on a small group of patients, in order to see the full benefits that manual therapy has on post stroke patients this study needs to be replicated on a larger scale.
Please provide your summary of the paper
This prospective pilot cohort study took place in the Netherlands, measuring the effects of manual mobilization of the wrist on patients with a chronic hemiplegic hand post-stroke who suffer from limited wrist extension, activity limitation, spasticity, strength deficits, and pain. For most daily tasks, wrist extension of 40-60* is required but many chronic post stroke patients only regain a very limited amount of hand function. There was a total of 18 participants 9 in each the interventions group and control group. The patients were compared at two nursing home locations with one location receiving the standard treatment according to the KNGF Guideline of Strokes and the other location receiving the standardized treatment as well as a 10 min manual mobilization of the wrist integrated into the SD treatment. The mobilization consisted of roll-glide movement with a focus on the proximal radio-carpal joint and posterior/anterior mobilizations of the scaphoid and the lunate. Grades II-III mobilizations techniques were used and combined with functional exercise tasks such as reaching for a cup. The primary outcome measures were ROM and activity limitation. ROM was tested with a standard goniometer measuring active and passive wrist extension (AWE and PWE). Activity limitation was measured with the Frenchay Arm Test (FAT) which consisted of 1) Holding a ruler with the affected hand while drawing a line with the other hand; 2) Grasping and lifting a small cylinder; 3) Grasping, lifting, and drinking from a cup of water without spilling it; 4) Pulling off and putting on a clothes peg from a stick and 5) Grasping a comb and combing ones own hair on both sides of the head. The secondary measurements were grip strength (measured through a JAMAR handheld dynamometer), spasticity (measured through Modified Ashworth Scale), and pain (measured through the Numeric Rating Scale). These measurements were taken at baseline (T0), at the end of the six-week treatment period (T1), and post treatment/after a four-week period of no treatment (T2). The results demonstrated improvement for the interventions group on the primary outcome measures due to the manual mobilization and the standard therapy they received. While the control group only received the standard therapy, they did not see improvements in the primary outcome measures. Due to the size of this study, it is recommended that similar research is done with a larger population.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
This paper showed the value of manual therapy and how it can improve overall wrist and hand function in post stroke patients with a chronic hemiplegic hand. It discussed the importance of manual wrist mobilization to increase active and passive wrist extension to achieve functional range of motion while also decrease pain and spasticity. While there was statistical significance found between the group receiving the manual therapy intervention and the control group, this is a small study population size with only 18 participants total. This study should be replicated on a larger scale in order to show that manual therapy should be implemented in all stroke rehabilitation protocols. Through this treatment plan the patient is forced to use the affected arm decreasing the ability for the patient to fall into the “learned non-use” cycle of the affected arm.
