Author Names
Liew, B., et al
Reviewer Name
Miles Moore SPT CSCS
Reviewer Affiliation(s)
Duke University School of Medicine, Doctor of Physical Therapy Division
Paper Abstract
Objective. The purpose of this study was to develop a data-driven Bayesian network approach to understand the potential multivariate pathways of the effect of manual physical therapy in women with carpal tunnel syndrome (CTS). Methods. Data from a randomized clinical trial (n = 104) were analyzed comparing manual therapy including desensitization maneuvers of the central nervous system versus surgery in women with CTS. All variables included in the original trial were included in a Bayesian network to explore its multivariate relationship. The model was used to quantify the direct and indirect pathways of the effect of physical therapy and surgery on short-term, mid-term, and long-term changes in the clinical variables of pain, related function, and symptom severity. Results. Manual physical therapy improved function in women with CTS (between-groups difference: 0.09; 95% CI = 0.07 to 0.11). The Bayesian network showed that early improvements (at 1 month) in function and symptom severity led to long- term (at 12 months) changes in related disability both directly and via complex pathways involving baseline pain intensity and depression levels. Additionally, women with moderate CTS had 0.14-point (95% CI = 0.11 to 0.17 point) poorer function at 12 months than those with mild CTS and 0.12-point (95% CI = 0.09 to 0.15 point) poorer function at 12 months than those with severe CTS. Conclusion. Current findings suggest that short-term benefits in function and symptom severity observed after manual therapy/surgery were associated with long-term improvements in function, but mechanisms driving these effects interact with depression levels and severity as assessed using electromyography. Nevertheless, it should be noted that between- group differences depending on severity determined using electromyography were small, and the clinical relevance is elusive. Further data-driven analyses involving a broad range of biopsychosocial variables are recommended to fully understand the pathways underpinning CTS treatment effects. Impact. Short-term effects of physical manual therapy seem to be clinically relevant for obtaining long-term effects in women with CTS.
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
- Yes
- Was the method of randomization adequate (i.e., use of randomly generated assignment)?
- Yes
- Was the treatment allocation concealed (so that assignments could not be predicted)?
- Yes
- Were study participants and providers blinded to treatment group assignment?
- No
- Were the people assessing the outcomes blinded to the participants’ group assignments?
- Yes
- 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?
- Cannot Determine, Not Reported, or Not Applicable
- 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)?
- Yes
- 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?
- No
- Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?
- No
- 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
Manual physical therapy reduced related disability in women with CTS.
Key Finding #2
Early improvement in function and symptom severity led to long-term improvement in function both directly and via more complex pathways involving baseline pain and depresion levels.
Key Finding #3
Current findings as a whole suggest that short-term benefits in function and symptom severity were associated with long-term improvement in related disability; however, the mechanisms driving the effects interacted with depression levels and EMG severity.
Please provide your summary of the paper
Carpal Tunnel Syndrome (CTS) is treated in various ways. Manual therapy is often deployed as a treatment method despite a clear treatment mechanism for the intervention. This doesn’t mean clinicians should abandon the use of manual therapy, but adequate research is needed before clinicians argue a specific pathway of effect. This Bayesian network analysis of a previously published randomized clinical trial revealed that manual therapy intervention pathways are multivariate. This analysis revealed interactions with depression and CTS severity levels within manual therapy efficacy mechanisms and overall outcomes associated with CTS. Additionally, this article recommends further data-driven analysis to uncover more interactions between the biopsychosocial model and manual therapy treatment for CTS. The RCT and Bayesian network analysis suggests that the short-term effects of manual therapy seem to be clinically relevant for obtaining long-term effects in women with CTS; however, the intervention pathway is unknown at this time.
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 describes potential variables at play within manual therapy treatment mechanisms. The paper doesn’t designate a clear mechanism pathway for manual therapy but it does highlight certain biopsychosocial factors that clinicians must consider when seeing patients. The highlighted variables within this paper were depression and the severity of CTS. This paper supports the need for clinicians to comprehensively deploy the biopsychosocial model when treating patients to adequately inform therapists’ clinical reasoning. A robust understanding of the patient is needed to make decisions around interventions and treatment, and this article supports that notion.
